Author Archives

Christina Liu

Training the Modern Physician: A Call to Incorporate Finance and Law into Medical Education

Oct 10, 2019

By SAI BALA, JD

The United States medical education system is heralded as one among the top in the world for medical training. Given the strict standards of education, multiple licensing boards, and continuous oversight by governing bodies, getting a placement to train in the US is extremely competitive. In 2017 alone, nearly 7000+ non-US citizens (commonly referred to as “foreign medical graduates”) applied to compete with 24,000+ US citizens for American residency spots to pursue specialty training. The reasons for this competitiveness are simple. The vast majority of medical institutions in the US boast a comprehensive curriculum that entails basic sciences, clinical principles, practical and hands-on didactics, and enriched exposure to the clinical aspects of patient care. This training produces astute clinicians that are capable of resolving the most complex diagnoses while providing comprehensive patient care.

However, it is high time to recognize that being a shrewd clinician is no longer a sufficient product for the demands of the healthcare market today. That is to say, the scope of medicine today for a physician has gone far beyond resolving complex medical problems, but demands a higher understanding of multidisciplinary skillsets, most important of which are finance and legal theory. In these aspects, the US medical education system direly underprepares physicians, and thus, requires a thorough reevaluation.

The art of medicine, as much as it was originally developed to be purely about the betterment of patient health, has become yet another siloed service industry. Simply put, patients are customers, and physicians are increasingly held accountable for the financial metrics and revenue their work produces. Compensation models are increasingly favoring productivity based payment methods, such as the relative value unit (RVU) system, and are moving away from the traditional, salaried physician. This has resulted in increased pressure on physicians to become more efficient with their workload and patient docket, while managing the often turbulent and contradictory interests of insurance, patients, and hospital administration.

The good, the bad, and the hopeful in new interoperability plans from Washington

Oct 9, 2019• 2

Claudia Williams, Manifest MedEx, Amazon

By CLAUDIA WILLIAMS

Robust exchange of health information is absolutely critical to improving health care quality and lowering costs. In the last few months, government leaders at the US Department of Health and Human Services (HHS) have advanced ambitious policies to make interoperability a reality. Overall, this is a great thing. However, there are places where DC regulators need help from the frontlines to understand what will really work.

As California’s largest nonprofit health data network, Manifest MedEx has submitted comments and met with policymakers several times over the last few months to discuss these policies. We’ve weighed in with Administrator Seema Verma and National Coordinator Dr. Don Rucker. We’ve shared the progress and concerns of our network of over 400 California health organizations including hospitals, health plans, nurses, physicians and public health teams.

With the comment periods now closed, here’s a high-level look at what lies ahead:

CMS is leading on interoperability (good). Big new proposals from the Centers for Medicare and Medicaid Services (CMS) will set tough parameters for sharing health information. With a good prognosis to roll out in final form around HIMSS 2020, we’re excited to see requirements that health plans give patients access to their claims records via a standard set of APIs, so patients can connect their data to apps of their choosing. In addition, hospitals will be required to send admit, discharge, transfer (ADT) notifications on patients to community providers, a massive move to make transitions from hospital to home safe and seamless for patients across the country. Studies show that readmissions to the hospital are reduced as much as 20% when patients are seen by a doctor within the first week after a hospitalization. Often the blocker is not knowing a patient was discharged. CMS is putting some serious muscle behind getting information moving and is using their leverage as a payer to create new economic reasons to share. We love it.

Health in 2 Point 00, Episode 97 | Walmart and Fertility

Oct 8, 2019

Today on Health in 2 Point 00, Jess is in Berlin for the Bayer G4A Signing Day where they’re announcing which startups are going to get deals and Glen Tullman is doing a fireside chat with Eugene Borukhovich. In Episode 97, Jess and I talk about Walmart and fertility. Fertility benefits startup Progyny files for IPO and I’m blown away by this relatively new company. Another startup—Halle Tecco’s Natalist—raises $5M to send care boxes to help women get pregnant. Finally, Jess has a conspiracy theory, noticing that Walmart is sneaking into all aspects of health tech… Walmart is expanding Grand Rounds, partnering with Doctor On Demand and HealthSCOPE to offer telehealth to their employees, Sam’s Club is offering $1 telehealth visits to members, and they just announced a partnership with Embold Health for employees in the southeast. Finally, I’ll be at Society for Participatory Medicine next week in Boston—see you all there. —Matthew Holt

The Opportunity in Disruption, Part 5: Five Strategies of Cooperation

Oct 8, 2019• 2

By JOE FLOWER

The system is unstable. We are already seeing the precursor waves of massive and multiple disturbances to come. Disruption at key leverage points, new entrants, shifting public awareness and serious political competition cast omens and signs of a highly changed future.

So what’s the frequency? What are the smart bets for a strategic chief financial officer at a payer or provider facing such a bumpy ride? They are radically different from today’s dominant consensus strategies. In this five-part series, Joe Flower lays out the argument, the nature of the instability, and the best-bet strategies.

There are five ways that both healthcare providers and payers can cooperate while they compete to bring the highest value forward to the customer.

Align incentives in the contracts: Healthcare providers must be able to provide performance guarantees that give at least some of the bottom-line risk to them. Work with third-party companies that can actually audit organizations’ abilities to give performance guarantees consistently over time.
Eschew embiggening: Size per se is not a safe harbor from risk. There are few economies of scale in healthcare. Concentration within a given market can be essential to success in offering a true range of services, well supported, at a lower price, customized to the regional population, the provider mix, the state laws, and the local economy. But local concentration is not the same thing as size per se.

And size does not help the customer. There just are no examples in the history of healthcare in which size alone has returned greater value to the patient, the consumer, or the buyer, whether lower cost, greater reliability, or higher quality.
Expand the definition: Widen the “medical services” that you fund and offer to include services such as functional medicine, chiropractic, acupuncture, and various other modalities that have been shown to be highly effective at far lower cost. There absolutely are ways to do this within licensing requirements.
Integrate behavioral health: Find ways to fund behavioral health and addiction treatment. Integrate behavioral health directly into the patient experience, triaging at the door to the Emergency Department and in every primary encounter. Find local innovators that can help pre-empt costly crises. Partner with community health, housing, and nutrition advocates. Helping people change their habits, manage their lives, and get beyond their addictions is far less expensive than fixing them over and over.
Retrain clinicians: Physicians and other clinicians are heavily trained to create and document reimbursable events. If you change the economics so that the system finds ROI in promoting health, preventing disease, managing population health, producing cures and reducing suffering as efficiently as possible, those very same clinicians will need to be retrained. Most of them will be deeply grateful, because they, like you, genuinely want to bring real value to the customer. In fact, if you do this you could end the physician shortage and the nurse shortage. People will flock back to do what they became a doctor or a nurse to do: Help people.

The Rise and Rise of Quantitative Cassandras

Oct 7, 2019

By SAURABH JHA, MD

Despite an area under the ROC curve of 1, Cassandra’s prophesies were never believed. She neither hedged nor relied on retrospective data – her predictions, such as the Trojan war, were prospectively validated. In medicine, a new type of Cassandra has emerged – one who speaks in probabilistic tongue, forked unevenly between the probability of being right and the possibility of being wrong. One who, by conceding that she may be categorically wrong, is technically never wrong. We call these new Minervas “predictions.” The Owl of Minerva flies above its denominator.

Deep learning (DL) promises to transform the prediction industry from a stepping stone for academic promotion and tenure to something vaguely useful for clinicians at the patient’s bedside. Economists studying AI believe that AI is revolutionary, revolutionary like the steam engine and the internet, because it better predicts.

Recently published in Nature, a sophisticated DL algorithm was able to predict acute kidney injury (AKI), continuously, in hospitalized patients by extracting data from their electronic health records (EHRs). The algorithm interrogated nearly million EHRS of patients in Veteran Affairs hospitals. As intriguing as their methodology is, it’s less interesting than their results. For every correct prediction of AKI, there were two false positives. The false alarms would have made Cassandra blush, but they’re not bad for prognostic medicine. The DL- generated ROC curve stands head and shoulders above the diagonal representing randomness.

The researchers used a technique called “ablation analysis.” I have no idea how that works but it sounds clever. Let me make a humble prophesy of my own – if unleashed at the bedside the AKI-specific, DL-augmented Cassandra could unleash havoc of a scale one struggles to comprehend.

Leaving aside that the accuracy of algorithms trained retrospectively falls in the real world – as doctors know, there’s a difference between book knowledge and practical knowledge – the major problem is the effect availability of information has on decision making. Prediction is fundamentally information. Information changes us.

Academic Medicine and the Peter Principle

Oct 4, 2019• 3

By BEN WHITE, MD

Over four years of medical school, a one-year internship, a four-year radiology residency, a one-year neuroradiology fellowship, and now some time as an attending, one of my consistent takeaways has been how well (and thus how badly) the traditional academic hierarchy conforms to The Peter Principle.

The Peter Principle, formulated by Laurence J Peter in 1969, postulates that an individual’s promotion within an organizational hierarchy is predicated on their performance in their current role rather than their skills/abilities in their intended role. In other words, people are promoted until they are no longer qualified for the position they currently hold, and “managers rise to the level of their incompetence.”

In academic medicine, this is particularly compounded by the conflation of research prowess and administrative skill. Writing papers and even getting grants doesn’t necessarily correlate with the skills necessary to successfully manage humans in a clinical division or department. I don’t think it would be an overstatement to suggest that they may even be inversely correlated. But this is precisely what happens when research is a fiat currency for meaningful academic advancement.

The business world, and particularly the tech giants of Silicon Valley, have widely promoted (and perhaps oversold) their organizational agility, which in many cases has been at least partially attributed to their relatively flat organizational structure: the more hurdles and mid-level managers any idea has to go through, the less likely it is for anything important to get done. A strict hierarchy promotes stability primarily through inertia but consequently strangles change and holds back individual productivity and creativity. The primary function of managers is to preserve their position within management. As Upton Sinclair wrote in The Jungle: “It is difficult to get a man to understand something when his salary depends upon his not understanding it.” (which incidentally is a perfect summary of everything that is wrong in healthcare and politics).

Primary Care Is at the Center of a Health Revolution

Oct 2, 2019• 2

By KEVIN WANG, MD

If our urgent-care-as-healthcare culture isn’t killing us, it’s certainly wasting our time and resources.

Consider these facts highlighted by Advanced Medical Reviews, based on various studies:

U.S. physicians report that more than 20 percent of overall medical care is not needed.
The Congressional Budget Office recently estimated that up to 30 percent of the costs of medical care delivered in the U.S. pay for tests, procedures, doctor visits, hospital stays, and other services that may not actually improve patient health.
Unnecessary medical treatment impacts the healthcare industry through decreased physician productivity, increased cost of medical care, and additional work for front office staff and other healthcare professionals.

Most of today’s primary care is, in retail terms, a loss leader — a well-oiled doorway to the wildly expensive sick care system. For decades, practitioners have been forced into production factories, seeing as many patients, ordering as many tests, and sending as many referrals as possible to specialists. Patients, likewise, have avoided going in for regular visits for fear of the price tag attached, often waiting until they’re in such bad shape that urgent (and much more expensive) care is necessary.

The system as it stands isn’t delivering primary care in a way that serves patients, providers, employers, or insurers as well as it could. To improve health at individual and population levels, the system needs to be disrupted. Primary care needs to play a much larger role in healthcare, and it needs to be delivered in a way that doesn’t make patients feel isolated, neglected, or dismissed.

Luckily, primary care is making a comeback — the kind that doesn’t just treat symptoms, but sees trust, engagement, and behavior change as a path to health.

How are hospitals supposed to reduce readmissions? Part II

Oct 1, 2019

By KIP SULLIVAN, JD

The notion that hospitals can reduce readmissions, and that punishing them for “excess” readmissions will get them to do that, became conventional wisdom during the 2000s on the basis of very little evidence. The Medicare Payment Advisory Commission (MedPAC) urged Congress to enact the Hospital Readmissions Reduction Program (HRRP) beginning in 2007, and in 2010 Congress did so. State Medicaid programs and private insurers quickly adopted similar programs.

The rapid adoption of readmission-penalty programs without evidence confirming they can work has created widespread concern that these programs are inducing hospitals to increase utilization of emergency rooms and observation units to reduce readmissions within 30 days of discharge (the measure adopted by the Centers for Medicare and Medicaid Services [CMS] in its final rule on the HRRP), and this in turn may be harming sicker patients. Determining whether hospitals are gaming the HRRP and other readmission-penalty schemes by diverting patients to ERs and observation units (and perhaps by other means) should be a high priority for policy-makers. [1]

In Part I of this series I proposed to address the question of whether hospitals are gaming the HRRP by asking (a) does research exist describing methods by which hospitals can reduce readmissions under the HRRP and, in the event the answer is yes, (b) does that research demonstrate that those methods cost no more than hospitals save. If the answer to the first question is no, that would lend credence to the argument that the HRRP and other readmission-penalty schemes are contributing to rising rates of emergency visits and observation stays. If the answer to second question is also no, that would lend even more credence to the argument that hospitals are gaming the HRRP.

In Part I, I noted that proponents of readmission penalties, including MedPAC and the Yale New Haven Health Services Corporation (hereafter the “Yale group”), have claimed or implied that hospitals have no excuse for not reducing readmission rates because research has already revealed numerous methods of reducing readmissions without gaming. I also noted many experts disagree, and quoted a 2019 statement by the Agency for Healthcare Research and Quality that “there is no consensus” on what it is hospitals are supposed to do to reduce readmissions.

In this article, I review the research MedPAC cited in its June 2007 report to Congress, the report that the authors of the Affordable Care Act (ACA) cited in Section 3025 (the section that instructed CMS to establish the HRRP). In Part III of this series I will review the studies cited by the Yale group in their 2011 report to CMS recommending the algorithm by which CMS calculates “excess” readmissions under the HRRP. We will see that the research these two groups relied upon did not justify support for the HRRP, and did not describe interventions hospitals could use to reduce readmissions as the HRRP defines “readmission.” The few studies cited by these groups that did describe an intervention that could reduce readmissions:

Apply to Pilot your Tech and Transform Mental Health Services in California!

Oct 1, 2019

Health in 2 Point 00, Episode 96 | Amazon Care, Echo, OneDrop & more

Sep 30, 2019

Today on Health in 2 Point 00, Jess and I catch up on loads of news in health tech. In this episode, Jess asks me about Amazon Care, doing telehealth, house calls, urgent care, drug delivery for their employees—could it change health delivery? Also, Eko raises $20 million for their smart stethoscope; Bayer leads a $40 million round for OneDrop’s blood glucose meter; GoodRx buys telehealth company HeyDoctor; Rock Health investing $10M in InsideRx, and an undisclosed amount to Arine; and Peloton IPO’s today and everyone’s looking at it as a healthcare company (but no, it’s not). We end on some gossip, so tune in. —Matthew Holt