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Category: Medical Practice

US Cardiac electrophysiologists meet reimbursement reality and don’t like it.

By ANISH KOKA

It’s been a while but Anish Koka, a one time regular writer on THCB and occasional THCB Gang member, is back publishing up a storm on his Substack channel. You may recall that his political and clinical views don’t always mesh with some of the wooly liberals we feature on THCB (cough, cough, me), but we are delighted to be back publishing some of his pieces–this one is on reimbursement.–Matthew Holt

The subspecialty of Cardiology known as electrophysiology has seen explosive growth over the last few decades in large part because of a massive expansion in the suite of procedures now offered to patients. It used to be that electrophysiologists would spend the majority of their careers implanting pacemakers and defibrillators, but the last 2 decades saw an explosion in electrophysiology procedures known as ablations. Ablations essentially involve burning cardiac tissue in a strategic manner to get rid of arrhythmias that may be afflicting a particular patient. The path humans took from first taking an electrical picture of the heart with a surface ECG to putting catheters into the heart to map and treat dangerous arrhythmias is one of the great achievements of the modern era.

Giants of the field like the recently deceased Mark Josephson essentially created a field by going where no humans had gone before. Dr. Josephson did much of his work in Philadelphia at the University of Pennsylvania publishing seminal papers that lead to a greater understanding and eventual treatment of previously incurable malignant arrhythmias. As is true of all trailblazing work in medicine , there were no reimbursement codes in the beginning , just desperate patients with no place to turn.

The procedures being embarked on were rare and the patients were very complex. The renumeration that was awarded from Medicare was reflective of this. But two things almost always happen once a highly reimbursed procedure code comes on line – technological advances makes the procedure easier, and the population that the procedure is intended for massively balloons.

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Matthew’s health care tidbits: Texas is the present future of abortion care

Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

In this edition’s tidbits, I have to return to the stunning impact of the Dobbs ruling. We know will happen because it is already happening in Texas where the 6 week law was already being enforced in contravention of Roe v Wade.

Taxpayer money is going to “pregnancy crisis centers” that flat out lie to vulnerable patients about the impact of abortions on their health. Doctors are questioning women who have miscarried–at a moment that is already terrible for them, and women who have miscarried are being denied basic D&Cs–which can kill them.

Don’t get me started on the absolute nonsense being talked–and passed into law –about ectopic pregnancies, of which there are over 130,000 each year in the US, being carried to term. How unlikely is it that an ectopic pregnancy makes it to term with no ill effects? Let me tell you a story. My dad was an OBGYN. He and his anesthetist saved the life of a woman and her baby who somehow had made it to term while being ectopic. During the surgery she needed 12 pints of blood (a normal woman has 7-8 pints in her body) and he considered it the greatest piece of surgery he did in his entire career. He thought that he and the patients were very lucky. So I demand that crazy legislation saying ectopic pregnancies have to be carried to term also mandates that my dad is around to do every single C-Section. Unlikely, as he’s dead, but no crazier than the legislation in Indiana.

Then there’s the impact on telehealth. Most abortions are done using drugs but more and more of the pandemic-era exemptions to prescribing drugs and seeing patients over telehealth across state lines are being withdrawn. Clearly the state-based licensing of doctors is itself ridiculous in an age of online commerce, but despite the DOJ statements the legality of prescribing abortifacients across state lines is very unclear and, as Deven McGraw explained in this harrowing piece on THCB Gang, HIPAA doesn’t protect patient privacy from local law enforcement. So what happens to someone in a state where abortion is banned if they have to go to hospital because of a complication from taking an abortifacient? Trump thinks they should go to jail.

What is clear is that bans on abortion don’t stop abortions. But they do endanger women. And if the pregnancy crisis center stops a woman from getting an abortion, do they help afterwards? Why yes, if you mean by “helping”, they have a celebratory dinner and light a fricking candle.

Matthew’s health care tidbits: Is Covid over for the health care system?

Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

I am beginning to wonder, is COVID over? Of course no one has told the virus that it’s over. In fact infection rates are two to three times where they were in the post-omicron lull and new variants are churning themselves out faster and faster. We still have 300 people dying every day. But since we went past a million US deaths, no one seems to care any more.

For the health care system, COVID being over means a chance to get back to normal, and normal ain’t good. Normal means trying to get rid of that pesky telemedicine and anything else that came around since March 2020.The incumbents want to remove the public health emergency that allowed telemedicine to be paid for by Medicare, re-enforce the Ryan Haight act which mandates in-person visits for prescribing controlled Rx like Adderall for ADHD, and make sure that tortuous state license requirements for online physicians are not going away. This also means restrictions on hospital at home, and basically delays any other innovative way to change care delivery. Well, it was all so perfect in February 2020!

But there is one COVID related problem that doesn’t seem to be going away. People. They’re just not going back to work and nurses in particular are resisting the pull of the big hospitals. I don’t know the end game here, but there is a clue in the “return to office” data. Basically every large city is below 50% of its office space being occupied and companies are having to figure out a hybrid model going forward, no matter how much Elon Musk objects.

Hospitals aren’t going willingly into the night. The big systems still control American health care, and are prepared to fight on all fronts to keep it that way. But like office workers, nurses and doctors want a different life. The concept of virtual-first, community-based, primary care-led health care has been around for a long while and been studiously ignored by the majority of the system.

If hospitals can’t get the staff and keep losing money employing the ones they have, there will be new solutions being offered to clinicians wanting a different life-style. We just might see a different approach to health care delivery rising phoenix-like from the Covid ashes.

Matthew’s health care tidbits: Hospital shooting reveals so much

Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

In this edition’s tidbits, the nation is once again dealing with an epidemic of shootings. Now a hospital joins schools, grocery stores and places of worship on the the recent list. I was struck by how much of the health care story was wrapped up in the tragic shooting where a patient took the life of Dr. Preston Phillips, Dr. Stephanie Husen, receptionist Amanda Glenn, 40; and patient William Love at Saint Francis Health System in Tulsa.

First and most obvious, gun control. The shooter bought an AR-15 less than 3 hours before he committed the murders then killed himself. Like the two teens in Buffalo and Uvalde, if there was a delay or real background checks, then these shootings would likely have not happened.

But there’s more. Hospital safety has not improved in a decade or so. Michael Millenson, THCB Gang regular, has made that plain. And that includes harm from surgery. We know that back surgery often doesn’t work and we know that Dr Phillips operated on the shooter just three weeks before and had seen him for a follow up the day before. Yes, there is safety from physical harm and intruders–even though the police got there within 5 minutes of shots being heard, they were too late. But there is also the issue of harm caused by medical interventions. Since “To Err is Human” the issue has faded from public view.

Then there is pain management. Since the opiate crisis, it’s become harder for patients to get access to pain meds. Was the shooter seeking opiates? Was he denied them? We will never know the details of the shooter’s case, but we know that we have a nationwide problem in excessive back surgery, and that is matched by an ongoing problem in untreated pain.

And then there are the two dead doctors. Dr. Husen, was a sports and internal medicine specialist. Obviously there are more female physicians than there used to be even if sexism is still rampant in medicine. But Dr. Phillips was an outlier. He was black and a Harvard grad. Stat reported last year that fewer than 2% of orthopedists are Black, just 2.2% are Hispanic, and 0.4% are Native American. The field remains 85% white and overwhelmingly male. So the chances of the patient & shooter, who was black and may have sought out a doctor who looked like him, having a black surgeon were very low in the first place. Now for other patients they are even lower.

The shooting thus brings up so many issues. Gun control; workplace safety; unnecessary surgery; pain management; mental health; and race in medicine. We have so much to work on, and this one tragedy reveals all those issues and more.

Matthew’s health care tidbits: Digital Health is dead (well, not quite)

Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

For today’s health care tidbits, the elephant in the room has truely come home to roost, and now it’s landed on the phone wire, it’s close to breaking it. OK, I have stretched that metaphor to death but you’ll get my point. Writing on THCB earlier this month Jeff Goldsmith and Eric Larsen picked up on something I’ve been saying for a while –the fall in valuation of publicly traded digital health companies will have a knock effect on private companies

It took a while–those public companies stock prices started falling from their heights 14 months ago–but in the last month the venture capital scene has gone quiet. The days of sub $20m ARR companies getting mutli-hundred million dollar valuations are over for now. They will be back at some point in the future, as that’s how Silicon Valley has always worked, but it’ll be a while and in the meantime everyone is going to have to figure out what to do in the new world.

The “What to do?” question is getting harder as the data starts to come in, and it’s getting ugly. On the one hand the two fastest growing digital health companies ever have both had their comeuppance. Livongo was a tremendous exit for its investors and ended up trading at 20 times future revenue before it got acquired by Teladoc for $18bn mostly in stock. This quarter Teladoc wrote off much of its investment in Livongo and the whole company is now only worth $5bn. Clearly those “synergies” between telehealth and chronic care management didn’t work. The other rocket ship was Cerebral, which went from nothing in Jan 2020 to by Jan 2022 having over 100,000 patients and thousands of providers on its system as it raised over $300m from Softbank et al. Its aggressive & expensive customer acquisition costs, with its controversial controlled medication prescribing patterns, brought it way too much controversy. Its young CEO is gone, and it’ll be a slow climb back with bankruptcy and collapse the likeliest of outcomes.

But the part of digital health that’s trying to replace the incumbents is not the only place showing ugliness. The technologies and services being rolled out are often not working. Exhibit A is a randomized controlled trial conducted a Univ of Pennsylvania. One set of heart patients was set up with connected blood pressure cuffs, a pillbox that tracked their Rx adherence and lots of coaching help. The others were sent home with the proverbial leaflet and told to call if they had problems. You’d assume many more deaths and hospital readmissions in the second group. You’d be wrong. There were no differences.

So digital health needs to see if it can produce services companies that move the needle on costs and outcomes. The advantage is that they are eventually competing with hospital systems whose DNA doesn’t allow them the ability to let them cross the chasm to the new world. The bad news is that those systems have huge reserves which they can use to subsidize their old world activities.

I’m hoping digital health’s impact in the next 2 years will be as big as it was in the past 2, It’s by no means dead or over, but I am pessimistic.

Health Care Through the Back Door: The Dangers of Nurse Visits

By HANS DUVEFELT

In some practices, patients with seemingly simple problems are scheduled to be seen by a nurse or medical assistant. Sometimes they can even just drop off a urine sample in case of a suspected urinary tract infection.

This is a dangerous trap. What if the patient rarely gets urinary infections, has back pain and assumes it is a UTI instead of a kidney stone or shingles on their back just where one kidney is located; what if they have lower abdominal pain from an ovarian cyst or an ectopic pregnancy?

Another dangerous type of “nurse visit” is when patients focus on one symptom or parameter, thinking for example that as long as their blood pressure is okay, their vague chest pressure with sweating and shortness of breath isn’t anything serious. It’s one thing if I want a couple of blood pressure checks by my nurse, but a whole different thing when it is the patient’s idea, assumption or self diagnosis.

In many cases, a telephone call with the provider or a triage nurse can be safer and more diagnostic than starting with a nurse visit. Because the symptom history is usually more important when making a diagnosis. And nurse visits tend to be skimpy when it comes to the clinical history, even though the provider assumes responsibility for the diagnosis and treatment of a patient they didn’t talk to or examine.

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Matthew’s health care tidbits: Hospital System Concentration is a Money Machine

Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

For today’s health care tidbits, there’s an old chestnut that I can’t seem to stay away from. I was triggered by three articles this week. Merril Goozner on GoozNews looked at the hospital building boom. Meanwhile perennial favorite Sutter Health and its price-making ability came up in a report showing that 11 of the 19 most expensive hospital markets were in N. Cal where it’s dominant. Finally the Gist newsletter pointed out that almost all the actual profits of the big health systems came from their investing activities rather than their operations.

None of this is any great surprise. Over the past three decades, the big hospital systems have become more concentrated in their markets. They’ve acquired smaller community hospitals and, more importantly, feeder systems of primary care doctors. Meanwhile they’ve cut deals with and acquired specialty practices. For more than two decades now, owned-physicians have been the loss leader and hospitals have made money on their high cost inpatient services, and increasingly on what used to be inpatient services which are now delivered in outpatient settings at essentially inpatient rates. Prices, though, have not fallen – as the HCCI report shows.

Source: HCCI

The overall cost of care, now more and more delivered in these increasingly oligopolistic health systems, continues to increase. Consequently so do overall insurance premiums, costs for self insured employers and employees, and out of pocket costs. And as a by-product, the reserves of those health systems, invested like and by hedge funds, are increasing–enabling them to buy more feeder systems.

Wendell Potter, former Cigna PR guy and now overall heath insurer critic, wrote a piece this week on how much bigger and more concentrated the health plans have become in the last decade. But the bigger story is the growth of hospital systems, and their cost and clout. Dave Chase likes to say that America has gone to war for less than what hospitals have done to the American economy. That may be a tad hyperbolic, but no one would rationally design a health care environment where non-profit hospitals are getting bigger and richer, and don’t seem to be able to restrain any aspect of their growth.

Hospital Systems: A Framework for Maximizing Social Benefit

By JEFF GOLDSMITH and IAN MORRISON

Hospital consolidation has risen to the top of the health policy stack. David Dranove and Lawton Burns argued in their recent Big Med:  Megaproviders and the High Cost of Health Care in America (Univ of Chicago Press, 2021) that hospital consolidation has produced neither cost savings from “economies of scale” nor measurable quality improvements expected from better care co-ordination. As a consequence, the Biden administration has targeted the health care industry for enhanced and more vigilant anti-trust enforcement.

However, as we discussed in a 2021 posting in Health Affairs, these large, complex health enterprises played a vital role in the societal response to the once-in-a-century COVID crisis. Multi-hospital health systems were one of the only pieces of societal infrastructure that actually exceeded expectations in the COVID crisis. These systems demonstrated that they are capable of producing, rapidly and on demand, demonstrable social benefit.

Exemplary health system performance during COVID begs an important question: how do we maximize the social benefits of these complex enterprises once the stubborn foe of COVID has been vanquished? How do we think conceptually about how systems produce those benefits and how should they fully achieve their potential for the society as a whole?

Origins of Hospital Consolidation

In 1980, the US hospital industry (excluding federal, psych and rehab facilities) was a $77 billion business comprised of roughly 5,900 community hospitals. It was already significantly consolidated at that time; roughly a third of hospitals were owned or managed by health systems, perhaps a half of those by investor-owned chains. Forty years later, there were 700 fewer facilities generating about $1.2 trillion in revenues (roughly a fourfold growth in real dollar revenues since 1980), and more than 70% of hospitals were part of systems. 

It is important to acknowledge here that hundreds more hospitals, many in rural health shortage areas or in inner cities, would have closed had they not been rescued by larger systems. Given that a large fraction of the hospitals that remain independent are tiny critical access facilities that are marginal candidates for mergers with larger enterprises, the bulk of hospital consolidation is likely behind us. Future consolidation is likely not to be of individual hospitals, but of smaller systems that are not certain they can remain independent. 

Today’s multi-billion dollar health systems like Intermountain Healthcare, Geisinger, Penn Medicine and Sentara are far more than merely roll-ups of formerly independent hospitals. They also employ directly or indirectly more than 40% of the nation’s practicing physicians, according to the AMA Physician Practice Benchmark Survey. They have also deployed 179 provider-sponsored health plans enrolling more than 13 million people (Milliman Torch Insight, personal communication 23 Sept, 2021). They operate extensive ambulatory facilities ranging from emergency and urgent care to surgical facilities to rehabilitation and physical therapy, in addition to psychiatric and long-term care facilities and programs.

Health Systems Didn’t Just “Happen”; Federal Health Policy Actively Catalyzed their Formation

Though many in the health policy world attribute hospital consolidation and integration to empire-building and positioning relative to health insurers, federal health policy played a catalytic role in fostering hospital consolidation and integration of physician practices and health insurance. In the fifty years since the HMO Act of 1973, hospitals and other providers have been actively encouraged by federal health policy to assume economic responsibility for the total cost of care, something they cannot do as isolated single hospitals.

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BREAKING at ViVE: Jenny Schneider on Launch of New Biz, Homeward

by JESSICA DAMASSA, WTF HEALTH

BREAKING! Livongo-famous Jenny Schneider stops by to talk to us first, on-site at ViVE in Miami, about the brand-new business she’s just launched today to “rearchitect” rural health and care. Called Homeward, the startup is coming out with a $20 million Series A backed by General Catalyst, and a novel model that will integrate virtual-and-in-person primary care and cardiology care for Medicare beneficiaries in rural markets. We get into the business model, care model, some shocking statistics about just how dire the market need is, AND all the gossip about the old friends she’s bringing into the business with her. PLUS: Bonus dishing on Glen Tullman’s new business Transcarent, and what connection Homeward might have to the SPAC that Jenny co-founded with Glen, Hemant Teneja and Steve Klasko of General Catalyst. Coming at you fast with this one!

How to Talk to Clinicians: Forget Workflows, Just Tell Us How Things Work

BY HANS DUVEFELT

Workflows are all the rage with EMR people. But doctors, NPs and PAs are smart. Nothing burns us out as fast or as completely as being told how to do things instead of why. We are not circus animals.

Let me explain:

If we had no professional education at all, we would have clinical workflows memorized instead of clinical knowledge. For example, two weeks after starting an ACE inhibitor like lisinopril, order a basic metabolic profile. That sounds pretty straightforward, but if you add up all the possible clinical workflows we would need if we didn’t know medicine at all, that would be a huge burden – a massive amount of seemingly random and senseless rules.

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