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Category: Medical Practice

Robin Berzin, CEO & Founder, Parsley Health

Robin Berzin used to work with me at Health 2.0 , as well as combining her medical training with lots of media production and other work. Fast forward a decade and Robin has left the rest of us in the dust. She’s now the Founder and CEO of Parsley Health, which is a really innovative primary care++ clinic that is based on the foundations of functional medicine, and is having tremendous success treating and transforming the lives of thousands of patients who were not getting what they needed from the traditional health care syste,. Now Parsley is aggressively moving into the employer market. I caught up with Robin at the recent HLTH conference.–Matthew Holt

Fay Rotenberg, CEO, Firefly Health

Fay Rotenberg is CEO of Firefly Health, which is an advanced virtual primary care group (a bastardized phrase she hates). That means they are both providing virtual care, with an integrated care and health plan coverage model, and are also a risk-bearing medical group working with other payers. They adjust the model using health guides, MDs, NPs, etc. and they help their patients manage their in person experience with specialists, labs, imaging, etc. — they have 1900+ partners nationwide who will actually know the patient is coming, and is integrated into Firefly’s model. Clinical outcomes are great, and costs are 12-15% lower, yet they have 5,000 members per MD. Maybe it really is the 21st century Kaiser?

“Doomscrolling” – Call the doctor!

by MIKE MAGEE

Exactly 1 year ago, mental health experts alerted the medical world to their version of an assessment scale for yet another new condition – “doomscrolling.”

As defined in the article, “Constant exposure to negative news on social media and news feeds could take the form of ‘doomscrolling’ which is commonly defined as a habit of scrolling through social media and news feeds where users obsessively seek for depressing and negative information.”

No one can deny a range of legitimate concerns. Faced with continued background noise from the pandemic, add global warming, renegade AI, and the Republican Congress. And now, the devastating attacks on Israel and growing instability in the Middle East. It is no wonder that we can’t turn off the Instagram feed.

With real challenges like these, our troubled world needs her doctors and nurses to stay focused more than ever on their primary professional missions – managing health and wellness, sickness and disease, fear and worry, and yes, now “doomscrolling.”

John J. Patrick PhD, in his book Understanding Democracy, lists the ideals of democracy to include “civility, honesty, charity, compassion, courage, loyalty, patriotism, and self restraint.” The 4.2 million registered nurses and 1 million doctors in America are agents of democracy.

Regrettably, they are already being drawn away from patients by three powerful forces.

  1. Corporate Dislocation – To assure maximum reimbursement, doctors and nurses are routinely asked to prioritize time and contact with data over time and access to patients.
  2. Health Technology and AI Substitution – Rather than engineering solutions to expand real-time patient contact, most innovations are further distancing patients from healthcare professionals.
  3. Legislative Intrusion – Complex medical decisions, long entrusted to the patient-health professional relationship to negotiate, are being transferred to ultra-conservative legislators.

We live under a constitutional and representative democracy, as do two-thirds of our fellow citizens in over 100 nations around the world. The health of these democracies varies widely. The case for democracy emphasizes its capacity to enhance dignity and self-worth, promote well-being, advance equal opportunity, protect equal rights, advance economic productivity, promote peace and order, resolve conflicts peacefully, hold rulers accountable, and achieve legitimacy through community-based action.

One of the challenges of democracy is to find the right balance in pursuing “the common good” which has dual (and often competing) arms. One arm is communitarian well-being and the other, individual well-being.

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Alex Katz, CEO, Two Chairs

Two Chairs has an interesting model. Their concept is to find the right therapist for you, and they actually start a patient off with a therapist who diagnoses AND directs in a session, separate from the one who treats. Once the “right” match is made, the patient gets set up with a therapist and the results have been pretty good in terms of the patient coming back–one of a number of things Two Chairs measures rather intently! CEO Alex Katz explained the model and the business–Matthew Holt.

Beyond the Scale: How organizations should evaluate the success of obesity management solutions

By CAITLYN EDWARDS

Obesity treatment is often framed as a race to the bottom — how much weight can someone lose? Five percent? Ten percent? And with recent scientific advancements in anti-obesity medications such as GLP-1s, what about even 15-20%?

Obesity treatment, though, isn’t just about the number on the scale. It’s about moving the needle on biomarkers that really matter to overall health. Seven out of the top ten leading causes of death and disability in the United States today are chronic diseases that have links to overweight and obesity. The metabolic benefits of just 5% weight loss can be life-changing for many people with obesity-related comorbidities. This means that for organizations looking to treat their chronic conditions, obesity care shouldn’t be all about striving for the lowest possible weight.

Indeed, consensus and practice statements from groups including the American Heart Association, the American College of Cardiology, the American Diabetes Association, and The Obesity Society, support weight loss programs that achieve clinically significant weight loss outcomes, defined as greater than or equal to 5% of an individual’s baseline body weight. This number is derived from decades of research demonstrating that even modest weight loss has impacts on physiological health including type 2 diabetes, dyslipidemia, hypertension, and many kinds of cancer.

People who attain just 5% weight loss see the following health improvements:

  • Reductions in systolic and diastolic blood pressure
  • Risk reductions of developing type 2 diabetes by almost 60%
  • Reductions in HbA1c and fasting blood glucose levels
  • Greater insulin sensitivity
  • Decreased need for newly prescribed diabetes, hypertension, and lipid-lowering medications

Understanding that obesity outcomes include more than just the number on the scale, how can benefit managers and health plan leaders measure success? Here are some things organizations should look for when evaluating an obesity management solution:

N-size of outcomes

While a high weight loss average may sound impressive, it doesn’t tell the whole story. A better measure might be the number of people in a program able to achieve greater than 5% weight loss. The fact is that weight loss averages are easily skewed by outliers.  An exceptionally high average may not be representative of what is actually taking place at the individual level. What matters is that a large percentage of people in the program are able to see clinically significant results.

Emphasis on behavior change

Another way to measure the success of an obesity management solution is by the sustainability of its outcomes — primarily through adopting healthier behaviors. Intensive behavioral therapy is crucial to obesity treatment and can reduce the risk of type 2 diabetes. Support from expert dietitians and coaches can help promote a healthy relationship with food for optimal weight loss.

Through medical nutrition therapy, dietitians create personalized calorie and macronutrient goals to foster weight loss in a healthy, sustainable way. Also, self-directed cognitive behavioral therapy can help people become more aware of underlying thoughts and behavior patterns around food.

Step therapy approach to treatment

Some obesity management solutions avoid medications entirely while others rely solely on expensive GLP-1s. But both of those methods fall short of providing the best care to the most people at the lowest cost possible.

The best obesity management solutions take a clinically rigorous step-therapy approach to treatment. This way, they carefully manage access to expensive anti-obesity medications while achieving meaningful outcomes. Many of their members will achieve clinically significant weight loss through behavior change alone. Some may need a boost from lower-intensity, lower-cost anti-obesity medications to reach their goals. Others, with severe obesity or multiple cardio-metabolic conditions, may require higher-intensity anti-obesity medications like GLP-1s. Treatment levels can be safely tried in succession with needs and costs in mind.

It’s likely only 5-10% of a given population would end up using GLP-1s with this step-therapy approach, while the majority of people would still get clinically meaningful results without such intensive treatment.

Address SDOH to personalize care

One-size-fits-all solutions — like those that insist on a highly restrictive diet — miss the mark on health equity. Not everyone can afford expensive meat-heavy diets and they don’t always line up with people’s cultural preferences. Similarly, a program that simply doles out GLP-1s without helping people manage side effects doesn’t work and will only drain budgets.

The key to unlock improved outcomes is by helping people address SDOH challenges like food insecurity, language barriers, cultural factors, physical environment, and more. A good obesity solution should expand access to bilingual registered dietitians who are trained in dietary considerations and eating patterns for many different cultures and ethnic groups. They can help folks plan meals around limited budgets and specific dietary needs.

Conclusion

Organizations have much to consider when evaluating obesity solutions for their population. It’s easy to be swayed by simple metrics that seem indisputable. But, in the end, outcomes like 5% weight loss and reductions in HbA1c for the majority of an eligible population are what counts. Sustainable outcomes rely on real behavior change, a careful step-therapy approach to medication, and personalized care when it comes to social determinants of health.

Caitlyn Edwards, PhD, RDN, is a Senior Clinical Research Specialist at Vida Health

All the Lonely People: Primary Care isn’t a Team Sport Anymore, We’re Only Interacting with Our Computers

BY HANS DUVEFELT

In spite of all the talk these days about health care teams and in spite of more and more physicians working for bigger and bigger healthcare organizations, we are becoming more and more isolated from our colleagues and our support staffs.

Computer work, which is taking more and more time as EMRs get more and more complex, is a lonely activity. We are not just encouraged but pretty much forced to communicate with our nurses and medical assistants through computer messaging. This may provide more evidence of who said or did what at what point in time, but it is both inefficient and dehumanizing.

Why do people who work right next to each other have to communicate electronically? Why can’t my nurse simply ask me a question and then document “Patient asked whether to take aspirin or Tylenol and I told her that Dr. Duvefelt advised up to 2,500 mg acetaminophen/24 hours”. It would be a lot less work for me, even if I have to sign off on the darn thing.

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How to Talk to a Doc

BY KIM BELLARD

For better and for worse, our healthcare system is built around physicians. For the most part, they’re the ones we rely on for diagnoses, for prescribing medications, and for delivering care.  And, often, simply for being a comfort.  

Unfortunately, in 2023, they’re still “only” human, and they’re not perfect. Despite best intentions, they sometimes miss things, make mistakes, or order ineffective or outdated care. The order of magnitude for these mistakes is not clear; one recent study estimated 800,000 Americans suffering permanent disability or death annually.  Whatever the real number, we’d all agree it is too high.   

Many, myself included, have high hopes that appropriate use of artificial intelligence (AI) might be able to help with this problem.  Two new studies offer some considerations for what it might take.

The first study, from a team of researchers led by Damon Centola, a professor at the Annenberg School for Communication at the University of Pennsylvania, looked at the impact of “structured information–sharing networks among clinicians.”  In other words, getting feedback from colleagues (which, of course, was once the premise behind group practices). 

Long story short, they work, reducing diagnostic errors and improving treatment recommendations.  

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Outpatient Vascular Care: Good, bad or ugly?

BY ANISH KOKA

Filling in the holes of recent stories in the New York Times, and Propublica on the outpatient care of patients with peripheral arterial disease

Most have gotten used to egregiously bad coverage of current events that fills the pages of today’s New York Times, but even by their now very low standards a recent telling of a story about peripheral artery disease was very bad.

The scintillating allegation by Katie Thomas, Jessica Silver-Greenberg and Robert Gebeloff is that “medical device makers are bankrolling doctors to perform artery clearing procedures that can lead to amputations”.

The reporters go on to tell a story about patient Kelly Hanna, who presented to a physician, Dr. Jihad Mustapha, in a private clinic with a festering wound. After being diagnosed with a poor flow to her leg that was likely contributing to the wound, Dr. Mustapha performed multiple procedures on her leg to improve blood flow in an attempt to ward off a future amputation. The procedures were unsuccessful, and Ms. Hanna ultimately did need an amputation.

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Truthfully, the Physician Shortage Doesn’t Exist!

BY HANS DUVEFELT

Conclusion: For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work. (Sinsky et al, 2016)

If we only had the tools and the administrative support that just about every one of us has been asking for, there wouldn’t be a doctor shortage.

The quote here is from 7 years ago and things have gotten even worse since then.

Major league baseball players don’t handle the scoring and the statistics of their games. They just play ball.

Somehow, when the practice of medicine became a corporate and government business, more data was needed in order to measure productivity and quality (or at least compliance with guidelines). And somehow, for reasons I don’t completely understand and most definitely don’t agree with, the doctors were asked not only to continue treating our patients, but also to more than double our workload by documenting more things than we ourselves actually needed in order to care for our patients. Even though we were therefore becoming data collectors for research, public health and public policy, we were not given either the tools or the time to make this possible – at least not without shortchanging our patients or burning ourselves out.

We didn’t sign up to do all this, we signed up to care for our patients. And we were given awkward tools to work with that in many ways have made it harder to document and share with our colleagues what our clinical impressions and thinking are.

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Reviewing the all-in-pod heart health segment

BY ANISH KOKA

The All-in podcast is a fairly popular show that features successful silicon valley investors commenting about everything worth commenting on from politics to health. The group has good chemistry and interesting insights that breaks the mold of the usual tribal politics that controls legacy media analysis of current events.

Last week, the podcast touched on a topic I spend a fair amount of time on: Cardiology.

Brad Gerstner, who is actually a guest host for this particular episode starts off by referencing something called Heartflow to evaluate the heart that has been recommended by one of the other hosts: Chamath Palihapitiya. Brad apparently asked his primary care physician about Heartflow and was instead directed to get a calcium scan.

Heartflow is a proprietary technology that purports to evaluate the presence of significant narrowing in the coronary arteries just by doing a heart CT scan. A calcium score is a low-dose CT scan used to identify the presence of calcium in coronary vessels.

The segment ends with a recommendation for everyone over the age of 40 to get some type of heart scan, so I thought it would be worth reviewing some of the main claims.

Question 1. Does Brad need a calcium scan?

Brad notes that his primary care physician told him he was young, fit, and had a low bad cholesterol (LDL) and needed a calcium scan rather than a heart flow scan. The answer to this question and the questions to follow depend on what outcome Brad is looking for. If the goal is to feel happier knowing if he has coronary calcium than the resounding answer is to get the calcium scan. But if the goal is to live longer and healthier, there is nothing to suggest a calcium scan will help. Most cardiologists believe that the lower the LDL, the better cardiovascular outcomes are. So if a calcium scan convinces Brad to NOT lower his LDL further either naturally or with medications, a calcium scan may be detrimental.

We have zero evidence to suggest patients who get calcium scans lower their risk of future mortality.

Question 2. Does Brad need a Heartflow scan?

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