Stephanie Strong is the CEO of Boulder, which has been blazing a trail in the virtual treatment of substance use disorder. She left venture capital to start the company and has been steadily building its capabilities and reach. We talked in depth about how Boulder helps its patients, who are predominantly on Medicaid and in general tend–as you’d expect–not to have easy circumstances. One remarkable thing Stephanie has done is spearhead resistance to the DEA’s proposal to ban telehealth prescribing of the anti-addiction drug Buprenorphine. And it looks like that campaign has been successful. that alone will save many lives. Watch this interview of a young female CEO who is making a real difference, and totally impressing me in the process—Matthew Holt
About That New Generation of Clinicians
By KIM BELLARD
I saw a report last week – Clinician of the Future 2023 Education Edition, from Elsevier Health – that had some startling findings, and which didn’t seem to garner the kind of coverage I might have expected. Aside from Elsevier’s press release and an article in The Hill, I didn’t see anything about it. It’s worth a deeper look.
The key finding is that, although 89% say they are devoted to improving patients’ lives, the majority are planning careers outside patient care. Most intend to say in healthcare, mind you; they just don’t see themselves staying in direct patient care.
We should be asking ourselves what that tells us.
The report was based on a survey of over 2,000 medical and nursing students, from 91 countries, as well as two roundtable sessions with opinion leaders and faculty in the United States and United Kingdom. Since I’m in the U.S. and think most about U.S. healthcare, I’ll focus mostly on those respondents, except when they’re not split out or where the U.S. responses are notably different.
Overall, 16% of respondents said they are considering quitting their medical/nursing studies (12% medical, 21% nursing), but the results are much worse in the U.S, especially for medical students – 25% (nursing students are still 21%). That figure is higher than anywhere else. Globally, a third of those who are considering leaving are planning to leave healthcare overall; it’s closer to 50% in the U.S.
Tate Erlinger, vice president of clinical analytics at Elsevier, noted: “There were several things [that] sort of floated to the top at least that caught my attention. One was sort of the cost, and that’s not limited to the U.S., but the U.S. students are more likely to be worried about the cost of their studies.” Overall, 68% were worried about the cost of their education, but the figure is 76% among U.S. medical students (and for UK medical students).
Having debt from their education is a factor, as almost two-thirds of nursing students and just over half of medical students are worried about their future income as clinicians, with U.S. medical students the least worried (47%).
It’s worth noting that 60% are already worried about their mental health, and the future is daunting: 62% see a shortage of doctors within ten years and 64% see a shortage of nurses. Globally, 69% of students (65% medical, 72% nursing) are worried about clinician shortages and the impact it will have on them as clinicians.
Where it gets really interesting is when asked: “I see my current studies as a stepping-stone towards a broader career in healthcare that will not involve directly treating patients.” Fifty-eight percent (58%) agreed (54% medical, 62% nursing). Every region was over 50%. In the U.S., the answer was even higher – 61% overall (63% medical, 60% nursing).
Dr. Sanjay Desai, one of the U.S. roundtable panelists, said: “I know this might evolve as they go through their education, but 6 out of 10 in school, when we hope that they’re most excited about that career, are looking at it with skepticism. That is surprising to me.”
Me too.
Continue reading…Joanna Strober, CEO, Midi Health
Women’s health in their mid-life has been very poorly treated. No one has been managing all of women’s health, and almost no one has been delivering hormone replacement therapy since a now debunked 2002 study. Midi is a new company with protocols for many conditions, and it has been training NPs to deliver the care (because no one has been training them!). CEO Joanna Strober explained how Midi is providing care in 14 states now and will be in all 50 next year, and how Midi is delivering virtual and comprehensive care to women–many of whom do not have access to any other type of regular care. They just raised another $25m from GV (Google) & others–Matthew Holt
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.
- 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.
- Health Technology and AI Substitution – Rather than engineering solutions to expand real-time patient contact, most innovations are further distancing patients from healthcare professionals.
- 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.
Continue reading…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.
Continue reading…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.
Continue reading…
