As U.S. providers continue their slow but steady march away from fee-for-service reimbursement and toward value-based payments, they’re increasingly seeking means of addressing patients’ health-related social needs. That’s because social determinants of health—life circumstances including socioeconomic status, housing, education, and employment—are estimated to have at least twice the impact on risk of premature death than health care. So addressing them is an important part of value-based strategies aiming to improve health while reducing health care costs.
Hennepin Health, a safety-net Accountable Care Organization (ACO) serving Medicaid patients in Minneapolis, Minnesota, is an encouraging example of the trend. Hennepin Health’s ACO is a partnership between the county’s local Human Services and Public Health Department, a local teaching hospital, a Medicaid managed care health plan, and a Federally Qualified Health Center. Its innovative care model is designed to meet the unique needs of the partners’ shared, “high-risk” members, whose complex combination of issues—such as mental illness, addiction, homelessness and/or other hallmarks of social deprivation—often prevent them from accessing or receiving appropriate care through the traditional health system.
The ACO is staffed by an integrated care team comprised of
physicians, nurses, pharmacists, social workers and community health workers.
Unlike traditional care processes, which often only involve medical assessment,
Hennepin Health’s begins with an assessment of members’ social needs, like
housing and food insecurity, or lack of transportation and unemployment, so
that its care team can tackle those barriers to health in conjunction with
members’ medical problems. And throughout members’ care, the team strives to
develop and maintain a trusting relationship with members, many of whom have
been let down by traditional health care, so that they can continue to identify
and assist with more health and social needs over time.
Results thus far has been impressive—according to a Commonwealth Fund case study, the ACO’s medical costs fell an average of 11% per year between 2012 and 2016. And, between 2012 and 2013, its members’ emergency room visits decreased by approximately 9%, with hospital admissions remaining flat and outpatient visits increased by 3.3%. Assuming its results have continued on the same trajectory (we could not find more recent figures), Hennepin Health’s innovative care model shows significant promise.
But does it have the potential to disrupt America’s traditional, episodic, acute care delivery model? We put it to the test with six questions for identifying a Disruptive Innovation.
What are the challenges of bringing advanced imaging services to India? What motivates an entrepreneur to start build an MRI service? How does the entrepreneur go about building the service? In this episode, I discuss radiology in India with Dr. Harsh Mahajan, Dr. Vidur Mahajan and Dr. Vasantha Venugopal. Dr. Harsh Mahajan is the founder of Mahajan Imaging, a leading radiology practice in New Delhi, and now a pioneer in radiology research in India.
Listen to our conversation on Radiology Firing Line Podcast here.
Saurabh Jha is an associate editor of THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partner.
Well, you might not have noticed that my blogs were missing for the last three months but anyways, its good to be back. I was having a little time off blogs and social media as I was transitioning in my career but now I am back. Sometimes, it is very difficult to manage time for things that you must do versus things you enjoy doing, especially when these two don’t intersect. For me, these last few months the things I had to do were all bureaucratic while I couldn’t find the time for things I enjoy doing like writing these blogs. But now that we are back, let’s recap what has happened in the oncology world in the year 2019 so far. I can’t cover all of them, but will try to summarise the major events in oncology.
Hundred Foxes’ Howl versus One LION’s Roar
In my country, there is a saying that goes somewhat like the roar of one lion will scare hundreds of howling foxes away. In medicine, I guess, it translates as one good RCT trumps the results from hundreds of observational studies. For patients with advanced ovarian cancer, primary surgery to achieve complete resection is the most important treatment and prognostic factor. However, what to do with the lymph nodes is a question that has troubled the oncology community for a long time. Logically, it makes sense to remove the lymph nodes too because they are the sanctuary sites for cancer cells. However, lymph node dissection carries high morbidity. Although multiple observational studies suggested a survival benefit with lymph node dissection, the LION trial, now published in the NEJM, shows that for women with macroscopic complete resection of primary tumour, lymph node dissection increases morbidity (postoperative complications) and post-operative mortality rates but doesn’t improve survival. I am glad that this trial was carried out and these results will now save many women with ovarian cancer worldwide from unnecessary harmful procedures, but I am also sad that we didn’t answer this question until now and thus, many patients suffered unnecessarily. I hope this LION’s roar scares us from jumping to conclusions based on logic or observational data alone and without RCT evidence in future. Another lesson here is the importance of public funds in supporting RCTs like these.
Every year at this time, you hear warnings that flu season has arrived. New data from the CDC indicates the season is far from over. So, you are urged by health authorities to get a flu shot. What you may not realize is how the flu can affect the hospitals you and your loved ones rely on for care.
In January, the large urban hospital where I am an intern faced the worst flu outbreak it has ever seen. Nearly 100 staff members tested positive for the flu. Residents assigned to back-up coverage were called to work daily to supplement the dwindling ranks of the sick. Every hospital visitor was required to wear a mask upon entry. At one point, every patient in the medical ICU had the flu and the whole unit had to be quarantined. Because of this, the hospital was put on diversion – no new patients could be admitted.
Why was this flu outbreak so bad? Doctors are still trying to understand all the causes, but one likely reason is that hospital staff with symptoms came to work and became a reservoir for the virus. A majority of visitors and patients don’t get their flu shots, making matters even worse.
Once administrators caught on to the mess this year’s flu was creating, they took some new and aggressive measures. In addition to the free vaccines provided to employees every year, they performed daily symptom check-ins, encouraged sick days, and held an influenza town hall. After discussion with the State Department of Health, medical residents were provided free Tamiflu and urged to take it as prophylaxis. Only 40% picked it up. Residency directors asked symptomatic house staff to stay home. A positive flu swab meant a mandated five days off work. One month later, we are still required to check in daily and confirm that we are symptom-free via a text messaging system or a checklist circulated to each hospital floor. These responses were effective, and the wave of flu appears to have passed. We must now plan ahead to prevent the next outbreak.
I’m going to show you the Match rate and mean Step 1 score for three groups of residency applicants. These are real data, compiled from the National Resident Matching Program’s (NRMP) Charting Outcomes in the Match reports.
U.S. Allopathic Seniors: 92% match rate; Step 1 232.3
U.S. Osteopathic Seniors: 83% match rate; Step 1 225.8
International Medical Graduates, or IMGs (both U.S. and non-U.S. citizen: 53% match rate; Step 1 223.6
Now. What do you conclude when you look at these numbers?
In the debate over the U.S. Medical Licensing Examination’s (USMLE) score reporting policy, there’s one objection that comes up time and time again: that graduates from less-prestigious medical schools (especially IMGs) need a scored USMLE Step 1 to compete in the match with applicants from “top tier” medical schools.
In fact, this concern was recently expressed by the president of the National Board of Medical Examiners (NBME) in an article inAcademic Medicine (quoted here, with my emphasis added).
“Students and U.S. medical graduates (USMGs) from elite medical schools may feel that their school’s reputation assures their successful competition in the residency application process, and thus may perceive no benefit from USMLE scores. However, USMGs from the newest medical schools or schools that do not rank highly across various indices may feel that they cannot rely upon their school’s reputation, and have expressed concern in various settings that they could be disadvantaged if forced to compete without a quantitative Step 1 score. This concern may apply even more for graduates of international medical schools (IMGs) that are lesser known, regardless of any quality indicator.”
The funny thing is, when I look at the data above, I’m not sure why we would conclude that IMGs are gaining advantage from a scored Step 1. In fact, we might conclude just the opposite – that a scored Step 1 is a key reason why IMGs have a lower match rate.
If someone we love has a physical ailment, we can list a variety of places for them to seek care: a clinician’s office, a pharmacy, an urgent care clinic, a school health clinic, an emergency department — the list goes on.
And, in every case, we would feel confident the clinicians in those places would know how to handle the case — or at least know where to send the patient if they need more intensive or specialized care.
But, sadly, the same isn’t true for a loved one with a mental health or substance misuse need, even thought mental health problems are more prevalent than many physical conditions.
As deaths of despair from drug or alcohol misuse or suicide continue to rise, we need a comprehensive, coordinated “no wrong door” approach that fully integrates mental health into the health care system and beyond. We need to transform our clinical practice, creating more options for care and putting mental health and substance use patients’ best interests first. Policy and payment reform must happen to make this new vision of care possible.
Say you want to know which baseball players provide the most value for the big dollars they’re being paid. A Google search quickly yields analytics. But suppose your primary care physician just diagnosed you with cancer. What will a search for a “high value” cancer doctor tell you?
Public concern over bloated and unintelligible medical bills has prompted pushback ranging from an exposé by a satirical TV show to a government edict that hospitals list their prices online. But despite widespread agreement about the importance of high-value care, information about the clinical outcomes of individual physicians, which can put cost into perspective, is scarce. Even when information about quality of care is available, it’s often unreliable, outdated, or limited in scope.
For those who are sick and scared, posting health care price tags isn’t good enough. The glaring information gap about the quality of care must be eliminated.
“When people are comparison shopping, knowing the price of something is not enough,” notes Eric Schneider, a primary care physician and senior vice president of policy and research at the Commonwealth Fund. “People want to know the quality of the goods and services they’re buying.”
Telepsychiatry is now an established form of mental health care. Many studies demonstrate that it meets all appropriate standards of psychiatric care and may be better than in-person consultations for certain groups of patients, such as children, adults with PTSD or anxiety disorders, or those who find it hard to leave their homes. At UC Davis all patients are now offered the option of either seeing their psychiatrist in person, online at home, or in any private setting. Many patients now choose to receive their care in a hybrid manner that can be significantly better than being seen exclusively in the clinic office for numerous reasons.
From the patient’s perspective it is more convenient, allowing them to fit their consultations into their lives, rather than having to take several hours out to travel and attend a clinic. Many patients also find this form of care to be more intimate and less threatening, with the slightly increased “distance” from the therapist allowing them to feel safer talking about stigmatized or embarrassing topics, such as trauma and abuse. We also know from numerous satisfaction studies that patients like being treated using video. In fact some groups, such as children and young adults, prefer this to conventional methods.
What has not been examined scientifically in as much detail is the impact telepsychiatry has on providers, although the latter are voting with their feet. Latest figures suggest that up to 15% of psychiatrists are now using video with their patients There are numerous advantages for psychiatrists and it is becoming clear that treating patients in a hybrid manner using telepsychiatry, as well as other technologies like messaging and secure email, may be a major response to the problem of physician burnout, making providers both more efficient and clinically effective.
So what are the advantages of telemedicine for mental health providers?