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Who Cares About the Doctor-Patient Relationship? A Review of “Next In Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health”

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By KIP SULLIVAN, JD

A mere two decades ago, the headlines were filled with stories about the “HMO backlash.” HMOs (which in the popular media meant most insurance companies) were the subject of cartoons, the butt of jokes by comedians, and the target of numerous critical stories in the media. They were even the bad guys in some movies and novels. Some defenders of the insurance industry claimed the cause of the backlash was the negative publicity and doctors whispering falsehoods about managed care into the ears of their patients. That was nonsense. The industry had itself to blame.

The primary cause of the backlash was the heavy-handed use of utilization review in all its forms –prior, concurrent, and retrospective. There were other irritants, including limitations on choice of doctor and hospital, the occasional killing or injuring of patients by forcing them to seek treatment from in-network hospitals, and attempts by insurance companies to get doctors not to tell patients about all available treatments. But utilization review was far and away the most visible irritant.

The insurance industry understood this and, in the early 2000s, with the encouragement of the health policy establishment, rolled out an ostensibly kinder and gentler version of managed care, a version I and a few others call Managed Care 2.0. What distinguished Managed Care 2.0 from Managed Care 1.0 was less reliance on utilization review and greater reliance on methods of controlling doctors and hospitals that patients and reporters couldn’t see. “Pay for performance” was the first of these methods out of the chute. By 2004 the phrase had become so ubiquitous in the health policy literature it had its own acronym – P4P. By the late 2000s, the invisible “accountable care organization” and “medical home” had replaced the HMO as the entities that were expected to achieve what HMOs had failed to achieve, and “value-based payment” had supplanted “managed care” as the managed care movement’s favorite label for MC 2.0.

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Giving Consumers the Tools and Support They Need to Navigate Our Complex Healthcare System

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By CINDI SLATER, MD, FACR

As physicians and healthcare leaders, we are already well aware that the majority of patients do not have the information they need to make a medical decision or access to appropriate resources, so we didn’t need to hear more bad news. But that is precisely what new research once again told us this spring when a new study showed that almost half of the time, patients have no idea why they are referred to a GI specialist.

While the study probably speaks to many of the communications shortcomings we providers have, across the board our patients often don’t know what care they need, or how to find high-value care. Last year, my organization commissioned some original research that found that while a growing number of patients are turning to social websites such as YELP, Vitals, and Healthgrades to help them find a “high quality” specialist, the top-ranked physicians on these sites – including GI docs – are seldom the best when we look at real performance data. Only 2 percent of physicians who showed up as top 10 ranked on the favorite websites also showed up as top performers when examining actual quality metrics. (The results shouldn’t surprise you as bedside manner has little to no correlation with performance metrics such as readmission rates).

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As providers and health care leaders, we lament that our patients are not better informed or more engaged and yet across the board, we have not given them the tools or resources they need to navigate our complex system. But now for some good news: all hope is not lost, and patients can become better consumers, albeit slowly, if we all do our part.

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Making Sense of the Health Care Merger Scene   

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By JEFF GOLDSMITH

In the past 12 months, there has been a raft of multi-billion-dollar mergers in health care. What do these deals tell us about the emerging health care landscape, and what will they mean for patients/consumers and the incumbent actors in the health system?

Health Systems

There have been a few large health system mergers in the past year, notably the $11 billion multi-market combinations of Aurora Health Care and Advocate Health Care Network in Milwaukee and suburban Chicago, as well as the proposed (but not yet consummated) $28 billion merger of Catholic Health Initiatives and Dignity Health. However, the bigger news may be the several mega-mergers that failed to happen, notably Atrium (Carolinas) and UNC Health Care and Providence St. Joseph Health and Ascension. In the latter case, which would have created a $45 billion colossus the size of HCA, both parties (and Ascension publicly) seemed to disavow their intention to grow further in hospital operations. Ascension has been quietly pruning back their operations in markets where their hospital is isolated, or the market is too small. Providence St. Joseph has been gradually working its way back from a $500 million drop in its net operating income from 2015 to 2016.

Another notable instance of caution flags flying was the combination of University of Pittsburgh Medical Center (UPMC) and PinnacleHealth, in central PA, which was completed in 2017.   Moody’s downgraded UPMC’s debt on the grounds of UPMC’s deteriorating core market performance and integration risks with PinnacleHealth. As Moody’s action indicates, investor skepticism about hospital mega-mergers is escalating. Federal regulators remain vigilant about anti-competitive effects, having scotched an earlier Advocate combination with NorthShore University HealthSystem in suburban Chicago. The seemingly inevitable post-Obamacare march to hospital consolidation seems to have slowed markedly.

However, the most noteworthy hospital deal of the last five years was a much smaller one: this spring’s acquisition of $1.7 billion non-profit Mission Health of Asheville, NC, by HCA. This was remarkable in several respects. First, it was the first significant non-profit acquisition by HCA in 15 years (since Kansas City’s Health Midwest in 2003) and HCA’s first holdings in North Carolina.  While Mission’s search for partnerships may have been catalyzed by a fear of being isolated in North Carolina by the Atrium/UNC combination, Mission Health certainly controlled its own destiny in its core market, with a 50% share of western North Carolina. Mission was not only well managed, clinically strong and solidly profitable, but its profits rose from 2016 to 2017, both from operations and in total.

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Information Blocking–The AHA Comments & PPR Responds

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By ADRIAN GROPPER

The focus on the CMS rules on information blocking continues on THCB. We’ve heard from Adrian Gropper & Deborah Peel at Patients Privacy Rights, and from e-Patient Dave at SPM and Michael Millenson. Now Adrian Gropper summarizes — and in an linked article –notates on the American Hospital Association’s somewhat opposite perspective–Matthew Holt

It’s “all hands on deck” for hospitals as CMS ponders the definition and remedies for 21st Century Cures Act information blocking.

This annotated excerpt from the recent public comments on CMS–1694–P, Medicare Program; Hospital Inpatient Prospective Payment Systems…  analyzes the hospital strategy and exposes a campaign of FUD to derail HHS efforts toward a more patient-centered health records infrastructure.

Simply put, patient-directed health records sharing threatens the strategic manipulation of interoperability. When records are shared without patient consent under the HIPAA Treatment, Payment and Operations the hospital has almost total control.Continue reading…

Maine Voices: Want better, less complicated health insurance? Push the narrative, not the name

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By WILLIAM ROSENBERG

A ‘single-payer’ plan is a target on the back of its supporters. But what about a ‘Medicare Public-Private Partnership’?

MOUNT VERNON — In February 2017, President Trump famously said: “Nobody knew health care could be so complicated.” Nobody other than about 99.9 percent of the almost 300 million people in the U.S. with insurance, that is. Yesterday, I received a copy of “Get to know your benefits,” the 236-page “booklet” for my new health plan. Like most people, I’ll never read the book, but its weight alone says “complicated.”

And it’s safe to guess that Trump also will never read his Federal Employee Health Plan information, even though one Aetna choice available to him has a “brochure” of only 184 pages. Thinking about the amount of information available to health insurance plan consumers, I began to wonder what Health and Human Services Secretary Alex Azar meant, also last February, when he said, “Americans need more choices in health insurance so they can find coverage that meets their needs.”

Presumably, were we to have more choices, we could study the hundreds of pages of information about each available plan and make better choices. According to the federal Office of Personnel Management, federal employees who live at 1600 Pennsylvania Ave., Washington, D.C. 20500, have a choice of 35 monthly plans. Too bad the president doesn’t live in Maine, where he’d have only 20 plans to study!

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CBD (Cannabidiol) 101

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By DONNA SHIELDS

I’ve been a proponent of marijuana legalization since I heard about it in high school.  I lived in the UK in the 1970s when it was not easily available! So I was a legalization proponent before I’d ever touched the stuff. Nearly four decades later, it’s legal in many states, Canada and Uruguay and most — but by no means all — of the drug war hysteria is recognized for the idiocy it is. But while anyone who’s got stone and had the munchies knows that pot is a good appetite enhancer and antiemetic, there are now a bunch of claims being made about cannabidiol (CBD). So I thought we’d explore them. We’re including a video from ZdoggMD which gives a balanced view of the (appalling lack of) data so far, and an article from Donna Shields, co-founder of the Holistic Cannabis Academy. Donna, as you may guess, thinks it’s pretty useful. And while you think this may still be on the edge, a CBD company called Sagely Naturals won the recent G4A contest held by old world big Pharma company Bayer—Matthew Holt

Understanding CBD

It’s come onto the healthcare scene like a rocket yet most people don’t really understand what cannabidiol (CBD) is, how to use it and the results one can expect. Here’s a primer on the basics you need to know.

Do you know about the endocannabinoid system

We all have an endocannabinoid system; a network of receptors throughout the body whose job is to maintain homeostasis and well-being for all our organs. Like a master control system. And while our bodies make their own cannabinoids, life, through stress, toxins, poor diet and illness, has a way of depleting the in-house supply or making those receptors “less receptive”. This is when adding cannabinoids, such as CBD, can be a helpful boost.

Marijuana vs Hemp

The mother plant, called Cannabis sativa, can be cultivated to grow marijuana (the plant containing THC, CBD, and other cannabinoid compounds) or hemp, a crop with many uses from food products to building materials. Hemp also contains CBD (cannabidiol), but less than 0.3% THC. CBD is just one of over 80 different cannabinoid compounds found in both marijuana and hemp. Hemp-derived CBD products are available at retail stores and online; while marijuana-derived CBD products are available cannabis dispensary stores.

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Stay Out of my Wellness

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By VA WEST HAVEN COE CLINIC

On a sunny New England morning at a secluded guest house with a perfectly manicured lawn, medical residents, each with their own brightly colored yoga mat, were getting ready to assume the downward dog position. They were on an annual retreat organized by their residency program to promote wellness. One embraced the opportunity with delight, smiling through every pose.  Another grimaced  as his back spasmed. And yet another wandered off towards a lake to find his own kind of respite.

Physician wellness has become something of a buzzword in recent years, and rightfully so considering that the rates of burnout and suicide within medicine are rising. Individual residency programs have found burnout rates between 55% and 76%. Such burnout erodes well-being over time and may be contributing to suicide, which is now the second leading cause of death among residents nationwide. In 2014, the suicides of two medical interns in New York prompted the American College of Graduate Medical Education to take action. A series of initiatives to combat burnout were rolled out, including the consideration of wellness in its review of residency programs during site visits. In 2017, emergency medicine physicians convened the first Residency Wellness Consensus Summit to devise a module-based curriculum on wellness. Hospital systems have attempted to respond as well, through the hiring of chief wellness officers.

It is unsurprising that the medical community has taken such an analytical approach towards diagnosing burnout, much as we do with other diseases, in search for a cure. But perhaps such a prescriptive approach fails to capture the highly individualized and somewhat abstract concept of wellness. The reasons for resident burnout are personal and vast. Decreased wellness has been attributed to the lack of time for self-care, inadequate sleep, social isolation, negative work environments, excessive paperwork, long work hours, poor relationships with colleagues, and insufficient mentorship, among others in a lengthy list. Any attempt to standardize the definition of wellness should be met with caution.

So how do we as a society go forward in ensuring our resident physicians are well?Continue reading…

Information Blocking–Gropper & Peel Weigh in

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By ADRIAN GROPPER & DEBORAH PEEL

Today is the last day for public comments on the proposed CMS regulations regarding Medicare hospital inpatient prospective payment systems (IPPS). While there are several changes proposed, the one that’s raised lots of attention has been the idea that access to Medicare may be denied to those providers guilty of information blocking. Here are the comments submitted by Gropper & Peel from Patients Privacy Rights— Matthew Holt

Executive Summary of PPR Comments on Information Blocking

Information blocking is a multi-faceted problem that has proved resistant to over a decade of regulatory and market-based intervention. As Dr. Rucker said on June 19, “Health care providers and technology developers may have powerful economic incentives not to share electronic health information and to slow progress towards greater data liquidity.” Because it involves technology standards controlled by industry incumbents, solving this problem cannot be done by regulation alone. It will require the coordinated application of the “power of the purse” held by CMS, VA, and NIH.

PPR believes that the 21st Century Cures Act and HIPAA provide sufficient authority to solve interoperability on a meaningful scale as long as we avoid framing the problem in ways that have already been shown to fail such as “patient matching” and “trust federations”. These wicked problems are an institutional framing of the interoperability issue. The new, patient-centered framing is now being championed by CMS Administrator Verma and ONC Coordinator Rucker is a welcome path forward and a foundation to build upon.

To help understand the detailed comments below, consider the Application Programming Interface (API) policy and technology options according to two dimensions:

API Content and Security Institution is Accountable Patient is Accountable
API Security and Privacy
  • Broad, prior consent
  • Patient matching
  • Institutional federation
  • Provider-directed interop
  • Compliance mindset
  • Directed authorization
  • Known to the practice
  • Individual credentials
  • Patient-directed interop
  • Privacy mindset
API Content / Data Model
  • Designated record set
  • FHIR
  • Patient-restricted data
  • De-identified data
  • Bulk (multi-patient) data
  • Designated record set
  • FHIR
  • Sensitive data
  • Social determinants
  • Wearables and monitors

This table highlights the features and benefits of interoperability based on institutional or individual accountability. This is not an either-or choice. The main point of our comments is that a patient-centered vision by HHS must put patient accountability on an equal footing with institutional accountability and ensure that Open APIs are accessible to patient-directed interoperability “without special effort” first, even as we continue to struggle with wicked problems of national-scale patient matching and national-scale trust federations.

Here are our detailed comments inline with the CMS questions in bold:Continue reading…

The EBM Wars: When Evidence has a Price – The ECMO Trials (Part 2)

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By ANISH KOKA

The year was 1965, the place was Boston Children’s and a surgery resident named Robert Bartlett took his turn at the bedside of a just born baby unable to breathe.  This particular baby couldn’t breathe because of a hole in the diaphragm that had allowed the intestines to travel up into the thoracic cage, and prevent normal development of the lungs.  In 1965, Robert Bartlett was engaged in the cutting edge treatment of the time – squeeze a bag that forced oxygenated air into tiny lungs and hope there was enough functioning lung tissue to participate in gas exchange to allow the body to get the oxygen it needed.  Bartlett persisted in ‘bagging’ the child for 2 days.  As was frequently the case, the treatments proved futile and the baby died.

The strange part of the syndrome that had come to be known as congenital diaphragmatic hernia was that repairing the defect and putting the intestines back where they belonged was not necessarily curative.  The clues to what was happening lay in autopsy studies that demonstrated arrested maturation of lung tissue in both compressed and uncompressed lung.  Some systemic process beyond simple compression of one lung must be operative.  It turns out that these little babies were blue because their bodies were shunting blood away from the immature lungs through vascular connections that normally close off after birth.  Add abnormally high pressures in the lungs and you have a perfect physiologic storm that was not compatible with life.

Pondering the problem, Bartlett wondered if there was a way to artificially do what the lungs were supposed to do – oxygenate.  Twelve years later in 1977, while most pediatric intensive care units were still figuring out how to ventilate babies, a team lead by Bartlett was using jerry rigged chest tube catheters to bypass the lungs of babies failing the standard treatments of the day.  In a series of reports that followed, Bartlett described the technique his team used in babies that heretofore had a mortality rate of 90%.  A home made catheter was placed in the internal jugular vein and pumped across an artificial membrane that oxygenated blood before it was returned via a catheter to the carotid artery.  The usual hiccups ensued.  The animal models didn’t adequately model the challenges of placing babies on what has come to be known as ECMO (Extra Corporeal Membrane Oxygenation).

bartlett1977

Patient 1 developed a severely low platelet count, hemorrhaged into the brain and died. Patient 2 survived but was on a ventilator for 7 weeks.  Patient 3 developed progressive pulmonary hypertension and died.  Patient 4 died because of misplacement of one of the ECMO catheters.

The team improved, and mortality in this moribund population improved to 20%.  The pediatric journals of the day refused to publish the data because they felt ECMO for neonates was irresponsible.  Once published, the neonatology community came out in force against ECMO, and some penned editorials implying the children only became supremely ill because Bartlett’s team was incompetent.  The team persisted, as is anyone that is driven by the desperate need of patients.  None of this should be surprising.  The constant battle between skeptics and proponents is a recurring theme known to anyone with even a limited understanding of  medical history.  But this is where the story goes off the rails.Continue reading…

The verdict is in: All three of CMS’s “medical home” demonstrations have failed

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By KIP SULLIVAN

Between September of 2016 and last month, CMS released “final evaluations” of all three of its “medical home” demonstrations. All three demos failed.

This spells bad news not just for the “patient-centered medical home” (PCMH) project, but for MACRA. The PCMH, along with the ACO and the bundled payment (BP), is one of the three main “alternative payment models” (APMs) within which doctors are supposed to be able to find shelter from the financial penalties inflicted by the MIPS (Merit-based Incentive Payment System) program which was recently declared to be unworkable by the Medicare Payment Advisory Commission. Medicare ACOs and virtually all Medicare BP programs are also failing. Thus, we may conclude what some predicted a long time ago – that neither arm of MACRA (the toxic MIPS program and the byzantine APM program) will work.

In this post I describe each of CMS’s three PCMH demos, review the findings of the final evaluations of the three demos, and then explore the reasons why all three demos failed. I’ll conclude that the most fundamental reason is that the PCMH is so poorly defined no one, including the doctors inside the PCMHs, knows what it’s supposed to do. That’s not to say that the hopes and dreams of PCMH proponents were never clear. They have always been clear. PCMH proponents have said over and over the PCMH is supposed to lower costs and improve care. But a clear expression of hopes and dreams is not the same thing as a clear description of what it is you’re dreaming about.Continue reading…

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