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As Doctor Burnout Climbs, Can We Save Primary Care?

By RONALD DIXON

Week after week, I hear from colleagues in diverse specialties about how exhausted they are from practicing medicine.

It’s no surprise that they are looking for careers outside of medicine. The demands and strain are unsustainable.

So it’s also no surprise that a recent survey showed 40% of primary care clinicians are worried that their field won’t exist in five years and that 21% expect to leave primary care in three years as a result of COVID-19-related burnout. 

While COVID-19 is the tipping point, this burnout is the result of the relentless and mounting administrative burden placed on us by electronic medical records (EMRs), coding and billing requirements and prior authorizations. And then it is exacerbated by uncertainty mounting in the primary care field, with new medical care entrants popping up everywhere — from retail pharmacies to digital health startups — aiming to create their own primary care model, replacing rather than working with existing ones.

Where it All Began

The roots of this burden began three decades ago with the advent of an acronym that few outside of the healthcare world know of today — the resource-based relative value scale (RBRVS). This payment system, launched in 1989 and subsequently adopted by Medicare in 1992, led to what we know now as the foundation of the U.S. healthcare payment system.  

The RBRVS system assigns procedures a relative value which is adjusted by geographic region. Prices are based on physician work (54%), practice expense (41%) and malpractice expense (5%).

Since the initiation of the scale, the relative value of specialist work has remained much higher than primary care. This disparate compensation, in combination with most health maintenance and patient supportive tasks delegated to primary care, has led to significant fatigue. 

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Anxiety, Worry or Fear? Disappointment, Grief or Depression?

By HANS DUVEFELT

Especially in these strange and uncertain times, many people feel uneasy. Some of them come to us with concerns over their state of mind.

In primary care, our job is in large part to perform triage. We strive to identify patients who need referral, medication or further evaluation. We also strive, or at last should strive, to reassure those patients whose reactions are normal, considering their circumstances.

A set of emotions we consider normal during the first weeks of the loss of a loved one may constitute pathology of protracted or if there is no apparent trigger.

But what is normal in today’s reality?

People today often have a low tolerance for deviations from the mean. They measure their heart rates, sleep times, steps taken, calories eaten and many other things on their smartphones. They compare their statistics to others’ or to their own from different circumstances.

Is it normal to sleep less when the last thing you do before bed is take in the latest disaster news? Is it normal to have a higher resting heart rate when you are threatened by eviction? Is it normal to feel sadness that life as we knew it doesn’t seem to be within our reach right now?

The worst thing we can do is tell people there is something wrong with them if we see them doing and hear them expressing what many other people also do.

It’s bad enough to feel bad, but even worse if you think your reaction is a sign of psychiatric illness or psychological or constitutional inferiority.

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Selfish Much?

By KIM BELLARD

In a week where we’ve seen the bungled Afghan withdrawal, had Texas show us its contempt for all sorts of rights, watched wildfires ravage the west and Ida wreak havoc on a third of the country, and, of course, witnessed COVID-19 continue its resurgence, I managed to find an article that depressed me further.  Thank you, Aaron Carroll.

Dr. Carroll – pediatrician, long-time contributor to The New York Times, and now Chief Health Officer of I.U. Health — wrote a startling piece in The Atlantic: We’ve Never Protected the Vulnerable.  He looks at the resistance to public health measures like masking and wonders: why is anyone surprised? 

Some of his pithier observations:

  • “Much of the public is refusing. That’s not new, though. In America, it’s always been like this.”
  • “COVID-19 has exposed these gaps in our public solidarity, not caused them.”
  • “America has never cared enough. People just didn’t notice before.”

Wow.  What was that about Texas again? 

Some of Dr. Carroll’s examples include our normally lackadaisical approach to influenza, our failure to recognize the dangers we often pose to immunocompromised people, our paltry family and sick leave policies, and our vast unpaid care economy.  He could have just as well pointed to our (purposefully) broken unemployment system or the stubborn resistance to Medicaid expansion in 12 states (Texas again!), but you probably get the point. 

Everyone likes to complain about our healthcare system – and with good reason – but it is not an abyss we somehow stumbled into.  It’s a hole we’ve dug for ourselves, over time.  We may not like our healthcare system but it is the system we’ve created, or, perhaps, allowed. 

Health insurance was once largely community-rated, spreading the risk equally across everyone to protect the burden on the sickest, until some insurers (and some groups) figured out that premiums could be cheaper without it.  Use of preexisting conditions and medical underwriting also served to protect the less vulnerable, until ACA outlawed those practices. 

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Does Our Healthcare System Work for the Most Vulnerable Americans?

By DEBORAH AFEZOLLI, CARL-PHILIPPE ROUSSEAU, HELEN FERNANDEZ, ELIZABETH LINDENBERGER

“Why did you choose this field?” Most physicians are asked this question at some point in their early careers. We are geriatrics and palliative medicine physicians, so when that question is posed to us, it is invariably followed by another: “Isn’t your job depressing?”

No, our job is not depressing. We are trained in the care of older adults and those with serious illness, and we find this work very rewarding.  What truly depresses us is how many vulnerable patients died during the pandemic, and how the scourge of COVID-19 revealed the cracks in our health system. Never before in modern times have so many people been affected by serious illness at the same time, nor have so many suffered from the challenges of our dysfunctional health system. Our nation has now witnessed the medical system’s failure to take comprehensive care of its sickest patients.  This is something those in our own field observed long before the pandemic and have been striving to improve.

All of us practicing geriatrics and palliative care have had a loved one who has been challenged by aging, by serious illness, or indeed by the very healthcare system that is supposed to help them. As medical students and residents, we personally confronted these systemic deficiencies and wondered about alternatives for those patients with the most complex needs. We chose fellowships in geriatrics and palliative medicine because we wanted to try and make a difference in the healthcare that is offered to our most vulnerable patients.

During the New York City surge in the spring of 2020, we were front line workers at a major academic medical center. While the global pandemic took us all by surprise, our clinical training and passion for treating vulnerable populations left us feeling capable and ready to serve. Due to the urgent needs of overwhelming numbers of extremely sick patients, our Department was charged with rapidly expanding access to geriatrics and palliative care across our seven hospitals. We were embedded in Emergency Departments (EDs), hospitalist services, and critical care units.  We roamed the hospitals with electronic tablets and held the hands of dying patients, while urgently contacting families to clarify goals of care.  For those who wanted to receive care in the community, we scrambled to set up telehealth visits and coordinate the necessary support. Way too often we could not meet their needs with adequate services, forcing them to visit overwhelmed Emergency Rooms.

While we helped individual patients and eased some of the strain on our hospitals, our system was overwhelmed and mortality numbers continued to steadily rise. Within our hospitals, staff were redeployed to care for the most critically ill in the emergency departments and intensive care units.  In this frantic time, we were fortunate that our hospitals had sufficient medical resources to care for the sickest patients and for the staff.  However, the sub-acute nursing facilities (SNF) and long-term care facilities strained to protect their residents and their employees. Shortages of PPE, staff, space, testing supplies, and funding all contributed to the high mortality numbers we saw in many NYC facilities and across the nation. There were also limited resources allocated to delivering outpatient care in our patients living in the community.  The rapid shift to telehealth was not feasible for many of our older patients, and even when it was possible, the delivery of diagnostic and therapeutic care was limited and suboptimal.

Data now shows that older adults and those with underlying chronic illnesses were disproportionately affected by the COVID-19 pandemic, experiencing higher hospitalization rates as well as higher death rates. Although adults 65 and older account for only 16% of the US population, they represent 80% of COVID-19 deaths. Residents of nursing homes, the frail homebound, and older people of color were the hit the hardest. Thirty-five percent of the deaths in the US from March-May 2020 occurred among nursing home residents and employees. Nationally, over 600,000 nursing home residents were infected with COVID-19 and over 100,000 died from the disease. These data are underestimates and the death toll is likely higher. We cannot explain why older Black Americans were 1.2 times more likely to die than white Americans nor why the odds of dying from COVID were nearly two times higher for persons living in South Dakota as compared to Wyoming or Nebraska. Often, the paid caregivers for these vulnerable patients were themselves vulnerable underpaid women of color who were at higher risk of contracting COVID.

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Burnout? Not Even Close!

By HANS DUVEFELT

I am a 68 year old family physician in rural Maine. This morning I read yet another article about physician burnout, this time in The New York Times. (I’m not linking to it, because they have a “paywall”.)

I did not end up exactly where and how I expected to be at the end of my career, or life in general to be brutally honest. But I am the happiest I have been since the beginning of my journey in medicine.

I have a balance in my life I didn’t have, or even seek, for many years as I juggled patient care, administration, raising a family and pursuing interests that often brought me away from home.

My days in the clinic are a bit shorter than they used to be, but in the past several years I have had to do much more work from home – even more so in the last two. The “half-empty glass” way to look at this is that work has intruded more into my personal life and my home. The “half-full” view is that I can do my computer work when it suits me the best. For one of my clinic positions, I can do charting on an iPad mini in bed, coffe on my nightstand and sleeping dogs at my feet. The clumsier EMR requires a laptop (which in my view can’t be used the way its name might suggest) I sometimes work on in the barn and sometimes on a picnic table in the grass outside.

Ironically, the pandemic has brought me a peace and clarity I probably wouldn’t have achieved otherwise.

I had thought moving back to Caribou for a position with no administrative responsibilities would open up social opportunities I hadn’t allowed myself for the last few years. I expected to become involved with the Swedish community here, connecting more with neighbors and other horse owners, and so on.

But the lockdown forced me to sit more with my own thoughts, my own feelings and memories. It forced me to consider, not for the first time but again, that in this unpredictable life, the only sure thing is that I am me and I am where I am.

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Healing at Home: Answering the $30,000 Question

By DAWN CARTER

If you’ve been working remotely for the past year, would a $30,000 raise entice you back into the office? In a recent survey of 3,000 workers at dozens of large US companies, the vast majority of respondents said they would forego the hefty raise if they could keep working in their pajamas.

I’ve spent more than 25 years in healthcare strategy and planning, and that was one of the most remarkable surveys I’ve ever seen – though not in terms of HR, because healthcare is one of the few industries where remote work never took hold during the pandemic.

Instead, I think the urgent lesson for healthcare planners is all about how – and where – services will be delivered in the future. Call it “the Covid effect”: In the same way that employees over the past year discovered the advantages of working at home, we’ve seen a huge number of new patients who discovered the advantages of so-called Hospital at Home programs.

Hospital at Home is not exactly a new model, but it’s been relatively unknown among patients until now. That’s because limited, early experiments suffered from low participation rates – just 7 to 15 patients per month. But those numbers got a huge boost over the past year as hospitals scrambled to preserve in-patient capacity for only the most extreme Covid cases. The Association of American Medical Colleges says interest in Hospital at Home “exploded” during the pandemic, and health systems from Boston to Cleveland to Seattle launched or expanded in-home programs that served thousands and thousands of new families.

It may be hard to put this genie back in the bottle. If workers won’t go back into the office for $30,000 what could possibly entice patients back into the traditional hospital setting once they’ve experienced the benefits of healing at home?

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DayTwo Scores $37M to Expand Microbiome-Based Personalized Nutrition Treatment for Diabetes

By JESSICA DaMASSA, WTF HEALTH

People with Diabetes can get ready to celebrate: “The ‘Era of Lancets’ is over.” Precision nutrition startup, DayTwo, is scaling up its microbiome-based program, which takes the guesswork (and finger pricks) out of Diabetes management by offering its members food predictions that identify how their bodies will respond to any food BEFORE they eat it. The startup just closed a fresh $37M in Series B funding (led by aMoon and Cathay Ventures) and is expanding the rollout of their fee-for-outcomes Diabetes program to health plans and large self-insured employers.

The science behind this has yielded DayTwo the largest gut microbiome dataset in the world, and years of empirical studies on exactly what happens in our bodies as our digestive systems process different foods. Josh Stevens, DayTwo’s President & Chief Commercial Officer, walks us through the research behind the offering, which uses a gut microbiome analysis to rank foods and food combinations based on how eating them will impact a person’s blood sugar – essentially revealing what foods will (or won’t) cause a member’s blood sugar to spike before they even take a bite.

Its 70,000+ members report lower A1C levels (1 point on average), sustained weight loss, and, probably most exciting, an ability to stick with the program because the app (and wrap-around telehealth support from registered dieticians) creates a completely bespoke diet that lets people learn how to eat their favorite foods and keep their blood glucose levels within range. Will this predictive approach really bring about the end of lancet-based blood glucose testing for Diabetes management? Josh says Diabetes remission is a goal made easier by this predictive approach, but how does it stack up to other food-as-medicine approaches out there? I have a gut-feeling that you’ll want to tune in and find out!

Health Care, Meet Gall’s Law

By KIM BELLARD

I can’t believe I’ve gone this long without knowing about Gall’s Law (thanks to @niquola for tweeting it!).  For those of you similarly unaware, John Gall was a pediatrician who, seemingly in his spare time, wrote Systemantics: How Systems Work and Especially How They Fail in 1975.  His “law,” contained therein, is:

Have you ever heard of anything that applied so perfectly to our healthcare system? 

As anyone who has been reading my prior articles may know, I’m a big believer in simple.  I’ve advocated that healthcare’s billing and paperwork should be much simpler, that “less is more” when it comes to design,  that healthcare should first do simple better but, above all,  that healthcare should stop doing stupid things.  I’ve equated the ever-increasing intricacies of our healthcare system to the epicycles that kept getting added to the Ptolemaic theory in a desperate attempt to justify it. 

Few would disagree that the U.S. healthcare system is complex.  Healthcare systems in general have evolved towards more complex, but the U.S. system takes complexity to extremes, with its thousands of payors, its powerful pharma/medical device industry, and its highly concentrated hospital markets (including ownership of physician practices), among other things. 

Simple isn’t always better, of course.  Life is complicated and so is our health, but, come on: how many people can explain why PBMs exist, what their heath insurance plan actually covers, how their health care bill was arrived at, or why we spend so much time in the healthcare system just waiting?  Literally no one understands our healthcare system.

It shouldn’t be that way.  It doesn’t have to be that way.  But it is.

Some pundits argue we don’t even have “a system” but, rather, thousand or even millions of smaller health-related markets that co-exist but don’t really work together.  For anyone who doubts that, try to explain the presence of workers compensation healthcare or why dental is at best a separate form of coverage (last I looked, the mouth was part of the body).  Try to explain why child care is most definitely not part of healthcare but home care is – depending, of course, on whether it is “custodial” or not.   Silos abound.

It could be argued that healthcare started with a simple system that “worked.”  Some are nostalgic for the days when people saw their family doctor, paid their doctor, and that was it.  It doesn’t get much simpler than that.  Of course, those doctors couldn’t really do all that much for their patients and didn’t really get paid all that much, so to say that it “worked” for either party is debatable. 

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Policies|Techies|VCs: What’s Next For Health Care–Virtual Conference is Sept 7-10

Policies|Techies|VCs: What’s Next For Health Care? is the conference bringing together the CEOs of the next generation of virtual & real-life care delivery, and all the permutations thereof. You can register here or learn how to sponsor.

This is a big week. We are one week out and we’ve started pre-recording a few sessions and they’ve been fascinating. Keynotes include government officials from the 3 most important agencies for digital health –Pauline Lapin (CMS), Micky Tripathi (ONC) & Bakul Patel (FDA). But wait there’s more! Keynotes from techies Glen Tullman (Transcarent), Sean Lane (Olive), Jonathan Bush (Zus Health), Jeff Dachis (One Drop) & Andrew Dudum (Hims & Hers). And we’re not forgetting the VCs sprinkled through the program, with a keynote from Andreesen Horowitz’s Julie Yoo.

Please look at the agenda for 20 power-packed panels and over 100 speakers – and then sign up!

Shout out to our sponsors – This week we welcome new Gold sponsor data privacy company Skyflow and new Silver sponsor Amwell. Thanks to both of them for supporting the conference. They join Avaneer Health (our Platinum sponsor) & exclusive Agency sponsor 120/80. Sliver sponsors are Transcarent & Lark . More sponsors are Aetion. Merck GHIF, Crossover Health, Zus Health, Newtopia, Aetion & Big Health! Many of them will have sessions you can catch on the web site.

It’s going to be a great conference–no need to leave your seat as it’s happening virtually September 7-10. Register here!! — Matthew Holt

Sleepless Nights For Evolutionary Biologists: A Greek Tragedy in The Making

By MIKE MAGEE

In my Jesuit high school, we were offered only one science course – chemistry. I took it in my Senior year and did pretty well. In contrast, I took four years of Latin, and three years of Greek, as part of the school’s Greek Honors tract.

Little did I know that Covid would create a pathologic convergence of sorts six decades later. Let’s review the Covid mutants:

Alpha – A variant first detected in Kent, UK with 50% more transmissibility than the original and has spread widely.

Beta – Originating in South Africa and the first to show a mutation that partially provided evasion of the human immune system, but may have also made it less infectious.

Gamma – First detected in Brazil with rapid spread throughout South America.

Delta – First seen in India with 50% more transmissibility than the Alpha variant, and now the dominant variant in America and around the world.

Our ability to track and identify mutating viruses in real time is now extraordinary. Over 2 million Covid genomes have been cataloged and published. But describing the “anatomy” of the virus is miles away from understanding the functional significance of their codes, or the various biochemical instructions they may instruct.

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