By BAILEY FITZGERALD, MD

“It’s a terrible way to die” The oncology fellow told me bluntly as we walked to the room. “There is nothing okay about this.”

Knocking on the open door, we entered his room. The blinds were raised to reveal a stunning view of the area surrounding the VA hospital, and light poured in.

Our patient reclined in bed, his eyes closed although he was not asleep. He opened his eyes at the sound of our entrance, and the eyes seemed to bulge, too large for his shrunken face with wasted muscles. A plastic tube, taped to the bridge of his nose, entered his nostril and disappeared. The other end of the tubing led to a canister filled with dark green liquid that had been suctioned from his gastrointestinal tract. Despite this invasion, his stomach remained distended, protuberant compared with his otherwise frail frame.

The man had an aggressive colon cancer. The tumor in his colon had grown so large that the hollow of his bowel had closed off, allowing no food to pass through. With nowhere else to go, the contents of his bowel backed up, puffing out his stomach and causing terrible nausea and vomiting. Even worse, the tumor invaded outwards too, anchoring tendrils into the surrounding tissue so that there was no longer any hope of removing the tumor surgically. “Palliative” chemotherapy to try to shrink the tumor would be offered, but it had no chance of curing his disease. The oncologist’s note summarized the situation: “Prognosis is extremely poor.”

It was a good learning case, a late presentation of a disease increasingly diagnosed at early stages by screening colonoscopies. This patient had not undergone screening, which might have diagnosed the cancer while there was still time for a cure. As an African American, this patient was more likely to develop this cancer than Caucasian patients his age.

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By MICHAEL J. ALKIRE

Pharmaceuticals play a major role in today’s population health era – they can prevent and cure disease, improve or maintain wellness and slow progression of existing conditions. Yet, their promise can also be a curse if high prices limit patient access and bankrupt the healthcare providers and insurers bearing significant financial risk for patient care.

The proactive new leadership at the FDA is promoting competitive markets by combatting the abuse of well-intentioned programs and market share monopolies. Commissioner Scott Gottlieb has ramped up the FDA’s efforts to prevent drug manufacturers from “gaming the system” in a number of ways.

Accelerating generic approvals and creating transparency to stimulate competition

For the first time, the FDA made publicly available a list of off-patent, off-exclusivity branded drugs without generic competition. Using the list, Premier immediately identified a number of critical drugs for patient care and has been working with manufacturers to participate in the FDA’s new expedited review process. Additionally, Congress recently enacted legislation creating an expedited review process for generic drug applications when there are fewer than three manufacturers in the market for a given drug product. We strongly support and helped to champion these efforts, and are hopeful that the FDA will use this new authority to foster competition and curb price spikes and shortages in generic drugs where only a few players dominate.

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By NIRAN AL AGBA, MD

Health Savings Accounts (HSAs) allow individuals to use pre-tax dollars to pay for high deductibles and other uncovered medical expenses. Currently, individuals are ineligible for tax-advantaged HSA contributions if they have “other” coverage in addition to a High Deductible Health Plan (HDHP.) Expanding HSAs to fund out-of-pocket expenses for routine healthcare places control directly in the hands of patients, a move that could bring down health expenditures. Large corporations are wrestling for control to direct where patients spend their hard-earned money.

A group of lawmakers recently introduced the “bipartisan” Health Savings Account Improvement Act of 2018 (H.R. 5138). This bill allegedly “expands” HSA coverage to allow use at “retail-based” (think CVS/Target) or “employer-owned” clinics (think Amazon) without losing eligibility to make tax-advantaged contributions to their HSAs. Increasing the flexibility of HSAs is a laudable goal yet, this legislation herds Americans like sheep into Minute Clinics for the benefit of corporate shareholders.

This bill should not become law. If HR 5138 passes, retail and employer-based clinics will become profit centers.   Alternative legislation, known as the Primary Care Enhancement Act (H.R. 365), amends the definition of “qualified medical expenses” to include fees paid to physicians as part of a “primary care service arrangement.” This common-sense legislation flounders in Congress every year.

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By STEPHEN BORSTELMANN, MD

Artificial Intelligence is at peak buzzword: it elicits either the euphoria of a technological paradise with anthropomorphic robots to tidy up after us, or fears of hostile machines breaking the human spirit in a world without hope. Both are fiction.

The Artificial Intelligences of our reality are those of Machine Learning and Deep Learning. Let’s make it simple: both are AI – but not the AI of fiction. Instead, these are limited intelligences capable of only the task they are created for: “weak” or “narrow” AI. Machine Learning is essentially applied Statistics, excellently explained in Hastie and Tibshirani’s Introduction to Statistical Learning. Machine Learning is a more mature field, with more practitioners, and a deeper body of evidence and experience.

Deep Learning is a different animal – a hybrid of Computer Science and Statistics, using networks defined in computer code. Deep Learning isn’t entirely new – Yann LeCun’s 1998 LeNet network was used for optically recognizing 10% of US checks.   But the compute power necessary for other image recognition tasks would require an additional decade. Sensationalism by overly optimistic press releases co-exists with establishment inertia and claims of “black box” opacity. For the non-practitioner, it is very difficult to know what to believe, with confusion the rule.

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By CHUCK SAUNDERS, MD and NEAL SHORE MD, FACS

2017 was a pivotal year for the growth of value-based care. For many practices, this meant completing their first performance year as part of the Merit-Based Incentive Payment System (MIPS). A much smaller percentage of practices was able to participate in approved advanced Alternative Payment Models (APMs).

While practices await feedback on their 2017 performance, early lessons have already become evident. Clearly, as practices are assigned greater responsibility and accountability for patient populations, it becomes increasingly important that they effectively navigate the reimbursement models upon which their financial viability depends.

Where should provider practices start? The MIPS model may not be a long-term answer. MedPAC has recently clearly articulated their disfavor with MIPS and desire to replace it. In contrast, advanced APMs provide a much more fertile ground for providers to work collectively. They can contribute their unique clinical expertise to define opportunities to improve quality and cost, focused on areas that have potentially greater beneficial impact on patient care and practice pathways. The Center for Medicare and Medicaid Innovation (CMMI) recently acknowledged as much by unveiling the Bundled Payments for Care Improvements (BPCI) effort that measures performance and sets payment against four broadly defined models of care.

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