ROBERT McNUTT, MD

What matters is what we know, not what we think

In the late 1980’s I cared for a pregnant woman with breast cancer. Breast cancer is the most common cancer in pregnancy, but uncommon in number, occurring in about 1 in 3000 pregnancies. It is a compounded emotional treating experience for sure, and at that time uncertainty in how to treat was the norm. The woman had a mastectomy but did not take chemotherapy based on concern for her baby.

Three months after her delivery, now getting chemotherapy for her aggressive breast cancer, the woman asked me to consider treating her newborn child with “mild” chemotherapy, a clear contrarian idea given her reluctance to expose her child while in her uterus. Her reasoning, she said, after giving it “lots” of thought, was that it made sense to her; she had cancer at a young age and reasoned her child would also. In her mind it was rational and reasonable to give her child treatment.

Fear and depression fueled her concern, for sure, and universally we would deny the request. The woman would not live to see her child’s second birthday and wanted to do what she could for her. But, there was no evidence of benefit to the baby, making her request irrational. So, I did not comply. In fact, what would you have thought of me if I had complied with this woman’s concerns?

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By SAURABH JHA, MD

The two writers who got inside my head were polar opposites. Christopher Hitchens was an atheist, who mocked religion incessantly, and spared few sacred cows – he went after both Mother Teresa and Bill Clinton, though for patently opposite reasons. G.K. Chesterton, the sardonic, plump Englishman, went after heretics. Hitchens destroyed orthodoxy. Chesterton mocked radicals. Hitchens once quipped that “what can be asserted without evidence can be dismissed without evidence.” Chesterton quipped that the rebel, the infinite skeptic, was in fact a decerebrate orthodox. If both were on Twitter they’d be trolling each other, non-stop. Though fighting on opposite sides, they had a commonality – they punished sloppy thinking, one with prose and the other with wit.

I’ve long wondered who would be healthcare’s Hitchens and Chesterton. Physician writers have generally been disappointments, because they veer, almost uncontrollably, towards tedious self-flagellation, ever keen to internalize medicine’s original sin – an imperfect science, a stubborn art. Unlike prophets of yore who risked harm in expressing their views, medicine’s prophets moralize from the comfort of their six-figure salaries. “We do too much”, they say, even as they’re grass fed by the excess they so disdain – count me in this army of hypocrites.

For many years healthcare watchers have been fed a steady stream of Disneyland economics, trite platitudes, which have simplified the complexities of healthcare – cheesecake factories and checklists, value not volume, “we must do things for patients, not to patients” (needless to say that often to do things for patients you must do things to patients), amongst others. Whatever purpose platitudes are supposed to serve, they bring all critical thinking to a jerky end. I recall several talks during the passage of the Affordable Care Act in which the speaker would romp to a standing ovation for stating blithely – “let’s pay doctors for doing the right thing”, with me still muttering “how?”

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By JOELLE JUNG & VALERIE LEWIS

Policymakers and providers all agree that addressing patients’ non-medical needs will be critical to improving health, health care, and health care costs, but little progress has been made towards integrating traditionally segmented services. What can and should a health care organization do? Realistically, most health care organizations will not build new lines of social services into their core clinical operations. Instead, leading organizations are connecting the dots by optimizing referrals to existing community resources. Based on phone interviews and site visits with executive leadership, frontline providers, and community partners, we highlight the work of nine innovative health care organizations. Here, we offer practical steps to reflect upon where your organization stands and where it might look to be in a referral model for community resources.

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By DAVID INTROCASO and SCOTT HINES, MD

The Medicare Payment Advisory Commission (MedPAC) has been discussing for well over a year how to reinvent the Medicare Access and CHIP Reauthorization Act’s (MACRA) Merit-Based Incentive Payment System (MIPS).   As a result the commission intends to finalize substantial MIPS program reform recommendations in January.  Though MedPAC has had good reason to question MIPS, the commission’s effort is misguided.  By choosing to address MIPS, MedPAC has lost the forest for the trees.  MIPS does nothing to fulfill MACRA’s intent.  Title I of MACRA is intended to accelerate the Centers for Medicare and Medicaid Services’ (CMS’) efforts to move Medicare Part B providers into participation in what MACRA terms Alternative Payment Models (APMs), or more specifically advanced APMs.  This goal remains in the balance.

MedPAC’s Critique

Authorized in 2015, MACRA was designed to replace the 1997 Sustainable Growth Rate (SGR) formula by moving physician practices from Fee For Service (FFS) to pay for performance arrangements, or APMs.  The MIPS simply replaces and consolidates three previously existing FFS payment incentive programs that date back to 2006: the Physician Quality Reporting System (PQRS); the Electronic Health Record Incentive Program (termed Meaningful Use or MU); and, the Physician Value-Based Payment Modifier program (termed VM). 

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By ART CAPLAN

Donald Trump and many of his closest advisors have been accused of colluding with Russia to win his election as President. We shall see what Robert Mueller and the FBI discover in that regard. But, whatever truth emerges there is no doubt that Trump has ripped a page from a long-dead leader of the Soviet Union, the monster Joseph Stalin, to undercut science in the name of his ideological goals.

Friday the Washington Post reported that a senior leader at the Centers for Disease Control and Prevention was told not to use certain words in documents “related to the budget and supporting materials that are to be given to the CDC’s partners and to Congress”. Policy analysts at the Centers for Disease Control and Prevention in Atlanta the Post said were given a list of forbidden words at a meeting with senior CDC officials. The seven prohibited words are:

• Vulnerable
• Entitlement
• Diversity
• Transgender
• Fetus
• Evidence-based
• Science-based

What does Trump’s disgraceful censorship of science by banning words known to be useful, valuable, essential and important have to do with Stalin and Russia? Everything.

Stalin like Trump only wanted to hear scientific words when they confirmed his political beliefs. He did not care if by implementing false news he killed millions of his citizens. Trump with his decision to ban scientific terms in public policy that don’t suit his taste is proudly marching in Uncle Joe’s bloody footsteps.

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By PETER LONG

With the implementation of the Affordable Care Act and the push toward the Triple Aim of patient-focused care, lower costs, and improved health of populations — “population health” has become a buzzword, often coming to mean improving medical care or simply delivering healthcare to larger groups of people. While providing high-quality healthcare is critical, improving the health of a population is a much bigger endeavor.

Improving population health ultimately means creating healthy communities. It involves a myriad of interrelated factors that contribute to an individual’s health – such as safety in the home, appropriate housing, education, access to healthy food, clean air, time and space for recreation, social connections, and mental health services.

In a large, diverse, and inclusive state willing to invest in its people—with many funders pledging support for new approaches, California has become a proving ground for innovative programs to improve population health and serve as models that can be replicated elsewhere. Successful models have some things in common: They use data to precisely identify which factors are impacting health: establish shared goals and benchmarks; and track progress over time.Continue reading…