Cooperating for better care.

News & Views

Four tenets for physician incentives

“Incentives are there to try to change behavior, to try to move things along,” noted John Jenrette, M.D., executive vice president for Cedars-Sinai Medical Network, during a talk on physician incentives, as reported in NEJM Catalyst.

His four tenets of physician incentives and behaviors, reports the NEJM article and video:

  1. Follow the money. ‘Physicians like money and financial incentives, yes, but they’re not at the core, at all. They aren’t. They maybe have this kind of incremental impact if you can put them in the right direction, but I truly believe that if physicians are compensated appropriately for the work they’re doing, the incentives become that icing on the cake, that top performance, the things that we want to pay attention to, want to try to focus on, and reward physicians for that type of behavior.’”
  2. Produce meaningful data. ‘That data has to be accurate, it has to be reliable, it has to be meaningful. If you have walked into a room with a bunch of physicians with data, and they begin to poke thousands of holes into it, you walk out of the room with your tail between your legs, completely discredited, and you will spend so much energy trying to get back there, and even have another conversation. The reliability and meaningfulness of the data and how that applies is important to the why I take care of patients and do the work that I do.”’
  3. Involve physicians. ‘Physicians want to be a part of the process. They want to be in the conversation. ….They want to help guide that and direct it, and make sure the data can be meaningful and helpful to their practices and the work that they do. …”’
  4. Ask why. Jenrette stresses that this fourth tenet is the most important. ”’It goes to the core of why we are physicians, in taking care of our patients, in taking care of families, in creating great outcomes and seeing people live healthy and happy. That’s why we become physicians, and why we need to continue to focus in that direction.”’

TO read/hear the article, please hit this link.


Breaking down health-care silos

Four staffers at Boston’s Brigham and Women’s Hospital write about breaking down health-care silos in this case regarding treatment of patients with end-stage renal disease.

Among their observations:

“{I}n 2016 we launched a coordinated ESRD program within Partners Healthcare, based at Brigham and Women’s Hospital (BWH) in Boston, one of the first to bring the care-coordination principles that are increasingly common in primary care to disease-specific specialty care. While other programs, like the CMS ESRD demonstration projects, have piloted care-coordination models with large dialysis organizations, ours is the only such program that we’re aware of that coordinates care across all stakeholders (dialysis units, hospitals, primary care providers, and others) rather than focusing on care within the dialysis unit itself. Further, unlike other programs, ours extends beyond dialysis-based care to facilitate transplant evaluations and, when needed, palliative care.”

To read the whole article, please hit this link.


Severe shortage in residency slots

FierceHealthcare reports:

“There’s more medical school students than ever before, but there’s still a big obstacle to solving a predicted physician shortage.

“While U.S. medical school enrollment has increased, averting a physician shortage now depends on more residency training slots, according to the results of an annual survey from the Association of American Medical Colleges (AAMC).

“The number of residency positions has increased only 1% a year, far lower than the 52% growth in medical school spots since 2002, the AAMC said. Federally supported residency training slots have been capped by Congress for more than 20 years, limiting the spots for medical school graduates to undergo additional training in a residency program before they can practice medicine….”

“The survey found that medical school deans are worried about the lack of residency slots: 75% expressed concern about the availability of residency slots nationally, and 44% expressed concerns about their own incoming students’ ability to find residency positions of their choice after medical school. Over half of schools reported they experienced difficulty in finding clinical training sites for obstetrics/ gynecology and pediatrics.”

To read the whole article, please hit this link.


Trump changes linked to worrisome decline in ACO partcipation

From FierceHealthcare:

“Some Accountable Care Organization (ACO) groups are worried that a dip in participation this year could be the start of a worrisome trend due to major changes made to the program by the Trump administration.

“The Centers for Medicare & Medicaid Services (CMS) announced Wednesday that 518 ACOs are part of the program as of July 1, a decline from 561 ACOs that participated in 2018. The new data have the National Association of ACOs (NAACOS) worried about whether the decline is an anomaly or the start of a trend thanks to major changes to the Medicare Shared Savings Program (MSSP).

“CMS Administrator Seema Verma wrote in a blog post on Health Affairs Wednesday that CMS approved 206 ACOs to start July 1 and that 41 of them are new to the program. The number of new entrants is below the normal rate of more than 100 ACOs that have signed up each year since the program started seven years ago.”

To read the whole article, please hit this link.


NYC value-based joint venture chalks up savings

In an NEJM Catalyst article headlined “Success in Hospital-Integrated Accountable Care Organization,” the authors write:

“Conventional wisdom holds that urban academic medical centers are ill-suited for value-based care initiatives such as the Medicare Shared Savings Program (MSSP). Nevertheless, NewYork Quality Care, the MSSP Accountable Care Organization (ACO) established in 2015 as a joint venture between NewYork-Presbyterian, Columbia University Vagelos College of Physicians and Surgeons, and Weill Cornell Medicine, achieved savings in each of its 3 performance years by implementing a range of operational, financial, and analytical initiatives.”

“The creation of NewYork Quality Care has established a blueprint for collaboration that has increased alignment among our three institutions. Looking ahead, our plan is to potentially expand NewYork Quality Care to include additional clinicians and their attributed beneficiaries. We also plan to leverage the care redesign and analytics capabilities that we have developed to inform other such efforts across our three institutions.”

To read the whole article, please hit this link.


Dealing with vast distances in health care

In a NEJM Catalyst piece, Amy Compton-Phillips, M.D., executive vice president and chief clinical officer for Providence St. Joseph Health, the big western U.S. hospital chain, discusses how to “decouple care from geography {especially in the vast and sparsely settled sections of the mountain West} so that we can break that constraint. To do this, we have to have a different business model than today. We can’t just be a hospital system.” Instead, she says, Providence is building business verticals, such as for the physician enterprise, ambulatory care and home and community services.

NEJM says:

“Providence is working on retrieving data to create a sustainable business model for this digital health care; with headquarters in Seattle, Amazon.com and Microsoft are down the street, meaning there are a lot of data scientists in the area. Providence is leveraging these data scientists to embed AImachine learning, and data science, and in terms of capacity is investing in tools that decouple care from geography, including a variety of apps.”

“The health system’s telemedicine network includes, for example, a Telestroke program in 100 hospitals. With telemedicine, Providence has been able to work around the conundrums that come with regulatory differences in different states. In addition to access to care, they’ve also developed online health professions education at the University of Providence, providing long-distance learning and simulation and matching up resources to where they’re needed so that students can stay in their rural communities rather having to move to a city,” NEJM reports.

To read and hear the full article, please hit this link.


What if our care were designed by patients?

In a NEJM Catalyst video and text piece, Stephen Swensen, M.D., of the Mayo Clinic College of Medicine, talks about what medicine would look like if patients designed it. Dr. Swensen is a Senior Fellow of the Institute for Healthcare Improvement.

Among his remarks:

“Our health care system has 40% waste by the most conservative estimates, and the top three categories of waste we own: overtreatment, failures of care delivery, failures of care coordination,” and he warns of the danger of being driven by financial considerations.

“Not only is putting patients’ interest first in the patient’s best interest, but it’s in ours. If you look at drivers of {physician} burnout, one of the drivers is moral distress, and a values dissonance. So not only is it good for patients to put their interests first, it’s good for us.”

To read/hear the package, please hit this link.


Yes, there are very good trends in medicine

In an NEJM Catalyst interview, Michael Dowling, the CEO for Northwell Health, and Charles Kenney, chief journalist there, talk about what they learned in putting together their new health-policy book, Health Care Reboot: Megatrends Energizing American Medicine. While the conventional wisdom is that the American health “system” is broken, the authors are optimistic about trends, especially regarding the benefits of value-based care, more appreciation of the social determinants of health, a growing emphasis on ambulatory care and expanded access as medicine becomes more consumer-driven.

To read and hear this feature, please hit this link.


Elisabeth Rosenthal: Why Alexa can be bad for health care

From Kaiser Health News

Amazon has opened a new health care frontier: Now Alexa can be used to transmit patient data. Using this new feature — which Amazon labeled as a “skill” — a company named Livongo will allow diabetes patients — which it calls “members” — to use the device to “query their last blood sugar reading, blood sugar measurement trends, and receive insights and Health Nudges that are personalized to them.”

Private equity and venture capital firms are in love with a legion of companies and startups touting the benefits of virtual doctors’ visits and telemedicine to revolutionize health care, investing almost $10 billion in 2018, a record for the sector. Without stepping into a gym or a clinic, a startup called Kinetxx will provide patients with virtual physical therapy, along with messaging and exercise logging. And Maven Clinic (which is not actually a physical place) offers online medical guidance and personal advice focusing on women’s health needs.

In April, at Fortune’s Brainstorm Health conference in San Diego, Bruce Broussard, CEO of health insurer Humana, said he believes technology will help patients receive help during medical crises, citing the benefits of home monitoring and the ability of doctors’ visits to be conducted by video conference.

But when I returned from Brainstorm Health, I was confronted by an alternative reality of virtual medicine: a $235 medical bill for a telehealth visit that resulted from one of my kids calling a longtime doctor’s office. It was for a five-minute phone call answering a question about a possible infection.

Virtual communications have streamlined life and transformed many of our relationships for the better. There is little need anymore to sit across the desk from a tax accountant or travel agent or to stand in a queue for a bank teller. And there is certainly room for disruptive digital innovation in our confusing and overpriced health care system.

But it remains an open question whether virtual medicine will prove a valuable, convenient adjunct to health care. Or, instead, will it be a way for the U.S. profit-driven health care system to make big bucks by outsourcing core duties — while providing a paler version of actual medical treatment?

After all, my doctors have long answered my questions and dispensed phone and email advice for free — as part of our doctor-patient relationship — though it didn’t have a cool branding moniker like telehealth. And my obstetrician’s office offered great support and advice through two difficult pregnancies — maybe they should have been paid for that valuable service. But $235 for a phone call (which works out to over $2,000 per hour)? Not even a corporate lawyer bills that.

Logic holds that some digital health tools have tremendous potential: A neurologist can view a patient by video to see if lopsided facial movements suggest a stroke. A patient with an irregular heart rhythm could send in digital tracings to see if a new prescription drug is working. But the tangible benefit of many other virtual services offered is less certain. Some people may like receiving feedback about their sleep from an Apple Watch, but I’m not sure that’s medicine.

And if virtual medicine is pursued in the name of business efficiency or just profit, it has enormous potential to make health care worse.

My doctor’s nurse is far better equipped to answer a question about my ongoing health problem than someone at a call center reading from a script. And, however thorough a virtual visit may be, it forsakes some of the diagnostic information that comes when you see and touch the patient.

A study published recently in Pediatrics found that children who had a telemedicine visit for an upper-respiratory infection were far more likely to get an antibiotic than those who physically saw a doctor, suggesting overprescribing is at work. It makes sense: A doctor can’t use a stethoscope to listen to lungs or wiggle an otoscope into a kid’s ear by video. Similarly, a virtual physical therapist can’t feel the knots in muscle or notice a fleeting wince on a patient’s face via camera.

More important, perhaps, virtual medicine means losing the support that has long been a crucial part of the profession. There are programs to provide iPads to people in home hospice for resources about grief and chatbots that purport to treat depression. Maybe people at such challenging moments need — and deserve — human contact.

Of course, companies like those mentioned are expecting to be reimbursed for the remote monitoring and virtual advice they provide. Investors, in turn, get generous payback without having to employ so many actual doctors or other health professionals. Livongo, for instance, has raised a total of $235 million in funding over six rounds. And, as of 2018, Medicare announced it would allow such digital monitoring tools to “qualify for reimbursement,” if they are “clinically endorsed.” But, ultimately, will the well-being of patients or investors decide which tools are clinically endorsed?

So far, with its new so-called skill, Alexa will be able to perform a half-dozen health-related services. In addition to diabetes coaching, it can find the earliest urgent care appointment in a given area and check the status of a prescription drug delivery.

But it will not provide many things patients desperately want, which technology should be able to readily deliver, such as a reliable price estimate for an upcoming surgery, the infection rates at the local hospital, the location of the cheapest cholesterol test nearby. And if we’re trying to bring health care into the tech-enabled 21st century, how about starting with low-hanging fruit: Does any other sector still use paper bills and faxes?

Elisabeth Rosenthal is a Kaiser Health News journalist
erosenthal@kff.org, @rosenthalhealth


Three pivots for returning to the best principles of medicine

Listen carefully and ask the right questions. “We need to listen carefully to people and ask what matters to them, not what’s the matter with them,” she says. Also ask what happened to them. “By listening through that lens, it opens up a curiosity. How do you capture [patient] nuance in the electronic records? How does that nuance not get lost? We have to ask the right questions.”

In an NEJM Catalyst text and video piece, Anna Roth, R.N., health director of Contra Costa County, Calif., lays out three pivots for returning to the best principles of medicine. They are:

Challenge your beliefs. “Beliefs set boundaries. Beliefs are the basis of our boundaries.” Roth provides an example: When she was CEO during the H1N1 epidemic, the hospital strengthened its visitor policy. For infection control reasons, they did not allow children ages 12 and under to visit, which meant denying an 8-year-old from saying goodbye to his grandfather — who was also his primary provider — in the critical care unit. “We prioritized infection control over love, and it was something we didn’t have to do.”

Trust people. “We need to trust people. We need to trust our workers,” says Roth. Continuing the story about the 8-year-old, she describes how upset staff were that his grandfather couldn’t see him. They came to her office to explain the situation and that it didn’t need to happen — they could’ve just put a mask on the boy, instead of following the policy that led to this tragedy.”

To read and hear her, please hit this link.

February 1918 drawing by Marguerite Martyn of a visiting nurse in St. Louis, Mo., with medicine and babies


Page 1 of 364123...Last

Contact Info

info@cmg625.com

(617) 230-4965

Wellesley, Mass