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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.

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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, @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

Medical lessons from ‘Avengers’

Amit Phull, M.D., writing in FierceHealthcare gives his “take] on a few characters {from Avengers: Endgame} that mirror key players in healthcare and what the industry can learn from these beloved characters’ story lines.”

But he concludes:

“A huge player in Avengers: Endgame that almost always seems to be forgotten are the innocent civilians—which in healthcare, are the patients. In the battle of New York, the entire city is destroyed and innocent lives are taken. Let’s not forget: As entrepreneurs and business executives in healthcare, we cannot overlook the patients

“In the end, each hero’s mission really distills down to two players: the patient and the doctor. The patient who needs access to high-quality healthcare and the physician who administers that care. No matter what your healthcare business may be, it’s important to always keep the patient and the physician top of mind, or else we will lose sight of the bigger picture and our version of the supervillain Thanos may win. ” 

To read his piece, please hit this link.

4 elements in resetting health-institution culture

Michael N. Abrams, Numerof & Associates managing partner, and Gordon Phillips, a Numerof consultant, write in FierceHealthcare:

“Resetting cultural beliefs and behaviors requires top-down commitment and a systematic approach to assessing and reshaping organizational culture. Organizations that have successfully navigated this transition have focused on four central elements:

  1. Establish a strategic vision. Leaders need to engage critical stakeholders in defining a vision for the future that considers changing market dynamics, the competitive landscape and unmet market needs.”
  2. “Develop an enabling organizational structure. Titles and reporting structures send clear messages to the organization about strategic priorities and cultural shifts. If a provider is committed to improving the experience of its patients, a chief customer experience officer reporting directly to the CEO demonstrates that the organization is serious about putting the customer at the center of strategic and operational decisions.”
  3. “Recalibrate performance measurement systems. As organizations define the new behaviors and competencies required for future success, they need to develop new performance measures and hold people accountable. Organizational goals and performance targets should cascade downward to ensure day-to-day work and decision-making align with the vision. As an example, organizations intent on improving patient access to primary care physicians need to be sure that access-related metrics are built into clinic-level performance standards as well as the performance targets of physicians and extenders.”
  4. “Create a tight feedback loop. Organizations seeking to change their culture must reinforce desired behaviors and recognize performance. Rewards can be intrinsic or extrinsic, ranging from compensation and incentives to public recognition and celebration of successes…. As new delivery models transcend organizational boundaries, it’s also critical to provide feedback and reinforce culture with strategic partners ranging from independent physician practices to post-acute providers and community resources.”

To read their whole article, please hit this link.

Employed physicians now outnumber those in private practice

For the first time, reports an American Medical Association press report, there are fewer physician owners (45.9%) than employees (47.4%), The data were collected in a national survey of 3,500 U.S. physicians and reported in a Physician Practice Benchmark Survey

A FierceHealthcare report on the news said:

“The trend was fueled by the preference of younger physicians toward employed positions. Nearly 70% of physicians under age 40 were employees in 2018.

“Whether physicians are owners, employees or independent contractors varied widely across medical specialties in 2018. For instance, surgical subspecialties had the highest share of owners (64.5%) while emergency medicine had the lowest share of owners (26.2%) and the highest share of independent contractors (27.3%). Family practice was the specialty with the highest share of employed physicians (57.4%).

“While the distribution of physicians has been shifting toward large practices and practices that are hospital-owned, 40% of physicians still worked in practices that were both small (10 or fewer physicians) and physician-owned in 2018, according to the report. More than half of doctors (56%) still work in practices with 10 or fewer physicians.”

To read the FierceHealthcare article, please hit this link.

To read the Physician Practice Benchmark Survey, please hit this link.

Who should lead culture change?

An NEJM Catalyst article looks at who should lead culture change at hospitals and other healthcare institutions: Should it be a physician and what should be the priorities of a change campaign — bottom line or patient care? To read the article, please hit this link.

How to improve gender equity in health-care leadership

In a Modern Healthcare essay, Joanne Conroy, M.D., president and CEO of Dartmouth-Hitchcock Medical Center, in Lebanon, N.H., discusses how to speed up progress toward gender equity in health-care leadership. Among her remarks:

“At my organization, Dartmouth-Hitchcock, we ask all of our vendors to disclose, in the request-for-proposals process, the diversity of their executive teams and board composition. We want to have partnerships with financially healthy organizations, and we know that diversity in management helps lead to sustainable financial performance.

“In a much broader effort, the Equity Collaborative will launch this summer with a design day just before Modern Healthcare’s “Women in Leadership”conference on July 31 in Chicago. The group will be a learning community of men and women, leading large healthcare organizations, who are committed to helping healthcare companies transform their cultures in order to accelerate the advancement of women in management and governance. By sharing practices that are effective, the Equity Collaborative participants will strive to accelerate progress in achieving gender equity in their organizations and promoting equity across the healthcare industry.”

“We don’t want to simplify the challenge by asserting that women make better leaders than men. Instead we want to stress that greater representation by women and attention to the environment at the top of an organization allow everyone to be empowered, engaged, included and respected in their pursuit of improving health….”

To read her essay, please hit this link.

Dartmouth-Hitchcock Medical Center.

Survey: Organizational culture is key in improving healthcare

An article in NEJM Catalyst, rich with survey material, says that “organizational culture” is the most important element in an institution meeting healthcare-improvement goals. The authors, Stephen Swensen, M.D., and Namita Seth Mohta, M.D., write:

“{I}t is notable that culture at many health care organizations is changing — and in the right direction, say nearly 60% of respondents to our latest NEJM Catalyst Insights Council survey. Three-quarters of respondents — who are clinical leaders, clinicians, and executives from organizations directly involved in healthcare delivery — label culture change a high or moderate priority in their organization.”

Those surveyed in NEJM Catalyst Insights Council Survey said, in the authors’ words, that “a commitment to quality, an emphasis on patient care, and a focus on each individual’s impact have resulted in positive culture change at their organizations, whereas concentrating too heavily on the bottom line and productivity has had negative repercussions.”

To read the NEJM article, please hit this link.

A independent specialty practice in pursuit of value-based care

An article in NEJM Catalyst looks at how an independent cardiology practice has transformed itself in pursuit of value-based care. To read it, please hit this link.

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