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Not too few physicians but bad distribution, not enough non-physician clinicians

It’s sort of a cliche to say that America has a  dangerous shortage of physicians. But a New York Times story challenges that.

It says, among other things:

“Some people think there’s no shortage at all — just a poor distribution of the doctors we have.”

“Adding data to this argument, the United States has fewer practicing physicians per 1,000 people than 23 of the 28 countries that reported data in 2013 (among nations in the Organization for Economic Cooperation and Development).”

“But there is strong evidence that we are thinking about this the wrong way. In 2014, the Institute of Medicine released a thorough analysis on graduate medical education that argued there was no doctor shortage, and that we didn’t really need to invest more in new physicians.

“The system isn’t undermanned, it said: It’s inefficient. We rely too heavily on physicians and not enough on midlevel practitioners, like physician assistants and nurse practitioners, especially because evidence supports they are just as effective in primary care settings. We don’t account for advances in technology, like telehealth and new drugs and devices that lessen the burden on physician visits to maintain health.”

“And we fail to recognize that what we really have is a distribution problem. Parts of this country have lots of doctors, perhaps too many. These are mostly in cities, especially in cities where it seems desirable to live. The problem is made worse by the ways we reimburse for care. Medicare, for instance, pays more to doctors who live in places that are more expensive. The argument for this is that the cost of living is higher, so reimbursements must be, too. But that also means that doctors can earn more in places where they already might want to live. A result is that many rural areas, and less popular cities, experience more of a doctor shortage than others.”

“The other distribution issue is in specialization. When it comes to generalists, we ranked 24th of 28 countries in doctors per 1,000 people. Specialists are a different story. There, we were 11th. This is an important fact about the American health care system. We sometimes hear that we have too many specialists and too few generalists. That’s not necessarily the case. We have an average number of specialists compared with other advanced countries, and even shortages in some specialties. It’s the ratio of specialists to generalists that’s the problem. …”

To read the full Times story, please hit this link.

Panel: Expand preventive services with no cost-sharing for women


For Kaiser Health News

The list of preventive services that women can receive without paying anything out of pocket under the health law could grow if proposed recommendations by a group of mostly medical providers are adopted by federal officials later this year.

The draft recommendations, which are open for public comment until Sept. 30, update the eight recommended preventive services for women. That list was developed by the Institute of Medicine — now called the National Academies of Sciences, Engineering, and Medicine — to build on existing recommendations and fill in gaps that weren’t addressed in the health law. Under the IOM list, which took effect in 2012, most health plans are required to cover well-woman visits, screening and/or counseling for sexually transmitted infections, domestic violence and gestational diabetes as well as breastfeeding support and supplies.IOK

In addition, most health plans must cover, without cost-sharing, all methods of contraception that have been approved by the Food and Drug Administration. That controversial requirement led to numerous lawsuits by religious institutions and employers that object to providing such coverage, including several cases that reached the Supreme Court.

When it developed the initial list, the IOM advised that the guidelines be reviewed and updated at least every five years in order to stay current with scientific evidence. This year, the review panel also weighed in on breast cancer screening, coverage of follow-up testing or procedures as part of the preventive services and male methods of birth control.

The proposed new recommendation would allow women at average risk for breast cancer to begin screening as early as age 40 and receive a mammogram every one or two years. That is a more liberal standard than the guidelines that insurers rely on for free screening from the U.S. Preventive Services Task Force, which recommends women generally be screened every other year starting at age 50.

“We have really confused the heck out of women,” said Dr. Hal Lawrence, executive vice president and chief executive officer of the American Congress of Obstetricians and Gynecologists. “Do I start at age 40, do I start at 50, do I do it every year or do I do it every other year? We wanted to get some uniformity.”

ACOG was awarded a 5-year grant to manage the review process, working in conjunction with a steering committee of nearly two dozen provider groups from different women’s health disciplines.

In addition to the breast cancer screening itself, the ACOG working group proposes that if imaging tests, biopsies or other interventions are required to evaluate the mammogram findings that those be considered an integral part of the screening, which would mean they would be provided without charge to women.

Such follow-up care emerged as a theme from the panel: If additional testing or procedures are necessary following a preventive service, it should be covered as part of the service. The recommendations also clarify that some of the preventive services may require more than one visit and provide other specifics on coverage requirements.

“It’s critically important for plans and people to recognize that the well-woman visit [required under the current guidelines] could happen in multiple places and require multiple visits,” said Mara Gandal-Powers, senior counsel at the National Women’s Law Center, which participated in the ACOG working group. “If you’re a woman who needs a Pap test and a colonoscopy, you’re probably not getting them from the same providers and you’re hopefully not getting them at the same time.”

The recommendations’ specificity is important: The original IOM guidelines left implementation details vague, leading to scuffles between patient advocates and insurers over precisely what was covered, and that ambiguity required ongoing guidance from the federal government. For example, if a plan covers oral contraceptives without cost sharing, could it charge for other hormonal methods such as the contraceptive patch? Answer: No.

“It’s helpful to get the real-world piece,” said Dania Palanker, assistant research professor at Georgetown University’s Center on Health Insurance Reforms. “For insurers, what do we mean when we say you have to cover a service?”

A spokesperson for America’s Health Insurance Plans said that the trade group will likely submit comments on the proposed recommendations and declined to comment before then.

The working group recommended expanding the scope of what’s covered without cost sharing in some important ways. The contraceptive coverage requirement, for example, would cover over-the-counter methods of birth control without a prescription and allow women to receive a full-year supply of contraceptives all at once, which has been shown to improve adherence.

The ACOG group also proposes covering contraception methods used by men, including condoms and vasectomy.

“The best contraceptive method for a woman at a particular time may be her partner,” said Adam Sonfield, a senior policy manager at the Guttmacher Institute, a reproductive health research and policy organization.

The working group will submit its final recommendations to the Health Resources and Services Administration, part of the Department of Health and Human Services, by Dec. 1, and HRSA will make the final decision on adoption of the recommendations. If adopted before the end of the year, they would go into effect for most plans at the beginning of 2018.


A cold look at expanding primary-care access



Terence Redmond McAllister, M.D., and Leann DiDomenico McAllister push back against the idea that primary-care practices should be available to patients all the time. This leads, they argue, to clinician burnout and doesn’t help patients in the long run either.

They write:

“According to the Institute of Medicine, America’s overuse of healthcare services costs nearly $300 billion a year. And while extended and weekend hours provide ‘convenience care’ to a demanding public, extended hours have been shown to encourage patients to run to the doctor for every minor symptom they experience. Our current healthcare system trains patients to ‘feel better fast’ by running to the nearest ER with an advertised short wait time, urgent-care clinic, or buy the newest over-the-counter snake oil remedy. Contrary to popular advertising, a typical cold lasts 7 days to 10 days. It’s time we teach our patients to self-sooth.”

“Rumor has it that our quality contracts and new ACO contracts will encourage our practice to stay open longer and provide weekend hours; to be available ‘whenever’ our patients want us. We believe extended hours will increase unnecessary care which will increase costs and lead to more physician burnout.”

“Does primary care really need to be totally accessible 365 days a year, with very early and very late hours? Won’t we all sleep better and lower our burnout rate if we help our patients lower their unrealistic expectations of being ‘picked up’ {like  babies} every time they cry out?”


Restore hospitals’ continuity of care



Murray Epstein, M.D., writes that it’s time to restore continuity of care in U.S. hospitals.

“I wish to unfurl a red flag, a challenge to the legions of bureaucrats who hover under the umbrella of the Centers for Medicare & Medicaid Services and other agencies governed by the Department of Health and Human Services. Rather than focusing on electronic medical records, and expending hundreds of hours honing and refining penalties and dictums for physicians who have transgressed for slight ‘errors,’ I recommend that you expend time and energy developing a viable algorithm that is readily comprehended for ensuring continuity of clinical care.

“When a patient is asked to name his or her physician in charge, and the response is a blank stare, a deafening silence, or a long list of names, we must recognize that the patient care model currently espoused is broken, and no ACGME dictate will resolve this problem. I suggest that we reach out to the Institute of Medicine, which I regard with great esteem, to become involved and prioritize this problem as one of the key issues to solve in an accelerated timeline.”

10 recommendations for nursing’s future


The Institute of Medicine has released 10 recommendations for the future of nursing. They are, as summarized by Becker’s Hospital Review:

1. “Build common ground around scope of practice and other issues in policy and practice.”

2. “Continue pathways toward increasing the percentage of nurses with a baccalaureate degree.”

3. “Create and fund transition-to-practice residency programs. ”

4. “Promote nurses’ pursuit of doctoral degrees.

5. “Promote nurses’ inter-professional and lifelong learning. ”

6. “Make diversity in the nursing workforce a priority.”

7. “Expand efforts and opportunities for interprofessional collaboration and leadership development for nurses.”

8. “Promote the involvement of nurses in the redesign of care delivery and payment systems.”

9. “Communicate with a wider and more diverse audience to gain broad support for campaign objectives.”

10. “Improve workforce data collection.”


Physicians can’t ‘memorize it all’



Children memorizing parts of the Koran in Mauritania.

Art Papier, M.D., writes:

“The recently published diagnostic errors report, ‘Improving Diagnosis in Health Care,’  by the Institute of Medicine (IOM) will receive much attention, as it should. … {T}he new report will be transformative because it substantiates how large a problem misdiagnosis is, and will force the medical care system to work on solutions.”

“There are many steps to be taken. One immediate action is to recognize that physicians cannot memorize it all — they require the best information at the right time, which is at the point of care. To curb medical misdiagnosis, our model of what a doctor is and does must change. The IOM diagnostic errors report forces us to think about augmenting our brains, not with simple computer-based references or reliance on more tests, genetic studies, and x-rays, but with new cognitive support systems designed to pull the history and physical exam together to answer questions as we work. New digital systems accessible on smart devices IOMwill engage patients and replace the outdated waiting room clipboard screening questionnaires. Now that the IOM is helping the public realize the extent of the diagnostic errors problem, we can start to invest in new point-of-care information tools as well as new methods to aid thinking, and hopefully diminish the number of patients who are misdiagnosed every year.”

Looking at best care models for high-need patients

Here are the basic findings from the Commonwealth Fund of an evidence synthesis of models of care for high-need, high-cost patients:

“In a review conducted for the Institute of Medicine, Chad Boult and his colleagues at Johns Hopkins University identified 15 models of comprehensive care for older adults with chronic illness, which fit into six broad categories related to care settings. Most models reduced hospital use or length of stay, although the evidence was mixed in some cases. Three models—interdisciplinary primary care for heart failure patients, transitional care from hospital to home, and ‘hospital-at-home’ programs that substitute care in the patient’s home in lieu of a hospital stay—showed some evidence of lower cost, although this was not directly measured in all studies.

Curadux CEO looks at overtreatment and undertreatment

We were pleased to read this essay in Modern Healthcare by David L. Brown, M.D., chief executive and co-founder of Curadux, a healthcare decision-support firm that’s partnering with Cambridge Management Group in some projects.

Americans dealing with advanced illness are at risk of overtreatment and undertreatment of their conditions because powerful and silent incentives are often driving their healthcare, rather than their own unique values and goals. After 38 years of practicing medicine inside the world’s elite healthcare institutions, and as a survivor of my own advanced illness, this is my foremost concern for current and future generations of patients and their families.

For those serving inside modern medical institutions, these risks are well known. As one caregiver recently told the Institute of Medicine, “When you take the time to find out what’s most important to patients and families, they make very reasonable choices. The challenge is that our healthcare system does not encourage these conversations, our professional providers frequently do not have the time or training, and treatment measures default to those that are health system centered.”

Healthcare is not always patient-centered because our third-party payer system disrupts the normal buyer-seller relationship we often take for granted. In healthcare, for reasons of public policy, the consumer isn’t always the paying customer for the services they consume, which distorts incentive structures throughout healthcare (and not always for the patient’s benefit).

Overtreatment — treatment that is unnecessary or futile for improving a person’s quality of life—is the dominant problem today. It may cause unwanted, invasive and expensive care, as well as unnecessarily prolonged and painful deaths. Health systems are subtly incentivized to overtreat patients because they generate more revenue based on the volume of services provided. Physicians are incentivized to recommend more services because they want to minimize perceived risks to patients and their own legal liability. Without clear guidance to the contrary, physicians default to treating a condition, often no matter how futile or painful for the patient.

Undertreatment — the lack of necessary treatment for improving a person’s quality of life — is the emerging problem. Policymakers are seeking ways to control healthcare costs as governments bear more financial responsibility for healthcare due to an aging population, the expansion of government programs, and increased consumption of healthcare by individuals. Since policymakers can’t change demographics and since a policy decision has been made to expand programs and subsidies, the primary option left for policymakers is to limit consumption of services.

Like most service industries, healthcare providers have traditionally been paid fees for the services they provide. Healthcare is unique, however, because the third-party payer system eliminates the natural market mechanism for limiting consumer demand and optimizing the quality and quantity of services around the perceived value to the consumer. At present, without a meaningful limit on consumer demand, providers act in their self-interest and deliver higher volume of services, which generates more revenue and increases costs.

To control costs, whether wise or unwise, policymakers opted against moving toward a market-based model whereby consumers assume more responsibility for healthcare and, instead, expanded the current system. They are now testing an artificial mechanism for controlling demand by simply capping payments to providers through population-health concepts. While this may reduce costs, it creates the risk that providers may discourage healthcare services for people who may legitimately benefit from them.

To permanently realign healthcare incentives around the individual would require overhauling the entire system so market forces could naturally optimize consumption. This is unlikely because of legitimate public policy issues and the practical difficulty of overhauling established commercial, financial, and regulatory frameworks in a polarized political environment.

Today, patients must educate themselves and stay actively involved in aligning their values and goals with their healthcare decisions. Primary-care physicians traditionally led this process through end-of-life conversations, but as clinical production pressures and demands have increased, physicians have less time to thoroughly discuss and analyze each patient’s unique values and goals. Instead, physicians now often rely more on other staff to perform this function. While these staff can be useful, the rich expertise provided by experienced physicians is often lost. True patient-centered care for patients and families facing an advanced illness is clearly ready for further innovation.

Dr. David L. Brown has practiced medicine for 38 years. He recently retired as chairman of the Anesthesiology Institute at the Cleveland Clinic. He has also led the anesthesiology departments at the University of Texas M.D. Anderson Cancer Center, University of Iowa Hospital and Clinics, and Virginia Mason Medical Center, as well as serving as professor of anesthesiology at the Mayo Clinic. 


IOM on how to avoid misdiagnoses


The Institute of Medicine, noting that most patients suffer from at least one case of misdiagnosis, has come up with eight goals in combating them. The report linked here provides detailed recommendations on how to achieve those goals.

Goal 1: Facilitate more effective teamwork in the diagnostic process among healthcare professionals, patients and their families.
Goal 2: Enhance healthcare professional education and training in the diagnostic process.
Goal 3: Ensure that health information technologies support patients and health care professionals in the diagnostic process.
Goal 4: Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice.
Goal 5: Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance.
Goal 6: Develop a reporting environment and medical-liability system that facilitates improved diagnosis by learning from diagnostic
errors and near misses.
Goal 7: Design a payment and care-delivery environment that supports the diagnostic process.
Goal 8: Provide dedicated funding for research on the diagnostic process and diagnostic errors.




Curadux pioneers new decision guidance model for patients

We just received this press release from a Cambridge Management Group friend, David L. Brown, M.D. We’re very happy to read this  exciting news:

Curadux has pioneered a new healthcare decision guidance model for individuals and families facing advanced illness


David L. Brown, M.D., the former chair of the Cleveland Clinic’s Anesthesiology Institute and a recent survivor of his own life-threatening illness, has announced the launch of  Curadux to help patients and families facing advanced illness make wise decisions and avoid overtreatment and undertreatment of their conditions.

“Americans facing advanced illness today are at risk of overtreatment and undertreatment of their conditions because powerful and silent incentives are often driving their healthcare, rather than the patient’s own unique values and goals,” Brown said. “After 38 years of practicing medicine inside the world’s elite healthcare institutions, and as a survivor of my own advanced illness, this is my biggest concern for current and future generations of patients and families. This is why I’m excited to launch Curadux and help solve this problem .”

In 2014, the Institute of Medicine released a landmark report highlighting the unfortunate reality that many Americans aren’t living well in advanced illness. The current health system incentivizes overtreatment which may cause unwanted, invasive, and expensive treatments, as well as unnecessarily prolonged and painful deaths. In the words of the IOM, “the default decision is to treat a disease or condition, no matter how hopeless or painful.” Undertreatment is an equal concern as policymakers, in their quest to reduce healthcare costs, begin to cap payments to providers which may incentivize the minimization of healthcare services for people who may legitimately need them.

Curadux solves these problems by establishing a new functional role called a “Care Guide,” staffed by experienced physicians who are solely dedicated to helping patients and families align their unique values and goals with their healthcare decisions, independently from healthcare payers and providers. Care Guides help patients and families to thoroughly assess their values and goals, understand the detailed implications of their options prepared by their medical teams, and ultimately document their healthcare decision, while also alleviating pressure on their primary care physician.

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