The role of these technologies in trauma, psychiatry, and neurosurgery are expected to be in widespread use one day, but the replacement of real practitioners is not the goal. From MedPage Today.
This article first appeared March 29, 2017 onMedPage Today.
By Ryan Basen
WASHINGTON -- Sarah Murthi, MD, stood between an ultrasound monitor and a University of Maryland student supine on a medical bed at the Newseum here. Clad in a pink scrub, the University of Maryland School of Medicine trauma surgeon demonstrated a new way to view ultrasound images as a dozen or so onlookers stared and occasionally chuckled. One by one, audience members donned goggles to see images from inside the student for themselves.
Murthi was one of a handful of practitioners who demonstrated augmented reality and virtual reality technologies for medicine at Newseum VRMeets: Health and Medicine Monday evening. They exhibited these technologies' roles in trauma, psychiatry, and neurosurgery—as well as sports psychology and pain management.
Augmented reality superimposes digital information on top of a natural sensual experience; the now terminated Google Glass was an early application. Virtual reality creates an immersive simulated environment in which, for example, turning one's head around causes the imagery to turn as well, and it can be displayed in 3-D.
While speakers at the event extolled the technologies and predicted widespread medical implementation one day, they were careful to note they are not advocating for either version of reality to replace real practitioners. "This is an additional tool," University of Southern California computer scientist Arno Hartholt said of a virtual reality program for treating psychiatric disorders that he works with. "The tool still needs clinician guidance."
Outside the studio, Ben Barone, MA, demonstrated a system he uses to show elite athletes their nervous system activity on a monitor in real time, to prepare them for competition. Observers donned measurement devices on their fingers and placed fingers on their neck to feel their pulse, while viewing their heart rates and breathing patterns. This is heart rate variability biofeedback, which promotes both parasympathetic and sympathetic nervous system activity, said Barone, co-founder of Coresights.
Neil Martin, MD, neuroscience director at Geisinger Health System in Pennsylvania; Hunter Hoffman, PhD, a cognitive psychology research scientist with the University of Washington; and Hartholt demonstrated and spoke about their work with augmented and virtual reality for:
Simulated brain surgery
Distracting burn victims from feeling pain during typically painful procedures by placing them in a virtual world
Exposure therapy to treat PTSD and anxiety disorders
Augmented and virtual reality can help train residents and students, connect experts with medical personnel in the field or operating room ("like a 3-D reconstruction of telemedicine," Murthi said), and rehearse procedures on simulated patients as opposed to live ones, these exhibitors said. They can also be leveraged to help patients understand treatment options.
Take the work of Murthi and Amitabh Varshney, PhD, a computer science professor at Maryland. Murthi and colleague Caron Hong, MD, demonstrated how augmented reality can be applied to ultrasounds and intubation. While Murthi showed how to view ultrasound data directly on the Maryland student-turned-patient without having to turn away, Hong coached volunteers as they donned large goggles and peered into a portioned medical dummy (head and neck only) via an inserted intubation tube to view the inside of a dummy trachea.
In practice, the goggles allow multiple people to see the same image without breaking communication or adjusting their head—critical in trauma centers, Hong said. The technologies should allow practitioners to multitask more efficiently in trauma centers, while merely adding one piece to established medical practices. (And not replacing practitioners, Murthi said.)
"We're really at the very beginning of this field," Martin said. Quality checks are being adjusted and many risks have not even been defined, he said. "There's going to have to be a much higher level of evidence required" before virtual reality is reimbursed in medicine.
Addressing another potential problem, Hong said she "absolutely" worries that practitioners could be overstimulated by such technologies. (Users of virtual reality games have reported feeling nauseated, for example.) Training should help, she said. Hong, a critical care anesthesiologist, became comfortable using the intubation tube over one weekend.
Many augmented and virtual reality medical tools still need FDA approval, regulations and venture capital before becoming clinically available. Murthi said the Maryland group's augmented reality tools, for example, could be ready within a year, but companies are skittish and don't foresee enough return on their investment to dive in as aggressively as they are funding virtual reality in gaming.
"Within one year, it will be available in some format," Murthi said. "How it will take hold is harder to tell."
Republican leaders were still making deals late Wednesday to possibly change portions of the legislation in order to round up more votes. From MedPage Today.
This article first appeared March 23, 2017 onMedPage Today.
WASHINGTON -- The House Rules Committee adjourned late Wednesday evening without taking the vote needed to send the House Republicans' bill to replace the Affordable Care Act to the House floor for a vote.
Before adjourning the hearing, committee chairman Rep. Pete Sessions (R-Texas) explained to the committee members that it would be hard to vote to send the bill, known as the American Health Care Act, to the House floor because Republican leaders were still making deals with some members to possibly change portions of the legislation in order to round up more votes.
"I had hoped we'd be here with an answer, [but] rather than keeping us here this evening ... we will come back [in the morning] to finish our work," he said. Sessions gaveled the hearing to a close at around 11:30 p.m., after the committee had been in session for 13 1/2 hours.
Democrats on the committee expressed dismay over the way the process was being conducted, although they made it clear that their anger was not directed at Sessions per se. "I just want to say for the record that it is a little bit extraordinary that we find ourselves in this situation," said committee member Rep. Jim McGovern (D-Mass.). "Here we are; it's almost midnight and we [don't] know what we're going to be voting on tomorrow."
"I would urge you to slow down," McGovern said to the Republicans on the committee. "I think the bill as drafted would do great harm to this country -- 24 million people would lose their health insurance, and millions more would lose their healthcare protections. I would strongly urge that we go back to the drawing board."
Among other things, the bill would halt the Medicaid expansion program started under the ACA, freezing new enrollment after 2 years while grandfathering in current enrollees. It would keep some provisions of the ACA, including a ban on discriminating against patients with pre-existing conditions and allowing children to stay on their parents' plans to age 26.
The bill would replace the current federal Medicaid contribution with a "per-capita cap" system, under which states would be given a set per-capita amount of money for each Medicaid enrollee. Under the current Medicaid program, the federal government gives states matching funds based on each state's Medicaid spending; poorer states receive a larger Medicaid match.
The committee heard testimony Wednesday evening on a number of proposed amendments to the bill, including:
An amendment that would allow veterans not enrolled in the Veterans Administration (VA) healthcare system to receive tax credits toward the purchase of private health insurance. "There is a 'manager's amendment' [being proposed] which would ... deny veterans access to the tax credits they would have received had they not served in the defense of this country," said Rep. Mark Takano (D-Calif.). "We know that 9 million veterans are not enrolled in the VA's care now ... This [amendment] appears to exclude all of them from receiving tax credits to pay for healthcare. For all this talk I hear about giving veterans [healthcare] choices, it's disappointing and frustrating that the majority would support a bill that limits the options veterans have to get the care they need."
An amendment that would exempt children enrolled in Medicaid -- including those with special needs -- from the per-capita cap calculation. "If it is applied to all children, my concern is that the cap could create a large shortfall, more particularly among these vulnerable populations," said Rep. Jaime Herrera Beutler (R-Wash.), who is the parent of a special needs child. "These kids are living longer and their quality of life is expanding; that's a great, great challenge to have. We need to make sure we're calculating [their costs] right ... I'm concerned that a reduction could put children's access to healthcare at risk."
An amendment that would freeze the Medicaid expansion enrollment earlier than originally proposed, thereby decreasing the extra federal funds that go to expansion enrollees; the federal government currently pays 90-95% for this Medicaid group -- which includes childless adults -- instead of the traditional Medicaid matching amount, which is around 57% depending on the state. "I don't think under any circumstances there's any program where we should be giving states 90% of the cost of something. It's just an invitation to irresponsibility," said Rep. Glenn Grothman (R-Wisc.). "Right now the expansion continues to the end of [2019]; this amendment makes it to the end of [2018]; quite frankly, if I had an expansion state, I'd want to phase it out earlier, because the longer it drags on the more it becomes an expectation."
Committee Democrats noted that while the hearing was continuing, stories were circulating that among the changes Republican House leaders were offering recalcitrant members was a proposal to get rid of the ACA's requirement that all health plans must offer certain "essential" health benefits, such as maternity care and emergency care. "It seems the chatter is that those are the areas that will be targeted, and we think that will make a very bad bill even worse," said McGovern.
MedPAC calls for reduced payments to inpatient rehab and others. From MedPage Today.
This article first appeared March 15, 2017 onMedPage Today.
By Shannon Firth
WASHINGTON -- Congress should reduce payments to home health agencies and inpatient rehabilitation facilities by 5% in 2018, according to a new report from the Medicare Payment Advisory Commission (MedPAC).
The report released Wednesday also advised that currently mandated payment updates for long-term care hospitals, hospice, and ambulatory surgical centers for 2018, and for skilled nursing facilities in 2018 and 2019, be scratched.
The report justified shrinking payment for agencies because of "chronic overpayment," noting that payments have outpaced costs for more than 10 years.
The commission also recommended that Congress undertake the following to improve payment accuracy:
Require ambulatory surgical centers to submit costs data
Freeze payment for skilled nursing facilities for 2 years while the payment system is revamped
Revise home health payment systems to exclude therapy visits as a factor in payment
Expand the inpatient rehabilitation facility "outlier pool"
"In this report, we continue to make recommendations aimed at finding ways to provide high-quality care for Medicare beneficiaries while giving providers incentives to constrain their cost growth and thus help control program spending," said the commission chair Francis J. Crosson, MD, of Los Altos, Calif., in a press statement.
For ambulatory surgical centers, MedPAC noted that these entities currently do not submit data on the cost of their services, as other providers do, and this makes determining a Medicare payment margin – a measure that looks at the relationship between payments and costs of providing care for patients – challenging. The commission has suggested that Congress require submission of this data.
The report dedicated a special chapter to post-acute care payments. An accompanying MedPAC fact-sheet noted that enacting its March 2017 recommendations across all four PAC settings "would reduce [fee-for-service] Medicare spending by over $30 billion over the next 10 years."
In its June 2016 report, the commission recommended strategies for implementing a "unified PAC payment system" where payments depend on patient characteristics rather than the site of care.
For skilled nursing facilities and home health agencies, MedPAC has asked to eliminate payment increases for 2 years, and also that the secretary of the U.S. Department of Health and Human Services (HHS) submit a report to Congress detailing the effects of its prospective payment system. The goal is to ensure payments are directed to providers more fairly, potentially reflecting more medically complex cases, while also improving access for beneficiaries.
MedPAC also suggested that Congress expand the "outlier pool," which gives providers protection when serving "exceptionally high-cost patients." These payment also help to ensure beneficiary access to care.
As for Medicare Advantage, the Commission has advised Congress to direct the HHS secretary to estimate Medicare Advantage (MA) benchmarks according to data from beneficiaries who are enrolled in both Part A and Part B.
Current benchmarks for MA spending are based on beneficiaries enrolled in Medicare Part A coverage alone, who are often younger and healthier, and those covered by both Part A and B plans. However, enrollees in MA are required to have coverage for both Part A and Part B, which means the MA spending benchmarks may be inadequate for the beneficiaries the program actually serves.
For three other sectors and settings – physicians and other health professionals; inpatient and outpatient services; and outpatient dialysis – MedPAC suggested preserving the current updates set in current law since indicators across these groups have been mainly positive or adequate.
Indicators for determining payment adequacy include the following:
Beneficiaries access to care
Quality of care
Provider access to capital
Provider costs and Medicare payments, when available
The probability that an opioid-naive patient would become a chronic opioid user increased sharply after as little as 5 days of use, said CDC researchers.
New accreditations may fend off competing specialists. From MedPage Today.
This article first appeared March 9, 2017 onMedPage Today.
By Nicole Lou
WASHINGTON -- Sweeping changes are coming for interventional radiology (IR), and an expert panel discussed the challenges to carving out a niche for a field that's currently fighting a turf war against other specialists, like vascular surgeons and cardiologists.
"Graduating numbers are going to be a little less in the future than they are now because of the job market. A quarter of practicing IRs do very little IR -- less than 5%. The solution is not to graduate more people. The solution is to have them do more," said Saher S. Sabri, MD, of the University of Virginia in Charlottesville, during a session at the Society of Interventional Radiology (SIR) annual meeting.
"If you come out [to the job market] knowing how to do transplants, but not venous disease and PAD [peripheral artery disease], you're going to be stuck. We need to be training them for the right things they'll need in the future. We just have this superb training program with what's in it but when they're in private practice, they don't have what they need to tackle what's out there," he added.
He asked the audience at SIR: "Do people think we're at the point where we need to have subspecialty societies? Are we at the point where we, as a society, are meeting the needs of all vascular specialists and venous specialists?"
"What everyone agrees on is that a defined set of core procedural competency that every IR fellow comes out with would be needles, catheters, and wires," Ray stated. "There is not a procedure I do now that I did as a fellow or trainee. So IR is rapidly evolving; what you know now may be obsolete in 10 years."
John A. Kaufman, MD,of the Dotter Interventional Institute at Oregon Health & Science University in Portland, agreed.
"You're not going to learn all the skills you'll need the rest of your life in your fellowship. You're really learning a set of competencies, and you'll juggle them, and mix, and use them in new ways. You're always adding new skills once you're in practice."
You have to go to meetings, talk to people, and get yourself proctored if you have to," he urged.
For Kaufman, if procedures are only performed once or twice a year, they may not be something trainees need to learn. "Think about how many diagnostic pulmonary angiograms we have done – maybe a lot during early training and now it's gone."
On the flip side, however, when learning does have to occur, it will need to be overhauled, according to Sabri.
"Most of us in IR, we're not as good at managing [surgery unit] patients. Others need to train us in procedural areas depending on what it is. Most people are going to rely on other specialists to teach us. It's better for us as a society to train each other," he stated. "It's an opportunity to include the private sector in training our trainees. It should be considered a significant project that we work on over the next couple of years, how we reach out to private practice."
In 2012, the American Board of Medical Specialties bumped interventional radiology up from a subspecialty of radiology to a primary medical specialty, beginning a 10-year process from decision to implementation.
Starting in 2020, two new IR training pathways will be offered: the independent IR residency and a shorter alternative ("Early Specialization in IR") that requires completion of 12 IR rotations during the diagnostic radiology (DR) residency. Graduates will take the IR/DR exam from the American Board of Radiology. Those who pass will be certified to practice both DR and IR.
"Patient care is really critical to IR, and IR is part of DR. We need the support to make this happen," Kaufman emphasized.
The current track to IR -- an integrated IR residency followed by a vascular/IR (VIR) fellowship -- will cease then, to be replaced by the independent IR residency.
Fears of disenfranchising all of VIR made this a controversial topic even in the 1990s, when IR fellowships first received accreditation from the Accreditation Council for Graduate Medical Education, according to Kaufman.
In a worst case scenario, he said, "we would be in a situation where people can't do neuro; can't do peds if they don't have the certificate. It's worked out that people managed to do that. There's been no increase in the scope of procedures going from the VIR certificate to IR/DR. What was added was the extra time in IR training to have a clinical care component."
"History so far has been on the side of everyone being able to do what they want to do in the appropriate environment. I have DR people doing some drainages. It's a matter of how you organize it," he noted.
Sabri and Kaufman disclosed no relevant relationships with industry.
Ray disclosed serving as editor-in-chief of Seminars in Interventional Radiology. He disclosed relevant relationships with BTG, Medtronic, Gore.
The president cited the plan's failures and outlined five principles that he said Congress should use in its legislation to replace the Obama administration’s healthcare reform law.
This article first appeared March 2, 2017 onMedPage Today.
President Trump, during a speech to lawmakers on Tuesday evening, presented a broad outline of how the Affordable Care Act should be replaced—incorporating many of the reform ideas traditionally offered by Republicans.
"Obamacare is collapsing—and we must act decisively to protect all Americans," he told a joint session of Congress. "Action is not a choice—it is a necessity."
The president began the Obamacare section of his speech by citing the plan's failures. "Mandating every American to buy government-approved health insurance was never the right solution for our country," he said. "Obamacare premiums nationwide have increased by double and triple digits ... One-third of counties have only one insurer and they're losing them fast—losing them so fast, and they're leaving, and many Americans have no choice at all."
"Remember when you were told that you could keep your doctor, and keep your plan? We now know that all of those promises have been broken," he said. "So I am calling on all Democrats and Republicans in Congress to work with us to save Americans from this imploding Obamacare disaster."
Trump outlined five principles that he said Congress should use in its legislation to replace the ACA:
Ensure that Americans with pre-existing conditions have access to coverage, with a "stable transition" for those currently enrolled in the healthcare exchanges
Help consumers purchase coverage using tax credits and "expanded" health savings accounts, "but it must be the plan they want, not the plan forced on them by our government"
Give governors "the resources and flexibility they need with Medicaid to make sure no one is left out," said Trump
Put in place legal reforms "that protect patients and doctors from unnecessary costs that drive up the price of insurance—and work to bring down the artificially high price[s] of drugs, and bring them down immediately"
Allow consumers to purchase health insurance across state lines—which, the president said, "will create a truly competitive national marketplace that will bring costs way down and provide far better care. So important."
Still to come, though, is the legislation that fills in the details of how these goals would be accomplished.
Trump also mentioned a few other healthcare issues in his speech. During a section on making America a great country again, he said, "Heroic veterans will get the care they so desperately need." He also pledged to "stop the drugs from pouring into our country and poisoning our youth—and we will expand treatment for those who have become so badly addicted."
Trump also criticized the FDA for its "slow and burdensome approval process." One of his guests at the speech was Megan Crowley, a 20-year-old woman with Pompe disease whose life was saved by a drug developed by a company her father founded.
"If we slash the restraints, not just at the FDA but across our government, then we will be blessed with far more miracles just like Megan," he said.
Former Kentucky governor Steve Beshear, who gave the Democratic response, criticized Trump's suggestions for ACA replacement. "Does the ACA need repairs? Sure it does," he said. "But so far, every Republican idea to replace the ACA would reduce the number of Americans covered, despite your promise to the contrary."
"These ideas promise access to care, but deny the importance of making care affordable and effective," he continued. "They would charge families more for fewer benefits and put the insurance companies back in control. Behind this is the idea that folks at the lower end of the economic ladder don't deserve healthcare—that it's somehow their fault that their employer doesn't offer insurance, or they can't afford to buy expensive health plans."
"In 2010, this country made a commitment that every American deserved healthcare they could afford and rely on. We Democrats are going to do everything in our power to keep President Trump and the Republican Congress from reneging on that commitment, but we're going to need your help by speaking out," he added.
An AMA survey found that practices reported submitting an average of 37 prior authorization requests each week, with an average of 16 hours of physician and staff time to complete them.
This article first appeared February 22, 2017 onMedPage Today.
The healthcare industry hasn't eliminated the hassles for providers that prior authorization often entails, but they're getting closer, several speakers said here at Healthcare Information and Management Systems Society (HIMSS) annual meeting.
"Studies have shown that prior authorization is the biggest 'pain point' among providers," Pam Jodock, senior director of healthcare business solutions at HIMSS, said at a Tuesday morning meeting session. "The issue is not automation; it's the business processes to which automation would be applied."
The six groups represented at the morning session are hoping to develop consistency in the requirements for getting a prior authorization and reducing the number of treatments and procedures that require it, she added. "The fact that we have six [groups represented] is because this is a critical issue of everybody on the stage today."
Standardizing the Transaction Bob Bowman, an associate director at CAQH CORE, an organization focused on streamlining healthcare business processes, said that his group has been working on prior authorization for 3 or 4 years. CAQH has developed a rule set to standardize prior authorization transaction, which includes "basic infrastructure requirements, response times, connectivity, and time-stamping," he said.
CAQH CORE also has established a six-member prior authorization advisory group that is trying to find more issues to address in this area, said Bowman; he noted that a 2016 CAQH survey found that the adoption of a standardized form—known as 278—mandated by HIPAA for prior authorizations only had an 18% adoption rate.
"Prior authorization is a huge issue," said Heather McComas, senior policy analyst at the American Medical Association (AMA). "We hear about this issue all the time from our members. Even more than that is the patient impact; they see that care can get delayed by this process and it really upsets them."
The AMA surveyed its members on the issue at the end of 2016 and found that practices reported submitting an average of 37 prior authorization requests each week, with an average of 16 hours of physician and staff time to complete them. "That's two business days—a lot of time," McComas said.
In total, "75% of respondents found prior authorization to be quite burdensome, and over a third reported having staff that work exclusively on prior authorization."
The AMA convened a prior authorization reform work group to discuss the issue; the group released its key principles a month ago. The association is also partnering with the University of Southern California in Los Angeles on a project to look at the costs associated with prior authorization, as well as how it is impacting patients.
"I hear from physicians anecdotally every year that more and more things are subject to prior authorization," she said.
Simplifying the Process
Some insurers have come up with their own solutions to simplify the process. "Our 'pain relief' strategy is to meet providers where they are, so they don't have to undertake a huge IT lift to make these [things] happen," said Elizabeth Hartley-Sommers, clinical data exchange manager at Blue Cross and Blue Shield of Louisiana. "We know where the money on administrative expenses is spent—it's mostly spent on prior authorization" rather than claims payment, eligibility verification, or claims submission. "It's a huge pain point for us and for providers, and for our members, because they're waiting for prior authorization to be completed in order to get treatment."
The increased cost of prior authorization comes mostly from the paperwork and the time expended. "It's a resource-waster and it can be done better," said Hartley-Sommers. "There are a lot of phone calls and secondary phone calls and faxes related to prior authorization."
The plan introduced an online authorization portal which allows providers to enter their own authorization information; they receive instant notification if their procedure is approved. "So far, our providers love it," she said. "They love not having to mail us huge boxes of medical records. They have noted they don't have to do as much faxing or save as much of that paper trail."
The plan also wants to work on more structured data standards; "right now everything is in PDF or TIF format," she said. "We also want to increase adoption of the 278 [form] and make sure we're in line with the industry moving forward."
Another organization working on this issue is the Healthcare Administrative Technology Association (HATA), a group of 33 businesses including practice management software vendors, value-added vendors, clearinghouses, and associations representing vendor clients. The 3-year-old organization held a strategic planning meeting last year and came away with three areas it wanted to work on, including prior authorization. HATA then established a work group on the issue.
"We didn't want to come up with a miracle cure, but we did feel like we could really identify what was the practice management vendors' perspective on the prior authorization transaction," said Sherri Dumford, a program consultant for the group. "We wanted to research and understand the barriers to developing a meaningful workflow for physician use, and how value-based payments might affect prior authorization in the future."
The panel also included Gregg Allen, MD, chief medical officer of eviCore, a vendor that processes 75,000 to 85,000 prior authorization requests daily for more than 100 health plans. "We have been working hard on this over time," he said. "We see the frustration. We spend a lot of time with physician offices talking with them ... day to day."
"A lot of [the issue] is, how do we get the right amount of information that's pertinent to a good care decision? That's not so easy to do," he added.
Currently, about 65% of prior authorization cases are initiated through the company's web portal, he noted. "For about 8 or 9 years, we have been very purposeful at driving people to use the web portal and ... not [have to] talk to anybody," Allen said. "We also have decision algorithms that ... give immediate feedback on whether a [procedure] is likely to be considered appropriate."
But even with all of that automation, prior authorizations still involve a lot of phone calls, Allen continued. "We'd like to see the peer-to-peer calls go away; we're bound and determined to find ways to do that. At the same time, these programs are not going away any time soon, and they do deliver real value in terms of improved patient care and the elimination of duplicate procedures."
Looking Ahead Charles Stellar, president and CEO of the Workgroup for Electronic Data Interchange (WEDI), a quasi-governmental organization that advises the federal government on the use of health information technology, said his group has been "working to identify the challengers that prior authorization submitters experience ... We are looking for ways to streamline the process to get the decision for prior authorization requests to the submitter in or as close to real time as possible."
He noted that among the groups represented at the meeting session, "It may be that we are replicating in our various activities but I suspect there's a great deal of lessons we could learn from each other. I have talked with colleagues about facilitating a group that would bring us all together, making prior authorization great again."
"There is an opportunity to see this through, to make the patient not wait, and the opportunity to have a better system," he added. "We are excited about this as an opportunity."
A pattern of higher performance or availability of PCMH-related functions was observed among physicians in PCMH practices compared with physicians in non-PCMH practices, regardless of practice size.
This article first appeared February 17, 2017 onMedPage Today.
By Alexandria Bachert
Nearly 20% of U.S. primary care physicians in 2013 were in practices certified as patient-centered medical homes (PCMH), a comprehensive care delivery model which provides team-based care for all patients, CDC researchers found.
Having at least one physician assistant, nurse practitioner, or certified nurse midwife on staff was more common among office-based primary care physicians (PCPs) in PCMH practices (68.8%) compared with those in non-PCMH practices (47.7%), reported CDC statistician Esther Hing, MPH, and colleagues in a report from the National Center for Health Statistics.
Specifically, more PCPs in PCMH practices had physician assistants and nurse practitioners on staff compared with PCPs in non-PCMH practices (31.3% versus 19.9% and 45.8% versus 27.7%, respectively).
Not surprisingly, a general pattern of higher performance or availability of PCMH-related functions was observed among physicians in PCMH practices compared with physicians in non-PCMH practices, regardless of practice size, noted Hing and colleagues.
When asked for comment on the findings, NCHS public affairs specialist Brian Tsai explained to MedPage Today that "the PCMH has been advocated by primary care physicians, other primary care providers and associated professional societies for decades."
"The report found that a substantial percentage of non-PCMH practices have non-physical clinicians on staff and use EHR systems. This suggests there is potential for more primary care practices to become certified as a PCMH as ongoing payment incentives from CMS, certain payers, and states continue to be implemented," he continued.
Just over 40% of PCMH physicians were certified by the National Committee for Quality Assurance. Other certifying organizations included the Accreditation Association for Ambulatory Health Care and The Joint Commission. The certifying body was unknown for 27%.
The researchers found that, compared with PCPs in non-PCMH practices, those who were part of a PCMH practice used EHR or EMR systems more frequently (94.2% versus 74.3%) and provided greater around-the-clock access to patient medical records (91.5% versus 74.1%).
Likewise, more PCPs in PCMH practices (69.6%) received information on patients who were hospitalized or seen in the ER through electronic transmission than their non-PCMH counterparts (41.5%), with usage greatest among those in practices with 2-10 physicians (73.8%) compared with those in similarly sized non-PCMH practices (47.9%).
Hing and colleagues concluded that PCPs in PCMH practices may be more focused on quality and safety, with 86.8% reporting healthcare quality measures or indicators to payers or organizations compared with 70.2% in non-PCMH practices.
Returned surveys from 1,671 U.S. neurologists showed that six out of 10 have experienced some symptom of burnout -- including emotional exhaustion, depersonalization, or low personal accomplishment. From MedPage Today.
This article first appeared January 26, 2017 onMedPage Today.
By Alexandria Bachert
High rates of self-reported burnout continue to plague U.S. neurologists, yet many still report being satisfied with their job overall, according to a recent survey from the American Academy of Neurology.
Returned surveys from 1,671 U.S. neurologists showed that six out of 10 have experienced some symptom of burnout -- including emotional exhaustion, depersonalization, or low personal accomplishment, Terrence Cascino, MD, of the Mayo Clinic in Rochester, Minn., and colleagues reported online in Neurology.
Still, 67% said they were satisfied with their job in general, and the same proportion said they would choose to be a neurologist if they were starting all over again.
"We love taking care of our neurological patients," Raghav Govindarajan, MD, a neurologist at the University of Missouri, who was not involved in the study, told MedPage Today. "In fact, neurology is one of the few specialties where we spend a lot of time taking history and doing exams."
The burnout, he said, "is due to external factors like increased paper work, insurance hassles, and ever-increasing regulation that is keeping us away from our patients and taking the pleasure out of being a neurologist."
In a statement, Cascino said the findings "confirm our recognition of burnout as a serious issue facing our profession and why the well-being of neurologists -- starting with decreasing regulatory hassles -- must be addressed to ensure our patients receive the highest quality care."
Cascino and his team sent their survey to 4,127 AAN members, and garnered a response rate of about 41%. Median responder age was 51, and they had an average of 17 years in practice, working about 56 hours per week. Most were from clinical practice, but a third spent time in academic practice.
The researchers found that 60.1% of neurologists reported at least one symptom of burnout, including high emotional exhaustion (53.4%), high depersonalization (41.4%), and low personal accomplishment score (21.2%).
A higher likelihood of burnout was tied to more hours worked per week (OR 1.016, 95% CI 1.005 to 1.027, P=0.003), more nights on call per week (OR 1.092, 95% CI 1.019 to 1.171, P=0.013), and a higher number of outpatients (OR 1.011, 95% CI 1.003 to 1.018, P=0.004).
Conversely, greater job autonomy, meaningful work, reasonable amounts of direct clerical tasks, and effective support staff were associated with lower burnout risk, the researchers reported.
Clinical practice neurologists had a higher burnout rate than academic neurologists (63% versus 56%, P=0.004), with higher scores in both emotional exhaustion (P=0.008) and depersonalization (P=0.014).
However, despite the high prevalence of burnout, 67% of neurologists indicated satisfaction with their work. The same proportion said they would choose to become a neurologist again, and 88% reported that their work was meaningful to them.
But the researchers noted that these numbers are somewhat lower than they are for all physicians, of which 71% would choose the same specialty over again, according to earlier data, they said. And oncologists, they noted, have higher rates of satisfaction than neurologists and only average burnout rates.
Cascino said burnout is especially troubling when paired with rising demand for neurologists that is growing faster than the supply: "By 2025, it's estimated that we will need nearly 20% more neurologists than are available. The high rate of neurologist burnout may contribute to -- and be exacerbated by -- this shortage," he said in a statement.
Efforts to help neurologists combat burnout include improving work efficiency, optimizing workload, decreasing clerical burden, and providing greater flexibility and control over support staff. Physician-friendly national policies to decrease regulatory burden and mandate clerical tasks could also benefit neurologists, Cascino concluded, acknowledging that the study was limited by the use of cross-sectional data.
Govindarajan shared his own advice for keeping neurologists content: Focus on doing what you love, which is taking care of patients.
"I would also advise adding teaching, leadership work or research to the clinical work so it does not become monotonous" he told MedPage Today. "Finally, participating in organized medicine through AAN or your local state societies to fight for your patients and profession would reduce the feeling of helplessness."
The federal government and organizations within HHS have about 600 medical responders pre-positioned in various locations throughout the inauguration venue. From MedPage Today.
This article first appeared January 19, 2017 onMedPage Today.
It's 8 a.m. on Thursday, the day before the presidential inauguration. And even though the ceremony is more than 24 hours away, some of the healthcare teams that will be on standby are already performing their first inaugural duties.
The Regional Hospital Coordinating Center (RHCC) in northern Virginia, located right outside Washington, did a live update Thursday morning to get information on bed availability and blood counts at northern Virginia hospitals, just in case that information is needed in the event of any kind of mass casualty incident, explained Sue Snider, MA, executive director of the Northern Virginia Hospital Alliance, in Herndon, Va.
The alliance was created in 2002 in response to the Sept. 11th and anthrax attacks, Snider explained in a phone interview. "The hospitals realized that while they may be competitors, they do need to function as a single healthcare system on the day of a [mass casualty] event." The alliance then established the coordinating center in 2003.
The information on bed availability and blood count "goes into an online system which [officials in] the District of Columbia can view and see online how many patients our hospitals can accept," Snider said. Staff from the RHCC will be on duty from 5 a.m. Thursday until 8 p.m. Friday, when most people will have left Washington, although those times can be extended as needed, she added. Ambulance transport out of Washington will be done by local emergency medical teams, and they would notify RHCC if patients were on their way so that the hospital can be aware and prepared.
The RHCC's work is but one piece of a big puzzle that the Department of Health and Human Services (HHS) needs to figure out as it puts together medical care for inauguration viewers and participants. "We started our Inauguration prep 6-8 months ago," Joe Lamana, BSN, MPA, director of the Regional and International Coordination Division at HHS's Office of Emergency Management, said during a phone interview at which a public relations person was present. "Those conversations started with our federal, state, and local partners," including the hospitals in northern Virginia and suburban Maryland.
The federal government and organizations within HHS have about 600 medical responders pre-positioned in various locations throughout the inauguration venues -- including along the National Mall, Lamana said. "Also, the VA [Department of Veterans Affairs] contributed some personnel, and then we have understanding and visibility with what the DoD [Department of Defense] is bringing too, so a lot of medical personnel are being thrown at this to support the event."
There will be 20 aid stations along the Mall, and a couple of medical trailers close to the Capitol building and also along the parade route, he explained. In addition, 32 roving two-person teams will be out among the crowd to help out if they see any medical issues occurring.
Besides all the personnel outside, there will also be medical teams posted in some of the House and Senate office buildings as well as in the Capitol itself, Lamana said.
The teams plan to care for both "bumps and bruises" as well as react to a more serious mass casualty event, "which could require us to move people away from the venues, so we need to coordinate ... with all hospitals in Virginia and Maryland and include them in our planning."
Most of the staff members on site are either emergency physicians, nurses, or emergency medical technicians; the medical tents also don't have very fancy equipment, he said. "We're there to treat and release [or transfer]," not to set broken bones or perform other serious procedures.
The budget for all this planning and personnel comes out of a fund for "National Security Special Events," which includes the inauguration, Washington's July 4th celebration, the annual joint session of Congress, and the U.N. General Assembly meeting in DC, Lamana said; the total funding for medical care at all of these events is $5 million. "We can go through that pretty quickly; we're in the millions for this event."
Similar to the Northern Virginia Hospital Alliance, the District of Columbia also has a regional healthcare coordination group called the DC Emergency Healthcare Coalition, which was formed in 2006, according to Craig DeAtley, PA-C, director of the Institute for Public Health Emergency Readiness at MedStar Washington Hospital Center, who spoke during a phone interview at which a public relations person was present.
"We've been working together for system readiness," DeAtley said. For example, "MedStar Washington Hospital Center is the [city's] busiest trauma center and the only adult burn center in the region, so we know if something happens, whether in DC, Maryland, or Virginia, we'll be the primary recipient of traumatized patients; we take that responsibility seriously."
To get ready for Friday's event, "we had a multidisciplinary committee of physicians, nurses, and administrators looking at lessons learned at past inaugurations as well as [what to watch for] at this one in particular," he said. "We looked at what we need to supplement for medications, equipment, and blood products, and a staffing plan for [Friday and the protest march on Saturday]."
One important player in the inauguration preparation is the behavioral health community, he added. "Among other reasons, we have a significant homeless population, and many of them have been moved out of what they normally use as their shelter; that has the propensity to stir up psychological problems they might be facing day in and day out. Also, when victims become traumatized, the behavioral health component is needed to support that injury as well as the physical injury."
If all goes well, very little of the healthcare system that's been set up will have to be used on Friday or Saturday. "We will not be disappointed if that's the case," said DeAtley. "It's the 'ounce of prevention, pound of cure' strategy."