A new study finds that female and minority medical students face significantly higher rates of mistreatment compared to male and white students.
Women, racial and ethnic minorities, and sexual minorities bear a disproportionate share of medical student mistreatment, new research shows.
In medical school, mistreatment of students includes a range of actions such as assault, discrimination, sexual harassment, and verbal abuse. Mistreatment has been linked to several negative consequences, including alcohol abuse, burnout, depression, and medical student attrition.
The new research, published today in JAMA Internal Medicine, suggests that mistreatment of women, racial and ethnic minorities, and sexual minorities in medical school impacts not only the quality of education but also efforts to boost diversity among physicians. "This differential burden of mistreatment may have substantial implications for the medical school learning environment and the diversity of the physician workforce," the research co-authors wrote.
The research is based on data collected from the 2016 and 2017 Association of American Medical Colleges Graduation Questionnaire. The AAMC Graduation Questionnaire is administered annually to all 140 accredited allopathic medical schools in the country.
The researchers analyzed 27,500 graduation questionnaires, which represents 72.1% of medical school graduates in 2016 and 2017. More than one-third of survey respondents reported experiencing at least one type of mistreatment. The most common form of mistreatment was public humiliation, which was reported by 21.1% of survey respondents.
Student mistreatment data
The JAMA Internal Medicine study generated several key data points.
1. Mistreatment by sex:
More female students reported at least one episode of mistreatment compared to male students (40.9% vs. 25.2%)
More female students reported public humiliation compared to male students (22.9% vs. 19.5%)
More female students reported unwanted sexual advances compared to male students (6.8% vs. 1.3%)
More female students reported a higher rate of gender-based discrimination compared to male students (28.2% vs. 9.4%), including being denied training opportunities and receiving lower evaluations
2. Mistreatment by race or ethnicity:
Among white students, 24.0% reported experiencing mistreatment. Reported rates of mistreatment were higher for Asian (31.9%), underrepresented minority (38.0%), and multiracial (32.9%) students.
Among white students, 3.8% reported discrimination based on race or ethnicity. Reported discrimination rates were higher for Asian (15.7%), underrepresented minority (23.3%), and multiracial (11.8%) students.
Among white students, 0.7% reported receiving low evaluations because of race or ethnicity. Reported rates of low evaluations because of race or ethnicity were higher for Asians (5.0%), underrepresented minorities (9.6%), and multiracial (3.4%) students.
3. Mistreatment by sexual orientation:
Nearly twice as many lesbian, gay, or bi-sexual (LGB) students reported an episode of mistreatment compared to heterosexual students (43.5% vs. 23.6%)
More LGB students reported being publicly humiliated than heterosexual students (27.1% vs. 20.7%)
More LGB students reported being subjected to unwanted sexual advances than heterosexual students (7.7% vs. 3.7%)
More LGB students reported discrimination based on sexual orientation than heterosexual students (23.1% vs. 1.0%)
More LGB students reported receiving lower evaluations based on sexual orientation than heterosexual students (4.0% vs. 0.3%)
Data interpretations and implications
The study's data reveals trends in the mistreatment of medical school students, the co-authors wrote. "The major findings of our national study include not only a high prevalence of medical student mistreatment but also differences in the prevalence of mistreatment by student sex, race/ethnicity, and sexual orientation," they wrote.
The data also demonstrate that several inappropriate behaviors are common in medical school, the co-authors wrote.
"These reported behaviors include, but are not limited to, unwanted sexual advances (6.8% of female students and 7.7% of LGB students), lower evaluations secondary to bias and discrimination (6.8% of female students and 9.6% of underrepresented minority students), and being subjected to sexist or bigoted comments (24.3% of female students, 18.9% of underrepresented minority students, and 21.8% of LGB students)."
The data indicate several disturbing implications, they wrote.
"The differential treatment reported by medical students in this study suggests a noninclusive learning environment, which could have profound implications for the well-being and academic success of students. … Another concerning negative experience reported by students was missed opportunities or lower grades because of discrimination. These experiences may have incremental consequences as trainees advance through their medical careers."
Medical schools can take actions to combat mistreatment of students, the co-authors wrote. "Potential interventions include implicit bias and bystander intervention training, better protections for individuals who have been subjected to and report instances of bias and discrimination, and greater transparency in policies for reporting and remediating instances of bias and discrimination."
New research findings are a step forward in understanding the harms and benefits of screening for dementia in the primary care setting.
Screening for Alzheimer disease and related dementias (ADRDs) in the primary care setting does not harm patients as measured by prevalence of depression and anxiety, recent research shows.
Primary care clinicians provide the most care to older adults, and at least half of primary care patients afflicted with ADRDs are never diagnosed with the conditions. For patients who do receive an ADRD diagnosis, the determination is often made two to five years after the onset of symptoms, which limits the benefits of early detection such as reducing family burden.
The recent research, which was published in the Journal of the American Geriatrics Society, examined data collected from 4,005 primary care patients over age 65. Half of the patients were screened for ADRDs and the other half served as a "no screen" control group.
"This is the first randomized controlled trial to evaluate the benefits and harms of population screening for ADRD among asymptomatic patients attending primary care. Our trial demonstrated no harm from screening, as measured by depressive and anxiety symptoms," the research co-authors wrote.
Research data
To assess harm to patients, prevalence of depression was measured with the Patient Health Questionnaire-9 (PHQ-9) and prevalence of anxiety was measured with the Generalized Anxiety Disorder seven-item scale (GAD-7). Assessment of benefits to patients included data collected for health-related quality of life (HRQOL).
The assessments generated several key data points:
At baseline for the ADRD screened group and the control group, the scores for the PHQ-9 and GAD-7 assessments were similar.
At one month, six months, and 12 months for the ADRD screened group and the control group, the mean scores for the PHQ-9 and GAD-7 assessments remained similar.
At baseline for the ADRD screened group and the control group, the mean HRQOL score was similar.
At 12 months for the ADRD screened group and the control group, the mean HRQOL score remained similar.
"We were unable to detect a difference in HRQOL for screening for ADRD among older adults. We found no harm from screening measured by symptoms of depression or anxiety," the researchers wrote.
Interpreting the data
The research is a significant contribution to the debate over whether ADRD screening should be standard practice in the primary care setting, the lead author of the study told HealthLeaders.
"The results from this study are some of the first to show that screening for dementia does not increase harm for patients, as measured by an increase in depression or anxiety. They get us a step closer to determining if screening for dementia should be part of routine care for older adults," said Nicole Fowler, PhD, an assistant professor of medicine at Indiana University School of Medicine in Indianapolis, and a research scientist at the Regenstrief Institute in Indianapolis.
Fowler said her research team is examining whether other harms may be linked to ADRD screening in the primary care setting. "For example, how does early detection of dementia via screening impact the older adults' family members who might be in a position to be a caregiver?"
More research is also required to determine the benefits of ADRD screening, she said. "This study measured benefits of screening using measures of health-related quality of life, healthcare utilization, and creation of new advance care plans. We did not find benefits among these measures. But the caveat is that only 66% of the people who screened positive sought follow-up testing to determine if they had ADRD, and if so, received collaborative care."
Future research on the benefits of ADRD screening need to account for essential actions after screening, Fowler said. "To truly determine benefit of screening, we need to ensure that screening is coupled with appropriate diagnostic follow-up and care for the patients and family."
A recent New England Journal of Medicine study is "not an indictment against all care management and care coordination programs," Camden Coalition's CEO says.
Despite the recent publication of a research article that generated disappointing results about its care management program for "superutilizer" patients, the Camden Coalition of Healthcare Providers is continuing its commitment to serve a complex patient population.
The Camden Coalition's "hotspotting" program targets complex patients with comorbidities and social needs. These kinds of superutilizer patients account for a disproportionate share of healthcare spending in the United States, with earlier research finding that 5% of the country's population accounts for 50% of annual healthcare expenditures. Programs such as the Camden Coalition's care management initiative are designed to help reduce these healthcare costs.
The recent research, which was published in the New England Journal of Medicine, assessed the hospital readmissions impact of the Camden Coalition's hotspotting program from 2014 to 2017.
The randomized, controlled trial featured 800 patients split evenly between participants in the Camden Coalition's care management intervention and a control group receiving usual care. The study found that the 180-day readmission rate for the intervention group was 62.3% compared to a 61.7% rate for the control group.
The Camden Coalition's care management intervention focuses on the 90-day period after hospital discharge. The program is staffed by a multidisciplinary team that includes community health workers, health coaches, registered nurses, and social workers. The team conducts several interventions such as connecting patients with social services, medication management, self-care coaching, and coordinating follow-up care.
Camden Coalition of Healthcare Providers CEO Kathleen Noonan, JD, recently spoke with HealthLeaders about the Camden, New Jersey–based organization's perspectives on the NEJM study. The following is a lightly edited transcript of that conversation.
HealthLeaders: What is your reaction to the NEJM study's finding that your hotspotting program had no effect on hospital readmissions?
Noonan: It's clear to us that there is still a lot to learn in this area. We don't think that there is a clear-cut solution for how to reduce utilization and costs for this very complex population. And because our healthcare and social service systems are siloed—and accessing services from either is complicated and difficult—we found that accessing the services that our population needed was difficult even with a skilled team.
We were dealing with issues of poverty, racism, and disinvestment that were front-and-center for our patients. Sometimes, these issues were even more front-and-center than the health issue that brought them into the hospital. So, the healthcare intervention that was trying to connect patients to social services within a 90-day time period was not sufficient.
You have to remember that this study was done between 2014 and 2017. If you did an Internet search of the phrase social determinants of health during that period, you would see it far less often than you would see it in the past couple of years. The changes that have occurred since 2017 have built up the ecosystem that is trying to connect health and social services.
HL: What lessons have you learned from the NEJM study?
Noonan: Our main lessons are that extreme hospital and emergency room over-utilization is driven by the patient's complexity and the inability of any one system to manage that complexity. What we are doing now is working with others across the country who are also trying to build new care models that can respond to the needs of complex patients.
We also are trying to figure out how to catch patients earlier. There is a lot of terrific work being done in predictive modeling and how to find complex patients earlier.
While we didn't reduce readmissions in the study, we did see an increase in SNAP participation in the intervention group, which is a promising outcome since food insecurity is a key social determinant—something we see in Camden over and over again. Many of our local hospital partners are responding to this need, with the development of food pantries, food prescriptions that are connecting patients to nutritionists, and other supports.
HL: Is Camden Coalition going to re-evaluate its hotspotting program?
Noonan: Before, during, and after the study, we have been learning about the patients and adjusting the hotspotting model. The authors of the study recognized that they knew that the Camden Coalition was going to modify certain parts of the intervention, so the examination of the intervention looked at the average effect of the program.
One thing we did two years into the study was to create a housing program called Housing First. We knew that it is difficult for us to help a patient when there is homelessness or severe housing instability. That's one change we made.
Another change we made that we were not able to get off the ground during the study period was the creation of a medical-legal partnership. For many of our patients, we found they faced difficulties because of civil cases or barriers to benefits that we needed legal help to resolve. We are now partnered with Rutgers Law School, and we have two lawyers who work with the care team. This has helped us to quickly deal with legal issues that our care team did not have the expertise to address.
We have also worked locally to support the development of medication-assisted treatment. We've worked at the state level with partners to waive prior authorization for medication-assisted treatment.
We are trying to look at the whole system around these patients and to work at the levels of care intervention, healthcare providers, and policy to make changes that can respond to some of the barriers identified during the study.
HL: How much more work do you have to do to perfect a care management model for complex patients?
Noonan: Now that the study's data has been published, we are continuing to analyze the data in partnership with the Abdul Latif Jameel Poverty Action Lab at MIT and Rutgers University, so we can understand more about sub-populations and promising trends. We are going to use that analysis to guide us through the demographics—and the health and social history—of this population to target patients better.
There was a broad population that was included in the study, from 18 to 80 years old. So, we are trying to understand different trends for different parts of the population.
HL: What advice can you offer to other healthcare providers that have launched hotspotting programs?
Noonan: The study's results make a significant contribution to the field. But it is important to consider what the results do not say. The results are not an indictment against all care management and care coordination programs.
Other studies have shown positive results, but the populations for those studies were older and predominantly Medicare populations. The NEJM study noted that our patients had much higher levels of complexity at baseline. We don't want other healthcare providers to think that the core elements of care management have been proven ineffective. That's not the case.
Angela Shippy shares her perspectives on quality improvement and C-suite leadership skills.
Angela Shippy, MD, is eager to apply her clinical and administrative experience in an expanded role at Memorial Hermann health system.
For the past five years, Shippy has served at the chief quality officer at the Houston-based health system. She has been promoted to senior vice president, chief medical officer, and chief quality officer.
Prior to joining Memorial Hermann, she was HCA Healthcare's Gulf Coast Division chief medical officer. Before working at HCA, Shippy was vice president of medical affairs at St. Luke's Episcopal Hospital, an affiliate of Houston-based Texas Medical Center, where she also practiced as a hospitalist.
Shippy recently shared her perspectives on the CMO and chief quality officer roles with HealthLeaders. The following is a lightly edited transcript of that conversation.
HealthLeaders: How will your experience as chief quality officer help you in your new role as CMO?
Shippy: There are a couple of different ways. First, as a chief quality officer you interact with everyone, you collaborate on projects, and you help to prioritize. We have strategic initiatives that are ongoing, so it helps me to continue to make connections on those initiatives.
Second, quality is involved in everything we do—particularly providing care to patients. The same could be said of the chief medical officer role. There are opportunities to be involved in multiple different aspects of the clinical care that we deliver.
HL: Give one or two examples of quality initiatives that you led as chief quality officer.
Shippy: Over the past six years, one of the key changes at Memorial Hermann from a quality standpoint is we went from an emphasis on process measures to outcome measures. Early on in value-based purchasing, the emphasis was on whether you were doing particular interventions. For example, you could check the box for heart failure if you gave an ACE inhibitor or did an echocardiogram.
Where we have been evolving over the past six years is to actual outcomes. So, if you are doing all of the processes properly, you should see outcomes such as decreased readmissions or decreased mortality. We have been working toward hardwiring processes, so we know the outcomes are good for patients and patients are able to take care of themselves outside of our acute interventions.
We also have been working outside of clinical areas to make sure that we have quality improvement methodology for operational areas. We have been identifying waste, we have been standardizing processes, and we have been sustaining changes once we have made them. We have been taking principles we use in clinical areas and helping operational colleagues and departments use those principles for their improvement.
HL: What aspects of your career best prepared you to work in C-suite roles?
Shippy: As a resident, I used to moonlight in the emergency department quite a bit. One of the hardest things to do there is to call one of your colleagues to admit a patient. So, very early on, I learned to completely assess a patient, to conduct all the testing that was needed, and to be able to succinctly present that patient to colleagues so they could understand the necessity to admit the patient. That teaches you how to put information together and put it in a format that other people can understand.
As a practicing hospitalist, I had the opportunity to interact with every member of the medical staff and every specialty. When you are taking care of patients who come through the ED, some are very ill, and you have to tap into your colleagues at all times of the day. So, you understand how the hospital works at 8 a.m., 8 p.m., and 2 a.m. You learn about the staff outside of the clinical staff that you have to deal with to make sure the patients get the care that they need. Having those interactions gives you a unique perspective on how to activate people and get things done.
HL: What are the essential leadership skills to be a successful CMO?
Shippy: To be a successful CMO, you have to understand that clinical skills and that background initially led you on the journey to get to the C-suite; but, ultimately, you need to have the ability to lead, collaborate, and inspire across multiple disciplines and across the entire organization.
In healthcare, you also must understand that caring for the patient is a team sport and the same can be said for administrative roles. You are never doing the work alone—it is a group of people coming together to provide the best outcomes or the best results.
The opportunity to be a chief medical officer is truly an honor for anyone who started their career as a practicing physician. It is an opportunity to take your clinical skills and combine them with what your organization wants to do from an operational standpoint to deliver the best possible care for patients.
In the largest-ever study of Medicare sepsis data, the increased rate of beneficiaries hospitalized with sepsis is nearly double the increased rate of enrollment in Medicare.
The largest sepsis study every conducted with Medicare data found a 40% increase in the rate of Medicare beneficiaries hospitalized with the deadly infection from 2012 to 2018.
Sepsis is diagnosed in at least 1.7 million adults annually in the United States, according to the Centers for Disease Control and Prevention. About 270,000 Americans die from sepsis every year, and 1 in 3 patients who die in hospitals are diagnosed with sepsis, the CDC says.
The new study was conducted by researchers from the U.S. Department of Health and Human Services. The journal of Critical Care Medicine has published the research in three articles:
"We were astonished by the study's results. To save lives in public health emergencies, we must solve sepsis. The findings of this study have implications not only for patient care, particularly after patients are discharged, but also for investments by industry, non-government organizations, and government agencies," Rick Bright, PhD, a study co-author, DHHS deputy assistant secretary for preparedness and response, and director of the Biomedical Advanced Research and Development Authority, said in a prepared statement.
Research data
The study features several key data points:
From 2012 to 2018, the annual number of fee-for-service Medicare beneficiaries with an inpatient hospital admission and a sepsis diagnosis increased from 811,644 to 1,136,889.
During the study period, the total annual cost of inpatient hospital admissions among fee-for-service Medicare beneficiaries increased from $17.8 billion to $22.4 billion.
The total annual cost of skilled nursing facility (SNF) care for fee-for-service Medicare beneficiaries in the 90 days after a hospital inpatient discharge with a sepsis diagnosis increased from $3.9 billion to $5.6 billion.
For Medicare Advantage beneficiaries with a sepsis diagnosis, the total annual cost of inpatient admissions and SNF care increased from $6.0 billion to $13.4 billion.
The total annual cost for fee-for-service Medicare and Medicare Advantage beneficiaries with an inpatient admission for sepsis and SNF admission increased from $27.7 billion to $41.5 billion.
The study includes a conservative forecast for sepsis care costs in 2019 for all Medicare beneficiaries and private payer patients. Last year, the cost of sepsis care for inpatient admissions and SNF admissions for these patients was estimated at more than $62 billion.
The 6-month mortality rate among fee-for-service Medicare beneficiaries with an inpatient hospital admission was about 60% for septic shock (the most serious form of sepsis) and 36% for severe sepsis.
The 40% increase in the rate of Medicare beneficiaries hospitalized with sepsis from 2012 to 2018 cannot be accounted for fully by increased Medicare enrollment, which rose 22% during the study period.
Interpreting the data
The total cost of sepsis care is significantly higher than earlier estimates, according to the DHHS study.
A highly cited study published in 2016 estimated the cost of all acute hospital inpatient care for sepsis in 2013 was $23.7 billion. The DHHS study was limited to Medicare beneficiaries, who accounted for 61.5% of the patients in the 2016 study. So, the earlier study estimated the total cost for inpatient care among Medicare beneficiaries at about $15 billion.
"We observe that the projected 2019 cost of inpatient sepsis care alone (not including SNF) for Medicare FFS beneficiaries alone (not including Medicare Advantage) is $23.5 billion," the DHHS study co-authors wrote.
The study provides new insights for the cost of sepsis care and the public health response necessary to address sepsis, they wrote.
"We now know the actual national expenditures for sepsis to far exceed widely cited contemporary estimates. The question is 'exceed by how much?' Answering this question requires new public-private partnerships that harmonize definitions of sepsis, that facilitate internal analyses and preparation of comparable summary data, and above all that promote the sharing of those summary data into the public space. Only when we understand the burdens, the trajectories, the predispositions, and the costs of sepsis can the nation fairly and prudently allocate the resources necessary to solve sepsis."
Sepsis is a significant burden on Medicare beneficiaries, their families, and the Medicare program, the DHHS study co-authors wrote.
"The human and economic burdens of sepsis experienced by Medicare beneficiaries continue to grow. Although there are improvements in mortality and in cost-per-case throughout a pragmatic hierarchy of sepsis severity, the year-over-year growth of the beneficiary population, the year-over-year increase in the total number of sepsis deaths, and the year-over-year increase in the total cost of sepsis care highlight the need to understand how beneficiaries become septic, their clinical courses once septic, and how sepsis survivors fare following discharge from the acute care hospital," they wrote.
Prevention and early detection of sepsis are critically important, the study co-authors wrote.
"Those strategies, which likely will require innovation in public health as well as improving individual immunoinflammatory health, are among the most promising strategies toward protecting populations and saving lives. Once sepsis is established, improving the immediate postsepsis trajectory—either by actions during the inpatient hospitalization or by actions during and after transfer to a facility offering prolonged care—appears to be an essential step toward value-based transformation of sepsis care."
Cost containment is a common theme of most trends that are expected to affect medical practices over the next 10 years.
The Medical Group Management Association (MGMA) has identified six trends that are likely to have a major impact on medical practices over the next decade.
MGMA, which is based in Englewood, Colorado, has about 55,000 members nationwide. The new trends report was produced by the organization's government affairs staff.
Cost containment is a common theme in most of the trends, Anders Gilberg, MGA, senior vice president of government affairs at MGMA, told HealthLeaders.
"The Medicare and Social Security trust funds are being quickly depleted. Short of full entitlement reform, which is fraught with political consequences, policymakers will look toward leveraging new technology and data and focusing on prevention as necessary first steps at bending the cost curve in healthcare. Medical groups are well positioned to take advantage of this trend," he said.
1. Ambulatory care ascendency: Changes in government and payer policies are expected to generate gains for medical practices relative to hospital-based care settings. For example, the federal government is likely to end payment differentials for outpatient settings that currently favor hospital-based sites.
"Clinical innovation and technological developments will continue to expand the types of services that can be performed in non-facility settings. With greater transparency, no one will be willing to pay the current mark-up on facility-based ambulatory care. The balance of power will shift toward group practices as payers realign incentives and facilities struggle with greater overhead and fixed costs," the MGMA trends report says.
2. Emphasis shifts from treatment to prevention: For decades, medical care has focused more on treatment than prevention. Several factors are promoting prevention in this decade, including telemedicine, chronic care management, and new payment models that do not put a premium on face-to-face patient visits.
"Data are beginning to show that services like chronic care management not only improve patient outcomes but save money in the long run. Expect to see greater alignment between reimbursement policy and preventative care, including non-traditional services like telemedicine. Primary care specialties will be obvious beneficiaries of this shift toward prevention," the trends report says.
3. The data decade: Data collection such as the widespread adoption of electronic medical records was a dominant data trend of the last decade. Efforts to harness data such as establishing interoperability, creating electronic decision-making tools, and applying data to precision medicine are likely to dominate the next decade.
"With effective population-based analytics, data will help practices with financial modeling and allow for more risk-based contracting or participation in advanced alternative payment models (APMs). As Medicare and commercial payers shift risk to physicians, group practices should prepare to monitor patient costs, measure outcomes, and improve population health," the trends report says.
4. Medicare Advantage edge: Regardless of healthcare reform efforts in the next decade, Medicare Advantage is likely to continue to expand. In the last decade, Medicare Advantage enrollment nearly doubled.
"The growing Medicare Advantage market could present new challenges and complexities for group practices stemming from non-standardized payment and administrative policies. It will also shift more power in the hands of private plans and exacerbate some of the most frustrating policy issues of the day, such as the increased use of prior authorization," the trends report says.
5. Twists and turns in the value journey: The slow pace of the federal government's efforts to develop value-based care payment models is likely to continue, the trends report says. "Medicare's Innovation Center is 10 years old yet has been frustratingly slow in producing new APMs, and results from existing models have been mixed. The lag in APM development has left most physicians participating in the Merit-based Incentive Payment System (MIPS), where resources and time spent on reporting have outweighed small bonuses."
There is more hope for speedier adoption of value-based care payment models among commercial payers, the trends report says. "Private payers … have greater opportunity to pilot innovation. Through data sharing and analytics, technological tools, infrastructure support, and less bureaucracy, the private sector will be better positioned than the government to facilitate value-based payment reform over the next decade."
6. Price transparency: Lawmakers have already proposed to increase hospital price transparency and medical practices are likely to face pressure to reveal charges and negotiated service rates.
The push for price transparency involves several challenges, the trends report says. "Anti-trust and anti-competitive concerns will continue. Posting prices may seem like a quick fix but getting to the true upfront cost for patients will prove difficult. Ultimately, health plans are in the best position to inform patients about their coverage and out-of-pocket costs, and lawmakers will hold plans' feet to the fire alongside providers."
An intellectual giant played a large role in shaping the career of Neel Shah, MD, MPP.
Shah is making his mark in Boston, where he is an obstetrician-gynecologist at Beth Israel Deaconess Medical Center, an assistant professor at Harvard Medical School, director of the Delivery Decisions Initiative at Ariadne Labs, and board chair of Costs of Care. He is a self-described health systems scientist—a calling that started when he studied neuroscience at Brown University in Rhode Island.
"My interest in neuroscience came from following a person. When I was in college, there was a professor named Leon Cooper who was my advisor. He won the Nobel Prize in Physics in 1972 for the theory of superconductivity at a relatively young age, then [he] moved on. He decided he was going to study the brain, and he came up with a bunch of theories about the brain that revolutionized the field," Shah says.
"Professor Cooper was an audacious thinker. For every young person, there is someone who believes a better world is possible, and he was that person for me. He was a mentor who taught me to think about systems because the brain is a complex system."
Healthcare reform advocate
Shah cofounded Costs of Care—a nongovernmental organization dedicated to providing better healthcare at lower cost—a decade ago.
"When we started, Costs of Care was focused on transparency. Abraham Verghese has a wonderful quote: 'If you are ordering off a menu with no prices, it's easy to get the filet mignon every time.' We wanted to put prices on the healthcare menu because there were brand-new clinicians clicking on a mouse who were spending tens of thousands of dollars without even knowing it," he says.
"Now, we have moved beyond transparency, which is important, but there are multiple failures at the point of care that are preventing people from accessing affordable, safe, dignified care. We can't tell people what services cost. We often don't tell patients whether a service is worthwhile to begin with. Then, when services are worthwhile and expensive, we are not deploying all of the resources to make sure that patients can comply with our recommendations."
Pursuing innovation
At Ariadne Labs—a joint healthcare innovation center of the Harvard T.H. Chan School of Public Health and Brigham and Women's Hospital, Shah has played a leadership role in the Team Birth Project. The initiative seeks to revolutionize the relationship between pregnant women, their families, and their healthcare teams to boost childbirth outcomes.
"The Team Birth Project is a large-scale experiment across the country that is trying to get clinicians and families on the same page to achieve more appropriate, safer, and more affordable care," he says.
Shah says even though he has always been "a little bit of a generalist," he gravitated toward the field of OB-GYN. He says that as he's spent more time in the field, it's become more personal for him. "I have a family of my own, and one of the things I have realized is that the period when you are growing your family from pregnancy to parenting an infant is a universal period of vulnerability. There are a lot of opportunities to make our systems of support and care better."
Perspectives on healthcare
Following are highlights from a conversation between Shah and HealthLeaders where he shares his perspectives on obstetrics-gynecology, value-based care, medical entrepreneurship, and health systems science.
"In childbirth, the main way we think about quality is the absence of injury. The absence of injury is good, but most women have goals beyond escaping unscathed from the process. Survival is the floor of what they are expecting and what they deserve. If we are going to design a better system, we should be aiming for the ceiling, but we haven't figured out what that looks like."
"Nobody goes to medical school thinking about GDP, but Americans have the least affordable healthcare compared to a half century ago. So, for the longest time of taking care of people, the ethic in U.S. medicine has been thoroughness rather than appropriateness. Thoroughness is a good goal, but appropriateness is a better goal."
"In the quest for thoroughness, 50 years ago there were only a handful of causes of chest pain; now, there are thousands. You literally cannot test for all of them—it's not efficient, it costs people a lot of money, and it can even be harmful to over-test. So, that's why appropriateness is important. We must find out how to deliver healthcare affordably for every American."
"The best models are the ones that put a contingency on payment over and above having simply provided a service. Any of those models are better than testing for something, drawing blood, or poking you with a sharp object, then billing for it irrespective of the outcome. That clearly is a crazy system. There is no other sector of the economy or other industry where that would be OK. There's no other area that tolerates the kind of paternalism or opacity that behavior requires."
"The mission of Ariadne Labs is trying to figure out how we can drive improvements at scale in healthcare. It's kind of the opposite of Costs of Care in some ways. Costs of Care is focused on catalytic, breakthrough innovations. Ariadne Labs is based on the recognition that the dominant cause of suffering in the world is not necessarily lack of knowledge—it's lack of execution. It's about fixing execution failures in a way that works in multiple settings across the world."
"It's 100% entrepreneurship in my mind because there's a vision, a commitment to realize that vision, and there's an ROI that is not necessarily cold, hard cash. It's more about making an impact. It's the same mindset and the same process as entrepreneurship. The things I invent are not widgets or artificial intelligence—the Team Birth Project has a totally analog whiteboard as a key tool. You write with a dry-erase marker, but it is fundamentally changing the way people experience care."
Pictured above: Neel Shah, MD, MPP, is an obstetrician-gynecologist at Beth Israel Deaconess Medical Center; assistant professor at Harvard Medical School; director of delivery decisions initiative at Ariadne Labs; and board chair of Costs of Care. (Photo credit: Jason Grow/Getty Images.)
Since 1997, CVS Health and its subsidiary Aetna have invested more than $1 billion in affordable housing and other social needs.
Woonsocket, Rhode Island-based CVS Health invested $67 million in affordable housing last year and plans to invest $75 million in affordable housing this year, the company announced today.
Housing is considered as one of the leading social determinants of health (SDOH), along with other social needs such as transportation and food security. By making direct investments in initiatives designed to address SDOH and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.
Last year, CVS Health supported affordable housing projects in 24 cities in California, Georgia, Hawaii, New Hampshire, Oregon and Texas, creating more than 2,200 affordable homes often with support services, the company reported. This year, CVS Health's plans to invest in affordable housing include $25 million in Ohio.
"Providing affordable housing options to people who are facing significant challenges can be their first step on a path to better health. However, we understand that more support is often needed—that is why we work with community organizations to provide access to services such as independent living skills, cooking and nutrition, financial literacy, health information classes, resident outreach and engagement, client-centered treatment plans, and social support," Karen Lynch, executive vice president of CVS Health and president of the company's Aetna Business Unit, said in a prepared statement.
CVS Health and healthcare insurer Aetna merged in 2018. Since 1997, CVS Health and Aetna have invested more than $1 billion in affordable housing and other social needs. The two-decade effort has supported the construction or renovation of more than 93,000 affordable rental units, the company reported.
Affordable housing investments in The Golden State
California has been a primary focus of CVS Health's and Aetna's affordable housing efforts, Kristen Miranda, California market president for Aetna, said in a prepared statement.
"We have made more than $160 million of affordable housing investments in California over the past 20 years, including nearly $50 million in the past two years alone. These investments are helping to address the unique needs of residents in California, helping to improve health at both the individual and community level," Miranda said.
The investments in California affordable housing include four recent projects, the company reported:
This month, CVS Health is working in partnership with CREA LLC to close an $8.1 million deal to finance development of 85 affordable housing units. The project is in collaboration with East LA Community Corporation and New Directions for Veterans.
On Feb. 14, there will be a grand opening of Sequoia Commons in Goshen, California. The 66-unit low-income community received funding from CVS Health, the California Department of Housing and Community Development, the Federal Home Loan Bank of San Francisco, Red Stone Equity Partners and Pacific Western Bank.
In December 2019, CVS closed on a $25 million commitment to an investment fund that will build or rehabilitate more than 500 affordable housing units in five California cities.
In November 2019, there was a grand opening of Bishop Street Studios in San Luis Obispo, California. The 33 permanent supportive housing units were established through the renovation of an abandoned orphanage and were funded by CVS Health, the Transitions-Mental Health Association, and the Housing Authority of San Luis Obispo. The affordable housing units are for individuals with mental health issues.
Cancer Treatment Centers of America CEO Pat Basu discusses three oncology care challenges and three challenges facing the healthcare sector.
The CEO of Boca Raton, Florida-based Cancer Treatment Centers of America (CTCA) recently talked with HealthLeaders about major challenges facing oncology care and the healthcare sector in 2020.
Pat Basu, MD, MBA, worked in several healthcare roles before taking on the top leadership position at CTCA last year.
The University of Chicago Pritzker School of Medicine graduate has worked as a physician at Stanford University Medical Center, as senior vice president at Optum, as a White House healthcare fellow, and as president, chief operating officer, and chief medical officer at vRad, a provider of radiology services. Basu is also one of the founders of telehealth pioneer Doctor On Demand.
He told HealthLeaders there are three primary challenges facing oncology care this year as well as three major challenges facing the healthcare sector this year and into the new decade. The following is a lightly edited transcript of Basu's comments.
Oncology care challenges
1. Access and affordability: This is simultaneously an environment where we have made exceptional strides in turning cancer into a chronic disease and adding years to life. At the same time, we still struggle with access and affordability.
On the affordability front, the cost of the therapies including the drugs and immunotherapy has implications for access. With such a prevalent and horrible disease as cancer, ideally you would want treatment to be 100% accessible.
2. Geographic barriers: In our case, we get a lot of patients who come from all over the country and all over the world. We get many patients who come to us after they have tried treatment at their local hospital. It's a major journey for these patients to travel.
By offering telehealth and partnering with local providers, we are trying to bridge this gap. But just because you have wonderful new therapies and protocols at facilities like ours, it doesn't mean that everyone can overcome the geographical barriers to access them.
3. Time: There might be a clinical trial that is in its infancy but it's so close to unlocking an important scientific discovery that I would wish that I could get it to patients today instead of a year from now.
Time is also a factor in catching disease early and preventing disease. Just like with cardiac care and diabetes, there are lots of things that can prevent cancer—upto 50% of cancer is preventable. Through prevention and very early detection and diagnosis, we can stop cancers at the cellular level before they progress to more complex diseases.
Healthcare sector challenges
1. Building a better American healthcare system: We need a healthcare system that is dramatically improved in quality, dramatically improved in access, and dramatically improved in affordability and sustainability for patients, doctors, employers, and the country as a whole. Quality, access, and cost are major challenges that are going to require transformative change.
For example, in the quality bucket, studies have shown that about 25% of hospital admissions have some sort of safety error or harm caused to the patient during their episode of care. That's totally unacceptable and can no longer be tolerated.
With access, one in four Americans will defer care because of cost reasons. One in three Americans will not take prescription drugs because of cost. One of the major causes of personal bankruptcy is healthcare. We have a highly inefficient system. Out of the $3.5 trillion that we spend on healthcare in this country, which is close to 19% of our gross domestic product, about $700 billion to $900 billion is wasteful care.
2. Siloed healthcare: It is so frustrating to me as a doctor and as someone who leads a large national care organization that we have siloes in healthcare. There are siloes down to the patient level, where there is limited compatibility of electronic medical records and limited portability of patient examinations.
We are also still struggling to establish robust partnerships. One of the things we are trying to do at CTCA is to determine how we partner with other providers and how we partner with payers, employers, pharmaceutical companies, and other members of the healthcare ecosystem. We want to lock hands together with partners to solve big problems. All of us take pride in how good we are and what we do, but we can do so much more if we partner with others.
3. Prevention and diagnosis: Often, the treatment side gets the most attention—more dollars and more resources. Treatment is very important, but we need to pay as much attention to devoting dollars and resources to prevention and diagnosis.
Although most cases of novel coronavirus have been reported in China, cases have been reported in 26 countries, including the United States.
An article published this week by the Journal of the American Medical Association provides clinical insights about the new coronavirus outbreak that started in China.
The Centers for Disease Control and Prevention (CDC) calls the new coronavirus 2019 novel coronavirus (2019-nCoV). Cases of 2019-nCoV mainly have been reported in China, where the epidemic began in the city of Wuhan in Hubei Province but cases have been reported in 26 countries, including 11 cases in the United States, the JAMA article says.
As of Feb. 4, more than 20,000 cases of infections had been reported, with 98.9% of the cases in China, and the virus had been tied to more than 400 deaths, the JAMA article says. A CDC webpage has updated information about the spread of 2019-nCoV and the response to the epidemic.
The JAMA article features several key points of information for clinicians:
Five cities with high volumes of travel from China have had the most cases of 2019-nCoV outside of the epicenter in China: Bangkok, Hong Kong, Singapore, Taipei, and Tokyo.
The first case of 2019-nCoV in Wuhan is believed to have spread from an animal to a human. There have been two other zoonotic coronavirus outbreaks in the past two decades: severe acute respiratory syndrome {SARS) and Middle East respiratory syndrome (MERS). Early data suggests that 2019-nCoV has greater infectivity and lower mortality than SARS and MERS.
One study reported the incubation period for 2019-nCoV is 5.2 days, but it could be as long as 14 days. It is possible that the virus can be transmitted when an infected person is asymptomatic, but it is likely that most transmission occurs when an infected person is symptomatic.
A study of 99 coronavirus patients in Wuhan found that most symptomatic people presented with fever and dry cough, with shortness of breath experienced by nearly a third of patients. Other symptoms included headache, sore throat and diarrhea. The study found the average age of patients was 55.5 years old.
There have been few cases reported in children.
Most cases appear to be mild. Patients who have required hospital admission have had pneumonia, and about a third of hospitalized patients have developed acute respiratory distress syndrome and have been admitted to an intensive care unit.
Clinicians should obtain a travel history when patients have fever and respiratory symptoms, especially a dry cough. If these patients have a history of travel to Hubei Province in the prior 14 days, they should be considered a person under investigation (PUI).
If a PUI presents, clinicians should report the case as soon as possible to their healthcare facility's infection prevention staff and to local or state health departments. Currently, the CDC is conducting all diagnostic testing for 2019-nCoV. Clinicians should test PUIs for other respiratory pathogens, and they should consider prescribing oseltamivir until influenza testing is completed.
If there is a high level of suspicion that a PUI has 2019-nCoV, the patient should don a face mask immediately and caregivers should wear N95 respirators.
There is no vaccine for 2019-nCoV and no medications have been proven effective against the virus. Care has been mainly supportive. The antiviral remdesivir was prescribed for the first U.S. coronavirus patient.
Public health measures that were effective in the SARS epidemic may be effective in the prevention of spreading 2019-nCoV: handwashing, respiratory etiquette such as covering the mouth when coughing, and staying home when sick.
