The industry has worked out as its supporters expected.
This article first appeared May 02, 2018 on Medpage Today.
By Joyce Frieden
WASHINGTON -- Remember the excitement around the medical tourism industry? Visions of thousands of U.S. patients heading to India and elsewhere to have medical procedures done at a fraction of the cost in the U.S.?
Well, that hasn't worked out so well, experts said here Monday at the World Health Care Congress.
In 2008, the consulting firm Deloitte predicted that the number of U.S. tourists traveling out of the country for medical care could reach as high as nearly 24 million by 2017, said Irving Stackpole, president of Stackpole & Associates, a consulting firm in Newport, Rhode Island. "These numbers are patently ridiculous," Stackpole said. "I believe roughly 2.6 to 3.4 million Americans have been leaving the country [each year] to purposely consume medical services elsewhere."
The bulk of those trips, he added, have been patients in the Southwestern U.S. traveling to Mexico for low-cost, high-value medical and dental care. And currently, there is only one health insurer that will pay for such travel: "a healthcare provider in the farm workers' union in southern California," where many of the workers are Mexican Americans.
"These numbers have a legacy, and [it's] the preposterous idea that medical tourism is an industry, that it's a sector in the economy," Stackpole said. "The amount of spending by those U.S. citizens in foreign destinations is a pimple on a duck's butt -- it's 0.001% of the trillions of dollars spent in the U.S. on healthcare ... It's not a sector and I'd argue it's not even a business."
Keith Pollard, editor-in-chief of the International Medical Travel Journal, agreed. "Patient interest turned out to be much lower than predicted," he said. "People didn't buy in at the numbers everyone hoped for."
Why didn't the medical tourism industry take off? Pollard listed several possible reasons:
Savings are insufficient to trump concerns about quality. People are always trying to balance value and risk, "and in their mind is always 'This is a risk -- it's a different culture, people I don't know, hospitals I may not trust,'" he said. "People are not yet convinced that this is a safe thing to do."
There is a lack of recourse if something goes wrong. "When something goes wrong, where does it end up?" Pollard said. "On the front page of the newspaper, on CNN, on BBC News. 'This patient went to this country for this, and it was a disaster.' In many countries, medical tourism does not have a very positive image. The providers tend not to handle stuff very well when things go wrong."
Insurers are reluctant to invest in this concept. "In the U.K., our [employer's] insurance company would not fund me to go to Croatia" for a procedure, said Pollard. "The reason for that is they can't measure the risk." A few years ago, Pollard said, he invested in a startup medical travel-based insurance product that would allow patients to travel to certain approved hospitals within Europe. "It took 2 years to find an underwriter who would underwrite this product," he said. The insurers were having trouble figuring out "How do we compare the risk of going to Barcelona or Dubrovnik or Zagreb or Poland or wherever?"
The medical tourism industry can learn from marketers' past mistakes, Pollard continued. One mistake was that "too many people believed the hype" about the market, and they didn't have a clear strategy in place before they jumped in. Instead, the attitude was "'Let's go sell what we've got before getting our product and service right,'" he said. "That's one reason [medical] tourism has a bad image in the media; the clinics providing the service haven't done a good enough job of providing an outstanding patient experience."
Marketers also need to think more about which markets to target. "There were lots of [medical tourism] providers coming to the U.S. 4-5 years ago because they thought that was a big opportunity," but that didn't pan out, he said. "The message is, think local, not global -- think about countries within a 3-hour flight time."
Targeting the proper customers is also important. "Who is going to pay for this -- employers? Governments? Patients? Insurance?" said Pollard.
Several new trends are beginning to affect the medical tourism business, said Elizabeth Ziemba, president of Medical Tourism Training, a medical travel consulting business, also in Newport. Technology is bringing more commodification of services, including online marketplaces for consumers to shop for healthcare internationally. "This works better in the traditional [medical tourism] services of in vitro fertilization, dental care, and cosmetic [procedures]" than for complex medical cases, she said.
In the "business to business" arena, "the traditional model has been healthcare providers and hospitals in high-income countries partnering with hospitals in lower-income countries to exchange knowledge and technology, and transfer skills," although that was often just a way to get more patients to come to places like the U.S. for treatment, Ziemba said. "That model has changed quite a bit." Now the providers in high-income countries are actually setting up shop in other places -- such as the Cleveland Clinic's building of a facility in Abu Dhabi -- "a more serious and more balanced approach to the transfer of skills and knowledge, to help other countries build their own infrastructure."
Self-insured employers are also having an effect on medical tourism, she added. For example, the Blue Lake Rancheria Indian tribe in northern California contracted with providers in France to send its casino employees there, she said.
"Government to business" contracts -- in which governments arrange with providers to provide services across borders -- are also popping up, said Ziemba. "We're starting to see this with small countries that can't provide their own complex care ... like the Maldives contracting with [providers in] India, or Palau contracting with the Philippines."
All in all, "it's a fascinating time and a confusing time" to be in the medical tourism marketplace, she said.
Recently, I was asked to give a talk on resilience and its role in reducing physician burnout. I was excited by the opportunity but asked if I could focus more on cultural change and institutional solutions for burnout. When the organizers said no, I declined. Why?
Well, it's not that I don't see the value in resilience. A lot of physicians that I really respect write and speak about resilience. I think it's a valuable concept, and I do think that we (or anyone, really) could benefit from becoming more resilient. But I'm really hesitant to link my work with physician burnout to resilience.
If you have ever seen one of my burnout talks, chances are one of my first slides was a radiograph demonstrating a fracture, usually with the line, "You thought you'd get through a talk from a radiologist without an x-ray -- think again." I regularly use this slide to lay the groundwork for my approach to physician burnout and solutions.
As a musculoskeletal radiologist, I frequently think about stress fractures versus insufficiency fractures. You probably don't, so as a refresher, a stress fracture is abnormal stress on normal bone, and an insufficiency fracture is normal stress on abnormal bone. So, your stress fracture is the 21-year-old college student who decides it's a good idea to run three marathons in a month (normal bone, abnormal stress), while your insufficiency fracture is when grandma comes to visit and trips over your child's Legos, breaking multiple bones (abnormal bone, normal stress).
I feel that the average physician is made of pretty strong bone. If you want to take that nerdy analogy further, our T-score on a DEXA scan would be unequivocally positive. We've survived over a decade of training that is rigorous mentally, emotionally, and physically, and therefore, I'd say that most graduates are quite "resilient."
So in my mind, physician burnout is much more of a "stress fracture" than an "insufficiency fracture."
When I do retreats or talks, I certainly touch upon personal wellness and physician empowerment as a way to address physician burnout. I think most of us could benefit from some education on the things they don't teach us in medical school, such as how to say no, knowing your worth, and other negotiation skills. I also think it's important to hear repeatedly that you can't be an effective physician if you don't take care of yourself.
But I also think we need to focus on how to change the culture of medicine and make changes on the institutional and national levels. At the end of the day, if you look at what has contributed to increases in physician burnout over the last decade, it's not that we have less resilient physicians. Physicians have always worked long hours, and physicians have always had stressful, demanding jobs. It's the loss of autonomy, the pressure to do more with less, the ever-increasing documentation requirements, RVU-, and patient satisfaction-based reimbursement, the rise in student debt, and increasing social isolation as doctor-patient relationships and relationships among colleagues suffer as a result of time constraints, uncertainty about the future, and lack of flexible work options that reflect changing physician demographics, amongst other things.
How do we address those things? That's what I'm interested in talking about.
This article first appeared April 20, 2018 on Medpage Today.
By Ian Ingram
Patients perceived physicians using electronic medical record (EMRs) during office visits to have poorer communication skills, and be less professional and compassionate compared with those conducting a face-to-face visit and simply using a notepad, a randomized trial found.
And most patients (71%) said they preferred the face-to-face visit, reported Eduardo Bruera, MD, and colleagues from MD Anderson Cancer Center in Houston, Texas in JAMA Oncology.
"The EMR has been found to have many negative effects on physician time and burnout rate," Bruera told MedPage Today. "But negative effects on patients had not been documented before to our knowledge."
Using scripted video vignettes, the study randomized 120 advanced cancer patients in a palliative care clinic at MD Anderson to first view either a video portraying a face-to-face office visit where the physician used a notepad to record notes, then followed by an EMR version where the physician used a stationary computer for typing notes and accessing information while minimizing disruption in eye contact (n=60); the second group saw the same two videos but in the reverse order (n=60).
"The face-to-face encounter with undivided attention from the physician has become less frequent," said Bruera. "Our findings suggest that patients prefer physicians who do not use the EMR as part of the encounter."
The face-to-face visit was better perceived across all study outcomes, with better median scores reported in questionnaires both after initial analysis of the first video and that following viewing of both.
Compassion score, where 0 is best and 50 is worst:
9 for face-to-face versus 20 for EMR after viewing the first video only (P<0.001)
4 versus 21 after crossover analysis (P<0.001)
Communication skills score, where 14 is poor and 70 is excellent:
65 versus 54 after first video (P=0.001)
68 versus 53 after crossover analysis (P<0.001)
Professionalism scores, where 4 is poor and 20 is very good:
19 versus 14 after first video (P<0.001).
20 versus 15 after crossover analysis (P<0.001)
"The result is not surprising," said Robert M. Wachter, MD, of the University of California San Francisco, commenting on the study. "Although it's worth taking a step back and asking why do people perceive things to be so different when the doctor is scribbling on a piece of a paper versus tapping on a computer."
The idea that physicians have to split their attention between the patients and documentation is not a new concept, he said. "It does leave you head scratching a little bit about what it is about this thing called the computer interface that appears to be particularly bothersome to patients."
Searching for improvements, some doctors have resorted to the use of scribes. "An awfully expensive and almost hilarious solution," Wachter told MedPage Today, yet tens of thousands have been hired by hospital and clinics.
In a recent article in Harvard Business Review, Wachter and Jeff Goldsmith, of the University of Virginia, described the advent of scribes as a "medieval" solution. "Only in healthcare, it seems, could we find a way to 'automate' that ended up adding staff and costs!" they wrote.
"New technology is needed," said Bruera, who described current EMR technology as "rudimentary" and seemingly designed solely for billing and regulatory compliance.
Wachter told MedPage Today that one option that has worked to varying degrees is an ergonomic solution where the computer is positioned in a triangle so both patient and doctor can see the record process, but said that the endgame is relatively clear. "I think it's probably 3-5 years away before this no longer is a major problem," he said. "There are a big number of companies working on what are called digital scribes."
He described an Amazon Alexa-like device that would sit in the doctor's office, but have intelligence to handle more than just dictation. More sophisticated functionality could identify that a conversation has shifted to the possibility of breast cancer, say, and begin searching the patient's record on its own to see if they've had genetic testing, a family history of the disease, or mammograms. This automated searching would be determined by thousands of previous doctor-patient interactions to find out what doctors had searched for during similar conversations. "When the conversation has content X, the doctor looks up in the chart for test Y and Z," said Wachter, "and then it can mimic that."
Patients in the study were enrolled from December 1, 2016, to May 30, 2017. Median age of patients was 58 years (44-66); most were white (67%), married (64%), and a majority (54%) were women.
The vignettes followed a format recommended in previous studies for this type of research. A script was developed (identical for both scenarios) and professional actors were hired. An independent review of the two vignettes was done to ensure the expressions and emotional quotients were the same.
This article first appeared April 18, 2018 on Medpage Today.
By Sheila Talton
Hospital executives might be inclined to shrug at news of Apple setting up its own health clinics for employees. The 84,000 people working for Apple in the U.S. are a collective drop in the bucket for a healthcare system with some 300 million patients.
It's true Apple alone is not going to break the system, but it could be the first tumbling rock before a landslide transforms the healthcare landscape. A more appropriate response from hospitals would be a determined effort to disrupt their own business model before outside innovators beat them to it.
Looking Beyond Savings
In an industry long dominated by the same players, this requires an openness to the reality that things change faster these days, and that companies that can't keep up get left behind faster. It's a lesson that's been learned time and again in the private sector but at an accelerating pace, whether with Blockbuster, Compaq, Kodak, or Sears. Complacency is often the last step on the path to irrelevance.
It's not like hospitals haven't been trying to innovate themselves out of trouble, and an elite cadre are making real progress. But from my perspective on multiple corporate boards outside of healthcare, and based on what I've seen as CEO of a healthcare startup, more hospitals need to look beyond how to save money and stay stable -- they need to become agile.
Stripping Down to Agility
Agility looks like the deceptively big predators circling them. Amazon appears to be a giant company that tries to do everything, but in reality, it focuses very narrowly on one thing it does very, very well -- online retail -- and then outsources almost everything else, not just to save money, but to get the very best of what they need immediately. They are big, but they are a nimble cloud of companies rather than a monolith. This is exactly what hospitals need to become.
Until now, most hospitals have tried to consolidate to achieve economies of scale -- think of HCA and Tenet's advances, or Mayo Clinic and Partners Healthcare, which have been echoed in numerous regional markets. Or they have outsourced non-medical operations like food service, parking lots and maintenance. But this does little to make them more agile in their core business of clinical care. That is where hospitals should be obsessively and narrowly focused.
Partner for Everything Except Care
Hospital executives should constantly be asking how their medical staff can best care for patients, and then make investments and forge partnerships that make that possible. That does not mean hiring an in-house team to design a new cafeteria or re-arranging other deck chairs. It means having an innovative and well-equipped medical staff with a clear mission, and a network of outside companies taking care of everything else and helping them achieve it, making everything else aligned with the care. That's not just outside partners who can do the work for less, it's outside partners who can help them do it better and faster and make the patient experience and patient outcomes better. We're not there.
If there's one certainty about the Darwinian future of healthcare, it's that those able to harness the possibilities of focus and technology will eventually prevail. If hospitals don't figure it out quickly, the likes of Apple and Amazon will.
Sheila Talton is president and CEO of Gray Matter Analytics and serves on the boards of companies and nonprofits including Deere & Co, Wintrust Financial Corporation, and Chicago's Northwestern Memorial Hospital Foundation.
Action Collaborative on Clinician Well-Being and Resilience take their case to Congress
This article first appeared April 11, 2018 on Medpage Today.
By Shannon Firth
WASHINGTON -- Approximately 400 physicians take their own lives each year, a clinician advocacy group said at a Tuesday congressional briefing.
The Action Collaborative on Clinician Well-Being and Resilience takes aim at the root causes of burnout, which can lead to depersonalization, depression, and even suicide, said Victor Dzau, MD, collaborative chair and president of the National Academy of Medicine (NAM).
Dzau cited a 2015 study that reported 54% of physicians experienced at least one symptom of burnout. In addition, 39% had suicidal thoughts, which is twice that rate of the general population, he noted.
Also in 2015, NAM published the report "Breaking the Culture of Silence on Physician Suicide," which included portions of letters from a medical student who committed suicide: "I have finally decided that I'd rather just not exist. I have found myself happy on occasion, and I have had many pleasurable things in my life, but mostly I feel overwhelmingly sad and exhausted from the weight of it. I would just rather not endure it any longer," wrote Kaitlyn Elkins, age 23, who was a medical student at Wake Forest University in Winston-Salem, N.C.
Since then, NAM, along with the American Academy of Family Physicians (AAFP) and others, formed the action collaborative to develop best practices for reducing burnout and promoting wellness among medical professionals.
The collaborative will focus on reducing the administrative burden on healthcare providers by simplifying quality reporting, reducing the need for prior authorizations, and standardizing documentation for payers, according to Clif Knight, MD, AAFP vice president for education.
In addition to examining the causes of burnout, the collaborative will investigate its consequences, including the cost to patients and the healthcare system. For instance, if a physician in a solo practice in rural Alaska leaves his practice because of burnout, this can have serious repercussions on patients' access to care, and the quality of care they receive, Knight explained at the briefing.
Another key element of the collaborative is the team of multi-disciplinary experts that will draft a consensus study that includes a "systems approach" to improving patient care by supporting clinician well-being, explained Charlee Alexander, MPH, collaborative director.
Knight noted that physician culture values "self-sacrifice more than self-care," and this is particularly true in medical schools.
He cited an editorial in response to 2015 study, telling MedPage Today "Until medical schools decide that the mental health outcomes of their student graduates are as important as where they get to go to residency, how much money they bring in for research, what their grades are... until that has the same level of priority, it's not going to get better."
Docs must gauge an agency's ability to find the right jobs in the right places.
This article first appeared April 03, 2018 on Medpage Today.
By Bill Heller
More than 40,000 physicians work locum tenens each year, and the vast majority find their assignments through a locum tenens agency. Because there are dozens of locum tenens companies out there, a lot of people ask me what makes them different or how to choose the right one.
From small mom-and-pop shops to large corporations, each locums agency has strengths and weaknesses that are important to consider. Thankfully, most people in our industry genuinely care about their providers and want to provide a great experience for them.
So it becomes a question of helping physicians narrow in on the choice that's right for them. This extends beyond finding a friendly locum tenens recruiter; physicians must also gauge the ability of the agency to find the right jobs in the right places while handling all the essential details for that assignment.
Here's a few tips.
Find an agency that upholds industry standards: A great place to start is NALTO membership (National Association of Locum Tenens Organizations). An agency that's an active member of NALTO indicates adherence to a set of standards and practices for professional conduct outlined by an independent industry organization. A good standing with NALTO offers a level of confidence the agency is reputable.
Your agency should be able to take care of all the details: Being a staffing agency is more than just having a job board. It's the services that truly set apart the premier partners. That's why I always encourage asking about key services, including credentialing, contract negotiations, and travel and housing. Not all agencies do it all. Finding out too late they don't do credentialing, or don't have the connections to get it done in a timely manner, can have a serious impact on that placement. Additionally, an agency that manages the transportation and living arrangements for assignments means you can focus on care, not searching for accommodations.
You need someone who takes care of licensing and privileging: The draw for many physicians to work locum tenens is traveling. That means working in states they might not already be licensed. The more reputable staffing agencies have teams dedicated to helping providers obtain state licenses and hospital privileges before taking locum tenens assignments. These teams build relationships with state boards and facilities throughout the country. This helps providers navigate the process much more quickly.
Your recruiter should understand your specialty: The person who tries to do everything will likely succeed at nothing. That's why I advise providers to ask about specialization. It seems like a no-brainer, but different specialties are different in more than just title. The job process for one specialty may not apply to another. A dedicated, or specialized, consultant will be better able to speak the language, understand the intricacies of the specialty, and know the right people in a desired location.
Don't forget to ask about malpractice insurance: Working locum tenens comes with its own set of considerations. One important matter is knowing who covers malpractice insurance. Make sure your agency protects you while on assignment with malpractice insurance coverage. Discuss whether the policy is comprehensive, if charges are associated, and if it covers any incident that may occur while you work for them, even after the assignment ends.
The bottom line is that you need to find an agency that is as good at their job as you are at yours. Knowing the right things to look for can make it easier to know if you've found the right agency for you and your goals.
The model aims to reduce avoidable emergency department visits, provide timely access to physician care, and lower costs for nursing home patients.
This article first appeared March 29, 2018 on Medpage Today.
By Shannon Firth
WASHINGTON -- A new payment model to improve care for nursing home residents will make its way to the secretary of the U.S. Department of Health and Human Services (HHS).
The Physician-focused Payment Model Technical Advisory Committee (PTAC) voted 10-0 on Tuesday to recommend full-scale implementation of Intensive Care Management in Skilled Nursing Facility Alternative Payment Model (ICM SNF APM). The model aims to reduce avoidable emergency department visits, provide timely access to physician care, and lower costs for nursing home patients (one PTAC member was absent for the vote).
"I think we're actually very close to something implementable on a wide scale," said Tim Ferris MD, MPH, a practicing internist and CEO of the Massachusetts General Physicians Organization in Boston. While he said he had misgivings about the level of accountability in the model, he stated that it wasn't "rocket science" to improve that element.
Grace Terrell, MD, an internist and CEO of Envision Genomics in Huntsville, Alabama, stressed that finding ways to improve care in nursing homes "ought to be considered an emergency." She voted for full implementation "with high priority."
The proposed model involves a geriatrician-led care team, which might include a nurse, social worker and pharmacist, working with the attending primary care provider (PCP) in partnership with a nursing home or skilled nursing facility. The care team provides 24/7 support via telehealth, mentorship, and "management of care transitions."
The model was put forth by Avera Health of Sioux Falls, South Dakota, based on its own Avera eLong Term Care (Avera eLTC) program. The model from the regional health system suggested two possible payment pathways: a performance-based payment and a shared savings model.
While PTAC got behind the model, members did express some reservations. Robert Berenson, MD, internist and institute fellow at the Urban Institute here, and Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform in Pittsburgh, expressed concerns over the shared savings pathway, which would overlay substantial financial risk on care for patients with a high chance of dying.
"The very cheapest patient of all is the patient who dies," Miller said, emphasizing the need to provide protections against stinting and inappropriately keeping patients out of the hospital.
Another concern was the model's ability to work in smaller settings. Avera serves 5,000 residents daily, according to its proposal. Joseph Rees, MD, a hospitalist at Avera McKennan Hospital, said the model could be implemented in smaller, rural geriatrician practices "if they have a really good interdisciplinary team."
Others at the meeting pointed out the model's advantages.
Joshua Hofmeyer, Avera eCare senior care officer, said the program improved staff retention at that facility. Also, staff felt they had time to serve patients, instead of constantly "putting out fires," he said.
David Basel, MD, vice president of Clinical Quality for Avera, noted that as the care team provides direct care, they are also training and mentoring nursing home staff. In addition, by providing a backstop for overburdened PCPs, the model also keeps relationships between PCPs and patients intact, Basel noted.
While the model's lack of risk adjustment is a shortcoming, a preliminary review team told the committee, PTAC members acknowledged that there currently aren't well-validated risk adjustment tools for the long-term care population.
Ferris said that performance measures should be enhanced and evaluated more quickly -- a 2-year reporting period before pay-for-performance kicks in seemed "generous," he said.
He also stressed that the letter to the HHS secretary should include explicit plans for goals of care.
The CMS principal deputy administrator tries to reassure House members concerned with proposed budget cuts.
This article first appeared March 22, 2018 on Medpage Today.
By Joyce Frieden
WASHINGTON -- Pay no attention to that funding cut behind the curtain -- physician payment reform and patient empowerment are alive and well, Demetrios Kouzoukas told House members at a hearing on Medicare's physician reimbursement system.
"I think we share the goal of making sure patients have access to care in a way that makes sense for them," Kozoukas, who is Director of Medicare at the Centers for Medicare & Medicaid Services (CMS), said Wednesday at a House Ways and Means Health Subcommittee hearing on the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA). "As we embark on this journey, we will do it in a way that makes sense for each community."
But committee Democrats did not seem convinced. "I'm more than a little troubled looking at contrasting what you're talking about here in encouraging tones, but [then there is] the budget from the administration that's a third-of-a-trillion-dollar cut, and their efforts to undermine attempts to pay for value over volume," such as making some Medicare programs in this area voluntary rather than mandatory, said Rep. Earl Blumenauer (D-Ore.). "I think we all ought to be troubled by this schizophrenia on the part of the administration."
Variety of Issues Raised
Rep. Terri Sewell (D-Ala.) was also concerned. "The president's proposal to cut Medicare ... would send shock waves throughout the healthcare system," she said. "A disproportionate amount of folks in my district live in remote rural areas; I can't tell you how many hospitals closings I have attended ... We have to make sure we look for creative ways to have access."
"So often, many of my constituents can't make primary care appointments because of the long distance, and they don't have anyone to help them get there," she said. "I know we'd save lots and lots of money if we could figure out a way to help people make [it to their] appointments."
Kouzoukas tried to reassure her. "We are working to make sure the programs we undertake and the way we implement them won't [harm] rural providers," he said of the possible cuts.
As for transportation, "I couldn't share your concern more," he said. "There are some really bright [steps] in transportation; Medicare Advantage plans can offer transportation benefits, and there is also recent guidance by the Inspector General's office that opened up rules and limitations around transportation. We have also focused on innovative models that might include transportation and care in the home."
Committee members expressed a variety of concerns about the MACRA program itself. Rep. Judy Chu (D-Calif.) noted that rates for psychotherapy services had dropped by an average of 17% in the last decade. "What is Medicare doing to increase the number of mental health providers in the system at a time when demand is increasing above beneficiaries due to conditions like Alzheimer's and dementia?" she asked.
Kouzoukas agreed that mental health providers were critical, especially in the wake of the opioid crisis. "We made changes last year to recognize that it's important for practices who don't have capital-intensive needs -- who operate with [just] a desk, a chair, and an office -- to [increase] their reimbursement," he said. "We set that out in the fee schedule last year; we look forward to hearing about the improvement it's hopefully made in addressing the issues you raise."
The Pain of Paperwork
Rep. Adrian Smith (R-Neb.) said the most common grievance he heard from rural healthcare providers in his district was about "the amount of administrative burdens imposed on them by the government." Again, Kouzoukas agreed.
"The notion of [administrative] burden isn't just an abstract idea -- it's very real," he said. To address this problem, Medicare has raised the claims threshold required for providers to have to participate in collection of healthcare quality data, and also allowed for providers to join "virtual groups" with doctors outside their own practice, in order to be measured on quality criteria as part of a larger group.
Kate Goodrich, MD, CMS's chief medical officer, also chimed in on the issue. "I'm a practicing physician; I know firsthand what administrative burdens are," said Goodrich, who was there to assist Kouzoukas with his testimony. "So we also provided a hardship exemption ... for small practices unable to procure an electronic health record" as required for Medicare reimbursement. In addition, CMS is making technical assistance available to smaller physician practices who need help with their EHR.
Besides helping smaller practices adjust to the new payment systems, Rep. Diane Black (R-Tenn.) asked Kouzoukas what the agency was doing to make MIPS [Medicare's Merit-Based Incentive Payment System] more feasible for physicians to take "downside risk" and move into advanced alternative payment models (APMs).
"We're working to create more APMs," he responded. "The more APMs we have, the more variation there will be for physicians to find the one that's right for them." For example, Kouzoukas said, CMS will be implementing an "all-payer" combination APM, in which physicians will be able to count their participation with a private plan or in a Medicare Advantage APM toward a "threshold" that qualifies them for an APM bonus.
"And we haven't stopped there," he continued. "We're working on ... a really exciting demonstration project that would create an opportunity for physicians to count their Medicare panel size toward APM participation in a two-sided risk arrangement. That's just to give a flavor of the breadth and scope we're looking at to make this fit right for each physician practice."
Self-Referral Laws a Concern
The big complaint in Rep. Kenny Marchant's (R-Texas) district is how the Stark self-referral laws -- which bar physicians from referring patients to facilities in which they have a financial interest -- "are creating barriers to the coordination necessary to get them to succeed in the new value-based programs," the congressman told Kouzoukas, adding that a bill sponsored by Marchant, the Medicare Care Coordination Improvement Act, would help physicians who are unable to participate in APMs due to self-referral laws. "What is CMS doing to relieve the Stark burden?"
"I think a discussion of Stark is really important," said Kouzoukas. "It has a really big impact on how relationships are structured in the healthcare space ... We acknowledge that MACRA is a piece of this [issue] ... and in the president's budget, we have a proposal similar to the concept you described."
Rep. Erik Paulsen (R-Minn.) asked what steps the administration was taking to include specialty-specific measures under the MIPS quality reporting requirements, as well as what efforts were being made to include rehabilitation providers.
"We're working with specialty societies and other stakeholders to develop the right kinds of outcomes measures," Goodrich responded. "Physical therapists and occupational therapists have long been enthusiastic participants [in similar reimbursement programs]. MACRA allows us to include those types of clinicians beginning in the third year of the program, so we'll be making proposals [on that]."
Rep. Tom Reed (R-N.Y.) had what seemed to be a more difficult question: how to explain to Medicare beneficiaries what the "volume to value" movement and empowering consumers was all about. "Tell me how to talk to a 65-year-old to say, 'This is how you participate in the program now'; translate that," he said.
"Tell her it's like choosing home or auto insurance ... so she [can know] she's got confidence and comfort in the person she's dealing with ... and feels like she's got a choice," Kouzoukas said.
"That [idea] is not getting to the people back home," Reed replied. "They don't get it ... We have to do a better job."
Maryland's switch to global budgets working well so far, say observers.
This article first appeared March 13, 2018 on Medpage Today.
By Joyce Frieden
As Medicare officials continue to refine that program's system for paying physicians, several states are experimenting with changes to the way their hospitals are reimbursed.
The granddaddy of unique hospital payment systems is Maryland, which started an "all-payer" reimbursement system in the 1970s. Under that system, hospitals were all paid the same rates by all the payers -- Medicare, Medicaid, private healthcare plans, and uninsured individuals. The rates were established by the state's Health Services Cost Review Commission (HSCRC).
Many Payers, Same Rate
"Under that system for decades, the way it worked was if you were going to get an appendectomy at [a particular hospital] you were going to pay $1,000, whether you were Medicare, Medicaid, private insurance, or paying out of your own pocket," said Joe Antos, PhD, scholar in healthcare and retirement policy at the American Enterprise Institute and HSCRC vice-chairman. "But if you were getting it at [another hospital], the price might be different ... It varied depending on the hospital, but [at that hospital] the price was the same for everybody."
However, this system ended up being expensive for the Centers for Medicare and Medicaid Services (CMS), since it was paying Maryland more on average for hospitalized Medicare and Medicaid patients than it was paying any other state, explained Karoline Mortensen, PhD, associate professor for health sector management and policy at the University of Miami Business School in Coral Gables, Florida. This was especially problematic as more Medicare patients began using outpatient care for procedures that were formerly performed in the hospital.
"[That was] making the metrics look all messed up," said Mortensen. "CMS said, 'You need to do something different or you will lose your waiver for the all-payer system.'"
So starting in 2014, armed with a new waiver from CMS, the state began using a "global budget" system in which each hospital is paid a set amount of money -- again, contributed by all payers -- to take care of all its patients. "What they did with these hospitals is look at historic revenues -- how much were they getting in 2013 -- and gave the hospital a little above that number," she explained.
Generally, hospitals seem fairly happy with the system, said Gene Ransom, JD, CEO of MedChi, The Maryland Medical Society, in a phone interview. "Hospitals are doing well although I think some of the hospitals [with out-of-state branches] would tell you they have better profit margins in other states," he said, adding that this may be partly because all the hospitals in Maryland are non-profits. As physicians, "We just want to make sure patients are taken care of and that we're getting treated fairly in the process."
Physicians Unaffected
So far, the budgeting system has not really impacted physician payment in the state; doctors are getting paid the same way as other places -- generally fee-for-service or salary, according to Ransom. However, CMS, which extended the state's global budget waiver to the end of 2019, is now negotiating with other payers and Maryland Governor Larry Hogan (R) for a longer-term extension. "The positive thing is as they change the waiver, they're attempting to modify it in line with existing [physician payment] programs," such as Medicare's Merit-Based Incentive Payment System (MIPS) and its accountable care organizations, he said.
"Hospitals take a lot of [financial] risk in Maryland, and a lot of physicians work with or for hospitals, so we're asking to get credit for that risk," Ransom added, noting that the 2014 waiver "allows for more gainsharing and gives exemptions in certain circumstances from antitrust [laws] and Stark [self-referral laws], so that's a positive, and we are hoping in the long run -- and we've been promised by CMS -- that we're going to have more qualifying physician programs."
But a lot of doctors aren't even aware that this experiment is going on, Mortensen said. When she was at a meeting with Maryland physicians recently and brought up global budgets, "they had no idea what I was talking about," although they control a lot of hospital expenditures, even as non-employees.
The point of the global budget demonstration "was to get more control over total hospital spending, because under rate-setting, there were not very many controls and we weren't very effective in any event," said Antos. "Spending went much higher than had been expected. So we had to cut the rates ... [Global budgets] would give hospitals more of a sense of planning because they would know what their [rate was] on a per-patient basis."
For hospitals who seemed to be on track to spend more than their budgets, "the commission would basically either require them -- or make strong suggestions -- to stay within their annual budget by any number of things they could do," he continued. "One is that they could adjust downward somewhat the charges for patients they were seeing. However, what we really wanted them to do was make investments to reduce unnecessary hospitalization, to reduce readmissions, which really add to the cost ... Maryland hospitals responded generally the way you'd hope; they did make these investments."
Maryland's global budgeting experiment "makes some sense, but it's halfway to what makes sense," Antos added. "If we're only doing hospital services, that's going to slow down the rate of spending in [Medicare] Part A" -- which pays for hospital care -- "but we're going to see a big increase in Part B," which covers physician office visits. "And in fact, that's exactly what we've seen. I'd like to extend the system to [both parts] altogether."
Other States Also Experimenting
Maryland is not the only state experimenting with all-payer programs. In Pennsylvania, under a CMS demonstration project which started last January and runs for 7 years, rural hospitals can voluntarily work under a global budgeting system, which, like Maryland's, will include contributions from all payers in the state. The program is being aided by a $25 million, 4-year grant from CMS.
"Pennsylvania commits to achieving $35 million in Medicare hospital savings over the course of the model," according to its CMS webpage. "In addition, the growth rate of rural Pennsylvania total Medicare expenditures per beneficiary must not exceed the growth rate of the rural National total Medicare expenditures per beneficiary, making this Model budget-neutral for Medicare."
Currently, the program is in its design phase; "organizers are currently working with five potential hospital partners and the state is looking to recruit more," according to a spokeswoman for the Hospital and Healthsystem Association of Pennsylvania. One of the ongoing challenges to the program is getting the needed funds to help the hospitals make the transformation "on an ongoing basis," she said in an email. "Some rural hospitals have experienced unstable finances and need resources to assist in redesigning their physical plant, restructuring a workforce to meet the population's needs, and improving technology (such as telemedicine services)."
In Vermont, the state is experimenting with an all-payer accountable care organization (ACO) model, in which the state "will limit the annualized per capita health care expenditure growth for all major payers to 3.5%," according to the model's webpage. In addition, "Vermont will focus on achieving Health Outcomes and Quality of Care targets in four areas prioritized by Vermont: substance use disorder, suicides, chronic conditions, and access to care." That model, which began in 2017, will run through the end of 2022.
A single error oft inters the good that doctors do. The case of Dr. Hadiza Bawa-Garba, a trainee pediatrician in the National Health Service (NHS) convicted of homicide for the death of a child from sepsis and hounded by the General Medical Council is every junior doctor's primal fear.
A Boy in Shock
Friday, February 18th, 2011 was not a typically unusual day in a British hospital. Dr. Bawa-Garba had recently returned from a 13-month maternity break. She was the on-call pediatric registrar -- the second in command for the care of sick children at Leicester Royal Infirmary. As a "registrar" she was both a master and an apprentice -- a juxtaposition of roles necessary for the survival of acute care in the NHS. The captain of the ship and Dr. Bawa-Garba's supervisor, Dr. O'Riordan, was not in the hospital but teaching in a nearby city. Dr. Bawa-Garba's colleagues -- i.e., other registrars -- were also away on educational leave.
Normally, a registrar each is assigned to cover the wards, the emergency department, and the Children's Assessment Unit (CAU). That day, Dr. Bawa-Garba covered all three.
At 10:30 am she assessed Jack Adcock, a 6-year-old boy with Down syndrome who was referred by the GP for nausea, vomiting, and diarrhea. Jack was normally a lively chap, with a past surgical history of a repaired atrioventricular canal defect and on enalapril. He was apyrexial but looked dehydrated and sick. Dr. Bawa-Garba made a presumptive diagnosis of fluid depletion from gastroenteritis and administered an intravenous fluid bolus immediately and started him on maintenance fluids. She requested a chest radiograph, sent off blood for blood count, renal function, and inflammatory markers and drew blood gases, which showed that Jack was acidotic, with a PH of 7 and a lactate of 11.
After the fluid bolus, Jack seemed to trend in the right direction metabolically. The repeat blood gas showed he was less acidotic, with a PH of 7.24, heading towards a normal PH of 7.4.
At 3 pm she looked at the chest radiograph, which showed pneumonia. She prescribed Jack antibiotics, which were given at 4 pm. The radiograph had been exposed at 12:30 pm. Radiographs aren't routinely interpreted by radiologists -- there aren't enough radiologists in the NHS. Jack was moved from the CAU to the ward. At 4:30 pm she met Dr. O' Riordan, her boss, in the hospital corridor. She showed him Jack's blood gas results and explained her plan of action. Her boss did not see Jack.
Jack received enalapril. Dr. Bawa-Garba had not prescribed enalapril, and she clearly stated in her plan that enalapril must be stopped -- the drug lowers blood pressure and is absolutely contraindicated in shock. Nor was enalapril given by the nursing staff -- they stick to the doctor's orders. An hour after receiving enalapril, Jack had a cardiac arrest.
Jack died from streptococcal sepsis. His circulatory system put up a fight, and he so bravely maintained his blood pressure that he deceived everyone about the true nature of his critical condition. His body had been fighting the bugs for some time. By the time he was assessed in the CAU, it was so knackered that it could not even mount a temperature. There is plenty of ruin in the circulation. And Jack might have prevailed. The fatal dose of enalapril took the sails out of his resistance and precipitated circulatory collapse.
To Err is Homicide
The trust's internal inquiry identified several system issues that contributed to Jack's death. But it is easier believing that a particular doctor "killed" the child than that a system failed to save the child. Thus, a black, Muslim, female physician wearing a headscarf, who should have been the face of NHS's glory became the face for all its failings.
Dr. Bawa-Garba and the two nurses who were caring for Jack were charged with manslaughter for gross negligence. With the power of hindsight, sepsis, the deadly deceiver, became a diagnosis that any half-competent pediatrician should casually be able to detect. Jack's care was meticulously decomposed. The delay in getting a chest x-ray, the delay in reading the x-ray, the delay in prescribing the antibiotics. Unwittingly, the court was exposing system failures, but Dr. Bawa-Garba was being held responsible for each failed component. It was as if she was all of NHS and all of NHS was her.
Expert witnesses opined that had Jack received antibiotics within 30 minutes, rather than 6 hours, his chances of survival would have increased dramatically. There was tremendous certainty in the counterfactual. Diagnostic medicine is a fog of uncertainty until you know what the patient had. Dr. Bawa-Garba was found guilty of manslaughter -- the jury returned the verdict 10:2.
Throwing the apprentice under the bus
Guilty of homicide for mistaking normalizing PH after a fluid bolus for hypovolemic rather than septic shock. The difference between jail and exoneration in Britain for a trainee physician is a multiple-choice question about a medical emergency.
Jack's blood gases were deemed characteristic of sepsis. Oddly, Dr. O'Riordan, Dr. Bawa-Garba's supervisor, was not guilty of not instantly recognizing sepsis. If a trainee doing the work of three registrars can be found guilty of homicide for not understanding acid-base physiology, what does it say about the competence of her supervisor? How can she be criminally negligent and not he? This is neither scientific nor logical. Dr. O' Riordan was either incompetent or lazy. Or there's another explanation -- perhaps sepsis in a child is difficult to diagnose even for a seasoned consultant pediatrician.
Had Dr. Bawa-Garba prescribed the fatal dose of enalapril she ought to have been found guilty of manslaughter -- that error is egregious. But she had not. And here, too, a failing, a mysterious failing, was internalized by the apprentice. It was deemed her fault for not anticipating that Jack would receive enalapril even though it was not on his drug chart. She was guilty for not thinking about all the contingencies.
The Hyenas in the General Medical Council
The law, for all its failings, is the law. One can't expect jurors to understand how trainees prop up the NHS, how any trainee could have been Dr. Bawa-Garba that day. But one does expect the General Medical Council (GMC), the regulatory body for physicians, to understand how the NHS works. GMC comprises physicians who were once junior doctors in the trenches.
Like hyenas drawn to a carcass, the GMC began circling Dr. Bawa-Garba. It was not enough that she was wrongly convicted of manslaughter. It was not enough that Health Education England withdrew her training number -- i.e., annulled her residency. They wanted to make sure she could never practice medicine again. They wanted to erase her name from the medical register.
Though the GMC's purpose is to protect patients and guide doctors, it's an organization that takes an uncompromising stance towards its own reputation and the reputation of doctors in general in the public sphere. It has long taken the reputation of the medical profession personally. Meaning, if there is a chance that a physician, who has been investigated for fitness to practice, will bring the profession into disrepute, the GMC axes them from the register.
For the GMC, Dr. Bawa-Garba was irresistible fodder. She had already been found guilty of manslaughter by a public court that led the GMC to apply elementary logic -- "found guilty; therefore guilty." To save face in the public eye, the GMC has to make sure she could never practice medicine again. The GMC wanted to stay internally consistent. The law was an ass, so for the sake of consistency, the GMC had to be an even bigger ass.
The GMC believed that Dr. Bawa-Garba was not remediable. How did the GMC convince itself that she was a perennial threat? The GMC's logic is best expressed in the submission of their counsel that "wholesale collapse of the standard of care provided by you (Dr. Bawa-Garba) came out of the blue and for no apparent reason. He submitted that it was therefore impossible to have any confidence that this would not happen again."
And this is the crux of the problem. The GMC can't see that when a physician with an unblemished track record fails to make a diagnosis -- then maybe the diagnosis is tricky. The GMC can't see that to err is to be a doctor. The GMC is out of touch with clinical medicine in the NHS. It is not evil -- it is profoundly ignorant, and it is playing a dangerous popularity contest with the public. This isn't good for either doctors or patients. It is hard to see how paying annual dues to the GMC can be considered ethical.
The GMC pursued Dr. Bawa-Garba's expulsion with extraordinary zeal. Finally, the high court sided with them, which opened the floodgates of the national angst of doctors in Britain.
Unsupported Junior Doctors
Junior doctors run the NHS -- the extent to which is difficult to explain to people who haven't worked in the NHS. As I mentioned before, Dr. Bawa-Garba was doing the job of both an apprentice and a consultant. This state of affairs is not without dividends. By relying so heavily on junior doctors, the NHS is able to employ fewer consultants. Consultants aren't cheap -- once you factor in their salary and benefits, particularly the pensions. Thus, the NHS saves money but -- and this is the crucial point -- so does the taxpayer.
So, junior doctors are workhorses, but when the sh*t hits the fan, they can't take advantage of a legal doctrine known as "respondeat superior," which means that the employer assumes responsibility for their actions. This is a win-win situation for hospitals and lose-lose situation for junior doctors -- not only must they make tough clinical decisions, but if they screw up, and unsupervised apprentices will screw up, they'll be thrown under the bus.
How this situation became palatable baffles me to no end. But it gets worse. When a junior doctor complains about being unsupported -- i.e., the whistle blows -- they lose their job, as Dr. Chris Day, an aspiring emergency physician, did. Thus, junior doctors must choose between the devil and the deep blue sea -- risk jail if they work unsupported or risk unemployment if they complain about being unsupported.
To emphasize, the problem isn't just that junior doctors work unsupervised -- to a large extent, this is unavoidable. The problem is that junior doctors work unsupervised and are fried for errors of judgment inevitably made because of their inexperience. Court marshaling the foot soldiers for making decisions their generals were too busy to make is extreme cowardice. Trainees should be remediated by their teachers -- not prisons. Junior doctors need complete legal protection -- this is fair and civilized.
A competent doctor's career was ruined by a virulent entity with a mortality as high as 80% and for which the NHS is neither any safer nor any wiser, though its lifeblood, the junior doctors, will have coagulated a bit. In prosecuting Dr. Bawa-Garba and the agency nurse who, sadly, was struck off the register, too, attention has been diverted from the shortcomings of the NHS. The General Medical Council has contributed to the grand public deception. The actions of the General Medical Council will outlive them.