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Saturday, September 14, 2019

Groupon for medical care is symptomatic of our broken system

Groupon for medical care is symptomatic of our broken system:

Groupon-type deals for health care aren’t new. They were more popular in 2011, 2012 and 2013, when Groupon and its then-competitor LivingSocial were at their heights.

Emory University medical fellow Dr. Nicole Herbst was shocked when she saw three patients who came in with abnormal results from chest CT scans they had bought on Groupon.

Yes, Groupon — the online coupon mecca that also sells discounted fitness classes and foosball tables.

Similar deals have shown up for various lung, heart and full-body scans across Atlanta, as well as in Oklahoma and California. California Groupon also offers discount coupons for expectant parents looking for ultrasounds, sold as “fetal memories.”

While Herbst declined to comment for this story, her sentiments were shared widely by the medical community on social media. The concept of patients using Groupons to get discounted medical care elicited the typical stages of Twitter grief: anger, bargaining, and acceptance that this is the medical system today in the United States.

But, ultimately, the use of Groupon and other pricing tools is symptomatic of a health care market where patients desperately want a deal — or at least tools that better nail down their costs before they get care.

“Whether or not a person may philosophically agree that medicine is a business, it is a market,” said Steven Howard, who runs Saint Louis University’s health administration program.

By offering an upfront cost on a coupon site like Groupon, Howard argued, medical companies are meeting people where they are. It helps drive prices down, he said, all while marketing the medical businesses.

For Paul Ketchel, CEO and founder of MDsave, a site that contracts with providers to offer discount-priced vouchers on bundled medical treatments and services, the use of medical Groupons and his own company’s success speak to the brokenness of the U.S. health care system.

MDsave offers deals at over 250 hospitals across the country, selling vouchers for anything from MRIs to back surgery. It has experienced rapid growth and expansion in the several years since its launch. Ketchel attributes that growth to the general lack of price transparency in the U.S. health care industry amid rising costs to consumers.

“All we are really doing is applying the e-commerce concepts and engineering concepts that have been applied to other industries to health care,” he argued. “We are like transacting with Expedia or Kayak while the rest of the health care industry is working with an old-school travel agent.”

A closer look at the deal

Friday, September 13, 2019

California legislature debates surprise medical bills

 Some doctors complain the proposed legislation would empower insurers to keep narrower networks and limit access to crucial health services.

In California, a fierce battle over surprise medical bills pits docs against insurers
For the second time in as many years, California legislators are debating a bill that would protect patients from paying surprise medical bills when they inadvertently get treatment from doctors who are not covered by their insurance.
Under the bill, AB 72, consumers would only pay the equivalent of in-network rates if, for example, during surgery covered by insurance, they are treated by an out-of-network anesthesiologist, or have X-rays read by an out-of-network radiologist. AB 72 is in the California Senate and must be approved before going to the state assembly and governor. The state legislature has until Aug. 31 to act, or the bill effectively dies in committee.
The legislation was sponsored by state Assemblyman Rob Bonta (D-Alameda), who sponsored a similar bill last year that languished over the finer points of what the lower, in-network-style payment would be.
Surprise medical bills occur in a small percentage of overall health care transactions, but they often result in thousands of dollars in unanticipated charges that are difficult for many people to afford. Patients get hit with these extra charges because, in the course of getting treatment, one or more ancillary providers aren’t on their insurance plan, even if the main provider, like a surgeon, is. That ancillary provider maybe someone who routinely works with a particular surgeon or hospital, or just happens to be the only one available that day, said Bonta, so even if patients do all their homework to make sure they are covered, it isn’t enough.
In California, this fight is on full display and the proposal is generating harsh criticism from some doctors because they have to take that lower rate or go to arbitration.  
“We’re supposed to hire an attorney or go off to a dispute resolution process, spend hours getting ready, and then hours at the process?” said Dr. Michael Couris, a San Diego ophthalmologist. “You’re telling me this is a tenable position? This is laughable.”
Some independent physicians argue the current proposal would only empower insurers to keep narrower networks, ignore independent physicians and small practices, and limit access to crucial health services.
Emergency Room surprise bills are common as well.
Mystery Solved: Private-Equity-Backed Firms Are Behind Ad Blitz on ‘Surprise Billing’

Two doctor-staffing companies are pushing back against legislation that could hit their bottom lines.
The emergency department doctor you see in the emergency room does not work for the hospital. He (She) is employed by an outside contract group who negotiated a contract with the hospital for care. This theoretically avoids the issue of hospitals employing physicians directly.  It eliminates the cost of benefits, vacation pay and deductions for taxes and health insurance.  Early this summer, Congress appeared on its way to eradicating the large medical bills that have shocked many patients after emergency care. The legislation to end out-of-network charges was popular and had support from both sides of the aisle. Legislation is also proposed in California and other states regarding surprise emergency medical bills.  The bills were well on their way to becoming law when a curious thing happened.  Private-Equity-Backed Firms launched an ad Blitz on ‘Surprise Billing’. Then, in late July, a mysterious group called Doctor-Patient Unity showed up. It poured vast sums of money (Dark Money) now more than $28 million — into ads opposing the legislation, without disclosing its staff or its funders.Trying to guess who was behind the ads became something of a parlor game in some Beltway circles. Whether this was by design or happenstance is moot, the end result will be the same.Now, the mystery is solved. The two largest financial backers of Doctor-Patient Unity are TeamHealth and Envision Healthcare, private-equity-backed companies that own physician practices and staff emergency rooms around the country, according to Greg Blair, a spokesman for the group.“Doctor-Patient Unity represents tens of thousands of doctors across the country who understand the importance of preserving access to lifesaving medical care and support a solution to surprise medical billing that protects patients,” said Mr. Blair, who issued the statement weeks after the group was first contacted about the campaign. “We oppose insurance-industry-backed proposals for government rate-setting that will lead to doctor shortages, hospital closures and loss of access to medical care, particularly in rural and underserved communities.” The two health staffing companies have both previously been accused of shifting the cost of uncompensated care in billing disputes to patients. Both say that's no longer the case and that they support a federal solution to surprise billings. But they don't like the congressional panels' approach, which they call government "rate-setting."Ending surprise bills, a big concern for voters of all stripes, was viewed as one of the only health issues in Congress with bipartisan appeal and the backing of the Trump administration. Everyone agreed that a patient who followed the rules and went to an in-network hospital shouldn't get slammed with enormous bills because he or she ended up with an out-of-network provider, such as an emergency physician or anesthesiologist. But insurers, employers, doctors and hospitals from the beginning have vigorously fought over how to solve the problem and who should pay.Two sources affiliated with Doctor-Patient Unity confirmed that Envision Healthcare and TeamHealth are funding a portion of the $28.6 million campaign that runs from July 30 to Sept. 17 in states including Alabama, California, Colorado, and New Hampshire, according to Advertising Analytics. The sources wouldn't say who else is involved but confirmed the two companies are funders.These two entities provide physicians through an obscure system which purchased multiple physician groups, not just in emergency medicine, but also many other hospital-affiliated physicians, HOSPITALISTS | CRITICAL CARE | RADIOLOGY | ANESTHESIA | WOMEN/CHILDREN | SURGICAL |andn OFFICE MEDICINE. It is a commonly accepted practice and affords ease of recruitment for hospital and physician groups.Greg Blair, a spokesperson for Doctor Patient Unity, also confirmed the two companies are funders, and in a statement said the pair represent tens of thousands of doctors who support an alternate approach to ending surprise medical bills that's been enacted in New York and Texas. Those states both use independent mediators to settle payment disputes — an approach known as arbitration — not a government-set pay scale.“We oppose insurance industry-backed proposals for government rate setting that will lead to doctor shortages, hospital closures and loss of access to medical care, particularly in rural and underserved communities,” Blair said in the statement.Envision and TeamHealth both confirmed they back Doctor Patient Unity and echoed similar sentiments.TeamHealth Executive Vice President Dan Collard said the group wants to submit billing disputes between health providers and insurers to arbitration instead of using government-set benchmark rates."We will continue to fight an insurance industry proposal to use government rate setting as a vehicle to increase their profits at the expense of potential hospital closures and doctor shortages in underserved communities," Collard said.

California legislature debates surprise medical bills:

Monday, September 9, 2019

Physicians aren't 'burning out.' They're suffering from moral injury - STAT


Burnout among physicians is a symptom of something larger: the moral injury of being unable to provide high-quality care in today's health care systems.

Physicians on the front lines of health care today are sometimes described as going to battle. It’s an apt metaphor. Physicians, like combat soldiers, often face a profound and unrecognized threat to their well-being: moral injury.

Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians, it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.

Burnout is a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of physicians report at least one of these. But the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work. Even at the Mayo Clinic, which has been tracking, investigating, and addressing burnout for more than a decade, one-third of physicians report its symptoms.

We believe that burnout is itself a symptom of something larger: our broken health care system. The increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the health care ecosystem to a tipping point and causing the collapse of resilience.

Related: Fighting the silent crisis of physician burnout
The term “moral injury” was first used to describe soldiers’ responses to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Journalist Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Most physicians enter medicine following a calling rather than a career path. They go into the field with a desire to help people. Many approach it with almost religious zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs, family strain, financial instability, disregard for personal health, and a multitude of other challenges. Each hurdle offers a lesson in endurance in the service of one’s goal which, starting in the third year of medical school, is sharply focused on ensuring the best care for one’s patients. Failing to consistently meet patients’ needs has a profound impact on physician wellbeing — this is the crux of consequent moral injury.

Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already.

In order to ensure that compassionate, engaged, highly skilled physicians are leading patient care, executives in the health care system must recognize and then acknowledge that this is not physician burnout. Physicians are the canaries in the health care coalmine, and they are killing themselves at alarming rates (twice that of active duty military members) signaling something is desperately wrong with the system.

Physicians aren't 'burning out.' They're suffering from a moral injury - STAT

Fraud Alert: Genetic Testing Scam | Office of Inspector General | U.S. Department of Health and Human Services

Senior citizens are often the target of scams. One must be constantly aware of unsolicited offerings which could compromise your personal identity or defraud you or a loved one.

The U.S. Department of Health and Human Services Office of Inspector General is alerting the public about a fraud scheme involving genetic testing.

Genetic testing fraud occurs when Medicare is billed for a test or screening that was not medically necessary and/or was not ordered by a Medicare beneficiary's treating physician.

Scammers are offering Medicare beneficiaries "free" screenings or cheek swabs for genetic testing to obtain their Medicare information for identity theft or fraudulent billing purposes. Fraudsters are targeting beneficiaries through telemarketing calls, booths at public events, health fairs, and door-to-door visits.

Beneficiaries who agree to genetic testing or verify personal or Medicare information may receive a cheek swab, an in-person screening or a testing kit in the mail, even if it is not ordered by a physician or medically necessary.

If Medicare denies the claim, the beneficiary could be responsible for the entire cost of the test, which could be thousands of dollars.

Protect Yourself
If a genetic testing kit is mailed to you, don't accept it unless it was ordered by your physician. Refuse the delivery or return it to the sender. Keep a record of the sender's name and the date you returned the items.
Be suspicious of anyone who offers you "free" genetic testing and then requests your Medicare number. If your personal information is compromised, it may be used in other fraud schemes.
A physician that you know and trust should assess your condition and approve any requests for genetic testing.
Medicare beneficiaries should be cautious of unsolicited requests for their Medicare numbers. If anyone other than your physician's office requests your Medicare information, do not provide it.
If you suspect Medicare fraud, contact the HHS OIG Hotline.

Related Material: Senior Medicare Patrol's Information on Genetic Testing Fraud

Fraud Alert: Genetic Testing Scam | Office of Inspector General | U.S. Department of Health and Human Services:

Sunday, September 8, 2019

That Beloved Hospital? It’s Driving Up Health Care Costs - The New York Times

By Elisabeth Rosenthal
Ms. Rosenthal, a journalist, and physician is a contributing opinion writer

It’s easy to criticize pharmaceutical and insurance companies. But we spend much more on hospitals.

As voters fume about the high cost of health care, politicians have been targeting two well-deserved villains: pharmaceutical companies, whose prices have risen more than inflation, and insurers, who pay their executives millions in salaries while raising premiums and deductibles.

But while the Democratic presidential candidates have devoted copious airtime to debating health care, many of the country’s leading health policy experts have wondered why they have given a total pass to arguably a primary culprit behind runaway medical inflation: America’s hospitals.

Data shows that hospitals are by far the biggest cost in our $3.5 trillion health care system, where spending is growing faster than the gross domestic product, inflation and wage growth. Spending on hospitals represents 44 percent of personal expenses for the privately insured, according to Rand.

Opening this link will bring you to an interactive map representing reimbursement differentials between private payer insurance companies and Medicare.

A report this year from researchers at Yale and other universities found that hospital prices increased a whopping 42 percent from 2007 to 2014 for inpatient care and 25 percent for outpatient care, compared with 18 percent and 6 percent for physicians.

 So why have politicians let hospitals off scot-free? Because a web of ties binds politicians to the health care system.

Every senator, virtually every congressman and every mayor of every large city has a powerful hospital system in his or her district. And those hospitals are as politically untouchable as soybean growers in Iowa or oil producers in Texas.

Opinion | That Beloved Hospital? It’s Driving Up Health Care Costs - The New York Times:

Saturday, September 7, 2019

Stop treating medical residents like indentured servants - STAT

The practice of indentured servitude is alive and well in U.S. teaching hospitals. Those laboring under its yoke are known as medical residents.

Hundreds of years ago, poor immigrants were forced to become indentured servants to repay the cost of their passage to the U.S. by performing years of hard labor. This practice lives on for U.S. physicians-in-training, who have no choice but to serve years of indentured servitude to teaching hospitals in order to qualify for a medical license or board certification. We know them as medical residents.

In recent months, the announcement that Hahnemann University Hospital would be closing in September has cast a pall of uncertainty over the future of hundreds of residents who suddenly did not know how or whether they would complete their training. Instead of helping residents find new hospitals that would best support their education, Hahnemann executives, in dealing with Chapter 11 bankruptcy proceedings, simply auctioned its 550 residency slots to the highest bidders, a consortium of regional hospitals, for a sum of $55 million.

The hospital’s recent “sale” of medical residents and their residency slots showcases how some teaching hospitals have subordinated their training mission in favor of the pursuit of profits.

The residents were commoditized and sold as chattels to the highest bidder. Had this occurred to any other group, there would almost certainly have been public outrage. Curiously, there was little protest by entities that oversee the education and well-being of resident physicians. The response from the Association of American Medical Colleges was half-hearted, with a representative telling the Philadelphia Inquirer that the sale “was a big surprise.” Medicare objected to the sale, not because it should be illegal to treat residents as transferable property but because the sale would not allow Medicare to recoup past overpayments to Hahnemann.

To independently practice medicine, students must complete multiyear residencies at accredited hospitals after they graduate from medical school. Once they are matched with a program during the fourth year of medical school, their multiyear funding is tied to the program with which they’ve matched for the duration of their training. Finding a new position mid-way through residency is not trivial, making the instability of a residency program highly stressful for residents.

Teaching hospitals have argued over the years that training physicians comes at a substantial expense. But studies show that graduate medical education programs positively affect hospital finances to the tune of $160,000 to $218,000 per resident physician. In the U.S., Medicare funds a fixed number of residency slots with direct government grants of at least $100,000 per resident — and that does not include the market value of services provided by the resident during his or her training. This amounts to about $15 billion a year in government funding for residencies.

The Hahnemann sale underscores how few strings are attached to this support.

The labor market for residents is controlled by nonprofit teaching hospitals through an intentionally monopolistic entity: the National Resident Matching Program. It is responsible for matching students with residency slots at teaching hospitals during their last year of medical school. These training programs are accredited by the Accreditation Council for Graduate Medical Education. Prospective residents can apply only through a single standardized process called The Match, which allows them to express a preference for where they would like to work, but ultimately locks them into a multiyear employment contract with a single hospital.

The National Resident Matching Program is exempt from antitrust regulation, joining a few other entities such as Major League Baseball and labor unions.

This framework allows a sticky web of private governing bodies in medicine, including the Association of American Medical Colleges, the National Resident Matching Program, the Accreditation Council for Graduate Medical Education, and a consortium of hospitals, to dictate the compensation and training conditions for medical residents.

Stop treating medical residents like indentured servants - STAT:

When Apps Get Your Medical Data, Your Privacy May Go With It - The New York Times

By Natasha Singer

 Medical groups are warning that new federal data-sharing rules, enabling people to get their health records through a smartphone, could lead to invasions of privacy.

Apple’s Health Records app lets people send a subset of their medical data to their iPhones from more than 300 health centers.

Americans may soon be able to get their medical records through smartphone apps as easily as they order takeout food from Seamless or catch a ride from Lyft.

But prominent medical organizations are warning that patient data-sharing with apps could facilitate invasions of privacy — and they are fighting the change.

The battle stems from landmark medical information-sharing rules that the federal government is now working to complete. The rules will for the first time require health providers to send medical information to third-party apps, like Apple’s Health Records after a patient has authorized the data exchange. The regulations, proposed this year by the Department of Health and Human Services, are intended to make it easier for people to see their medical records, manage their illnesses and understand their treatment choices.

Yet groups including the American Medical Association and the American College of Obstetricians and Gynecologists warned regulators in May that people who authorized consumer apps to retrieve their medical records could open themselves up to serious data abuses. Federal privacy protections, which limit how health providers and insurers may use and share medical records, no longer apply once patients transfer their data to consumer apps.

Tech executives are promoting data-sharing in health care. From left, Taha Kass-Hout of Amazon, Aashima Gupta of Google and Peter Lee of Microsoft attended a conference in July for Medicare’s Blue Button system.CreditMicrosoft

Without federal restrictions in place, the groups argued, consumer apps would be free to share or sell sensitive details like a patient’s prescription drug history. And some warned that the spread of such personal medical information could lead to higher insurance rates or job discrimination.

“Patients simply may not realize that their genetic, reproductive health, substance abuse disorder, mental health information can be used in ways that could ultimately limit their access to health insurance, life insurance or even be disclosed to their employers,” said Dr. Jesse M. Ehrenfeld, an anesthesiologist who is the chair of the American Medical Association’s board. “Patient privacy can’t be retrieved once it’s lost.”

There are now many electronic medical records that allow smartphone access, such as Epic (MyChart), DrChrono, Kaiser and countless others.  When retrieving medical records directly via a desktop computer your records are secure. For EHRs that are HIPAA compliant, the vendor must show compliance for desktop retrieval.   If you are using a smartphone and the app provided by the institution it should also be HIPAA compliant.

Dr. Don Rucker, the federal health department’s national coordinator for health information technology, said that allowing people convenient access to their medical data would help them better manage their health, seek second opinions and understand medical costs. He said the idea was to treat medicine as a consumer service, so people can shop for doctors and insurers on their smartphones as easily as they pay bills, check bus schedules or buy plane tickets.

The new rules are emerging just as Amazon, Apple, Google, and Microsoft are racing to capitalize on health data and capture a bigger slice of the health care market. Opening the floodgates on patient records now, Dr. Rucker said, could help tech giants and small app makers alike develop novel consumer health products.

The regulations are part of a government effort to push health providers to use and share electronic health records. Regulators have long hoped that centralizing medical data online would let doctors get a fuller, more accurate picture of patient health and help people make more informed medical choices, with the promise of better health outcomes.

In reality, digital health records have been cumbersome for many physicians to use and difficult for many patients to retrieve.

Americans have had the right to obtain copies of their medical records since 2000 under the federal Health Insurance Portability and Accountability Act, known as HIPAA. But many health providers still send medical records by fax or require patients to pick up a paper or DVD copies of their files.

The new regulations are intended to banish such bureaucratic hurdles.

Dr. Rucker said it was self-serving for physicians and hospitals, which may benefit financially from keeping patients and their data captive, to play up privacy concerns.

“The moment our data goes into a consumer health tech solution, we have no rights,” said Andrea Downing, a data rights advocate for people with hereditary cancers. “Without meaningful protections or transparency on how data is shared, it could be used by a recruiter to deny us jobs,” or by an insurer to deny coverage.

When Apps Get Your Medical Data, Your Privacy May Go With It - The New York Times:

Thursday, September 5, 2019

Doctors more likely to prescribe opioids later in the day — or if running late

Author information: Hannah T. Neprash, PhD1; Michael L. Barnett, MD, MS2,3
Author affiliations: 
1Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
2Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
3Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts

Physicians were more likely to prescribe opioids later in the day and when appointments were running behind schedule.

After seeing dozens of patients in a hectic and long day in the clinic, when a doctor is faced with another patient in pain, it may be easiest to prescribe opioids and move on to the next one. New research suggests that doctors who practice with this habit could be contributing to the opioid epidemic.

A study published in JAMA Network Open on Friday reveals that physicians were more likely to prescribe opioids later in the day and when appointments were running behind schedule.

“Physicians play a crucial role in the opioid epidemic and it’s important to find the factors that drive decisions to prescribe opioids,” said Hannah Neprash, an assistant professor of health policy and management at the University of Minnesota and the study’s lead investigator. “Many studies have looked at looked at differences in prescribing patterns between physicians but few have looked at variation within physicians.”

The study utilized claims and electronic health data in 2017 for 678,319 patients with new pain who saw 5,603 physicians at health care clinics. The patients’ complaints ranged from back pain and headaches to muscle and joint aches. The researchers looked at the order of appointments and whether an appointment started at its scheduled time. Opioid prescriptions were compared to prescriptions of non-steroidal anti-inflammatory drugs and physical therapy.

When working with patients in pain who want opioids, offering them alternative therapies such as NSAIDs or physical therapy can require time-consuming discussions, Neprash said. “Prescribing opioids may be the quick fix when they do not have enough time to discuss non-opioid options.”

In 2017 there was six times the number of opioid-related deaths compared to 1999. While much of the opioid epidemic is due to illicit drug use, prescription opioids still play a large role. The authors note that if prescribing practices remained constant throughout the day, 4,459 opioid prescriptions would not have been written in 2017.

The study draws attention to demands placed on doctors who are incentivized to see as many patients as possible. The authors recommend protocols to guard against physician fatigue, arguing that if time pressures are affecting opioid prescriptions, other major medical decisions could also be at risk.
This should come as no surprise to a clinician.  Pain is bad, and immediate relief is wanted by the patient and physician.  Prescribing a pill gratifies both doctor and patient rewarding the encounter clinically, and gratifying a fee for service (pain relief). In today's medical environment satisfaction surveys are supreme. Health insurance companies and plans regularly survey patient's satisfaction quotients based on many subjective metrics.

Dr. Mark Linzer, director of the Office of Professional Worklife at Hennepin Healthcare in Minneapolis, said adding more clinical team members, such as physician assistants and nurse practitioners, could help diffuse the workload of the day and allow clinicians to spend more time with patients. He also proposed making individual visits longer for certain patients in order to provide the time needed to address pain and other sensitive medical problems.

“I suspect this is the tip of the iceberg: that time pressure has numerous adverse consequences, and that these poor outcomes could be attenuated by providing the time that complex patients (including those with acute and chronic pain) need with their clinicians,” said Linzer, who was not involved in the study.

“The conversation that avoids narcotics just takes time,” he said
Was the doctor on time?
Was the staff courteous?
Are you satisfied with the results of your encounter?
How long did you have to wait?
Would you recommend this doctor to a friend or family member?

None of these questions ask for an objective response. None of them are measuring the real quality of care (ie, clinician accuracy).  In most cases, patients are incompetent in assessing their doctor's clinical competence.

Worse than that are newer measures of supposed physician competence, MOC (maintenance of competence) (taken five to ten years after initial board certification). Many insurers now list whether a doctor is maintaining MOCs.  These tests and certifications reveal no correlation of results, patient satisfaction, nor a reduction in medico-legal events.  It may set a totally irrelevant and inaccurate measure of physician quality of care.

Doctors more likely to prescribe opioids later in the day — or if running late:

Friday, August 30, 2019

Physician Incomes Up in 2018, but Productivity Stagnant: AMGA

Are physicians maxed out?  The incidence of depression, frustration and burnout have been increasing. MGMA, an association for medical consultants just released a study from 2018 that harbors a fact. While physician compensation has risen, productivity has not increased.

"Data from this year's survey shows compensation is increasing without an equivalent increase in wRVU [work relative value unit] production for many specialties. This trend is causing organizations to absorb additional compensation expenses without balancing revenue from production increases," said Fred Horton, MHA, president of AMGA Consulting, the association's consulting arm, in a news release.

The AMGA survey found that in 2018, overall physician compensation increased by a median of 2.92%, compared to a 0.89% increase the previous year. Productivity increased by 0.29%, compared to a 1.63% decline in 2017. Compensation per wRVU rose 3.64%, slightly more than the 3.09% increase the prior year.
In primary care — including family medicine, internal medicine, and pediatrics — median compensation was up 4.91%, a significant increase from 0.76% the previous year. Although this was the largest jump in compensation in several years, productivity was flat, with wRVUs increasing by only 0.21% in 2018. As a result, the median compensation per wRVU increased 3.57%.
AMGA's report also presents median compensation and productivity statistics for 2014–2018. These figures reveal that although primary care wRVUs were fairly flat during that period, compensation for family physicians and internists increased more than in most other specialties.
Family doctors' productivity increased by 3.7% during the 4-year period, while their compensation shot up 15%. Similarly, median wRVUs for internists barely budged, yet their compensation increased by 13.8%.

Family doctors or primary care physicians (PCPs) are already maxed out in terms of patient volume. Their increase in income is due to several factors, a readjustment of CPT codes for visits, d-emphasizing procedural CPT codes. PCPs do fewer procedures than specialists.  Medicare, realizing this made a modification to office visit CPT codes (which are the majority of PCP visits) .  At the same time demand for PCPs exceeds their availability and groups in order to attract PCPs have raided the reimbursement accordingly.

Primary care physicians are apparently being paid more, regardless of productivity, because of their important role in value-based care. "As healthcare organizations move from volume-based to value-based payment models, we've observed increased scrutiny on primary care performance," said Elizabeth Siemsen, director of AMGA Consulting, in the release. "Medical groups continue to focus on delivering care in the most appropriate setting with the greatest efficiency — and often place primary care providers at the center of this strategy."

In recent years, Siemsen noted, the AMGA survey has shown a slow increase in the percentage of part-time primary care providers. She thinks this may have contributed to the hefty compensation increases for family doctors and internists.

"In order to recruit and retain the primary care workforce, it may be that the market demanded a compensation course correction this past year," she said.

Work RVU Calculator

Physician Incomes Up in 2018, but Productivity Stagnant: AMGA: A 2019 medical group compensation and productivity survey also shows hefty increases for primary care specialties as value-based care gains traction.

Thursday, August 29, 2019

Virtual Bodies For Real Drugs: In Silico Clinical Trials Are The Future | LinkedIn

Yes, a body in a chip.

If possible this would be a quantum leap and sea-change for pharmaceutical companies and regulatory agencies. The magic expression is in silicon.

As technologies transform every aspect of healthcare, medicine, and the pharma industry, the monstrous clinical trial enterprise cannot be left out either. One way to modernize the testing The present testing process is applying technologies to the traditional framework, for example through online platforms to seek out participants; while an alternative way is to build a completely new setting. Human organs-on-chips and in silico trials represent the second approach. Researchers of the Wyss Institute have been working on the first strand, human organs-on-chips for years. These microdevices lined by living human cells can mimic the microarchitecture and functions of human organs, and this makes them ideal for replacing clinical testing.

In silico is the term scientists use to describe the modeling, simulation, and visualization of biological and medical processes in computers. The emergence of in silico medicine is a result of the advance of medical computer science over the last 20 years.

As technologies transform every aspect of healthcare, medicine, and the pharma industry, the monstrous clinical trial enterprise cannot be left out either. One way to modernize the drug testing process is applying technologies to the traditional framework, for example through online platforms to seek out participants; while an alternative way is to build a completely new setting. Human organs-on-chips and in silico trials represent the second approach. Researchers of the Wyss Institute have been working on the first strand, human organs-on-chips for years. These microdevices lined by living human cells can mimic the microarchitecture and functions of human organs, and this makes them ideal for replacing clinical testing.  What if these cells could be replaced by software, an artificial intelligence (a virtual body) contained in code? And what if instead of using an actual drug it could be a virtual drug, coded in software.  It sounds like a fantasy, yet so was Google, the internet, and reusable rocket boosters.   Science fiction? Not for long as these futurists predict this evolution.

Certain Phase I studies involve laboratory animals, such as mice.  There is a significant cost to maintaining libraries of genetically altered animals.

No need for lab rats in the future. Source:

We firmly believe that drug development and new therapy experimentation will largely happen through in silico trials in the future, since who would want to test new drugs on animals or humans if we have the possibility to accurately measure the consequences of novel medications or treatment paths virtually. However, we have to mention that regulators will face a new, so far unknown challenge here: they will have to let more and more personalized, cheaper, and more efficient drugs be introduced on the market without being tested on actual humans for years.

Not only clinical trials for new drugs, this also will allow for testing of medical devices, such as cardiac pacemakers in a virtual heart simulation.

FDA Seeks Virtual Heart to Test Medical Devices
By Brandi Vincent,
Staff Correspondent,

The Food and Drug Administration is looking for computational software and services modeling the whole human heart to incorporate in a project that aims to evaluate new medical devices and therapies, according to a recently released request for information.

Through an ongoing collaborative project with French software company Dassault Systèmes, the agency hopes to demonstrate how involving computer modeling and simulation, digital evidence and a virtual patient population could potentially speed up the regulatory evaluation and approval processes through which innovative medical solutions go to market.

“We will need a physics-based computational model of a whole human heart, one that includes all critical functions of the heart: electrophysiology, solid mechanics, and fluid dynamics, including all relevant anatomical features (such as ventricles, atria and vessels),” the agency said in the program’s project brief. “The FDA intends to develop a generic medical device that will be virtually implanted in the whole human heart computational model.”

In 2014, FDA initiated its collaboration with Dassault around the company’s simulated 3D heart model, which the duo used to test pacemakers and other cardiovascular devices. Through the new project, researchers will incorporate virtual patients and testing to quicken the pace in which devices are tested and adopted.

“Integration of [virtual patient] data within the clinical trial simplification framework has the power to revolutionize how device companies conduct clinical trials, sustain this paradigm shift, and satisfy patient and provider demands for safety, efficacy and improved access,” the agency said.

Through the trial, researchers will design, manufacture and physically and virtually test a generic medical device on virtual populations and new methods will be created to combine digital evidence from the simulations to physical evidence from real patients. The objective is to receive FDA concurrence on the simulated approach, not to actually obtain approval of the device.

Ultimately, the agency aims to use digital evidence and computer modeling to tackle the delays and costs that hinder patients from trying new treatments.

“Modeling and simulation can help to inform clinical trial designs, support evidence of effectiveness, identify the most relevant patients to study, and assess product safety. In some cases, in silico clinical trials have already been shown to produce similar results as human clinical trials,” Tina Morrison, deputy director of applied mechanics in the FDA’s Center for Devices and Radiological Health, said in a statement.

Interested vendors that can offer the capability to perform whole human heart computations with virtually implanted devices using high-performance cloud-computing should submit capability statements to the FDA by Aug. 12..

Virtual Bodies For Real Drugs: In Silico Clinical Trials Are The Future | LinkedIn:

Tuesday, August 27, 2019

Researchers Push Primary Care Teams to 'Power Up'

 Researchers describe a new model that extends clinician visits to team visits by pairing each physician with highly trained nurses or medical assistants.

The authors of an article published in the July/August issue( of Annals of Family Medicine say there's a reason why. They contend that "primary care teams are underpowered."
"They are underpowered because they do not maximally redistribute team functions," write corresponding author Thomas Bodenheimer M.D., M.P.H., and co-author Christine Sinsky, M.D., vice president of professional satisfaction at the AMA, in an article titled "Powering-Up Primary Care Teams: Advanced Team Care with In-room Support."
However, "a new team model is bubbling up across the country with the potential to reinvigorate primary care," they add.

This new model comes with a bit of twist and has been dubbed "advanced team care with in-room support." The authors explain that in this core team model, each physician is paired with two or three highly trained medical assistants or nurses -- referred to as care team coordinators.

This is not a new or radical concept. It takes place in many hospitals already whereby the physician, floor nurse and any number of allied health professionals 'round' on patients.  With the concurrent use of the electronic health record, it unitizes and bypasses the hierarchy or transmitting orders across the 'chain of command' It markedly reduces the time for delivery of care.

 "This model extends the clinician visit into a team visit," say the authors, with a care team coordinator, beginning the visit by completing a number of tasks, including taking an initial history, reconciling medications, addressing chronic and preventive care gaps, and setting the visit agenda based on patient concerns.
The physician joins the visit after 10-15 minutes, "sits face-to-face with the patient (without the computer dividing her attention)," expands the history and does a focused physical exam. The physician talks with the patient about a diagnosis and a care plan while the care team coordinator types notes and enters documentation into the EHR.
The team coordinator stays with the patient to review the care plan; set up referrals, labs, and follow-up visits; and provide health coaching as indicated.
Meanwhile, the physician moves on to the next patient, where a second team coordinator is already completing the initial tasks.
The Evidence:
That evidence is compelling. For instance, practices report benefits that include increased productivity of as much as 20%, growth in net revenue of 10.5% per encounter, increased capacity to accept new patients, improved blood pressure and diabetes control, improved performance on quality measures, and increased patient and staff satisfaction.
At Bellin Health in northeastern Wisconsin, where the model was piloted in 2014, the authors note that "clinician satisfaction went from 34% without the team model to 88% with the model."
And at the University of Colorado Health System, physician burnout dropped from 56% to 28% just one year after implementing advanced team care with in-room support.
Ripping Away Barriers
Implementing this new model requires a change in mindset that includes redistributing team functions that would "allow clinicians to shed that portion of clinical and administrative work that a well-trained, well-staffed team could easily perform," say the authors.
They discuss the downside of technology and point out that in health care, the EHR "has added rather than subtracted work." Tasks that used to take mere seconds now require minutes, they say, and "work previously done by others has now been shifted to physicians."
The authors say advanced care team with in-room support is all about creating teams in which well-trained support personnel "can assist with the clinical care of patients and assume much of the administrative burden."
"By distancing the EHR from the patient-clinician interaction, technology assumes its rightful supportive role," they add.
Additional Author Thoughts
Bodenheimer, founding director of the Center for Excellence in Primary Care( at the University of California, San Francisco, Department of Family & Community Medicine, told AAFP News that he spent 32 years as a general internist in a low-income San Francisco community. In the following Q&A, he provides additional comment about this article.
Q. Why is this discussion important at this juncture in the U.S. health care system?
A. Family physicians are dealing with large patient panels, frustrating EHRs and exhausting administrative work. The existing model is not sustainable. Physicians need teams with well-trained personnel to take on both clinical and documentation tasks.
Q. What are some of the barriers to widespread adoption of this model?
A. As the commentary argues, there are significant obstacles. First and foremost, the financial leadership of the health system in which the primary care practice is situated must understand that there is a business case for hiring two or more clinical assistants per physician.
Second, there needs to be a physician champion who pilots the new model, adapts it to his or her practice, and then creates and leads a robust training program.
Third, there needs to be an evaluation after the model is in place to determine if the physician and patient satisfaction increases, clinician burnout decreases, quality of care is preserved, and financial performance improves.

Q. Is it possible to get physician buy-in at the individual level?
A. Yes, if a few things go right (and they should): if the burden of EHR documentation is virtually eliminated from the physician's day, if clinical assistants do a good job and quality markers and patient satisfaction go up, if physicians can eliminate the burden of documentation tasks after they've put their kids to bed.  If these things happen, physician burnout will decrease, and I would expect to see almost 100% buy-in because that is what has happened in the practices that piloted the advanced team care with in-room support model. Physicians were begging to start the new model.
Q. What's the most important takeaway for family physicians?
A. It's becoming increasingly hard for family physicians to sustain a primary care practice. This model allows them to focus exclusively on their patients without the interference of EHRs and documentation tasks. Importantly, this model gets physicians out of the clinic earlier and without take-home work.

This study formally illustrates the advantages of Team-Based Care, as promoted by the American Academy of Family Practice


Researchers Push Primary Care Teams to 'Power Up':

Thursday, August 22, 2019

Multiple Hospitals Close in Wake of Fraud Allegations

When it's too good to be true, it probably is.  

I-70 Community Hospital shut its doors in February, taking with it dozens of jobs and lifesaving emergency care for the residents of Sweet Springs, Mo.

Small rural hospitals are always at risk of insolvency and closure.  These communities look to entrepreneurs (usually nonmedical venture capitalists and/or other hospitals to absorb their hospital(s)

It was his "secret sauce," the rotund Miami entrepreneur would smilingly tell people in their no-stoplight towns. The money-making ventures he proposed sounded complicated, sure, but he said they would bring in enough cash to save their hospital and dozens, even hundreds, of good jobs in rural towns where gainful employment is hard to come by.
And, in town after town, the people believed him. He offered what they could not resist: hope, and the promise of survival.
Then a few major health insurance companies got suspicious, as did some government officials. How could Unionville, Mo? — a town of 1,790 — generate $92 million in hospital lab fees for blood and urine samples in just six months? Why had lab billings at a 25-bed hospital in Plymouth, N.C., nearly tripled to $32 million in the year after Perez's company took control?
At the height of his operation, Perez and his Miami-based management company, EmpowerHMS, helped oversee a rural empire encompassing 18 hospitals across eight states. Perez owned or co-owned 11 of those hospitals and was CEO of the companies that provided their management and billing services.  Their website contains the slick marketing quotes of venture capitalists.
Desperate hospitals and desperate communities take desperate measures when a local isolated hospital may close.  "Creative" revenue streams are an opportunistic measure to fund hospitals from sources including Medicare and private insurance companies.
This is not an unusual occurrence and has been seen previously.
The staggering collapse left hundreds of employees without jobs and many more owed months of back pay. Only in recent months did they learn that their medical coverage had been terminated because EmpowerHMS had stopped making payments, according to interviews and bankruptcy documents.
At some of the hospitals, EmpowerHMS stopped paying employee payroll taxes, Perez acknowledged in an interview. Some of the shuttered hospitals owe hundreds of thousands in property taxes, according to local officials.
How companies run by this Miami businessman and his associates were able to drive so many hospitals into the ground so quickly, devastating their communities, is a story about the fragility of health care in rural America and the types of money-making ventures that have flourished in legal gray areas of America's complicated medical system.
The scheme involved laboratory referrals to labs owned by Perez and his partners. It was a convoluted trail of self-referrals to companies owned by Perez.
The analysis found 80% of that money was flowing to laboratory companies, including some in which Byrns had a financial stake; another 6% to a Perez-controlled billing company; and a major portion to 33 out-of-state phlebotomists — blood draw specialists — they had put on the hospital payroll.
I-70 Community Hospital in Sweet Springs, Mo., is one of eight hospitals owned or managed by Miami businessman Jorge A. Perez that closed in recent years. Twelve Perez-affiliated hospitals are in bankruptcy.
"What was astounding to me was that the hospital was not better off during and after this lab activity," Galloway told KHN.
The reaction was explosive. Dozens of major insurers banded together to file lawsuits against Perez-affiliated hospitals in Missouri and other states, demanding hundreds of millions in restitution. The lawsuits, still ongoing, describe the lab-billing operation as a "widespread fraudulent scheme" that aimed to enrich Perez, some of his associates and affiliated companies, as well as participating labs.
The department of justice in Missouri is still investigating, however, the town of Unionville, MO is now without a hospital.  Perhaps it could not be saved.  However, there were other solutions to this challenge.
With the increasing use of health information technology and telemedicine, mobile ambulances and urgent care centers health care could still be present in Unionville, MO.

Multiple Hospitals Close in Wake of Fraud Allegations: Jorge A. Perez and his management company, EmpowerHMS, helped run an empire of rural hospitals. Now, 12 of them have entered bankruptcy and eight have closed their doors. So, what happened?

Wednesday, August 7, 2019

The Secret of Health Care Prices: Why Transparency Is in the Public Interest - California Health Care Foundation

Katherine L. Gudiksen, University of California Hastings College of the Law
Samuel M. Chang, University of California Hastings College of the Law
Jaime S. King, University of California Hastings College of the Law

In 2018, California lawmakers sought to design and create a state Health Care Cost Transparency Database, an all-payer claims database (APCD), which would collect information on the cost of health care in the state. The law tasks the Office of Statewide Health Planning and Development (OSHPD) with designing a database to best fit the needs.  California’s APCD may collect information about amounts paid for health care services, including data about negotiated rates between insurance plans and providers. Many health care providers and payers seek to maintain the confidentiality of these paid amounts as trade secrets, claiming their secrecy provides a competitive advantage.

There are some issues regarding the public release of health care prices. 

Economists and antitrust enforcers have theorized about how disclosure of negotiated rates in health care markets could facilitate price collusion and drive price increases. To date, however, no US
state with an existing APCD has experienced competitive harm, and, in fact, a decade of public disclosure of negotiated health care rates in New Hampshire resulted
in increased competition and reduced prices for health care services. Although, in some markets, disclosure of negotiated health care rates could theoretically result
in price collusion and increased prices.

The Secret of Health Care Prices: Why Transparency Is in the Public Interest - California Health Care Foundation: