Physicians will keep fighting on these 6 key issues in 2020

Health care policy debates must include the trusted voices of doctors advocating for their patients, says AMA President Patrice A. Harris, MD, MA.

When most people hear the word AMA they often think of it as a doctor lobbying group and compare it with all other lobbying groups.  That is a misperception, perhaps fostered by the government and the media at times.  What is often overlooked by physicians and patients alike are it's two primary goals, physician education, and patient advocacy. It is not a union nor a trade association.  Because of these issues, many physicians no longer belong to the AMA.  Competing medical associations compete for membership.  They use an argument the AMA does not represent all physicians. 

A confounding fact is AMA dues are small compared to the fees charged by licensing authorities, state and local societies, specialty membership groups, medico-legal premiums and other essential overhead. The AMA has no enforcement nor legal authority to regulate physicians. The AMA has a code of ethics for membership. AMA membership terms and conditions. The AMA functions as an educational tool, financially it derives income from licensing CPT codes to insurers, advertising, and promoting a number of insurance programs to doctors,  It has a diverse source of income which some physicians consider unethical for a lofty group such as the American Medical Association.

Prior authorization

“We fight back against prior-authorization requirements because we see the negative impact on our patients and we know these requirements create unnecessary headaches and burdens for our practices,” Dr. Harris said. Payers continue to implement harmful policies that delay patient care and interfere with physicians’ ability to practice medicine.

The AMA has supported federal legislation to streamline prior authorization in Medicare Advantage plans and to improve the process in states across the country. Efforts include using the FixPriorAuth.org website to capture hundreds of patient and physician stories that bring home the negative impact prior authorization has on patient care.

Surprise medical bills

“We work toward reasonable legislation and regulation on surprise billing because we don’t want our patients stuck with bills that are unexpected and they cannot afford,” Dr. Harris said. The AMA believes patients should only be accountable for normal in-network cost-sharing amounts and supports an independent resolution system for settling payment disputes between physicians and insurers.

The AMA has worked with state medical associations and national specialty societies to:

Craft principles to guide surprise-billing legislation and policymaking.
Work closely with members of Congress to develop legislation that adheres to those principles.
Prevent an objectionable congressional bill from being passed.
Stop numerous state bills that would reduce the adequacy of provider networks.
Learn more about how the AMA’s work to prevent surprise medical bills.

Related Coverage

The AMA’s top 10 must-read news stories of the year

Health insurance coverage

“We continue our call for Medicaid expansion because we know it improves access to care and the health of our patients,” Dr. Harris said. The AMA promotes Medicaid expansion to cover the uninsured in all 50 states and has opposed Medicaid work requirements in state legislatures and in the courts.

The AMA continues to seek opportunities to improve the Affordable Care Act and expand options to those who do not qualify for subsidized coverage. Learn more about the AMA vision of health care reform.

The opioid epidemic


Dr. Harris, who chairs the AMA Opioid Task Force, also touched on AMA advocacy efforts to help end the opioid epidemic while ensuring that patients in pain maintain access to the medications they need. “We speak up for our patients in chronic pain and who have substance-use disorders because they deserve the same care and compassion as anyone with any other chronic disease,” she said, adding that the AMA also advocates for “policymakers to enforce mental health parity laws.”

The AMA has released an in-depth analysis of the opioid epidemic response by four states: Colorado, Mississippi, North Carolina, and Pennsylvania. The report, “National Roadmap on State-Level Efforts to End the Opioid Epidemic; Leading-edge Practices and Next Steps,” analyzes successful strategies used and lessons learned to guide policymakers and others in the months ahead.

E-cigarettes and vaping

When it comes to the dangers of e-cigarettes and vaping, Dr. Harris said “half measures are never acceptable,” echoing her recent comments on how a new Trump administration policy to limit flavors in some vaping products was “a step in the right direction, but does not go far enough.”

At a minimum, a total ban on all flavored e-cigarettes, “in all forms and at all locations,” is prudent and urgently needed, she said.

Gun violence

Dr. Harris also noted the AMA’s advocacy for common-sense gun laws. The AMA supports the Bipartisan Background Checks Act of 2019, which the U.S. House of Representatives passed in February but has been stalled in the Senate. AMA advocacy efforts helped secure long-sought funding for gun-violence research by the National Institutes of Health and the Centers for Disease Control and Prevention.

“Everyone benefits when health care and our health system is affordable, accessible and responsive to the unique needs of individual needs,” Dr. Harris said. “That is the goal, and certainly advocacy is how we get there.”


The AMA also has a Foundation, charitable arm that provides scholarships to offset student loans, improve community health, to train physician leaders, awards for excellence.















Physicians will keep fighting on these 6 key issues in 2020 | American Medical Association:

Can We Drain the Swamp ?

Like Washington, D.C.  Healthcare seems to have become a swamp. Perhaps the situation is similar. As we have witnessed in politics when the swamp is drained it exposes the muck and rotten roots below the waterline.

As I was doing my background research on this topic I discovered my title was already coined by the American Association of Family Physicians (AAFP)

If health economics were exposed (transparent) and the public knew what transpires below the water level there would be an uprising.

The swamp already existed prior to ObamaCare

Trump Needs to Drain the “Healthcare” Swamp

Let's say at the outset that Trump cannot drain the swamp. What it will take are congressional hearings (public) and transparent first to identify what the swamp contains.

Congress allowed the swamp to be built and now every taxpayer or healthcare user needs to stand up and demand Congress to fix it. There is however a problem.  I have seen many . ' experts and physicians drawn upon by congress as advisors. Their recommendations are rarely accepted. These are authoritative sources from the private sector, think tanks and other repositories of credible knowledge.  Many have resigned after their ideas were left on the table and discarded.

Our federal government is huge and has great inertia.  It takes a lot to move it.  Most suggestions will affect a segment of health care and health care financing. When that occurs the lobbyists show up paid for by interested parties. 

In his Feb 28 address to the Joint Session of Congress, President Trump called the Affordable Care Act (ACA, or “ObamaCare”) an “imploding disaster.”

His references to soaring premiums, contracting choices, and market collapse are all spot on. And of course, everybody wants “reforms that expand choice, increase access, lower costs, and at the same time, provide better Healthcare.” Trump wants Americans to be able to choose “the plan they want, not the plan forced on them by the Government.”

But what must we do “first” and “second”? From a physician’s perspective, “first” is to make the diagnosis. “Second” is to remove the cause of the ailment if possible. And that means to drain the swamp.

Unfortunately, Trump’s “first” is to “ensure that Americans with pre-existing conditions have access to coverage” and “second” to “help Americans purchase their own coverage, through the use of tax credits….”

These “popular” ideas emanate from the swamp, percolating up through lobbyists, think tanks, and congressional “leadership.” Correctly translated, these mean to abolish true insurance—and the only reason for buying it when healthy—and to force healthy or higher-income people to pay more than their fair share. A “refundable tax credit” is a disguised subsidy, courtesy of present and future taxpayers.

And who are the swamp dwellers? They are the ones who siphon off a huge portion of $3 trillion “healthcare” dollars—perhaps 50 percent or more—before it goes to anything recognizable as a medical good or service received by an actual patient. They are part of the vast growth in the number of administrators compared with physicians. They include the “nonprofit” hospitals that charge up to ten times as much for a surgical procedure as the Surgery Center of Oklahoma does. They include brokers who “re-price” medical bills—getting a 30 percent “discount” from a bill that is overpriced by a factor of two or more and pocketing a cut of the “savings.” And they include the code writers, the regulation writers and auditors, the software and hardware vendors, and the data aggregators who are selling your medical record for profit.

Denizens of the swamp are self-identifying, as in a Jan 25 letter to President Trump and Vice President Pence offering to help implement “value-based” care. The more-than-120 signatories include the American Medical Association (whose main cash cow is the CPT procedure codes that doctors must purchase), numerous other medical trade associations (who help doctors learn how to comply with ever-changing rules), insurers, giant hospital systems, pharmaceutical companies, and self-certified “quality” agencies.

The “resources” they plan to save come from care denied to patients, and especially from the 19 percent of medical spending that goes to physicians’ practices. Instead of paying doctors more if they work more (“fee for service”) the system will pay for data collection and protocol compliance, and punish doctors if they order more tests or treatments for patients. And of course, all those involved in determining “value” get paid first.

The healthcare planners’ bane is the 10 percent of medical spending that goes directly from the person getting the service to the person providing it. None of this leaks into the swamp, and the value is determined by patients, who are presumably too ignorant to make complex judgments.

Swamp dwellers generate reams of studies about the resources that go to actual medical care—some of which would be exposed as being of limited value if patients had to pay out of pocket for them voluntarily. But such studies avoid mention of the enormous resources that go to “planning,” “certifying,” “evaluating,” “reviewing,” etc.—which vanish without a trace into the bureaucracy. Of course, these agencies like to conflate “care” with “coverage”: care is a loss, not a profit center. Even if ACA demands a “medical loss ratio” of 85 percent, that means at least 15 percent is diverted from actual care, and 15 percent of $3 trillion is a huge amount of money. If coverage is “comprehensive,” third-party managers have access to much more than they would if insurance covered only unpredictable catastrophes.

Everyone has an idea, what is yours. Please comment 

Health-care costs soar so high, it’s like a tax, economists say - The Washington Post

Every American family basically pays an $8,000 ‘poll tax’ under the U.S. health system, top economists say

Congress showers health-care industry with multibillion-dollar victory after wagging a finger at it for much of 2019

America’s sky-high health-care costs are so far above what people pay in other countries that they are the equivalent of a hefty tax, Princeton University economists Anne Case and Angus Deaton said. They are surprised Americans aren’t revolting against these hidden taxes.

“A few people are getting very rich at the expense of the rest of us,” Case said at a conference in San Diego on Saturday. The U.S. health-care system is “like a tribute to a foreign power, but we’re doing it to ourselves.”

Despite paying $8,000 more a year than anyone else, American families do not have better health outcomes, the economists argue. Life expectancy in the United States is lower than in Europe.

What would happen if a federal tax of %8000 for each family unit was collected via the IRS system or a separate tax?  The ACA attempted to tax individuals using a penalty administered by the IRS.  It did not work.

“We can brag we have the most expensive health care. We can also now brag that it delivers the worst health of any rich country,” Case said.

Case and Deaton, a Nobel Prize winner in economics, made the critical remarks about U.S. health care during a talk at the American Economic Association’s annual meeting, where thousands of economists gather to discuss the health of the U.S. economy and their latest research on what’s working and what’s not.

Deaton made a point that the waste in our health system (6%) is more than %50 greater than our military expenditure.

Most Americans want the freedom of choice, but at what price? Despite mergers, acquisitions we have a polyglot of health insurance (plans). The bottom line is profit motives by shareholders and other self-interest groups such as Pharma It is a nightmare of choices between private payors, medicare, medical, government-run systems such as the Indian Health Service, and the IHS receives reimbursement from for Indian Veterans, and the VA system. The options for safety net coverage vary from state to state and in some cases, it is administered by the county.  

The Affordable Care Act banned discrimination based on prior existing disease. It, however, directed safety net coverage up to the state or county jurisdiction. Despite these advances, many providers do not participate in safety-net programs due to poor reimbursements.  Private payors and hospitals subsidized the safety net increasing premiums for patients, and increasing charges at hospitals.

The well-intentioned motives of Americans to provide health coverage to all citizens and others within the confines of the   United States have been distorted by our system of waste, inefficiency, and lack of organization.




Health-care costs soar so high, it’s like a tax, economists say - The Washington Post:   

How We Got Here From There In the Past Ten Years

For all who hate computers in medicine: here’s what we got before.

Acknowledgment to ePatient Dave DeBronkart

The photo below shows what “visit notes” from a doctor's appointment might look like in the era before computers. Just two days before my first speech where I said “Gimme my damn data,” I had an ENT visit, and on the way out I asked for a copy of the doctor’s notes. The clerk snickered out loud and showed it to me, saying, “If you really want it….”

No joke; this is what the doctor had recorded.

Visit notes from my ENT appointment, Sept 15, 2009

The photo above shows what “visit notes” from a doctor's appointment might look like in the era before computers. Just two days before my first speech where I said “Gimme my damn data,” I had an ENT visit, and on the way out I asked for a copy of the doctor’s notes. The clerk snickered out loud and showed it to me, saying, “If you really want it….”

No joke; this is what the doctor had recorded.

The horrible usability of many of today’s EMRs has understandably caused a lot of bitching from their users (clinicians). I totally empathize and I want it fixed. I’m grateful for the dozens of very smart people whose years of study, training, and clinical experience helped save my life in 2007, and I want them to have a good life, not one filled with horrible machines.

But the remedy for usability problems is not to go back to paper, it’s to force vendors to fix it. (I spoke in 2010 and blogged the video in 2011 about a major reason for the usability problems: the EMR executive who was strongly rumored to have said that usability would be a system criterion “over my dead body.”)

Another example: Peter Elias MD (retired), my colleague in the Society for Participatory Medicine, says that when he repeatedly asked his employer (a large medical center in Maine) to grant patients access to all their chart data, every time the management said they couldn’t because the data is such poor quality. (That is now a federal crime as per HIPAAs latest update.

Peter loves wisecracks and perverse aphorisms; his email signature says “The chief cause of problems is solutions.” We cannot assess solutions to system problems without remembering why the systems were needed in the first place: pages of crap like that were of no use in improving healthcare, or even in knowing what was going on nationwide. (Imagine being an E.R. doctor or someone providing coverage for a doc on vacation, and having to practice medicine based on that sheet.)

For healthcare to achieve its potential, the information gathered by smart clinicians must get digitized, the same as all the other information in every other industry in the world. If the systems to do that are bad, we should insist that the vendors fix them – not return to scribbles.

We have come away with meaningless usability metrics from HHS so they can collect data. No change has been forthcoming in the usability of the system for the doctors.  I have been harping on this since 2005.  HHS bribed the whole bunch us by financial incentives. No one in their right mind would buy one of these EHRs (unless someone else paid for it.  We got what we deserved and for which we did not pay.

 For healthcare to achieve its potential, the information gathered by smart clinicians must get digitized, the same as all the other information in every other industry in the world. If the systems to do that are bad, we should insist that the vendors fix them – not return to scribbles.















https://www.epatientdave.com/2020/01/07/for-all-who-hate-computers-in-medicine-heres-what-we-got-before/


https://thehealthcareblog.com/blog/2020/01/08/for-all-who-hate-computers-in-medicine-heres-what-we-got-before/#comment-865355

CA presidential primary: Healthcare plans of 2020 candidates | The Sacramento Bee

 Before the 2020 presidential primary in California, learn where top candidates like Joe Biden, Elizabeth Warren, Bernie Sanders, and Pete Buttigieg stand on healthcare, the Affordable Care Act and Medicare for all.

California Democrats most want to hear candidates presidential candidates talk about health care as the state’s March 3, 2020 primary approaches. It’s the top issue among likely voters, according to the most recent survey conducted by the Public Policy Institute of California.

Here’s how the top candidates on the Democratic ballot would try to improve the country’s health care system, sorted in order of their recent national polling averages and performance in early-voting states:

JOE BIDEN

Former Vice President Joe Biden wants to preserve the Affordable Care Act passed under the Obama administration, rather than eliminate private health insurance. His plan would cost $750 billion over the next decade and be funded by reversing some provisions of the Tax Cuts and Jobs Act that President Donald Trump signed into law in December 2017.

BERNIE SANDERS

Vermont Sen. Sanders “wrote the damn bill” calling for a government-run, single-payer health care system that eliminates private health insurance. It would cost a hefty $34 trillion over 10 years, according to a report from the Urban Institute.

“The function of health care is not to make huge profits for the wealthy, it is to guarantee health care to every man, woman, and child through a Medicare-for-All, single-payer system,” Sanders said at an August 2019 rally in Sacramento.

WHILE HE HAS ACKNOWLEDGED TAXES WOULD GO UP FOR AMERICANS IN THE MIDDLE CLASS, HE INSISTS OVERALL COSTS WOULD GO DOWN BECAUSE HE’D ELIMINATE COPAYS, DEDUCTIBLES, AND SURPRISE BILLS. TOP ARTICLES

ELIZABETH WARREN

Massachusetts Sen. Elizabeth Warren has said she is “with Bernie” on health care. But unlike Sanders, Warren doesn’t talk about taxes going up. She instead focuses on overall health care costs going down.

“Because I have identified trillions in revenue to finance a fully functioning Medicare for All system — without raising taxes on the middle class by one penny — I can also fund a true Medicare for All option,” Warren wrote in a November post on Medium.

PETE BUTTIGIEG

Former South Bend, Indiana, Mayor Pete Buttigieg is pushing a “Medicare for All Who Want It” plan that would cost about $1.5 trillion over 10 years and be funded almost entirely by rolling back the tax cuts law Trump approved in 2017.

Buttigieg wants people to have access to a government-run public option that would present a more affordable alternative to private health insurance and guarantee contraception coverage. Poorer Americans living in states that have refused to expand Medicaid would be automatically enrolled in his public option plan.

He’d eliminate surprise billing, which commonly occurs when in-network hospital patients receive treatment from a doctor outside of their insurance network.Warren wants to prove the viability of her plan before implementing a universal, single-payer plan that abolishes private health insurance.

MICHAEL BLOOMBERG

The former New York City mayor is looking to build on Obamacare by creating a Medicare-like public option administered by the federal government but paid for by customer premiums.

To reduce insurance costs, he’d extend tax credits for individuals and families who spend more than 8.5 percent of their income on health insurance premiums. If elected president, he’d work with Congress to have the Department of Health and Human Services negotiate drug prices with pharmaceutical companies and make prices more comparable with other industrialized countries

AMY KLOBUCHAR

Minnesota Sen. Klobcuhar has called Sanders’ Medicare for All proposal a “bad idea” because “149 million Americans will no longer be able to have their current insurance” within four years.

She instead wants a non-profit public option that gives Americans the ability get lower insurance costs and drug prices. Like Sanders, though, she would allow people to personally buy drugs from countries like Canada. She also wants to allow Medicare to negotiate for cheaper prescription drug costs.

In her first 100 days, Klobuchar would direct the Centers for Disease Control and Prevention to “study gun violence as a public health issue and help identify approaches to reduce gun violence and save lives.” She’d also allow health providers like Planned Parenthood to receive funding under Title X.

ANDREW YANG

Entrepreneur Andrew Yang believes Democrats are “having the wrong discussion on healthcare,” arguing that the 2020 field is spending all its time “arguing over who is the most zealous in wanting to cover Americans.”

While he supports “the spirit of Medicare for All,” he wants to focus on the underlying causes of rising drug and insurance costs. He’s open to allowing the importation of drugs from other countries, but only if his three other preferences fail. He’d rather have Congress pass a law to negotiate drug prices, adopt pricing models more in line with costs people from other countries are paying and create public manufacturing sites in the United States to produce generic drugs.

TOM STEYER

Tom Steyer, a billionaire activist in California who has pushed for solutions to global warming, wants a public option that would administered by the Centers for Medicare and Medicaid Services, a federal agency within the Department of Health and Human Services. That public option would be financially separated from Medicare and Medicaid.

Private health insurance providers wanting to participate in Medicare or Medicaid would also need to participate in the public option. He estimates his plan will cost about $1.5 trillion over 10 years.

CORY BOOKER

New Jersey Sen. Cory Booker, as well Warren, is a sponsor on Sanders’ Medicare for All bill. As president, Booker would push a health care plan that includes universal paid family and medical leave.

He would lower prescription drug costs by importing drugs from countries like Canada and allowing Medicare to negotiate for lower prices. He also wants to create a tax penalty for drug companies that “unfairly raise the cost of their drugs and take patents away from drug companies that sell the same medication for less in other countries.”

CA presidential primary: Healthcare plans of 2020 candidates | The Sacramento Bee:.

Patient Expectations Then vs. Now

There was a time when a whole family went to one doctor and it was paid for by their insurance. They rarely saw a specialist because they trusted their doctor’s word as law. Patients were patients and doctors were doctors but lines have blurred and patient experience has changed. Today’s patients have consumer expectations and they are knowledgeable. Healthcare is making the transition from the pure traditional model of patient to the world of patient/consumer. Understanding what this shift from patient to consumer looks like is the first step toward successfully navigating these changes.

The rapidity of health care transformation can overwhelm even the most knowledgable patient and provider. Patients and providers must collaborate to ensure avoiding errors and excellent patient care. The battle is now between the allies (patients and providers) vs bureaucracy.  Without intention CMS, payors, information technologists have unleashed a gordian knot upon us all, funded by the government with your tax dollars. 

The integration of parts, patient engagement patient-centered, electronic health records, interoperability, patient portals, remote monitoring, telehealth, text messaging for patient and provider notifications. 

Health Train Express is hoping to narrow that new divide and we also publish Digital Health Space and Occupy Health on Facebook to that end.

If your download does not start automatically, download it here.

https://mhealthintelligence.com/resources/white-papers/patient-expectations-then-vs.-now?eid=CXTEL000000089112&elqCampaignId=12867&utm_source=ded&utm_medium=email&utm_campaign=dedicated&elqTrackId=44ece7ad08eb46409b4d935abcfb1c78&elq=c7bf8df0cfc649debb9f23f7e8764405&elqaid=13539&elqat=1&elqCampaignId=12867

Hospital Profitability Declines Due to Weak Volumes

Hospital Profitability Declines Due to Weak Volumes, Revenues   By Jacqueline LaPointe (email)

"Margins indicating hospital profitability, including EBITDA and operating, fell as volume and revenue performance weakened in November 2019.

An analysis of November 2019 data from over 800 hospitals revealed weakened hospital profitability as margins significantly declined compared to the previous month.

Conducted by consulting firm Kaufman Hall, the National Hospital Flash Report from December 2019 detailed the drop in margins. The firm found that the operating earnings before interest, taxes, depreciation, and amortization (EBITDA) margin was down 14.5 percent of 200.1 basis points (bps) year over year while operating margins experienced a 21.3 percent or 208.1 bps decline.

Month over month, operating EBITDA margin dropped by 14.3 percent in November, or 215.6 bps, and operating margin decreased by 23.4 percent or 239.2 bps.

"A one month report of hospital profitability may not be a solid indicator for a hospital, especially during a holiday season. Many patients chose not to be hospitals during this time of year.  However, profitability margins are small, to begin with, except for some exceptional institutions.  The fragility of even major hospitals such as the former Hahnemann Medical School and it's supporting hospital in Philadelphia supports this concern. Hospitals in highly competitive markets may be impacted more."

Hahnemann Sale and Closure

Researchers attributed the drop in hospital profitability to weak performance across volumes and revenues, as well as higher-than-excepted expenses.

“Expense data from 2018 and 2019 illustrate the rough road hospitals and health systems face in trying to get a handle on the high costs of providing healthcare,” the analysis stated. “While year-over-year variances show dramatic fluctuations from month to month, overall expenses continue to creep steadily upward.”

In November 2019, both labor and non-labor expenses rose. The most recent National Hospital Flash Report showed that total expense per adjusted discharge increased by 2.7 percent year over year and 5.2 percent month over month. Other metrics indicate a general decline in revenues, an increase in expenses and overall decreases in volume and income.

It is predicted this trend will be reversed in the first quarter of 2020. These predictions are also subject to further unknown changes in CMS reimbursements.

Hospital Margins Decrease again

in November 2019

https://tinyurl.com/yfgj3lhz

Are Primary Care Visits on the Decline?

Primary care is essential for a high-performing healthcare system, as patients with a regular primary care physician (PCP) have higher rates of recommended screenings and lower rates of preventable hospital admissions and mortality. Although recent studies suggest declining rates of primary care visits during the last decade in the United States, the contribution of practice changes, such as the use and content of such visits, to this decline is still undetermined. To address this question, researchers used nationally representative data from the National Ambulatory Medical Care Survey to analyze adult visits to PCPs and physician practice characteristics from 2007 to 2016.

The goal of a second study was to examine changes in individuals' contact with the medical system during the implementation of the Patient Protection and Affordable Care Act (ACA) within longer-term trends.

This study used data from the 2002 to 2016 Medical Expenditure Panel Survey to determine rates of contact per 1000 individuals per month for physicians, PCPs, specialty physicians, and emergency departments; inpatient hospitalizations; dental visits; and home health visits for the overall population and by age, financial status, health status, and race/ethnicity.

The number of primary care visits in the United States is unexpectedly decreasing at a time when the ACA has reduced financial barriers to care and ushered in a new era of prevention and wellness, 2 studies have found.

Experts disagree on whether this trend is good or bad for the health system. The passage of the Affordable Care Act should have increased the frequency of visits, while the use of telehealth would decrease face to face visits.  The availability of online laboratory test results obviates a clinic visit.

Other factors also changed. The length of a patient visit increased with the addition of education, coaching,  and more comprehensive visits.

In 1 study, Aarti Rao, BA, from the Icahn School of Medicine at Mount Sinai, New York City, and colleagues found that from 2008 to 2015, the average number of PCP visits per person dropped by 20% in a sample of 3.2 billion visits (−0.25 visits per person; 95% confidence interval [CI], −0.32 to −0.19). Visits dropped particularly for acute and chronic diseases, but not for general medical exams and mental illness.

Appointment Length Increased

The time of each appointment lengthened, on average, by 2.4 minutes, and each appointment addressed more concerns, enabled in part by electronic health records, and provided more preventive services and procedures, such as vaccines and wound care. In addition, appointments were less likely to have scheduled a follow-up for certain patients and conditions.

Physicians also offered much more non-face-to-face care, such as secure messaging and virtual care. For instance, it is no longer necessary in most cases for patients to come in to obtain laboratory results.

The researchers say that fewer visits can be explained partially by more comprehensive appointments and more out-of-office care.

They acknowledge, however, that the rise of high-deductible health plans may also be keeping some people from coming in at all; in addition, other factors could play a role, such as more patients seeking care at retail and urgent centers or appointments with nurse practitioners or physician assistants, which the investigators were not able to measure.

Specialist Care and Emergency Department Care Have Not Increased

The decrease in the numbers of primary care visits has not, for the most part, resulted in an increase of visits to specialists and emergency departments, Michael Johansen, MD, from Grant Medical Center, OhioHealth in Columbus, and Caroline R. Richardson, MD, from the University of Michigan, Ann Arbor, write in a second study published in the journal.[2]

In fact, the likelihood of visiting a specialist decreased for all patients younger than 65 years, Donald Pathman, MD, MPH, director of the Program on Primary Care at the University of North Carolina at Chapel Hill, explains in an accompanying editorial.[3]

That is a welcome finding, he writes, considering some "balloon" theorists have suggested when primary care visits go down, the use of more expensive care goes up.

Some changes were specific to age groups.

In this second study, emergency department visits did not change for individuals aged 18 to 40 years and those aged 65 years and older but increased for those aged 41 to 65 years.

Even though the intent of the ACA was to have a heavier primary care focus, what may be happening is that we are receiving more efficient primary care, albeit, in fewer visits, he said.

The intent of models such as accountable care organizations, he notes, is that care will be delivered and received where it is most appropriate, "and that oftentimes means you don't need an office visit," he explained.

Patients are getting more questions answered electronically, and more follow-up telephone calls are taking the place of in-office visits.

It seems the changes in the system are working in unplanned ways and most of it is good.  Perhaps we are getting more bang for ours. expensive health system.

Providers are becoming more proficient at using all the resources that have developed in IT and administrative matters.

He added that the studies show a surprising lack of response to the ACA, in that it appears the ACA did not increase the numbers of contacts with primary care or influence where people were seeking care.

In the end, neither of these studies gives a clear answer on whether less contact with primary care is a good or bad thing, Dr. Johansen explained, noting that who is not accessing primary care, where they are going instead, and how the trend affects outcomes are still unknown.









Are Primary Care Visits on the Decline?: US primary care visits are unexpectedly declining, despite the

Affordable Care Act implementation, which was intended to lower financial barriers to care and improve access to prevention and wellness.

Who Are the Key Players in Social Determinants of Health Strategy?

As healthcare organizations continue to target the social determinants of health, they must collaborate with other key players to deliver on programs.

 - The healthcare industry has come to a consensus that the social determinants of health and population health are essential considerations for delivering value-based care. But it takes a village, as the adage says, and organizations need to anticipate a number of stakeholders for making these programs a reality.

SDOH programs are inherently multi-stakeholder — they require the medical provider who will identify high-risk patients, fund sources, care coordinators or caseworkers, and the community-based partners that will help carry out interventions. Each of these stakeholders needs to be working in the same direction in order for programs to be successful.

Some hospital boards have already considered the SDH and how hospitals can effect change in SDOH for prospective patients.  The question being "Is there a return of investment? "Will this lower the direct cost of health care?

READ MORE: How Addressing Social Determinants of Health Cuts Healthcare Costs

Nutrition programs, housing initiatives, and ridesharing partnerships are some of the ways providers are reducing healthcare costs by addressing social determinants of health.

And as a fundamental part of that duty, board members are considering where to allocate financial resources to fund SDOH programming.

Adjusting Medicaid Payments for Social Determinants to Boost Care

Using a per-person adjustment for Medicaid payments to hospitals would address social determinants of health and help hospitals fund more comprehensive care, experts say. While some hospitals and organizations have outreach programs to increase accessibility for higher risk groups, this approach is to directly influence  SDH by other means. Some of these programs are already funded by other organizations, non-profits, food banks, homelessness programs. Hospitals can be a source of information as well.  Emergency room demographics reveal the data on homelessness, substandard housing, and poor nutrition. Substance abuse organizations can network with hospitals to deliver this information as well.  Emergency rooms function as social crisis centers. Public health and federally qualified health centers are organized centers of SDOH information. The information is already in place from Medicare and county hospitals.

READ MORE: How Food Security Programs Target Social Determinants of Health

How Social Risk Factors Influence Value-Based Reimbursement

The AHA (American Hospital Association) recommends that provider organizations take the following steps to implement similar housing initiatives:

Identify issues, opportunities, and risk
Establish strategic partnerships inside and beyond the hospital
Research potential interventions, such as successful programs run by other health systems
Consider funding implications and what sources are available for funding (i.e. local government and community agencies)
Educate patients, providers, and the community about the initiative
Assess and modify initiative to improve housing options, patient eligibility, and outcomes

Population health management and value-based reimbursement success hinge on reducing healthcare costs not only when a patient is in the exam room, but also when they are beyond the walls of the practice or hospital. Therefore, understanding where a patient lives, their income, education level, job status, and other social determinants of health (SDOH) is critical as providers aim to reduce healthcare costs and unnecessary utilization.

Socioeconomic factors are responsible for approximately 40 percent of a patient’s health, while just 20 percent were tied to care access and quality of care, the American Hospital Association (AHA) recently reported.

Despite the impact SDOH has on a patient’s outcomes and costs, many providers are not equipped to address housing, economic stability, education, food security, and other social determinants.

Providers in a recent Leavitt Partners survey cited insufficient appointment time and lack of compensation as top barriers to addressing SDOHs. Fee-for-service payments do not reimburse providers for extending care beyond the practice’s or hospital’s walls and even some alternative payment models have yet to branch out into integrating medical, social, and behavioral services.

This approach requires a collaborative approach and unique leadership skill to develop, maintain and develop resources, both financial and human to attain.

It is a brave new world with enormous opportunities as organizations and providers realize an ability to influence SDOH as never before.

In the past providers have recognized this aspect of patient care, with little resources to affect the major SOH affecting patient care as well as prevention

Patients can also contribute to this concept by communicating these needs and fully encompass a patient-centered health system.


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Factors Affecting Clinician Well-Being and Resilience – Conceptual Model – Clinician Well-Being Knowledge Hub

What is  Physician Burnout?

It is the beginning of a new year and a new decade. Most of this month's work will address physician wellness, which very much affects every patient. Patients have become aware of physician burnout. Burnout is characterized by three components: (1) emotional exhaustion or loss of passion for one’s work, (2) depersonalization or treating patients as objects, and (3) the sense that your work is no longer meaningful;  caused by the rapid influx of technology, increased patient volume, a new payment method based upon the value, rather than the volume of patient visits. Physicians and patients usually have their forums and spaces. It used to be the 'doctor's lounge' or the doctor's dining room. This has become much less true in recent years. While the administrative suites have grown larger, the spaces set aside for physicians has decreased and perhaps has contributed to a loss of self-esteem.

Many physicians now blog in public blog spaces, have their facebook pages and Instagram page While web pages are static social media offers an almost synchronous platform for doctors and patients to communicate. Add to that secure messaging and telemedicine, the internet provides an almost spider web for communications, physician-patient-patient-physician.

This conceptual model was developed by the National Academy of Medicine Action Collaborative on Clinician Well-Being.

What is Clinician Burnout?

This conceptual model depicts the factors associated with clinician well-being and resilience; applies these factors across all health care professions, specialties, settings, and career stages; and emphasizes the link between clinician well-being and outcomes for clinicians, patients, and the health system. The model should be used to understand well-being, rather than as a diagnostic or assessment tool. The model will be revised as the field develops and more information becomes available.

The external and individual factors of the conceptual model are hyperlinked to corresponding landing pages on the Knowledge Hub, allowing users to navigate seamlessly between the two resources. By viewing the Conceptual Model on your computer, you will find that each factor is linked to a landing page within the Knowledge Hub. Each landing page provides additional information and resources.

 The body of medical literature on burnout has demonstrated significant professional repercussions including decreased patient satisfaction, increased medical errors and litigation, and the personal consequences of substance abuse and depression [5–7]. One proposed solution to physician burnout is to address physician wellness [8, 9]

Numerous study groups have evaluated this subject and published their results and recommendations.

Transforming Clinical Documentation in EHRs for 2020: Recommendations from the University of Minnesota's Big Data Conference Working Group

The Royal Society of Medicine Open Section’s Medical Humanities Conference: Physician Resilience and Compassionate Practice

Physicians have in the past been at the top of the hierarchy of responsibility.  Leadership is a lonely place, and the inability to share responsibility and authority comes with a price. Today's brand of medicine is a team approach. This is demonstrated by a number of reports

Team Structure and Culture Are Associated with Lower Burnout in Primary Care

Factors Affecting Clinician Well-Being and Resilience – Conceptual Model – Clinician Well-Being Knowledge Hub: Factors Affecting Clinician Well-Being and Resilience – Conceptual Model

******HAPPY NEW YEAR 2020*****

Why six trends are pointing to a revolution in healthcare | Health Data Management

Healthcare is in the midst of a dramatic shift, as new players surge into the business of health.

The latest step in this evolution came Friday, with reports that Walmart is in discussions to partner with—or perhaps even acquire—Humana, one of the nation’s largest insurers.

If these reports come to fruition, it would represent the latest in a series of new companies showing renewed interest in consumer health—a divergence in the way that the nation has treated health in years past. The move away from sick care to health preservation is built on six trends—and of those, a unifying theme is that the technological acumen and infrastructure is in place to support this shift.

Consumerism

It’s taken a while, but consumer-patients have taken more responsibility for their own care. For a generation now, an increasing number of people no longer rely solely on what they’re told by their medical providers. They’re researching medical conditions on the Internet and wanting to know more about their treatment options. Consumers also are demanding control over their medical information and seeking to add their own patient-reported data to it.

This involvement is no accident, nor by the thoughtfulness of patients.  Anyone seeing a physician or admitted to a hospital sees how busy providers are, and much of the medical information and is automated.  Machines have great memories but do not exercise executive life or death decisions.

This evolution came about when someone asked: "why can't medicine work like an airline or a bank" Everyone said, "yeah" great idea, then along came the gurus of information systems. Then they did it. No one asked are the cultures the same?   Information technology came to medicine late in the game. Medicine is one of the last bastions of the pen and paper. Our cognitive processes of writing by hand and typing on a keyboard are very different. This may very well be the major factor in physician burnout.  The conversion takes time and energy to discard a time-worn process into a new paradigm.

Patients are rightfully concerned about the accuracy of their records,  even if the provider knows who they are. They correctly ask questions, do research before the visit and are careful to remind their caregivers who they are and what their conditions are.  It is even worse for the nurses and paramedical assistants who screen the patient robotically recording their findings.


Business migration

New players are casting an eye at healthcare as both opportunity and business imperative. The recognition of the rise of consumerism is reflected in the companies now looking for a place to play within the health industry—Amazon, Apple, CVS, Walmart, and Walgreens, to name a few. These companies have deep experience and data systems necessary for dealing with the customer as a consumer. Similarly, traditional health insurers see their long-time business approaches changing. For decades, insurers have primarily served as care purchasers—the entities through which patients’ bills were filtered, often in a contentious duel with care providers. Increasingly, health insurers see their roles changing, because they are no longer the only entities taking on the actuarial risk of care. To a greater extent, consumers and providers are taking on those roles. Insurers increasingly want to see their roles morph, providing data and services that improve patient care and optimize consumer health. Hence, they are seeking partners that enable them to take on a broader role in health.

Price frustration

Initiatives intended to slow the rise of healthcare prices over the last three decades have ultimately failed to slow the rise in healthcare expenses. That’s why the U.S. spends more than $3 trillion dollars on healthcare annually, and why it’s no longer acceptable for solutions to aim to only slow the rate of growth. Healthcare currently consumes 18 percent of the gross domestic product, and the trendline is not good, especially as more Baby Boomers retire and are likely to see their medical needs—and costs—increase.







Why six trends are pointing to a revolution in healthcare | Health Data Management: The Walmart-Humana combination is the latest of a series of moves that point to an abrupt change in the industry.