8 Things CFOs Must Know About Health Reform

Whether a Chief Financial Officer is running the fiscal operations of a hospital system, an insurance company or a company that simply employs individuals with health coverage, the decision-making process for sustainability is changing at a rapid pace. However, after years of hearing about reformation in the health system, broad, sweeping and revolutionary changes are finally happening. Major shifts are also occurring in the population, as well as technological advances that will disrupt the entire premise of a four-walled institution for care and the very model we use for health delivery.

Health care in the US is a business – a multi-billion dollar business – and understanding the financial implications of health reform will make or break every CFO. Knowing that health access, demand, quality and payment changes are inevitable there is an immediate need for CFOs across the ecosystems to embrace and plan for transformation.

1. You have too many beds.
   While many hospital leaders won’t accept this at face value due to lengthy wait times, surgical demands and desire to shift beds, the truth is there are too many beds in a lot of hospitals. Between transferals to the outpatient setting and telemedicine, the need for expensive inpatient beds is declining. Additionally, hospital leadership are increasingly finding that they face problems with state authorities when they apply to move beds. Most recently at the University of Chicago, where 338 beds were being used for a 304-person utilization pattern, the state rejected a University application to move surgical beds.
2. Food, housing and transportation of patients is your problem.
   As Americans begin to define and attempt to tackle community and population-based care, the access individuals have to quality food, affordable housing and efficient transit matter.  No one living in a food desert will have the same health outcomes as someone living next door to a Whole Foods, just as an individual with a new car will always be more consistent in making appointments and picking up prescriptions than someone who has to access three public transit buses for the same activities. Real patient engagement and activation begins with understanding the environment of each patient.
3. Your patient demographics are shifting, and so too should your leaderships. As the US continues to brown, hospital leadership must be representative of the population to understand and meet need. At a recent Modern Healthcare Top 25 Minority Executives session, an awardee remarked that the United States is now a country of minorities, and “our leadership as minorities is our future for health outcomes.” With this in mind, it is inevitable and paramount to success that the leadership of any organization resembles and represents those it serves, so it makes the financial investments and decisions that influence the community.
4. More bodies in beds will never work again.
   Value-based purchasing means that a warm body in a bed not only drives costs higher for the payer, but that the longer a patient remains in the hospital – or the more often they return – the more penalties that accrue. Therefore, the goal should not be for more bodies, but for cost-effective bodies. Depending on the community serviced, this can mean desire for more Masters Athletes, specialized services or elective services. Additionally, as we shift to a world where technology enables more clinical procedures and recovery to be done in the outpatient setting, or at home, and expensive inpatient procedures decrease in volume and reimbursements, hoping to fill beds is futile.
5. Alignment with physicians is nonnegotiable.
   No leader can effectively attain a goal without buy in from those who carry out the work.  However, it is important to be aware that “physician alignment” is a term that causes almost all physicians to turn and walk the other direction out of fear that this indicates buying their autonomy and dictating their day-to-day, moment-to-moment ability to practice. According to Healthcare Financial News the implications of physician behavior are so important in 2014 that more revenue than ever will be spent recruiting physicians who see the world the same way you do, which is not very different from how corporation CFOs think about their employee hires.
6. As consumers take on more and more pay responsibility, unexpected payment shifts will keep occurring.
   Many experts estimate that defined contribution, health insurance exchanges and the growing individual health insurance market means that patients will become more informed about spending their health care dollars, and therefore, more unwilling to spend. The future of reimbursements and pricing strategies is presently a puzzle wrapped in an enigma because of extreme uncertainty. However, it is general knowledge that Medicare and Medicaid reimbursements are going to continue decreasing, with the American Hospital Association and Moody’s already estimating an, “unequivocally negative” outlook for hospitals on the reimbursement fronts.
7. Technology and data utilization can save you money.
   While the learning curve with new technology can be excruciating and the meaningful utilization of collected information seems daunting, everything from workflow to health activities and employee/patient engagement can be monitored – and altered in real time – using new technology. Moreover, the more information that is known today, the better predictive analytics and behavioral change that can be made tomorrow. However, as the amount of technology available to leadership continues to grow exponentially, the purchasing of new tech will be a balancing act between what is a passing fad versus what is sustainable and transferable.
8. Your EHR is going to cost you. Big time.
   Now this seems obvious to most hospital CFOs, as they have already seen the initial price tags that come with implementing a “holistic” electronic system. However, the most costly elements may not yet be realized. As mergers and acquisitions continue, technology advances and EHR capabilities increase, the need to refresh systems will continue.  At present there is not one system that meets end-to-end patient or provider needs, leaving the ecosystem open for further disruption, which inherently includes more interoperability, more upgrades, more plugins and more costs.

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Balance of Power

In researching a novel I am writing I have been reading about the history of the treatment of depression.  As often happens, I ran into an historical issue with echoes of the future.

Here’s an interesting paragraph from Howard Kushner’s book American Suicide.

“While asylum superintendents [in the 1840s] were as much captive of bourgeois ideology [the conviction that the insane could be reformed and that the suicidal could be cured] as were other social reformers, they were influenced on a daily basis by more parochial concerns.  Not least of all, these men sought stable employment in the medical profession at a time when, buffed by competing medical sects, medicine promised neither prestige nor a regular income.  A career as an asylum superintendent offered a solution to the contradictions between humanitarian desires to help others and a quest for economic security.  Like most professionals then and now, these asylum physicians saw no conflict between an increase in their professional power and the improvement of the condition of the patients they served.  Indeed, they viewed the former as essential for the latter.”  (Bold letters are my addition.)

Let’s look at that second-to-last sentence.  Professional physicians see no conflict between increases in power and the improvement of patient condition.  Conflict may not be quite the right word.  Maybe correlation is a better one.  Professional physicians see correlation between increases in power and improved patient condition.  Up to a point the statement is historically accurate.  There was no conflict in the eighteenth and early nineteenth centuries because as trained doctors from legitimate medical schools began to have more influence than the untrained barber-surgeons and apothecaries, patient health did get better.  Education and science eventually led to treatments that truly helped people.  This resulted in a medical profession which, unlike that of 1840, had great prestige and good income.

Since those early days of medical professionalization, however, power has shifted.  The turn away from paternalism toward autonomy has shifted the balance.  Regulation, legislation, and an omnipresent media have shifted it further.  Power, which used to be in the hands of doctors, for better or worse, is now in the hands of regulators, administrators, and the patients themselves.  The question is, does the decrease in physician power correlate with a change in the health of patients?

The answer, of course, depends on who you ask.

You could ask Timothy Quill and Howard Brody, who would tell you they doubt extremes of patient power increase the well-being of patients.  In 1996 they wrote the following in the Annals of Internal Medicine: (Ann Intern Med. 1996;125(9):763-769)

“At one extreme end of this [patient autonomy] spectrum is the “independent choice” model of decision making, in which physicians objectively present patients with options and odds but withhold their own experience and recommendations to avoid overly influencing patients. This model confuses the concepts of independence and autonomy and assumes that the physician’s exercise of power and influence inevitably diminishes the patient’s ability to choose freely.”

You could ask the Physician Regulatory Issues Team at CMS, which claims that the power of regulation, in the form of government money, improves the condition of patients:

“Physicians have a special role in our health care system, as they not only care for the health of individual patients, but also help to shape the broad health care delivery system. As the federal Medicare agency, CMS respects the bond of trust between physicians and their patients, and appreciates the need to support physicians in the leadership they provide in service delivery. The Medicare program and physicians share a common mission, the provision of high quality medical care for patients.” (http://www.cms.gov/Outreach-and-Education/Outreach/PRIT/index.html?redirect=/prit/)
You could ask Drs Bell, Wilkes, and Kravitz, who may say that the power of advertising is not improving anyone’s condition.  They found that “A sizable fraction of patients believed they would react negatively if their physician refused to provide a prescription for a drug advertised in the general media.”  The Journal of Family Practice [1999, 48(6):446-452]
You could ask Louis Goodman and Tim Norbeck of Forbes, who would probably say that regulations are not increasing patient health.   “…Physicians are already spending 22 percent of their time interacting with insurers on formularies, claims, billing, credentialing, pre-authorizations, and quality measure data.  The workload can only increase with the new [ICD-10] codes.” http://www.forbes.com/sites/physiciansfoundation/2013/11/05/healthcare-is-turing-into-an-industry-focused-on-compliance-regulation-rather-than-patient-care/

You could ask the people of Florida, where doctors abuse their power of the prescription pad.  They would say that absolutely, regulation has improved the condition of patients.  An article in the New York Times reported that “New laws are also cutting off distribution [of prescription painkillers]. As of July, Florida doctors are barred, with a few exceptions, from dispensing narcotics and addictive medicines in their offices or clinics. As a result, doctors’ purchases of Oxycodone, which reached 32.2 million doses in the first six months of 2010, fell by 97 percent in the same period this year.” http://www.nytimes.com/2011/09/01/us/01drugs.html

Balance of power is important in health care, just as it is in government and marriages.  No one will argue that giving physicians full power to do anything they want is a great idea.  But we need to be careful about how much power we take away.

 

American Heart Association Launches Accelerator To Find Internal Game Changers

Accelerator programs and incubators are growing rapidly in number within the health care industry, with most replicating standard tech incubator models. But one organization has worked to redefine what an accelerator program can look like in the health space by joining one of the country’s largest and most influential associations in its landmark effort to court healthcare innovation. Dr. Ross Tonkens, a cardiologist and Chief Medical Officer in Cary, North Carolina has directed the creation of the Science and Technology Accelerator Program inside the American Heart Association (AHA), that targets and supports ground-breaking ideas from residents to senior clinicians.

Breaking The Mold

Although the AHA is most well known for its Heart Walks, Heart Ball and various awareness efforts such as the Go Red campaign, with a growing accelerator program, the Association could soon be known for changing how health associations and organizations think about growing overall impact. Not only do new ideas, technologies, and products improve the branding and public relations of an association, but it also leads to innovation that improves cost-effective practices, patient experience and standards of care.

According to Dr. Donald Lloyd-Jones, Senior Associate Dean for Clinical and Translational Research at Northwestern University, “When the prevalence of atrial fibrillation is presently estimated between 2.5-6 million Americans, but also estimated to be 6-16 million by the end of 2015, we know invention and innovation are needed.”

The AHA’s 2020 Impact Goals are to reduce deaths from cardiovascular disease and stroke by 20% as well as improve cardiovascular health of all American’s by 20%. Lloyd-Jones said the kind of disruption and change necessary to make these goals achievable will have to come from newer and more effective ideas and products through the Accelerator program in addition to continued research funding.

Dr. Lloyd-Jones set the tone of the AHA’s “Get Pumped” efforts by highlighting that, “continuing to fund research efforts will ensure tomorrow’s health and science discoveries make it from bench to bedside.”

Dr. Tonkens adds that investments through the Accelerator program can encourage industry and venture capital interests to “pick up the baton and carry it to the finish line after we fund proof of concept clinical research.”

Funding

Presently, the AHA is the second largest funder of cardiovascular research after the federal government. AHA has spent over $3.5 billion in supporting basic science research, and continues to do so. The Accelerator on the other hand is focused on identifying the game changers that can be propelled to market as quickly as possible, and helping the industry and investors feel confident in having a lower amount of risk on innovative products.

While AHA gave an estimated  $134 million last fiscal year in research, the AHA Science and Technology Accelerator Program is independent. To date it has not collected money directly from AHA, but instead, relies solely on donations directed to the Accelerator through awareness and fundraising efforts.

While this can make funding difficult, it also means any return on investment by the Accelerator is used to drive game changers into the market faster; the gift that keeps on giving.

Challenging The Status Quo

The Accelerator program not only invests money, but also expertise in areas such as scientific research, regulatory issues, intellectual property and commercialization strategies. This is done to ensure that all ideas are solicited, vetted and implemented to the best of their abilities, even those from younger individuals in the AHA that may not have yet been granted government funding or published in journals.

At the Heart Innovation Forum in Chicago last October, Jill Seidman of Healthbox agreed. During a panel discussion on accelerating discovery to patient experience she examined to audience that it was ideal for Chicago to host the AHA Forum because it was on the forefront of young innovation. She explained that, “bridging academic medical centers (AMCs) with community centers and clinics is imperative to improving outcomes, and Chicago has more AMC and medical schools than any other region in the United States.”

Dr. Tonkens message was clear at that same Forum. He said that like Healthbox, the Science and Technology Accelerator within AHA could fund – and has – great ideas. As he put it, “small amounts of money can dramatically improve life expectancy and decrease death from heart attack and stroke when leveraged by the global expertise in science, medicine, IP, regulatory and commercialization strategies which AHA is uniquely capable of bringing to bear.

American Heart Month And Beyond

As February closes out National Heart Month it is important for American’s to think about the implications of the country’s most detrimental health condition, heart disease. As a nation we have a long way to go to improve overall outcomes as they pertain to cardiovascular health, and especially those of our minority populations.

Through initiatives that range from the new Get Pumped phone app to high-end fundraisers to advocacy campaigns, the AHA is working hard on its outreach, educational, and public policy efforts. “Funding research and encouraging technological innovation is critically important,” said AHA Illinois Government Relations Director Alex Meixner, “but we also work with stakeholders ranging from hospitals to local, state, and federal governments to ensure that today’s scientific breakthroughs become tomorrow’s universal standards of care.”

Further, the status quo must be disrupted, and must be met with acceptance by veteran clinicians. Although current best practices exist for a reason, there cannot be progress using older methods to care for our aging and changing population.

 

An Engineering Feat Gives Hearts Extra Life

With the release of their new HeartAssist5 heart pump, ReliantHeart is making real-time, personalized feedback possible for the millions of Americans suffering from heart failure. The new technology allows for real-time, remote monitoring of implantable devices, years of added life for patients, and flexibility to travel without a physician nearby. With a staggering projected 46% growth in heart failure by 2030, advances in heart failure innovation are on the forefront of changing medical treatment, policy, device research and physician reimbursements. Further, with heart failure and disease disproportionately affecting minorities in the US, advances in length and quality of life could be huge strides for medical equality.

Heart Failure In America

Approximately 7.5 million people in the United States currently suffer from heart failure, a figure that is increasing over time as more people survive heart attacks and various other heart conditions. According to the Heart Failure Society of America, an estimated 400,000 to 700,000 new cases of heart failure are diagnosed each year, with deaths averaging 250,000 annually, more than double since 1979. Even worse, an estimated one half of heart failure patients die within five years of diagnosis and 20% within the first year.

With a waiting list for heart transplants at an overwhelming 3,736 at publication, and less than 2,500 hearts donated annually, the need for a bridge between heart failure and transplant is literally life and death.

LVADs

Left ventricular assist devices (LVAD) are implantable heart pumps that were created to temporarily support patients with advanced heart failure as the bridge between diagnoses and transplant. However, with new scientific advancements, LVADs are becoming a long-term tool for improving heart function without transplant.

The right ventricle pumps blood to the lungs, but the left ventricle is responsible for pumping blood to the rest of the entire body, making it much more susceptible to failure. Therefore, LVADs have been the focus of most modern research to prolong and improve life saving implants.

Patient-Centered Care

Reliant’s system acts like your car’s dashboard. “If a patient’s pump has any sign of a challenge, like dehydration or low flow, the remote monitoring system signals the change to a data-collection center that notifies the transplant center as well as the individual,” ReliantHeart CEO Rodger Ford says. This is what makes the HeartAssist5 unique; at the first sign of a problem the right people are notified immediately.

Essentially, if the engine light goes on, the heart center and patient are notified to get the engine checked.

He also notes that the patients can set monitors to send text message notifications, thus making changes in blood flow, speed and power truly personalized. Individual blood flow is collected and transmitted every 5 minutes, making one’s own body the standard comparator.

The greatest importance to Founder and CTO Bryan Lynch is his ability to use his background as an engineer to, “Get involved in a project where you can actually see how you saved a life. While the docs and nurses are the real lifesavers, we give them the tool to make it possible.” He continues that it is vitally important for engineers and innovators to gain a patient-centered approach to get a real reduction in cost burden and improve quality of life.

Sailesh Saxena, CFO, continues highlighting the patient focus of the company by telling about the origination of the design of the VAD pack. “Bryan and I used to go to Schlotsky’s Deli ($BUNZ) for lunch,” he said, “and we used to see this man wearing a coat although it wasn’t cold out. Bryan noticed immediately that he was attempting to hide an LVAD controller and batteries. Well, this happened more than once, and we recognized that he was always concealing the VAD controller. So we decided that we needed to create a unique insert so that our LVAD control system could slip right into a Louis Vuitton ($LVMH) or Gucci ($GUC) bag unnoticed. It’s the small things that make the patient feel like we understand what they really want.”

Expanding The Geography Of Care

Remote monitoring, like other methods of telemedicine, is a key to expanding the geography of health care. “As technology matures, with the help of remote monitoring, the cardiologist and patient will feel safer with greater distances between them,” says Saxena.

This growth in telemedicine as a whole, and specifically in heart care, has major implications for the Centers for Medicare & Medicaid Services (CMS) as well as health care policy and reform. Because CMS is beginning to assign reimbursements and penalties based on patient outcomes instead of traditional fee-for-service metrics, it will become more and more important to have reimbursements reflect remote monitoring and its likely benefits.

Reimbursement codes also need to be reworked to genuinely target geographic discrepancies in care, which are fundamentally important for transplant centers. However, at present, CMS is slowly beginning to take growth rates of heart implants seriously based on the agency’s continued increases in payments, including their slight variations in geographic differences.

An Engineering Feat

In a recent study, researchers found that platelets flowing through the HeartAssist5 are exposed to significantly lower cumulative shear stress levels than in competitive devices tested. Ultimately, this means that the ReliantHeart product allows for what the CTO calls “a more physiologically normal cardiac output, including the pulse.”

What Bryan means is that people with failing hearts have low blood flow throughout the body, which is why they are so sick. When an LVAD is implanted, patients return to a more normal flow, but they also need blood flow that is as natural as possible. With the HeartAssist5, blood is not damaged and any pulse that the recovering heart produces is naturally transmitted to the body.

The LVAD and heart now work together to help the patient recover.

Although there are two other continuous flow LVADs on the market (THOR and HTRW), the ReliantHeart team claims their careful design capitalizes on working with the natural ventricle to the benefit of the patient, almost like a gym trainer for your heart.

Their “implantable flow probe” is also a revolutionary aspect of the HeartAssist5. This ultrasonic probe measures the blood flow from the LVAD in real-time providing critical feedback that is a one-of-a-kind technology providing data that makes the aforementioned remote monitoring so valuable. Ford says this ability to see patient-specific trends remotely in real time not only helps all patients improve quality of life, but the longevity of the HeartAssist5 creates a life support system, far beyond the “bridge” that the LVAD was originally created to be.

So this month, for American Heart Month, think about what innovation really is. It might be the ability to prolong and add quality of life for individuals and families across the nation, to share more time with loved ones.

 

Health IT Thrives With New Startup Companies

As the health insurance exchanges opened for enrollment just days ago, the federal government, including the President and the Department of Health and Human Services (HHS), had to acknowledge that it was not technologically ready. The IT infrastructures by which individuals tried to sign up for health insurance crashed and were unavailable throughout the first day and the weeks after. Those same sights were supposed to track enrollment, but proved to not be as well tested and far more expensive than originally anticipated. However, despite the shortages and disappointments with government IT readiness for exchange websites, there was a surge in US-based startup companies that demonstrated just how innovative and forward thinking technology can be in the health care arena. Nine new companies, all curated through BluePrint Health were introduced at that same time three weeks ago on “Demo Day,” and were ready to show the new frontier of health care, and how to transform care delivery through technology.

Health IT Incubators Driving Innovation

Blueprint Health is an accelerator program geared towards health care companies that want an intensive three-month mentorship to help find customers and capital, and learn from leading industry experts. The companies that are selected for the program range from individuals with a clever value proposition to well-established organization leaders that have existing customers, investors and are generating significant revenue, but with new ideas. According to Doug Hayes, a Principal at BluePrint Health, “We are seeing an acute need for innovation at the seed stage of the health care ecosystem. With top-down changes in regulations and quickly shifting incentive structures, the most successful companies will be those who can nimbly adapt.”

He asserts that what makes BluePrint successful is that it is, “uniquely positioned to attract, identify, and support the entrepreneurs that fill the gaps of service left in the wake of massive industry changes.” The accelerator program promotes the mindset that new businesses should not have to focus exclusively on fundraising. Hayes says, “Building a company is extremely difficult, and a founders’ time is best spent on customer and product development, not fundraising.” With that mentality, BluePrint does not use many pre-established filters when evaluating the near 1,000 applications it receives each year, but instead concentrates on business models.

The nine particular startup companies that were cultivated during the summer of 2013 range from Healthify, which focuses on creating platforms that connect and standardize medical homes to treat social needs to Board Vitals, an organization that improves the testing system of our nation’s providers. Each of these new businesses gives hope to innovators and entrepreneurs.

The Companies

Artemis

Artemis is a health care analytics firm specializing in benefit claims. With employers spending billions of dollars on health care, benefits managers need more information than the historical, once a year paper reports of the past. With the Artemis platform, benefit managers have graphical, real-time updates for claims and assessments. The creators claim that that deploying its tactics not only saves money for organizations, but also heads off future costs through prevention and determination of key cost drivers.

Board Vitals

Board Vitals brings together publishers, universities, and top physicians into a single digital platform for medical specialty education, with pass rates that are 10% higher than the national average. According to co-founder, Dan Lambert, “Content is continually voted up and down, meaning that the very best material comes to the top and outdated or incorrect content is voted out.” His partner, Andrea Paul added that their aggressive, but attainable, goal is to have materials for 20 of the 35 specialties in 2014.

CredSimple

The founders of CredSimple created a system to make the mandatory credentialing of physicians cheaper and more efficient. According to co-founder Garry Choy, at present, credentialing takes two to three months per physician and hospitals spend millions a year on the routine, but inefficient process. CredSimple uses an impressive 214 data sources to verify credentials, saving all provider parties time and resources, with downstream positive implications for entire hospital systems.

Genterpret

Pharmaceutical companies strive to gain pricing power and market share using genetic information about how patients respond to drugs. Genterpret, started by two system biology PhDs, links genetics to drug responses in one-third of the time (six months) of previous genetic testers. The faster turn-around time and vast outreach program created by the founders suggests that the Genterpret technology can soon be applied to thousands of diseases, improving health outcomes and saving money.

Healthify

After years of working in Baltimore health clinics, the creators of Healthify joined forces to start a company that addresses social needs such as food insecurities to improve health in communities. Medicaid spending on medical homes averages about $15 billion, much of which is spent on social needs. The data collected by Healthify will become vital as medical homes and accountable care organizations begin to address social needs as integral to overall health and well being.

ReferBright

ReferBright helps health practitioners with digital marketing in a world full of medical advertisements. The goal, according to the founders, is to improve outreach and referral rates for various kinds of professionals. Additionally, the automated system makes updating personal information easy for practitioners and makes vetting of practitioners easy for hospitals, knowing the information on ReferBright has been inspected and verified.

SpotMe Fit

According to co-founder, Jarrod Wolf, SpotMe, “allows employers to reward their employees for attending any fitness facility, running in races, or for using fitness apps and devices. When the barrier to incentives are removed–like eliminating paperwork and providing immediate rewards–and employees are given the flexibility to choose how they engage in fitness, then program participation rates skyrocket.” This focus on wellness and fitness programs is to improve health outcomes and lower health costs through incentives, monetary and physical.

Staff Insight

The premise of Staff Insight is to increase workforce productivity, specifically through hospital leadership being able to understand and staff facilities to the optimal levels. The company aims to use real-time dashboard to identify staffing levels in units, test baseline productivity, set new benchmarks for productivity and ultimately save revenue for facilities by optimizing productivity. The founders claim that early adopters have already seen a two to four percent increase in productivity.

WellTrackOne

WellTrackOne conducts a Medicare-approved personal assessment that hospitals can use to track patient data and identify potential risk factors. To lessen the administrative burden and disruption to the workflow, WellTrackOne claims that it can integrate all electronic health records, from multiple systems to improve data and health outcomes.

The Future Of Health Technology

Despite the federal governments success in getting support from professional athletic organizations and celebrities like Jennifer Hudson, the technological infrastructure just wasn’t ready for consumer usage. In contrast, Doug Hayes says that a key reason BluePrint startups were ready on Demo Day is due to the mentor community and outreach.

He claims that a by-product of their focus on business models and portfolio is that it, “includes many enterprise solutions. The long sales cycle and disparate channels within health care makes enterprise sales an especially tough nut to crack. However, our experience within enterprise and our mentor community, 150 strong, makes us especially well positioned to help founders sell into large payers, provider networks, pharma, and other enterprise customers.

 

Mental Health Loses Funding As Government Continues Shutdown

In the months leading up to World Mental Health Day, DC has been shaken by a series of violent events that ended with innocent lives lost and our country’s mental health services called into question. During this same time period, Washington, DC has been consumed by a government shutdown, with lawmakers and policymakers trying to determine how to rein in our country’s financial burdens and overspending. Unfortunately, as federal and state governments look to cut budgets at every turn, mental and behavioral health services are often on the chopping block first. Financial cuts, compounded with US stigma often applied to mental health troubles and disparate access to services across the county, mean that those who need services most are often those left without proper care.

August though October brought DC into the spotlight for many reasons, the saddest of which is the violence that was covered by mass media as two shootings occurred. In one case, Aaron Alexis, a 34-year-old, perpetrated a mass shooting that left 12 people dead, in Washington’s Navy Yard. Previous to the shooting, it was reported that Mr. Alexis was treated at the VA for mental health issues including sleep disorders and paranoia, but had not lost clearance.

Miriam Carey, also 34, reportedly had an unhealthy obsession with the White House when she drove her car into the White House gates and led police on a chase around DC before being killed. Although she had no reported psychosis or supposed violent intent, it was noted in the months leading up to the incident she believed that the President had beenstalking her and might have suffered from postpartum depression. When killed by authorities on Pennsylvania Avenue, she had her 18-month-old child in the car.

Budget Cuts

Although societal stigma and knowledge of where to access behavioral and mental services are often barriers to care, budget cuts continue to make seeking care more difficult. Whether this be through decreases in available services, lack of providers due to poor reimbursements or less preventative actions in communities, the impact of mental health funding shortages is great. According to the National Alliance on Mental Illness, “increasingly, emergency rooms, homeless shelters and jails are struggling with the effects of people falling through the cracks due to lack of needed mental health services and supports.”

In the last five years, significant budget cuts have befallen mental health programs and services. From 2009 to 2011, states cut mental health budgets by a combined $4 billion- the largest single combined reduction to mental health spending since de-institutionalization in the 1970s. In Chicago alone, state budget cuts combined with reductions in county and city mental health services led to shutting six of the city’s 12 mental health clinics. These closures, along with other public and private center closures in Chicago, have eliminated vitally needed services, especially on the south and west sides where they are indispensable.

Threats of sequestration in 2013 had a significant impact on people’s ability to access mental health services and programs, including children’s mental health services, suicide prevention programs, homeless outreach programs, substance abuse treatment programs, housing and employment assistance, health research, and virtually every type of public mental health support. The Substance Abuse and Mental Health Services Administration(SAMHSA) claimed it alone would be cutting $168 million from its 2013 spending, including areduction of $83.1 million in grants for substance abuse treatment programs.

Consequences

Despite the need to balance budget and make all health care services more efficient, many argue that society has better long-term outcomes if more federal and state dollars are allocated to mental and behavioral health care. This includes preventative services as well as mental health testing and treatment.

Because individuals with untreated mental illness often find themselves in emergency rooms, homeless shelters and prisons, the societal cost of prevention and treatment may be exponentially less than funding those other outlets and catchment areas. This is especially true in the case of children, who face cycling in and out of the system throughout their lives if left untreated.

These costs can be exceptionally large over the lifetime given that the National Institute of Mental Health (NIMH) estimates that two-thirds of children with lifetime mental health problems never receive treatment. This takes substantial emotional and financial tolls on individuals and families, as well as the broader society. However, programs that address the mental health needs and provide services for youth show better outcomes in health and education that carry over the lifetime. For example, in the University of Chicago’s Crime Lab, therapy is being used to curb youth violence, especially amongst those with behavioral and mental health care needs.

Additionally staining on the mental health care system is that during times of recession and budget cuts the caseload for mental health actually increases. It has been estimated that during this most recent recession, the caseload of community mental health services alone has increased almost 50 percent. This increase has most notably been seen in the Native American community, where suicide prevention is an essential part of the cultural health care demands.

Everyone Benefits

The NIMH contends that one in 17 people suffer from a “seriously debilitating mental illness,” we as a society are accountable for ensuring that those in need have resources for care. Not only does access to quality mental and behavioral health care ensure that individuals are being properly treated, but that America as a whole saves money and resources caring for those in need in other, more expensive settings. It may further prevent violent acts like those in DC from happing.

On this World Mental Health day think about the ways in which access to and support of mental and behavioral health care can be improved in your community.

 

Primary Care Deserts Do Not Disappear With Nurse Practitioners

In coming years the US could see growing shortages in the availability of primary care physicians (PCPs). With the number of individuals seeking care increasing and the current medical system continuing to incentivize physicians to specialize, the number of available PCPs will decline proportional to the population. To fill that gap, Ezra Klein and others have asserted that expanded scope of practice will allow nurse practitioners (NPs) to serve as viable substitutes for primary care shortages.

While NPs serve a vital role in the system and meet need, the argument that they are a 1:1 substitute for PCPs (but for the greedy doctors and pesky regulations holding them back) is singular and shortsighted. The argument also fails to address broader policies that influence both NP and PCP behaviors. Policies that unjustifiably lead to the unequal distribution of caregivers, location or expertise, inherently parlay into unequal care for patients. Sadly, a broader scope than “freeing nurse practitioners” is necessary to meet primary care needs, as NPs are complements, not substitutes. Policy must address the need for more primary care and assist to realign the system to meet our country’s basic care and equality through redistribution.

Primary care is the foundation of the evolving health care system, with equal access the intended goal of the ACA. Along the way to meeting future demand for primary care, NPs can be increasingly utilized to meet the needs of Americans and improve the health of the nation. And let it be known I am a strong proponent and supporter of nurse practitioners and all non-physician providers and coordinators. However, the argument that most NPs practice in primary care and will fill the primary care gap, estimated at about 66 million Americans, is inaccurate. It isn’t a 1:1 substitute, especially given that models of the solo practitioner are vanishing in lieu of complementary and team-based care.

The US, unlike many western countries, does not actively regulate the number, type, or geographic distribution of its health workforce, deferring to market forces instead. Those market forces, however, are paired with a payment system whose incentives favor high volume, high return services rather than health or outcomes. These incentives are reflected in where hospitals steer funding for training, and in the outputs of that training.

Throughout the US there are geographic pockets that fail to attract medical professionals of all kinds, creating true primary care deserts. These deserts occur in part due to the unequal distribution of practitioners in the health care system, with our medical schools and salary opportunities producing low numbers of generalists across the board. We have even continued to see shortages in nurses throughout the US.

In fact, 2012 residency matching rates not only show continued unfilled positions in primary care, but that the rates of graduating minorities are highly skewed from programs. This contributes to even greater problems with finding primary care providers that reflect the populations they serve. Sadly, this is also true for nurse practitioners, where only 4.9% are African American, 3.7% are Asian or Pacific Islander and 2% are Hispanic. Further, the geographic distribution of NPs and physicians assistants alike is close to that of physicians. A June 2013 assessment found that the distribution for urban, rural and isolated rural frontier primary care providers is within a few percentage points for NPs and PCPs.

Ezra Klein was not wrong in his assessment that physicians are often influenced by income. However, it seems likely that financial incentives are drivers for many professionals in the health care sector, including nurse practitioners, registered nurses and physicians assistants (PAs). Dr. Andrew Bazemore, Director of the Robert Graham Center for Policy Studies in Primary Care in Washington, DC has done significant research in this area. His perspective is that, “The suggestion that runaway health system costs could be contained simply by replacing higher salaries of physicians for lower salaried substitutes with less training misses the point – that cost containment will most likely result from optimizing primary care functions such as prevention, population management, care coordination, and avoidance of unnecessary referrals, procedures, ER use and hospitalizations of primary care providers.” Dr. Bazemore asserts that, “Achieving that level of effectiveness likely involves teams that include primary care physicians, NPs, PAs, behavioral and community health workers, and other important components, operating in a transformed practice setting.”

It is also correct that regulation on NPs is onerous and sometimes oppressive. Across the nation, regulation on NPs is exceptionally disjointed and often results in unnecessary hurdles for all involved, called scope-of-practice laws. Although impediments are common in the health care system, it is extensively difficult for NPs and similar non-physicians to break into a system that is deeply rooted in tradition.

However, by honing in on one piece of the puzzle, Mr. Klein missed the bigger picture. The principals of substitution do indicate that on the supply side, NPs stepping into roles for PCPs would better meet demand. But that is not the real world outcome. The broader landscape shows us that instead of a 1:1 substitution, nurse practitioners are compliments in the overall care system, important roles that fulfill many primary care needs.

Therefore, policy changes are still needed to improve patient health outcomes and forge a team-based relationship between care providers. Incentives to enter primary care and needed across the disciplines, as are models of team-based training that build on the strengths of each in managing whole persons and populations. Ezra Klein fails to note that most primary care shortage estimates implicitly include NPs and PAs already working in primary care while not accounting for the fact that NPs and PAs are choosing specialization over primary care for the same reasons as physicians.

Instead of an environment where NPs and PCPs are positioned to compete with one another, federal and state legislators should spend more time crafting policy that equalizes the distribution of care providers across the system. That redistribution means incentivizing, monetarily or otherwise, primary care clinicians to stay in general medicine and work in tandem with other providers. Whether it be the reformation of medical school, constructing a more honest approach to population health or restructuring pay scales and incentives, team-based medicine with improved access and outcomes should be the real discussion.

 

Is Your Doctor Lying To You?

The doctor-patient relationship, like any good relationship, is built on trust. After all, the patient is naturally at the mercy of their physician in most cases, because the physician is the expert. Sure, the patient should have the ultimate say in their care, but the information they are basing their decisions on typically comes from the physician, and they must trust that what they are being told is the truth. Unfortunately, a recent study by Lisa Iezzoni and colleagues finds that doctors aren’t always so honest with their patients.

In a survey of a representative sample of physicians, more than a third of doctors fail to completely agree with the statement “Physicians should disclose all significant medical errors to affected patients.” Nearly one-in-five fail to completely agree with the statement “Physicians should never tell a patient something that is not true.” That’s right, more than 17% of doctors felt that there were times when it was okay to lie to patients.

As for their actual behavior, 11% of physicians reported rarely, sometimes, or often (in contrast to never) telling a patient something that was not true, and 55% reported rarely, sometimes, or often describing a patient’s prognosis in a more positive manner than warranted. Admittedly, the latter case could be perceived as compassionate rather than dishonest depending on the circumstances.

What are we, as patients, to make of these findings? Well, on the one hand, the truth could be even worse than the results suggest because of “social acceptability bias.” In other words, doctors know that admitting to being dishonest isn’t the “right” answer to give, so they may ironically be dishonest about reporting their dishonesty. At the same time, the framing of the results may actually be misleading. By taking four responses (never, rarely, sometimes, and often) and grouping them into two categories (never vs. not never), important information is obscured. If most of the doctors who admit to lying are in the “rarely” category, perhaps that’s not so bad. If, on the other hand, most of them reported lying “often” that’s a little scary. Unfortunately, the way the data are presented, it isn’t clear which is the case. I think it would have been better to put two responses in each category so that “never” and “rarely” were combined and compared to “sometimes” and “often.”

My sense is that doctors, like all people, sometimes lie–perhaps more often by omission rather than commission–but that we should not be too worried about the results of this survey. Don’t assume your doctor is lying to you or that they are always being honest. That’s what second opinions are for.

 

 

Wasting Money At the End of Life?

Peter Bach is a physician with a recent op-ed appearing in the New York Times. Dr. Bach’s piece about whether or not end-of-life health care spending is wasteful is compelling. I recommend you read his essay, but I want to hit some of the high points.

The first is that we may be making an error based on hindsight. Precisely because hindsight is 20/20, we can fall into the trap of evaluating health care decisions after the outcome is known, which is not how health care decisions are actually made. So, as Dr. Bach stresses, a tremendous amount of health care spending may be deemed warranted if it saves the life of the patient, but the same spending would be labeled wasteful if the patient dies. This is an excellent point.

Other points Dr. Bach makes relate to supposed sources of bias. For example, sick people need more health care (which costs more money) and are also more likely to die. Ergo, the link between health care spending and death is likely to be positive, but the reality is that health status is the common denominator. He also laments the fact that data on end-of-life spending is much more readily available than data on other types of health care spending. That’s also a pretty accurate assertion.

It’s in his concluding remarks that Dr. Bach gets to the real matter at hand: We don’t know who is going to benefit and who isn’t. In his essay, he describes how he saved someone’s life. As it turns out, the condition that person had is fatal in about 1 of every 8 cases. In other words, paying to intervene for that condition seems like a good bet. If, on the other hand, only 1 out of 8 people with the condition survived, it might be a tougher sell. Of course, what that scenario underscores is that the overall costs and benefits are important to understand, but so are the individual risks and benefits. For example, if you have the condition, you are probably hoping that you are the 1 person who will survive after receiving the intervention, not counting on your being 1 of the other 7.

Research that can help us understand not only which procedures are generally more effective than others, but also who the 1 person who loses or benefits (given the two scenarios above) will be, are the next frontier in improving the health care system–cutting costs without harming quality. Of course, this type of research will bring accusations of “death panels” back out of the woodwork. I just hope few people will actually take such things seriously, so that the necessary work can proceed. Without it, I’m not sure that there’s much hope.

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Using Medicare Data to Rate Physician Quality

Last week, the federal government announced that it would allow Medicare claims data to be used for the purpose of disseminating physician quality information to the public. What’s news is not that there will be attempts at creating so-called quality “report cards”–attempts at those have been around for some time–rather it’s that the Centers for Medicare & Medicaid Services (CMS) has finally agreed to let a wide range of folks access Medicare claims data for the purpose, which hasn’t happened before on this level.

But what are we to make of this new development? Is it a good thing or not? Giving the “consumer” more information on which to base their selection of a physician and their use of health care services seems like a good thing. After all, it’s essentially central to the idea of a well-functioning free market. As any health economist will tell you, the information asymmetry between consumers and providers leads to all sorts of peculiarities that cause the health care market not to behave like the market for other goods and services. This could then conceivably be a step in the direction of correcting some of those peculiarities.

The real question, though, is how good will this information be? Or, said another way, is poor information preferable to no information? Now, that doesn’t mean that there’s not a lot of excellent potential in these Medicare claims data. On the contrary, there’s much to be learned here. Of course, the realization of that potential is a function of the empirical rigor of the analyses researchers like myself undertake. No, the real worry I have is how this translates to the lay public without grossly oversimplifying things.

Let’s say a system is devised that, in true “report card” fashion, assigns physicians a grade ranging from “A” for outstanding to “F” for visit at your own risk. The public would certainly understand such a grading system, and people would be expected to show a clear preference for “A”-rated physicians over “F”-rated ones, but what about the bulk of physicians in the “B” and “C” range? It’s entirely possible, depending on the rating algorithm used, that a physician who excels in one particular area nevertheless gets a “C” rating. Would the public do its homework, or would it avoid doctor “C”? I worry that the latter may be the most likely outcome.

Again, I’m not saying that efforts to monitor quality and report that information publicly are a bad idea. Far from it. I’m merely suggesting that we must be extremely thoughtful in how we engage in such efforts, because the potential for significant unintended consequences is quite real. We must figure out how to approach these data using the most sophisticated of techniques, all the while with an eye on translating what we find in a manner that is accessible to the public without being “watered down” or less than accurate. The risks and the rewards are great.

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