A major concern during the Covid-19 pandemic has been that Americans, especially those with underlying conditions, will delay necessary care. New survey results show this concern is not unfounded.

As of last September, about 40% of Americans with one or more chronic health conditions reported delaying or avoiding care, according to a new report from the Urban Institute and Robert Wood Johnson Foundation.

Report authors analyzed data from the second wave of the Urban Institute’s Coronavirus Tracking Survey, a nationally representative survey conducted Sept. 11-28, 2020. The survey polled 4,007 adults, ages 18 to 64 years.

About 36% of Americans said they delayed or did not receive healthcare due to a fear of exposure to the coronavirus or because a provider limited services during the pandemic, the report states. Black adults (39.7%) were more likely than white (34.3%) or Hispanic/Latinx (35.5%) adults to report delaying or forgoing care because of concerns about virus exposure.

About four in 10 adults with one or more chronic health conditions (40.7%) said they delayed or avoided care because of the pandemic, as compared with 26.4% of adults with no chronic conditions.

In addition, more than half of adults with both a physical and mental health condition (56.3%) reported delaying or avoiding healthcare due to the pandemic. About 43% of this group also reported delayed or forgoing multiple types of care.

The impacts of delaying or avoiding care were acutely felt by those with chronic conditions, the report shows. An estimated 23.2% of these adults reported that going without or delaying care worsened a health condition, 21% said it limited their ability to perform daily activities and 15.2% said it limited their ability to work.

Further, the report shows the kinds of care that Americans were avoiding. Dental care was the most common type of care adults delayed or did not receive because of the pandemic (25.3%), followed by seeing a general doctor or specialist (20.6%) and receiving preventive health screenings or medical tests (15.5%).

“Tackling unmet healthcare needs requires effectively assuaging fears about exposure to the coronavirus,” report authors concluded. Providers need to reassure patients that they are following public health guidelines and that these precautions can effectively prevent virus transmission.

“More data showing healthcare settings are not common sources of transmission and better communication with the public to promote the importance of seeking needed and routine care are also needed,” the authors wrote.

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Behavioral health startup Concert Health raised $14 million in funding. The San Diego-based company helps primary care providers connect patients to behavioral health services.

Vertical Venture Partners led the series A round, with participation from Town Hall Ventures and Silicon Valley Bank. Concert plans to use the funds to grow its team, ramp up training programs and built out its technology platform.

The company currently operates in seven states, and partners with 44 medical groups. They include Chicago-based CommonSpirit Health and Women’s Health USA, a group of more than 600 ObGyns, as well as several smaller independent practices.

The idea is to connect patients with licensed clinical social workers or nurses that can provide therapy and help come up with a care plan. They also serve as a liaison between a patient’s primary care physician and psychiatric provider.

“Primary care physicians are stuck managing and identifying a huge amount of depression and anxiety. They’re already writing the majority of prescriptions for antidepressants and anti-anxiety medications,” Concert Health CEO Spencer Hutchins said in a phone interview.

One of the challenges physicians face is getting patients in to see someone, either because patients can’t find a therapist that takes their insurance or don’t want to start therapy. Through Concert Health, they can introduce patients to a behavioral health provider, and hold weekly consultations with psychiatrists for advice.

Those services are reimbursed as collaborative care management, which is covered by Medicare, Medicaid plans in 18 states, and most commercial insurance plans.

“You’re finding, finally, a general recognition in the industry that we need to integrate behavioral health,” Hutchins said.

Last year, Concert launched a collaboration with CommonSpirit to provide behavioral health services, starting in Bakersfield, Calif. and expanding across Southern California’s Inland Empire. The partnership is expected to extend to additional states.

Concert also works with several independent practices in New York, many of whom were hit hard in the initial surge of Covid-19 in the U.S. Some physicians became sick as patients came into their offices, while others had trouble staying open as volumes dropped.

“Being able to be part of a partnership that allows them to deliver better care and be compensated for it has been helpful,” Hutchins said. “It’s been exciting for us to be a part of that, helping folks not only survive but thrive during the hardest professional year of their lives.”

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CMS recently finalized changes to Stark Law regulations that will go into effect Jan. 19, and healthcare law experts generally believe that these changes will make it easier for hospitals and physician groups to comply with the law, and provide them with greater flexibility as they move toward value-based care.

Stark Law, also known as the Physician Self-Referral Law, was initially enacted in 1989. It prohibits physicians from referring patients to an entity for certain healthcare services if the physician has a financial relationship with the entity. But as the healthcare industry evolved and started moving toward a value-based care model, many in the industry worried that the move would be hindered by Stark Law regulations.

“The government has recognized the need to update the Stark regulations that were originally developed at a time when the unnecessary volume of services was of primary importance,” Philip Sprinkle, a healthcare partner at Akerman LLP, said in an email. “The concepts of value-added services, cost savings, systemic efficiencies and overall quality outcomes were just in their naissance.”

According to CMS, the changes finalized Nov. 20 aim to alleviate the administrative burden of complying with the law. The reforms will “modernize the regulations that interpret the Stark Law while continuing to protect the Medicare program and patients from bad actors,” a press release states.

Tim Fry, a healthcare associate at McGuireWoods LLP, said in a phone call that the changes update Stark Law regulations in three primary ways:

1. CMS has adopted new exceptions for value-based enterprises and goals. If a healthcare provider has a value-based or care coordination goal and there are certain hallmarks in place, such as a governing board or contracts, they can “share revenue in novel ways, in ways that are not based off of a fair market value fee-for-service model,” Fry said. The exceptions will allow physicians and other healthcare providers “to design and enter into value-based arrangements without fear that legitimate activities to coordinate and improve the quality of care for patients and lower costs would violate the Stark Law,” a CMS factsheet states.

2. The changes include new exceptions to protect “non-abusive, beneficial arrangements” between physicians and other healthcare providers. These include exceptions for sharing technology providing cybersecurity, Fry said. For example, a hospital would be permitted to help provide cybersecurity provisions to physician groups they share EMRs with that may not have enough resources to protect against cybercrime on their own.

3. CMS has also provided helpful clarifications and guidance on various parts of the law, many of which have led providers in the past to think they violated the statute, Fry said. This includes guidance on how to determine if the compensation being given to physicians is at fair market value, a CMS factsheet states.

“We’re still digesting the 600-plus pages that [CMS] put out,” Fry said. “But some of our initial feelings and views are that the final rule is going to be helpful in reducing some of those questions [we get from clients], providing more clarity and hopefully allowing the industry to avoid things that CMS thinks is improper.”

Kathleen McDermott, a partner at law firm Morgan Lewis and former assistant U.S. attorney, agrees with Fry, and said via email that she believes the Stark Law changes provide “greater flexibility” for physician arrangements and compensation. The changes also encourage collaboration in patient care activities, she said.

Though Sprinkle also said that the new regulations will help ease anxiety around complying with Stark Law in many cases, he noted that the changes could add pressure on physicians still involved in the traditional fee-for-service operations of Medicare.

“[The changes will] impose additional pressure on these traditionalists to become part of a managed care network undermining, in the opinion of at least some of these physicians, their independence,” he said. “In addition, it is not clear that previously approved programs that did not require the physician partners to assume risk will be included in these exceptions. To that extent, those physicians may feel that they have been unfairly treated.”

But all three lawyers expect the changes to be implemented next year. None of them think the changes will facing hurdles related to the presidential transition of power, with McDermott nothing that the changes to the law have bipartisan support.

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Nearly three decades of research show that doctors are influenced by the payments they get from drug companies, according to a new review published in the Annals of Internal Medicine.

Doctors write more prescriptions for the drugs made by companies that pay them, even if the drugs are less effective or are equally effective but more expensive than the alternatives, according to the review, which is based on 36 published studies dating back to 1992.

“Taken together our results support the conclusion that personal payments from industry reduce physicians’ ability to make independent therapeutic decisions and that they may be harmful to patients,” wrote the authors, a team of doctors and researchers from Memorial Sloan Kettering Cancer Center in New York City. “The medical community must change its historical opposition to reform and call for an end to such payments.”

The authors were supported by a grant from the National Cancer Institute. However, they acknowledged that a ban would likely draw little support from doctors. Most believe that industry gifts do not exert any influence, the authors wrote.

“Our findings suggest that this belief is not well-founded.”

The review is the latest in a string of articles and studies arguing that doctors are impacted by the money they receive from drug companies, whether in the form of meals and entertainment or consulting fees and honoraria.

Though they are often controversial, the payments are common. Roughly two-thirds, or 67%, of physicians received some kind of payment between 2015 and 2017, with the number reaching 80% in specialties like medical oncology and orthopedic surgery, according to the review in the Annals.

While a ban may be off the table, doctors and drug companies have taken steps over the years to police themselves and reverse perceptions of bias.

The ethics code of the American Medical Association, for example, says physicians should “decline cash gifts in any amount from an entity that has a direct interest in physicians’ treatment recommendations.” The code also warns doctors to decline any kind of compensation tied to prescribing drugs or devices.

In response to earlier rounds of criticism, the Pharmaceutical Manufacturers Association updated its voluntary code in 2008 to restrict some of the practices that gave rise to concern, such as hosting meetings at restaurants between doctors and sales reps.

In recent years, efforts have focused on increased transparency. The Affordable Care Act, for example, included provisions requiring public reporting of any financial transfers greater than $10. The first data was published in 2014 by the Centers for Medicare and Medicaid Services under a program called Open Payments.

Transparency hasn’t made much of a difference, one of the new study’s authors, Dr. Aaron Mitchell, wrote in an emailed response to questions. Nonetheless, other efforts may have left a mark.

“If anything, I would think that payments probably matter somewhat less today, because we have cracked down on some of the most egregious forms of gifts,” Mitchell wrote.

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I’ve worked in health care for more than 30 years, serving in various roles in and outside of finance. I’m not proud to say that in the past, I’ve played a role in cutting behavioral health programs in an effort to navigate budget constraints and mitigate financial losses. I’ve seen other health executives and systems do the same.

It wasn’t until about 10 years ago, when my own niece needed these programs, that I discovered the lack of an adequate care infrastructure. I’ve been living with that personal guilt for a decade.

Florida, our family’s home state, ranks 48/50 in access to care by Mental Health America. My organization, AdventHealth, regularly conducts Community Health Needs Assessments (CHNAs) in Florida and the other states in which we operate. In terms of identified needs in the CHNAs from across the system, mental and behavioral health are chosen 70 percent of the time as an area to address in our communities.

Add this to existing issues negatively impacting Americans and people around the world (e.g., a global pandemic, racial unrest and political division), resulting in a major crisis on our hands. If there was ever a time that we should see the need for behavioral health resources, it’s now.

We All Know Someone Who Struggles with It
Behavioral health is an umbrella term for a variety of conditions, including anxiety, personality disorders, learning and developmental disorders, trauma, addiction and more. Each one of these components breaks out into subcomponents. In some cases, these conditions may manifest themselves in alcoholism or bulimia; in others, in panic attacks or depression.

As a member of AdventHealth’s Behavioral Health Steering Committee and chair of its employee workgroup, I recently shared a presentation with our executive leadership team that included an eye-opening statistic from our short-term disability provider: 42 percent of mental illness disability claims are related to depression.

And yet, at times it seems like we’re not openly talking about this. Whenever we suffer from other ailments, we’re very likely to ask colleagues or friends for recommendations on specialists like cardiologists. Unfortunately, that doesn’t seem to be the case for psychiatrists or therapists. The truth is, it doesn’t matter who you are – what gender, race or socioeconomic status you come from ­­– we all know someone who struggles with behavioral health, and sometimes it’s ourselves.

It takes real courage to be in a position of leadership and admit that you struggle. If you happen to be one of those individuals, show that courage.

For the Good of Our Health and Our Communities
The science is very clear: Depression exacerbates other medical issues. That’s because the components of our health – body, mind and spirit – are interconnected.

How can we address this? We need to be better at using our primary care network to meet the behavioral health needs of our communities, as well as the behavioral health resources we provide to our health system team members.

The health care industry needs to be thinking about behavioral health more “wholistically”, which is why I like the idea of utilizing primary care. A study several years ago revealed that 45 percent of suicide victims had seen their primary care physician (PCP) within 30 days of taking their life. The Collaborative Care Model allows PCPs to manage mild to moderate severity behavioral health patients with the assistance of a care manager and consultation of a psychiatrist. It surrounds PCPs with a team so they don’t have to do it all themselves.

It’s important that we also engage community partners to see how we can get them to lean into these issues. No single organization should be tackling this on its own. We should partner with other health systems and city and county governments to put a comprehensive network in place.

And clearly, there needs to be more sources of funding, whether it’s the state, private insurance or employers. There has to be an increase in funding for these issues so those who provide this type of care can be compensated for it.

I can tell you that my perspective as a finance executive is not what it used to be. Today, I tend to intervene when people start talking about reductions in their behavioral health programs. Instead of hitting the “easy button,” I believe we’re going to have to do the hard work of figuring out how we reduce losses.

The good thing is, I’m finding I have colleagues of like mind who are committed to doing the same – the right thing.

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Researchers are sounding the alarm that a growing number of women are being pushed of the workforce during the Covid-19 pandemic. In September alone, 865,000 women dropped out of the workforce — nearly four times the rate of men, according to data from the Bureau of Labor and Statistics.

McKinsey and Company called it “an emergency for corporate America,” with a separate report finding one in four women were considering downshifting their careers or leaving the workforce entirely.

The healthcare industry is not immune to these stresses. While employment in healthcare increased modestly, the total number of jobs was still down by 1 million since February, according to BLS data.

And for women in healthcare, new data from Doximity show that the pay gap may be widening.

In its annual physician compensation report, the company found that the gender pay gap widened from 25.2% to 28%, with female doctors earning an average of $116,289 less than male doctors.

These gaps varied by specialty, with the widest pay gap for otolaryngology, where men made an average of $108,905 more than women, who were paid an average of $384,983. Nuclear medicine, on the other hand, had the smallest wage gap, with men making $368,829 compared to $359,674. These data were based on surveys of 44,000 full-time physicians.

There were no specialties where women made as much or more than men.

“It’s just a multitude of issues which are making a persistent problem that much harder to rectify,” said Dr. Peter Alperin, vice president at Doximity. “This is a disturbing trend given that there are more women entering the medical field, at least on the physician side, than ever before.”

The Doximity report didn’t delve into the reasons behind the growing pay gap, but the pandemic is expected to be a contributor.

Before the pandemic, working women still spent more time on housework and childcare than their male counterparts — and physicians were no exception. And Covid-19 has brought additional pressures, including grueling work hours and more financial strain on independent practices. Families had to adjust to online schooling, reduced access to childcare, and new challenges in caring for aging parents.

In an article published in JAMA Network earlier this year, Dr. Linda Brubaker, a professor of obstetrics, gynecology and reproductive services at UC San Diego, pointed to systemic assumptions that only widen the pay gap:

“The dogmatic status quo remains in place: long (and perhaps even longer) work hours are necessary, and physicians will need to make personal sacrifices and compromises to meet these demands,” she wrote. “The COVID-19 pandemic has made it easier to see this flawed narrative of life-work balance for medicine. Women physicians do not have trouble balancing competing demands any more than men physicians do. It is simply a more common expectation that women physicians will adjust their professional lives.”

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