The classic battle between time and the best interest of the patient is real in primary care.

The average primary care doctor has between 1200 to 1900 patients, with Kaiser Permanente reporting a mean per-physical panel size of 1,751. This most likely is not accurate nowadays, with some reports saying 2500 to 4000 is the new norm, as stated brilliantly by a LinkedIn comment by Sharon Ng M.D.

I asked my followers to share their thoughts on how they can make the healthcare system better, and they posted some great comments on this Linkedin Thread – 70 comments and counting.

What does this mean?

Basically, primary care doctors do not have much time to do anything but the basics and very little time for preventive care measures.

With basic math you can see the numbers do not add up, 24 hours in a day, proper care takes 26.7 hours.  And unfortunately, we are not robots that can work non-stop or manipulate time with the Infinity Gauntlet or have special powers like Dr. Strange to make up the difference.

PCPs were estimated to require 26.7 h/day, comprising

  • 14.1 h/day for preventive care
  • 7.2 h/day for chronic disease care
  • 2.2 h/day for acute care
  • 3.2 h/day for documentation and inbox management

“There is this sort of disconnect between the care we’ve been trained to give and the constraints of a clinic workday,” said Dr. Justin Porter, assistant professor of Medicine at the University of Chicago and lead author of the paper. “We have an ever-increasing set of guidelines, but clinic slots have not increased proportionately.”

With most doctors spending less than 15 to 20 minutes with their patients per visit, there is not much time for fact-finding, let alone education for the doctor to learn what preventive screening resources are available for their patients, even if that care is reimbursable by Medicare/Medicaid, such as a lung cancer screening.

To many chronic disease screenings to manage

Chronic diseases are a leading cause of morbidity and mortality worldwide, and preventative screenings are the most effective way to reduce the risk of developing a chronic disease. However, many individuals do not take advantage of preventative screening services for chronic diseases, especially in rural areas.

Another study from Duke in 2005 calculated that doctors would need an additional 10.6 hours per workday to manage the top 10 chronic diseases among their patients.

And it has real consequences for the delivery of health care; the researchers said that time pressure helps explain why improvements in outcomes have not kept pace with advances made in the field, the study said.

If you do surveys with patients about what frustrates them about their medical care, you’ll frequently hear, ‘My doctor doesn’t spend time with me’ or ‘My doctor doesn’t follow up,’” said Porter in the UChicago article. “I think a lot of times this is interpreted as a lack of empathy or a lack of willingness to care for a patient. But the reality—for the majority of doctors—is simply a lack of time.

Why is this?

The bottom line is the education of the physician, time, and patient access.  All things can be fixed if given the proper allocation of resources and expertise.

With 59% of all Americans (194 million) suffering from at least one chronic disease, and almost one in three adults having three or more chronic conditions doctors are tasked with doing the impossible. ent lives and cost of care for risk-bearers.

Source: Rand Corporation

The authors suggested “team-based care,” where nurses, physician assistants, counselors, and others help to deliver recommended care, as one solution to the problem of overworked, burned-out primary care docs.

Using team-based care, they estimated that the amount of primary care physician time could decrease to 9.3 hours per day.

Photo: malerapaso, Getty Images

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From left: Dr. Cheryl Pegus of Walmart, Dr. Sachin Jain of SCAN Health Plan and Matt Holt of The Health Care Blog at HLTH 2022

The HLTH 2022 conference in its fifth year was more expansive than ever before. The conference at the Venetian Expo included drug developers, diagnostics and medtech companies, each with an assortment of health tech components. There was also a great deal of content on the consumer experience in healthcare, mindfulness and wellness both in the form of sessions as well as sponsors. It was also the first year HLTH presented the conference in an open plan setting, which worked surprisingly well.

The conference attracted 2,500 healthcare CEOs, with one-third of the estimated 9,000 attendees coming from the C-suite of their businesses. HLTH also made the splashy announcement that the event producer would debut a European version of HLTH in Amsterdam in 2024. 

Here’s a look at some of the themes of the event.

The clinician exodus in healthcare and what can be done to improve it

After years of consolidation, particularly health systems acquiring hospitals and physician practices, Sachin Jain, SCAN Group CEO, described the toll these deals have taken on physicians as part of a wider conversation with Walmart EVP Health and Wellness Dr. Cheryl Pegus.

“The job of being a front-line clinician is no longer what we imagined it to be in medical school – building meaningful relationships with patients that are long lasting and that produce great outcomes for patients…I would say that with the largest health systems, in many ways, their management infrastructures have not kept up with the needs that they have. We used to have health systems where doctors used to know each other, where they could just pick up the phone and get things done for their patients. We’ve added a lot of bureaucratic red tape as organizations have gotten bigger and bigger and bigger, so that the average physician in a large health system feels anonymous, invisible, and even lonely. They don’t necessarily feel like they have agency or mastery over their work anymore because it’s complex and it’s been made complex in ways that aren’t value-add for patients anymore.”

Pegus observed that last year, over 300,000 healthcare professionals left medicine – over 120,000 were doctors in many different areas.

“[They left] not just because there’s a lot to do. We’ve introduced two times the number of treatment modalities and have allowed no room for people to take that science and put it into practice. If you continue to push that innovation, which we’re all hoping for, into a very narrow funnel, something has to give.”

For Pegus, the solution is to add more clinicians to the care team to support physicians at Walmart. She pointed out that Walmart has come to be a place people in rural communities can rely on for their healthcare and reminded the audience of the role big box pharmacies like Walmart played in providing Covid-19 testing and vaccines. 

SCAN, which serves patients on Medicare Advantage plans, is expanding into new markets, such as Texas, driven by invitations from local health systems and medical groups who align with SCAN’s approach. It also has initiated a program to deliver care to homeless older adults called Healthcare in Action.

Hybrid approaches to care

There was also the recognition that even as they leave traditional hospital settings, physicians are still interested in practicing medicine. Virtual care companies such as Wheel and MD Integrations are providing a way for some of these physicians to continue to practice and set their own hours. Elsewhere at the conference, health tech companies presented refined approaches to natural language processing and clinical decision support tools with the goal of making the job of physicians easier, saving them time, and helping patients get healthier.

In a session discussing different forms of primary care, Zak Holdsworth, co-founder and CEO of Hint Health, acknowledged that the healthcare consolidation trend worries him.

“We are trying to make primary care a revenue generator rather than the heart of healthcare,” said Holdsworth. “We need to make payments predictable and avoid layering additional administrative burdens.”

Another aspect of the care delivery discussion that intersects with the consumerization of healthcare is a growing number of hybrid care models. One of the challenges is that only 40% of physicians feel equipped to do virtual care. The goal is to balance delivering primary care through telemedicine or other types of virtual care with the acknowledgement that in-person care should be a critical component of primary and specialized care.

Assure Health sits at the intersection of virtual care and remote patient monitoring, delivering virtual-first care and helping patients manage chronic conditions. The company recently closed a $8.7 million Seed round from strategic investors. There are not enough endocrinologists to meet diabetes patients in person, so the company enlists the support of nurse care managers who engage with patients.

In an interview at the conference, COO and co-founder Craig Bolz said the business is leveraging devices that rely on cellular connections (rather than bluetooth) around diabetes, hypertension, COPD, and congestive heart failure.

Assure Health has also launched a comprehensive diabetes program where it takes full ownership over the diabetes disease state and can prescribe lab tests.

Bolz said the business has a fee-for-service side and value-based care side. In 2023, it plans to expand its value-based care business, supported by the recent fundraise.

Redi Health co-founder Like Buchanan explained that his startup helps patients improve the way they manage their chronic conditions, in part, by identifying pharmaceutical company programs patients may not be aware they are eligible to participate. Its app enables pharma manufacturers, health systems, and payers to integrate their patient support programs directly into the application.

CEO and bioengineer Jane Zhang founded Remmie Health and developed the Home Ear Monitor / Otoscope as a way to better address her son’s chronic ear infections. as part of the Plug and Play pavilion. The device has two functions, according to Zhang. Embedded with a camera, it works as a monitor to capture ear, nose, and throat symptoms. There’s also an app that helps parents track symptoms, images, and videos, which can be shared with a physician through software plug-ins such as MyChart. Chief Commercial Officer Lorren Wyatt joined the company two years ago — HLTH marked the first time the two met in person.

Among the milestones Remmie Health achieved was a deal with Medtronic Labs last year to provide the device to underserved markets in Asia to treat non communicable diseases. It’s also working on a device to assess hearing loss from noise pollution in these markets.

Based in Seattle with offices in San Francisco, Los Angeles, London, Remmie won an SBIR grant last month. The $350,000 grant from the National Institutes of Health’s National Institute on Deafness and Other Communication Disorders will be used to support the development of a deep learning diagnosis assistance engine for ENT diseases.

Health equity

In a panel discussion on different approaches to primary care, Dr. Kyu Rhee, senior vice president and Aetna chief medical officer with CVS Health, talked about the importance of promoting “techquity” or using health tech to promote health equity. He also urged newcomers to the space to embrace these tenets.

  1. “Ensure that your workforce represents the people you serve. One thing I’m very proud of at CVS Health is that 40%-50% of pharmacists and pharmacy technicians represent the people they serve and have made a difference with vaccine delivery across the country by brokering that trust.
  2. You have to collect race, ethnicity, and language data. Aetna was the first to do this. You have to collect the data to show the inequities that exist.
  3.  You need to have a health equity dashboard as standard when you do assessments and contracts to reduce the disparities.
  4. Need to ensure AI is ethical and transparent.
  5. It’s not enough to know; you have to be prepared to act.”

Intersection of mind and body 

The connection between our state of mind and how we physically feel was also a significant theme at the conference as many of us try to reduce the stress and anxiety that exploded with the onset of the Covid-19 pandemic.

Calm, a company that promotes breathing and other mindfulness exercises to help people reduce stress and anxiety, shared its plans to expand from its d2c business through its app into the b2b world. Calm Health and Calm for Business serve self-insured employers, health systems and payers. CEO David Ko noted that a combined 400 million people have downloaded the app or visited its website.

Ko pointed out that the first set of customers who used Calm did it mainly for meditation. Then people came to the app because they had trouble sleeping. But during Covid-19 pandemic they’ve seen a spike in users arising from depression and loneliness. As more people return to the office after years of working remotely, anxiety is increasing.

The recent launch of Calm for work seeks to make employees happier and healthier in the workforce, Ko said.

“Three thousand employers are coming to us to help with their workforce and employees. We wanted to take what we’ve done with Calm and bring that to healthcare.”

Lucid is another company focused on the mind but uses music therapy to help users relax, energize, and sleep. Based in Toronto, Ontario, the company is also working with research institutions to use music to manage symptoms of Alzheimer’s disease and work with patients’ caregivers.

Making diagnostics more easily accessible 

Meeting patients/consumers where they are was a theme that permeated several areas, not just primary care delivery. In-home testing has been on the rise for years, whether it’s for genetic testing, STDs, or more recently, Covid-19. Pouria Sanae, ixlayer CEO and founder, offered an overview of the company, which provides lab testing services to people through CVS Health and health systems, as well as testing as part of clinical trial support for CROs.

“The goal is to be a new layer that lives on top of diagnostic testing that integrates many different services, to power remote testing — in-home and in-office testing,” Sanae said. “We focus on preventive care and consumerization of healthcare.”

In 2018 when ixlayer launched, its first test was a polygenic Alzheimer’s test for Alzheimer’s patients’ family members. Since then, it has rolled out testing services for people with chronic conditions, such as Type 2 diabetes. The Covid-19 pandemic led the company to rapidly expand its testing capabilities. Among its customers are DNA testing business PlumCare, Him & Hers, and the U.S. Coast Guard. Its board includes Paul Martino, co-founder and chief strategy officer of VillageMD, David Shulkin, a former Secretary of the U.S. Dept of Veterans Affairs, and Moncef Siaoul, chief adviser to Operation Warp Speed — the public-private partnership created to speed up the development, manufacturing and distribution of Covid-19 vaccines, therapeutics and testing.

Food as medicine

The acknowledgement that access to fresh, nutritious food is a social determinant of health and plays a critical role in helping people manage chronic conditions has led to the launch of healthcare startups focused on this niche as well as initiatives by healthcare organizations. A panel discussion on this topic led to some compelling insights from players in the space on how making access to fresh, nutritious food could reduce the need for some medications to manage chronic conditions, making such programs cost effective.

Sven Gierlinger, chief experience officer with Northwell Health, deplored the quality of food hospitals and health systems serve to patients. He discussed an initiative to change that on a few fronts. Gierlinger said the health system made a commitment five years ago to serve food with the best ingredients available prepared by a team of chefs. The health system also began offering cooking classes to physicians in training so that they could appreciate the benefits of preparing their own meals. Northwell also formed a partnership with a 400-acre farm in Queens, New York.

“Incentives need to be aligned better – the U.S. health system isn’t set up to incentivize a healthy population,” Gierlinger said. “The food industry has to change and that’s where I think the government and policy need to work together or it will never move forward.”

To address food insecurity, Gierlinger noted that the health system connects patients to resources and community-based organizations through the Unite Us app.

Ashley Tyrner, FarmboxRx founder and CEO, shared that the company, which started in 2014, is moving into its third year of being offered as a benefit by health plans supporting Medicaid, Medicare and Medicare Advantage programs. Its condition-specific food boxes are designed by a team of Registered Dietitian Nutritionists to support the wellness of those with certain health conditions.

Tyrner said a health plan that piloted its program reported that FarmboxRx was an effective care management tool to engage members in their health and to spur them to get their flu shot. She also emphasized that it’s important for providers to make patients aware of their eligibility for Farmbox Rx.

Photo: HLTH

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Charity, care, cost, expense

Large, single-specialty cardiology practices were not uncommon during the 1990s and early 2000s, but that changed over the past decade as hospitals and health systems have purchased cardiology practices, directly employed cardiologists, and entered into professional services agreements (commonly referred to as “PSAs”) with cardiologists. The migration of private practicing cardiologists to hospitals was caused in large part by the significant site-of-service fee differential between the reimbursements to hospital outpatient departments (HOPDs) and the reimbursements for identical services furnished in an independent physician’s office or ambulatory surgery center (ASC).

During the past 10 years, the primary vehicles for physician alignment with hospitals have been employment agreements, whereby the physicians are employees of the “captive” or “friendly” medical practice; or PSAs, whereby hospitals provide administrative services to physician practices, and the practices remain independent. In this model, practices can access some of the advantages of employed physicians – most notably, the hospital’s favorable payer contracts.

According to a recent opinion piece in The Wall Street Journal “Medicare has paid hospital outpatient departments nearly twice as much as it pays independent physicians or ASCs for the same services. Even off-campus facilities, which are hospital-owned but otherwise identical to independent physicians, have until recently enjoyed higher rates.”

There has been a major push for site-neutral cardiac testing payments in order to migrate more services to outpatient settings. This shift could reportedly reduce Medicare spending by more than $150 billion in the next decade and reduce beneficiary spending on premiums and cost-sharing by more than $90 billion during that time. It is remarkable that such dramatic savings may be achieved without reducing the breadth of services or otherwise compromising the quality of care. As an increasing number of Baby Boomers retire and enroll in Medicare, the corresponding economic burden on the Medicare Trust Funds necessitates these kinds of value-based cost-saving measures.

This shifting of services to outpatient settings will likely cause hospitals to unwind their contractual relationships with cardiologists, sending the physicians back into private practice. Indeed, we have observed this process beginning with some of our clients already. Unwinds present several challenges, including but not limited to the fact that the cardiologists transitioning back to private practice no longer have their own Tax Identification Numbers (TINs) and payer contracts. In light of these logistical challenges and as a longer-term survival strategy, we are likely to see a reconstitution of large cardiology practices, this time with the potential for private equity participation.

Until recently, there were few private equity opportunities for cardiology practices, but that could change relatively quickly. In the Wall Street Journal’s opinion piece, authors Neil M. Gheewala and Bobby Jindal noted: “Cardiac care is on the cusp of a major transformation, but hospitals need not be left behind.” Astute hospital administrators will have already anticipated the migration of cardiologists away from hospital inpatient care and started to prepare for a different type of alignment with cardiologists. We anticipate significant opportunities for single-specialty and/or multi-specialty roll-ups in which an investor, such as a private equity firm, purchases multiple medical practices and combines them into a larger practice.  We also expect that Management Services Organizations (commonly referred to as “MSOs”) will continue to be utilized to achieve economies of scale in the furnishing of administrative services to practices.

Experienced health care attorneys who have represented both private practitioners and institutional providers throughout dynamic changes in the healthcare landscape can lead this transformation, working with various stakeholders to develop and implement mutually beneficial alignment models, while ensuring compliance with applicable laws and regulations.

Photo: eakrin rasadonyindee, Getty Images

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Behavioral health providers face numerous challenges. One of the most significant obstacles is getting patients to attend their scheduled appointments. In fact, according to industry research, approximately one in five patients is a no-show to their appointments. Late cancellations and no-shows can derail an office’s day, costing time and money and hindering patient outcomes.

This is particularly important in the behavioral health setting, compared to other medical specialties, due to the high frequency that patients are in the office–often one-to-two times per month or more.

There are many reasons why patients don’t show up for their behavioral health appointments. Some patients may feel like they’re not ready to address their issues while others may forget or have scheduling conflicts.

The nature of many mental health diagnoses can hinder clients’ efforts to attend therapy consistently. Those struggling with depression may lack motivation; socially anxious clients may back out of commitments at the last minute. Increased engagement, from upfront communication to automated reminders, gives them space to mentally prepare and make faithful attendance more likely.

Whatever the reason, it is important for behavioral health providers to find ways to encourage their patients to attend their scheduled appointments. Here are a few ideas:

Clear communication

Clear communication can help ensure that patients understand the importance of attending their appointments and what they can expect when they do. Providers should take the time to speak  with their patients about why appointments are important and what they can expect during their visit. By taking the time to have this conversation, providers can help build trust and confidence with their patients, which can lead to better attendance, care, and health outcomes.

Scheduling flexibility

Today, patients want flexibility related to scheduling. Practices offering online scheduling via computer or mobile device make it easier for patients to ensure their appointment date and time complements their schedule. Also, if the patient knows they can reschedule an appointment if needed, they will be more likely to attend. This can be especially helpful for patients who have busy schedules or who need to see a provider outside of normal business hours.

Automate patient appointment reminders

Consumers are busier, more stressed, and more distractible than ever. Automatehd therapy appointment reminders received one or two days in advance go a long way toward reducing accidental no-shows.

Using electronic health record software (EHR), practices can remind patients of appointments in a personal and timely way. Built-in appointment reminder features can help by automating patient communications with customized messages tailored to a specific practice. Automation makes it easy to send reminders at the right time and frequency either via a text message or email depending on the patient’s preference.

Automating messages also helps improve front office efficiency and cuts down on administrative staff time by reducing the number of calls and emails that they have to handle. Not only does automation reduce no-shows and save time, it also helps ensure a steady flow of revenue and a schedule full of patients.

While automated reminders can be a useful feature, they need to be strategically used and timing is everything. If the appointment reminder is sent too early, the patient may forget about it. If it is sent too late,  patients might end up missing the appointment altogether. Finding the right balance is key and it will depend on an individual practice and client appointment cadence. Practices should run a test to determine the best schedule for sending reminders.

While automated reminders are convenient, they can also feel impersonal. To combat this, providers should include a personal message with each reminder. When crafting the messages, providers should include the patient’s preferred name, their appointment date and time, and the name of the doctor they will be seeing.

Identify client trends

Because automated reminders help avoid forgotten appointments, they give practitioners a better picture of who is dedicated to the therapy process, who cancels frequently, and who fails to show up even after outreach. Tracking these trends to see if cancellations or no-shows tend to follow a specific program, provider, or client demographic is also helpful. If a program or provider suffers from high cancellation rates, the practitioner may need to intervene, assess  why clients are discouraged and uninterested, and work to fix the problem. If certain types of patients show spotty attendance, practitioners will know who to focus on for more attentive follow-up.

The more patients appreciate and trust a practice, the easier it is to build rapport and keep them deeply engaged in the therapy process. And since reminders cut down on missed appointments, patients benefit from regular therapy and move through their mental health journey more quickly. The sheer nature of back-and-forth communication with an office outside of appointments signals that patients are active participants in the process. Patients who feel like active participants tend to show better outcomes.

Encouraging patients to attend their behavioral health appointments is essential for both providers and patients. By taking a few simple steps, practices can help ensure that their patients get the care they need while reducing unnecessary losses of revenue and time within the business model.

Photo: SIphotography, Getty Images

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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.

Photo: YinYang, Getty Images

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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.”

Photo credit: Benjavisa, Getty Images

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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.

Photo credit: smolaw11, Getty Images

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Stethoscope and coins on the wooden table vector illustration

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.

Photo credit; Alkov, Getty Images

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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.

Picture: Benjavisa, Getty Images

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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.”

Photo credit: Alkov, Getty Images

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