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Opinion and Commentary from TMA

Confusing Medicare Program Gets Another New Name

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Promoting_Interoperability

“What’s in a name,” Juliet asked. “That which we call a rose by any other word would smell as sweet.”

Reading yesterday’s news from the Centers for Medicare & Medicaid Services (CMS), Shakespeare’s tragic young heroine might add, “And that which we call a skunk would still smell as foul.”

Seems that along with a proposed new rule that offers hospitals a break in administrative burden, CMS says it is renaming the Medicare and Medicaid Electronic Health Record Incentive Programs. The new name: “Promoting Interoperability.”

Sounds promising, right? One of physicians’ biggest complaints about electronic health records (EHRs) is that they don’t talk to each other. They’re not interoperable. And they should be. So that’s a worthy goal. But the name change isn’t worth any more than the pixels it’s written with until there’s some real action. 

And like I said, yesterday’s proposed rule is all about hospitals. The eligible providers (that’s the group where CMS lumps in physicians)? 

Not so much.

This marks the third name for this program in just nine years. First, it was “Meaningful Use,” which physicians soon started calling “Meaningless Use,” and then “Meaningless Abuse.” 

They found themselves investing tens of thousands of dollars each to install EHRs that began to rule their lives like Hal in “2001: A Space Odyssey.” CMS required that check boxes be checked to satisfy the Meaningful Use overlords. Interacting with patients took a back seat to interacting with the mouse. As Hal told Dave when he asked the computer to do something practical, “I'm sorry, Dave. I'm afraid I can't do that.”

Sensing the hatred, then-CMS Acting Administrator Andy Slavitt declared in 2016 that Meaningful Use was dead. Did that mean the rules and regulations and required clicks were going away? 

Not so much. 

But we did get a new name. Meaningful Use became “Advancing Care Information,” as CMS introduced the even-more-costly, even-more-confusing quality measurement program under the Medicare Access and CHIP Reauthorization Act (MACRA).

A quick perusal of the 50 recommendations to fix Medicare that the Texas Medical Association sent to congressional leaders last week reveals that Advancing Care Information was no more popular, no more meaningful among physicians than was its predecessor. Among the recommendations: 

  • Eliminate arbitrary EHR requirements and allow physicians to determine how best to use their EHR.
  • Redesign and overhaul certified EHR technology and enhance interoperability.
  • Require EHR vendors to build and maintain products that meet all Quality Payment Program specifications rather than force physicians to purchase and constantly upgrade expensive and often-balky systems.
  • If technology requirements continue for physicians, shift the burden of meeting regulatory requirements from physicians to the for-profit EHR and registry vendor communities.   

So, do I believe CMS Administrator Seema Verma means it when she says, “Today’s proposed rule demonstrates our commitment to patient access to high quality care, while removing outdated and redundant regulations on providers”? Yes. 

The intentions are good. The track record? 

Not so much.

So welcome to our world, “Promoting Interoperability.” Goodbye, “Advancing Care Information.” We hardly knew ye.

 

Making Strides in Preventing Child Abuse, But More Steps Needed

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Child_abuse_blog

By Courtney Welch

Over the past few years, Texas made a tremendous effort to address the poignant issues surrounding child abuse and neglect. Thanks in great part to U.S. District Judge Janis Graham Jack, attention was brought to the flaws in the Texas Foster Care system, and drastic changes were made to policies and the infrastructure of the state of Texas. 

Now the Department of Family Protective Services (DFPS) and its branch of Prevention and Early Intervention (PEI) are beginning to implement and review these changes, and they’re being rewarded with measured success. However, the need for evidence-based recommendations and research-confirmed results is still great. 

Below is a review of past mistakes, an overview of present efforts, and a projection for the future regarding Texas’ attempt to tackle one of the most daunting issues facing children today.

An Acknowledgement of Historical Need

Only three short years ago, Judge Jack accused the state of Texas of violating children’s constitutional right to be free from harm while in custody. The investigation and ruling were prompted by an alarming number of deaths due to child abuse and neglect. In 2015 there were 171 confirmed cases of child death due to maltreatment or neglect, some occurring while children were under the care of the state. Though this number was down from the all-time high of 280 deaths in 2009, Judge Jack accused the state of having a broken system. She demanded reform. 

The ruling sent a shockwave through Texas, prompting the state, and especially DFPS, to make swift changes. Since 2015, the DFPS made incredible strides — thanks to the efforts of the PEI. 

PEI houses the Office of Child Safety (OCS), oversees the Texas Home Visiting program, and works with other community programs and non-profits around the state. Its mission is “[to help] create opportunities for children, youth, and families to be strong and healthy by funding community-level, evidence-informed programs and systems of support upstream from crisis and intensive interventions.” Simply stated, its goal is to work with communities to intervene before child abuse happens. 

An Overview of Current Efforts

After Judge Jack’s 2015 ruling, the PEI set to work on a Five-Year Strategic Plan, published in 2016. The plan created the following seven overall goals. PEI will:

  1. Adopt a public-health framework to prevent child abuse and fatalities, and support positive child, family, and community outcomes. 
  2. Maximize the impact of current investments and seek additional resources to serve more children, youth, and families and strengthen communities.
  3. Make and share decisions about investments in families and communities based on an analysis of community risk and protective factors, as well as community-developed needs assessments. 
  4. Utilize research findings to improve program implementation, to direct program funding toward the most effective programs, and ultimately to achieve better results for children and families. 
  5. Measure and report on the effectiveness of its programs on an annual basis and make timely course corrections based on available data.
  6. Maximize its impact by collaborating with other state entities and external organizations working with similar populations. 
  7. Be transparent and inclusive in its planning and operations and will proactively publish its strategic plan and progress towards its goals.

Throughout Texas, PEI’s presence can be felt through programs including Community-Based Family Services; Community Youth Development; Service to At-Risk Youth, Statewide Youth Services Network; Texas Families Together and Safe; and Texas Home Visiting. Organizations such as these are specifically paired with a research and evaluation partner — usually a department in an institution of higher education — that reviews the goals of PEI in relation to these programs, summarizes the outcomes of these programs, and makes recommendations for further improvement. A review of the previous fiscal year — as well as business strategies for upcoming years — are published on the DFPS website, which also contains more information about PEI and their associated programs.

A Charge for the Future

The changes and growth in DFPS and its PEI division have played a substantial role in how the state addresses the public health issue of child abuse and neglect. Many agencies associated with PEI have worked tirelessly with the organization to set measurable goals. Many of these brainstorming efforts have led to good and noble ideas. 

But good ideas without plans and the means to execute them are just dreams with no promise of accomplishment. The Texas Legislature moved in the right direction by offering financial support to many of the programs under PEI, increasing funding by more than $25 million from 2016-17 to 2018-19. With these funds, DFPS and PEI have increased their capability to serve their mission, but the final question DFPS, PEI, and lawmakers must ask themselves is, “Are we making a measurable and positive difference in the lives of families and children in the state of Texas?” 

Remember: At stake here is not just public approval or taxpayer dollars, but the health and lives of children. Therefore DFPS and PEI must implement a solid plan, based on evidence of its efficacy. There are not enough funds to ensure that the policymakers’ dreams do not become another child’s nightmare. It is tempting to set goals, measure accomplishments, and stop when those tasks have been completed, but it has never been more important to resist the urge to self-congratulate in the face of assumed achievement. The work does not end when the checklist is complete. The need to edit, refine, reframe, and execute new and improved plans will never fade where child abuse and maltreatment is concerned. 

To further emphasize the necessity of continued monitoring and revision, it should be noted that this is not the first time the state of Texas has made sweeping changes to its foster care system. 

One of the most disheartening discoveries in Judge Jack’s 2015 ruling was reviewed under the Findings of Facts and Law. This section specifically noted that in 2009, then-Gov. Rick Perry commissioned a committee to review and make recommendations on the Texas Foster Care System. That 2009 committee proposed 14 different recommendations in response to their review. After their proposal was completed, the committee then unearthed a 1996 report from a similarly charged committee under the direction of former Gov. George W. Bush. The 2009 committee found that 11 of the 14 recommendations they had just written were nearly identical to recommendations made in 1996. 

This finding effectively accused a well-meaning system of failing our youth. Since 1996, all the wishful thinking, recommendations, and even the executed plans had not changed some of the broken system’s underlying flaws. 

This time around must be different. It is up to us — as legislators, policymakers, community leaders, health care workers, parents, and Texans — to be honest and critical with ourselves. We cannot wait for another Judge Jack to hold up a mirror so we can see our ugly reflection once it is already too late. We must admit that trial is rarely without error, and that mistakes will be made. We must be humble enough to acknowledge our weaknesses and courageous enough to make changes for the future. 

According the 2015 DFPS Databook, 66,721 of the 7.3 million children in Texas are confirmed victims of abuse and neglect, and 17,151 Texas children are placed in substitute care. 

Children cannot speak or act on behalf of themselves. So now I ask you with a spirit of hope and a hunger for positive change: Are you willing to be their advocate?

Courtney Welch is a 2019 M.D. candidate at the Texas Tech University Health Science Center School of Medicine

Special thanks to Desiree Ojo, Texas Tech University Health Sciences Center master’s in public health and public administration Candidate, 2019, who for this article shared resources and research she gathered in preparation for her upcoming roundtable, “Saving the Texas Foster Care System: A Special Panel.” More information about the panel and Facebook live stream on May 8 can be found here: https://www.facebook.com/events/159758271370722/


U.S. Health Outcomes Compared to Other Countries Are Misleading

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By Walker Ray, MD, and Tim Norbeck

outcomes_blog

This article originally appeared on Forbes.com and is reprinted with permission of the authors.

Well, here we go again. More new studies that indict the U.S. health care system directly — and by inference, America’s physicians — have been published.

A new report in JAMA published in March comparing U.S. statistics with those of the highest-income countries (United Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland and Denmark) indicates that the American health care system fares quite poorly. Surprise!

The primary author is Irene Papanicolas, PhD, affiliated with the Department of Health Policy, London School of Economics and Political Science. She and co-authors, Liana R. Woski, MSc., and Ashish K. Jha, MD, MPH (affiliated with the Department of Health Policy and Management at Harvard), deserve credit for compiling the numbers in such a comprehensive report. Throughout, the point is made frequently that the U.S. spends far more per capita on health care when compared with other countries, but has less in health care outcomes to show for it. These conclusions are not so different from other studies previously published. However, there are valid reasons for these differences, and we feel compelled to address them.

For one thing, even our system’s captious critics admit that it is far easier to manage health outcomes in smaller and more homogeneous countries. The U.S., with a population of 323 million, is far larger than any of the other countries mentioned in the sample. In fact, the mean population for all of them is a mere 69 million. Recent research, including an insightful book by Dr. Buz Cooper, all suggest that poverty and other social determinants have a significant impact on our health and health care costs. Unfortunately, the U.S. poverty rate is higher than the other countries at 12.7 percent of the population.

In an accompanying JAMA article also published in March 2018, Ezekiel J. Emanuel, MD, observes that “administrative costs contribute significantly to the cost difference between the U.S. and others used in the comparison.” This is a point on which Papanicolas et al. resoundingly agree. Emanuel also mentions that a major driver of cost differences is high-margin, high-volume procedures. For example, he points to knee replacements where the U.S. performs nearly twice as many per capita as in the Netherlands.

Tim had a knee replacement himself in May and enjoys far greater mobility. He also has a tennis friend in Connecticut who in the past year had both knees replaced and is back to playing tennis three times a week. His age: 90! We suspect that it would be very difficult, if not impossible, for a 90-year-old to receive two knee replacements in any of the other countries and in a very timely fashion. However, much of America prides itself on physical fitness and quality of life at every age. The price of this is certainly reflected in our higher health care costs.

Papanicolas et al. also call attention to the fact that the U.S. performed the second highest number of MRI scans per capita (behind Japan) and the most CT scans. We don’t find that unusual, given the current medical liability environment that exists in the U.S. The medico-legal Sword of Damocles hangs precariously over every physician for every procedure.

If little Johnny falls off his bike and strikes his head in the U.S., a physician will order some type of scan. If not, if the child were to suffer serious complications from the injury and files a lawsuit because the physician failed to do a scan, the jury will likely side with the victim. Similarly, physicians require patients to have a CT scan for many injures to avoid potential complications that would be missed by x-rays or physical examinations. As stated in Scientific American: “No physician wants their patient to die because they didn’t find an injury.” We would add: especially in view of the present liability system! It is also sad that, along with a jury’s recognition that the insurer will pay, so “don’t worry about it,” little do they realize the physician’s (and their family’s) anguish during malpractice trials, and that their premiums will just keep going up. It is a threatening and pernicious liability system, and, of course, we lead the world in the number of CT scans performed. No other country has our onerous liability laws.

Of course, one of the big “knocks” on America’s health care system is our infant mortality rate, especially when compared to the other countries. Experts all agree that there is a lack of consistent and reliable data out there in which to make truly valid comparisons. But they are made anyway.

As Alice Chen, Emily Oster, and Heidi Williams mention in a recent and very comprehensive study article that appeared in American Economics Journal, cross-county comparisons of aggregate infant mortality data rates provide very limited insight. One of the reasons is that countries vary in their reporting of births. Another serious study, performed by Korbin Liu, Marilyn Moon, and Juki Chawla for the Centers for Medicare and Medicaid Services, entitled: International Infant Mortality Rankings: A Look Behind the Numbers, sheds more light on the subject. “These rates,” the authors mention, “are affected by the socioeconomic status of mothers and their children.”

Unfortunately, the U.S. poverty rate is higher than all of the countries, and considerably higher than half of them. Furthermore, the Liu-Moon-Chawla study points out that in infant mortality reporting, mechanisms vary greatly among the countries compared with the U.S. For example, in France, “a baby has to be alive at the time of registration, which could be 24 to 48 hours after delivery. If the infant does not survive at that point, it is recorded as a false stillbirth.” On the other hand, if a newly born infant in the U.S. takes one breath and dies, it is recorded in the infant mortality stats. 

“Germany requires evidence of the function of both the heart and the lungs before it is reported. Russia excluded from their report of live births infants who were less than 1000 grams in weight or less than 28 weeks of gestation — if they die within seven days of birth.” The reporting differences are such that it is impossible and unfair to make valid comparisons on infant mortality. But people continue to make them.

But there is even more to be said on the subject. Experts agree that low birth weight and teen pregnancies vitally affect infant mortality rates. Teen birth rates in the U.S. are higher than most other countries. According to the Centers for Disease Control and Prevention, 80 percent of teenage pregnancies in the U.S. are unintended. “Pregnant teenagers tend to gain less weight than older mothers, due to the fact that they are still growing and fighting with the baby for nutrients during the pregnancy.” Papanicolas et al. observe that the U.S. is second only to Japan in low birth weight babies. In still another JAMA article (March 13, 2018), Stephen T. Parente, PhD, calls attention to how high the preterm birth rate in the U.S. is compared to other countries and that “infant mortality is nearly 30 times greater for very low birth weight births compared with normal birth weight births.”

We do not intend to make light of infant mortality, because it is important and needs to be continuously monitored. But clearly, it is not fair or accurate to compare problem apples with problem oranges. The effectiveness of our health care system should not be denigrated because of infant mortality statistics. Serious social problems like poverty, teen pregnancies and low birth weight infants must be resolved, and the reporting has to be uniform. When they are, our numbers will be every bit as good as those in the rest of the world.

Life expectancy has been another “knock” on the U.S. health care system. Unfortunately, our suicide rate is higher than the other countries mentioned in the Papanicolas et al. study, with the exceptions of only France, Switzerland and the world leader, Japan. We have the worst rate of car crash deaths and the highest rate of gun homicides. Furthermore, we lead the world in another very dubious “distinction” — that of obese or overweight adults. The Centers for Disease Control and Prevention reports that 36.5 percent of the U.S. population suffers from obesity, which sets the U.S. apart as the most obese nation when compared with the other listed countries.

With obesity comes diabetes, which greatly affects mortality and health care costs. The International Diabetes Foundation (IDF) reports that the U.S. has the highest rate of diabetes in the developing world, with an estimated 13 percent of Americans who struggle with the disease. In fact, the IDF reports that nearly four times as many Americans may die of diabetes as indicated on death certificates, which would bump the disease up from the seventh-leading cause of death to No. 3, according to estimates in a recent study.

Finally, when discussing or comparing U.S. health care costs with those in other countries, the cost of pharmaceuticals must be considered. Among the 11 countries listed, as mentioned by Papanicolas et al., the U.S. had the highest pharmaceutical spending per capita at $1,443, with a mean of half of that ($749) for all 11 countries. Regarding a “measure of innovation,” the U.S. and Switzerland had the highest number of “new chemical entities” at 111 and 26 respectively. All this said, it’s noteworthy that one of the virtues of our health care system is that its citizens have access to break-through brand-name drugs sooner than other nations.

We must continue to strive to improve our health statistics and the general health of our people. To that end, more attention must be spent in addressing the social determinants that currently compromise the health of too many and result in higher health care costs. These determinants, such as poverty, poor housing, job and income status, and socioeconomic characteristics (such as education) are relevant in every respect. It is one thing to merely look at the numbers and quite another to examine the very valid reasons for the differences. We must look at health care comparisons with transparency and truth. That requires a great deal of improvement in reporting mechanisms of all other countries, as well. Most importantly, we must also do what we can to reduce overall health costs without jeopardizing the high quality and access to care.

Walker Ray, MD, president of the Physicians Foundation and chair of the Research Committee, is a retired pediatrician in Georgia. Tim Norbeck is the chief executive officer of the Physicians Foundation and served as the nonprofit’s first president. He previously served as the executive director of the Connecticut State Medical Society, the Rhode Island State Medical Society, and president of the American Association of Medical Society Executives.


Does a Medical Home Still Truly Exist?

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home_health_blog

Not much is new about an emerging concept in medical care — the “medical home.”

There was a time when a single physician or a team of doctors cared for a patient regardless of the situation or setting — from routine checkups in a doctor’s office to acute care in a hospital. But as medicine has become more specialized, and the dollar — not the doctor — dictates care, the relationship between the patient and physician has been fragmented.

The “medical home” model seeks to reforge that relationship through patient-centered care that is coordinated, accessible, and open to improvement.

But does a medical home truly exist today? That question was the subject of a dialogue recently between two Texas physicians: Retired obstetrician-gynecologist Robert Frischer, MD, and internist Sue Bornstein, MD.

Dr. Frischer questioned whether the medical home is still a reality, while Dr. Bornstein demonstrated how the model can work.

Their thoughts are published below.

If you want to learn more about ways to enhance the care you deliver, plan to attend the upcoming Texas Primary Care and Health Home Summit. The Texas Medical Association is a founding sponsor of the sixth-annual summit, which will be held April 5-6 at the Renaissance Hotel at the Arboretum in Austin. 

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Robert Frischer, MD:

As a retired physician I really have to wonder what a "medical home" is. 

It is a concept that does not really exist anymore, as far as I can tell. 

You see your primary care physician for your entire life. But if you get sick and are in the hospital, you are no longer under the care of the doctor that knows you (he/she doesn't go to the hospital). Instead, you see a hospitalist on one day, a different one on the next day, you have a million lab and x-ray procedures done based on symptoms without hands on by a physician. 

I have been called for "vaginal bleeding" for women with hemorrhagic cystitis. I have been called for pelvic masses as large as a basketball easily palpated by abdominal exam, but only picked up after a CT scan because no abdominal exam was done.

Once upon a time general practitioners (GPs) and family practitioners (FPs) followed their patients in the hospital. 

That is when we had a medical home. That no longer exists. So what is the concept of a medical home now? As long as you are not sick and hospitalized you have a "home," but it is not there when you need it most. Maybe it exists in really small towns where there are only GPs and FPs, and they are the only hospital staff, but it is not this way in most hospitals.

Maybe Texas Medicine will do a survey and see how many hospitals have GPs and FPs on staff. If GPs and FPs are still delivering babies, you probably still have a medical home. The downside with that is that you have GPs and FPs sometimes over their heads doing obstetrics. But at least you have a doctor that knows you.

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Sue Bornstein, MD:

Dr. Frischer,

Your post sums up the feelings many doctors and their patients have about our current medical system: That it is fragmented, inefficient, and at times, bewildering. 

I recall how my own mother, the wife and mother of physicians, was greeted by the hospitalist who assumed her care on one of her admissions. She was a frail 80-year-old woman, and the concept of a hospitalist was foreign to her. When he said to her, “Hi, I’m Dr. S., your physician,” she replied: “The hell you are!” 

This is not a knock on hospitalists who, like all physicians, do the best they can to care for their patients every day. It simply points out the complexity of the system. 

As medical science and technology have advanced, it’s difficult for any physician, no matter how hard-working and dedicated he or she is, to keep up with all the latest treatments. Combined with the pressure to get hospitalized patients discharged as quickly as possible, and also to “check the boxes” for quality measure, it’s increasingly difficult for the office-based primary care doc to do both inpatient and outpatient medicine.

Your question about what is a medical home is a good one. In my mind, it’s a place where you, your medical and social histories, and family dynamics are known by the doctors and their team. If you must be referred to a specialist, the team helps arrange that and follows up on the results. You are reminded to have screening exams like mammograms and colonoscopies on time. The physician and his/her team may not be directly involved in your hospital care, but they are informed on a daily basis of your status, and when you’re discharged, the treatment plan is shared with your medical home.

You need look no further to find a true medical home than the practice of our TMA President-Elect, Douglas Curran, MD. Dr. Curran is a family physician in Athens who not only delivers babies, but does C-sections and other abdominal surgeries. He takes care of multiple generations of families and is beloved and respected by all. He is a partner in a large family medicine practice and still delights in teaching residents and students, as well as his new colleagues. Dr. Curran works long hours, but is still filled with the joy of caring for his patients after 30 years in practice. 

So there is hope — medical homes do exist!