https://hbr.org/cover-story/2019/03/how-employers-are-fixing-health-care
A 56-year-old man who works at Walmart — we’ll call him Bill — had been suffering from mild neck pain for years. Recently the pain had worsened, and his wife noticed a subtle tremor in his hands. An MRI showed some narrowing of the spinal column along with disc degeneration. A local surgeon explained that Bill’s best option was spine surgery.
https://www.healthleadersmedia.com/finance/winners-and-losers-healthcares-q4-earnings-season
Earnings season for Q4 2018 has concluded for companies across the healthcare industry, from insurers, for-profit providers, telemedicine companies, and others in between.
Given the challenging market conditions during the final quarter of last year, including the surprise federal ruling that struck down the Affordable Care Act as unconstitutional, many companies reported weaker earnings than they did earlier in 2018.
However, some were buoyed by new intitiatives and product performance that sustained a level of success they intend to carry into 2019.
Below is a list of healthcare’s winners and losers from the 2018 Q4 earnings season:
Screening programs take shape in San Diego as nationwide trend gains steam.
Interventional cardiologist Jerrold Glassman, MD, spent the first week of March schussing down Park City’s powdery slopes. He even braved black diamond runs, belying the fact that this July, he’ll be 69 years old.
“A 60-year-old today is not the 60-year-old of three decades ago,” he said proudly. “Skiing is my passion and I’m going back up tomorrow.”
He and his ski buddies, older physicians like himself, dodge moguls some 30 days a year. A new app tracks his stats, like altitude, speed and distance, and said he did 25 downhill miles that day.
Glassman has no plans to retire from the cath lab — or from skiing — anytime soon. But in coming weeks, medical executive committees for his 3,000-physician Scripps Health system in San Diego are expected to require screening for all physicians age 70 and older for cognitive impairment, among other things. It’s to be a condition for recredentialing every two years.
Doctors up for review will sit in a room alone, with no pencil or mobile aid, while they answer dozens of questions in the MicroCog, a computer-based test also used by the Air Force. The test scores thinking skills, such as the ability to solve simple math problems, count backwards from 100, or find similarities among shapes or pictures.
Following the computer test comes history, physical, and mental health screens that review issues like substance use and tests for hearing and vision. They fill out a form that asks about sleep patterns, continuing medical education, patient load, and typical hours at work. The entire process takes about three or four hours.
The policy is a major change for the system, acknowledged James LaBelle, MD, chief medical officer for Scripps Health. “About 150 physicians 70 or older are due to be recredentialed in 2019 and all would be subject to the policy,” he said. LaBelle did not respond when asked whether the two-year recredentialing cycle would subject a similar number to mandatory screening in 2020 — which would bring the total to about 10% of Scripps’ medical staff.
An undisclosed number of allied health professionals such as dentists and optometrists who seek status as a Scripps staff member are also covered by the policy, LaBelle said.
For most hospitals around the country, “this is pretty new. I do think Scripps is leading in trying to understand how to manage the aging physician,” he said, adding, “I hope it’s going to be easier than I think it’s going to be.”
Failing the MicroCog won’t automatically end a physician’s credentialing at Scripps. But it will flag him or her for further evaluation, perhaps prompting recommendations for more rigorous fitness-for-duty review lasting several days. Physicians who perform poorly there would see their ability to practice limited or revoked.
Come to PAPA
For Scripps and many other organizations, the plan is for screening to be done by PAPA, the University of California, San Diego’s PACE Aging Physician Assessment program — said to be the largest to provide this service in the nation. (PACE is an acronym for Physician Assessment and Clinical Education.) Many other organizations perform various screenings in house, with or without cognitive computer tests, or are working on plans to contract with four other service providers.
Surgeons and interventionalists like Glassman will likely also undergo PAPA’s 15-minute dexterity screen — in which they must correctly place shaped pegs into grooves in a board.
Although leadership’s commitment to a uniform policy is set at Scripps, some details are still being worked out, like how the system’s peer review committees will repurpose those long-time senior physicians who fail the tests but can still provide value to the workforce. LaBelle suggested the exact process Scripps will adopt “is a moving target” that may change, but added, “I have no doubt we’re going to learn a lot over the next few years around how to do this right.”
PACE is a multiple-day testing program which began 22 years ago to assess doctors referred by the Medical Board of California after negligence or behavioral issues threatened their license. Of the 1,000 physicians referred to PACE, an undisclosed number had age-related cognitive impairment that resulted in colleagues’ concerns, but the physicians continued to practice because the complicated peer review process takes a long time, and doctors don’t want to report on each other.
“In all honesty, when we started PAPA, it was because we saw so many wonderful careers that ended in disgrace and tragedy,” said PACE/PAPA director David Bazzo, MD. “Time and time again, the message we heard was ‘Gosh, I wish I had known, or I wish I had stopped or retired one case sooner,’ maybe because of a cognitive issue or dexterity issue. The regret is there.”
Absent screening, procedures for dealing with accusations of physician impairment, can take years. For example, a California medical board filing indicated that concerns about one gastroenterologist with a tremor were expressed internally in 2015, including that he “had forgotten that he was on call … exhibited occasional forgetfulness and confusion and had shown up on at least two occasions at the wrong surgery center.” The medical board didn’t receive a complaint until January 2017, however, and another 15 months elapsed before his license was revoked.
So it’s understandable that proactive screening is gaining traction. “I know it provokes a lot of anxiety, but in the end, it’s really around assessing how much deeper a doctor needs to be looked into, or doesn’t need to be looked into,” LaBelle said. It’s not a slam dunk that they would be sent packing — unless they refuse the tests, LaBelle said. “That’s a hard stop.”
Growth mode
With five PAPA contracts with healthcare organizations or medical groups now active and three more pending, Bazzo sees the demand for late career physician screening as a service line in growth mode. He gives talks about the process to hospitals and medical groups around the country, and estimates 10% of health systems now have some form of screening triggered only by a birthday, even if limited to certain departments. “It’s on the national radar,” he said.
Outside San Diego, other hospitals and health systems have also begun screening their senior clinicians, with or without the MicroCog. Among them are Stanford Hospital, Clinics in Palo Alto, and Eisenhower Medical Center in Rancho Mirage, California; Driscoll Children’s Hospital in Corpus Christi, Texas; and the University of Virginia Health System in Charlottesville. Many others have policies they declined to discuss with MedPage Today.
An American Medical Association report discussed at the November interim meeting noted that 300,752 physicians were 65 years or older in 2017, up from 241,641 in 2013, and 120,000 were “actively engaged in patient care,” up from 97,000. The literature is clear, an AMA report said, that cognitive and physical skills generally decline with age, and physicians are not excepted.
That report urged delegates to adopt principles to guide screening senior physicians for competency. “It is critical that physicians take the lead in developing standards … to head off a call for nationally implemented mandatory retirement ages or imposition of guidelines by others that are not evidenced based,” it said. The suggested guidelines failed to win approval but are being rewritten.
Clearly the issue is a touchy one at many organizations around the country, especially those with many clinicians who’ve long served as their hospitals’ elder statespeople and may serve on influential committees.
Asked if UCSD’s hospitals and clinics screened their senior physicians, a communications director replied, “UC San Diego Health is in discussion on a potential policy, however, it hasn’t established one because the science on the topic is unsettled.”
That prompted a strongly worded retort from William Perry, PhD, vice chair of the UCSD department of psychiatry and a PACE program psychologist.
Robust data
“The data is fairly robust in two domains,” regarding the impact of age on physician care, Perry told MedPage Today, emphasizing that the communications director’s message was patently incorrect. “Abilities decline after a certain age and, as one gets older, adverse outcomes increase,” he said, citing unpublished data from PACE and other studies. “There’s no denying it; as we get older a lot of our functions decline.”
Perry said that these days, he’s receiving calls every week from around the country wanting him to give talks. “Organizations in North Carolina and New Jersey are putting together policies. It’s not a question of if, it’s a question of when this will become standard,” he said.
“I’m struck by how much science has demonstrated a connection between aging and impaired physician practice,” said Richard Barton, an attorney who represents physicians, medical groups, and hospitals and helped author a paper on the topic in 2015 for a Sacramento-based physician wellness group. In San Diego alone, Barton knows of three organizations, including Rady Children’s Hospital and UCSD Medical Center, who are also working on late career screening policies due to concern that some older physicians are at higher risk for causing patients harm.
Glassman, who has practiced at 655-bed Scripps Mercy Hospital since 1979 and was chief of staff for four years, said most older Scripps physicians favor the idea. “It’s kind of mom and apple pie. How can you say a physician who is not competent should be allowed to practice?” The big question is, after a clinician fails, which follow-up tests correctly determine whether an experienced physician can still practice?
One of Glassman’s fellow skiers, Jeff Sandler, MD, a Scripps endocrinologist, will be 72 this June and supports the idea of screening doctors his age. “If you think you shouldn’t be screened, maybe you shouldn’t be practicing,” he said. “It sounds discriminatory, but we have to protect the public from bad actors.”
But the issue remains controversial because screening based solely on age smacks of illegal discrimination and the age cutoffs are inherently arbitrary.
This segment reviews steps that viewers can take locally as well as civic actions that can support healthcare restraint and reform at a national level.
In the last Segment we looked at what I call the Big Fix. It is based on the idea of setting limits fairly. I highlighted the Oregon Health Plan that was successfully implemented from 1994 to 2002.
In this final Segment, I hope to motivate you to action: Think National, and Act Local.
Here are some ideas for acting locally.
Healthcare is a big topic to talk about. Tell friends about the need to set limits. Send out links to this You Tube on your social media. Also ask questions of your doctors to let them know that cost is an issue for you, such as those suggested by Elisabeth Rosenthal on NPR News Hour.
An “I don’t know” or “It depends on your insurance” from the doctor is not an answer. The doctor should give you a ballpark range or the cash price at the center where he or she refers.
If the answer is “It won’t, but it might be good to know,” take a pass.
When doctors order blood work, they are frequently just ticking off boxes on a long electronic checklist, with no awareness of how much any might cost. Your questions alone will make them more discriminating.
If you go to a pharmacy or a lab and encounter a high price, call your doctor’s office and tell him or her about it. Force your doctor to learn. He or she likely didn’t know.
Doctors often practice and do procedures in different places on different days of the week. If you go on a Thursday and that happens to be your doctor’s day at the hospital, it could double the price of your biopsy or colonoscopy. If he or she refers you to an ambulatory surgery center, ask, “Are you an owner?” A little shaming might encourage better behavior.
Avoid a lot of unexpected charges up front by making sure that whoever is involved in your care — doctor, physician assistant, pathologist, anesthesiologist — is in your insurer’s network.
Here are some ideas for thinking national. Write your congressmen. Join small groups — or form them — to meet with congressmen. Write letters to the newspaper editor.
The key talking point is: Ask them to support fair limits on Essential Benefits using the combination of cost-benefit research and public input, modeled after the Oregon Health Plan of 1994. It may surprise you that this research is already authorized in the Affordable Care Act at Section 6301. Tell Congress to retain or expand this provision.
Thank you for your interest in reforming the US healthcare system for ourselves and for future generations.
Stay involved. A lot is riding on it.
This segment reviews the “Big Fix,” based on the idea of setting limits fairly. It describes the success of the Oregon Health Plan of 1994.
In the first 8 Episodes, we have reviewed the evolution of the US healthcare delivery system and insurance system. We have identified the relentless growth of healthcare spending as the root of the problem. And how rising costs are literally built into the system as it is now. Finally we have looked at American traditions and values that we all agree on, and we identified loaded political words and the seeming conflict between market justice and social justice that voters disagree on.
Based on this understanding of the US healthcare system, we are now ready to look at what I’m calling the Big Fix. It is based on the idea of setting limits fairly. You’ll be surprised to know that it was already tried 20 years ago in Oregon. And it worked!
So, let me tell you the story of the Oregon Health Plan. It all starts with a Roseburg Oregon emergency room doctor named John Kitzhaber. Half of his ER patients – as everywhere – were not real emergencies, just uninsured patients with no other place to get healthcare.
So in 1989 when the Medicaid budget was being cut, he realized that many Medicaid patients would lose coverage, and would be flooding into his ER. Unless something was done.
He came up with an idea. Rather than keep the same level of benefits and cut patients, why not keep all the patients on Medicaid but limit their benefits? He formed a non-profit group to lobby for these low-income patients. This propelled him to the state senate and eventually to the governorship. He first created a list of 709 diagnosis-treatment pairs ranked by the dollar cost per life saved by each treatment (or “quality-adjusted-life-year”).
But this produced some odd results, for example ranking lower-cost dental care above life-saving appendectomies. And so he next organized 60 town hall meetings to re-prioritize the list with common-sense consumer input. Actuaries then calculated the line (Line 581) above which the fixed Medicaid budget could cover all eligible patients. The final list gave priority to life-saving treatments such as antibiotics for pneumonia and appendectomy for appendicitis, as well as to proven effective treatments for heart disease and treatable cancers. It also included routine preventive care, maternal care, newborn care, well-child care and preventive dental care. Kidney dialysis was covered above the Line. The list did not cover conditions like remedies for the common cold that get better on their own, conditions where “home” treatment is effective like sprains, ineffective or futile care such as surgery for most back pains or aggressive treatment of end-stage cancer. For those terminal cancers, it did cover comfort care.
Here are the other main provisions of the Oregon Health Plan. By eliminating low-value health services, it was able to cover 100 percent of low-income citizens. The combination of sound research and consumer input gained it public acceptance.
Here is the time line for the Oregon Health Plan. It actually took 5 years to gather public input and then to get necessary federal waivers approved.
Here is a summary of the key successes of the Oregon Health Plan. Oregon was able to extend plan eligibility of those below federal poverty level from 57% to all 100%. This meant 100,000 more Oregonians on Medicaid. However 65,000 still did not enroll, presumably due to complicated enrollment procedures or copays up to $28. Total uninsured in Oregon did drop from 18% to 11%. Most importantly, Medicaid stayed within its budget. Medicaid physicians were paid on a par with others, resulting in robust doctor participation and 88% patient satisfaction.
Let’s pause to consider a key question, Is it ethical to limit health benefits for low-income patients? Philosopher Paul Menzel (who I introduced in the last Segment) gives a resounding Yes. Here is his thinking. The right to prioritize healthcare services is especially important for lower-income patients. If they were given their Medicaid premium in the form of cash, many would spend only 33% of it on healthcare because they have more pressing needs for food, clothing, and shelter. Menzel also points out that these low-income patients would gladly accept a package of more restricted health services in exchange for first-dollar coverage. Lower-income patients live from paycheck to paycheck and don’t want the uncertainty of a large unexpected medical bill. Medicaid patients want healthcare insurance, but neither they – nor society at large – should pay more than it’s worth to them.
In plain language, lower-income patients – and other savvy insurance buyers — need the real choice for a lower-cost package of limited health benefits that is “worth the money,” not just a menu of higher deductibles and copays but the same old package of exorbitantly costly, low-value care.
Please notice that this idea blends both market justice and social justice. It acknowledges that low-income patients are not entitled to everything, no matter what the cost. But it also provides for them a package that they – and society – think is costworthy. And does so with their consent freely given. Costworthy care is one of the key features of a fair health system, according to Menzel, as we saw in the last Segment, and consent is a key principle.
It is instructive to look at the fate of the Oregon Health Plan over the 8 years of its existence. Here is what happened. The legislature cut taxes. Healthcare costs rose with inflation. Oregon tried to get the poor to accept higher co-pays, but they could not afford them and so dropped out. Eventually these patients went back to traditional Medicaid or became uninsured again, spelling the end of the Oregon Health Plan.
What are the lessons to be learned?
First, limit-setting is politically feasible, ethically acceptable and pragmatically successful in controlling cost, access and quality.
Second, priority setting takes years to plan and years to implement.
Third, healthcare priority setting should be informed by cost-benefit research but driven by public participation, respecting minority rights and protection of the sick and vulnerable.
Fourth, two-tiered health benefits packages – one lower-cost and one higher-cost – is politically feasible and ethically acceptable (but so-called Essential Benefits should not arbitrarily cut entire categories of benefits like maternity care).
Fifth, sufficient primary care provider pay is needed to ensure doctor participation and patient access.
Sixth, sustaining healthcare system restraints and cost controls requires continual monitoring and periodic updating to keep up with new medical research and changing public values.
This is a critical point, because the casual observer might conclude that the Oregon Health Plan failed in 2002.
But I argue that the fact that the Plan was designed, politically adopted, implemented and sustained for 8 years proves the concept that limit setting can work, but also shows that something so big and so intricate needs ongoing political and administrative energy to sustain it.
Of course I have over-simplified the Oregon Health Plan. There are innumerable technical, legal, budgetary and administrative details involved.
Also, adopting a plan like Oregon’s today would need us to take into account 20 more years of research since then, with some very expensive but very effective treatments newly available. There are also many ethical nuances, such as should we budget for one patient needing a $100,000 treatment in place of 100 patients with $1,000 treatments, or vice-versa? But Oregon showed that all these issues can be managed in an orderly fashion.
I have also over-simplified that merely adopting the Oregon Health Plan cost-benefit method for limit setting would solve the entire cost problem. For example, many commentators have exposed the quirks of the US healthcare system that result in over-pricing, as discussed in Segment 5. That means that the same drugs, tests or treatments cost 2 to 10 times more in the US than in other countries. Those quirks should each be addressed in policies and regulations.
But the basic idea of fair limit setting – call it rationing, if you like – is the key, in my opinion. Limit setting would firmly challenge the common presumption that all healthcare is equally cost-worthy. It would put on notice the vested interests: if they play games with exorbitant pricing, they would ultimately lower their benefit-for-cost below the cut-off point, and drop themselves off the covered list altogether.
In the final Segment, I will talk about what each of us can do to promote health system reform and cost control.
I’ll see you then.
HENRY KOTULA 