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Telehealth – Will the Pandemic Reveal its Potential?

By: David P. Lind

Telehealth has been around for at least a few decades, but its’ steady growth trajectory was injected with rocket fuel a year ago when the pandemic erupted. Most every medical provider was thrust into embracing telehealth services, and for many, a rather uncomfortable, but necessary pivot to serve patients. Going forward, one key question to address will be if the outcomes of telehealth are at least as effective as in-person visits. 

Technology and Reimbursement Concerns of Telehealth

For telehealth to become deeply rooted in the long-term medical-delivery process, a few important barriers will need to be addressed. Making the telehealth technical systems easy to use – for both physicians and patients – will require additional tweaks to simplify the physician workflow process and patient acceptance. Additionally, physicians desire to have a more-intimate rapport with patients, such as reading body language, listening to breath sounds while providing an actual physical examination.

But the elephant in the room regarding the growth of telehealth is simply this: the complicated challenges of reimbursements from payers – a key component that could determine long-term adoption. State telehealth commercial payer laws vary. For Iowa, the legislature is considering a payment parity bill that would treat telehealth reimbursement no differently than in-person care (HF294).

Telehealth Outcomes – What is Known Today

Is the quality-of-care provided remotely at least comparable to in-person care? Are patients satisfied with telehealth? There are some studies, all from the pre-pandemic period, that evaluated patient outcomes between telehealth and in-person visits. Rest assured, new pandemic data on telehealth will eventually emerge to help connect the dots on satisfaction, safety and outcomes.  

For now, pre-pandemic outcome results appear to be tepidly encouraging. The federal Agency for Healthcare Research and Quality (AHRQ) provided funding to the Pacific Northwest Evidence-based Practice Center to produce two reports on telehealth. Each report provides helpful insights on how telehealth can positively impact appropriate and safe care.

STUDY #1: Telehealth: Mapping the Evidence for Patient Outcomes from Systematic Reviews (2016): This report included over 950 studies of telehealth based on data from 58 systematic reviews published between 2007 and 2015. High-level findings show that telehealth is beneficial for specific uses and patient populations. In fact, “There is a large volume of research reporting that clinical outcomes with telehealth are as good as or better than usual care and that telehealth improves intermediate outcomes and (patient) satisfaction.” Benefit evidence was concentrated in specific uses of telehealth services for: 

  • Remote, home monitoring for patients with chronic conditions, such as chronic obstructive pulmonary disease and congestive heart failure
  • Communicating and counseling patients with chronic conditions
  • Providing psychotherapy as part of behavioral health
STUDY #2: Telehealth for Acute and Chronic Care Consultations (2019):  This report includes evidence about telehealth for acute- and chronic-care consultations from research published between 1996 and May 2018. The findings from this study provides overall conclusions that are relevant to telehealth expansion during the COVID-19 pandemic. Twenty-one studies evaluated remote intensive care units (ICUs), showing lower, statistically significant inpatient and ICU mortality rates and small, nonsignificant reductions in length of stay. Only one study specifically addressed adverse events, reporting lower rates of complications with remote ICUs.

Other Resources for Telehealth Outcomes

A few other 2018 studies also provide insight on telehealth care:

  1. Impact of Telemedicine on Mortality, Length of Stay, and Cost Among Patients in Progressive Care Units: Experience From a Large Healthcare System (2018) – Finding: Telemedicine intervention decreased overall mortality and length of stay within progressive care units without substantial cost incurrences.
  2. Effect of the School-Based Telemedicine Enhanced Asthma Management Program on Asthma Morbidity (2018) – Telemedicine intervention significantly improved symptoms and reduced healthcare utilization among urban children with persistent asthma.
  3. Telemedicine in the Mangement of Type 1 Diabetes (2018) – Finding: “Specialty diabetes care delivered via telemedicine was safe and was associated with time savings, cost savings, high appointment adherence rates, and high patient satisfaction. Our findings support growing evidence that telemedicine is an effective alternative method of health care delivery.”
  4. Telemedicine and Mobile Health Technology are Effective in the Management of Digestive Diseases: A Systematic Review (2018) – Finding: “Telemedicine and mobile health technology may be effective in managing disease activity and improving quality of life in digestive diseases.”

What Can Be Learned?

Overall, these pre-pandemic reports suggest that when patients and clinicians had a choice or when telehealth addressed an access issue, benefits of telehealth occurred. Further, this research found evidence that telehealth might benefit groups of patients during the pandemic when expanding critical care, help speed emergency care decisions, and reduce exposure to infection when replacing face-to-face care. But AHRQ issued an evidence summary report in April 2019 cautioning that more rigorous research will be needed to fully comprehend the effectiveness of telehealth consultations.

The rapid expansion of telehealth during the pandemic may provide better opportunities to learn whether telehealth is an appropriate application to use in given medical situations. Measuring the most appropriate outcomes will be extremely important for researchers to assess and analyze.

Summary

Most people agree that telehealth is here to stay. Two important influencers on telehealth growth will likely include documented health outcomes and third-party reimbursement levels. Telehealth usage will not remain at the elevated levels that COVID-19 required, but it will reach a more reasonable level and then grow where it makes most sense. Applying telehealth wisely will be important to research goals coming from the pandemic experience. New research with rigorous and detailed telehealth models will be needed to help answer these questions, and the answers may very well depend on what type of care is given under various specialties of care.

To be sure, the pandemic will reveal important findings that will determine how telehealth will expand in the future.

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Exercise, Diet and Weight Control
Time-Tested Advice

By: David P. Lind

On a recent blustery January day, I decided to seek some preventive medical advice that would sharpen my understanding on how to live a healthier life during a rather static time spent at home throughout this pandemic.

I picked up a monthly periodical entirely dedicated to the wisdom of living a healthier life, and it provided some timeless gems for our lives in 2021.  I found in-depth insight about nutrition, weight control, hypertension, heart disease, emotions, chronic ‘tiredness’ and a host of other factors affecting our physical and mental well-being.

One particular article was chock-full of wisdom that was shared by the “world’s most famous heart specialist” about maintaining a healthy heart through diet, appropriate exercise and weight control.

The kicker is that this particular periodical, Wisdom Magazine, was published 60 years ago. Wisdom Magazine, by the way, ceased publication in 1964. The May 1961 publication spent a sizeable portion on just one man, Dr. Paul Dudley White, who, at the time, was considered to be one of America’s top cardiologists.  Until I opened this periodical, I was unaware of him, nor of his substantial contributions.

Below are just a few arbitrary pearls of wisdom that he shared. Although many sound rather elementary for us in today’s world, they are worth repeating:

  • We know a thousand times more about diseases than our predecessors did generations ago, but apparently infinitely less about health.
  • The greatest challenge of public health today is keeping the middle-aged physically fit.
  • America is physically unfit as a nation and heart disease is definitely on the increase.
  • I have long advocated moderate exercise as one of the best ways to keep the heart in good condition.
  • We must give first priority to research in preventive medicine.
  • In this push-button age, man is overeating and pampering himself and “the life of Riley” often leads us into the lot of early coronary disease, high blood pressure and diabetes.
  • I would like to emphasize the beneficial effect of work on body, mind and soul in any occupation in which it is possible for a cardiac patient to engage. Idleness breeds unhappiness and is actually bad for the health.
  • Overeating may play even more of a role in the destiny of the world than the under-nutrition of hundreds of millions…As a result, the problem of overeating is far broader than that of the so-called starving millions…
  • Exercise is one of the best ways to counteract nervous tension and the best antidote is physical activity when one feels tired.
  • Just how much heredity actually counts in any given case remains for future researchers to discover, but that it plays a most significant role is a certainty.
  • Our medical ancestors were obliged to exercise much more than is the custom of most inhabitants of the so-called more-civilized countries of today.
  • Activity, both physical and mental, within reason, is important for health at any age and I think it is actually helpful for longevity. Many retire long before they should.
  • It is true that those who smoke most heavily are more likely to live shorter lives and also to have trouble with their hearts.
  • I would like to put everybody on bicycles, not once in a while, but regularly as a routine. That is a good way to prevent heart disease.
  • The easiest exercise of all, requiring no equipment except shoe leather, is walking.
  • Improvement of health in middle age and old age in this country today is greatly needed and must begin with well-established habits in youth.
  • One is never too old to exercise.

 

Dr. White was born the same year as my paternal grandmother, 1886, and was President Dwight D. Eisenhower’s physician during his heart attack in 1955.

White’s accomplishments were enormous. He helped create the International Association of Cardiology and International Cardiology Foundation, in addition to serving as executive director of the National Advisory Heart Council and chief consultant to the National Heart Institute. He was one of the founders of the American Heart Association and influential in establishing the National Institutes of Health. He wrote many papers about how lifestyle affected coronary artery disease. An avid walker and bicycle rider, he reportedly inspired Lyndon B. Johnson to return to the Senate in 1955 after his heart attack. Later in 1964, President Johnson presented Dr. White with the Presidential Medal of Freedom.

In countless ways, the world has immensely evolved over the last 60 years. Yet, when it comes to Americans’ health, the challenges we face today with diet and exercise remain daunting. Unfortunately, the population health metrics have changed dramatically during this span of time. In 1960 America, 54.2 percent of adults were not overweight or obese, yet by the year 2020 (60 years later), only 31 percent met this measurement. Conversely, over 14 percent of Americans were either obese or extremely obese in 1960. Today, this number stands at 42.4 percent.

Despite the knowledge that we had in the middle of the 20th century, positive health trends remain elusive from what has been recommended. Until Americans can connect the dots to transform personal behaviors into healthier lives, it is quite evident that Dr. White’s admonishments – multiple decades ago – will continue to be largely ignored and yet stand the test of time.

We should heed the advice of our medical ancestors, who apparently knew more, or at least preached and practiced more than we, a program of positive health habits. The habit of adequate exercise, for example, is just as important, I believe, as one’s sleep, one’s work and one’s food. – Dr. Paul Dudley White

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Surprises Should Only Come in Packages, Not from Medical Bills

By: David P. Lind

Surprises come in all shapes and sizes…and in the latest coronavirus stimulus package passed and signed into law in late December, there is at least one medical-related surprise – and it’s a pleasant one.

Many goodies are included in this massive legislation, much of it related to jump-starting an economy adversely impacted by the COVID-19 pandemic. After two years of debate in Congress, one long-standing issue that has been elusive from legislative action has now become law – curbing surprise medical bills.

The End to Surprise Medical Billing

Also known as the ‘No Surprises Act’, consumers (patients) will no longer receive unexpected ‘balance bills’ when seeking ‘emergency’ care, such as air ambulance transportation, or when receiving ‘nonemergency’ care at an in-network hospital. A balance bill represents the difference between the provider’s charge and the allowed amount (negotiated between the insurance company and providers). This law will take effect in 2022.

In a survey released in early 2020, about 18 percent of emergency room visits resulted in at least one surprise bill. In the past few years, about 1-in-5 insured adults had an unexpected medical bill from an out-of-network provider.

Typical scenarios occur when patients are required to pay additional costs due to the contract between the network provider and a non-network provider who will not accept the insurer’s negotiated fee. Prior to the enactment of this new law, the non-network provider could legally bill unsuspecting patients their non-negotiated fee. When this law takes place, patients will pay only the deductibles, coinsurance and copayment amounts they would under the in-network terms of their insurance plans.

How Non-Network Providers Are Paid

Going forward, non-network providers will need to work out acceptable payments with the affected patient’s insurer. If the patient is uninsured, then all providers are considered out-of-network, and this will require the secretary of the Department of Health and Human Services to create a provider-patient resolution process for billing purposes.

Balance billing for air ambulatory transportation, a frequent and egregious practice, will not be allowed under the new law. A far more commonly-used service, ground ambulatory transportation, has not been addressed under this legislation. However, an advisory committee will be established to recommend how to solve payment for this service.

Can Patients Still be Balanced-Billed?

In nonemergency circumstances, physicians can balance-bill their patients for services, but to do so, they must obtain consent in advance of the medical procedure. As an example, a patient may want to seek care from a non-network physician, such as a surgeon. The surgeon will need to provide a cost estimate and get the patient to consent at least 72 hours before treatment. If the turnaround time is shorter than this, the patient must receive the consent information the day the appointment is made. Additionally, the estimate must be made in good faith.

Many types of physicians, however, may not be allowed to seek consent to balance-bill for their services. Among these include: anesthesiologists, radiologists, pathologists, neonatologists, assistance surgeons or laboratories.

For Providers and Insurers – ‘Devil in the Details’

With patients being held harmless, the struggle is really between how much non-network providers will be paid by insurers. Hospitals and physicians have opposed any kind of benchmark or standard to determine the amount of the bill, while payers argued for benchmarks. The legislation found a middle ground, giving insurers and providers 30 days to negotiate payment of out-of-network bills. Should this fail, an independent dispute resolution process with an arbitrator would make the ultimate decision.

Needless to say, there are other provisions within this legislation that flesh out many other details on how to settle payment disputes between providers and payers. Thankfully, this backroom process of payment details will not require undue anxieties from innocent patients.

Summary

The No Surprise Act will fundamentally fix a problem that existed for a long time. Surprises should only come in packages we receive on special occasions, such as birthdays, anniversaries, or holidays. An unwanted invoice in the mail sent by a non-network provider will hopefully be a thing of the past.

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Lobbying for Social Determinants of Health?

By: David P. Lind

In healthcare, there is a HUGE amount of money flowing in many directions. The law of gravity determines the flow, originating with the lobbying that is directed to those we elect to state and federal offices. In healthcare, somewhat similar to the trickle-down theory of economics, lobbying efforts grease the skids for how money eventually changes hands.

Effective lobbying, therefore, can establish who gets paid and by how much.

Open Secrets – Center for Responsive Politics

Lobbying Congress and federal agencies to influence decisions made by the government comes at a price – but it can be worth the ‘investment.’ According to OpenSecrets.org, a nonpartisan, independent and nonprofit organization that tracks money in U.S. politics, the top 13 sectors in 2020 shows that ‘Health’ is the top lobbying sector, spending over $464 million so far this year. Since 1998, this sector has dished out over $9.5 billion, edging out ‘Misc. Business’ ($9.4 billion) and Finance/Insurance/Real Estate ($9.36 billion).  ‘Health’ lobbyists represented include the American Medical Association, American Hospital Association, pharmaceuticals, and so on.

In the $3+ trillion healthcare industry, lobbying efforts can pay off handsomely. The ‘investments’ mentioned above are merely a drop in the bucket for the eventual returns that will come sometime later. Please understand, I am not suggesting that lobbying ‘investments’ are illegal, they usually are not.

Social Determinants of Health (SDOH)

According to the National Academy of Medicine, clinical care accounts for only 10-20 percent of healthy outcomes, while our behaviors, physical environment, and social and economic factors determine the other 80-90 percent – widely known as ‘social determinants of health’ (SDOH). Using the Centers for Disease Control and Prevention’s definition, social determinants of health are “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of-life-risks and outcomes.” In short, SDOH are all external factors that affect our health outside of the hospital or doctor’s office.

To reign in ever-increasing healthcare costs and enhance better population health, why not explore new solutions ‘upstream’ to invest in our collective health and well-being? It’s about using our limited resources more wisely on key determinants of overall health that can ultimately improve health and control healthcare costs.

When comparing the U.S. to other wealthy industrialized countries, medical spending in the U.S. accounts for a greater share of gross domestic product than social services spending. Other countries spend more of their GDP upstream attempting to address the SDOH issues that directly and indirectly impact the health of their population.

Unfortunately, such investments are often viewed as ‘socialism’ or something worse in the U.S. As Dr. Donald M. Berwick published in JAMA this past summer, The Moral Determinants of Health, “…SDOH is motivated by an embrace of the moral determinants of health, including, most crucially, a strong sense of social solidarity in the U.S.” This solidarity, by the way, includes the removal of institutional racism. Until this happens, we may not have the necessary push to pursue SDOH.

Value-Based Care

Value-based care (VBC) has become a large focus for Medicare and private payers. VBC is a payment approach by which purchasers of healthcare hold the healthcare delivery system (physicians and other providers, hospitals, etc.) accountable for both the quality and cost of care. In fact, VBC programs are all about improving population health management strategies and center on how well healthcare providers can improve quality of care based on specific measures, including the reduction of hospital readmissions, using certified health information technology, and improving preventative care. VBC is the new-age approach to replacing the now-ancient fee-for-service payment arrangement in the U.S.

Healthcare providers are justifiably uneasy because they are being required to somehow ‘fix’ the social infrastructure by improving population health management. This is made more difficult when our own legislators and political system have problems agreeing whether the sky is blue or not on any given day. As mentioned earlier, a healthier population comes from non-clinical environmental determinants that influence how people live their lives. As a result of the ACA, all not-for-profit hospitals, since 2014, have been required to conduct a community health needs assessment every three years and implement a strategy to meet those needs.

What if…

What if healthcare lobbyists leveraged their efforts to meaningfully impact SDOH? Why couldn’t healthcare lobbyists on the Hill take half of their lobbying energy and financial resources and repurpose it into a lobbying campaign to address SDOH problems, such as availability of healthy food, improved education, access to housing, transportation, safe neighborhoods, etc.? If improving community health is the direction in which VBC is moving, and health providers are being financially incented to move this needle to improve population health, perhaps healthcare lobbyists SHOULD push legislators in this new direction to help move an otherwise unmovable mountain. Set a deadline to initiate SDOH programs – perhaps in the next five or seven years. Would it be possible for legislative gridlock to succumb to bipartisan support if powerful lobbyists sang from the same sheet of music?

One example of a similar approach, as reported by Modern Healthcare, comes from Louisiana-based Ochsner Health, which is pledging $100 million over the next five years to help eliminate healthcare disparities. Obviously, there is a huge need for the healthcare community to improve SDOH challenges in the communities they serve.

The potential ‘return’ for this new approach could be massive, for both the healthcare establishment and for all Americans. If healthcare providers serve as ‘repair shops’ to mend those needing care, and are ‘graded’ and subsequently paid on how well the health of the community has improved, local and national policies must be in place to make this happen.

This may sound too straightforward and, perhaps somewhat naive. But thinking ‘differently’ may prove to be worthwhile for what ails our healthcare system. Maybe Dr. Berwick’s morally guided campaign for better health is a great start.

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A Compendium of Patient Safety Concerns for 2020…and Beyond

By: David P. Lind

According to a March 2020 report by non-profit, independent organization, ECRI Institute, diagnostic errors and maternal health issues are considered to be the top two patient safety concerns for healthcare organizations. This report, however, was released prior to Covid-19 becoming the national focal point in the U.S.

ECRI’s list of the top 10 patient safety concerns was based on analysis of more than 3.2 million patient safety events recorded via the institute’s reporting program.

The list (in order) is as follows:

    1. Missed and delayed diagnosis.
    2. Maternal health across the continuum.
    3. Early recognition of behavioral health needs.
    4. Responding to and learning from device problems.
    5. Devise cleaning, disinfection and sterilization.
    6. Standardizing safety across the system.
    7. Patient matching in the Electronic Health Records.
    8. Antimicrobial stewardship.
    9. Overrides of automated dispensing cabinets – This refers to overrides to remove medications from a computerized drug storage device before pharmacists have reviewed and approved the move.
    10. Fragmentation across care settings.

11 Takeaways for the #uniteforsafecare Public Awareness Campaign

The World Health Organization designated September 17 as World Patient Safety Day to raise awareness of healthcare safety and its importance. During that virtual event, the Patient Safety Movement provided 11 takeaways on its Patient Safety Blog for the public, patients and their families to understand while seeking care:

    1. Recognize that the system is not perfect.
    2. Stay engaged in your own health care process.
    3. Recognize that your voice matters.
    4. Don’t be intimidated.
    5. Get a second opinion.
    6. Don’t be afraid to “shop around” for healthcare.
    7. Follow your gut.
    8. Double-check everything.
    9. Minority communities must be cognizant of the social disparities in patient care.
    10. Keep in mind that health workers are not to blame, the system is to blame.
    11. Remember that we’re all in this together.

The Joint Commission’s Seven Most Common Sentinel Events

Through the first half of 2020 – ending June 30 – The Joint Commission (TJC) reviewed a total of 437 sentinel events, with 85 percent being voluntarily self-reported by an accredited or certified organization. A sentinel event is a patient safety event that results in death, permanent harm, severe temporary harm or intervention required to sustain life. That total of 437 is a very low number because it is a grossly underreported by medical organizations. In fact, TJC estimates that only two percent of all sentinel events are reported.

The most common sentinel events for the first six months of this year are as follows:

    1. Care management – 165 reported events
    2. Surgical or invasive procedures – 131
    3. Unassigned events at the time of the report – 46
    4. Suicide – 41
    5. Protection events – 38
    6. Environment events – 12
    7. Product or devise – 4

New National Action Plan for Patient Safety

To combat preventable medical harm, the Institute for Healthcare Improvement (IHI) released a National Action Plan on September 17. The report, “Safer Together: A National Action Plan to Advance Patient Safety” was arranged by 27 federal agencies, safety organizations and experts, and patient and family advocates. The plan focuses on four key areas:

    1. Culture
    2. Leadership and governance
    3. Workforce safety
    4. Learning systems
Keeping patient safety front and center is critical to force-needed changes within our healthcare environment.

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Physician and Caregiver Burnout – Yet Another Epidemic

By: David P. Lind

My particular primary-care doctor has been my medical ‘counselor’ for about 25 years. I visit her at least annually for my routine physicals, but have frequently consulted with her about obtaining referrals to specialists outside her scope of practice. I see her because I have unquestionable trust in her abilities to put my interests above any other outside influences.

On numerous occasions, I have confided in her about my family medical history, specifically having lost two siblings to different cancers. Through her own tears, I have come to accept her as yet ‘another sister’ to me – my fifth! Her compassion for my well-being is both genuine and reassuring. Suffice it to say, I have the utmost admiration for the medical professionals who work diligently on a daily basis to care for patients.

Much of what I have written in the past, whether through blogs or op-ed pieces, is directed to help educate the general public about the problems (and potential solutions) of our healthcare system. Not only is the healthcare service delivery we seek local, it is also very personal, especially as it relates to the relationships we have with the doctors, nurses and other caregivers in our communities.

But what patients may not understand is the ‘backroom’ in which clinicians are required to perform their daily work. It is within this ‘black box’ of their work environment that their human frailty may become tested and subsequently exposed, negatively impacting their own mental well-being, and possibly undermining patient care.

Caregiver Burnout

The opioid epidemic has become a large concern of our local and national conscience. But another troublesome public health crisis persists in our society, and it greatly impacts each of us, whether we know it or not – physician and caregiver burnout.

Physician and caregiver burnout have troubling symptoms, such as depression, exhaustion, dissatisfaction and a sense of failure. Losing the passion or purpose to serve others can be a powerful setback that steals the joy of practicing a noble profession. If left unaddressed, this burnout will erode the caregivers’ mental health and adversely impact patient safety.

The nurse burnout rates are reported to be between 35 and 45 percent. The burnout rates also vary by specialty. For example, specialties with the highest rates of burnout include1:

  • Urology – 54 percent
  • Neurology – 53 percent
  • Physical medicine and rehabilitation – 52 percent
  • Internal medicine – 49 percent
  • Emergency medicine – 48 percent
In fact, doctors who report burnout are twice as likely to commit a medical error. From our 2017 Iowan’s Views on Medical Errors study, Iowans reported the top cause of medical errors was from “Doctors and nurses who are overworked, stressed and tired.”

Quite understandably, when surveyed about the causes of burnout, physicians point to a plethora of bureaucratic tasks that include too much government and private insurance interference, too little pay, too many office hours, and too much time spent in front of the computer screen using electronic health records that are more about submitting the correct procedure codes to get paid by private, Medicaid and Medicare payers. Completing administrative and insurance requirements takes precious time away from providing face-to-face care to patients – perhaps twice as much time compared to treating patients.

According to an October 23, 2019 report, “Taking Action Against Burnout: A Systems Approach to Professional Well-Being,” the National Academy of Medicine (NAM) reports that 35 to 54 percent of nurses and physicians have substantial symptoms of burnout, while medical students and residents have symptoms of burnout between 45 percent and 60 percent. A recent Mayo Clinic report confirms similar findings, suggesting that 44 to 54 percent of physicians report having ‘burnout’ symptoms. A newly-released study by Medscape reported that almost half of physicians would take a pay cut to work fewer hours, and more than a quarter of physicians would give up between $20,000 and $50,000 per year in salary.

Potential Solutions to Burnout?

There is no clear consensus on what solutions will quickly ‘fix’ this growing crisis. Physicians want or favor the simplicity of administrative requirements from key payers, more relaxed insurance regulations, more stream-lined technology that allows caregivers to spend less time on computers and more time with patients. But the devil is clearly in the details.

The above-mentioned NAM report was prepared by the Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. This committee made six recommendations to serve as guidelines to help healthcare organizations design and implement systems to mitigate the factors that contribute to burnout:

  1. Create positive work environments
  2. Create positive learning environments
  3. Reduce administrative burden
  4. Enable technology solutions
  5. Provide support to clinicians and learners
  6. Invest in research (on clinician professional well-being)
Similar to the opioid epidemic, our state and country will need to become more involved to meaningfully address this particular crisis. Physician and caregiver burnout is a public health crisis that requires urgent action by healthcare organizations, state and federal governing bodies, including regulatory authorities.

Afterall, don’t we want our own doctors to be healthy, too?

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1 2017 Mayo Clinic

“Alexa, diagnose my cough” – Part 2

By: David P. Lind

Last April, I published a blog about potentially using cloud-based voice services, such as Amazon Echo (Alexa) or Google Home, to serve as artificial intelligence (AI) when seeking a healthcare diagnosis based on symptoms we experience. By merely sharing our medical symptoms with a smart-voice service, we could receive a diagnosis that is based on the latest peer-reviewed medical literature available.

As pointed out in the blog, one cautionary note about using such a tool was the ‘legal liability hurdles,’ such as being HIPAA-compliant (a U.S. health privacy law) – making sure that our private-patient information is being securely transmitted.

This particular hurdle appears to have been cleared. On April 4, the publication STAT reported that Amazon unveiled HIPAA-compliant software allowing pre-selected healthcare companies to build Alexa voice-program tools giving patients access to personalized information such as progress updates after surgery, prescription delivery notifications, in addition to learning nearby urgent care facility locations. Health firms can use Amazon’s Alexa Skill Kit to build voice programs that can create products to transmit and receive patient data.

As mentioned in STAT, “The move will embolden hospitals, insurers, and other healthcare firms to expose Alexa to more sensitive details of patients’ lives and medical conditions, and potentially embed the technology deeper into clinical settings.”

Developments like this one may not be highly-visible to the casual observer, however, it might be similar to a simple mist that ultimately results in a torrential downpour, causing a Tsunami of change.  Who knows, perhaps in just a few short years, ‘Alexa’ and other cloud-based services may actually simplify our daily lives that, today, seem complex and frustratingly lost in unchartered waters.

Hold on tight for the next rush of change that will no doubt disrupt how we will eventually live.

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National Trend – Insurance Companies Investing in Affordable Housing Projects

By: David P. Lind

National Trend – Insurance Companies Investing in Affordable Housing ProjectsIn 2016, Dr. Yogi Shah and I co-wrote a blog about moving ‘upstream’ to make investments in population health, more specifically, the social determinants that impact our health. As indicated in our work, when compared to other industrialized countries, the U.S. spends disproportionately large amounts on medical services, while largely ignoring the living environment that greatly affects the health of our population. We spend considerably more for medical care, yet our outcomes compare unfavorably to those countries.

In the U.S., we have done a great job of ‘medicalizing’ our social problems. But instead of focusing on how to pay for medical care, we would be wise to re-direct our limited resources toward improving basic social determinants of health, such as education, housing, nutrition and poverty.

UnitedHealthcare, the nation’s largest health insurer, and a division of UnitedHealth Group, announced this past week that their program of investing in affordable housing projects has now surpassed $400 million. Since 2011, UnitedHealthcare has invested in 80 affordable-housing communities across 18 states with more than 4,500 new homes for individuals and families in need.

It should be noted that the shortage of affordable housing greatly impacts population health. It limits choices about where people live, often pushing lower-income families to substandard housing in unsafe, overcrowded neighborhoods with higher rates of poverty and fewer resources for healthy outdoor and exercise activities. Further, unaffordable housing can prevent people from meeting other basic needs including nutrition and healthcare.

Not to be outdone, other insurers are also making affordable housing investments. The nation’s second largest insurer, Indiana-based Anthem, has committed about $380 million developing affordable housing over the past decade. Kaiser Permanente, a California-based healthcare provider that also sells health insurance, has invested $200 million to address housing stability, homelessness and other community issues. Blue Cross and Blue Shield of Minnesota, HealthPartners and UCare, all in Minnesota, are also supporting smaller projects to do the same. I’m sure there are other insurers making similar investments elsewhere.

As we all know, healthcare payers are having difficulty controlling escalating healthcare costs. One mindset change is to look ‘upstream’ and find local priorities that are linked to poor health outcomes needing attention. According to one study brief, social determinants account for about 80 percent of health outcomes, meaning that the majority of our healthcare costs can be attributed to non-clinical factors.

Research continues to confirm that unmet social needs are associated with higher rates of hospital admissions, readmissions, and emergency room use. One prime example is that supportive housing has been shown to decrease Medicaid costs by up to 67 percent, which includes reduced emergency room visits and inpatient admissions. Such outcomes can positively impact the private-payer ledger by saving monies paid to medical providers who care for the low-income population.

Investing ‘upstream’ is a smart alternative to the avoidable problems that become more expensive ‘downstream.’ It is good to see that more insurers are also taking this approach.

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Tepid Improvement in Patient Safety Progress
But Massive Savings Are Possible

By: David P. Lind

Healthcare Cost Savings - Tip of the IcebergAs our healthcare delivery system evolves, we must reach beyond the endless discussion and distractions over who pays and how much. The cost, compliance, coverage and political discussions are no doubt important, but these are inextricably linked to the safety outcomes of medical care we expect to receive – but, in too many cases, do not.

The patient safety dialogue has been buried from the general public under many other pressing national concerns:  the general economy, global terrorist activities, general elections later this year, immigration, Middle East unrest, gun control – as well as countless other issues.

In addition to covering more Americans, the premise of the Affordable Care Act (ACA) was to initiate new care delivery models that would eventually make healthcare more affordable and achieve better outcomes. The hope is that our healthcare ‘system’ is now on the path to recovery – we just need to give the initiatives time to work.

But is it really that simple?

If the Centers for Disease Control (CDC) were to include preventable medical errors in hospitals as a category, it would be the third leading cause of death in the U.S. – behind heart disease and cancer. Quite simply, the numbers for those seriously and fatally injured are massive. National estimates indicate that between 6.6 million to 11.5 million patients are seriously harmed in our hospitals – EACH YEAR. For those fatally harmed, the annual estimated range is 98,000 to 440,000 deaths.

Are improvements being made, and if so, by how much? The short answer is Yes, but…

The federal Agency for Healthcare Research and Quality (AHRQ) released a report in late 2015 indicating that hospitals have averted many types of preventable injuries (such as infections and medicine reactions) during the period 2011 – 2014, using 2010 as the base year. During this four-year period, officials examined 30,000 medical cases and, from this, extrapolated the number of complications that were possibly avoided. The cumulative results appear to be downright impressive: 2.1 million fewer incidents of harm, 87,000 fewer deaths and about $20 billion in healthcare savings.

No doubt, this is encouraging news. On the surface, the general public (and media) appear to have only tepid concerns about patient safety issues, most likely because the federal government, hospitals, grant-receiving medical provider collaborations, academia and other organizations are “all over” this national problem.

But these improvements only represent the proverbial ‘tip of the iceberg.’

Even Dr. Richard Kronick, director of the AHRQ, commented that these findings have yet to be fully understood and improvements most likely came from “low-hanging fruit.” In other words, these are the relatively easy problems. Problems in the past that should’ve been averted in the first place, but were not.

Loaded with curiosity, I decided to compare these improvements to national estimates of medical errors to understand how much progress was really made during this four-year period. Using the conservative estimate of 6.6 million patients harmed annually in hospitals, the 2.1 million averted conditions reported by AHRQ during the cumulative four-year period equates to an eight percent improvement. By using the high-end estimate of 11.5 million harmed patients annually, this reported improvement is under five percent. Keep in mind, that 2.1 million was a cumulative amount over four years, while the 11.5 million is EACH year.

As for preventable hospital fatalities, using the conservative 98,000 annual estimate that came from the Institute of Medicine in 1999 (which is now widely considered as being grossly low), about 22 percent of fatalities were averted. The high-end 440K estimate translates to a five percent fatality aversion.

Employers must understand that by averting preventable injuries, the potential cost savings are enormous, dwarfing the $20 billion reported by AHRQ. The cost savings per hospital-acquired condition found in the AHRQ report is almost $9,500. If we use this number, the potential annual cost savings by having all 6.6 million preventable injuries averted would be $63 billion annually. Should 11.5 million preventable injuries be averted, the savings would be estimated around $109 billion annually. This savings would translate into a sizeable benefit to communities, employers, employees and taxpayers. But this projected savings does not even approach the social costs associated with preventable medical errors.

Yes, progress in patient safety improvement is inching forward. But to move the needle beyond this anemic pace, this issue must become a top priority for the general public to force the care delivery system to be more transparent, effective, efficient and, most importantly, safe.

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What is Your Cultural ‘Pie?’

By: David P. Lind

Strawberry Rhubarb Pie

Full Disclosure: This particular strawberry rhubarb pie was NOT made by Deb.

My wife, Deb, makes a scrumptious strawberry rhubarb pie. In fact, I really think she could win a blue ribbon at the Iowa State Fair with her recipe. OK, I must admit that I am just a tad bias – but it’s true!

Carefully measured sugar, flour, salt, butter and eggs are added to freshly-harvested rhubarb and strawberries. The pie crust is prepared to ensure the quality and appearance of the pie will not be compromised. How can the tartness of rhubarb and the sweetness of sugar make this pie so delectable to one’s palate? I have come to the realization that my taste buds must be suffering some sort of culinary schizophrenia – especially when a scoop of vanilla ice cream is added on top!

Using consistent ingredients, coupled with the desire to make the same tasting pie each time is a great recipe for success. Unique and positive experiences eventually result in an ongoing trust that the pie will be equally pleasing to the palate in future interactions.

What a powerful and priceless combination – creating a positive experience for the consumer and, consequently, earning their trust.

Developing and maintaining an organizational culture designed to elicit trust is similar to baking a consistently-prepared strawberry rhubarb pie. It takes the right ingredients and level of determination and commitment to use the same tried-and-true process without compromise.

The idea for this particular blog originated after I finished reading a recently published book, “Think Big, Start Small, Move Fast.” Written by three insiders from Mayo Clinic’s Center for Innovation, this excellent book is about developing and implementing a new culture of transformative innovation for not only healthcare organizations but for any organization that desires to adapt to, and possibly disrupt, the future environments and markets in which they operate.

According to former Mayo CEO Dr. Glenn Forbes, a desired culture must be imbedded into the DNA of the ENTIRE organization. “If you’ve communicated a value but you haven’t driven it into the policy, into the decision making, into the allocation of resources, and ultimately into the culture of the organization, then it’s just words.”

Of all health care organizations, one would think that Mayo could rest on their laurels and continue down the path of excellent care to their patients. After all, Mayo is all about the effective care experience for their patients. Simply put, Mayo practices that the patient comes first – at all times.

It started 150 years ago with William Worrall Mayo and his two sons, Will and Charlie. It continues today because of the consistent ingredients the organization has passed down generation-to-generation, with the same passion to serve each patient today and tomorrow. Similar to the pie, each slice is consistently processed and delivered. Each bite allows the customer to trust that the next slice will be no different.

Mayo continues to search for new ways to accentuate their tried-and-true culture so that they will be prepared to address the needs of the future. This never-ending quest serves as a great lesson for other organizations, both inside and outside of healthcare. When the public sees and feels that the organizational values are consistently customer-centric and baked within the culture of that organization, trust will inevitably endure.

So what beliefs, values and behaviors are reflected in your organization? What are the desired attitudes and behaviors that you wish to seek in the people you hire? Does your organization desire creativity, safety, collaboration or innovation?

Whatever the desired culture is for your organization, hopefully it is a positive one that permeates beyond the workplace setting and soundly resonates with the public.

Just like Deb’s strawberry rhubarb pie!

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