| equity_in_medicine | Equity in Medicine | WSMA_Reports | Shared_Content/News/Latest_News/2020/August/equity_in_medicine | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/WSMA-Reports-Sept-Oct-Article-Image-645x425px%20(002).jpg" class="pull-right" alt="WSMA Reports September-October 2020 cover" /></div>
<h5>August 31, 2020</h5>
<h2>Equity in Medicine</h2>
<p>
By John Gallagher
</p>
<h5><em>Members only; sign-in required.</em></h5>
<p>
An estimated 10,000 health care professionals and students, wearing white coats and scrubs, walked from Harborview Medical Center to Seattle City Hall on June 6 in a Doctors for Justice event to protest racial violence. They had responded to a call to action from Estell Williams, MD, an acute care surgeon at the University of Washington Medical Center and an assistant professor of surgery at the UW School of Medicine, who asked her colleagues to "show the full strength of Medicine that seeks justice for the most marginalized of our community."
</p>
<p>
Motivated in part by the experiences of her own family, Dr. Williams organized the march with her husband, Edwin Lindo, JD, a lecturer at the UW School of Medicine. "I have experienced police violence, racism, and mortality as a result of disparate outcomes experienced by the Black community within my family," Dr. Williams says.
</p>
<p>
In a letter announcing the march, she recalled a childhood event seared in her memory. Her father was pulled over by police while they drove home through a predominantly white neighborhood. As the officers searched their car, "I cried in fear and terror in the backseat, thinking of what they had done to others who looked like my dad," she wrote. "They handcuffed him, took him to the police station and forced him to stay there, while I had to wait in the street for my mother to pick me up. They released him two days later without a charge or valid reason for arresting him. To be clear, my father never committed a crime in his life, and the pain and fear I felt for the days he sat in the jail never leaves my mind. I knew there was a possibility that I would never see him again."
</p>
<p>
Just as importantly, she believes doctors should use their position of privilege to call out all the issues that harm the health of their patients, from overrepresentation in the justice system to poverty, housing, and employment.
</p>
<p>
"All of these things interconnect," Dr. Williams says, "and we as health care workers have to recognize it and speak out because the true health of our communities exists outside the walls of the hospitals and clinics."
</p>
<p>
The renewed awareness about racism has led to a fresh look at health equity issues. For decades, physicians have known that the race or ethnicity of patients or the language that they speak can have an effect—often negative—on their health. According to the Kaiser Family Foundation, Blacks, Hispanics, and Native Americans/Alaska Natives had higher infant mortality rates, die from diabetes at a higher rate than whites, and are in general more likely than whites to report fair or poor health status. Asian Americans/Pacific Islanders overall often fare better than whites, but with wide variation among subgroups.
</p>
<p>
Health equity has always been a complex issue.
</p>
<p>
"Defining 'equity' depends on who you are," says Michael Schaffrinna, MD, chief medical officer at Community Health of Central Washington, which operates federally qualified health centers (FQHCs) in underserved areas. "For some, it's access to care. But there's much more to health care than just getting an appointment or, for that matter, having good clinical care."
</p>
<p>
The COVID-19 pandemic has thrown into sharp relief the issue of health disparities, with much higher rates of infection and death among Blacks and Hispanics. But another event this spring has also affected the discussion about health equity: the killing of George Floyd by police officers in Minneapolis and the subsequent demonstrations about racial injustice.
</p>
<p>
The extent to which racism has affected medicine's ability to eliminate health disparities is now part of the conversation in a way that it never has been in the past. "Racism is a public health emergency of global concern," a recent editorial in The Lancet said. "It is the root cause of continued disparities in death and disease between Black and white people in the USA."
</p>
<p>
"It feels that the normalization of the conversation is much more universal," says Benjamin Danielson, MD, chair of the Governor's Interagency Council on Health Disparities and clinic chief at Seattle Children's Odessa Brown Children's Clinic. "I spent a lot more time preaching to the choir before. Now perhaps the sense of importance and maybe the less compromising nature of the situation does put some emphasis behind real conversations about health equity."
</p>
<p>
Certainly, medical systems have been working hard for years to reduce health disparities. Dale Reisner, MD, medical director (OB-GYN Quality &amp; Safety) at Swedish Health Services and a past president of WSMA, notes that her health system started working to address the issues well before the latest focus on racism.
</p>
<p>
"Even before George Floyd, we have really been trying to enhance our abilities to address health disparities with trainings, information sessions, and respectful treatment of all patients," she says. Reisner has had a particular focus on reducing Black maternal mortality, which in Washington state is twice the rate than for white women, even with the state's mandate for access during pregnancy. (The mortality rate for Black mothers nationally is threefold higher than for white women.)
</p>
<p>
Suicide and postpartum overdoses are major contributors to Black maternal mortality. "Women with mental health and substance use disorders often are not respected, so we've had a very innovative addiction recovery program at Swedish with compassionate care basically as the core of the model," Dr. Reisner says. She adds that the fact that such an approach is even necessary is "sad, when you think about it."
</p>
<p>
Swedish has a program that includes doulas, trained professionals who serve as support for women during pregnancy, birth, and the postpartum period. "Many of them have come from disenfranchised communities, so [they] can relate to the patients," Dr. Reisner notes. "As an advocate with white skin, I can do my best, but someone with brown skin is not going to trust me as much because I don't share their same experience."
</p>
<p>
But as Dr. Reisner and other physicians point out, the progress to date still leaves a lot to be desired, Dr. Williams says.
</p>
<p>
"Even though medicine is getting better, we're still seeing the same disparities," she says. "You can make the argument that people are not only not getting the same level of care but are getting a worse level care."
</p>
<p>
The real challenge with addressing health disparities is that many of the factors that drive it happen outside the clinic. "We give this prescription in the clinic, but we don't then try in a meaningful way to address the ways patients experience the world when they leave the clinic," Dr. Williams says. "We need to recognize that there are certain diseases that need to be treated in a hospital setting, but a lot of problems are directly related to systemic racism."
</p>
<p>
Researchers have long documented the impact that social determinants of health—the conditions in which people are born, live, and work—have on outcomes. Now, the urgency of that work is gaining more recognition and acceptance. "There is greater regard for social determinants of health in embracing health equity in a systematic way," says Dr. Danielson. "Health care systems getting involved in social determinants is a health equity act."
</p>
<p>
Dr. Schaffrinna says that for those kinds of discussions to be successful, "we have to approach it not with blame, but 'How do we change?' " That means acknowledging up front that racism is a problem.
</p>
<p>
"Is there discrimination? Absolutely," he says. "We must confront it."
</p>
<p>
But he believes that medicine should also focus on how poverty is a driver of disparities.
</p>
<p>
"When you look at Americans suffering from the effects of poverty, it appears that all of them suffer," he says.
</p>
<p>
Even within the confines of the system, barriers exist, notably the chronic challenge of financing. Addressing health disparities costs money, such as Swedish's investment in doulas. Investing in such efforts is especially difficult when practices and medical systems are facing huge drops in revenue as a result of the pandemic.
</p>
<p>
"Everybody is recognizing that it's an issue, but no one is willing do anything," says Dr. Schaffrinna. "Most of the FQHCs are trying to begin the process of addressing social determinants, but there's no revenue coming in for that expense."
</p>
<p>
Moreover, some solutions have the potential to shift money away from the medical system altogether. "As a nation we spend an enormous amount of money on health care, and it's not giving us the biggest bang for buck," adds Dr. Schaffrinna. "We should put some of that money into addressing social determinant factors. Our country can't afford to do it all, and the only way to do it is to reallocate resources to other areas, similar to what people are saying about police departments." (Activists have been pushing for cities to invest in mental health workers as front-line respondents to individuals in crisis, instead of the police.)
</p>
<p>
The respect that society places on physicians offers them a special opportunity to play a role in tackling the problem of health equity. "Because we have by nature and profession a caring tendency and because we're interacting with patients who manifest all the effects of this social injustice, it positions us in a unique way to be the ones who also can bring awareness and advocacy for the need to make change," says Okechukwu Ojogho, MD, a transplant surgeon at Providence Medical Group in Spokane.
</p>
<p>
The really thorny question is the extent to which medicine is willing to broaden the conversation about health equity to racism, including institutional racism in medicine. The profession is starting to recognize, as the New England Journal of Medicine said in a recent editorial, that "slavery has produced a legacy of racism, injustice, and brutality that runs from 1619 to present, and that legacy infects medicine as it does all social institutions."
</p>
<p>
Dr. Williams says that the current conversation about racism reveals some long-standing assumptions about medicine. "We've done a disservice to medicine as an entity by attempting to exist as an apolitical, neutral entity," she says. "We have for a long time felt that we're altruistic human beings who are neutral and somehow colorblind, and in doing so, we have blinded ourselves to the root causes that perpetuate the health outcomes we see."
</p>
<p>
Ultimately, the profession has to have a painful conversation about racism if it is going to conquer health disparities, Dr. Danielson says.
</p>
<p>
"I'm hoping a health equity conver- sation is not a substitute for a conversation about racism," he says. "You can do a whole lot toward health equity without changing any power paradigm. You can still hold all the strings and be in a position of power and do more things to promote health equity. An anti-racism perspective has built into it a pretty strong power shift."
</p>
<p>
How much change happens depends on doctors themselves, says Dr. Danielson.
</p>
<p>
"I would imagine a lot of us are on the edge of our seats right now," he says. "Will this really be a transformational time? It would be too bad if people sit on their seats and wait for something external to show them it's time to move forward. Moving forward is the thing we need to do, not the thing we wait for someone else to do."
</p>
<p>
Dr. Williams says that just a year ago, something like the march would have been impossible to imagine. But one conversation with another doctor that she had at the event stood out. In her speech at the march, Dr. Williams noted that "we scrutinize all our actions in the hospital to minimize harm to patients, but we don't consider actions in our greater community with the same scrutiny." The physician that Dr. Williams spoke to had never considered this.
</p>
<p>
"Hearing that physician declare that their eyes were opened showed me that we did something good that day," Dr. Williams says. "And if we opened just a few more eyes, we can do something good for many more lifetimes to come."
</p>
<p>
<em>John Gallagher is a freelance journalist who specializes in health care issues. He is a regular contributor to WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the Sept/Oct. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 8/31/2020 10:32:10 AM | 8/31/2020 10:22:40 AM | 8/31/2020 12:00:00 AM |
| faith_through_action | Faith Through Action | WSMA_Reports | Shared_Content/News/Latest_News/2020/August/faith_through_action | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/WSMA-Reports-Sept-Oct-Article-Image-645x425px%20(002).jpg" class="pull-right" alt="WSMA Reports September-October 2020 cover" /></div>
<h5>August 31, 2020</h5>
<h2>Faith Through Action</h2>
<p>
By Milana McLead
</p>
<h5><em>Members only; sign-in required.</em></h5>
<p>
If you ask what he was like as a child, Nathan Schlicher, MD, answers with a smile, and says, "I was probably a precocious kid."</p>
<p>
That might be an understatement, considering he skipped first, fourth, seventh, and ninth grades, graduated from high school at 14, skipped a year of college, completed law school a year early, and started medical school at 19. “It was normal to me, as crazy as that sounds,†he says.
</p>
<p>
Perhaps that was because a strong, bright family grounded him and kept him humble. “My grandfather was a brilliant physician,†Schlicher says. “He taught me early on: ‘You may be very successful, but there’s probably somebody who’s done it faster, younger, smarter. Don’t get hung up on yourself. Be happy with who you are and try not to make anyone feel any different.’ â€
</p>
<p>
His father, Peter, was a hospital administrator and his mother, Carol, a nurse, so medicine was ever-present in the household. “We grew up talking about medicine and enjoying stories around the dinner table,†he says. “Since my dad wasn’t clinical, my mom would try to gross him out. We all had a great time with that.â€
</p>
<p>
While Dr. Schlicher’s intellect and relative youth are front and center, one quickly learns that a strong faith and a deep passion for service are at his core.
</p>
<p>
An early mentor and Methodist minister known as “Big David†solidly influenced his teen years. “Big David was a good man who lived the message and cared for the people. He was open, loving, and kind, and very much believed in faith through actions,†Dr. Schlicher says. “I try to live as he did in terms of doing what I can for the community; remembering that faith is not words, but actions; and the importance of caring for others.â€
</p>
<p>
A career in medicine was the perfect companion for that framework for life. “I grew up volunteering and always knew that medicine would be part of my life. And emergency medicine—to be able to make a difference, to be there at some of the most challenging times of people’s lives—I love being there in the moments when it matters so much,†he says.
</p>
<p>
If anything keeps him awake at night—at least on the nights he’s not working in the ER at CHI Franciscan’s St. Joseph Medical Center—it’s unsolvable problems. “If I feel like I missed an opportunity to make a difference, to solve a problem I could have had an impact on—my mind churns on ‘What should I have done differently? What could we have done differently?’ We do the best we can, we plan ahead, and think through every scenario to get the right answer. Sometimes it works, sometimes you fail, but you learn and try not to repeat those mistakes.â€
</p>
<p>
Problem-solving comes naturally to Dr. Schlicher, as does taking the lead in finding solutions. Observe that your patients need a voice in the Legislature? Solution: Seek and win appointment to an open seat in the Washington State Senate, and serve as a state senator advocating for effective health care policy. See a need to reduce preventable emergency room visits? Solution: Create an “ER is for Emergencies†campaign that shifted behavior and perceptions about seeking care in the ER.
</p>
<p>
Need to encourage better opioid prescribing behaviors while protecting patients from highly addictive medications? Solution: Design “Better Prescribing, Better Treatment†program as a peer-to-peer, non-punitive initiative that has reduced opioid prescribing
in Washington state, with more than 20,000 prescribers in 50+ health systems participating in the program.
</p>
<p>
Impatient with inaction—a side effect of his life in emergency medicine—Dr. Schlicher’s inner drive to make things better compels him to lead and to step up where needed. “I very much try to live the philosophy that we are going to do things,†he says. “I think that’s what we need to work on in medicine—it’s not just showing up, it’s leading.â€
</p>
<p>
His leadership philosophy serves him well in the ER, in advocacy, and in the WSMA. “It’s important that you listen to the people you’re working with—a leader is a team member. It’s not just leading the team, it’s inspiring them, working to hear their thoughts, and building relationships,†he says. “That comes through listening and having a vision of where you’re going and communicating that vision well.â€
</p>
<p>
He steps into his role as president of the WSMA at an unprecedented time. The impact of COVID-19 has shaken the house of medicine especially hard; Dr. Schlicher sees that as one of the big issues ahead. “COVID is a window into all the dysfunctions in medicine,†he notes. “It’s a lens into the systemic structural problems of health care. That strain on the system is challenging, but it offers us an opportunity to bring positive change for better access to health care, better health systems, and better environments for clinicians to practice in.â€
</p>
<p>
He sees a connection between the issues uncovered by the pandemic and an associated opportunity to improve physician wellness. “The things likely to drive us to burnout are the systemic structural problems, poorly designed EMRs, lack of backup and support, and being asked to do things outside of our scope or abilities,†he says. “We need to build a better work environment to help people be happier in all parts of their lives. If you do it right, people are happy.â€
</p>
<p>
As he leads the work of the WSMA in the year ahead, his focus will be on improving access to health care, physician wellness, and driving quality. And he sees the WSMA as the conduit to making positive change happen. “Physicians need to lead health care because we see it through a clinician’s lens. If you don’t have that, there’s a knowledge deficit in leadership. We need to grow the next generation of trailblazers so that physicians are leading the health systems, regulatory entities, and in Olympia. Physicians need to be at the tables where decisions are made so our voice is heard, and that’s what you support when you join the WSMA.â€
</p>
<p>
<em>Milana McLead is WSMA senior director, strategic communications and growth, and editorial director of WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the Sept/Oct. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 8/31/2020 11:14:07 AM | 8/31/2020 10:29:46 AM | 8/31/2020 12:00:00 AM |
| the_unseen_covid_19_risk_factor | The Unseen COVID-19 Risk Factor | WSMA_Reports | Shared_Content/News/Latest_News/2020/August/the_unseen_covid_19_risk_factor | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/WSMA-Reports-Sept-Oct-Article-Image-645x425px%20(002).jpg" class="pull-right" alt="WSMA Reports September-October 2020 cover" /></div>
<h5>August 31, 2020</h5>
<h2>The Unseen COVID-19 Risk Factor</h2>
<p>
By Pat Curry
</p>
<h5><em>Members only; sign-in required.</em></h5>
<p>
With a high-desert climate and rich, volcanic soil, the Yakima Valley is one of the most important agricultural regions in the country. More than 1.7 million acres in Yakima County are farmland, producing 21% of the state's agriculture sales, according to the U.S. Department of Agriculture.
</p>
<p>
It is also has been one of the nation's COVID-19 hot spots; in May, Yakima County had the highest case rate of any county on the West Coast, according to the Institute for Disease Modeling in Bellevue.
</p>
<p>
According to July data from the Washington State Department of Health, Hispanics make up 13% of the state's population, but had accounted for 44% of the state's confirmed COVID-19 cases and 29% of its hospitalizations.
</p>
<p>
In Yakima County, about 55% of the COVID-19 patients are Hispanic, says Bismark Fernandez, MD, an internal medicine physician and hospitalist at Virginia Mason Memorial who has been working in the COVID-19 unit for several months. That number is probably low, he says, because about 20% of their patients don't report their ethnicity.
</p>
<p>
Dr. Fernandez has seen a recurrent pattern that might contribute to the higher rate of infection in Hispanic patients, he says.
</p>
<p>
"Many have told me that often, family members or friends don't always believe this is a real pandemic; or if they believe it, they are not always aware how easily the virus can spread or how serious this pandemic is," Dr. Fernandez says. "If they don't always believe it or are not made aware of how the virus can spread or how severe the pandemic really is, they may not always follow the safety measures we try to implement. That puts their family members and coworkers at risk. We're trying to educate them; labs and CT scans won't lie."
</p>
<p>
(These problems seem to be improving as Virginia Mason Memorial health care leaders have voiced their concerns and educated the public through various media outlets about the importance of universal masking, adequate hand hygiene, social distancing, and staying at home when sick. In July, Yakima was cited as one of the metro areas where new COVID-19 deaths are decreasing most.)
</p>
<p>
The patient demographic Dr. Fernandez has seen is being repeated across the state. A July report from the DOH said "the impacts of COVID-19 morbidity and mortality have not been felt equally by all populations in Washington state. The pandemic has exacerbated the underlying and persistent inequities among historically marginalized communities and those disproportionately impacted due to structural racism and other forms of systemic oppression."
</p>
<p>
When adjusted for age, Hispanic people and Native Hawaiian or other Pacific Islanders have infection rates nine times higher than white people. Blacks and American Indian or Alaska Native case and hospitalization rates are three times higher than those of whites, the report says.
</p>
<p>
The Cross Cultural Health Care Program is a Seattle nonprofit training and consulting organization founded to advance access to quality health care that is culturally and linguistically appropriate. Bryon Lambert, the organization's director of equity and inclusion, says he's "not surprised that people of color are succumbing to COVID-19 at much higher rates than their white counterparts."
</p>
<p>
The work of the CCHCP is getting "a lot more interest in the wake of the protests of the killing of George Floyd while in police custody." Lambert notes that health equity requires health care leaders to recognize that systems have their own cultures and biases that can create issues for patients.
</p>
<p>
"One of the big misconceptions we try to dispel is when people believe it's the patients who are non-compliant or don't seek care, or don't eat healthy or are doing all these things to themselves," he says. "We kind of flip it. We help them understand that the institutions that are designed with the intention of helping people often can be unintentionally amplifying disparities."
</p>
<p>
Jeff Duchin, MD, the local health officer for Seattle and King County, is another health care leader who says the numbers are not unexpected.
</p>
<p>
"It's been an ongoing national tragedy and shame that we have communities of color throughout our country suffering disproportionate adverse health impacts from a wide variety of health conditions," Dr. Duchin told a Seattle Times reporter.
The reasons for the disparities are numerous and long-standing. A recent interview in Scientific American with public health specialist and physician Camara Phyllis Jones, MD, MPH, PhD, goes as far as to say that racism, not race, is a risk factor for dying of COVID-19. A former medical officer and director of research on health equity at the Centers for Disease Control and Prevention, Jones says racism has increased exposure to the virus for people of color, given them less protection from it, and burdened them with chronic illnesses, such as diabetes and hypertension, that put them at high risk.
</p>
<p>
People of color are more exposed to the virus, Dr. Jones says, because of residential and educational segregation that leads to limited job opportunities, crowded housing conditions, and overrepresentation in prisons and jails. Testing sites for the virus have tended to be located in more affluent neighborhoods or in drive-in locations that require having a car.
</p>
<p>
Some of those scenarios are familiar to Dr. Fernandez in Yakima. Many of his Hispanic COVID-19 patients are living in very small dwellings with a large number of family members. If one person has symptoms, it's difficult to self-isolate.
</p>
<p>
Because they work in lower-paying jobs, they don't stay home or go to the doctor when they're sick.
</p>
<p>
"The symptoms are very broad and can be very mild, so they continue to go to work," Dr. Fernandez says. "One of the reasons they continue to work is they don't get sick benefits. They can't afford to miss 10 days of work. But by doing that, they're putting their co-workers and their family members at high risk."
</p>
<p>
People of color also tend to work in jobs that can't be done from home. The study by the Institute for Disease Modeling noted that in Yakima County, 14% of the population works in agriculture, forestry, fishing, and hunting, jobs which require leaving the house. In King County, the top employment category is professional/technical jobs that often can be done remotely.
</p>
<p>
"Our community has been fortunate to receive the highest quality care possible for everyone that has needed it," Dr. Fernandez says.
</p>
<p>
Virginia Mason Memorial has been working hard to make the public aware that race, financial status, or immigration status "won't keep you from getting high- quality care. We don't refuse anyone."
</p>
<p>
<em>Pat Curry is WSMA Reports' senior editor.</em>
</p>
<p>
<em>This article was featured in the Sept/Oct. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 8/31/2020 10:34:15 AM | 8/31/2020 10:27:03 AM | 8/31/2020 12:00:00 AM |
| white_coats_for_black_lives | White Coats for Black Lives | WSMA_Reports | Shared_Content/News/Latest_News/2020/August/white_coats_for_black_lives | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/WSMA-Reports-Sept-Oct-Article-Image-645x425px%20(002).jpg" class="pull-right" alt="WSMA Reports September-October 2020 cover" /></div>
<h5>August 31, 2020</h5>
<h2>White Coats for Black Lives</h2>
<p>
By John H. Vassall II, MD
</p>
<h5><em>Members only; sign-in required.</em></h5>
<p>
I was gratified to join with thousands of masked colleagues in a recent march from Harborview Medical Center to Seattle City Hall in support of the struggle against racism. This felt different than when I participated in a march across the Edmund Pettis Bridge in Selma, Alabama, on the 50th anniversary of Bloody Sunday, or when I first tasted tear gas during the March on Washington in my college days.
</p>
<p>
The size and diversity of the crowds and the depth of the conversations were greater than in the past. Systemic racism and the oppression of people of color was acknowledged, not defensively denied.
</p>
<p>
Yet discussions of "social determinants of health" can deflect attention from racism in medicine and health care delivery. James Marion Sims, the "father of modern gynecology," developed his surgical techniques after experimental surgery without anesthesia on enslaved women. The Tuskegee syphilis study, in which Black men were observed as a deadly, treatable disease ravaged their bodies, has left a legacy of mistrust of American medicine among many African Americans. To this day, biomedical corporations continue to reap billions of dollars from HeLa cells, cancerous cells used in research that were removed and cloned from the cervix of a Black woman named Henrietta Lacks taken without her knowledge or consent; Henrietta and her family were not compensated.
</p>
<p>
How might we address racism in medicine? We can learn from our efforts to address safety in medicine. In 1999, the Institute of Medicine issued its landmark report, "To Err Is Human: Building a Safer Health System," documenting that 44,000 to 98,000 people each year died in American hospitals because of preventable medical errors.
</p>
<p>
Like many of my colleagues, my reaction was denial. I was a practicing primary care physician dedicating every day of my life to healing. I refused to believe that I could be responsible for the unnecessary death of my patients.
</p>
<p>
But when I studied the literature, I came to understand that unsafe policies and procedures, a hierarchical culture, and lack of error-prevention skills made hospitals dangerous environments. To prevent needless deaths from errors and to make substantive change, I came to the painful realization that I was putting my patients at risk with every hospital admission. Despite my best intentions and doing everything I was trained to do, I almost certainly must have had patients who died in my care from an error I did not recognize.
</p>
<p>
As with systemic safety issues, so it is with systemic racism. It may be difficult to see, but it still causes harm.
</p>
<p>
What should we do? Make it personal. We can do everything in our power to make health care safer or we remain complicit with unsafe conditions; there is nothing in between. We can either do everything in our power to recognize and deconstruct racism or remain complicit with racism. There is no other choice.
</p>
<p>
Become educated about systemic racism. Racist ideas, policies, and practices have been developed, entrenched, and refined over hundreds of years. They are inculcated in culture and are self-perpetuating. They will not change without intention and effort, just as hospitals became safer only after systemic changes and education of physicians, all hospital workers, and patients about recognizing and mitigating unsafe practices and behaviors.
</p>
<p>
Act. Have brave, respectful conversations that focus on the system and the problem, not the people. With faith in ourselves and in our collective humanity, we can and will prevail against racism if we continue the effort we've started.
</p>
<p>
<em>John H. Vassall II, MD, is CEO of the Foundation for Health Care Quality and serves as a WSMA trustee.</em>
</p>
<p>
<em>This article was featured in the Sept/Oct. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 8/31/2020 10:32:33 AM | 8/31/2020 10:28:26 AM | 8/31/2020 12:00:00 AM |
| quality_improvement_put_to_the_test | Quality Improvement Put to the Test | WSMA_Reports | Shared_Content/News/Latest_News/2020/July/quality_improvement_put_to_the_test | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="WSMA Reports: July/August 2020 issue cover" src="/images/Newsletters/Reports/2020/COVER-WSMA_JulyAug-2020-645x425px.jpg" class="pull-right" /></div>
<h5>July 2, 2020</h5>
<h2>Quality Improvement Put to the Test</h2>
<p>
By Rita Colorito
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
At 8 p.m. on Feb. 28, Jeff Tomlin, MD, CEO of EvergreenHealth in Kirkland, received the news he'd been dreading. Ettore Palazzo, MD, the chief medical and quality improvement officer, confirmed that Evergreen had its first case of COVID-19.
</p>
<p>
Evergreen had been on alert since Jan. 20, after The Everett Clinic, some 20 miles north, reported the first U.S. case of the novel coronavirus. Evergreen recorded the state's first COVID-19 patient death on Feb. 29. That same day, Gov. Jay Inslee declared a state of emergency.
</p>
<p>
Within 30 minutes, Evergreen activated its incident command system and sent its administration team to literally take the information to the front lines, an approach based on its belief that quality improvement needs to filter from leadership to teams to empower them to develop solutions that work.
</p>
<p>
Dr. Tomlin was dispatched to the obstetrics floor, where nurses asked what they would do with expecting mothers and their families who may have COVID-19. "The staff weren't panicked. They were in problem-solving mode right away," says Dr. Tomlin. Two weeks later, obstetrics admitted a pregnant woman with fever and flu-like symptoms. "Thanks to that discussion, we had a structure in place to deal with that. It's an example of leadership being present and learning from the front-line staff," he says.
</p>
<p>
Evergreen's response to the challenge flowed from the guiding principles of its quality improvement program—absolute safety, effective care, and service to the patient, says Dr. Tomlin. Like other health care providers throughout the state, Evergreen's QI infrastructure has been both validated and challenged by the rapidly unfolding pandemic. The lessons learned, say Drs. Tomlin and Palazzo and other QI leaders, will carry them not only through this crisis and others, but also in their day-to-day quest for quality improvement.
</p>
<h3>Preparation determines response</h3>
<p>
Beginning with the worldwide SARS outbreak in 2003, and the threats of H1N1 in 2009 and Ebola in 2014-16, pandemic preparedness has become an increasing concern of U.S. health care systems.
</p>
<p>
For the last decade, EvergreenHealth has participated in the Northwest Healthcare Response Network, a coalition focused on building a disaster-resilient health care system. Through NHRN, 200 of Evergreen's QI and leadership staff have attended all-hazards training at the CDC's Center for Preparedness and Response in Alabama. UW Medicine and Seattle Children's are also NHRN members.
</p>
<p>
"Your response is completely dependent on your preparation," says Dr. Tomlin. "It doesn't have to be a pandemic. If you don't have some of these systems in place to respond to any disaster... if you haven't thought of them in advance, your response is going to be delayed. And it's going to add uncertainty within your staff."
</p>
<p>
Over the Cascades and 150 miles east of Seattle, Confluence Health activated its incident command on March 1, bracing for the worst. Three days later, Confluence recorded its first coronavirus case. The processes put in place early on prepared for the surge that came two weeks later, says CEO Peter Rutherford, MD.
</p>
<p>
As nursing home cases and deaths increased in Kirkland, Confluence dispatched a palliative medicine rapid response team to local skilled nursing and assisted living facilities, adult family homes, jails, and homeless shelters. The focus was on teaching isolation measures and ensuring personal protective equipment in those facilities was adequate. "That really shut down outbreaks in those facilities and really saved us," says Dr. Rutherford.
</p>
<p>
The palliative team also provided advance care planning that helped prevent the system from being overwhelmed, says Rachel Reeg, MD, a Confluence hospitalist and a member of WSMA's board of trustees.
</p>
<p>
Making sure health systems have the necessary resources to adequately treat patients while protecting staff remains a top concern around COVID-19. Confluence's ethics committee changed the focus of its regularly scheduled meeting to address a potential resource shortage, says Dr. Reeg, the committee's vice chair since March.
</p>
<p>
"We knew that many COVID patients would require intensive care. Our main response was preparing to coordinate crisis standards of care with regional and state committees, and then introducing the organization to the idea of crisis management and allocation of scarce resources through our virtual meetings," she says.
</p>
<h3>Communication and transparency matter</h3>
<p>
"Nature abhors a vacuum. And if you don't fill that with facts, it will get filled with rumor and innuendo and that's incredibly destructive," says Dr. Rutherford.
</p>
<p>
Soon after its founding in 2013, Confluence's board of directors passed its first QI policy known as Speak Up, which encourages staff to voice any concerns regarding quality or safety to address problems in the moment, if possible. "That really set us up pretty well to move forward when this whole COVID endemic and then pandemic got started," says Dr. Rutherford.
</p>
<p>
Specialists and other providers at Confluence have felt freed to do what they need to do, says Dr. Reeg. "Our organization has been extremely supportive of individual responses and willingness to help. A lot of people have been happy for the opportunity to contribute," she says.
</p>
<p>
Communication and transparency breed trust, says Dr. Tomlin, a necessary component to keeping staff committed to the mission. "Having good quality improvement systems in place is important. But perhaps the most important aspect of those systems is 'have you developed the trust and collaboration with the groups that you are leading?' " he says. "If the staff doesn't have trust and a sense that you are working closely with the front lines to keep everyone safe, then it's hard to ask them to put themselves in harm's way."
</p>
<p>
Effective risk communication— understanding how best to share information to not only health care workers, but also the public and the press—has proven critical for developing that trust, says John Lynch, MD, MPH, an associate medical director at Harborview Medical Center in Seattle.
</p>
<p>
"Every infectious disease doc out there, because of the work we do, needs to be prepared in how we communicate to our facilities and colleagues," says Dr. Lynch. He also recommends that all doctors have a knowledge of incident command (IC) structure. "Especially with a novel pandemic, it's like an earthquake every day, so it's important for every doctor to have some sort of knowledge on their role in IC," he says.
</p>
<p>
As the urgency grew at the end of February, Dr. Lynch, a University of Washington associate professor, was asked to lead the clinical response across the UW system. He and a team of 15 infectious disease, infection prevention and control, employee health, and QI experts spent the first two months working more than full time, seven days a week, almost exclusively on the crisis response. They provided guidance and support, but also empowered and relied on front-line staff to develop protocols and policies that made sense for them.
</p>
<p>
The knowledge and credibility of these physicians have been the important leadership qualities needed to steer the UW system through the crisis, says Dr. Lynch. "The other doctors know we're there to offer support, not to hold data against them when they start seeing infections."
</p>
<p>
Dr. Lynch says he also learned the value of well-being when it comes to managing a pandemic. At the request of Patricia Kritek, MD, Ed.M., a UW critical care and pulmonary physician, Dr. Lynch joined a weekly virtual town hall to field questions from front-line workers worried about the unknowns of the virus and looking for support and answers.
</p>
<p>
The town halls average about 500 participants; one topped 1,000 people. "Taking an extra hour felt like a huge
ask at the time when there was so much other emergency stuff going on, but it was absolutely the right thing to do," he says.
</p>
<h3>Rethinking improvement</h3>
<p>To prepare for any crisis, quality improvement needs to be a continual process, says Dr. Palazzo. In September 2019, months before the coronavirus appeared in China, EvergreenHealth's infection control and QI team began meeting monthly to review its pathogen response policies and protocols.
</p>
<p>
"It had been several years since we had performed a comprehensive review of our High Consequence Infectious Disease Pathogen protocol," says Dr. Palazzo. "When this all hit us in late February, we were fortunate that we didn't have to dust off any books on how to move areas to negative airflow or to cohort patients. It literally had been worked on the months ahead of time and that really put us in a good position when we got our first cases."
</p>
<p>
While cost-benefit analysis factors into any QI program, COVID-19 caused financial considerations to take a back seat, says Dr. Rutherford, as health care systems halted elective surgeries and procedures to flatten the curve.
</p>
<p>
"We took a perspective at the beginning of this that, as an organization, we were going to do the right thing for the community and deal with the financial impacts later; that having money in the bank in a broken care system later wasn't where we wanted to be," says Dr. Rutherford. Feeling freed from the financial considerations helped Confluence get a handle on the virus quickly, he says.
</p>
<p>
The virus forced action on both immediate and long-term needs. Within a week, Confluence had converted its entire third floor to negative pressure. And it finally implemented telehealth capabilities, after years of discussing it.
</p>
<p>
Despite the financial hit from COVID-19, Dr. Rutherford sees a silver lining going forward. "These aren't things that will go away. They are now done. They are part of our organization," he says. "It's really just, let the right people lead it. Let them do their piece."
</p>
<p>
<em>Rita Colorito is a freelance journalist who specializes in covering health care. She is a regular contributor to WSMA Reports.</em>
</p>
</div> | 7/2/2020 12:04:12 PM | 7/2/2020 11:11:56 AM | 7/2/2020 12:00:00 AM |
| small_steps_to_wellness | Small Steps to Wellness | WSMA_Reports | Shared_Content/News/Latest_News/2020/July/small_steps_to_wellness | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="WSMA Reports: July/August 2020 issue cover" src="/images/Newsletters/Reports/2020/COVER-WSMA_JulyAug-2020-645x425px.jpg" class="pull-right" /></div>
<h5>July 2, 2020</h5>
<h2>Small Steps to Wellness</h2>
<p>
By Pat Curry
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
When health care leaders pay attention to quality improvement, physician wellness is a beneficiary.
Virginia Mason saw an example of this with one of its early QI efforts: standardizing exam rooms in the outpatient primary care department.That meant finding out what was in the rooms and talking to clinicians to find out what they needed at their fingertips to do their jobs well, says Carrie Horwitch, MD, an internal medicine physician at Virginia Mason Medical Center.
</p>
<p>
"Now, I know any room I go into anywhere in my section is the same. I can find anything I need in my room; I don't have to go looking for things."
</p>
<p>
It may seem like a small thing, but it means physicians can give better care to their patients. When systemic failures keep doctors from doing it, it contributes to what many refer to as burnout. Dr. Horwitch prefers the term "moral distress" or "moral injury."
</p>
<p>
"If I can't do my work well to care for my patients, that causes distress to me as a physician because that is my obligation," Dr. Horwitch says. "The tenor of an organization comes from its leaders. If they value, respect, and truly care for the people who work for them, you'll have more engagement and, I think, less moral distress."
</p>
<p>
It's essential, Dr. Horwitch says, for health care leadership to not only have skill in the financial areas of medicine, but also to have compassion for the people doing the caregiving. "Emotional intelligence is really important and it needs to be taught to head leadership and middle management leadership as well," she says.
</p>
<p>
The value of quality improvement on physician wellness became extraordinarily apparent during the COVID-19 pandemic, when Virginia Mason was able to make what seemed like an "overnight transition from in- person to virtual visits," Dr. Horwitch says. "We turned something that could have been a several-months project into a couple weeks, making sure we could take care of our patients and keep ourselves safe."
</p>
<p>
For her, the rapid implementation of telehealth was evidence that Virginia Mason cared about her well-being.
</p>
<p>
"It made me feel valued making sure we have adequate protective equipment and having systems in place to keep us safe," she says. "It made me feel very good."
</p>
<h3>Broken systems</h3>
<p>
Edward Walker, MD, MHA, who just retired from a 40-year career at the University of Washington, works on the connection between leadership, quality improvement, and physician wellness. As a former senior medical executive and psychiatrist, he has coached physician leaders in the art of self- and organizational transformation as a pathway to wellness. One of the ways physicians can become distressed is working within systems that were not designed properly to support their effort, he says.
</p>
<p>
"Instead of telling our colleagues that they need to do mindfulness or yoga to deal with this stress, we should be helping them learn to transform their systems to support better care," he says. "When I see a distressed patient in clinic, the first thing I do is try to figure out whether the person is experiencing an abnormal reaction to a normal situation or a normal reaction to an abnormal situation.
</p>
<p>
"Quite often, physician burnout is an understandable and appropriate reaction to a very broken system," he says. "The solution to broken systems is quality improvement, and the key to quality improvement is leadership."
</p>
<p>
As lead educator for the WSMA, Dr. Walker has mentored nearly 1,000 individuals through its Physician Leadership Course. System transformation is a learnable skillset involving quality improvement, emotional intelligence, and community building; the skills taught in the course are invaluable to quality improvement and gaining buy-in from front-line physicians.
</p>
<p>
"I think some people approach quality improvement as a technical, analytic skill without fully understanding the leadership component and the connection to wellness," he says.
</p>
<p>
Leaders not only have to know what to do, but they have to build consensus around best practice standards and then "gently inspire and nudge" colleagues to follow and maintain those standards. Efficient and safe care is better for the patient, but it also feels better for the physician.
</p>
<p>
Physician-led systems have the advantage of designing work processes that are more directly influenced by the needs of the doctor-patient relationship and the ability of the physician to practice the art, as well as the science, of medicine.
</p>
<p>
"I've never met a physician who didn't feel fulfilled realizing he or she had done the absolute best for a patient," he says. "Quality improvement makes that possible."
</p>
<h3>The search for joy</h3>
<p>
Quality improvement and physician wellness is so vital to health care that the American Medical Association has a provider satisfaction, practice sustainability department. Its overall goal is to identify where "joy, purpose, and meaning can be possible for our health care professionals," says Kevin Taylor, MD, the AMA's director of organizational transformation.
</p>
<p>
"It sounds odd to have organizational transformation as part of a physician wellness program," Dr. Taylor says. "It's actually crucial to this kind of work. We understand there are major drivers of burnout and dissatisfaction or lack in meaning in your work. A good portion of that is the inefficiencies of our current workflow and the leadership culture in the systems we're part of."
</p>
<p>
Many evidence-based strategies can save physicians and care teams time that then can be devoted to their patient care. Dr. Taylor recommends the AMA StepsForward website, <a href="mailto:stepsforward.org">stepsforward.org</a>.
</p>
<p>
"There are dozens of modules that will enhance your clinical workflow and restore meaning in your work," he says.
</p>
<p>
Direct leaders of our physicians have a major influence on the culture of their health system and as a result, have an impact on their colleagues' sense of well-being and burnout. To help drive physician satisfaction, "leaders need to be active and visible; they need to actively listen, engage, and empower physicians to identify problems and help them to become part of the solution."
</p>
<p>
For many physicians, the health care culture has taken away their autonomy, choice, and agency. "Autonomy is an internal motivator for physicians," Dr. Taylor notes. "They want to have a voice in the system design and workflow but feel they are losing influence as the care delivery systems become more and more complex."
</p>
<p>
To be successful, physician leaders should take time to listen to their colleagues, give them the opportunity to identify the "pebbles in their shoes," and empower them to work with their teams to develop action plans that will improve their care delivery.
</p>
<p>
Physicians also need coaching on how to work collaboratively in a participative leadership style, he says. This is not a skill physicians learn in medical school, but they need it in the current health care environment where teams are so important. This requires new skills with process improvement and change management tools to effectively communicate and facilitate teams to achieve our mutual goals.
</p>
<p>
"You must be able to collaborate with your care teams to be successful in a clinically integrated network," Dr. Taylor says. "Participative leadership is the new reality for our physicians."
</p>
<p>
<em>Pat Curry is senior editor of WSMA Reports.</em>
</p>
<p><em>
This article was featured in the July/August 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div>
<br />
<div class="telerik_paste_container" style="border-width: 0px; position: absolute; overflow: hidden; margin: 0px; padding: 0px;">&nbsp;</div> | 7/2/2020 11:39:11 AM | 7/2/2020 11:19:14 AM | 7/2/2020 12:00:00 AM |
| the_crucible_of_covid_19 | The Crucible of Covid-19 | WSMA_Reports | Shared_Content/News/Latest_News/2020/July/the_crucible_of_covid_19 | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/Newsletters/Reports/2020/COVER-WSMA_JulyAug-2020-645x425px.jpg" class="pull-right" /></div>
<h5>July 2, 2020</h5>
<h2>The Crucible of Covid-19</h2>
<p>
By Nariman Heshmati, MD
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
When the first known COVID-19 patient in the United States was admitted to my local hospital, we quickly understood this would be a far-reaching battle that would surely involve many more patients.
</p>
<p>
As that case made national news, colleagues from around the country called, texted, and emailed asking how things were going in Washington state and how they could help. Even as they were reaching out, we were coordinating between health care systems, together trying to understand a path forward, to provide guidance to state officials, and to ensure we were prepared to take care of our communities.
</p>
<p>
When the epicenter of COVID-19 shifted to New York and overwhelmed their health care systems, soon I was calling, texting, and emailing those same physicians to see how they were faring. And as a practicing OB-GYN, I was shocked when I heard that New York hospitals were not allowing laboring women to have their partners be present with them. Obviously, one-to-one emotional support during labor is critical and can improve outcomes.
</p>
<p>
The day I read those news reports, I walked into an exam room to see one of my own patients. Terrified that she would be forced to give birth alone, she was considering a home birth. This, despite evidence that even low-risk home birth outcomes are worse than those in a hospital setting. As a high-risk pregnancy, she was last person who should deliver anywhere but in a resource-rich hospital prepared for emergencies. I reassured her that physician leaders overseeing labor units in Washington were supportive of having partners present during labor.
</p>
<p>
Ultimately, New York state reversed its policies and allowed laboring women to have partners present, but I wondered: What was the difference between Washington and New York? We faced the same crisis, but responded to it differently. The answer? Here in Washington, we relied more on physician leadership.
</p>
<p>
We've seen more clearly how physician leadership can make a difference as a result of the COVID-19 crisis. As physicians, being involved in leadership ensures that the future health care system is one in which our patients not only will receive the best care, but also one in which physicians want to practice. We can make a difference on a large scale even when not faced with a worldwide pandemic.
</p>
<p>
Studies show that health care systems with physician CEOs have improved quality and outcome measures over those that do not. Physicians bring a unique perspective when taking on leadership roles in health care organizations. We understand the struggles on the front line, we have been exhaustively trained to gather data and make rapid difficult decisions, and we view scenarios through the lens of clinical care.
</p>
<p>
Times of crisis such as the COVID-19 pandemic can illuminate the shortcomings in our systems, but more importantly, they demonstrate our immense ability to adapt nimbly and respond to care needs in ways we could never otherwise imagine.
</p>
<p>
We also put our patients first. And my anxious patient? She had a beautiful and safe hospital birth with the support of her husband at her side.
</p>
<p>
<em>Nariman Heshmati, MD, is an OB-GYN at The Everett Clinic and serves as the secretary-treasurer on WSMA's executive committee.</em>
</p>
<p><em>
This article was featured in the July/August 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 7/2/2020 11:40:09 AM | 7/2/2020 11:19:18 AM | 7/2/2020 12:00:00 AM |
| controlling_the_cost_of_care | Controlling the Cost of Care | WSMA_Reports | Shared_Content/News/Latest_News/2020/May/controlling_the_cost_of_care | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/COVER-WSMA_MayJune-2020-645x425px.jpg" class="pull-right" alt="WSMA Reports cover - May/June 2020" /></div>
<h5>May 5, 2020</h5>
<h2>Controlling the Cost of Care</h2>
<p>
By John Gallagher
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
Companies are always looking for ways to trim costs, so it's no wonder that health care is often on the top of the list. Employer-sponsored health insurance covers about half of the non-elderly population in the United States, but at a significant cost. The Kaiser Family Foundation estimates that the average family insurance premium is more than $20,000 a year. On average, workers in 2019 paid $6,015 toward the cost of family coverage, with employers paying the rest.
</p>
<p>
For years, some employers have tried to manage the financial burden by sharing more of it with their employees. Employee share of premium costs has risen more than 70% in the past 10 years. High-deductible plans were introduced on the grounds that workers with more skin in the game would be better health care consumers. (In fact, studies show the plans lead to a decrease in high-value care for patients.)
</p>
<p>
The approach invariably created a backlash. "One of the reasons I think this has become more acute is the cost of a care episode has become more transparent with high-deductible plans," says David Grossman, MD, senior medical director for community health and external relations at Kaiser Permanente Washington. "The cost is hitting consumers in the face. High-deductible plans have unleashed a lot of concerns."
</p>
<p>
Having failed to curtail their health care costs so far, employers are now looking to a new target to save money: physicians. According to a Jan. 13 article in Modern Healthcare, employers are "eyeing more aggressive measures to counter the formidable market power of consolidated hospitals and physician groups."
</p>
<p>
The COVID-19 epidemic may only make that pressure worse. Faced with severe financial losses due to the economic downturn, companies will be increasingly desperate to squeeze every possible savings they can from their expenses.
</p>
<p>
However, making cost the primary driver for decision-making about health care is short-sighted at best, even in light of the epidemic. While costs are driving the conversation, the real issue is the way the system is structured. Employers can help make the necessary changes in collaboration with physicians.
</p>
<p>
"If you're talking about reducing the cost of care, you need comprehensive change," says Jennifer Hanscom, executive director and CEO of the WSMA. "It's not an easy fix. The concern about controlling costs, while important, could unfairly single out physicians and overlook other drivers of cost."
</p>
<h3>The search for solutions</h3>
<p>
Several public- and private-sector purchasers in Washington are pursuing innovative solutions that rely upon close collaboration with physicians. The Washington State Health Care Authority, which covers more than 2 million people through its Apple Health and state employee programs, has an ambitious goal: having 90% of health care it purchases be value-based, which rewards physicians and providers for the quality of care that they offer. State employees can choose from several value-based plans.
</p>
<p>
Along with the HCA, Boeing has been a pioneer in this effort. In 2014, it contracted directly with UW Medicine and Providence Health &amp; Services to offer a value-based plan for its employees. The HCA and Boeing plans promise not only lower costs for the employers, but a better patient experience for employees.
</p>
<p>
Capitation can offer a way out of the fee-for-service cycle that can perversely reward overuse. "Payment mechanisms like capitation are the way to go for the future," says Dr. Grossman.
</p>
<p>
Capitation is one way to solve the confusion inherent in the current payment system, agrees Philip Chan, MD, MHA, associate medical director for population health for UW Medicine/ Valley Medical Center. While the predominant fee-for-service system rewards physicians for the volume of care they provide, capitation rewards physicians for the quality of care they provide.
</p>
<p>
However, few employers are as large as the HCA and Boeing. Smaller and mid-size companies lack the size to create similar plans. Their interest may be more in cost savings and less in innovation. As a result, employers may be tempted to use a much blunter approach to saving money by creating narrow networks and slashing physician payments.
</p>
<p>
"We have to manage the problem of unintended consequences, such as the downside of narrow networks," says Hanscom. "Also, reducing reimbursements to physicians is a disincentive to participating in a plan, to say nothing of putting financial pressures on already struggling practices and contributing to physician burnout."
</p>
<h3>Targeting cost drivers</h3>
<p>
Considering physicians to be the problem and not the solution to health care costs overlooks a critical factor: Physicians know better where the waste is in the system and, as a result, where the savings lie.
</p>
<p>
For example, a local company came to Confluence Health in North Central Washington seeking help to reduce the number of workers using emergency departments for regular primary care. As it turned out, the main reason why employees were turning to the ED for routine care was that they were afraid of missing work during regular business hours.
</p>
<p>
Working with the company, Confluence set up a family practice clinic at the jobsite for employees and their dependents. The agreement provided Confluence with a bonus if it could reduce the company's total cost of care, while employees got incentives to improve their own health markers. As a result, ED visits declined by 25% and diabetic control measures improved by 40%.
</p>
<p>
Confluence's example highlights one of the main drivers of cost: overuse. "When it comes to total health care costs, two factors have to be addressed: utilization and unit price," says Dr. Grossman.
</p>
<p>
Simply ensuring clinical standards of care are followed more rigorously can lead to significant savings. "Utilization is the one thing we can tackle sooner than later," says Dr. Chan. "We have to try really hard to standardize our care and follow evidence-based clinical practice guidelines: If you're treating this, this should be your initial approach."
</p>
<p>
As for unit price—the measure of how much it costs to deliver a particular treatment or service—the current system provides no incentive to measure or control it.
</p>
<p>
"As a system, we don't understand what it costs to do things," says Edwin Carmack, MD, medical director for value-based care at Confluence Health. "We're the only business that doesn't know what it costs us to do something. We estimate based on what we get paid. What it costs us to do it, we don't know." A system in which physicians are responsible for the total cost of care would make that knowledge of unit cost essential and incentivize ways to control it.
</p>
<p>
Plenty of cost drivers are available for employers to target. Spending on drugs is high on the list.
</p>
<p>
"Having a tighter formulary can bring costs down a lot," says Dr. Grossman. "Ensure the right meds are going to the right people, not giving them too many drugs and expensive drugs unnecessarily."
</p>
<h3>Changing the system: a benefit for employers and physicians</h3>
<p>
As much as physicians are interested in employers moving toward a value- based system, they remain caught in a confusing world where fee-for-service is the primary system and demands are fragmented across different insurers.
</p>
<p>
"It is challenging working with various versions of value-based contracts," Dr. Chan notes. "The requirements and number of quality metrics vary among payers. This results in labor-intensive data reporting and tracking. It makes it harder to home in and focus on clinically important metrics that providers can actually control."
</p>
<p>
Ultimately, the question about how employers can cut costs should really be about how they can finally change the system for the better. Doing so will lead to the cost savings companies seek.
</p>
<p>
In the meantime, physicians remain stuck in a system that is always pushing for change, but never quite does.
</p>
<p>
"From the perspective of the physicians, they're still in two canoes: fee-for-service and value-based purchasing," says Hanscom. "For all the talk about innovation, we're not seeing enough of it."
</p>
<p>
<em>John Gallagher is a Washington state- based freelance journalist who specializes in covering health care.</em></p>
<p><em>
This article was featured in the May/June 2020 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="[@]WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:21:36 AM | 5/5/2020 11:36:44 AM | 5/5/2020 12:00:00 AM |
| hope_in_the_time_of_covid_19 | Hope in the Time of COVID-19 | WSMA_Reports | Shared_Content/News/Latest_News/2020/May/hope_in_the_time_of_covid_19 | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/COVER-WSMA_MayJune-2020-645x425px.jpg" class="pull-right" alt="WSMA Reports cover - May/June 2020" /></div>
<h5>May 5, 2020</h5>
<h2>Hope in the Time of COVID-19</h2>
<p><em>Members only; sign-in required.</em></p>
<p>
"As a species, we have coexisted and survived with an immense assortment of organisms, all pushing for a niche in which they, too, can flourish. We turn out to be fantastically resourceful - both in our physical and in our social structures. Each challenge results in subtle changes to our systems. SARS-CoV-2 is just the latest of these challenges, and it, too, will require us to adapt in ways that are likely to strengthen our resilience even more. Humanity will get through this fine, but we need to be willing to make major changes in how we function and behave until either we're through the pandemic or we have mass immunization available. Our past successes give me great optimism about our future." - <em>John Bramhall, MD, PhD</em>
</p>
<p>
"I am hopeful because I have seen teammates doing everything in their power to care for patients. Health care entities have collaborated in ways we would have never imagined - embracing technology to provide care in a matter of days instead of years. The way health care is delivered will be forever changed for the better. I am hopeful because I see compassionate people step forward to lend a helping hand. This crisis could have brought out the worst in us or the best in us - I am hopeful because it did the latter." - <em>Nariman Heshmati, MD</em>
</p>
<p>
"What brings me hope is that each generation of Americans is challenged with fears and despair, but always comes through. Some call this American exceptionalism. I call it the American people. We will work together to defeat the enemy, and you can take that to the bank." - <em>William K. Hirota, MD</em>
</p>
<p>
"Being at home with my daughter and seeing life through her eyes brings me hope. Being a doctor and mommy during these times is not easy. But looking to the future is what being a doctor mom is all about. Taking care of my patients, my work family, the residents I train, and my daughter is what brings me hope. Seeing us all come together... that brings me hope." - <em>Katina Rue, DO</em>
</p>
<p>
"I am given hope by two responses that, together, give our society the strength to get through this: neighbors looking for ways to help each other even at risk to themselves, and organizations getting past corporate inertia to respond rapidly and appropriately to a crisis." - <em>Tom Schaaf, MD, MHA</em>
</p>
<p>
"I find hope in my teammates in the emergency department where we see some of the darkest moments in people's lives. We provide compassion and hope to our patients, while caring for each other as a team. As we endure this season of COVID on the front lines, it is our ED family and those at home that help us through." - <em>Nathaniel Schlicher, MD, JD, MBA</em>
</p>
<p>
"I'm impressed by the generosity of our patients who are obviously feeling poorly and suffering from chronic illness but are willing to forgo or delay treatment so that others who are more urgent can get the care they need. Stressful and life-changing events like this bring out the best in people. I see that in my patients. I also see hope in everyone pulling together and getting the job done. In this crisis, we've learned to keep nimble and not make simple things overly complicated." - <em>Mika Sinanan, MD, PhD</em>
</p>
<p><em>
This article was featured in the May/June 2020 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="[@]WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:22:59 AM | 5/5/2020 11:40:18 AM | 5/5/2020 12:00:00 AM |
| what_are_we_spending_on_health_care | What Are We Spending on Health Care? | WSMA_Reports | Shared_Content/News/Latest_News/2020/May/what_are_we_spending_on_health_care | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/COVER-WSMA_MayJune-2020-645x425px.jpg" class="pull-right" alt="WSMA Reports cover - May/June 2020" /></div>
<h5>May 5, 2020</h5>
<h2>What Are We Spending on Health Care?</h2>
<p>
By Pat Curry
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
When Washington State Rep. Eileen Cody started her career as a nurse more than 40 years ago, "insurance wasn't that big of a deal," she said. "A lot of people didn't have insurance. You could go into a hospital without being insured."
</p>
<p>
Today, with health care costs, insurance premiums, and out-of-pocket expenses higher than ever, some 400,000 Washingtonians are uninsured. For the tens of thousands more who buy insurance from the state's health benefit exchange, the out-of-pocket expenses are so high they can't afford to use it. It's insurance in name only. With the outbreak of COVID-19, access to high-quality, affordable health insurance is more important now than ever.
</p>
<p>
Cody, who represents the 34th Legislative District (Vashon Island, West Seattle, White Center, and Burien), chairs the House Health Care and Wellness Committee. The most senior Democrat in the state House of Representatives, she has been a state legislator since 1994; with her decades of medical experience, Cody is a health policy leader in Washington state's legislature.
</p>
<p>
WSMA Reports spoke with her about the recent legislative session and her vision for reducing health care costs in Washington state. The starting point for achieving that goal, Cody said, is getting a clear grasp of how much health care actually costs in the state. For that reason, she co-sponsored House Bill 2457 to establish a state health care cost transparency board.
</p>
<p>
The purpose of the board is to calculate and analyze information and trends related to all health care costs in Washington. The board also must annually establish the health care cost growth benchmark for increases in total health expenditures and analyze provider and facility cost increases. At press time, the bill had passed both houses of the Legislature and was awaiting Gov. Jay Inslee's signature.
</p>
<p>
"I'm trying to look at what we're really spending on health care across the state," Cody said. "It'd be nice to know what (health care) should cost. ... The CEO of a hospital said in front of our committee, 'Our billing has nothing to do with cost.' I've been saying that for 26 years! That's the problem."
</p>
<p>
With a goal of reducing health care costs for the state's residents, the first thing Cody said she would like to do is to raise the Medicaid reimbursement rate and to lower reimbursement on other health plans, namely those for teachers and state employees. The health care cost transparency board will provide the data to make a case for that.
</p>
<p>
The new panel, which will consist of public- and private-sector health insurance purchasers, will be responsible for annually calculating and releasing information on health care costs in Washington, including increases statewide for each health care provider, system, and payer. As in other states, the panel also will establish benchmarks for future health care cost increases and track expenditures against the annual benchmark. (The WSMA will nominate a physician to participate on an advisory committee that informs the panel's work.)
</p>
<p>
"First we need to find out what we're spending and then look at how it's spent," Cody said. "We don't know what people are paying. If we can get [information on] the spend, then we can see where the cost drivers are."
</p>
<h3>Gaining insight from other states</h3>
<p>
Washington is not the first state to tackle total cost of care or implement a method of tracking health care expenses. Massachusetts, which enacted a health care cost containment law in 2012, is furthest along, Cody said. They established a new agency, the Massachusetts Health Policy Commission, to oversee health care system performance and provide policy recommendations regarding health care delivery and payment system reform. Its sister agency, the Center for Health Information and Analysis, collects health care information from payers, providers, provider organizations, and third-party administrators and is a primary source of health care analytics that support policy development.
</p>
<p>
Cody said she doesn't want that kind of system for Washington state.
</p>
<p>
"In Massachusetts, they have a whole commission and did a whole big hoopla," she said. "I didn't want another agency looking at health care costs."
</p>
<p>
Data Washington state gets now from its all-payer claims database provide most pricing information but don't address total health care spending or the cost drivers behind the prices.
</p>
<p>
"The question has been raised how much is regulation driving cost," Cody said. "That's a little down the road. First, let's find out what we're spending and then we can look at how it's spent."
</p>
<h3>The public option compromise</h3>
<p>
Looking back on the 2019 session, Cody readily admits that the state's public insurance option—the nation's first, which is set to go into effect next year— diverged from what she proposed in her initial bill. That was a plan that capped reimbursement at Medicare rates. In the bill that ultimately passed and was signed into law, the state-sponsored plan will cap reimbursement to providers and facilities at 160% of Medicare.
</p>
<p>
"I always start out very aggressive knowing we'll have to compromise," she said. "The good thing is we have a standardized benefit package on the exchange. If nothing else happens, that's a good thing. It lowers the out-of-pocket expense and the deductible. That was outrageous; that's not really insurance."
</p>
<p>
The state estimates the standardized benefit package, coupled with the reimbursement cap, could lower premiums by 5-10%. That's not a huge savings, but given the massive premium increases on the health benefit exchange plans (35% in 2018), any drop in the premium would be cause for celebration. (The WSMA participated in public option negotiations throughout the 2019 session. We opposed the final bill due to concerns that physicians and health care facilities would not be able to contract to participate in the plan under the terms envisioned in the law, resulting in health plans that don't have adequate access to care for enrollees.)
</p>
<p>
The range of options being discussed at the state and national levels run from market-rate coverage to Medicare for All, "but there's no discussion about the rates," Cody said. "People still want choice, but they want everything for nothing and it just doesn't work too well that way.
</p>
<p>
"I think it's great to have the total cost of care discussion to own up to how much does it cost for things," she said.
</p>
<p>
Noting that prescription drug prices play a significant role in driving up health care costs, Cody noted that is one area that needs to be addressed at a federal level. It is ludicrous, she said, that the same drugs in other countries cost a fraction of the price than they do in the United States.
</p>
<p>
"The U.S. does the research and everyone enjoys that benefit," she said. "We can't allow that to continue."
</p>
<p>
State legislators passed a bill this session to cap the monthly out-of- pocket expense of insulin to $100 per month; at press time, that bill also was awaiting the governor's signature. Cody also favors legislation and/or regulation that would require insurers to apply prescription costs—and prescriptions bought using discount coupons—toward their customers' deductible and out-of- pocket expenses.
</p>
<p>
"It's ridiculous they aren't counting the cost of drugs toward the deductible," she said. She noted that her former patients, who had multiple sclerosis, needed prescription drugs that cost $7,000-$8,000 a month.
</p>
<h3>Paying doctors the right amount</h3>
<p>
Asked whether recent and proposed tax increases on physicians and health care entities, such as the business and occupation tax, run counter to the push to make health care more affordable, Cody said she agreed that it "doesn't help, necessarily. That's designed to make sure we have the next generation of doctors through college and practicing."
</p>
<p>
Given the opportunity to share what she wants Washington state doctors to know, Cody said, "We have to figure out how to get people paid the right amount of money for the work they do," she said. "It's wrong that doctors might get their bonuses from Press Ganey [patient satisfaction] scores. It tells them they can't say 'no' to a patient. That's not the way patient care should be measured. It should be patient outcomes. I appreciate a crusty doctor who does the right thing.
</p>
<p>
"In my 40 years as a nurse and 26 years as a legislator, I have seen a lot
of changes in health care," she said. "We still haven't made any headway
on [addressing the cost]. There used to be an incentive to order tests; now, it's the other way around. I personally like more global budgeting, which increases payment if you do a good job. It's very hard to make those kinds of changes."
</p>
<p>
<em>Pat Curry is senior editor of WSMA Reports.</em>
</p>
<p><em>
This article was featured in the May/June 2020 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="[@]WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:24:04 AM | 5/5/2020 11:40:24 AM | 5/5/2020 12:00:00 AM |
| a_virtuous_cycle | A Virtuous Cycle | WSMA_Reports | Shared_Content/News/Latest_News/2020/March/a_virtuous_cycle | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/Cover-WSMA_MarApril-2020-v6-645x425px.jpg" class="pull-right" alt="WSMA Reports cover" /></div>
<h5>March 4, 2020</h5>
<h2>A Virtuous Cycle</h2>
<p>
By Nicholas Rajacich, MD
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
I was surprised to hear a colleague express hesitation when I suggested that her practice, struggling with caseloads and administrative work, hire a physician assistant. After all, at my orthopedic practice, we were preparing to hire even more PAs (which will mean more than one PA per doctor).
</p>
<p>
For our practice, it's simple: PAs help us increase access to our services (more care for more people) and help manage many of our day-to-day tasks (fewer hours spent by our physician specialists on administrative work and less-complex procedures). Put even more simply, the bottom line is that our PAs are good for our practice's bottom line - both for patient care and practice revenue.
</p>
<p>
With most PAs trained in primary care, few come to us with experience or training in our surgical specialty. Some choose to do an additional year of specialized training, which we have found to be quite valuable. While it requires a significant commitment of time to train them both in the clinic and in the OR, the returns on this investment accrue rapidly.
</p>
<p>
For example: In the OR, our PAs prep the patients for surgery, handle the post-op orders, apply tourniquets during the operation and, in the case of a PA who's been around a while, close and dress incisions. Complicated patient discharges? Our PAs have us covered, arranging follow-up visits, DME prescriptions, and so on.
</p>
<p>
As their training moves along, and as the individual PA gains more experience, we give them expanded independence in our practice. With experience, we allow our PAs to see an independent panel of patients, saving the complex patients for our physicians.
</p>
<p>
And of course, a PA can do many of the tasks that doctors are being tasked with (more and more...and more) these days. With the development of EMRs and increasing regulatory requirements, there's a large burden of administrative material that a PA can help me with.
</p>
<p>
At this point, our investment in teaching these PAs has more than paid off. Our physicians are now freed up to practice at the highest level of our training and to see more new patients, which is a win-win for everyone.
</p>
<p>
We do at times allow PAs to run clinics offsite. In most situations when a PA is seeing patients in clinic, there is a physician available, either by phone (with the ability to review X-rays via PACs) or in person, to answer questions or provide advice as needed.
</p>
<p>
There are some relatively simple legal hurdles that one must address before hiring a PA, most of which can be navigated with the help of staff at the WSMA and the Washington Academy of Physician Assistants. Promising work is being done by those organizations at the state level to modernize the requirements around the PA delegation agreement - the document describing what training and supervision will be provided and what duties delegated to the PA. Ultimately, what's important is to clearly define and document the clinical partnership and to regularly revisit and revise as needed. This is key to building a successful physician-PA team and to ensure the highest quality of care for our patients.
</p>
<p>
At our practice, the use of PAs has led to greater access to care, which, in turn, has led us to hire more PAs (I envision a day when we may well have two PAs per doctor). It's a virtuous cycle if there ever was one, and one I'll continue to recommend to other physician colleagues.
</p>
<p>
<em>Nicholas Rajacich, MD, is a pediatric orthopedic surgeon at Mary Bridge Children's Orthopedic Clinic.</em>
</p>
<p>
<em>This article was featured in the March/April 2020 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:25:19 AM | 3/4/2020 12:41:00 PM | 3/4/2020 12:00:00 AM |
| partnering_to_solve_the_health_care_puzzle | Partnering to Solve the Health Care Puzzle | WSMA_Reports | Shared_Content/News/Latest_News/2020/March/partnering_to_solve_the_health_care_puzzle | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/Cover-WSMA_MarApril-2020-v6-645x425px.jpg" class="pull-right" alt="WSMA Reports cover" /></div>
<h5>March 4, 2020</h5>
<h2>Partnering to Solve the Health Care Puzzle</h2>
<p>
By Rita Colorito
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
Residents of rural Grays Harbor County know what it means to wait for health care. The coastal southwestern Washington community has one primary care physician for every 2,980 residents, compared to the statewide ratio of one physician for every 1,220 residents, according to a 2019 analysis by the Robert Wood Johnson Foundation. Lack of access, among other factors, has taken its toll: The county ranks 36th of out 39 for overall health outcomes.
</p>
<p>
Working in an environment that's chronically underserved requires a collaborative approach to health care, says Ken Dietrich, MD, chief medical officer for Summit Pacific Medical Center in Elma. That's where physician assistants come in. These practitioners are nationally certified and licensed to prescribe medication and practice medicine in inpatient and outpatient settings in all 50 states and the District of Columbia.
</p>
<h3>Improving access to care</h3>
<p>
To improve patient access to care, Summit takes a team-based approach, using non-physician practitioners such as physician assistants as primary care providers, or PCPs. Over the last decade, Summit has focused on recruiting PAs to fill the PCP gap. The use of these skilled and flexible practitioners, says Dr. Dietrich, is something medical centers and physician practices should consider.
</p>
<p>
"We tell patients we have all these PCPs; does it matter who they see? Oftentimes, they say, 'I just want to get in as soon as I can,' so that's really created an opportunity for us," he says.
</p>
<p>
Two kinds of patients need access to care, says Dr. Dietrich: those who don't have a primary care physician and those who do, but can't get in to see them. To accommodate in-paneled patients, a PA runs Summit's same-day clinic, serving as a conduit between the patient and their physician.
</p>
<p>
"Patients can get in when they need to and the PA communicates collaboratively with that patient's physician, if necessary," says Dr. Dietrich.
</p>
<p>
For rural communities such as Elma, PAs have proven to be an essential piece of the health care puzzle. They're also invaluable in urgent care, where reducing wait times is paramount regardless of geographic location, says Eileen Ravella, a PA-C with 36 years' experience who works in urgent care for Kaiser Permanente in Olympia.
</p>
<p>
"The flexibility of PAs helps with patient care and throughput," says Ravella, who also serves as the president of the Washington Academy of Physician Assistants. "I'm seeing all levels of acuity I'm comfortable with. I may see a complicated patient and work with physicians to get the patient admitted, do all the evaluations, and order tests. Or I may see the lesser acuity patients and the physicians may see the extremely complicated patients to help patient flow."
</p>
<h3>What collaboration looks like</h3>
<p>
Physicians who work with PAs say they help practices see more patients and provide continuity of care. Collaboration is at the core of the PAs role in health care.
</p>
<p>
"The collaboration looks different depending on the context, the geographic location, and the complexity of the patient," says Leah Yoke, PA-C, MCHS, who holds a joint appointment at the Seattle Cancer Care Alliance (SCCA) and Fred Hutchinson Cancer Research Center.
</p>
<p>
Yoke, who specializes in internal medicine and infectious disease, works in inpatient and outpatient settings in concert with oncologists and hematologists to diagnose, prevent, and treat infections in patients with cancer.
</p>
<p>
Cancer care centers also face a shortage of infectious disease physicians. Here, too, PAs can fill the gap, says Yoke, who promotes PA usage to cancer centers nationwide in her member ambassador role with the Infectious Diseases Society of America. For cancer patients, who often face a cascade of treatments and a dizzying number of specialists, PAs provide a familiar presence, says Yoke, as they are often the only provider who sees them across multiple treatments and teams.
</p>
<p>
"Typically, we're seeing really complex patients that have multiple comorbidities," says Yoke. "Because we don't have a ton of ID physicians, I'm able to see all the patients and help teams make decisions in a timely manner and provide some of that logistical legwork that we wouldn't otherwise be able to do."
</p>
<p>
"For the transplant service in particular, they're really a major piece of how cancer patients are cared for," says Steve Pergam, MD, MPH, an infectious disease faculty member and medical director of infection prevention at SCCA.
</p>
<p>
"We see patients together. We review cases together. But I think they've really allowed us to see more patients in our practice," says Dr. Pergam. "Because they're consistently on service whereas as doctors we're coming on and off service all the time, they have the ability to provide additional context and continuity for patient care."
</p>
<h3>At the top of everyone's profession</h3>
<p>
PAs also allow physicians and other PCPs to work at the top of their license to focus their energies on their most complex cases.
</p>
<p>
"In academic environments where we're often doing lots of things—research, teaching, and other responsibilities beyond just direct patient care—they are critical to our service. They communicate with teams directly and we often do a lot of shared decision-making, specifically for our complex patients," says Dr. Pergam, an associate professor in the division of allergy and infectious diseases at the University of Washington School of Medicine in Seattle.
</p>
<p>
PAs practice in nearly every area of medicine, with approximately 50% providing primary care services. The next largest proportion, some 23%, focus on surgery or surgical subspecialties.
</p>
<p>
"The physician assistants I've been most familiar with definitely assist the entire team in being able to be more efficient in what we do," says Jeanne Poole, MD, a professor of medicine in the division of cardiology at UWSOM.
</p>
<p>
PAs can do a fair amount of high- level work alongside surgeons and proceduralists, says Dr. Poole. "We train them to be able to specialize and do portions of procedures, like sutures and getting access to venous systems."
</p>
<p>
Lyle Larson, PA-C, PhD, entered the field of cardiac electrophysiology in 1986 when it was a new subspecialty at the UW Medical Center in Seattle. Along with Dr. Poole, who was a new attending physician at the time, Larson helped build the practice into what it is today. In 2018, the two also co-edited the textbook "Surgical Implantation of Cardiac Rhythm Devices."
</p>
<p>
"It has been a positive, collaborative experience," says Larson. Because of his deep experience, Larson helps to teach electrophysiology fellows how to do the surgical aspects of pacemaker and defibrillator implantation. "When there are particularly difficult cases, the electrophysiologists expect and ask for me to be on their cases to assist them," he says.
</p>
<p>
Dr. Poole says highly experienced PAs such as Larson are integral to the cardiac electrophysiology practice. In the operating room, a PA's experience with complicated procedures, such as carefully implanting or removing cardiac rhythm devices and leads, makes the entire procedure safer, she says. "It's also an educational opportunity for young physicians who may not have had that same degree of experience."
</p>
<h3>The question of oversight</h3>
<p>
Despite the many positives, Ravella says PAs aren't being used to their fullest potential as a result of ongoing misconceptions.
</p>
<p>
"We're coming up against physicians who have real concerns about the perceived competition between physicians and PAs, and there is none. We can't practice without them. They are our team," says Ravella. "We're not here to replace physicians. We can't replace you. We are dependent practitioners."
</p>
<p>
Larson echoes that sentiment: "I'm certainly qualified to do procedures on my own, but that does not make me a surgeon. That does not make me an electrophysiologist. That makes me a very, very skilled PA who can function as a right-hand man for the physicians to take care of their patients."
</p>
<p>
Another barrier to utilization: the idea that PAs require direct supervision. In reality, PAs need minimal supervision, says Ravella.
</p>
<p>
At Summit, physicians are available if a PA has a question or concern, but they don't have to be there physically to provide oversight, says Dr. Dietrich. "Because we have such an integrative model, on a day-to-day basis, our PCPs are touching base with one another, connecting with patients, so there's a lot of collaborative care."
</p>
<p>
"Certainly, you don't have to have a physician right next to a physician assistant if they are working within the scope of their training," says Dr. Poole. "For procedures, that's different because you are really working as a team— multiple hands trying to accomplish a certain procedure."
</p>
<p>
PAs can and do serve as resources for others in the medical community. Larson and Yoke both work as teaching associates at the UW Medical Center. Dr. Dietrich says experienced PAs at Summit often serve as mentors for new doctors.
</p>
<p>
"Our PAs are highly expert, spending all of their time dealing with high- risk, immunocompromised patients," says Dr. Pergam. "Because they are so knowledgeable, they can be a great first resource for the teams to ask questions directly. And then the PA will come to us with the more complex questions."
</p>
<h3>Investing in the future</h3>
<p>
The approach to using PAs to their fullest credentialed potential needs to be well thought out, says Dr. Dietrich. Summit has a flat hierarchical structure. All team members go through initial onboarding and an external yearly peer review. This makes for a more effective, integrative, and collaborative approach to care, he says.
</p>
<p>
Summit typically hires experienced PAs, but about three years ago, it began adding PAs directly out of training. For these PAs, Summit provides a year- long residency-style program. While there's a lot of initial oversight, as these PAs gain experience and confidence, they are given more responsibility and eventually obtain their own panel of patients to manage.
</p>
<p>
"By investing in their training, you're investing in a resource who is hopefully going to stay with you," says Dr. Dietrich. "Can they see all complexity of patients? No. But they can see 75% of patients."
</p>
<p>
The investment has paid off. About 25% of Summit's PCPs are PAs. If a patient develops a complex diagnosis while under a PA's care, the PA consults with physicians or other PCPs, but they would continue to manage that patient's care, says Dr. Dietrich. "It's the right care by the right person at the right time."
</p>
<p>
It comes down to the breadth of skills PAs bring to a team, says Dr. Poole. "PAs are very well-educated individuals. Many have had some sort of prior experience, such as medic experience in the military, so their training is solid," she says. In her work, PAs have proven highly valuable members of the team. "They should be sought after and included as part of the allied professional team for anyone considering expanding their practice in that manner."
</p>
<p>
<em>Rita Colorito is a freelance journalist who specializes in writing about health care.</em>
</p>
<p>
<em>This article was featured in the March/April 2020 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:26:25 AM | 3/4/2020 12:42:30 PM | 3/4/2020 12:00:00 AM |
| training_to_address_the_regions_unmet_health_care_needs | Training to Address the Region's Unmet Health Care Needs | WSMA_Reports | Shared_Content/News/Latest_News/2020/March/training_to_address_the_regions_unmet_health_care_needs | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/Cover-WSMA_MarApril-2020-v6-645x425px.jpg" class="pull-right" alt="WSMA Reports cover" /></div>
<h5>March 4, 2020</h5>
<h2>Training to Address the Region's Unmet Health Care Needs</h2>
<p>
By Pat Curry
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
In 1968, 14 former medics or corpsmen enrolled in a new program jointly sponsored by the WSMA and the University of Washington School of Medicine and funded by the National Center for Health Services Research. The 18-month program, called the MEDEX Demonstration Project, would allow them to continue the training they had gained in the military and use it to begin careers in civilian health care as physician assistants.
</p>
<p>
The program, only the second of its kind in the nation, was created by Richard A. Smith, MD, to address a shortage of qualified medical professionals. By the time MEDEX Northwest celebrated the 50th anniversary of that first graduating class in 2019, the program had graduated more than 2,600 physician assistants.
</p>
<p>
Over the years, the program expanded beyond accepting former military medics—it now accepts applicants with health care experience, including nurses, EMTs, Alaska community health aides, medical assistants, and athletic trainers. The original class of 14 is now 140 students training in four locations in Seattle, Spokane, Tacoma, and Anchorage, with a fifth location in Hawaii in the works.
</p>
<p>
Central to the mission at MEDEX Northwest is a commitment to educating "experienced health personnel from diverse backgrounds to practice medicine with physician supervision."
</p>
<p>
"As one of the original programs in the country, our program was established on people with prior health care experience," says Terry Scott, PA-C, MPA, DFAAPA, program director of MEDEX Northwest. "We still think that matters. When you walk into medicine after just two years of study, you need some experience with the health care field."
</p>
<p>
A graduate of MEDEX, Scott trained and worked in both rural and urban communities in Washington, worked in HIV vaccine research, and provided primary care to HIV-positive patients. He joined the MEDEX faculty in 1996 and maintains a practice at the University of Washington Family Practice Residency in Seattle.
</p>
<p>
The PA program also has gotten longer; it is now a master's degree with 27 months of training and a capstone project. The first year consists of didactic training, followed by a four- month family practice preceptorship and then six one-month clerkships in behavioral medicine, emergency medicine, surgery, inpatient, and underserved populations; and one elective. During that time, the students also work on an in-depth, clinically relevant capstone project.
</p>
<p>
"There's been a maturing of the profession," Scott says. "The complexity of the profession requires the education be extensive and exhaustive."
</p>
<h3>Keeping the vision alive and moving forward</h3>
<p>
Senior Medical Director Tim Evans, MD, PhD, FACP, is one of the MEDEX faculty the students see in the classroom in their first year of training. Dr. Evans gives 250-300 hours of lectures a year; he says he has immense admiration for their commitment to medicine.
</p>
<p>
"Our students, year after year after year, are really terrific," Dr. Evans says. "They're smart, they're hardworking, they're here for a reason. ... They're making some very serious sacrifices. You have to honor that, and I do."
</p>
<p>
With the MEDEX program residing in UW's department of family medicine, the training PAs receive complements that of physicians in the same way PAs complement physicians in clinical practice.
</p>
<p>
"Medicine is a team sport," Scott says. "You need to teach everyone how to get the highest level from their training. We want all of us out there making a difference in the lives of our patients, delivering care to the public."
</p>
<p>
While much has changed over the last half century, Scott notes that one thing has stayed the same: the program remains committed to diversity and inclusion, equity and justice.
</p>
<p>
"We want to provide training and education to meet the nation's health care needs," he says. "That's from Dr. Richard Smith. He had an idea of what he wanted this program to be; those values have remained. It's in our DNA. We are the current caretakers of that vision."
</p>
<p>
The message Scott would share with WSMA members is that MEDEX is a well-established program and that PAs are not technicians.
</p>
<p>
"We are health care providers trained to deliver high-quality health care in collaboration with physicians," he says. "What doesn't change is a team- based approach to medicine. We are still here determined to deliver high-quality health to the region and the country."
</p>
<h3>A mission of rural service</h3>
<p>
Heritage University, Washington state's second PA training program, currently is training its fifth class of PAs. Program Director Linda Dale, PA-C, DHEd, has been a PA since 1996 and taught for 10 years at MEDEX.
</p>
<p>
The mission of Heritage University's program is to put its students in primary care in rural, underserved areas.
</p>
<p>
"We are in Toppenish," she says. "We're in the middle of the hop fields; we are a Hispanic-serving institution. I was born and raised in this area; it's always been medically underserved. Most Washington counties are. Even in King County and Spokane County, there are pockets that are underserved. Our mission is to increase access to health care for those populations."
</p>
<p>
"That's an intense need," says Medical Director Joseph DiMeo, DO. "I'm also a clinician in town. The deficits in patient access to care are acute."
</p>
<p>
The school has "done pretty well so far" in addressing that mission, Dale says. The national average for PAs working in rural areas is 12.5%; Heritage has 24% of its grads working in rural areas, she says. Nationally, 26.7% of PAs work in primary care; for Heritage grads, it's 46%.
</p>
<p>
The focus of Heritage University's training is primary care. It complements the training of physician students by following the medical model for training. On a weekly basis, students attend class with DO students at Pacific Northwest University.
</p>
<p>
"We are side-by-side with DO students doing case discussions and workshops where they'll do sutures, splinting, casting," she says. "It's an interprofessional education, not only with DO students but nursing, pharmD, and paramedic students, for some of our clinical case discussions."
</p>
<p>
Heritage teaches in systems modules, such as the cardiovascular system. A module covers anatomy and physiology, how to do an exam, what it looks like in a child, an adult, an elderly patient, chronic conditions and how that presents in the ER, Dale says.
</p>
<p>
"In that same model, we'll teach how to treat it, including pharmacology and lifestyle," she says. "When complete, we test on it. Once that's tested, we moved to the next system."
</p>
<p>
The biggest difference from MEDEX's curriculum comes in the clinical year, Dale says. Heritage places students in a clinical site for a full year, working there two days a week. For the rest of the week, they do their specialties—surgery, pediatrics, obstetrics and gynecology, inpatient, emergency medicine, and mental health—switching about every six weeks. Sites are primarily in Washington, Idaho, Montana, and Alaska.
</p>
<p>
"The beauty of that is that when they learn something in their specialty, they'll bring it back to primary care," she says. "It gives them a great handle on it and takes the fear away from having to know everything as a primary care provider. I think that is why we have 46% of our students in primary care; they've been in it for a full year.
</p>
<p>
"This training is what a family practice physician used to do in the old days," she says. "Now with changes in their training, we're seeing more and more physicians go to specialties. We're trying to go back to the family medicine model. Sometimes, the old ways might be better."
</p>
<p>
That focus is being coupled with more and more simulation, Dr. DiMeo says. The result is that students get a greater experience of hands-on integration with medical decision-making "so they can handle more difficult things in a safe environment before they go into clinical practice."
</p>
<h3>Evidence of impact</h3>
<p>
Even with just four graduating classes under its belt, Heritage University already is seeing its efforts rewarded with increased access to health care in underserved areas.
</p>
<p>
"The impact on those patients' lives is difficult to measure, but relieving the pressure on the other clinicians in the area cuts down on their stress and ultimately keeps them practicing in those areas longer," she says.
</p>
<p>
To help address the workforce challenges physicians are facing, Heritage University works to get students ready to see patients as soon as they finish their clinical rotation, Dr. DiMeo says. "They're not a draw against the number of patients the [physician] has to see in a day."
</p>
<p>
"Over the course of their training and then when they go into clinical practice, their education needs to continue," he says. "They need to fit into the practice; there needs to be a comfort level between what the PA thinks they can handle and what the physician thinks they can handle, communicating on a daily basis about any complicated things. That's less and less over time. ... Even at times a physician will be challenged and call for a consult. That is the way medicine is practiced."
</p>
<p>
<em>Pat Curry is senior editor of WSMA Reports. </em>
</p>
<p>
<em>This article was featured in the March/April 2020 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:27:24 AM | 3/4/2020 12:42:33 PM | 3/4/2020 12:00:00 AM |
| Behind_the_Cover | Behind the Cover | WSMA_Reports | Shared_Content/News/Latest_News/2020/January/Behind_the_Cover | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMAReports-Extras-Website-645x425.jpg" class="pull-right" alt="WSMA Reports Extras logo" /></div>
<h5>January 17, 2020</h5>
<h2>Behind the Cover</h2>
<p><em>Members only; sign-in required.</em></p>
<p>Kicking off the new year with our January/February edition of <em>WSMA Reports</em>, art director Erin Foster selected internationally renowned Spanish-Argentinian illustrator <a href="http://www.martinelfman.com/" target="_blank">Martín Elfman</a> as the issue's cover illustrator. </p>
<p>"What drew me to Martín's work is his keen sensibility for pinpointing a story's concept with striking minimalist elements," she says. "He also has a deft line quality and sense of color that I felt would make for a strong cover art. He definitely did not disappoint!"<br />
<br />
<a href="javascript://[Uploaded files/News and Publications/Publications/WSMA Reports Archive/WSMA_JanFeb 2020-PRINTERS FINAL.pdf]">View the cover illustration for <em>WSMA Reports</em>' January/February 2020 issue</a>.</p>
<p>
The cover story focuses on the federal and state actions that may impact the medical profession during the legislative sessions in 2020. From that broad-based topic, the article touched on many of the concerns currently plaguing physicians—administrative burdens caused by prior authorization, the threat to independent physician practices from the state’s business and occupation (B&amp;O) tax, and the need for reimbursement to catch up with the emerging technology of telemedicine. </p>
<p>
Here’s how Martín saw the challenge: “The story behind the cover is about the challenges lawmakers will face in the next legislative session. How to give a graphic shape to concepts as abstract as legality and health? After much thought, I suddenly realized that the dome of the Washington State Capitol building can easily be transformed into the bell of a stethoscope. This is my favorite moment of the creative process, the spark in which everything fits and an unexpected solution appears. From there, with that little finding in my pocket, it was just about adding a doctor at the other end of the stethoscope, listening carefully to measure the state of health of the legislative chamber."</p>
<p>
His concept was spot on from our perspective. All that was needed was to make the Capitol building look like our own state Capitol in Olympia, and to write a headline that tied it all together. And done! Check it out and let us know what you think.
</p>
<p><em>WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:38:07 AM | 1/17/2020 10:36:14 AM | 1/17/2020 12:00:00 AM |
| a_doctor_in_the_house | A Doctor in the House | WSMA_Reports | Shared_Content/News/Latest_News/2020/January/a_doctor_in_the_house | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMA_JanFeb-2020-PRINTERS-FINAL-Cover-645x425px.jpg" class="pull-right" alt="WSMA Reports January-February 2020 cover" /></div>
<h5>January 2, 2020</h5>
<h2>A Doctor in the House</h2>
<p>
By John Gallagher
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
It was just a year ago that Issaquah pediatrician Rep. Kim Schrier, MD, entered the U.S. House of Representatives representing Washington state's 8th Congressional District. She became not only one of 89 first-time members of the House, but also the only woman physician in Congress. "I had no idea really what to expect," Dr. Schrier says now, looking back. "I had no idea of what a day-to-day life of a member of Congress would be."
</p>
<p>
What she discovered was that the environment on Capitol Hill wasn't the snake pit that most people think exists in the current Congress.
</p>
<p>
"I was so pleasantly surprised to find good people who just want to do the best for their communities, who sacrifice their lives at home, their time, and their privacy," Dr. Schrier says. "They're very welcoming. It's an honor to be part of the freshmen class with so many people from different backgrounds, but all motivated to run for the same reasons."
</p>
<h3>A doctor's heart for health care</h3>
<p>
Dr. Schrier's reason for running was to advance health care policy. "I spent a lot of time on the campaign trail talking about having a woman doctor in Congress," she says. "A lot is happening in the health care arena, and we shouldn't leave these decisions up to people who haven't worked in, lived in, and been patients in this crazy system of ours."
</p>
<p>
Living up to her promise, Dr. Schrier began her first term by diving right in to health care policy and legislation and serves as co-chair of the New Democratic Coalition Health Care Task Force. As is befitting for a pediatrician, one of her key issues has been the Vaccines Awareness Campaign to Champion Immunization Nationally and Enhance Safety (VACCINES) Act, which she introduced. The bill would track places with high vaccine hesitancy, or decreasing vaccine rates, study why this is happening, and then target information to those places specifically tailored to the reason.
</p>
<p>
"If my VACCINES bill can help increase immune rates and push back against the narrative of the anti-vaxxers, I would feel great, even if that's the only thing I accomplished," she says.
</p>
<p>
Dr. Schrier has been heavily involved in other health care legislation, such as efforts to shore up the Affordable Care Act. She has also been active in efforts to expand Medicare to include vision coverage and to protect patients against surprise billing.
</p>
<p>
She heard stories of patients who checked their plans' provider directories to make sure that their physician would be in network, only to discover when they were hit with a huge bill that the directory was out of date. As a result, Dr. Schrier reached across the aisle to co-sponsor legislation with Republican and fellow physician Rep. Phil Roe that would mandate insurance companies update their provider directories in a timely manner.
</p>
<p>
Dr. Schrier is also a supporter of HR 3, The Lower Drug Costs Now Act, which would authorize the Secretary of Health and Human Services to negotiate prices for the 250 most expensive drugs covered by Medicare, with the cost savings passed on to the private market.
</p>
<p>
"I'm really excited about HR 3," she says. "I've heard over and over again, 'I don't understand why they pay less in Canada than we do.' That's essentially would this bill would do."
</p>
<p>
Dr. Schrier has also introduced a bill that would speed up development of a biosimilar version of insulin. But her perspective on the issue is as much as a patient than as a physician, since she has Type 1 diabetes.
</p>
<p>
"I just yesterday called to order another bottle of my own insulin, Humalog, and it was no longer on the dispensary," she says. "It would cost $300 for a bottle! It's kind of crazy to me that it costs so much and that formularies change like that for no apparent reason."
</p>
<h3>A trusted resource</h3>
<p>
While all these legislative initiatives are the logical outgrowth of her own experience, Dr. Schrier has also become a resource for other members of Congress.
</p>
<p>
"What I find is my colleagues come to me to run questions by me about surprise billing or women's health," she says. "I get questions about milk and the Dairy Council pressuring my colleagues to support sweet milk in schools."
</p>
<p>
That extends to medical advice.
</p>
<p>
"I still get to be the consultant for all my colleagues with children about their rashes, fevers, and sleeping through the night," she notes. Then there was the time when a member of Congress fainted and she offered medical assistance.
</p>
<p>
Dr. Schrier also brings her perspective as a pediatrician to issues that for many outside of medicine may seem unconnected to health care, such as immigration. The Trump administration's policy of separating children from their parents at the border is also a health crisis because it is creating adverse childhood experiences (ACEs), which studies have shown carry lifelong consequences.
</p>
<p>
"They've already been through all kinds of trauma in journey, then we take them away from parents, and it's adding ACEs upon ACEs and creating a generation with problems with their mental and physical health," she says. "This is no way to treat kids."
</p>
<p>
Whether any of Dr. Schrier's proposed legislation can make it to the president's desk in a polarized Congress is impossible to predict.
</p>
<p>
"I can always hope for cooperation," she says optimistically. "I think that's up to the president to rise above it. Then I think we can get a lot done."
</p>
<p>
Sometimes that polarization spills over into Dr. Schrier's congressional workday. A Republican colleague tried to introduce an amendment into a higher education bill that would prohibit universities with an associated medical center from getting federal funds unless they promised to provide medical care for any baby born alive.
</p>
<p>
"That's just a dog whistle for the crazy notion on the other side that doctors are killing babies," she says. "A woman doctor carries weight in that position. I would speak so authoritatively to it."
</p>
<p>
All these experiences and more have confirmed to Dr. Schrier that her decision to run for Congress was the right call.
</p>
<p>
"I worried that I might give up practice and not win, but I have to tell you that I have grown a ton as a person through this experience and I have not had a moment of regret," she says. "I can do a lot more good for kids from Washington than from the confines of my own doctor's office."
</p>
<p>
Besides, Dr. Schrier says, being in Congress isn't all that different from being a resident, with one big difference. "There's just a lot of running around, up and down stairs, hustling to get to somewhere where you're only going to be for 10 minutes, then hustling back to somewhere else," she says. "Except that I have to do it much less comfortable shoes."
</p>
<p>
<em>John Gallagher is a Washington state-based freelance writer who specializes in covering health care.</em>
</p>
<p>
<em>This article was featured in the January/February 2020 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:37:07 AM | 12/30/2019 2:48:09 PM | 1/2/2020 12:00:00 AM |
| policy_prognosis_uncertain | Policy Prognosis: Uncertain | WSMA_Reports | Shared_Content/News/Latest_News/2020/January/policy_prognosis_uncertain | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMA_JanFeb-2020-PRINTERS-FINAL-Cover-645x425px.jpg" class="pull-right" alt="WSMA Reports January-February 2020 cover" /></div>
<h5>January 2, 2020</h5>
<h2>Policy Prognosis: Uncertain</h2>
<p>
By John Gallagher
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
At a national level, the number of challenges affecting physicians and their practices seems almost endless. Administrative burdens, financial pressures, and emerging technologies are all changing the profession. Whether it's congressional legislation on tax policy or state-level insurance regulations, physicians around the country are buffeted by constant changes. In response, legislators are being forced to play catch-up with a rapidly shifting landscape.
</p>
<p>
Washington state is no exception.
</p>
<p>
Last year's legislative session was exceptionally busy, with bills addressing a broad range of issues, including vaccination exemptions, opioid prescribing, a public option plan, and a prohibition on balance billing.
</p>
<p>
"Last year saw a slew of big-ticket items," says Sean Graham, WSMA's director of government affairs. "Lawmakers told us they wanted to let those policies sink in. Of course, they always say that—then the next session everyone has bills they're pushing."
</p>
<p>
Still, the upcoming legislative session offers an opportunity to tackle plenty of other pressing issues. Among them are the administrative burdens caused by prior authorization, the threat to independent physician practices from the state's business and occupation (B&amp;O) tax, and the need for reimbursement to catch up with the emerging technology of telemedicine.
</p>
<h3>The prior authorization nightmare</h3>
<p>
The exact shape of any legislation about the first two issues will be determined as the session gets underway. In terms of the breadth of its impact, prior authorization is the biggest concern.
</p>
<p>
Imagine a patient presenting at a practice at 4 in the afternoon with severe abdominal pains. "We can't order a CT scan to rule out appendicitis because it requires prior authorization," says Amber Pedersen, the administrator for Valley Obstetrics and Gynecology in Spokane Valley. Because prior authorization takes at least one to three days, Pedersen says the patient will be referred to the ED, where the costs to her and to the health care system are far higher.
</p>
<p>
"Prior authorization is an everyday nightmare for every single doctor in every single specialty," says Teresa Girolami, MD, president of the King County Medical Society. "Prior authorization gets in the way of good medical care."
</p>
<p>
Prior authorization is also a major source of physician burnout. The American Medical Association estimates that physician practices complete an average of 31 prior authorizations a week per physician, consuming roughly 14.9 hours—almost two full business days—of physician and staff time. A bill is pending in Congress to standardize prior authorization across Medicare Advantage plans.
</p>
<p>
The AMA released its 2018 Prior Authorization Physician Survey results last year, surveying 1,000 practicing physicians about the impact of prior authorization on their work. More than 90% of the physicians reported care delays associated with prior authorization, and almost as many said that the burdens of prior authorization have increased over the past five years. Most disturbing was the fact that 28% of the physicians reported that prior authorization had led to a serious adverse event for a patient in their care.
</p>
<p>
Physicians and practice administrators in Washington echo the national survey results. Dr. Girolami recalls a patient who came to her office on a Friday. Dr. Girolami ordered a CT scan, which led to a biopsy and a diagnosis of metastatic colon cancer. By Wednesday, the patient was meeting with an oncologist.
</p>
<p>
"Then someone had the nerve to call me about prior authorization," Dr. Girolami says. After telling the insurer that she had quickly identified a lifethreatening condition, Girolami was able to get the plan to back down.
</p>
<p>
Then, there's the cumbersome administrative burden imposed by prior authorization. Pedersen, who works at a practice with nine providers, says that one staffer in the office deals with an average of five to seven prior authorizations each day.
</p>
<p>
"I can grasp the concept, but it's gone too far," she says. "We spend anywhere from 30 minutes to an hour for one prior authorization for certain carriers. What the staff complain about most is that when you call the carrier for assistance, on average you get transferred three times. Sometimes, it takes 10 minutes just to get to the right person to answer a question or to get the correct form that needs to be filled out. Some carriers have different forms depending on the test or medication."
</p>
<p>
For an obstetrics practice, genetic screening is now the standard of care, but Pedersen says that most screenings still require prior authorization. New medications almost invariably require prior authorizations, but plans also request prior authorizations for even common treatments.
</p>
<p>
"When I first started in health care, I don't remember getting prior authorizations except for chemo meds," Pedersen says. "Now I'm getting them for everyday therapy."
</p>
<h3>B&amp;O tax burden unfairly targets independent practices </h3>
<p>
While all practices struggle with the costs that prior authorization imposes on them, independent practices are now struggling with an additional burden due to legislation passed last year. The state legislature increased the B&amp;O tax on independent practices by 20%, threatening the viability of many of those practices, particularly in already underserved rural areas where they are common. Getting the legislature to roll back the increase, which funds college financial aid for students from families earning below the state median income, will be a challenge.
</p>
<p>
While other professions were included in the tax increase, they can make their customers pay for it. "Medicine should have been excluded from this increase because we are not like other forms of business getting taxed," says Chelsea Unruh, MD, a physician at Yelm Family Medicine and president of the Thurston-Mason County Medical Society. "We don't get to control our prices and we don't get to say what we charge."
</p>
<p>
Dr. Unruh says managing a private practice is difficult enough, given the tight margins. "I have to make sure I pay staff and keep the lights on, and pay my salary, too, so I can pay my loans back," they say.
</p>
<p>
The B&amp;O tax has had a direct impact on the care the practice is able to provide, leading to care being restricted or even ended for poorer patients. "I have to limit how many Medicaid people I can see because of the overhead of being in a private practice," they say. "The B&amp;O tax added even more pressure onto that already-tight overhead and is making it more difficult to be able to serve the vulnerable population. It's one of the most frustrating parts of being in medicine."
</p>
<p>
As an internist in a solo practice, Dr. Girolami experiences similar pressures. "If you take charity care, Medicaid, or Apple Health, you're already running in the hole," she says. "You have to limit the number of people you see, which gives them way less choice. It's painful."
</p>
<p>
Dr. Girolami also says that the additional expense leads to diverting investments that could improve office efficiency. "That money may have been earmarked for a texting service or software," she says. "Now you have to take a hard look at it." As a result, she says, the tax "is punitive to smaller groups."
</p>
<p>
The fallout may not be limited to current investments. Dr. Unruh says that the tax will make it harder to recruit physicians to rural practices, worsening an already bad problem.
</p>
<p>
"Folks coming out of medical school are coming out with more loans than we've ever seen in the past and not as much incentive to go into private practice," they say. "We're limiting our ability to be competitive for a new workforce."
</p>
<h3>The technology reimbursement gap</h3>
<p>
Technology—specifically telemedicinewill also be on the agenda for the next legislative session. By allowing for long-distance clinician-patient contact, telemedicine has the potential to provide medical care to those who would otherwise have to travel for it or not receive it at all.
</p>
<p>
However, while Washington insurers must provide coverage, telemedicine may be reimbursed at a lower rate than an in-person visit, which disincentivizes use of the technology. About 10 states, including California and Florida, have passed legislation to correct this disparity, but a bill to do so in Washington, SB 5385, failed to pass last year. The bill will automatically be reintroduced in the new session. Sen. Randi Becker, sponsor of the legislation, worked in the medical field for 24 years, starting as a practice receptionist and ending as an administrator.
</p>
<p>
"The intent of the legislation is to acknowledge the value of treating patients in a location that works for them," she says. "We want people to get the care they need at the time they need without having to travel." She points out that the need is especially keen in rural areas of the state where specialists are in short supply.
</p>
<p>
Becker notes that advances in health care technology often lag behind policy. (As an administrator, she led her clinic in developing the first internet billing system to transmit a claim to Medicare.) "I have always believed in technology in the health care arena," she says. "As a nation, we have embraced technology. But why do we not embrace it as easily in health care? We can't get in the way of technology."
</p>
<p>
By eliminating the payment disparity, Becker believes that telemedicine will be able to develop its potential more readily. She's hopeful about the bill's chances this time around. "Time was a factor last time," she says. "There's optimism about this going through this year."
</p>
<p>
<em>John Gallagher is a freelance journalist specializing in covering health care.</em>
</p>
<p>
<em>This article was featured in the January/February 2020 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:39:10 AM | 12/30/2019 2:42:59 PM | 1/2/2020 12:00:00 AM |
| practice_health_in_jeopardy | Practice Health in Jeopardy | WSMA_Reports | Shared_Content/News/Latest_News/2020/January/practice_health_in_jeopardy | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMA_JanFeb-2020-PRINTERS-FINAL-Cover-645x425px.jpg" class="pull-right" alt="WSMA Reports January-February 2020 cover" /></div>
<h5>January 2, 2020</h5>
<h2>Practice Health in Jeopardy</h2>
<p>
By Teresa M. Girolami, MD
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
<em>Dear Valued Customer: Due to an increase in operating costs, we're raising prices on our coffee beverages - please pardon the inconvenience.</em>
</p>
<p>
When I read that note at my favorite coffee shop, I didn't hesitate to accept the price increase. As the owner of small private practice in Redmond, I empathize with decisions that must be made with increasing expenses.
</p>
<p>
It also got me thinking again, as I often do, of the ways in which running a private practice or independent clinic differs from other small businesses—and how our business model is increasingly under threat in Washington state.
</p>
<p>
Last year, state lawmakers passed a 20% increase in the business and occupation (B&amp;O) tax on small service businesses, including independent physician practices like mine. I doubt the Legislature realized the impact this tax increase has on independent practices and clinics—where roughly a third or more of our state's physicians practice—and the patients they serve.
</p>
<p>
How are physician businesses unlike other small businesses? We get paid mainly by insurance companies, not by our primary customers. We have limited negotiation power and we get paid less each year. Unlike a coffee shop, when our expenses go up, we have no way to recover the resulting loss. We cannot—and don't want to—pass this expense on to our patients.
</p>
<p>
And yet it's patients—largely our most vulnerable ones—who bear the brunt of this legislative decision. Unfairly targeting independent physician businesses with tax increases forces them to make hard decisions to keep their doors open in a highly competitive environment. Patients covered by public programs that are low payers, like Medicare and Medicaid (which covers many of our state's children), are being turned away.
</p>
<p>
In a worst-case scenario, a practice will close, with many more patients losing access to their primary physicians. Just last year, three rural practices closed, citing increasing business expenses.
</p>
<p>
The health of our state's independent practices should concern all physicians. Patients who can't access preventive care often end up in urgent care clinics and emergency rooms. This adds strain to already over-burdened emergency centers and drives up everyone's cost of care. In other instances, patients are absorbed by employed physicians with panels already stretched thin, leading to more burnout.
</p>
<p>
Increasing the B&amp;O tax impacts businesses like mine in too many crucial ways to cover here, but each is essential to maintaining the health of independent practices and the balance of our health ecosystem.
</p>
<p>
On behalf of King County Medical Society, I sponsored a resolution passed unanimously by the WSMA House of Delegates that directs the WSMA to advocate to amend state law to exempt all physicians from the B&amp;O tax increase to protect the vital health interests of our communities. I urge all WSMA members, and all Washington state physicians, to oppose this unfair tax increase that will disproportionately harm independent practices and clinics.
</p>
<p>
I trust my local coffee shop will weather its increased expenses. But I am deeply concerned about thousands of small businesses like mine. Our health, and the health of Washington's medical community, is in jeopardy. Those consequences are far more serious than the loss of a morning cup of coffee.
</p>
<p>
<em>Teresa M. Girolami, MD, is the president of King County Medical Society and owner of BelRed Internal Medicine, PLLC.</em>
</p>
<p>
<em>This article was featured in the January/February 2020 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:40:12 AM | 12/30/2019 2:48:05 PM | 1/2/2020 12:00:00 AM |
| behind_the_cover | Behind the Cover | WSMA_Reports | Shared_Content/News/Latest_News/2019/December/behind_the_cover | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMAReports-Extras-Website-645x425.jpg" class="pull-right" alt="WSMA Reports Extras logo" /></div>
<h5>December 17, 2019</h5>
<h2>Behind the Cover</h2>
<p>With this year's redesign of <em>WSMA Reports</em> by <a href="https://www.journeygroup.com/">Journey Group</a>, we began featuring illustrations on the magazine cover to convey the complex topics of medicine we wanted to cover. The issue theme for the November/December 2019 edition centered around preparing for value-based care.</p>
<p><em>WSMA Reports</em> Art Director <a href="https://www.erinfostercreative.com/">Erin Foster</a> chose internationally renowned artist <a href="https://hannabarczyk.com/about">Hanna Barczyk</a> to create the original illustration. "I love Hanna's unique illustration style and how she whittles down complex concepts to a simple human emotion so well," she said. "This edition's <a href="https://wsma.org/Shared_Content/News/Latest_News/2019/November/preparing_for_value_based_care">cover story about value-based care</a> needed exactly that touch, and Hanna's illustration perfectly pinpointed the heart of the story."</p>
<p><a href="javascript://[Uploaded files/News and Publications/Publications/WSMA Reports Archive/WSMA_NovDec19-PRINTERS FINAL-singles.pdf]">View the cover illustration for <em>WSMA Reports'</em> November/December 2019 issue</a>.</p>
<p>Hanna began by closely reviewing the cover article written by health care journalist <a href="https://ritacolorito.com/">Rita Colorito</a>. With that inspiration, she worked on several concepts for review by Erin and the publication's editors. Of the six sketches, we selected the one that best visually conveyed the issue.</p>
<p>"I wanted to focus on the physicians' care for the patient, using scale; the two large doctors, both focusing, holding up, and providing support and attention to the patient's needs," Hanna says about that particular concept. To create the art, she used ink, and hand-rolled acrylic texture to create a grunge effect.</p>
<p>Hanna's award-winning work has appeared in <em>The New York Times</em>, <em>The New Yorker</em>, Penguin/Random House, <em>National Geographic Traveller</em>, <em>The Atlantic</em>, and <em>The Economist</em>, as well as many other national and international publications. Born in Germany, she's inspired by her family's Hungarian folk art traditions, vintage Polish film posters, German Expressionism, memories, love, music, movement, and a passion for dance often illustrating emotionally driven solutions that are bold, conceptual, and delicate all at once.</p>
<p>We think Hanna's graphic concept worked well for this issue. What about you? Let us know your thoughts by writing <a href="mailto:editors@wsma.org">editors@wsma.org</a>.</p>
<p><em>This WSMA Reports Extra is exclusive to the WSMA website.</em></p>
<p>
<em>This article was featured in the November/December 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 12/17/2019 3:16:53 PM | 12/17/2019 2:55:25 PM | 12/17/2019 12:00:00 AM |
| cognitive_dissonance | Cognitive Dissonance | WSMA_Reports | Shared_Content/News/Latest_News/2019/November/cognitive_dissonance | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/Nov-Dec-2019-Reports-645x425px.jpg" class="pull-right" alt="WSMA Reports November/December 2019" /></div>
<h5>November 5, 2019</h5>
<h2>Cognitive Dissonance</h2>
<p><em>Members only; sign-in required.</em></p>
<p>
</p>
<p>
By Pat Curry
</p>
<p>
For 10 years, Carl Berliner, MD, has been a solo family practitioner. He runs his practice out of a renovated house in Mt. Vernon, a community of 30,000 known for its annual tulip festival. His patients range in age from two days old to their late 90s. It brings him great joy, he says, to have delivered a third of them, many of whom call him "Dr. B."
</p>
<p>
Being a solo practitioner gives him what he calls "agency," the ability to control his day and his practice. A lot of physicians traded agency for better pay "and now they wish they hadn't," he says.
</p>
<p>
"It's just enormous, that ability to make extra time in your schedule and treat patients the way you think you should. … I always have this joke that I'm the last happy doctor in Washington. I live frugally enough that I weather these insanities. 'Cognitive dissonance' is the term I use."
</p>
<p>
The dissonance comes from trying to make enough money to keep the doors open.
</p>
<p>
"I don't like to talk about finances, but we are a business and have to pay bills and pay staff," he says. "We say we want healthy families, then make that almost impossible to happen. … Keeping up with the rules and fighting over every $14 charge is very discouraging. In the execution, you feel like you've been run over by a tractor."
</p>
<p>
And then there are the day-in and day-out challenges in getting approval from insurers to perform even the most standard levels of medical care.
</p>
<p>
"Prior authorization is an enormous time suck," he says, "and it's a reason why so many [physicians] are demoralized. At the end of the day, I don't leave with a smile because for six of the drugs I prescribed, I needed to click another radio button. I had a pregnant woman I prescribed prenatal vitamins for and the insurance company required prior authorization. On the form, I wrote, 'You are the worst insurance company ever.' "
</p>
<h3>Difficult decisions with few options</h3>
<p>
Without relief, some physicians have found that they have no choice but to shut down and go on someone else's payroll. In August, Cascade Family Medical Clinic in Centralia closed after more than 40 years.
</p>
<p>
Eric DeMun, MD, and Christopher Yarter, MD, posted on the clinic's website that the practice was "one of a shrinking group of small, independent primary care clinics that is suffering from increasing administrative burdens, rising costs of health care delivery, and a reimbursement system that has not kept pace with these costs. We have been unable to recruit physicians to partner with us in the face of these changes and have been unsuccessful in finding larger companies willing to buy the practice and keep it open."
</p>
<p>
Many physicians in small practices in Washington state face the same kind of gut-wrenching decisions. Eric Frankenfeld, MD, FACE, FACP, is an endocrinologist in solo practice in Bellingham, a physician-shortage area. This summer, he sweated out a lease renewal; the rent increase would determine if he stayed in business or retired. He negotiated a two-year lease instead of five years, enough for him to decide to keep at it a bit longer.
</p>
<p>
He's been aware for 25 years that it was "no way to make money," he says.
</p>
<p>
"I thought it was me, that I'm not enough of a hustler, not in a busy-enough practice, whatever," he says. "Then I talked to other colleagues over the years and found out they were doing worse than I was. You need a gimmick if you're going to make money in medicine. The gimmick is you perform a nice expensive procedure like endoscopy. Internists in general, and nonprocedural subspecialists without a gimmick, need to get themselves employed."
</p>
<p>
At 66, Dr. Frankenfeld says that as long as he can break even, fund his pension and his staff's pensions, he will continue to practice. He is ready to retire, though, from his second career as a hospitalist, which he has done half-time for 10 years.
</p>
<h3>The burden of fees and taxes</h3>
<p>
Working both as a solo practitioner and as a health system employee has been an eye-opener, he says, especially when it comes to state fees and taxes. With the state eyeing drastically increasing physician licensing fees, Dr. Frankenfeld wondered if it might be time for him to think about closing the doors on his private practice.
</p>
<p>
"This may be what does it for me," he says. "My reimbursements certainly haven't doubled in the last few years. How does a license become that valuable to me?"
</p>
<p>
He says the "biggest burr in my saddle" is the business and occupation, or B&amp;O, tax.
</p>
<p>
"I think that is the most unfriendly thing to small businesses," he says.
</p>
<p>
The B&amp;O tax, which is applied on a business' gross revenues, has been a long-standing point of contention for independent physicians, says Sean Graham, WSMA's director of government affairs. A bill passed last year added a 20 percent surcharge on certain industries with a significant number of highly educated workers, with the additional revenue going to higher education.
</p>
<p>
The fiscal impact of the tax increase on the physician community over the next two years is estimated at about $50 million, Graham says. Hospital systems were exempted from the tax surcharge as they are classified separately for the purposes of B&amp;O.
</p>
<p>
WSMA strenuously opposes the B&amp;O tax on all segments of health care and "vehemently" fought the surcharge, Graham says. Repealing the tax on physicians will be the "A-1 priority of WSMA for the 2020 legislative session," he says.
</p>
<p>
"It's simply a wrongheaded tax increase on a couple of levels, among them that it further increases the cost of health care," he says. "And it puts independent practices at a competitive disadvantage, jeopardizing access to care for patients in many communities."
</p>
<p>
The WSMA will be rolling out a broad advocacy campaign on repealing or ameliorating the B&amp;O tax in the next legislative session and will be asking our physician members for their help.
</p>
<p>
"We'll be working to raise awareness of the impact of the surcharge on patients and physicians, as well as to get physicians directly connected to their legislators," he said.
</p>
<p>
Mark T. Anderson, MD, a founding member of the independent Mill Creek Family Practice in Mill Creek, is one of the physicians who has volunteered to share his concerns with elected officials. His practice is "still doing OK," but faced with lower reimbursements, burdensome documentation and preauthorization requirements, and the B&amp;O tax increase, it's getting harder and harder to compete against hospital-based primary care clinics.
</p>
<p>
"We are one of the very few independent family practice clinics left," Dr. Anderson says. "We would like to continue to practice independently."
</p>
<p>
<em>Pat Curry is WSMA Reports' senior editor.</em>
</p>
<p>
<em>This article was featured in the November/December 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/9/2020 10:55:55 AM | 11/5/2019 10:49:42 AM | 11/5/2019 12:00:00 AM |
| do_no_harm | Do No Harm | WSMA_Reports | Shared_Content/News/Latest_News/2019/November/do_no_harm | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/Nov-Dec-2019-Reports-645x425px.jpg" class="pull-right" alt="WSMA Reports November/December 2019" /></div>
<h5>November 5, 2019</h5>
<h2>Do No Harm</h2>
<p><em>Members only; sign-in required.</em></p>
<p>
</p>
<p>
By Daniel Low, MD
</p>
<p>
In the midst of ever-increasing health care costs, we are obligated to think about and practice value-based care. What sadly is too often lost in this conversation, however, is the definition of "value." What are our values?
</p>
<p>
As physicians, we have all proclaimed via the Hippocratic Oath that we will "first, do no harm." Yet, current data seems to suggest that this theoretically unifying value reflects more of a distant ideal than a guiding principle.
</p>
<p>
By now, it is well known that black patients are less likely to be treated for pain in emergency departments, women are less likely to be treated for heart disease, immigrants are less likely to receive care, and those who are economically disadvantaged are more likely to suffer early morbidity and mortality.
</p>
<p>
While acknowledged as unfortunate, these disparities are generally viewed as inevitable, and thus, acceptable. This convention of normalcy must stop. Patients deserve health care providers who advocate for their best interests.
</p>
<p>
What might this look like? It means taking responsibility as physicians to not just organize to benefit ourselves financially—which has been the historic norm (e.g., the American Medical Association's partnership with the Sunbeam Corporation, the American Heart Association's exploitation of its heart logo for profit over health, the American Academy of Family Physicians' collaboration with Coca-Cola, etc.)—but rather to organize for our patients. Specifically, this would mean formally supporting campaigns targeting health inequities.
</p>
<p>
Fortunately, we don't have to look far for obvious opportunities. Study after study over the last 30 years has shown that income inequality drives poor health outcomes and may be one of the central causes of poor health in the United States. In Washington state, this is perpetuated by regressive tax systems—Washington ranks last in the country in disproportionately burdening low-income earnershelping guarantee the poor stay poor and continue enduring harm that we, as physicians, claim we will not do. We can instead follow the lead of groups like Washington Physicians for Social Responsibility, which advocates for cleaning up our tax code and enacting a capital gains tax.
</p>
<p>
As we discuss value-based care, we too often excuse rising health care costs as unrelated to our individual responsibility because physician salaries are not the cause for increasing costs. But such claims, while true, are red herrings. They distract us from the reality that increasing economic inequality is arguably the central force driving poor health outcomes in our communities, and economic inequality is something we can address.
</p>
<p>
Continuing business as usual—or trying to incrementally alter payment models in value-based care without addressing the structural violence enacted by our tax system—is a formula to ensure we continue harming disenfranchised individuals and communities. Ultimately, if our value is to do no harm, we must attack a system that guarantees unequal care to those who are different. We must organize, and we must support the redistribution of resources, putting our own pocketbooks on the table.
</p>
<p>
<em>This opinion piece was submitted by Daniel Low, MD, a family medicine resident physician at Swedish Cherry Hill in Seattle and an alternate delegate from King County Medical Society to the WSMA House of Delegates.</em>
</p>
<p>
<em>This article was featured in the November/December 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/9/2020 10:56:53 AM | 11/5/2019 10:27:29 AM | 11/5/2019 12:00:00 AM |