| 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 |
| preparing_for_value_based_care | Preparing for Value-Based Care | WSMA_Reports | Shared_Content/News/Latest_News/2019/November/preparing_for_value_based_care | <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>Preparing for Value-Based Care</h2>
<p>
</p>
<p>
By Rita Colorito
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
When a homeless cancer patient came to Northwest Cancer Clinic in Kennewick for radiotherapy, Sheila Rege, MD, a radiation oncologist and co-founder of the clinic, knew treatment would be challenging.
</p>
<p>
The patient's situation made maintaining hygiene difficult, and Dr. Rege worried it could cause her to develop skin infections during radiation. Plus, she had other chronic medical issues, including uncontrolled diabetes that once caused dangerously elevated blood pressure. Dr. Rege and her staff put systems in place to achieve the best outcome possible for the patient. They let her shower at the clinic and delivered food and warm clothing to the car she called home. They called her daily to remind her to take her medications.
</p>
<p>
When the patient needed more help, Dr. Rege's staff negotiated with a hotel to house her for the remainder of treatment. "There was a lot more time and care that we had to do for her," Dr. Rege says.
</p>
<p>
The patient is now doing well, a function of value-based care being applied across the clinic's patient population, Dr. Rege says.
</p>
<p>
"We really try and not highlight who is on a risk-based contract. We focus on keeping people out of the emergency room," she says. "So, we're going to accept a risk-based contract, but we're really going to bring everyone else to that level."
</p>
<p>
As public and private payers undergo a major transition to value-based care (VBC) models, Dr. Rege hopes physicians can continue to care for this type of vulnerable patient, and those with treatment challenges, without the patient or the practice getting short shrift.
</p>
<p>
"All of us want to do better for our patients; everyone is trying to reduce what I call the hassle factor in medicine," Dr. Rege says. "But as we're going through these dramatic changes in how we pay for care, we have to make sure the vulnerable people, the people having a harder time either accessing care or tolerating treatment, don't suffer. We also have to make sure incentives are aligned to allow physicians to care for them."
</p>
<h3>A dramatic shift in focus</h3>
<p>
It seems like only a few years ago that VBC entered the lexicon of health care buzzwords. This reimbursement model rewards physicians for meeting agreed-upon quality metrics. It can also penalize them when those metrics aren't met.
</p>
<p>
If you've been sitting on the fence about VBC, you may no longer have the option of waiting, says Micah Thorp, DO, a nephrologist and clinical researcher with Northwest Permanente.
</p>
<p>
"Value-based is going to be the primary form of payment in the not-too-distant future. It's coming pretty fast and you've got to get ready for it," says Dr. Thorp, who also serves as vice president of business strategy for Kaiser Permanente.
</p>
<p>
At the state level, the Health Care Authority's Healthier Washington initiative plans to drive 90 percent of state-financed health care—more than 2 million people on Medicaid and those who receive public employee, state school employee, and retiree benefits—to value-based payment by 2021. At the federal level, the Centers for Medicare &amp; Medicaid Services has rolled out eight value-based care models since 2018, with the triple aim of better care for individuals, better care for populations, and lower cost.
</p>
<p>
The aim of VBC models is to allow physicians to concentrate on taking care of patients. "For value-based care to work, it's important for providers to free up their PCPs. They can really drive savings in other areas," says Mark Mantei, CEO of Vancouver Clinic. "This isn't a model built on seeing 30 patients a day. This is a model that takes up more time, but we're rewarded for that because your patients don't end up in the ER or hospital."
</p>
<p>
Vancouver Clinic began transitioning to VBC for its Medicare population six years ago, after realizing traditional Medicare was no longer sustainable. Earlier this year, it partnered with Humana to open a dedicated primary care clinic in Southwest Washington designed to serve Medicare Advantage beneficiaries and those on Dual Eligible Special Needs Plan (those who qualify for both Medicare and Medicaid); it also accepts commercial insurance.
</p>
<p>
The clinic's integrated care team includes doctors, nurses, nutritionists, and health coaches. Representatives from both Humana and the Agency on Aging and Disabilities of Southwest Washington hold office hours several days a week to help patients navigate their benefits and manage outside factors that affect health outcomes, such as housing, transportation, mental health, and home care.
</p>
<p>
Despite a 40 percent higher-than-average risk adjustment factor for the clinic's Medicare population, it's had some amazing successes already that speak to the power of value-based care, Mantei says. "We saw patients that were in the hospital 16 times last year before that clinic was implemented. And since then, they've only been in the hospital once."
</p>
<h3>Despite challenges, smaller practices and specialties can benefit</h3>
<p>Dr. Thorp oversees contracting with external providers in areas where Kaiser Permanente lacks a local specialty presence. These physician groups often struggle with transitioning from an efficiency mindset to a utilization mindset, the latter of which is central to value-based care, he says.
</p>
<p>
"Fee-for-service drives great efficiency. It also does terrible things to utilization," he says. "The value-based model basically says, 'Let's treat people with what they actually need' rather than just treating them with a lot of stuff they don't need, but doing it very efficiently."
</p>
<p>
Having enough high-quality baseline data is another issue physicians struggle with in negotiating and implementing VBC contracts, Dr. Thorp says. "You need to have a good idea of where you are starting from to gauge progress," he says, adding that electronic medical records can provide a wealth of information to track clinical quality, population data, and other metrics. Robust patient data, he says, also safeguards against a common criticism of VBC—that physicians will take a lump-sum payment and withhold services to meet metrics.
</p>
<p>
To position her practice to best take advantage of VBC models, Dr. Rege entered into a joint venture and management contract with 21st Century Oncology, a large national physician-owned oncology group.
</p>
<p>
"Value-based and risk-based only work if you can provide data that shows you are improving outcomes and being more efficient," which is something Dr. Rege says her clinic lacked. It made sense to partner with 21st Century Oncology, she says, because they have experience managing risk-based contracts and could provide the necessary investments to train her team and conduct financial reporting.
</p>
<p>
To better serve patients, it's important to be able to access a patient's health records in a HIPAA-compliant manner in and outside the office, says Dr. Rege. Northwest Cancer Clinic also benefited from 21st Century's more advanced medical records capabilities. "We were on the same system, but they were able to beef it up," she says. "[And] they already had an existing contract with an electronic medical record provider to generate all those reports that would be needed by the insurance companies."
</p>
<p>
Risk adjustment is another major concern when transitioning to a capitated payment system. It's even more so with cancer treatment, says Dr. Rege.
</p>
<p>
"We don't know what causes someone to do great with cancer treatment and what causes some people to end up in the ICU," she says. "In a value-based system, we have to figure out a way that sicker patients aren't left out. And so far, no insurance company knows who's going to do okay on treatment and who is going to have trouble."
</p>
<p>
Northwest Cancer Clinic's VBC contracting has flexibility to account for that uncertainty, Dr. Rege says. The corporate office of 21st Century Oncology acts as a "shadow team," she says, that helps her staff assist patients who are struggling with treatment by acting as an intermediary with insurers.
</p>
<p>
She warns physicians and practices against entering into VBC systems with rigid metrics. "If a patient is an outlier, it's important to have the flexibility with insurance providers to discuss next steps," she says. An open dialogue with insurers allows Dr. Rege to manage costs while providing patients the best care possible.
</p>
<p>
As Medicare is driving the larger health care space toward VBC, Dr. Rege expects it to drive oncology reimbursement as well. For now, Northwest Cancer Clinic's VBC contracts are in the commercial insurance space. Medicare oncology care model (OCM) pilot projects are only a few years old. "While quality and cost performance results across OCM practices continue to improve, only 33 percent of practices have earned a performance-based payment so far," Dr. Rege says. As these models evolve, she remains hopeful Medicare and Medicaid will keep the health of both the patient and the physician practice in mind.
</p>
<p>
Despite some of the challenges faced by smaller clinics, Dr. Thorp says he's seen some of the biggest benefits of VBC among smaller physician practices. "You're getting a guaranteed per-patient, per-month money. It can stabilize cash flow," he says.
</p>
<p>
One of the biggest rewards for Northwest Cancer Clinic's VBC contracting has been eliminating prior authorization for evidence-based treatment, a huge time saver for both physicians and patients, Dr. Rege says. The clinic receives capitated payments specific to each cancer type, with care decisions following established clinical guidelines.
</p>
<p>
"You have to reduce the cost for the practice in some way," Dr. Rege says.
</p>
<p>
"If a bunch of your staff is doing prior authorizations and documentation, that's time the staff could've spent on the patient. So when a patient comes in, we can say, 'This is what you need.' If they say, 'Can we start now? ', we can say, 'Yes, we can.' "
</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 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 10:58:32 AM | 11/5/2019 10:47:33 AM | 11/5/2019 12:00:00 AM |
| lead_is_still_a_public_health_culprit | Lead is Still a Public Health Culprit | WSMA_Reports | Shared_Content/News/Latest_News/2019/September/lead_is_still_a_public_health_culprit | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMA-Reports-S-O_Website-Graphic_645px.jpg" class="pull-right" alt="WSMA Reports cover" /></div>
<h5>September 10, 2019</h5>
<h2>Lead is Still a Public Health Culprit</h2>
<p>
By Amish Dave, MD, MPH
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
At a recent meeting of the Somali Health Board in Seattle, concerned parents raised questions about the prevalence of lead in their communities. They wondered if their children's low birth weights and hyperactive behavior might be associated with the age of their apartments, paint on the walls, or what they were eating.
</p>
<p>
Even though lead-based paint was banned by 1978, lead remains an issue today. Lead is everywhere, from older plumbing fixtures, soil, imported medicines, and ceramics. It is found adjacent to highways and via occupational exposures. Even more concerning, the attorney general's office in Washington recently found lead in children's school products. Further, many of Washington's counties have a high percentage of homes with lead paint, lead piping, and environmental lead exposures.
</p>
<p>
There is no safe level of lead in the human body. Even low blood lead levels (&lt;5 micrograms/deciliter) can harm a child’s ability to learn and increase behavior problems. Research shows an association of childhood lead exposure and later risk of poorer educational attainment and incarceration.
</p>
<p>
Lead has also been causally linked with attentiondeficit hyperactivity disorder diagnosis. Most children exposed to lead remain asymptomatic, as longterm effects of lead exposure manifest later in life. Importantly, pregnant mothers with elevated lead levels can transfer lead from their blood to the fetus.
</p>
<p>
Massachusetts and New York are leading the way in screening for lead and conducting blood testing in 50 percent of their children. By comparison, in Washington, we test fewer than 5 percent of our children, making this state one of the five worst in the country for that metric. In King County, we estimate more than 6,000 children are likely lead poisoned, are not tested, and don’t receive services that could support their development.
</p>
<p>
Besides the personal toll on affected children, there are hard costs as well. One study estimates that for children born in 2014, with lead exposure, they would experience a total loss of $195 million in lifetime earnings and 393,000 healthy years lived. When long-term lead-exposure effects (hypertension, organ damage, reproductive problems, behavioral impacts) are factored over a five-year period, the costs expand to $1 billion in financial loss and 2 million healthy years lost.
</p>
<p>
</p>
<p>
We have a responsibility to advocate for the health and well-being of vulnerable children. For the past two years, Public Health – Seattle &amp; King County and the King County Medical Society Board of Trustees partnered with the Washington Chapter of the American Academy of Pediatrics, the Washington State Department of Health, the Washington Poison Center, and the Northwest Pediatric Environmental Health Specialty Unit to highlight the seriousness of lead poisoning. We introduced a comprehensive resolution at the 2018 WSMA Annual Meeting to increase awareness about lead poisoning, which was adopted by delegates and is now association policy (<a href="http://bit.ly/wsma-lead">bit.ly/wsma-lead</a>).
</p>
<p>
But we need to do more. To get involved, contact Salem Adisu at <a href="mailto:sadisu@kcmsociety.org">sadisu@kcmsociety.org</a>.
</p>
<p>
<em><strong>Amish Dave, MD, MPH</strong>, is a rheumatologist with Virginia Mason Medical Center in Seattle, in addition to being chair of the Public Health Committee for King County Medical Society and a delegate to the WSMA House of Delegates.</em>
</p>
<p>
<em>This article was featured in the September/October 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 11:01:01 AM | 9/10/2019 3:16:22 PM | 9/10/2019 12:00:00 AM |
| ending_death_by_a_million_clicks | Ending Death by a Million Clicks | WSMA_Reports | Shared_Content/News/Latest_News/2019/September/ending_death_by_a_million_clicks | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMA-Reports-S-O_Website-Graphic_645px.jpg" class="pull-right" alt="WSMA Reports cover" /></div>
<h5>September&nbsp;6, 2019</h5>
<h2>Ending Death by a Million Clicks</h2>
<p>
By John Gallagher
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
Every physician knows the problem: an additional box to check in the EMR, a flurry of prescription refills, lab results that arrive after the patient's visit. Individually, each item may require just a few minutes. But collectively, the minutes add up to hours that rob physicians of time with patients and contribute to the epidemic of burnout.
</p>
<p>
The WSMA has been working on this problem for more than four years with its Healthy Doctors, Healthier Patients initiative. Because of Washington state's role in the forefront of addressing the issue, the WSMA was one of just three medical associations in the nation awarded a grant from the Physicians Foundation to work with the American Medical Association to test potential projects to improve physician wellness. (New Jersey and North Carolina are the other states participating in the grant.)
</p>
<p>
"We know a lot about the degree of burnout, the drivers, and the impact, but there's been little research on interventions," says Jessica Martinson, director of clinical education and professional development at the WSMA Foundation for Health Care Improvement.
</p>
<p>
Eight organizations in Washington are participating in the project. The grant covers four subject areas—pre-visit planning, pre-visit labs, synchronized prescription renewal, and implementing team-based care—with participants in Washington tackling the first three. (Implementing team-based care presents unique challenges for a time-limited grant, including the need for additional staff.)
</p>
<p>
The interventions will run for one year, with results to be shared nationally. To test the effectiveness of the interventions, the participating organizations conducted baseline surveys of physician burnout at the clinics where the interventions are implemented, with a follow-up survey once the intervention is completed. Organizations also are frequently pairing the intervention site with a control clinic. Each organization has a team that is composed of both physicians and administrators working on its project.
</p>
<p>
The grant builds upon the AMA's STEPS Forward program, which offers a free collection of interactive educational modules developed by physicians to help address common practice challenges. Each module offers real-world solutions, practical steps for implementation, case studies, and downloadable resources for anyone to use.
</p>
<h3>An ongoing struggle with serious consequences</h3>
<p>
The need for the interventions is obvious; 43 percent of Washington's physicians are experiencing burnout, according to a recent physician and advanced practitioner wellness survey conducted by Stanford University's The Risk Authority (TRA) and commissioned by the WSMA and the Washington State Hospital Association. (For comparison, the TRA national benchmark is 36 percent.)
</p>
<p>
Moreover, studies have found that the impact extends to patient care; doctors suffering from burnout have poorer patient outcomes.
</p>
<p>
"We're struggling to meet the demands of modern medicine," says Scott Itano, MD, a family medicine physician at Washington Permanente Medical Group. "Regardless of the model you're in, people are having a tough time. We are the most highly trained clerical workers in the country. It's death by a million clicks."
</p>
<p>
Dr. Itano and other leaders testing interventions attended a boot camp hosted by the AMA in April. What they learned there was that 80 percent of burnout was related to the way the health care system affects doctors in their work.
</p>
<p>
"I thought burnout was pretty touchy-feely and that you just needed to get tougher," Dr. Itano acknowledges. "But when you see the data and see how widespread the epidemic is, you realize that no matter who you are, it affects your day-to-day life."
</p>
<p>
The AMA research aims to make small but impactful improvements to the system; Dr. Itano is part of the team at Kaiser Permanente working on pre-visit labs. "We wanted to focus on something simple that we could execute in a year," he says. "We want to show that whatever staffing model you have, this is something you can do."
</p>
<p>
Having a patient get lab tests before a visit gives physicians the opportunity to discuss the results during the visit, instead of reviewing results afterward and then coordinating follow-up care. Something as simple as scheduling a patient's next set of labs at the end of each visit can save precious time. So can empowering staff to manage a physician's inbox. Even these small changes can have a big impact, according to AMA calculations.
</p>
<p>
"I was really surprised that pre-visit labs increase patient satisfaction, decrease cost by $26 per visit, and decrease the number of calls a clinic receives," says Dr. Itano.
</p>
<p>
In planning its project, the Kaiser Permanente team realized that physicians don't need to do many of the tasks of pre-visit labs. "My medical center manager and medical assistants are going to be doing the bulk of the work because we will be shifting a lot of day-to-day work from physicians to staff," Dr. Itano says.
</p>
<h3>Small changes yield big time savings</h3>
<p>
Labs aren't the only pre-visit intervention being tested. Four organizations, including The Everett Clinic, are testing ways to improve pre-visit planning so that visits themselves are more productive and don't add time to the doctor's day.
</p>
<p>
"We're doing a small checklist to have in the exam room for orders," says Michael Rohrenbach, DO, associate medical director of clinician engagement at The Everett Clinic. "When we're done with the visit, we can check off what we want the medical assistant to do with follow-up labs, visits, and referrals."
</p>
<p>
The assistant—not the physician—will then enter that information into the computer. "We'll sign the checklist at the bottom, and they'll be able to order for themselves," says Rohrenbach. "They will scan the orders into the EMR." Dr. Rohrenbach estimates this one change will save physicians 15 minutes a day, or about 91 hours in a year.
</p>
<p>
Even something as straightforward as a having a checklist required a significant amount of work, a sign of the challenges inherent in the system.
</p>
<p>
"It has been no small undertaking," Dr. Rohrenbach says. "We had to get corporate compliance to buy off on this. We had to get the Epic team to make changes so medical assistants could do the ordering. We had to get quite a few people in the room to change processes."
</p>
<p>
Synchronizing prescription refills presents its own problems, as the team at UW Valley Medical Center knows.
</p>
<p>
"It sounds simple, but it's a challenge," says Michele Despreaux, MD, medical director of senior care and internal medicine clinics at UW Valley Medical Center. "We're trying to reduce phone calls and frustration for the clinicians, staff, and patients, so that patients get their meds and we get way fewer messages."
</p>
<p>
Dr. Despreaux and her colleagues are trying to tackle three issues. The first is relatively straightforward: getting doctors to renew all of a patient's stable medications for the maximum duration period. The other issues are thornier.
</p>
<p>
"It's ingrained in many medical office cultures and in many patients that the refill is contingent on them having an appointment," Dr. Despreaux says.
</p>
<p>
But patients often don't realize that their prescription needs renewal until they are almost out of their medication. That leads to a stopgap request for a 30-day refill until they can get in for an appointment—all of which takes time.
</p>
<p>
The actual synchronization is the most difficult problem to solve. The AMA estimates that if 1,000 patients taking five meds call their doctor twice a year for each medication, with a call lasting just two minutes each time, the doctor and staff spend more than 330 hours a year on refills alone.
</p>
<p>
Theoretically, patients taking multiple medications for chronic conditions should be able to have their refills on the same schedule. But insurance and pharmacy issues make it hard to line up refill times.
</p>
<h3>Physicians need to lead the process</h3>
<p>
Each of the areas of intervention in the grant share a common thread: the importance of having physicians at the table to make the changes that improve their work lives. Many of the systemic problems affecting physician wellness—especially the additional work EMRs require—are the result of changes made without input from the doctors who would have to live with them.
</p>
<p>
It can feel like a losing battle at times. "Someone comes up with great idea, but they don't realize the downstream effect on the workflow for the clinical teams," says Dr. Rohrenbach, who in his role is responsible for physician engagement and satisfaction. "We don't realize how much that does to the teams working on the front line doing clinical care."
</p>
<p>
The grant participants are optimistic that the interventions can reduce burnout rates and increase satisfaction.
</p>
<p>
"My hope is that when our teams look back, they can say it took effort, but was well worth it," says Martinson. "The hope is really in physicians reclaiming their role as decision-makers within health care organizations."
</p>
<p>
Besides, doing nothing to improve physician wellness is no longer an option.
</p>
<p>
"This is probably one of the biggest crises in the health care profession," Dr. Itano says. "I see physicians leaving their jobs because they're just burned out. It's almost akin to climate change. We have to be aggressive now to prevent those downstream effects from occurring.".
</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 September/October 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 10:59:50 AM | 9/6/2019 10:44:15 AM | 9/6/2019 12:00:00 AM |
| prioritizing_wellness | Prioritizing Wellness | WSMA_Reports | Shared_Content/News/Latest_News/2019/September/prioritizing_wellness | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMA-Reports-S-O_Website-Graphic_645px.jpg" class="pull-right" alt="WSMA Reports cover" /></div>
<h5>September&nbsp;6, 2019</h5>
<h2>Prioritizing Wellness</h2>
<p>
By Kim Moore, MD and Kent Hu, MD, MPH
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
Physician and advanced practitioner wellness have always been priorities for the members of the Medical Officer Collaborative. We have worked over the years to address issues that contribute to burnout and overwhelm because we see the harmful effects to our colleagues on a daily basis. Now, Healthy Doctors, Healthier Patients - the WSMA physician wellness and administrative simplification initiative - joins Better Prescribing, Better Treatment, Honoring Choices® Pacific Northwest, and Partnership for Patients as one of our "Call to Action" initiatives, making it a central element of our work as physician leaders.
</p>
<p>
Call to Action initiatives are health care quality and safety initiatives that aim to improve patient care, health care delivery, and ultimately the health of our communities. The members of our collaborative have robust discussions about developing statewide strategies and implementation plans to advance improvements in these areas.
</p>
<p>
The word "statewide" is key. As a joint initiative of the WSMA and the Washington State Hospital Association, the Medical Officer Collaborative provides physician leaders from hospitals and medical groups throughout the state the opportunity to work collaboratively to improve care and make Washington known for its achievements in safety and quality.
</p>
<p>
Adding Healthy Doctors, Healthier Patients to our Call to Action initiatives recognizes the importance of this issue; a 2003 study published in JAMA ("Confronting Depression and Suicide in Physicians") estimated 300 physicians die by suicide in the U.S. each year. Wellness demands our ongoing attention, and we will build on our discussions of this important topic at every meeting.
</p>
<p>
The recent data from our physician and advanced practitioner wellness survey, based on Stanford WellMD's model of burnout and fulfillment, gave us valuable insights into what physicians in our state are experiencing and what is driving burnout. Being able to compare our health care organizations and our state with the rest of the country was very meaningful. With these results in hand, many of us are taking action.
</p>
<p>
That change is palpable. We now are moving from a conversation about burnout to pursuing a series of small, medium, and large initiatives to address the systemic issues that can improve wellness.
</p>
<h3>Open and honest dialogue</h3>
<p>
Our Medical Officer Collaborative Safe Tables are regularly scheduled events at which physician leaders can have open, honest dialogue on key issues and how they affect their staff, patients, and their health care organizations. It's clear from our meetings that health systems are continually looking for ways to support the wellness of their physicians, whether it's by providing scribes, reducing the number of clicks needed to reach information in EMRs, or handling physicians' laundry and grocery shopping.
</p>
<p>
At a Safe Table meeting earlier this year, we heard about health systems that:
</p>
<ul>
<li>Restructured employee contracts to promote wellness.</li>
<li>Addressed workplace inefficiencies using Kaizen and Lean principles so that physicians could finish documentation faster and leave work on time.</li>
<li>Changed the name and focus of the Impaired Physician Committee to a Wellness Committee.</li>
<li>Offered peer mentorship with young, up-and-coming leaders.</li>
<li>Provided peer-support volunteers to distressed physicians.</li>
</ul>
<h3>A history of effectiveness</h3>
<p>
A prime example of the effectiveness of the work of the Medical Officer Collaborative is its success in addressing the opioid epidemic. We have been monitoring opioid safety for many years. Members of the collaborative encouraged increased access to the state's prescription monitoring program and supported the creation of metrics, as well as guidelines, policies, and procedures. We collaborated to implement an overdose notification process that now is being rolled out across the state.
</p>
<p>
We now hope to achieve the same kind of success with addressing wellness. The Safe Table is a place where we can openly discuss what works and what doesn't. Knowing that we all have similar issues and concerns, we learn from organizations that are finding new and innovative ways to help support physicians in their daily work..
</p>
<p>
<em><strong>Kim Moore, MD</strong>, is associate chief medical officer at CHI Franciscan. <strong>Kent Hu, MD</strong>, is associate medical director at The Everett Clinic. They serve as chair and chair-elect, respectively, of the Medical Officer Collaborative.</em>
</p>
<p>
<em>This article was featured in the September/October 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 11:02:04 AM | 9/6/2019 10:33:28 AM | 9/6/2019 12:00:00 AM |