| meet_dr_umair_a_shah | Meet Dr. Umair A. Shah | WSMA_Reports | Shared_Content/News/Latest_News/2021/meet_dr_umair_a_shah | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2021/may-june-reports-article-graphic-645x425.jpg" class="pull-right" alt="May/June 2021 cover of WSMA Reports" /></div>
<h5>April 29, 2021</h5>
<h2>Meet Dr. Umair A. Shah</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
By Rita Colorito
</p>
<p>
The power of medicine to impact society has been the defining thread in the life and career of Umair A. Shah, MD, MPH, Washington state's new secretary of health.
</p>
<p>
That seed was planted in Dr. Shah's life before he was even born. His parents emigrated from Pakistan to Cincinnati in 1960. The son of immigrants, Dr. Shah grew up watching his father cope with serious health challenges.
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<p>
"One time, I remember he was in an incredible amount of pain and had to be taken into emergency surgery. I saw him going behind some doors ... and then a few hours later, the surgery was over, and he wasn't in pain. As a young boy, I attributed that to the doctors and nursesand health care professionals who took care of him," he says.
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<p>
Despite those early experiences, Dr. Shah almost didn't go into medicine. He kept thinking about pursuing law. He nearly set on that path as an undergraduate at Vanderbilt. And then his mother had a devastating stroke.
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<p>
That's when he made the mental shift to a career in medicine. "I felt so strongly that I wanted to help people through difficult times," he says. "I also started to recognize the absolute critical importance of not just medicine, but also public health."
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<p>
In medical school, the history of smallpox eradication caught his interest and he began his foray into global public health. He traveled for a two- month internship at the World Health Organization in Geneva, Switzerland. Global health's symbiotic relationship with domestic health is something Dr. Shah hopes to highlight in Washington state.
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<p>
Getting the public through health crises is something Dr. Shah has been doing throughout his 22-year career. Before taking the public health helm in Washington state in December 2020, Dr. Shah served as executive director for Harris County Public Health in Texas for seven years, managing a $100 million budget and 700 public health professionals, which grew to more than 1,500 staff during COVID-19. He not only led the community through numerous public health emergencies, he and his family (his wife and three children) have survived them, too.
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<p>
As Houston residents, they've been through dozens of natural and man-made emergencies, including hurricanes, flooding, chemical incidents, novel H1N1, Ebola, Zika, and now COVID -19. Dr. Shah spent the bulk of 2020 fighting on the front lines of the pandemic, both as a physician and leading the public health response.
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<p>
In late February, his family—including his wife (an accomplished dentist) and kids, all of whom stayed in Houston to see the school year through—saw so many people impacted during Texas' devastating winter storm. Even that couldn't disrupt Dr. Shah's whirlwind schedule as Washington's top doctor. Since late December, he's crisscrossed Washington state virtually and in person to meet with a wide net of public health and community stakeholders.
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<p>
"I believe strongly that I am the secretary of health for the entire state of Washington," he says. "That's why it is so important for me to go to different parts of the state, whether it's Spokane, or Tri-Cities, Yakima, Mason [County], the Jamestown Tribe, Port Angeles, or the Puget Sound area. At the end of the day, it is important for me to understand and recognize what is happening in those communities."
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<p>
Dr. Shah's lived experience is something he includes when given the opportunity to testify before local, state, and national legislators. In February, Dr. Shah testified in a virtual hearing of the U.S. House Appropriations Subcommittee on public health response capabilities, and the following month, he appeared before the U.S. Senate Health, Education, Labor, and Pensions (HELP) Committee. His overarching message: Public health should be invested in and a fully funded, ongoing priority, not a line item.
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Public health at the state level can't work as well as it should without committed and sizable federal funding and initiatives, says Dr. Shah. "Chronic underinvestment in public health, not just in Washington, but across the country, is a real issue," he says. "We're seeing it play out in the middle of COVID-19."
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A big sports fan, Dr. Shah likes to use sports analogies when discussing public health needs. "Public health is the offensive line of the football team, yet everybody focuses on the quarterback, which is health care," he says.
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His emergency department experience also deeply informed his view of theimportance of prevention. "I realized you could continue to just treat the trauma, or you could go out into the neighborhood and community and try to prevent it in the first place," he says. His other takeaway: Health happens outside of the four walls of a health care setting.
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<p>
"I could tell Mrs. Johnson to exercise. And if Mrs. Johnson goes back into a neighborhood where there aren't parks, or it's not safe for her to walk, or if she has to take two buses to get her around town so time is short, how likely is it she is going to be able to exercise and come back losing weight the next visit?" he says.
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"It's these social factors of equity—all the housing, transportation, education, and everything else ... that really drive health. And yet we spend so much of our precious dollars in this country on health care delivery, and not on prevention and public health," he says.
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Equity, in fact, is the first of three core values, followed by innovation and engagement, that Dr. Shah says he will champion as Washington's public health leader. During WSMA's virtual Legislative Summit in February, he presented his big-picture priorities, which also include partnership, capacity building, and global-domestic health.
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<p>
In a coronavirus-free world, Dr. Shah says he would have started his first 100 days focused on listening sessions to get at these core values—he pushed that down the road so he could focus on COVID-19. For now, pandemic response and vaccine rollout remain his top priorities. "The immediate goals are to protect Washingtonians and get us out of this horrific pandemic," he says.
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<p>
Dr. Shah says he accepted Gov. Jay Inslee's appointment for several reasons. "Washington has always championed equity, championed taking care of its fellow Washingtonians," he says. The numerous opportunities for public- private partnerships in both domestic and global health also drew Dr. Shah to swap the sunny confines of Texas for the warmth of Washington's people, if not exactly its cold, rainy days—something he's still getting used to.
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<p>
And then there's the innovation piece— the potential to tap some of the brightestminds at the intersection of technology and health located in Washington, particularly to create state-of-the-art public health data and response systems. "There's a real important opportunity for public-private partnership here," he says.
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<p>
As Washington state's first secretary of health who is also a medical doctor, Dr. Shah wants WSMA members to know they've got a colleague in the public health sector.
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<p>
"I'm somebody who has talked to patients, who has understood the challenges on the ground, in a health care setting, who knows what it's like to be in the middle of a code situation," he says. "Oftentimes public health and health care are in opposition to each other, but they're so intertwined. If we can really bring ourselves together, not because of a crisis, but because it really makes common sense, we have the opportunity to achieve the goal for everyone, which is optimizing their health."
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<p>
He also knows firsthand the overwhelming exhaustion public health and health care professionals have felt throughout the pandemic. "My team had to force me to take a day away, around maybe September, I think, after about eight months of responding to the crisis," he says.
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<p>
In the long term, Dr. Shah aims to transform public health "... to really think about how we can work together, not just in a traditional way, but in an innovative way with equity leading our efforts and engaging all partners and doing everything we can to champion health."
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<p>
As Gov. Inslee rolls out his public health restructuring plan, Dr. Shah views his role and that of the Department of Health as supportive. "We want to provide information. We want to do what we can to explain where we think there are vulnerabilities in the system. We want to be good stewards of public funds. And we want to be subject matter experts providing what the data show," he says. "At the end of the day, our role is to champion the fact that public health must be prioritized."
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<p>
The politicization and vilification of public health is another reason Dr. Shah believes in the power of positive engagement and communication. "We all know that COVID-19 has been politicized. And we've seen in this last year how horrific that can be. More than 500,000 Americans have died, and we have 5,000 Washingtonians who have died," he says.
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<p>
One of his first retweets as the state's top doctor was on COVID-19 vaccine equity. "COVID-19 didn't start public health inequities, but it certainly has unearthed [them] and made them markedly worse," he says.
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<p>
Dr. Shah is adept at social media and uses it often to overcome what he calls public health's "invisibility crisis." From his parents, he learned one shouldn't just call out a problem but work toward a solution. And his solution to this problem requires visibility, value, and validation.
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<p>
"We must raise the visibility of public health. When there is visibility, people seevalue. When people value something, they tend to want to validate it with pro-health policies and/or pro-health resources," he says. "The problem is I never thought public health would see its visibility raised with the fourth 'v', which was virus. COVID-19 has raised the visibility of public health not in a way that's systematic or methodical ... So I really hope COVID-19 is an inflection point for allofusasanationandasaglobeaswe think about transforming health."
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<p>
He offers this assessment of the past year: "2020 was like the first half of the football game and we didn't do so well. We were behind. We came back at halftime, which was right around the holidays, and with the new administration coming in, we have come out of halftime with new strategies and reenergized. Now we're in the second half. And we're hoping we don't see a further surge and continue to move in the right direction."
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<p>
While we don't know yet how the pandemic will end, there is the one certainty in public health. "There will be another emergency lurking around the corner, and we have to be ready for it," Dr. Shah says.
</p>
<p>
For his part, Dr. Shah is committed to investing in the public health offensive line, so the next time, public health isn't stuck scrambling for the next crisis.
</p>
<p>
<em>Rita Colorito is a freelance journalist who specializes in writing about health care. She is a regular contributor to WSMA Reports.</em>
</p>
<p><em>This article was featured in the May/June 2021 issue of WSMA Reports, WSMA's print newsletter.</em></p>
</div> | 4/30/2021 1:13:23 PM | 4/29/2021 1:22:27 PM | 4/29/2021 12:00:00 AM |
| supporting_washingtons_safety_net | Supporting Washington's Safety Net | WSMA_Reports | Shared_Content/News/Latest_News/2021/supporting_washingtons_safety_net | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2021/may-june-reports-article-graphic-645x425.jpg" class="pull-right" alt="May/June 2021 cover of WSMA Reports" /></div>
<h5>April 29, 2021</h5>
<h2>Supporting Washington's Safety Net</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
By John Gallagher
</p>
<p>
For years, public health in Washington functioned largely beneath the radar. Occasionally, issues such as a 2019 measles outbreak in Clark County would raise the visibility of public health departments, only to have them fade into the background once the immediate crisis passed.
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Then came COVID-19.
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<p>
For more than a year, public health has been front and center in addressing the pandemic. What quickly became apparent was that years of underfunding left public health departments ill- equipped to handle the overwhelming volume of work that the pandemic triggered.
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<p>
"Would we have been more prepared if we had invested in public health infrastructure?" asks Scott Lindquist, MD, Washington state's acting public health officer. "The answer is absolutely yes."
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<p>
Under the state's last two-year budget cycle, foundational public health services received $28 million. A 2018 assessment by the state Department of Health, state Board of Health, local health jurisdictions, sovereign tribal nations, and Indian health programs estimated that fully funding foundational public health services would cost $450 million per biennium budget.
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<p>
In fact, public health in Washington state has been underfunded for nearly two decades. In the 1990s, the state created a dedicated funding source for public health through the motor vehicle excise tax. A 1999 ballot initiative removed that funding, and another ballot initiative shortly afterward limited property tax increases that would have funded public health initiatives. (The WSMA has been calling for a dedicated funding source for public health since 2002.)
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<p>
"I love the analogy that public health is a house that is 100-plus years old, but the foundation is crumbling and the infrastructure is showing signs of wear," says Dr. Lindquist. "But we keep having events like H1N1 where we get streams of funding, which is like getting a curtain for the third story of the house."
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The failure to adequately resource public health infrastructure meant that a crisis was inevitable. Like the 100-year-old house where maintenance had been deferred for years, at some point the infrastructure for public health was bound to buckle under stress.
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<p>
"COVID-19 just illustrates some of the outcomes you get" from underfunding public health, says Alan Melnick, MD, public health director and Clark County health officer. "I'm not blaming lack of public health funding for COVID, but in terms of having preparation early on and being able to respond quickly, we were challenged because of the way we've been underfunded and understaffed for many years."
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<h3>An all-encompassing mandate</h3>
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While the coronavirus has focused attention on communicable diseases, public health encompasses far more than that. Its portfolio covers everything from chronic disease and injury prevention to environmental health and maternal, child, and family health—from tobacco cessation to septic systems.
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<p>
"It's not just infectious disease we're worried about," says Jeff Duchin, MD, health officer for Public Health — Seattle &amp; King County. "I'm increasingly concerned about climate change and [its] impact, and all of our chronic disease influenced by social determinants of health. These are chronically neglected areas of work that have never been adequately funded, yet are responsible for the largest portion of morbidity and mortality."
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Indeed, public health is a critical component of patient care.
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"It's easy to get lost in the day-to-day as an individual physician caring for patients," says Andrea Carter, MD, chief medical officer for Samaritan Health Care in Moses Lake. "But we don't reach the whole community."
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By contrast, says Dr. Carter, public health can collaborate with all the clinics in the district on a coordinated response to local challenges. "When we do a gun safety event, it's spearheaded by the health district and all the clinics work together," she says. "It's a community- wide initiative. Those are big issues that can be addressed, and we can gain a lot more ground doing it that way." While individual providers may be addressing the same problems in one-on-one settings or even through an institutional effort, the impact can't be as great.
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Dr. Carter says the pandemic brought home just how vital public health is for all patient care. "There has been a unified command and weekly public health briefings," she says. "We were able to have a common goal and the same message for patients. We learned to appreciate the important role of public health through COVID."
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Dr. Lindquist notes that despite its limitations, the public health system and the people working within it performed heroically in the face of the pandemic.
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<p>
"COVID did not break the public health system in Washington state," he says. "We identified the first case in the country. We got this person tested, got results the next day, and got him hospitalized, all seamlessly because the system was in place. COVID probably wasn't in Washington first, but our system was intact enough to detect it."
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Still, the pandemic revealed cracks in the system that are undeniably deep. Long-standing problems with data systems, lab capacity, and staffing became abundantly and painfully clear.
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"One of the big things the pandemic pointed out was how fragmented our data systems are, in terms of providing real- time access to data," says Amy Person, MD, the health officer for the Benton- Franklin Health District. "We still get a lot of our info from labs and hospitals by fax. It's one thing when in a normal year you have at most 1,500 to 2,000 cases, and it's another when at the high point you have hundreds of cases a day. Then people couldn't even fax to us."
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Dr. Duchin notes that states had to scramble to create a large-scale immunization system. "We had to scale one up cobbling together new data- management technology," he notes.
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Limited lab capacity constrained testing at the start of the epidemic. Staffing problems were inevitable after years of budget cuts.
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"During the pandemic, it was all hands on deck," says Jaime Bodden, managing director of the Washington State Association of Local Public Health Officials. "You had environmental public health staff who normally work with restaurants or permitting septic systems working on the pandemic."
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<h3>A lack of advocacy</h3>
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All of these challenges were the result of a long and steady decline in public health funding.
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"We have woefully underfunded public health," says Rep. Marcus Riccelli, D-Spokane, the House sponsor of Senate Bill 5149, which would strengthen public health funding. Riccelli is also the sponsor of House Bill 1152. That measure, which passed the House by a 56-41 vote in March, would create four regional centers to coordinate shared services across local health jurisdictions and the state.
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"We talk about public health as the front line of defense, and we see what happens when we don't fund it," he says. "Everyone everywhere should be able to get some standardized level of public health that is reliable. We know that a strong public health system is possible with intentional investments."
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Part of the challenge for public health is that its work is easily overlooked. "There's no advocacy group for people who don't get sick," says Dr. Melnick.
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"You can't point to a road and say, 'This was brought to you by public health,'" Bodden says. "When public health does its job, nothing happens, and that's not a good selling point."
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Since the loss of a dedicated revenue source, "our funding has become very destabilized, very piecemeal and stagnant," Bodden says. "It's been the same amount for the past 20 years." Over that period of time, the population in the state has grown by more than 1.7 million.
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<p>
The lack of funding may make sense to legislators in the short term, but in the long term, the costs are simply deferred, not eliminated. Dr. Duchin notes that there are thousands of undetected cases of latent tuberculosis in King County alone. Treating latent tuberculosis costs about $500. Treating active tuberculosis costs about $17,000.
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<h3>Chasing dollars</h3>
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To make up for the revenue shortfall, health districts end up chasing dollars from other sources. Unfortunately, the funding that is available is often structured in a way that limits its impact.
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"There are programs that come and go," says Dr. Duchin, citing chronic disease and injury prevention as examples. "The funding is episodic and not stable, and it requires competition. It's a significant investment in time and energy just applying for grant funding."
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"The funding tends to be very project- based and very specific, which is a challenge because in public health things aren't separated," agrees Dr. Person.
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The project-specific grants also create other problems. "You have funding to work on tobacco-related things, so you build up a network of community partners and start moving things forward," says Dr. Person. "Then tobacco is not a big issue, but diabetes is. Suddenly, the work you've done with tobacco is done, and you can't just shift that over to diabetes."
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The emphasis on projects and deliverables rubs against the long-term emphasis that public health should have. However, desperate for some funding sources to help their communities, health districts feel the need to pursue them, despite the downside.
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<h3>Politics over science</h3>
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Simply increasing funding for public health will not solve all its problems. Like all too many institutions, the system and its leadership have become targets of intense politicization. Last November, the Spokane health board fired health commissioner Bob Lutz, MD. Dr. Lutz was a focus of attention from Spokane Mayor Nadine Woodward, who complained that the county was not moving forward rapidly enough toward reopening. She also criticized Dr. Lutz for talking about what she termed "controversial" topics, such as climate change, without the board's consent.
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<p>
Such episodes highlight the delicate role that public health plays.
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<p>
"Public health officers are sometimes forced to implement policy that will have a significant negative impact on some individuals and their livelihood," says William Hirota, MD, a gastroenterologist at Virginia Mason Franciscan Health and a member of the Tacoma-Pierce County Board of Health. The Tacoma-Pierce County Health Department faced its own political firestorm in November, when several Pierce County Council members proposed to dissolve the joint city and county department. "You end up with some animosity."
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In retrospect, some of the problem could have been alleviated with closer ties to community stakeholders, he says.
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<p>
"Part of the problem of not being completely prepared is a lack of relationship building," says Dr. Hirota, who is the immediate past president of the WSMA. "One of the lessons learned is that in order to build an effective public health foundation, we're going to need to have a clear reassessment of our needs, develop policies that are going to be timeless, build these plans out, and be accountable for them. That means we need to be very engaged in public-private partnerships."
</p>
<p>
Even with improved funding and structural change, other challenges will remain. "Our workforce is diminishing" as a result of funding cutbacks over time, says Dr. Melnick. "We have to train a workforce to do this work, and we need to have a more diverse workforce."
</p>
<p>
Ultimately, says Dr. Lindquist, the goal should be to provide enough unrestricted funding so that every public health district in the state can provide the same level of services.
</p>
<p>
"When I look at rabies, am I going to get the same level of protection in Seattle as I will in Othello?" he asks. "No matter where you are a resident of Washington state, you should have the same level of public health protection."
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Dr. Lindquist is cautiously optimistic that such a goal is attainable as a result of the pandemic. "I have been in public health since 2001," he says. "We have never had as much attention paid to the need to fund the infrastructure for public health as we are seeing now."
</p>
<p>
<em>John Gallagher is a freelance journalist who specializes in covering health and the health care system. He is a regular contributor to WSMA Reports.</em>
</p>
<p><em>This article was featured in the May/June 2021 issue of WSMA Reports, WSMA's print newsletter.</em></p>
</div> | 4/29/2021 10:53:36 AM | 4/29/2021 10:36:59 AM | 4/29/2021 12:00:00 AM |
| health_equity_101_class_is_in_session | Health Equity 101: Class Is in Session | WSMA_Reports | Shared_Content/News/Latest_News/2021/health_equity_101_class_is_in_session | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2021/march-april-cover-645x425.jpg" class="pull-right" alt="WSMA Reports March/April 2021 cover image" /></div>
<h5>March 22, 2021</h5>
<h2>Health Equity 101: Class Is in Session</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
By Pat Curry
</p>
<p>
After working as a street medic and having extensive involvement in the anti-war movement in New York, Luis Manriquez, MD, decided to go to medical school to gain "the technical skills to address social justice."
</p>
<p>
As a student at the University of Washington School of Medicine, he founded the Health Equity Circle, an interprofessional group that equips students to take action on health equity using the tools of community organizing.
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<p>
"When I started medical school, people knew about social determinants of health and thought it was cool, but it wasn't expected to be part of your medical training," says Dr. Manriquez, who now is an assistant clinical professor at Spokane's Washington State University Elson S. Floyd College of Medicine, where he also leads health equity development efforts. "Now, it's an expectation when students come in, and I think that's great. The mindset of students is that this is part of being a doctor."
</p>
<p>
Indeed, health equity has become part of the fabric of medical training in Washington state. All three of the state's medical schools have extensive ongoing efforts to incorporate equity into their curriculum, and they are working to address systemic implicit bias and expand the diversity of their student bodies.
</p>
<p>
There's no better time than during medical school to plant the seeds, says Michael Lawler, MSW, PhD, president of Pacific Northwest University of Health Sciences in Yakima.
</p>
<p>
"If you train people to work with each other, they'll do that when they go out in the field," Lawler says. "It's an aspirational vision, but when we think about COVID, the two issues facing us are health and equity. They're both apparent."
</p>
<h3>Creating an inclusive environment</h3>
<p>
At PNWU, equity and inclusion are being integrated across the university's strategic five-year plan. That includes organizing an office dedicated to equity, diversity, and inclusion. Workshops on bias and microaggression have been held for students, faculty, staff, and the board of trustees "at their request," says Mirna Ramos-Diaz, MD, MA, FAAP, who recently was named PNWU's first chief diversity officer. The university also is creating a restorative justice model, which emphasizes repairing harm through collaboration.
</p>
<p>
In 2020, the University of Washington School of Medicine created the Office of Healthcare Equity. The office has been hard at work to make addressing equity and implicit bias central to how the school runs. Almost all of UWSOM's 32 clinical teams currently have an equity team and a bias reporting tool is making it easier for members of the community to speak up.
</p>
<p>
"After the events of the summer— the killing of George Floyd and others and the protests—our leadership took the strong stance to require equity, diversity, and antiracist training for all members of our community," says Paula Houston, EdD, chief equity officer for UW Medicine, the parent health care system for UWSOM. "The fact that people are having the conversation has really built awareness and the realization they need to change behavior."
</p>
<p>
The office also has created an equity impact review tool so that policies and procedures can be viewed through an equity lens. The goal is to make it as easy as possible to say who a policy will benefit, who it will burden, and how to mitigate that burden.
</p>
<p>
Houston says that when she presented it at a leadership meeting, she thought one or two people might be interested in piloting it.
</p>
<p>
"Nine departments wanted to do it immediately," she says. "People want to do the right thing; they just didn't know how to do it. They want to make this a better environment."
</p>
<p>
David Garcia, MEd, WSU's assistant dean for health equity and inclusion, says the work being done today on health equity and implicit bias is much like it was with technology in the early 1990s, when organizations had to develop the infrastructure to embrace the digital world.
</p>
<p>
"At some point, we all had to get email," Garcia explains. "With inclusion, we are at a point where we need to develop the infrastructure and become healthier as organizations. We want to be able to look back in 10-15 years and say we're doing our part. Our communities depend on it. The rationale has never been clearer to me on why we need to be doing this work."
</p>
<h3>Weaving equity into curriculum</h3>
<p>
How do medical schools ensure the educational experience doesn't perpetuate stereotypes?
</p>
<p>
"That is the million-dollar question," Garcia says. "We do case-based learning and a lot of small-group learning. When we introduce a case at the beginning of the week, how are we ensuring cases are reflective of the state of Washington?"
</p>
<p>
Dr. Manriquez says a health equity thread is woven through all four years of training at the WSU medical school.
</p>
<p>
"My approach is that medical school doesn't make you an expert in anything; you get an introduction," he says. "If that's true of the liver and the heart and the kidneys, it's also true of health equity. We want to develop a foundation to understand the concept. So, in the first two years, we have foundational sessions; in the session on bias, we explain the science of bias, how it works, and antibias tools. We do the same thing with racism, sexism, disabilities, health literacy, and making use of an interpreter."
</p>
<p>
In the third year's longitudinal integrated curriculum, there's more content in understanding bias and equity in a clinical setting. "Why do you see this difference in health outcomes by race or status? Some are assumptions on the part of the provider or the patient; some are actual barriers to access. ... These inequities in health are a huge deal; the differences in black and white life expectancies are tremendous."
</p>
<p>
UWSOM went through a curriculum renewal in 2015 that added eight themes that go across all four years of study, says Suzanne Allen, MD, MPH, vice dean for academic, rural, and regional affairs for the medical school. Those themes are communication, diversity, ethics, health equity, inter- professionalism, lifelong learning, quality and safety, and professionalism.
</p>
<p>
The school also recommends that all students read a common book each year on a social justice issue. For 2020-2021, the book is the thought-provoking "How to Be an Antiracist" by Ibram X. Kendi.
</p>
<p>
Through its Pathways programs, students can focus on serving a marginalized population.
</p>
<p>
"The idea is they do an elective course in the first year or two of medical school and do a summer clinical experience with that population," Dr. Allen says. "We then ask them to do one of their required third-year rotations with a clinic or facility where they'll see a large number of those patients."
</p>
<p>
Standardized patient encounters provide a great opportunity for faculty to make students think about their own bias and whether it is creating blind spots in care, says Thomas Scandalis, DO, dean of the College of Osteopathic Medicine at PNWU.
</p>
<p>
Sometimes, it's as simple, and as crucial, as making students aware that assumptions can lead them astray.
</p>
<p>
"A student sees a mom with a child and says, 'Where's the dad? Tell me about your husband,' " says PNWU's Dr. Ramos-Diaz. "They're assuming the other parent is a man."
</p>
<p>
Students also need to be prepared "for working with [older] people like me who aren't current on how to address people," Dr. Scandalis says. "Our students are very comfortable in their own skin. Some get a little freaked out, though, when they get on rotation and hear that bias."
</p>
<p>
"That is why we have training at the beginning of the year," Dr. Ramos-Diaz says. "Their eyes are opened."
</p>
<h3>Recruitment</h3>
<p>
Perhaps the most exciting and potentially impactful effort at the medical schools is in recruiting future classes of medical students. All three schools are looking closely at the methods used to select applicants.
</p>
<p>
Both the WSU Elson S. Floyd College of Medicine and PNWU take a holistic approach to the admissions process and avoid making decisions solely on grades and MCAT scores. "An overreliance on GPA and MCATs can really eliminate diverse populations you want to enroll," says Leila Harrison, PhD, MA, MEd, senior associate dean for admissions and student affairs at the WSU medical school. "It can be a barrier; we focus on the mission."
</p>
<p>
The school also recruits at rural colleges and community colleges. "That's not common for medical schools," Harrison says.
</p>
<p>
But efforts go far beyond that, even to connecting with children as young as elementary school age to spark an interest in becoming a doctor. PNWU's communications staff has produced a children's book, "I Want to Be a Doctor! A Day at Medical School." The book also has been translated into Spanish.
</p>
<p>
A year-long peer mentoring program called Roots to Wings pairs Native American and Mexican American middle and high school students with PNWU students.
</p>
<p>
"We use cultural values and traditions as a conduit to teach sciences," Dr. Ramos-Diaz says. "When you bring cultural values and science together, students have a greater desire to participate and that science has meaning. Then, they're excited. I remember a student saying to a med student, 'So does that mean as a Native, I can be a doctor?' Of course, yes! It was like an awakening."
</p>
<p>
Students who are particularly interested are invited to participate in a two-month summer internship at the National Institutes of Health in Bethesda, Maryland, where they are paired with scientists from their own background when possible.
</p>
<p>
LeeAnna Irvine Muzquiz, MD, associate dean for admissions at UWSOM, is a member of the Confederated Salish and Kootenai Tribes and grew up on the Flathead Reservation in Montana. She says the admissions office has moved away from the concept of creating "pipelines" of applicants to more of an "ecosystem" approach.
</p>
<p>
"When we think about pipelines, they tend to break and leak," Dr. Muzquiz explains. "A pipeline seemed to work for me, but it was the mentoring and the surrounding ecosystem that helped me make it through [medical school]. All of us have a role to play in nurturing the next generation; we can all have an influence on what the ecosystem looks like."
</p>
<p>
UWSOM's efforts include Doctor for a Day. The vision of the program, which is organized by medical students, is to bring a hands-on, educational day of activities to students of color, featuring volunteer doctors, physical therapists, nurses, and dental students who look like them.
</p>
<p>
At that age, having someone believe in and encourage you can have a tremendous impact, says UWSOM's Dr. Allen. She was planning to be a nurse until a visit to her family physician for a school physical. On hearing her plans for nursing, "He asked me, 'Why don't you want to be a doctor?' and he let me follow him around," Dr. Allen says. "I can trace five women from the same era who became physicians because of him."
</p>
<p>
<em>Pat Curry is senior editor of WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the March/April 2021 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 3/22/2021 1:01:53 PM | 3/22/2021 1:00:41 PM | 3/22/2021 12:00:00 AM |
| trial_by_covid_19 | Trial by COVID-19 | WSMA_Reports | Shared_Content/News/Latest_News/2021/trial_by_covid_19 | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2021/march-april-cover-645x425.jpg" class="pull-right" alt="WSMA Reports March/April 2021 cover image" /></div>
<h5>March 18, 2021</h5>
<h2>Trial by COVID-19</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
By Rita Colorito
</p>
<p>
Vera Schulte had two weeks left in her third year of medical school when the University of Washington School of Medicine locked down due to COVID-19. Because UWSOM has a condensed pre-clinical curriculum, Schulte finished almost on time. Friends in other medical schools, she says, weren't so lucky.
</p>
<p>
"They were delayed in finishing their third year, which makes applying for residency quite a bit more difficult. If
you haven't rotated in pediatrics, family medicine, or general surgery, etc., it's hard to realize that's the kind of doctor you want to be," says Schulte, whose chosen specialty is obstetrics and gynecology.
</p>
<p>
Much of clinical training is trial by fire. Being in the room where health care happens is critical to medical education and residency. Under normal circumstances, that means long hours
interacting directly with faculty and patients in a team-based approach.
</p>
<h3>Starting from scratch</h3>
<p>
COVID-19 burned medical-education- as-usual to the ground—at least in the short term. As the pandemic surged, medical schools and residency programs grappled with staying safe. Personal protective equipment was running low. Preceptors manning the pandemic front lines couldn't oversee usual rotations. Statewide clinical training and rotations ceased mid-March, going virtual over risking the unknowns. Most wouldn't resume in-person training until July.
</p>
<p>
Nationwide, the American College of Surgeons shut down clinics and operating rooms to fellows and residents. "[It was] very frightening because this had never been done in the history of the ACS," says Byron Joyner, MD, MPA, UWSOM's vice dean of graduate medical education, who sent residents and fellows home to ensure their safety.
</p>
<p>
"We didn't know how our trainees should be involved in a pandemic and we didn't have enough PPE at the time," says Dr. Joyner. He spent the first weeks of lockdown fielding calls from anxious students and calling the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties for guidance.
</p>
<p>
"Residents and fellows were afraid that they might not be able to take their boards after graduation without having done enough rotations," says Dr. Joyner. "The most subtle and nerve-wracking concern was just the uncertainty and the ambiguity. What was next? When would this be over?"
</p>
<p>
The response to the shutdown from students was a mixed bag, says Suzanne Allen, MD, MPH, UWSOM's vice dean for academic, rural, and regional affairs. Some didn't feel safe on their clerkships, while others expressed frustration at missing a once-in-a-lifetime opportunity to care for patients during a pandemic.
</p>
<p>
The solution to both: a virtual course in pandemics the first half of spring
quarter, followed by virtual rotations the second half. These proved very popular, says Dr. Allen.
</p>
<p>
Being honest about what they knew and didn't know helped Washington State University's Spokane-based Elson S. Floyd College of Medicine quell anxiety, forge forward safely, and build institutional resilience, says Judith Bowen, MD, PhD, its associate dean for curriculum.
</p>
<p>
"In this way, we are able to help students understand our obligation to keeping them, their family members, and our faculty (and staff) safe, and to avoid having any of us inadvertently contribute to ongoing viral transmission," says Dr. Bowen.
</p>
<h3>Embracing opportunity, virtually</h3>
<p>
WSU College of Medicine's longitudinal integrated clerkship design allowed students pulled from clerkship to continue learning through a virtual, case-based curriculum, says Dr. Bowen. The longitudinal design meant that all students had completed some direct patient care experience in all of the clerkship disciplines before moving to the virtual curriculum. As the clinical environment settled and more PPE became available, in-person training resumed in June. "Although we planned for future disruptions, third- and fourth- year students have been fully engaged as part of the clinical workforce since then," says Dr. Bowen.
</p>
<p>
Despite initial drastic measures, medical schools not only adapted, but also strengthened the way they teach thanks to the pandemic, says Anita Showalter, DO, associate dean for clinical education at Pacific Northwest University of Health Sciences in Yakima.
</p>
<p>
Used only sporadically pre-COVID-19, medical schools and residencies fully embraced Zoom and other online platforms for town halls, webinars, team meetings, and to provide eyes-on patient care. Within a week of the shutdown, all PNWU core rotations were online. To replicate the in-clinic experience, PNWU used standardized patient simulations via teleconferencing (one example: working through videos of a vaginal birth).
</p>
<p>
"The goal was to make them work through analyzing patients and clinical decision-making as they would have if they had been in the clinic with their preceptors," says Dr. Showalter. As students have returned to rotations, PNWU has maintained the online curriculum to accommodate students and preceptors testing positive for COVID-19 or needing to quarantine.
</p>
<p>
Even though rotations have resumed, they still look different. To reduce the risk of transmission and to be sensitive to patients, rotations have limited team size. "It didn't seem right to let medical students participate when the patient's own family couldn't come in," says Dr. Showalter.
</p>
<p>
Wherever medical schools can go virtual, they have. At UWSOM, that includes clerkship orientations and lectures. "We don't want large groups of people congregating in the same place," says Dr. Allen. The benefit to that, she says, is all clerkship students, regardless of where they are across UWSOM's six regional campuses and 200 clinical sites, can now attend all lectures.
</p>
<p>
Amid the chaos, the goal remains to give students enough experiential learning to graduate, says Dr. Showalter. That's where newfound teleconferencing skills have come in. "We had one situation where the doctor contracted COVID. The student went into the clinic and via teleconferencing, connected the patient with the doctor. [The student] could be the hands for the doctor who was not able to be on site," she says.
</p>
<p>
The pandemic has also affected residents who aren't patient-facing, says Elizabeth (Libby) Parker, MD, a third- year UW resident in anatomic pathology last spring. As elective procedures were cancelled or delayed, Dr. Parker saw a shift in the kinds of specimens she received.
</p>
<p>
"We're very closely linked to what our clinical and surgical colleagues are able to perform, procedure-wise. What they're able to do really impacts our clinical work," she says. As elective procedures have increased, Dr. Parker is now seeing the full spectrum of cases.
</p>
<h3>Silver linings</h3>
<p>
While students are required to complete yearly infection control reviews, the hyper-awareness surrounding COVID-19 has had a measurable impact. "It's already led to a decrease in other kinds of hospital infection rates," says Dr. Allen; it's something she sees continuing.
</p>
<p>
"Students who are in medical school right now, who are 'growing up' during a pandemic, are going to be so much better at infection control, because that's what they've known from the start," she says.
</p>
<p>
Resident research and scholarly activity also increased because of the pandemic, says Dr. Parker, who co- published medical education literature on her experience teaching remotely. "There's been a bolus of research on COVID-19. It's been exciting to have so many minds working on the same problem from so many different specialties," she says.
</p>
<p>
Dr. Parker has also welcomed the didactic creativity offered by online platforms. She still uses Path Presenter, a virtual platform where pathologists worldwide can share digital slides. "We're able to use it to teach and still be interactive and simulate our day-to-day work," she explains.
</p>
<p>
COVID-19 also highlighted inequities in health care—and the need for clinical training to address those concerns head on. Graduating doctors with more robust telemedicine experience is one downstream effect of the increase in virtual clinical training and a real benefit for rural patients, says J. Miguel Lee, MD, residency program director for Providence St. Peter Family Medicine's Chehalis Rural Training Program (CRTP). "It was actually one of the silver linings, if you will, of this catastrophe," he says.
</p>
<p>
A small residency program and clinic, CRTP gathered its faculty and nine residents to develop a plan for patients who couldn't get to the clinic or were too wary of coming. "We went from no virtual care to 100% virtual care in a matter of two days," says Dr. Lee.
</p>
<p>
In the neighboring communities, telemedicine has been embraced, he says. "We had 95-year-olds with their grandkids holding their phone up for virtual care and it's really worked quite well."
</p>
<p>
Even though residents have seen patients virtually, it hasn't taken away from their experience serving rural communities. "It's just an added tool
in our toolbox," Dr. Lee says, "and, you know, potentially, it will increase access to people who can't drive for two hours for an appointment but can turn on the computer at home."
</p>
<h3>From health care to human care</h3>
<p>
Amid the winter surge, many of the same trainee concerns around safety, education, and patient care remain, says Dr. Joyner from UWSOM. "They're worried about getting sick and getting others sick," he says. "They're worried about not having enough education to graduate, not enough competence and confidence. It strikes at their very core of being a doctor."
</p>
<p>
The availability of vaccinations for themselves and their families also worries residents, says Dr. Joyner, adding that most of UWSOM's 1,400 trainees have already received their first dose.
</p>
<p>
One year after the first COVID-19 cases, Dr. Showalter says her biggest concern is students' mental health and well-being. "Medical school tends to be a very alone time, with students working very hard but isolated from other social supports," she says. "With all the COVID restrictions, that was doubly bad. So, we're really watching our students to make sure they're staying in a good place mentally," she says.
</p>
<p>
Dr. Lee echoes her concerns. "Wearing masks all the time and not being able to gather, I think that is taking away one of our tools for wellness—the activities we normally did together," he says. "Despite the fact we can't do those things, I think we still feel very, very united with our group."
</p>
<p>
"In some ways we are missing out on human connection," Dr. Parker says. "But I think that hopefully time will show we're still able to do a lot of good and we're still able to have enthusiastic engagement."
</p>
<p>
To keep students engaged and feeling connected during isolation, medical schools encouraged service and research projects. "When vaccine supplies began to arrive, our clinical partners reached out to invite student volunteers to assist with administration," says WSU's Dr. Bowen.
</p>
<p>
UWSOM created many opportunities for COVID-19-related service learning. Many, like Schulte, volunteered for the Seattle Coronavirus Assessment Network to assist with screening and testing. In her spare time, Schulte also babysat for health care workers. Academically, she participated in a research project on COVID-19's impact on pregnant women in Washington state.
</p>
<p>
"Although being pulled from clinical duties was difficult, I was tremendously grateful for the plentiful opportunities during this time to continue supporting the community and continue my medical education, even if it was outside of the hospital," Schulte says.
</p>
<p>
Residents and faculty have shown incredible resilience throughout the pandemic, says Dr. Joyner. Many trainees have repeatedly asked to be redeployed to the COVID-19-dedicated ICUs. "They have contributed enormously to our effort to keep our community safe and to care for our sickest patients," he says.
</p>
<p>
Last fall, Schulte's six-days-a-week clinical training schedule returned to pre-COVID-19 levels. During her gynecologic oncology sub-internship, she started pre-rounds by 5:45 a.m. and signed out at 6 p.m. After a quick dinner, she reviewed medical student projects and worked on her own research, finally getting to bed by 11 p.m. The more things change, the more they stay the same.
</p>
<p>
<em>Rita Colorito is a freelance journalist who specializes in writing about health care. She is a regular contributor to WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the March/April 2021 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 3/18/2021 4:11:48 PM | 3/18/2021 4:02:28 PM | 3/18/2021 12:00:00 AM |
| stormy_seas | Stormy Seas | WSMA_Reports | Shared_Content/News/Latest_News/2021/stormy_seas | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/Newsletters/Reports/2021/Jan-Feb-2021-Reports-Cover-645x425px.jpg" class="pull-right" /></div>
<h5>January 19, 2021</h5>
<h2>Stormy Seas</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>By John Gallagher</p>
<p>
When the COVID-19 pandemic exploded in early March, Ki Shin, MD, was on
vacation in Hawaii with his wife, also a physician, taking a break from
their practice in the small town of Montesano. "We got there on Monday
and then the governor's restriction happened," Dr. Shin recalls. "All
of a sudden, we were out of town and my staff was freaking out. It was
an immediate crisis. Not a lot of information was available to us, and
we had a lot of scared people, staff and patients included."
</p>
<p>
Upon their return home, the Shins immediately set about trying to
stabilize their practice. Faced with a 40% drop in appointments, the
couple took a 50% pay cut so that they could keep their staff on
payroll.
</p>
<p>
"For us not to get paid for a couple of months was totally doable, but
that was not true for the staff," says Dr. Shin.
</p>
<p>
After a rough few months, some of the financial pressures eased. The
Shins obtained a loan under the Paycheck Protection Program (PPP), the
part of the federal Coronavirus Aid, Relief, and Economic Security Act
designed to help small businesses. They also received $30,000 from
Medicare, which covered the practice's overhead for a month.
</p>
<p>
Eventually, patients started returning, and Dr. Shin's practice is
stable again, but still not entirely recovered. "The [patient] volume
is coming up, but it's not back to normal," he says. "It's about 90% of
what it was previous to COVID."
</p>
<h3>Survey answers detail challenges</h3>
<p>
The recovery of Dr. Shin's practice, and other practices around
Washington, is a hopeful sign. However, the new normal falls short of
the old one. Moreover, the ever-changing course of the pandemic,
including the potential for another lockdown, makes the outlook for
practices in Washington uncertain at best.
</p>
<p>
"Physicians are doing okay right now, but they are still so
vulnerable," says Jennifer Hanscom, executive director and CEO of the
WSMA. "The ground they're standing on is shaky. There might be an
earthquake brewing underneath."
</p>
<p>
Shawn Andrews, primary care medical director at Summit Pacific Medical
Center in Elma, says that the effects of the pandemic seem to vary by
type of practice.
</p>
<p>
"In terms of finances, the larger practices will survive," she says.
"Our budgets are not pretty but we're viable, and that's not a given
for everyone this year. We're not in the same boat as folks in private
practice or even some other critical access hospitals."
</p>
<p>
A fall 2020 survey of WSMA members found that the pandemic has taken a
significant toll on practices, making their financial viability a real
concern. Of 69 members from a range of practices and specialties who
responded to the survey, more than half reported a temporary reduction
in compensation because of the pandemic. Nearly half the survey
respondents said that they had to lay off or furlough staff, including
physicians.
</p>
<p>
Almost a quarter of the respondents said that the financial impact of
the pandemic on their practice is between $500,000 and $1 million.
Those figures echo a national survey of 3,500 physicians conducted by
the AMA last summer, which found practice revenue dropped by roughly
one-third.
</p>
<p>
While the worst of the pandemic appears to be over, the ripple effects
continue. The vast majority of the physicians who responded to the WSMA
survey said that their patient volume was down compared to before the
pandemic, with more than a third saying it was down between 25% and
75%. Even more troubling was that fact that more than 40% reported
having a month or less of cash on hand to pay operating expenses. The
WSMA benchmark is 18 weeks.
</p>
<h3>
Extra costs, curtailed services drive need for more financial help
</h3>
<p>
As it did for Dr. Shin's practice, the federal PPP loan provided a
financial lifeline for many practices.
</p>
<p>
"Luckily we got one of the PPP loans," says Juliette Erickson, MD, a
physician in a private practice in Grays Harbor. "That helped us
tremendously and got us over the hump. We stopped having weekly
meetings on how to pay the next paycheck and started focusing on
medicine again."
</p>
<p>
However, as much as the loans helped, their benefit was limited. More
than 80% of the physicians in the WSMA survey said that additional
financial support would be helpful. In part, that's because new safety
protocols have also meant more expenses.
</p>
<p>
Chelsea Unruh, MD, a physician at Yelm Family Medicine, says that the
expenses related to COVID-19 requirements have added up. Like other
clinics, Yelm Family Medicine does initial screenings of patients in
its parking lot, but the costs don't stop there.
</p>
<p>
"We have had to rebuild our back parking lot for these car visits,"
says Dr. Unruh. "We have had to outfit our front desk with shields. We
are investing in rapid testing and signing contracts for long-term use
of specific machines."
</p>
<p>
Then there is the extra expense of additional personal protective
equipment. "The cost of PPE went up," notes Hanscom. Now practices are
having to bear the costs of full PPE, masks, and sanitizers that
previously were used much more sparingly.
</p>
<p>
Like Dr. Unruh, Dr. Erickson also sees clients with COVID-19 symptoms
in the clinic parking lot. "I'm dressed in full PPE," she says. "It's
not the best way to see an ill person, but it's the best we can do and
still protect our staff and patients."
</p>
<p>
The need to sanitize exam rooms thoroughly between patient visits can
also have a direct impact on patient volume. "We decreased the number
of patients we're seeing per hour," says Dr. Shin. "I was able to see
four patients an hour, but with the cleaning between visits, we chose
to limit it to three patients per hour."
</p>
<p>
Even with such precautions in place, some staff still have to
quarantine because they were exposed to the virus outside of work.
</p>
<p>
"The other income challenge has been the loss of time from our staff,
from exposures or from being ill themselves," says Dr. Unruh. "None of
those exposures happened at work, but we don't get to control the
private lives of our staff. To exclude someone for 14 days because they
made a poor choice has been rough on morale and staffing."
</p>
<p>
To protect staff and patients, some practices have curbed services,
including Dr. Shin's. "In Montesano, there are no blood draw labs, so
lots of patients were coming into our clinic even though [the labs]
were for someone else," Dr. Shin says. The practice eliminated that
service, forcing patients in the area to travel farther for it. Dr.
Erickson says that she is referring more patients to the ER because her
clinic lacks the proper PPE to treat suspected COVID-19 patients.
</p>
<p>
But Dr. Andrews says that patient volume at her hospital's ER, as well
as its urgent care clinics, is still down significantly. "Many people
wait until they are very ill to seek services, and often suffer much
worse outcomes," she says. Nonetheless, she says that larger practices
have been better positioned to withstand the pressures from the
pandemic for a variety of reasons, including business plans less
impacted by long term drops in volumes, better PPE availability, and
space to separate well patients from symptomatic ones.
</p>
<h3>Telehealth use soars</h3>
<p>
The pandemic accelerated several trends that were already underway.
Chief among these has been the growth of telehealth. Three-quarters of
the physicians in the WSMA survey said that they implemented telehealth
as a result of the pandemic.
</p>
<p>
"We had never done telehealth before," says Dr. Unruh. "Then suddenly
we had half a day per provider devoted to telehealth visits."
</p>
<p>
As helpful as telehealth has proven, it has its drawbacks. In rural
areas, internet connections can be spotty, if patients have broadband
service at all.
</p>
<p>
"It's hard to do telehealth where people don't have iPads or iPhones,"
says Dr. Erickson.
</p>
<p>
For Dr. Erickson, telehealth has also inadvertently caused a staffing
problem. One of the three doctors in her practice began doing
telehealth at the start of the coronavirus outbreak as a way of
bringing income into the practice and fell in love with it. She has
accepted a full-time job as a telehealth physician and will be leaving
the practice.
</p>
<p>
"This is her way of moving with her career, but she would never have
found that job if we were not financially struggling in the first
place," says Dr. Erickson.
</p>
<p>
Moreover, as useful as telehealth has proven, its long-term future as a
viable option is still in doubt. "CMS holds the key for that," says Dr.
Andrews. "CMS will decide what we can and can't get paid to do." If
telehealth is not reimbursed or not reimbursed at a reasonable rate,
practices will not be able to sustain it. Accordingly, the WSMA has
made telehealth reimbursement a priority for its advocacy efforts in
the 2021 state legislative session.
</p>
<h3>Independent practices face tough challenges</h3>
<p>
Among the other changes hastened were retirement decisions. "We have a
group of anesthesiologists who are in their late 50s to late 60s," says
Brian Nyquist, MD, a partner at Olympic Anesthesia in Bremerton. "We
had several people who were close to retirement that retired. We knew
it was coming, but it's not like you can hire people before you need
them."
</p>
<p>
The flip side of the retirements, says Dr. Nyquist, is that the
"business kerfuffle of COVID" has made recruiting easier. While
previous attempts to recruit were uphill battles, he says that there
are more physicians applying for open positions at his practice. He
believes that because of COVID-19, "a lot of corporate owners,
management services, and practices have clamped down on people and
contracts," leading physicians to look for new opportunities.
</p>
<p>
Whether that applies to rural practices is an open question.
"Recruiting is incredibly challenging, but more physicians are
realizing that independent practices are a joy to work in because you
are more autonomous," says Dr. Erickson.
</p>
<p>
However, the financial pressures of the past year may make it harder
for independent practices to survive. "There's been a nationwide trend
away from private groups," says Dr. Nyquist. "We are privileged to
continue to be a private group. For now we're positioned pretty well,
but there are lots of pressures—most of them financial, some
societal—that want to drive physicians to work for hospitals. I
fear that this is probably going to exacerbate that."
</p>
<p>
Even when a vaccine is available, the effects of the pandemic will
still be felt. "For the next year, I don't see how we don't do things
we're doing now, like not have a waiting room," says Dr. Shin. "I don't
think we're going to change the number of patients we serve per hour. I
think we're looking at this as a long- term issue."
</p>
<p>
While the financial situation for Washington physicians had stabilized
by year's end, the specter of another spike in coronavirus cases still
haunts practices. "If we went back to a dark winter where we couldn't
even see patients in the office, we would absolutely struggle again,"
says Dr. Erickson. "It keeps you up at night."
</p>
<p>
Still, she remains committed to keeping the clinic afloat. "We've been
here 35 years, and there are literally not many options in town," she
says. "The most important thing is how we continue to do our work."
</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 2021 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 1/19/2021 12:13:40 PM | 1/19/2021 11:57:02 AM | 1/19/2021 12:00:00 AM |
| virtual_advocacy | Virtual Advocacy | WSMA_Reports | Shared_Content/News/Latest_News/2021/virtual_advocacy | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="WSMA Reports Jan-Feb 2021 cover art" src="/images/Newsletters/Reports/2021/Jan-Feb-2021-Reports-Cover-645x425px.jpg" class="pull-right" /></div>
<h5>January 19, 2021</h5>
<h2>Virtual Advocacy</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>By Pat Curry</p>
<p>
As with so many other institutions, the 2021 session of the Washington State Legislature has been fundamentally changed by the coronavirus pandemic. No one thinks it’s a good idea to put hundreds of people together in a room for hours a day over several weeks.
</p>
<p>
So, the structure of this year’s session will be quite different. It will be conducted largely—or entirely—remotely, and the Capitol campus will be closed to the public.
</p>
<p>
Due to the remote nature of the session, fewer bills will likely be considered, with a focus on the state budget and responding to the pandemic. Given the public’s outpouring of support for health care workers, it might seem that this would be the year to shoot for the moon in terms of asking the legislature for health care funding.
</p>
<p>
That would absolutely be true if there was a surplus of cash.
</p>
<p>
“The state’s budget outlook has improved somewhat from the nadir in the spring, but there remains a revenue shortfall,†says WSMA Government Affairs Director Sean Graham. “Actions will need to be taken to keep the budget in balance in the short term and the longer outlook our top priority in the budget realm is staving off any cuts that would impact access to care for the state’s patients.â€
</p>
<p>
“I’m grateful we represent the individual physician because we can put a human face on the situation and speak for people who were racing in to solve the problem,†says WSMA Executive Director/CEO Jennifer Hanscom. “That’s an added benefit.â€
</p>
<p>
Even with the sympathy that physicians and other health care providers have garnered from policymakers, any number of tax increases are likely to be proposed in the 2021 session and some will impact physicians. Among WSMA’s legislative priorities this year is ensuring the financial viability of practices, including opposing tax increases that will unduly impact the physician community.
</p>
<p>
“We know that virtually all our state’s businesses have been impacted by the pandemic, but that’s particularly true of physician practices and medical groups,†Graham says. “Most physician practices have had a substantial loss of patient volume and some are teetering on the brink financially.â€
</p>
<h3>Advancing telemedicine</h3>
<p>
The top policy issue for the WSMA this year relates to increasing the availability of telemedicine. Washington state has been a leader in telemedicine policy, but more can be done. For example, the state’s telemedicine coverage is limited to services that require a patient to have internet access.
</p>
<p>
“A lot of our state doesn’t have access to reliable broadband,†Graham explains. “We need insurance coverage for services offered over the phone. We also need to make sure there’s reliable broadband; it’s a health equity and education issue. The pandemic has made it clear that access to the internet isn’t a luxury; it’s a necessity.â€
</p>
<p>
In the regulatory realm, the WSMA will be working to address telemedicine reimbursement inequities.
</p>
<p>
“We found out that some of the insurers are trying to play games with the reimbursement parity requirement passed by the Legislature last year,†he says. “We’ll be working to ensure that payment parity means just that—services are reimbursed the same whether they’re delivered in person or via telemedicine.â€
</p>
<h3>Monitoring scope of practice</h3>
<p>
The WSMA also will be paying close attention this year to attempts to promote inappropriate scope of practice increases.
</p>
<p>
“Just about every provider advocacy group with a presence in Olympia will be
bringing a scope of practice increase in 2021, most of which will have ostensible ties to the pandemic,†Graham explains. “As an example, we know of several provider groups that will look to be granted prescriptive authority or to have their prescriptive authority increased.
</p>
<p> “They have wanted it for years,†Graham says. “They’ll come in 2021 and say, ‘There’s this need for access to care. Physicians are overwhelmed. Let us take this off their hands.’ When the WSMA looks at those proposals, our lens is balancing access to care with patient safety. We want to make sure any scope of practice increase would include sufficient training to ensure quality of care.†</p>
<p>
WSMA President Nathan Schlicher, MD, JD, MBA, is more pointed in his position on the issue.
</p>
<p>
“We believe that if you want to be a doctor, you should go to medical school,†says Dr. Schlicher, who also is a former Washington state senator. “We value all our fellow professionals and we want them to be an incredibly important part of the team, but physicians should lead the team and people should practice within their scopes.â€
</p>
<h3>Facing structural racism</h3>
<p>
In light of the global protests against racism, the WSMA is taking a strong stand in this year’s legislative session to promote health equity and racial justice. To that end, the association is taking the rare stance to advocate for having professional boards develop continuing medical education for physicians and other health care providers to address structural racism and health disparities within the medical community.
</p>
<p>
“This is so outside our box,†says Hanscom. “At the WSMA we have traditionally opposed mandating clinical education. How do you make sure the content, especially clinical content, you’re mandating is accurate? Medicine is ever evolving.
</p>
<p>
“But with this topic, the Legislature wouldn’t be mandating the content and it’s not clinical in nature,†she says. “I think it’s well recognized that we need to look deep in medicine’s history and develop content that addresses what has led to disparities in health care, particularly in the areas of race and culture. It’s a first step to overcoming larger societal issues. You have to start at home first.â€
</p>
<p>
And while it might seem like improving cell phone and broadband access is off topic for WSMA’s advocacy efforts, telemedicine has made it important for the WSMA to join with other groups to support those efforts.
</p>
<p>
“With this new way of delivering care, we find it particularly beneficial to physicians to get to know patients in their own environment,†Hanscom says. “Imagine what you can pick up. You’re seeing things that might give you clues to why their chronic conditions aren’t well managed.â€
</p>
<p>
In an example the WSMA used in a newspaper op-ed, a physician had a patient who was a cellist and was struggling with her wrists.
</p>
<p>
“She’ll never bring her cello into the clinic,†she says. “In telemedicine, the physician saw her play her cello. Seeing her movements helped the physician develop a course of treatment for her.â€
</p>
<p>
Telemedicine visits delivered over the phone are also helping physicians connect with chronic disease patients who aren’t able to take time off from work for a clinic appointment. But they might take a break from work and talk to their doctor on the phone.
</p>
<p>
“That’s just better patient care,†Dr. Schlicher says.
</p>
<h3>New opportunities for physician advocacy</h3>
<p>
If there is a silver lining to the elimination of in-person lobbying in the Legislature this year, it's that it exponentially increases the opportunities for WSMA members to serve as advocates. Committee testimony won’t be limited to individuals on the Capitol campus; anyone in the state could testify, Graham says.
</p>
<p>
“People in more rural areas that often feel left out have the same opportunity to participate,†he says. “Those are the areas often with the most dire need for access to care. They have unique needs in their areas; it’s a good opportunity to highlight those disparities.â€
</p>
<p>
Plus, the WSMA has been a vital source of information for the state’s elected officials during the pandemic, making them aware of the issues facing physicians. Legislators already know what the medical community is facing and they’re willing to listen.
</p>
<p>
“No one will be surprised by what we have to say,†Hanscom says.
</p>
<p>
Even better, WSMA members can advocate from their own offices.
</p>
<p>
“We need people to send emails and letters and set up virtual meetings, which we’re all getting more familiar with,†Dr. Schlicher says. “It takes a little more planning, but it’s a lot easier on your schedule.â€
</p>
<p>
With many of the traditional avenues for advocacy closed in terms of lobbyist access, it will be imperative that the physician community is fully engaged, he says. The 2021 Legislature is still going to be dealing with the pandemic and how to control it, and it’s vital that physicians are there to guide the discussions.
</p>
<p>
“Social determinants of health, access to education, food, internet—all those things impact the health of our community,†he says. “All those issues need our voice.â€
</p>
<p>
In addition to the issues affecting patients, Dr. Schlicher notes, the WSMA needs members to remind legislators that the same physicians risking their lives on the front lines of the pandemic are struggling financially. They need and deserve help to be able to keep their doors open and keep serving their patients.
</p>
<p>
“If we’re not involved and we’re not at the table, then we’re on the menu; the Legislature will look at us as a source of revenue,†he says. “Practices are facing significantly higher costs, fewer patients, and impending CMS cuts. Small practices risking their lives shouldn’t be the source of revenue for the budget.â€
</p>
<p>
<em>Pat Curry is senior editor of WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the January/February 2021 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 1/19/2021 12:12:56 PM | 1/19/2021 12:10:27 PM | 1/19/2021 12:00:00 AM |
| answering_the_call | Answering the Call | WSMA_Reports | Shared_Content/News/Latest_News/2020/November/answering_the_call | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/Newsletters/Reports/2020/Nov-Dec-2020-Reports-Cover-645x425px.jpg" class="pull-right" /></div>
<h5>November 6, 2020</h5>
<h2>Answering the Call</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>
By Pat Curry
</p>
<p>
At times, 2020 has broken our hearts and our spirits. The global pandemic of the novel coronavirus SARS-CoV-2 made its American landfall in Washington state, slamming into our health care system with a vengeance that spared no one. An extremely efficient predator, the virus attacked the most vulnerable first and made the connection points that humans value most - a touch, a hug, a kiss, a song - potentially lethal.
</p>
<p>
The pandemic required an unprecedented response from our health care community, who accepted the challenge without hesitation. In this issue of WSMA Reports, we recognize the efforts of just some of the physicians who exemplified the best that health care has to offer.
</p>
<p>
It would be impossible to fully capture the extraordinary sacrifice and exemplary service demonstrated by WSMA members during this difficult year. As you read these profiles, consider each of them as representative of the thousands of physicians and medical professionals who faithfully served our communities during these past months, often at great risk to their own health. To each of you, we are grateful.
</p>
<h3>Policy</h3>
<p>
<strong>Kathy Lofy, MD</strong>. As the state health officer and chief science officer at the Washington State Department of Health, Dr. Lofy is one of a handful of people at the helm of the state's response to the COVID-19 pandemic. Dr. Lofy has
been a frequent participant at Gov. Jay Inslee's press conferences sharing information about the pandemic, using her medical training and calm demeanor to deliver critical updates on the latest science, data, and state policy. Dr. Lofy received WSMA's 2020 President's Unsung Hero Award for her extraordinary service.
</p>
<p>
<em>Ed. note: As this issue of WSMA Reports went to press, Dr. Lofy announced she will step down from her position as the state's top health officer at year's end. She will be missed and we wish her the very best.</em>
</p>
<p>
<strong>John Lynch, MD</strong>. As medical director of infection control and prevention at Harborview Medical Center/ UW in Seattle, Dr. Lynch has had a significant impact on national health care policy as it relates to the pandemic. He served on the panel to develop and write the guidelines for infection prevention in patients with suspected or known COVID-19 for the Infectious Diseases Society of America, of which he is a board member. "John is kind of the scientific cheerleader for this," said Chris Baliga, MD, medical director for infection prevention at Virginia Mason in Seattle. "He's a full-time academician. They're the ones who ponder the big questions, working nationally to advance the science, trying to keep the guidelines and opinions and position pieces in line with what we know. He heavily influenced the state and CDC policy in the early days from King County. That was work very much appreciated by all of us."
</p>
<h3>Public Health</h3>
<p>
Throughout the state, our public health officers have worked nonstop to provide up-to-date, evidence-based information to the health care community and the public to help reduce the spread of the highly contagious virus. Faced with ever-changing guidance, these health care guardians also have been forced to address everything from health inequity to conspiracy theorists insisting the virus is a hoax and that mask requirements are unconstitutional.
</p>
<p>
With King County the first epicenter of virus spread in the state, two public health heroes came to the fore:
</p>
<p>
<strong>Jeff Duchin, MD</strong>. In his role as health officer for Public Health - Seattle &amp; King County, Dr. Duchin has risen to national prominence. An epidemiologist and an infectious disease physician, Dr. Duchin used his position not only to provide the public with clear, science- based information, but also to shine a light on health inequities exacerbated by the pandemic. Dr. Duchin is a winner of WSMA's 2020 Grassroots Advocate Award for his informed, articulate, and committed advocacy work.
</p>
<p>
<strong>Scott Lindquist, MD</strong>. The former health officer for the Kitsap Public Health District and the current state epidemiologist for communicable diseases, Dr. Lindquist has helped lead multiple facets of the COVID-19 public health response, including testing, treatment, coordinating with local health officers, tribal health centers, and health care. Dr. Lindquist has also led surge activities by assisting local public health in testing, case contact investigation, and health care response.
</p>
<p>
Other counties soon saw their own struggles with COVID-19 and the emergence of their own public health heroes. Those include <strong>Anthony Chen, MD</strong>, director of health at Tacoma-Pierce County Health Department and chief health strategist for Pierce County; <strong>Teresa Everson, MD</strong>, public health officer for Yakima County, the state's second hotbed for COVID-19 cases; and <strong>Amy Person, MD</strong>, health officer for the Benton-Franklin Health District and the Klickitat County Health Department and immediate past president of the Washington State Public Health Association.
</p>
<p>
During an exceedingly challenging public health crisis, all of our public health officers across the state are heroes. Thank you for your service to keeping Washington's communities healthy.
</p>
<h3>Advocacy</h3>
<p>
<strong>Donna Smith, MD</strong>. Past president of the WSMA and medical director at Virginia Mason in Seattle, Dr. Smith is well known and respected, which helped facilitate her ability to jump into the political fray on behalf of the WSMA during discussions on issues such as the state's non-urgent procedure delay order and appropriate use of personal protective equipment. Her help in persuading the Legislature to extend the COVID-19 proclamations was key to WSMA's success in providing the state's health care professionals with the support they needed during the crisis. For her tireless work on behalf of the state's physicians, Dr. Smith is a winner of WSMA's 2020 Grassroots Advocate Award.
</p>
<h3>Telehealth</h3>
<p>
<strong>John Scott, MD</strong>. Officially the medical director for digital health at UW Medicine in Seattle, Dr. Scott is unofficially the Washington state telehealth czar. After participating in years of legislative negotiations that helped establish Washington as a leader in telehealth policy, Dr. Scott chairs the Washington State Telehealth Collaborative, which is charged with advancing excellence and innovation in telehealth for all Washington communities. During the pandemic, he worked tirelessly to support physicians who were transitioning care to telehealth, helping them stay connected with their patients and helping their practices stay afloat. For his own staff, Dr. Scott guided UW Medicine through its explosive growth in the use of telemedicine during the pandemic, from training physicians in all 45 specialties to establishing home monitoring for patients recovering from COVID-19. Dr. Scott is a winner of WSMA's 2020 Grassroots Advocate Award for his advocacy work in telehealth.
</p>
<h3>Trailblazers</h3>
<p>
<strong>George Diaz, MD</strong>. Chief for infectious diseases at Providence Regional Medical Center in Everett, Dr. Diaz treated the nation's first confirmed COVID-19 case, a Seattle-area man who had recently returned from China, alerting the medical community to the reality that COVID-19 was spreading globally. Dr. Diaz had guided the hospital through a pandemic drill just three weeks earlier and oversaw admitting the patient to an isolation unit within two hours after the CDC confirmed that he had the virus.
</p>
<p>
<strong>Francis Riedo, MD</strong>. An infectious disease specialist at EvergreenHealth in Kirkland, Dr. Riedo had the wisdom to do the first test for the COVID-19 virus in a hospitalized patient in Washington state. He had to scramble to contain the virus in his ICU, hospital, and community. He was responsible for reverse airflow rooms, PPE, screening protocols for 5,000 employees, employee testing, rotating shifts, daily communication to staff, press statements, and now is conducting one of the first trials for a COVID-19 vaccine. "Frank was living a nightmare scenario with the exposure and staff and number of patients," Dr. Baliga said. "He was the voice of pragmatism. He was having to navigate the reality of it early on in a horrific, dramatic way. [The Evergreen leadership] rose to the challenge and are a great example of what can be done."
</p>
<h3>Logistics</h3>
<p>
<strong>Michael Myint, MD</strong>. As physician executive for population health at MultiCare in Seattle, Dr. Myint has provided thoughtful guidance on hospital efforts to provide personal protective equipment. He set up a PPE inventory and sharing program that would allow hospitals to access and to share PPE. Health care systems received many donations, but sometimes only small numbers. By aggregating the available inventory, one institution would be able to have enough supply of that mask to adequately fit, test, and protect that cohort of staff.
</p>
<h3>Mental Health</h3>
<p>
<strong>Avanti Bergquist, MD, MS, FAPA</strong>. A child and adolescent psychiatrist with the Eating Recovery Center of Washington in Bellevue, Dr. Bergquist has been a constant and consistent source of information for physicians and parents to help children deal with difficulties related to the pandemic. A distinguished fellow of the American Academy of Child and Adolescent Psychiatry, Dr. Bergquist also is vice president of the Renton School Board and has been an advocate for schools providing mental health support to students as they return to the classroom.
</p>
<h3>Volunteerism</h3>
<p>
<strong>Lucas Hansen, MD</strong>, emergency room physician at Providence St. Peter Hospital in Olympia. Early in the pandemic, Dr. Hansen responded to New York Gov. Andrew Cuomo's plea for health care workers from across the country to go to New York to help. He spent two weeks treating patients at Elmhurst Hospital in Queens, a hospital described by The New York Times as "the epicenter of the epicenter" of the COVID-19 epidemic in New York City. On his return to Washington state, he shared lessons learned with fellow physicians. Dr. Hansen's example of commitment and caring is echoed by the thousands of health care professionals in Washington state and across the nation who have put their own health at risk to care for COVID-19 patients.
</p>
<h3>Research</h3>
<p>
<strong>Lisa Jackson, MD</strong>, Kaiser Permanente Washington Health Research Institute in Seattle. Dr. Jackson is the principal investigator for a National Institutes of Health- funded investigational vaccine for SARS- CoV-2. Their Phase 1, dose-escalation, open- label trial of the mRNA-1273 vaccine was held in March; it included 45 healthy adults who received two doses 28 days apart. It was successful in producing an immune response in all participants evaluated. In July, Dr. Jackson and her team reported on the results of their trial in the New England Journal of Medicine. Following the report, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told the Associated Press, "No matter how you slice this, this is good news." The study has now moved forward to a 30,000-person trial to determine if the vaccine is effective.
</p>
<p>
<strong>Alison Roxby, MD</strong>. An assistant professor of global health and medicine at the University of Washington in Seattle, Dr. Roxby received national attention on how a study team prevented a COVID-19 outbreak in an assisted living community by testing and surveying all the staff and residents and implementing stringent social distancing, sanitation, and other prevention measures. The CDC's Morbidity and Mortality Weekly covered Dr. Roxby's study; she spoke with Rachel Maddow on MSNBC on the importance of the research findings, as a high percentage of coronavirus deaths have been associated with community spread in senior living facilities.
</p>
<h3>Infectious disease physician "superheroes"</h3>
<p>
In the last days of February, a group of King County infectious disease physicians began a furious email string about the guidance coming from the Centers for Disease Control and Prevention and what they were facing in their respective hospitals. It quickly became an unofficial peer support group of physicians. But it was much more than that, Dr. Baliga said.
</p>
<p>
"Our entire infection prevention plan - precautions we were using for people with COVID, deciding who gets the respirators, what to do as you run out of various parts of PPE, what to do when your staff is exposed - is based off this group, especially early on when the guidance was very vague or didn't work. ... In the first few months, we had this scenario where we were really the front-line team trying to help navigate the CDC and public health guidance and directing it back. This group was instrumental in that."
</p>
<p>
Together, they were selected as winners of WSMA's William O. Robertson, MD, Patient Safety Award, which recognizes patient safety initiatives in the ambulatory care setting. They are:
</p>
<p>
<strong>Chris Baliga, MD</strong>, medical director for infection prevention, Virginia Mason in Seattle.
</p>
<p>
<strong>Peter Hashisaki, MD</strong>, infectious disease specialist, Overlake Medical Center &amp; Clinics in Bellevue.
</p>
<p>
<strong>John Lynch, MD</strong>, medical director of infection control and prevention, Harborview Medical Center/University of Washington in Seattle.
</p>
<p>
<strong>John Pauk, MD, MPH</strong>, infectious disease specialist, Swedish Center for Comprehensive Care in Seattle.
</p>
<p>
<strong>Francis Riedo, MD</strong>, infectious disease specialist, EvergreenHealth in Kirkland. Olympia Tachopoulou Stafford, MD, infectious disease specialist, Franciscan Infectious Disease Associates at St. Joseph in Tacoma.
</p>
<p>
<strong>Danielle Zerr, MD, MPH</strong>, infectious disease specialist, Seattle Children's; division chief of pediatric infectious diseases at the University of Washington in Seattle.
</p>
<p>
Dr. Baliga was quick to point out that the King County ID doctors are far from being alone in their efforts to fight the virus. Dr. Riedo cited the work of <strong>Mark Johnson, MD</strong>, an infectious disease specialist with Confluence Health in Wenatchee. Dr. Johnson "has been instrumental working with health care providers in Central Washington to provide both clinical care and the public health messaging needed to stem the tide of new patients," Dr. Riedo said.
</p>
<p>
Indeed, physicians are working together at unprecedented speed to bring the virus under control.
</p>
<p>
"Part of the messaging," Dr. Baliga said, "is that this group is part of a much larger group of people trying to deal with this."
</p>
<p>
<em>Pat Curry is senior editor of WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the Nov./Dec. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 11/6/2020 11:17:51 AM | 11/6/2020 11:16:33 AM | 11/6/2020 12:00:00 AM |
| doctors_making_a_difference_yuan_po_tu_md | Doctors Making a Difference: Yuan-Po Tu, MD | WSMA_Reports | Shared_Content/News/Latest_News/2020/November/doctors_making_a_difference_yuan_po_tu_md | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/Newsletters/Reports/2020/Nov-Dec-2020-Reports-Cover-645x425px.jpg" class="pull-right" /></div>
<h5>November 2, 2020</h5>
<h2>Doctors Making a Difference: Yuan-Po Tu, MD</h2>
<h5><em>Members only; sign-in required.</em></h5>
<p>
<em>Ed. Note: The November/December issue of WSMA Reports featured an edited interview with Dr. Tu. Read the full-length version below. </em>
</p>
<p>
After the first community-acquired U.S. case of COVID-19 was identified in late January at The Everett Clinic, Yuan-Po, Tu, MD, and his colleagues at The Everett Clinic, part of Optum, reacted quickly. Drawing on their experience with the H1N1 pandemic in 2009, clinic leaders knew that securing personal protective equipment for health care workers would be vital. Despite having a stockpile of PPE and orders placed for more, by the first week of March, the clinic was burning through PPE at an alarming and unsustainable rate.
</p>
<p>
In January, Dr. Tu, an internal medicine physician who works at the urgent care walk-in clinics at The Everett Clinic, had been awarded a United HealthCare clinical research fellowship to study the impact of clinical decision support in the electronic medical record system on antibiotic stewardship. With the impact of the emerging pandemic in March, he shifted the study focus to what he thought could help alleviate the strain on PPE supplies by designing and executing a study to examine the sensitivity of patient-collected specimens for COVID-19 testing.
</p>
<p>
<strong><em>WSMA Reports:</em> What brought about the idea to study patients self-administering nasal swabs for testing?</strong>
</p>
<p>
In the early days following identification of the first COVID-19 patient, we could see that we were consuming surgical masks and PPE at an alarming rate. In the first three days of the response, the warehouse had issued nearly 10,000 surgical masks. We calculated that we were using 2.2 sets of PPE with N-95 respirators to test each patient for COVID-19. This was a huge amount of PPE and represented a non-sustainable burn rate.
</p>
<p>
Nasopharyngeal sampling has been the tried-and-true method for testing for upper respiratory viruses. I knew that we could recover influenza virus from nasal samples, as we have been using nasal samples to test for influenza for years.
</p>
<p>
One of the basic principles of occupational health is to remove the danger from workers. I hypothesized that we would be able to recover the SARS-CoV-2 virus from nasal samples and that we could remove the risk to the health care workers by having the patient self-collect the samples.
</p>
<p>
<strong>What advantages do nasal swabs self-collected by the patient have over testing done by a health care worker?</strong>
</p>
<p>
Nasal collection saves PPE by decreasing the potential for aerosolization and, hence, the risk of exposure to health care workers. Nasal sampling is a lot faster than nasopharyngeal sampling and is much more comfortable for the patient compared to NP swabs.
</p>
<p>
<strong>How do you see the pandemic playing out this fall and winter? </strong>
</p>
<p>
I anticipate that the number of COVID cases will increase, as we always see more upper respiratory illness in the fall and winter months. Congregation of people in close quarters indoors can results in rapid outbreaks, as we have seen with the opening of colleges.
</p>
<p>
Testing continues to evolve. Since March, clinical innovation has changed testing for COVID. We have evolved from nasopharyngeal sampling to self-collected nasal swabs. Other studies have shown that foam polyester swabs are equivalent to flocked nylon swabs. Other transport media, including 0.9% saline and phosphate-buffered saline, have been shown to be equivalent to viral transport media.
</p>
<p>
We now know that dry swabs used to collect nasal specimens are stable for three days and are equivalent to swabs transported in liquid media. This has facilitated home collection and shipping the specimen to a central testing lab.
</p>
<p>
<strong>What complications do you anticipate with COVID-19 colliding with flu season?</strong>
</p>
<p>
The winter season will increase the challenge of identifying patients with COVID-19, as any person with upper respiratory viral symptoms will have COVID-19 in the differential and will need to be tested. In a normal flu season, patient census is often close to capacity of hospitals. Adding COVID-19 patients will put additional strain on hospital systems.
</p>
<p>
Every effort should be made to maximize influenza vaccinations this fall to try to decrease the burden of influenza in our community.
</p>
<p>
<strong>In an ideal world, how would testing look for the remainder of the pandemic?</strong>
</p>
<p>
Ideal testing would be inexpensive, fast, accurate, simple to perform, and widely available. Ideal testing would be a test that could be performed at home without the need for medical supervision, with the results available in minutes without a reader or instrument.
</p>
<p>
<strong>What is the biggest barrier standing in the way of achieving that?</strong>
</p>
<p>
Just like nasal testing changed how we collect specimens for testing, we will need a fundamental change in how testing is performed. Molecular testing for COVID-19 currently is expensive, complicated, and requires complex equipment.
</p>
<p>
Multiple antigen tests have been approved by the FDA, with EUA for symptomatic individuals. Depending on the sensitivity and specify, antigen testing may be able to be used to test a wider number of individuals.
</p>
<p>
Other technologies are in development that have potential for changing how we test. But they are much further from commercial release.
</p>
<p>
<strong>What has the pandemic response so far revealed in terms of what systems we should have in place to better respond to future crises?</strong>
</p>
<p>
Severe pandemics cause unprecedented medical, social, and economic impacts. Pandemic infections affect the entire world. Effective political leadership, coupled with medical and social guidance, is key to responding effectively. There will be a next time. Analysis of how we respond will be key to learning how to respond better to the next pandemic. No single individual or single system will be able to succeed alone. To do better, we need our entire political, public health, and medical systems to be better as a team.
</p>
<p>
<em>This article was featured in the Nov./Dec. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 11/2/2020 3:36:18 PM | 11/2/2020 12:32:27 PM | 11/2/2020 12:00:00 AM |
| wsma_responds_to_covid_19 | WSMA Responds to COVID-19 | WSMA_Reports | Shared_Content/News/Latest_News/2020/November/wsma_responds_to_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/Nov-Dec-2020-Reports-Cover-645x425px.jpg" class="pull-right" /></div>
<h5>November 2, 2020</h5>
<h2>WSMA Responds to COVID-19</h2>
<h5><em>Members only; sign-in required.</em></h5>
<p>
By Rita Colorito
</p>
<p>
Shortly after the Centers for Disease Control and Prevention confirmed the first U.S. coronavirus case in Snohomish County on Jan. 20, officials from the Washington State Department of Health reached out to the WSMA. At the time, the DOH had minimal information to share.
</p>
<p>
Jennifer Hanscom, WSMA's executive director/CEO says she appreciated the heads up. "I remember thinking, 'Oh, that's good that they're informing us, but it sounds like it's well controlled,'" she says.
</p>
<p>
In late February, Hanscom received another call from DOH, this time more urgent. Coronavirus was racing through the Life Care Center in Kirkland. "They told us they were mobilizing an information center to deal with COVID-19," says Hanscom. "That's when I knew, 'Wow. This is it. This is going to be big.'"
</p>
<p>
Within weeks, Washington state had become the U.S. coronavirus epicenter. On March 11, the World Health Organization formally declared COVID-19 a global pandemic. The WSMA found itself on the front lines of helping its members manage a novel coronavirus with little understanding at the time of how the virus spread or how to contain it.
</p>
<p>
"We quickly realized that we have to be the eyes and ears for our physician members," Hanscom says. "We also had to make sure patients felt informed and safe. We wanted to be a trusted voice for them as well."
</p>
<h3>Getting the word out</h3>
<p>
The WSMA's first order of business was keeping members and the public informed in real time. That meant sifting through an overload of constantly changing—and often conflicting—medical information. Most of this was done virtually, as the association encouraged its staff to work remotely beginning on March 10.
</p>
<p>
"We realized we needed a physician lens on this, so that we could understand the clinical implications," says Hanscom. To accomplish this, WSMA's executive committee met virtually at 7 a.m. every Wednesday. Consensus was then shared with WSMA members and other public health stakeholders.
</p>
<p>
Armed with clear, science-based information from the state's physician leaders, Hanscom managed a response she described as "fast and furious." Association staff often worked late into the night and on weekends. "I was counting on my team to be available 24/7, to make sure we were getting accurate information," she says.
</p>
<p>
"Fast and furious" is an appropriate way to describe the level of activity, says Jessica Martinson, WSMA's director for continuing professional development.
</p>
<p>
"I remember having four concurrent meetings on my calendar and trying to be at one of them on my cell phone and one on my computer simultaneously," she recalls. "It was this huge flurry of activity."
</p>
<p>
Email blasts were sent to every physician and physician assistant in the state, regardless of membership, as well as to county and specialty medical societies, and to the CEOs and CMOs of clinics, hospitals, and hospital-based medical groups. The WSMA also updated its website with the latest information and conducted outreach through press releases, contacting reporters, and using social media, particularly Twitter.
</p>
<p>
To reinforce emerging best practices and tackle misinformation, the association coordinated messaging with the Public Health - Seattle &amp; King County, the University of Washington, and Virginia Mason. "From a public health perspective, it was important we were all saying the same things," says Hanscom.
</p>
<h3>Managing public health</h3>
<p>
That coordination was critical; in the early days of the pandemic, COVID-19 mitigation efforts were scattershot. Lacking guidance from the federal government, Washington state and the WSMA were left to figure things out on their own.
</p>
<p>
On March 6, Martinson went to EvergreenHealth in Kirkland to teach a scheduled course to certify advance care planning facilitators. (Health care systems would come to rely on such planning to help elderly patients navigate end-of-life decisions precipitated by COVID-19). This was before the now- standard practice of wearing masks.
</p>
<p>
"We wrestled with whether we had any business being there," says Martinson. EvergreenHealth had registered the state's first COVID-19 death on Feb. 28. Most of the Life Care Center cases had been taken there. The hospital was quickly becoming ground zero for COVID-19 deaths.
</p>
<p>
Martinson focused on making the class as safe as possible, ensuring social distancing, and providing hand sanitizer. "Everyone was cool-headed, but you could tell they were under intense pressure," she says. "But we weren't talking about rationing ventilators yet. We weren't in that mindset at all. It wasn't part of the national conversation," says Martinson.
</p>
<p>
By mid-March, WSMA's executive committee had reached a stunning conclusion: The state could run out of ventilators, beds, and personal protective equipment. The WSMA sent an urgent letter to Gov. Jay Inslee advocating for the shutdown of non-urgent medical procedures—a step that the University of Washington Medical Center and Swedish Health Services had already taken.
</p>
<p>
The governor quickly followed the medical community's advice. On March 19, he announced restrictions on non- urgent medical and dental procedures, which remained in effect until May 18.
</p>
<p>
WSMA members also began raising the alarm that "business as usual" was a threat to public health. They were adamant the state shut down non-essential businesses and gatherings, says Hanscom.
</p>
<p>
In response, the association submitted another letter to Gov. Inslee. WSMA's members were part of the catalyst for Inslee's "Stay Home, Stay Healthy" orders, which went into effect on March 25 and include a four-phase, county-by-county "Safe Start" reopening plan.
</p>
<h3>Tackling legislative issues</h3>
<p>
The state's legislative session, which ended on March 12, was in its waning weeks as the virus became the top priority. The Legislature scrambled to appropriate $200 million in state budget reserves to fund the pandemic response. WSMA negotiations on other issues took a back seat as it grappled with a host of shutdown-related issues, says Sean Graham, WSMA's director of government affairs.
</p>
<p>
"We had calls with each member of our state's congressional delegation to update them on what was happening in our physician community," says Graham. Legislative priorities included ensuring sufficient personal protective equipment for physician clinics, creating flexibility around the state certificate of need laws and physician licensure law, and ensuring appropriate liability protections for care that was delivered or delayed during the pandemic. The WSMA focused on how members could keep patient care front and center.
</p>
<p>
Ensuring payment parity for telemedicine, long a WSMA priority, became even more essential, says Jeb Shepard, WSMA's director of policy. In fact, the legislative session ended with WSMA achieving long-fought success in the creation of the Washington State Telehealth Collaborative. It requires insurance carriers to pay for telehealth services if they reimburse providers for face-to-face service.
</p>
<p>
"That piece of legislation was signed by the governor in early April, but the issue was it wasn't effective until January 2021," says Shepard. With the legislative session over, the WSMA had to get creative to get telehealth covered in 2020.
</p>
<p>
"We urged the Office of the Insurance Commissioner and the governor's office to take whatever action was in their emergency authority to implement payment parity," says Shepard. In Washington state, the governor can strike out portions of a legislative code, but can't add to them, explains Shepard. To get telehealth payment parity immediately, Gov. Inslee struck out the effective date of the law that had just passed.
</p>
<p>
"That unleashed a proliferation of telemedicine and we saw a rapid transition to telehealth among smaller and mid-sized practices," says Shepard.
</p>
<p>
By May, the medical community had a better understanding of COVID-19 and how to mitigate spread of the virus. The WSMA began hearing from members that the shutdown of non-urgent procedures was hurting their economic viability.
</p>
<p>
It was also taking an emotional toll, as physicians had to furlough personnel to keep their practices solvent.
</p>
<p>
The WSMA worked with the Washington State Hospital Association, Washington State Nurses Association, and the Ambulatory Surgery Center Association to help clarify Gov. Inslee's proclamation on non-urgent procedures so that physicians could use their clinical judgment without fear they were breaking the law.
</p>
<h3>Going forward</h3>
<p>
With a handle on the logistics of COVID-19, the WSMA began shifting its focus to physician well-being. In April, Martinson conducted a five-part webinar series to help members discuss what it means for patients with serious underlying conditions who develop COVID-19. "These are really hard conversations for physicians to have, but they're necessary," says Martinson. More than 500 members participated. The association also conducted webinars on telehealth and communicating under stress and hosts the COVID-19 Grand Rounds series.
</p>
<p>
"We were hearing from our members that they were under enormous pressure and that they were not getting the support they needed," says Martinson.
</p>
<p>
The WSMA reached out to several employee/physician assistance programs in the state. "We wanted to make sure our members had access to professionally trained mental health experts," says Martinson. The association also connected members to resources that could facilitate group debrief sessions. This was separate from WSMA's work on physician burnout.
</p>
<p>
"Everyone's grappling with COVID-19; some were more directly impacted than others," Martinson says. "Front-line physicians may experience trauma and are susceptible to PTSD. So, it's not just a matter of being resilient and having good workflow."
</p>
<p>
The WSMA also facilitated weekly Zoom meetings for ICU and critical care physicians to share their experiences. About 30 regularly attend these now- monthly virtual meetings.
</p>
<p>
Both the WSMA and Washington state are preparing for the uncertainty of the fall and winter months, and the association's work to promote an evidence-based approach to the pandemic is far from over. In September, in a necessary, but previously unfathomable move, WSMA corrected CDC misinformation.
</p>
<p>
"We had to explain to our members that Washington state isn't following CDC guidelines on COVID testing because those guidelines don't follow the science," says Hanscom.*
</p>
<p>
Retired Navy Vice Adm. Raquel Bono, MD, state director for COVID-19 Health System Response Management, has convened a series of pandemic-focused working groups. WSMA's secretary- treasurer, Nariman Heshmati, MD, has participated in working groups on personal protective equipment and contact tracing.
</p>
<p>
"Our work is still continuing," Hanscom says. "It's just happening in a more organized, less frantic fashion."
</p>
<p>
<em>* On Sept. 18, the CDC reversed its guidance and recommended that people without symptoms who have been in close contact with an infected person need to be tested.</em>
</p>
<p>
<em>Rita Colorito is a freelance journalist who specializes in covering medicine and health care. She is a regular contributor to WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the Nov./Dec. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 11/2/2020 3:37:13 PM | 11/2/2020 3:31:55 PM | 11/2/2020 12:00:00 AM |
| equity_in_medicine | Equity in Medicine | WSMA_Reports | Shared_Content/News/Latest_News/2020/August/equity_in_medicine | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/WSMA-Reports-Sept-Oct-Article-Image-645x425px%20(002).jpg" class="pull-right" alt="WSMA Reports September-October 2020 cover" /></div>
<h5>August 31, 2020</h5>
<h2>Equity in Medicine</h2>
<p>
By John Gallagher
</p>
<h5><em>Members only; sign-in required.</em></h5>
<p>
An estimated 10,000 health care professionals and students, wearing white coats and scrubs, walked from Harborview Medical Center to Seattle City Hall on June 6 in a Doctors for Justice event to protest racial violence. They had responded to a call to action from Estell Williams, MD, an acute care surgeon at the University of Washington Medical Center and an assistant professor of surgery at the UW School of Medicine, who asked her colleagues to "show the full strength of Medicine that seeks justice for the most marginalized of our community."
</p>
<p>
Motivated in part by the experiences of her own family, Dr. Williams organized the march with her husband, Edwin Lindo, JD, a lecturer at the UW School of Medicine. "I have experienced police violence, racism, and mortality as a result of disparate outcomes experienced by the Black community within my family," Dr. Williams says.
</p>
<p>
In a letter announcing the march, she recalled a childhood event seared in her memory. Her father was pulled over by police while they drove home through a predominantly white neighborhood. As the officers searched their car, "I cried in fear and terror in the backseat, thinking of what they had done to others who looked like my dad," she wrote. "They handcuffed him, took him to the police station and forced him to stay there, while I had to wait in the street for my mother to pick me up. They released him two days later without a charge or valid reason for arresting him. To be clear, my father never committed a crime in his life, and the pain and fear I felt for the days he sat in the jail never leaves my mind. I knew there was a possibility that I would never see him again."
</p>
<p>
Just as importantly, she believes doctors should use their position of privilege to call out all the issues that harm the health of their patients, from overrepresentation in the justice system to poverty, housing, and employment.
</p>
<p>
"All of these things interconnect," Dr. Williams says, "and we as health care workers have to recognize it and speak out because the true health of our communities exists outside the walls of the hospitals and clinics."
</p>
<p>
The renewed awareness about racism has led to a fresh look at health equity issues. For decades, physicians have known that the race or ethnicity of patients or the language that they speak can have an effect—often negative—on their health. According to the Kaiser Family Foundation, Blacks, Hispanics, and Native Americans/Alaska Natives had higher infant mortality rates, die from diabetes at a higher rate than whites, and are in general more likely than whites to report fair or poor health status. Asian Americans/Pacific Islanders overall often fare better than whites, but with wide variation among subgroups.
</p>
<p>
Health equity has always been a complex issue.
</p>
<p>
"Defining 'equity' depends on who you are," says Michael Schaffrinna, MD, chief medical officer at Community Health of Central Washington, which operates federally qualified health centers (FQHCs) in underserved areas. "For some, it's access to care. But there's much more to health care than just getting an appointment or, for that matter, having good clinical care."
</p>
<p>
The COVID-19 pandemic has thrown into sharp relief the issue of health disparities, with much higher rates of infection and death among Blacks and Hispanics. But another event this spring has also affected the discussion about health equity: the killing of George Floyd by police officers in Minneapolis and the subsequent demonstrations about racial injustice.
</p>
<p>
The extent to which racism has affected medicine's ability to eliminate health disparities is now part of the conversation in a way that it never has been in the past. "Racism is a public health emergency of global concern," a recent editorial in The Lancet said. "It is the root cause of continued disparities in death and disease between Black and white people in the USA."
</p>
<p>
"It feels that the normalization of the conversation is much more universal," says Benjamin Danielson, MD, chair of the Governor's Interagency Council on Health Disparities and clinic chief at Seattle Children's Odessa Brown Children's Clinic. "I spent a lot more time preaching to the choir before. Now perhaps the sense of importance and maybe the less compromising nature of the situation does put some emphasis behind real conversations about health equity."
</p>
<p>
Certainly, medical systems have been working hard for years to reduce health disparities. Dale Reisner, MD, medical director (OB-GYN Quality &amp; Safety) at Swedish Health Services and a past president of WSMA, notes that her health system started working to address the issues well before the latest focus on racism.
</p>
<p>
"Even before George Floyd, we have really been trying to enhance our abilities to address health disparities with trainings, information sessions, and respectful treatment of all patients," she says. Reisner has had a particular focus on reducing Black maternal mortality, which in Washington state is twice the rate than for white women, even with the state's mandate for access during pregnancy. (The mortality rate for Black mothers nationally is threefold higher than for white women.)
</p>
<p>
Suicide and postpartum overdoses are major contributors to Black maternal mortality. "Women with mental health and substance use disorders often are not respected, so we've had a very innovative addiction recovery program at Swedish with compassionate care basically as the core of the model," Dr. Reisner says. She adds that the fact that such an approach is even necessary is "sad, when you think about it."
</p>
<p>
Swedish has a program that includes doulas, trained professionals who serve as support for women during pregnancy, birth, and the postpartum period. "Many of them have come from disenfranchised communities, so [they] can relate to the patients," Dr. Reisner notes. "As an advocate with white skin, I can do my best, but someone with brown skin is not going to trust me as much because I don't share their same experience."
</p>
<p>
But as Dr. Reisner and other physicians point out, the progress to date still leaves a lot to be desired, Dr. Williams says.
</p>
<p>
"Even though medicine is getting better, we're still seeing the same disparities," she says. "You can make the argument that people are not only not getting the same level of care but are getting a worse level care."
</p>
<p>
The real challenge with addressing health disparities is that many of the factors that drive it happen outside the clinic. "We give this prescription in the clinic, but we don't then try in a meaningful way to address the ways patients experience the world when they leave the clinic," Dr. Williams says. "We need to recognize that there are certain diseases that need to be treated in a hospital setting, but a lot of problems are directly related to systemic racism."
</p>
<p>
Researchers have long documented the impact that social determinants of health—the conditions in which people are born, live, and work—have on outcomes. Now, the urgency of that work is gaining more recognition and acceptance. "There is greater regard for social determinants of health in embracing health equity in a systematic way," says Dr. Danielson. "Health care systems getting involved in social determinants is a health equity act."
</p>
<p>
Dr. Schaffrinna says that for those kinds of discussions to be successful, "we have to approach it not with blame, but 'How do we change?' " That means acknowledging up front that racism is a problem.
</p>
<p>
"Is there discrimination? Absolutely," he says. "We must confront it."
</p>
<p>
But he believes that medicine should also focus on how poverty is a driver of disparities.
</p>
<p>
"When you look at Americans suffering from the effects of poverty, it appears that all of them suffer," he says.
</p>
<p>
Even within the confines of the system, barriers exist, notably the chronic challenge of financing. Addressing health disparities costs money, such as Swedish's investment in doulas. Investing in such efforts is especially difficult when practices and medical systems are facing huge drops in revenue as a result of the pandemic.
</p>
<p>
"Everybody is recognizing that it's an issue, but no one is willing do anything," says Dr. Schaffrinna. "Most of the FQHCs are trying to begin the process of addressing social determinants, but there's no revenue coming in for that expense."
</p>
<p>
Moreover, some solutions have the potential to shift money away from the medical system altogether. "As a nation we spend an enormous amount of money on health care, and it's not giving us the biggest bang for buck," adds Dr. Schaffrinna. "We should put some of that money into addressing social determinant factors. Our country can't afford to do it all, and the only way to do it is to reallocate resources to other areas, similar to what people are saying about police departments." (Activists have been pushing for cities to invest in mental health workers as front-line respondents to individuals in crisis, instead of the police.)
</p>
<p>
The respect that society places on physicians offers them a special opportunity to play a role in tackling the problem of health equity. "Because we have by nature and profession a caring tendency and because we're interacting with patients who manifest all the effects of this social injustice, it positions us in a unique way to be the ones who also can bring awareness and advocacy for the need to make change," says Okechukwu Ojogho, MD, a transplant surgeon at Providence Medical Group in Spokane.
</p>
<p>
The really thorny question is the extent to which medicine is willing to broaden the conversation about health equity to racism, including institutional racism in medicine. The profession is starting to recognize, as the New England Journal of Medicine said in a recent editorial, that "slavery has produced a legacy of racism, injustice, and brutality that runs from 1619 to present, and that legacy infects medicine as it does all social institutions."
</p>
<p>
Dr. Williams says that the current conversation about racism reveals some long-standing assumptions about medicine. "We've done a disservice to medicine as an entity by attempting to exist as an apolitical, neutral entity," she says. "We have for a long time felt that we're altruistic human beings who are neutral and somehow colorblind, and in doing so, we have blinded ourselves to the root causes that perpetuate the health outcomes we see."
</p>
<p>
Ultimately, the profession has to have a painful conversation about racism if it is going to conquer health disparities, Dr. Danielson says.
</p>
<p>
"I'm hoping a health equity conver- sation is not a substitute for a conversation about racism," he says. "You can do a whole lot toward health equity without changing any power paradigm. You can still hold all the strings and be in a position of power and do more things to promote health equity. An anti-racism perspective has built into it a pretty strong power shift."
</p>
<p>
How much change happens depends on doctors themselves, says Dr. Danielson.
</p>
<p>
"I would imagine a lot of us are on the edge of our seats right now," he says. "Will this really be a transformational time? It would be too bad if people sit on their seats and wait for something external to show them it's time to move forward. Moving forward is the thing we need to do, not the thing we wait for someone else to do."
</p>
<p>
Dr. Williams says that just a year ago, something like the march would have been impossible to imagine. But one conversation with another doctor that she had at the event stood out. In her speech at the march, Dr. Williams noted that "we scrutinize all our actions in the hospital to minimize harm to patients, but we don't consider actions in our greater community with the same scrutiny." The physician that Dr. Williams spoke to had never considered this.
</p>
<p>
"Hearing that physician declare that their eyes were opened showed me that we did something good that day," Dr. Williams says. "And if we opened just a few more eyes, we can do something good for many more lifetimes to come."
</p>
<p>
<em>John Gallagher is a freelance journalist who specializes in health care issues. He is a regular contributor to WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the Sept/Oct. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 8/31/2020 10:32:10 AM | 8/31/2020 10:22:40 AM | 8/31/2020 12:00:00 AM |
| faith_through_action | Faith Through Action | WSMA_Reports | Shared_Content/News/Latest_News/2020/August/faith_through_action | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/WSMA-Reports-Sept-Oct-Article-Image-645x425px%20(002).jpg" class="pull-right" alt="WSMA Reports September-October 2020 cover" /></div>
<h5>August 31, 2020</h5>
<h2>Faith Through Action</h2>
<p>
By Milana McLead
</p>
<h5><em>Members only; sign-in required.</em></h5>
<p>
If you ask what he was like as a child, Nathan Schlicher, MD, answers with a smile, and says, "I was probably a precocious kid."</p>
<p>
That might be an understatement, considering he skipped first, fourth, seventh, and ninth grades, graduated from high school at 14, skipped a year of college, completed law school a year early, and started medical school at 19. “It was normal to me, as crazy as that sounds,†he says.
</p>
<p>
Perhaps that was because a strong, bright family grounded him and kept him humble. “My grandfather was a brilliant physician,†Schlicher says. “He taught me early on: ‘You may be very successful, but there’s probably somebody who’s done it faster, younger, smarter. Don’t get hung up on yourself. Be happy with who you are and try not to make anyone feel any different.’ â€
</p>
<p>
His father, Peter, was a hospital administrator and his mother, Carol, a nurse, so medicine was ever-present in the household. “We grew up talking about medicine and enjoying stories around the dinner table,†he says. “Since my dad wasn’t clinical, my mom would try to gross him out. We all had a great time with that.â€
</p>
<p>
While Dr. Schlicher’s intellect and relative youth are front and center, one quickly learns that a strong faith and a deep passion for service are at his core.
</p>
<p>
An early mentor and Methodist minister known as “Big David†solidly influenced his teen years. “Big David was a good man who lived the message and cared for the people. He was open, loving, and kind, and very much believed in faith through actions,†Dr. Schlicher says. “I try to live as he did in terms of doing what I can for the community; remembering that faith is not words, but actions; and the importance of caring for others.â€
</p>
<p>
A career in medicine was the perfect companion for that framework for life. “I grew up volunteering and always knew that medicine would be part of my life. And emergency medicine—to be able to make a difference, to be there at some of the most challenging times of people’s lives—I love being there in the moments when it matters so much,†he says.
</p>
<p>
If anything keeps him awake at night—at least on the nights he’s not working in the ER at CHI Franciscan’s St. Joseph Medical Center—it’s unsolvable problems. “If I feel like I missed an opportunity to make a difference, to solve a problem I could have had an impact on—my mind churns on ‘What should I have done differently? What could we have done differently?’ We do the best we can, we plan ahead, and think through every scenario to get the right answer. Sometimes it works, sometimes you fail, but you learn and try not to repeat those mistakes.â€
</p>
<p>
Problem-solving comes naturally to Dr. Schlicher, as does taking the lead in finding solutions. Observe that your patients need a voice in the Legislature? Solution: Seek and win appointment to an open seat in the Washington State Senate, and serve as a state senator advocating for effective health care policy. See a need to reduce preventable emergency room visits? Solution: Create an “ER is for Emergencies†campaign that shifted behavior and perceptions about seeking care in the ER.
</p>
<p>
Need to encourage better opioid prescribing behaviors while protecting patients from highly addictive medications? Solution: Design “Better Prescribing, Better Treatment†program as a peer-to-peer, non-punitive initiative that has reduced opioid prescribing
in Washington state, with more than 20,000 prescribers in 50+ health systems participating in the program.
</p>
<p>
Impatient with inaction—a side effect of his life in emergency medicine—Dr. Schlicher’s inner drive to make things better compels him to lead and to step up where needed. “I very much try to live the philosophy that we are going to do things,†he says. “I think that’s what we need to work on in medicine—it’s not just showing up, it’s leading.â€
</p>
<p>
His leadership philosophy serves him well in the ER, in advocacy, and in the WSMA. “It’s important that you listen to the people you’re working with—a leader is a team member. It’s not just leading the team, it’s inspiring them, working to hear their thoughts, and building relationships,†he says. “That comes through listening and having a vision of where you’re going and communicating that vision well.â€
</p>
<p>
He steps into his role as president of the WSMA at an unprecedented time. The impact of COVID-19 has shaken the house of medicine especially hard; Dr. Schlicher sees that as one of the big issues ahead. “COVID is a window into all the dysfunctions in medicine,†he notes. “It’s a lens into the systemic structural problems of health care. That strain on the system is challenging, but it offers us an opportunity to bring positive change for better access to health care, better health systems, and better environments for clinicians to practice in.â€
</p>
<p>
He sees a connection between the issues uncovered by the pandemic and an associated opportunity to improve physician wellness. “The things likely to drive us to burnout are the systemic structural problems, poorly designed EMRs, lack of backup and support, and being asked to do things outside of our scope or abilities,†he says. “We need to build a better work environment to help people be happier in all parts of their lives. If you do it right, people are happy.â€
</p>
<p>
As he leads the work of the WSMA in the year ahead, his focus will be on improving access to health care, physician wellness, and driving quality. And he sees the WSMA as the conduit to making positive change happen. “Physicians need to lead health care because we see it through a clinician’s lens. If you don’t have that, there’s a knowledge deficit in leadership. We need to grow the next generation of trailblazers so that physicians are leading the health systems, regulatory entities, and in Olympia. Physicians need to be at the tables where decisions are made so our voice is heard, and that’s what you support when you join the WSMA.â€
</p>
<p>
<em>Milana McLead is WSMA senior director, strategic communications and growth, and editorial director of WSMA Reports.</em>
</p>
<p>
<em>This article was featured in the Sept/Oct. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 8/31/2020 11:14:07 AM | 8/31/2020 10:29:46 AM | 8/31/2020 12:00:00 AM |
| the_unseen_covid_19_risk_factor | The Unseen COVID-19 Risk Factor | WSMA_Reports | Shared_Content/News/Latest_News/2020/August/the_unseen_covid_19_risk_factor | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/WSMA-Reports-Sept-Oct-Article-Image-645x425px%20(002).jpg" class="pull-right" alt="WSMA Reports September-October 2020 cover" /></div>
<h5>August 31, 2020</h5>
<h2>The Unseen COVID-19 Risk Factor</h2>
<p>
By Pat Curry
</p>
<h5><em>Members only; sign-in required.</em></h5>
<p>
With a high-desert climate and rich, volcanic soil, the Yakima Valley is one of the most important agricultural regions in the country. More than 1.7 million acres in Yakima County are farmland, producing 21% of the state's agriculture sales, according to the U.S. Department of Agriculture.
</p>
<p>
It is also has been one of the nation's COVID-19 hot spots; in May, Yakima County had the highest case rate of any county on the West Coast, according to the Institute for Disease Modeling in Bellevue.
</p>
<p>
According to July data from the Washington State Department of Health, Hispanics make up 13% of the state's population, but had accounted for 44% of the state's confirmed COVID-19 cases and 29% of its hospitalizations.
</p>
<p>
In Yakima County, about 55% of the COVID-19 patients are Hispanic, says Bismark Fernandez, MD, an internal medicine physician and hospitalist at Virginia Mason Memorial who has been working in the COVID-19 unit for several months. That number is probably low, he says, because about 20% of their patients don't report their ethnicity.
</p>
<p>
Dr. Fernandez has seen a recurrent pattern that might contribute to the higher rate of infection in Hispanic patients, he says.
</p>
<p>
"Many have told me that often, family members or friends don't always believe this is a real pandemic; or if they believe it, they are not always aware how easily the virus can spread or how serious this pandemic is," Dr. Fernandez says. "If they don't always believe it or are not made aware of how the virus can spread or how severe the pandemic really is, they may not always follow the safety measures we try to implement. That puts their family members and coworkers at risk. We're trying to educate them; labs and CT scans won't lie."
</p>
<p>
(These problems seem to be improving as Virginia Mason Memorial health care leaders have voiced their concerns and educated the public through various media outlets about the importance of universal masking, adequate hand hygiene, social distancing, and staying at home when sick. In July, Yakima was cited as one of the metro areas where new COVID-19 deaths are decreasing most.)
</p>
<p>
The patient demographic Dr. Fernandez has seen is being repeated across the state. A July report from the DOH said "the impacts of COVID-19 morbidity and mortality have not been felt equally by all populations in Washington state. The pandemic has exacerbated the underlying and persistent inequities among historically marginalized communities and those disproportionately impacted due to structural racism and other forms of systemic oppression."
</p>
<p>
When adjusted for age, Hispanic people and Native Hawaiian or other Pacific Islanders have infection rates nine times higher than white people. Blacks and American Indian or Alaska Native case and hospitalization rates are three times higher than those of whites, the report says.
</p>
<p>
The Cross Cultural Health Care Program is a Seattle nonprofit training and consulting organization founded to advance access to quality health care that is culturally and linguistically appropriate. Bryon Lambert, the organization's director of equity and inclusion, says he's "not surprised that people of color are succumbing to COVID-19 at much higher rates than their white counterparts."
</p>
<p>
The work of the CCHCP is getting "a lot more interest in the wake of the protests of the killing of George Floyd while in police custody." Lambert notes that health equity requires health care leaders to recognize that systems have their own cultures and biases that can create issues for patients.
</p>
<p>
"One of the big misconceptions we try to dispel is when people believe it's the patients who are non-compliant or don't seek care, or don't eat healthy or are doing all these things to themselves," he says. "We kind of flip it. We help them understand that the institutions that are designed with the intention of helping people often can be unintentionally amplifying disparities."
</p>
<p>
Jeff Duchin, MD, the local health officer for Seattle and King County, is another health care leader who says the numbers are not unexpected.
</p>
<p>
"It's been an ongoing national tragedy and shame that we have communities of color throughout our country suffering disproportionate adverse health impacts from a wide variety of health conditions," Dr. Duchin told a Seattle Times reporter.
The reasons for the disparities are numerous and long-standing. A recent interview in Scientific American with public health specialist and physician Camara Phyllis Jones, MD, MPH, PhD, goes as far as to say that racism, not race, is a risk factor for dying of COVID-19. A former medical officer and director of research on health equity at the Centers for Disease Control and Prevention, Jones says racism has increased exposure to the virus for people of color, given them less protection from it, and burdened them with chronic illnesses, such as diabetes and hypertension, that put them at high risk.
</p>
<p>
People of color are more exposed to the virus, Dr. Jones says, because of residential and educational segregation that leads to limited job opportunities, crowded housing conditions, and overrepresentation in prisons and jails. Testing sites for the virus have tended to be located in more affluent neighborhoods or in drive-in locations that require having a car.
</p>
<p>
Some of those scenarios are familiar to Dr. Fernandez in Yakima. Many of his Hispanic COVID-19 patients are living in very small dwellings with a large number of family members. If one person has symptoms, it's difficult to self-isolate.
</p>
<p>
Because they work in lower-paying jobs, they don't stay home or go to the doctor when they're sick.
</p>
<p>
"The symptoms are very broad and can be very mild, so they continue to go to work," Dr. Fernandez says. "One of the reasons they continue to work is they don't get sick benefits. They can't afford to miss 10 days of work. But by doing that, they're putting their co-workers and their family members at high risk."
</p>
<p>
People of color also tend to work in jobs that can't be done from home. The study by the Institute for Disease Modeling noted that in Yakima County, 14% of the population works in agriculture, forestry, fishing, and hunting, jobs which require leaving the house. In King County, the top employment category is professional/technical jobs that often can be done remotely.
</p>
<p>
"Our community has been fortunate to receive the highest quality care possible for everyone that has needed it," Dr. Fernandez says.
</p>
<p>
Virginia Mason Memorial has been working hard to make the public aware that race, financial status, or immigration status "won't keep you from getting high- quality care. We don't refuse anyone."
</p>
<p>
<em>Pat Curry is WSMA Reports' senior editor.</em>
</p>
<p>
<em>This article was featured in the Sept/Oct. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 8/31/2020 10:34:15 AM | 8/31/2020 10:27:03 AM | 8/31/2020 12:00:00 AM |
| white_coats_for_black_lives | White Coats for Black Lives | WSMA_Reports | Shared_Content/News/Latest_News/2020/August/white_coats_for_black_lives | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/WSMA-Reports-Sept-Oct-Article-Image-645x425px%20(002).jpg" class="pull-right" alt="WSMA Reports September-October 2020 cover" /></div>
<h5>August 31, 2020</h5>
<h2>White Coats for Black Lives</h2>
<p>
By John H. Vassall II, MD
</p>
<h5><em>Members only; sign-in required.</em></h5>
<p>
I was gratified to join with thousands of masked colleagues in a recent march from Harborview Medical Center to Seattle City Hall in support of the struggle against racism. This felt different than when I participated in a march across the Edmund Pettis Bridge in Selma, Alabama, on the 50th anniversary of Bloody Sunday, or when I first tasted tear gas during the March on Washington in my college days.
</p>
<p>
The size and diversity of the crowds and the depth of the conversations were greater than in the past. Systemic racism and the oppression of people of color was acknowledged, not defensively denied.
</p>
<p>
Yet discussions of "social determinants of health" can deflect attention from racism in medicine and health care delivery. James Marion Sims, the "father of modern gynecology," developed his surgical techniques after experimental surgery without anesthesia on enslaved women. The Tuskegee syphilis study, in which Black men were observed as a deadly, treatable disease ravaged their bodies, has left a legacy of mistrust of American medicine among many African Americans. To this day, biomedical corporations continue to reap billions of dollars from HeLa cells, cancerous cells used in research that were removed and cloned from the cervix of a Black woman named Henrietta Lacks taken without her knowledge or consent; Henrietta and her family were not compensated.
</p>
<p>
How might we address racism in medicine? We can learn from our efforts to address safety in medicine. In 1999, the Institute of Medicine issued its landmark report, "To Err Is Human: Building a Safer Health System," documenting that 44,000 to 98,000 people each year died in American hospitals because of preventable medical errors.
</p>
<p>
Like many of my colleagues, my reaction was denial. I was a practicing primary care physician dedicating every day of my life to healing. I refused to believe that I could be responsible for the unnecessary death of my patients.
</p>
<p>
But when I studied the literature, I came to understand that unsafe policies and procedures, a hierarchical culture, and lack of error-prevention skills made hospitals dangerous environments. To prevent needless deaths from errors and to make substantive change, I came to the painful realization that I was putting my patients at risk with every hospital admission. Despite my best intentions and doing everything I was trained to do, I almost certainly must have had patients who died in my care from an error I did not recognize.
</p>
<p>
As with systemic safety issues, so it is with systemic racism. It may be difficult to see, but it still causes harm.
</p>
<p>
What should we do? Make it personal. We can do everything in our power to make health care safer or we remain complicit with unsafe conditions; there is nothing in between. We can either do everything in our power to recognize and deconstruct racism or remain complicit with racism. There is no other choice.
</p>
<p>
Become educated about systemic racism. Racist ideas, policies, and practices have been developed, entrenched, and refined over hundreds of years. They are inculcated in culture and are self-perpetuating. They will not change without intention and effort, just as hospitals became safer only after systemic changes and education of physicians, all hospital workers, and patients about recognizing and mitigating unsafe practices and behaviors.
</p>
<p>
Act. Have brave, respectful conversations that focus on the system and the problem, not the people. With faith in ourselves and in our collective humanity, we can and will prevail against racism if we continue the effort we've started.
</p>
<p>
<em>John H. Vassall II, MD, is CEO of the Foundation for Health Care Quality and serves as a WSMA trustee.</em>
</p>
<p>
<em>This article was featured in the Sept/Oct. 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 8/31/2020 10:32:33 AM | 8/31/2020 10:28:26 AM | 8/31/2020 12:00:00 AM |
| quality_improvement_put_to_the_test | Quality Improvement Put to the Test | WSMA_Reports | Shared_Content/News/Latest_News/2020/July/quality_improvement_put_to_the_test | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="WSMA Reports: July/August 2020 issue cover" src="/images/Newsletters/Reports/2020/COVER-WSMA_JulyAug-2020-645x425px.jpg" class="pull-right" /></div>
<h5>July 2, 2020</h5>
<h2>Quality Improvement Put to the Test</h2>
<p>
By Rita Colorito
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
At 8 p.m. on Feb. 28, Jeff Tomlin, MD, CEO of EvergreenHealth in Kirkland, received the news he'd been dreading. Ettore Palazzo, MD, the chief medical and quality improvement officer, confirmed that Evergreen had its first case of COVID-19.
</p>
<p>
Evergreen had been on alert since Jan. 20, after The Everett Clinic, some 20 miles north, reported the first U.S. case of the novel coronavirus. Evergreen recorded the state's first COVID-19 patient death on Feb. 29. That same day, Gov. Jay Inslee declared a state of emergency.
</p>
<p>
Within 30 minutes, Evergreen activated its incident command system and sent its administration team to literally take the information to the front lines, an approach based on its belief that quality improvement needs to filter from leadership to teams to empower them to develop solutions that work.
</p>
<p>
Dr. Tomlin was dispatched to the obstetrics floor, where nurses asked what they would do with expecting mothers and their families who may have COVID-19. "The staff weren't panicked. They were in problem-solving mode right away," says Dr. Tomlin. Two weeks later, obstetrics admitted a pregnant woman with fever and flu-like symptoms. "Thanks to that discussion, we had a structure in place to deal with that. It's an example of leadership being present and learning from the front-line staff," he says.
</p>
<p>
Evergreen's response to the challenge flowed from the guiding principles of its quality improvement program—absolute safety, effective care, and service to the patient, says Dr. Tomlin. Like other health care providers throughout the state, Evergreen's QI infrastructure has been both validated and challenged by the rapidly unfolding pandemic. The lessons learned, say Drs. Tomlin and Palazzo and other QI leaders, will carry them not only through this crisis and others, but also in their day-to-day quest for quality improvement.
</p>
<h3>Preparation determines response</h3>
<p>
Beginning with the worldwide SARS outbreak in 2003, and the threats of H1N1 in 2009 and Ebola in 2014-16, pandemic preparedness has become an increasing concern of U.S. health care systems.
</p>
<p>
For the last decade, EvergreenHealth has participated in the Northwest Healthcare Response Network, a coalition focused on building a disaster-resilient health care system. Through NHRN, 200 of Evergreen's QI and leadership staff have attended all-hazards training at the CDC's Center for Preparedness and Response in Alabama. UW Medicine and Seattle Children's are also NHRN members.
</p>
<p>
"Your response is completely dependent on your preparation," says Dr. Tomlin. "It doesn't have to be a pandemic. If you don't have some of these systems in place to respond to any disaster... if you haven't thought of them in advance, your response is going to be delayed. And it's going to add uncertainty within your staff."
</p>
<p>
Over the Cascades and 150 miles east of Seattle, Confluence Health activated its incident command on March 1, bracing for the worst. Three days later, Confluence recorded its first coronavirus case. The processes put in place early on prepared for the surge that came two weeks later, says CEO Peter Rutherford, MD.
</p>
<p>
As nursing home cases and deaths increased in Kirkland, Confluence dispatched a palliative medicine rapid response team to local skilled nursing and assisted living facilities, adult family homes, jails, and homeless shelters. The focus was on teaching isolation measures and ensuring personal protective equipment in those facilities was adequate. "That really shut down outbreaks in those facilities and really saved us," says Dr. Rutherford.
</p>
<p>
The palliative team also provided advance care planning that helped prevent the system from being overwhelmed, says Rachel Reeg, MD, a Confluence hospitalist and a member of WSMA's board of trustees.
</p>
<p>
Making sure health systems have the necessary resources to adequately treat patients while protecting staff remains a top concern around COVID-19. Confluence's ethics committee changed the focus of its regularly scheduled meeting to address a potential resource shortage, says Dr. Reeg, the committee's vice chair since March.
</p>
<p>
"We knew that many COVID patients would require intensive care. Our main response was preparing to coordinate crisis standards of care with regional and state committees, and then introducing the organization to the idea of crisis management and allocation of scarce resources through our virtual meetings," she says.
</p>
<h3>Communication and transparency matter</h3>
<p>
"Nature abhors a vacuum. And if you don't fill that with facts, it will get filled with rumor and innuendo and that's incredibly destructive," says Dr. Rutherford.
</p>
<p>
Soon after its founding in 2013, Confluence's board of directors passed its first QI policy known as Speak Up, which encourages staff to voice any concerns regarding quality or safety to address problems in the moment, if possible. "That really set us up pretty well to move forward when this whole COVID endemic and then pandemic got started," says Dr. Rutherford.
</p>
<p>
Specialists and other providers at Confluence have felt freed to do what they need to do, says Dr. Reeg. "Our organization has been extremely supportive of individual responses and willingness to help. A lot of people have been happy for the opportunity to contribute," she says.
</p>
<p>
Communication and transparency breed trust, says Dr. Tomlin, a necessary component to keeping staff committed to the mission. "Having good quality improvement systems in place is important. But perhaps the most important aspect of those systems is 'have you developed the trust and collaboration with the groups that you are leading?' " he says. "If the staff doesn't have trust and a sense that you are working closely with the front lines to keep everyone safe, then it's hard to ask them to put themselves in harm's way."
</p>
<p>
Effective risk communication— understanding how best to share information to not only health care workers, but also the public and the press—has proven critical for developing that trust, says John Lynch, MD, MPH, an associate medical director at Harborview Medical Center in Seattle.
</p>
<p>
"Every infectious disease doc out there, because of the work we do, needs to be prepared in how we communicate to our facilities and colleagues," says Dr. Lynch. He also recommends that all doctors have a knowledge of incident command (IC) structure. "Especially with a novel pandemic, it's like an earthquake every day, so it's important for every doctor to have some sort of knowledge on their role in IC," he says.
</p>
<p>
As the urgency grew at the end of February, Dr. Lynch, a University of Washington associate professor, was asked to lead the clinical response across the UW system. He and a team of 15 infectious disease, infection prevention and control, employee health, and QI experts spent the first two months working more than full time, seven days a week, almost exclusively on the crisis response. They provided guidance and support, but also empowered and relied on front-line staff to develop protocols and policies that made sense for them.
</p>
<p>
The knowledge and credibility of these physicians have been the important leadership qualities needed to steer the UW system through the crisis, says Dr. Lynch. "The other doctors know we're there to offer support, not to hold data against them when they start seeing infections."
</p>
<p>
Dr. Lynch says he also learned the value of well-being when it comes to managing a pandemic. At the request of Patricia Kritek, MD, Ed.M., a UW critical care and pulmonary physician, Dr. Lynch joined a weekly virtual town hall to field questions from front-line workers worried about the unknowns of the virus and looking for support and answers.
</p>
<p>
The town halls average about 500 participants; one topped 1,000 people. "Taking an extra hour felt like a huge
ask at the time when there was so much other emergency stuff going on, but it was absolutely the right thing to do," he says.
</p>
<h3>Rethinking improvement</h3>
<p>To prepare for any crisis, quality improvement needs to be a continual process, says Dr. Palazzo. In September 2019, months before the coronavirus appeared in China, EvergreenHealth's infection control and QI team began meeting monthly to review its pathogen response policies and protocols.
</p>
<p>
"It had been several years since we had performed a comprehensive review of our High Consequence Infectious Disease Pathogen protocol," says Dr. Palazzo. "When this all hit us in late February, we were fortunate that we didn't have to dust off any books on how to move areas to negative airflow or to cohort patients. It literally had been worked on the months ahead of time and that really put us in a good position when we got our first cases."
</p>
<p>
While cost-benefit analysis factors into any QI program, COVID-19 caused financial considerations to take a back seat, says Dr. Rutherford, as health care systems halted elective surgeries and procedures to flatten the curve.
</p>
<p>
"We took a perspective at the beginning of this that, as an organization, we were going to do the right thing for the community and deal with the financial impacts later; that having money in the bank in a broken care system later wasn't where we wanted to be," says Dr. Rutherford. Feeling freed from the financial considerations helped Confluence get a handle on the virus quickly, he says.
</p>
<p>
The virus forced action on both immediate and long-term needs. Within a week, Confluence had converted its entire third floor to negative pressure. And it finally implemented telehealth capabilities, after years of discussing it.
</p>
<p>
Despite the financial hit from COVID-19, Dr. Rutherford sees a silver lining going forward. "These aren't things that will go away. They are now done. They are part of our organization," he says. "It's really just, let the right people lead it. Let them do their piece."
</p>
<p>
<em>Rita Colorito is a freelance journalist who specializes in covering health care. She is a regular contributor to WSMA Reports.</em>
</p>
</div> | 7/2/2020 12:04:12 PM | 7/2/2020 11:11:56 AM | 7/2/2020 12:00:00 AM |
| small_steps_to_wellness | Small Steps to Wellness | WSMA_Reports | Shared_Content/News/Latest_News/2020/July/small_steps_to_wellness | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="WSMA Reports: July/August 2020 issue cover" src="/images/Newsletters/Reports/2020/COVER-WSMA_JulyAug-2020-645x425px.jpg" class="pull-right" /></div>
<h5>July 2, 2020</h5>
<h2>Small Steps to Wellness</h2>
<p>
By Pat Curry
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
When health care leaders pay attention to quality improvement, physician wellness is a beneficiary.
Virginia Mason saw an example of this with one of its early QI efforts: standardizing exam rooms in the outpatient primary care department.That meant finding out what was in the rooms and talking to clinicians to find out what they needed at their fingertips to do their jobs well, says Carrie Horwitch, MD, an internal medicine physician at Virginia Mason Medical Center.
</p>
<p>
"Now, I know any room I go into anywhere in my section is the same. I can find anything I need in my room; I don't have to go looking for things."
</p>
<p>
It may seem like a small thing, but it means physicians can give better care to their patients. When systemic failures keep doctors from doing it, it contributes to what many refer to as burnout. Dr. Horwitch prefers the term "moral distress" or "moral injury."
</p>
<p>
"If I can't do my work well to care for my patients, that causes distress to me as a physician because that is my obligation," Dr. Horwitch says. "The tenor of an organization comes from its leaders. If they value, respect, and truly care for the people who work for them, you'll have more engagement and, I think, less moral distress."
</p>
<p>
It's essential, Dr. Horwitch says, for health care leadership to not only have skill in the financial areas of medicine, but also to have compassion for the people doing the caregiving. "Emotional intelligence is really important and it needs to be taught to head leadership and middle management leadership as well," she says.
</p>
<p>
The value of quality improvement on physician wellness became extraordinarily apparent during the COVID-19 pandemic, when Virginia Mason was able to make what seemed like an "overnight transition from in- person to virtual visits," Dr. Horwitch says. "We turned something that could have been a several-months project into a couple weeks, making sure we could take care of our patients and keep ourselves safe."
</p>
<p>
For her, the rapid implementation of telehealth was evidence that Virginia Mason cared about her well-being.
</p>
<p>
"It made me feel valued making sure we have adequate protective equipment and having systems in place to keep us safe," she says. "It made me feel very good."
</p>
<h3>Broken systems</h3>
<p>
Edward Walker, MD, MHA, who just retired from a 40-year career at the University of Washington, works on the connection between leadership, quality improvement, and physician wellness. As a former senior medical executive and psychiatrist, he has coached physician leaders in the art of self- and organizational transformation as a pathway to wellness. One of the ways physicians can become distressed is working within systems that were not designed properly to support their effort, he says.
</p>
<p>
"Instead of telling our colleagues that they need to do mindfulness or yoga to deal with this stress, we should be helping them learn to transform their systems to support better care," he says. "When I see a distressed patient in clinic, the first thing I do is try to figure out whether the person is experiencing an abnormal reaction to a normal situation or a normal reaction to an abnormal situation.
</p>
<p>
"Quite often, physician burnout is an understandable and appropriate reaction to a very broken system," he says. "The solution to broken systems is quality improvement, and the key to quality improvement is leadership."
</p>
<p>
As lead educator for the WSMA, Dr. Walker has mentored nearly 1,000 individuals through its Physician Leadership Course. System transformation is a learnable skillset involving quality improvement, emotional intelligence, and community building; the skills taught in the course are invaluable to quality improvement and gaining buy-in from front-line physicians.
</p>
<p>
"I think some people approach quality improvement as a technical, analytic skill without fully understanding the leadership component and the connection to wellness," he says.
</p>
<p>
Leaders not only have to know what to do, but they have to build consensus around best practice standards and then "gently inspire and nudge" colleagues to follow and maintain those standards. Efficient and safe care is better for the patient, but it also feels better for the physician.
</p>
<p>
Physician-led systems have the advantage of designing work processes that are more directly influenced by the needs of the doctor-patient relationship and the ability of the physician to practice the art, as well as the science, of medicine.
</p>
<p>
"I've never met a physician who didn't feel fulfilled realizing he or she had done the absolute best for a patient," he says. "Quality improvement makes that possible."
</p>
<h3>The search for joy</h3>
<p>
Quality improvement and physician wellness is so vital to health care that the American Medical Association has a provider satisfaction, practice sustainability department. Its overall goal is to identify where "joy, purpose, and meaning can be possible for our health care professionals," says Kevin Taylor, MD, the AMA's director of organizational transformation.
</p>
<p>
"It sounds odd to have organizational transformation as part of a physician wellness program," Dr. Taylor says. "It's actually crucial to this kind of work. We understand there are major drivers of burnout and dissatisfaction or lack in meaning in your work. A good portion of that is the inefficiencies of our current workflow and the leadership culture in the systems we're part of."
</p>
<p>
Many evidence-based strategies can save physicians and care teams time that then can be devoted to their patient care. Dr. Taylor recommends the AMA StepsForward website, <a href="mailto:stepsforward.org">stepsforward.org</a>.
</p>
<p>
"There are dozens of modules that will enhance your clinical workflow and restore meaning in your work," he says.
</p>
<p>
Direct leaders of our physicians have a major influence on the culture of their health system and as a result, have an impact on their colleagues' sense of well-being and burnout. To help drive physician satisfaction, "leaders need to be active and visible; they need to actively listen, engage, and empower physicians to identify problems and help them to become part of the solution."
</p>
<p>
For many physicians, the health care culture has taken away their autonomy, choice, and agency. "Autonomy is an internal motivator for physicians," Dr. Taylor notes. "They want to have a voice in the system design and workflow but feel they are losing influence as the care delivery systems become more and more complex."
</p>
<p>
To be successful, physician leaders should take time to listen to their colleagues, give them the opportunity to identify the "pebbles in their shoes," and empower them to work with their teams to develop action plans that will improve their care delivery.
</p>
<p>
Physicians also need coaching on how to work collaboratively in a participative leadership style, he says. This is not a skill physicians learn in medical school, but they need it in the current health care environment where teams are so important. This requires new skills with process improvement and change management tools to effectively communicate and facilitate teams to achieve our mutual goals.
</p>
<p>
"You must be able to collaborate with your care teams to be successful in a clinically integrated network," Dr. Taylor says. "Participative leadership is the new reality for our physicians."
</p>
<p>
<em>Pat Curry is senior editor of WSMA Reports.</em>
</p>
<p><em>
This article was featured in the July/August 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div>
<br />
<div class="telerik_paste_container" style="border-width: 0px; position: absolute; overflow: hidden; margin: 0px; padding: 0px;">&nbsp;</div> | 7/2/2020 11:39:11 AM | 7/2/2020 11:19:14 AM | 7/2/2020 12:00:00 AM |
| the_crucible_of_covid_19 | The Crucible of Covid-19 | WSMA_Reports | Shared_Content/News/Latest_News/2020/July/the_crucible_of_covid_19 | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/Newsletters/Reports/2020/COVER-WSMA_JulyAug-2020-645x425px.jpg" class="pull-right" /></div>
<h5>July 2, 2020</h5>
<h2>The Crucible of Covid-19</h2>
<p>
By Nariman Heshmati, MD
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
When the first known COVID-19 patient in the United States was admitted to my local hospital, we quickly understood this would be a far-reaching battle that would surely involve many more patients.
</p>
<p>
As that case made national news, colleagues from around the country called, texted, and emailed asking how things were going in Washington state and how they could help. Even as they were reaching out, we were coordinating between health care systems, together trying to understand a path forward, to provide guidance to state officials, and to ensure we were prepared to take care of our communities.
</p>
<p>
When the epicenter of COVID-19 shifted to New York and overwhelmed their health care systems, soon I was calling, texting, and emailing those same physicians to see how they were faring. And as a practicing OB-GYN, I was shocked when I heard that New York hospitals were not allowing laboring women to have their partners be present with them. Obviously, one-to-one emotional support during labor is critical and can improve outcomes.
</p>
<p>
The day I read those news reports, I walked into an exam room to see one of my own patients. Terrified that she would be forced to give birth alone, she was considering a home birth. This, despite evidence that even low-risk home birth outcomes are worse than those in a hospital setting. As a high-risk pregnancy, she was last person who should deliver anywhere but in a resource-rich hospital prepared for emergencies. I reassured her that physician leaders overseeing labor units in Washington were supportive of having partners present during labor.
</p>
<p>
Ultimately, New York state reversed its policies and allowed laboring women to have partners present, but I wondered: What was the difference between Washington and New York? We faced the same crisis, but responded to it differently. The answer? Here in Washington, we relied more on physician leadership.
</p>
<p>
We've seen more clearly how physician leadership can make a difference as a result of the COVID-19 crisis. As physicians, being involved in leadership ensures that the future health care system is one in which our patients not only will receive the best care, but also one in which physicians want to practice. We can make a difference on a large scale even when not faced with a worldwide pandemic.
</p>
<p>
Studies show that health care systems with physician CEOs have improved quality and outcome measures over those that do not. Physicians bring a unique perspective when taking on leadership roles in health care organizations. We understand the struggles on the front line, we have been exhaustively trained to gather data and make rapid difficult decisions, and we view scenarios through the lens of clinical care.
</p>
<p>
Times of crisis such as the COVID-19 pandemic can illuminate the shortcomings in our systems, but more importantly, they demonstrate our immense ability to adapt nimbly and respond to care needs in ways we could never otherwise imagine.
</p>
<p>
We also put our patients first. And my anxious patient? She had a beautiful and safe hospital birth with the support of her husband at her side.
</p>
<p>
<em>Nariman Heshmati, MD, is an OB-GYN at The Everett Clinic and serves as the secretary-treasurer on WSMA's executive committee.</em>
</p>
<p><em>
This article was featured in the July/August 2020 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 7/2/2020 11:40:09 AM | 7/2/2020 11:19:18 AM | 7/2/2020 12:00:00 AM |
| controlling_the_cost_of_care | Controlling the Cost of Care | WSMA_Reports | Shared_Content/News/Latest_News/2020/May/controlling_the_cost_of_care | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/COVER-WSMA_MayJune-2020-645x425px.jpg" class="pull-right" alt="WSMA Reports cover - May/June 2020" /></div>
<h5>May 5, 2020</h5>
<h2>Controlling the Cost of Care</h2>
<p>
By John Gallagher
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
Companies are always looking for ways to trim costs, so it's no wonder that health care is often on the top of the list. Employer-sponsored health insurance covers about half of the non-elderly population in the United States, but at a significant cost. The Kaiser Family Foundation estimates that the average family insurance premium is more than $20,000 a year. On average, workers in 2019 paid $6,015 toward the cost of family coverage, with employers paying the rest.
</p>
<p>
For years, some employers have tried to manage the financial burden by sharing more of it with their employees. Employee share of premium costs has risen more than 70% in the past 10 years. High-deductible plans were introduced on the grounds that workers with more skin in the game would be better health care consumers. (In fact, studies show the plans lead to a decrease in high-value care for patients.)
</p>
<p>
The approach invariably created a backlash. "One of the reasons I think this has become more acute is the cost of a care episode has become more transparent with high-deductible plans," says David Grossman, MD, senior medical director for community health and external relations at Kaiser Permanente Washington. "The cost is hitting consumers in the face. High-deductible plans have unleashed a lot of concerns."
</p>
<p>
Having failed to curtail their health care costs so far, employers are now looking to a new target to save money: physicians. According to a Jan. 13 article in Modern Healthcare, employers are "eyeing more aggressive measures to counter the formidable market power of consolidated hospitals and physician groups."
</p>
<p>
The COVID-19 epidemic may only make that pressure worse. Faced with severe financial losses due to the economic downturn, companies will be increasingly desperate to squeeze every possible savings they can from their expenses.
</p>
<p>
However, making cost the primary driver for decision-making about health care is short-sighted at best, even in light of the epidemic. While costs are driving the conversation, the real issue is the way the system is structured. Employers can help make the necessary changes in collaboration with physicians.
</p>
<p>
"If you're talking about reducing the cost of care, you need comprehensive change," says Jennifer Hanscom, executive director and CEO of the WSMA. "It's not an easy fix. The concern about controlling costs, while important, could unfairly single out physicians and overlook other drivers of cost."
</p>
<h3>The search for solutions</h3>
<p>
Several public- and private-sector purchasers in Washington are pursuing innovative solutions that rely upon close collaboration with physicians. The Washington State Health Care Authority, which covers more than 2 million people through its Apple Health and state employee programs, has an ambitious goal: having 90% of health care it purchases be value-based, which rewards physicians and providers for the quality of care that they offer. State employees can choose from several value-based plans.
</p>
<p>
Along with the HCA, Boeing has been a pioneer in this effort. In 2014, it contracted directly with UW Medicine and Providence Health &amp; Services to offer a value-based plan for its employees. The HCA and Boeing plans promise not only lower costs for the employers, but a better patient experience for employees.
</p>
<p>
Capitation can offer a way out of the fee-for-service cycle that can perversely reward overuse. "Payment mechanisms like capitation are the way to go for the future," says Dr. Grossman.
</p>
<p>
Capitation is one way to solve the confusion inherent in the current payment system, agrees Philip Chan, MD, MHA, associate medical director for population health for UW Medicine/ Valley Medical Center. While the predominant fee-for-service system rewards physicians for the volume of care they provide, capitation rewards physicians for the quality of care they provide.
</p>
<p>
However, few employers are as large as the HCA and Boeing. Smaller and mid-size companies lack the size to create similar plans. Their interest may be more in cost savings and less in innovation. As a result, employers may be tempted to use a much blunter approach to saving money by creating narrow networks and slashing physician payments.
</p>
<p>
"We have to manage the problem of unintended consequences, such as the downside of narrow networks," says Hanscom. "Also, reducing reimbursements to physicians is a disincentive to participating in a plan, to say nothing of putting financial pressures on already struggling practices and contributing to physician burnout."
</p>
<h3>Targeting cost drivers</h3>
<p>
Considering physicians to be the problem and not the solution to health care costs overlooks a critical factor: Physicians know better where the waste is in the system and, as a result, where the savings lie.
</p>
<p>
For example, a local company came to Confluence Health in North Central Washington seeking help to reduce the number of workers using emergency departments for regular primary care. As it turned out, the main reason why employees were turning to the ED for routine care was that they were afraid of missing work during regular business hours.
</p>
<p>
Working with the company, Confluence set up a family practice clinic at the jobsite for employees and their dependents. The agreement provided Confluence with a bonus if it could reduce the company's total cost of care, while employees got incentives to improve their own health markers. As a result, ED visits declined by 25% and diabetic control measures improved by 40%.
</p>
<p>
Confluence's example highlights one of the main drivers of cost: overuse. "When it comes to total health care costs, two factors have to be addressed: utilization and unit price," says Dr. Grossman.
</p>
<p>
Simply ensuring clinical standards of care are followed more rigorously can lead to significant savings. "Utilization is the one thing we can tackle sooner than later," says Dr. Chan. "We have to try really hard to standardize our care and follow evidence-based clinical practice guidelines: If you're treating this, this should be your initial approach."
</p>
<p>
As for unit price—the measure of how much it costs to deliver a particular treatment or service—the current system provides no incentive to measure or control it.
</p>
<p>
"As a system, we don't understand what it costs to do things," says Edwin Carmack, MD, medical director for value-based care at Confluence Health. "We're the only business that doesn't know what it costs us to do something. We estimate based on what we get paid. What it costs us to do it, we don't know." A system in which physicians are responsible for the total cost of care would make that knowledge of unit cost essential and incentivize ways to control it.
</p>
<p>
Plenty of cost drivers are available for employers to target. Spending on drugs is high on the list.
</p>
<p>
"Having a tighter formulary can bring costs down a lot," says Dr. Grossman. "Ensure the right meds are going to the right people, not giving them too many drugs and expensive drugs unnecessarily."
</p>
<h3>Changing the system: a benefit for employers and physicians</h3>
<p>
As much as physicians are interested in employers moving toward a value- based system, they remain caught in a confusing world where fee-for-service is the primary system and demands are fragmented across different insurers.
</p>
<p>
"It is challenging working with various versions of value-based contracts," Dr. Chan notes. "The requirements and number of quality metrics vary among payers. This results in labor-intensive data reporting and tracking. It makes it harder to home in and focus on clinically important metrics that providers can actually control."
</p>
<p>
Ultimately, the question about how employers can cut costs should really be about how they can finally change the system for the better. Doing so will lead to the cost savings companies seek.
</p>
<p>
In the meantime, physicians remain stuck in a system that is always pushing for change, but never quite does.
</p>
<p>
"From the perspective of the physicians, they're still in two canoes: fee-for-service and value-based purchasing," says Hanscom. "For all the talk about innovation, we're not seeing enough of it."
</p>
<p>
<em>John Gallagher is a Washington state- based freelance journalist who specializes in covering health care.</em></p>
<p><em>
This article was featured in the May/June 2020 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="[@]WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:21:36 AM | 5/5/2020 11:36:44 AM | 5/5/2020 12:00:00 AM |
| hope_in_the_time_of_covid_19 | Hope in the Time of COVID-19 | WSMA_Reports | Shared_Content/News/Latest_News/2020/May/hope_in_the_time_of_covid_19 | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/COVER-WSMA_MayJune-2020-645x425px.jpg" class="pull-right" alt="WSMA Reports cover - May/June 2020" /></div>
<h5>May 5, 2020</h5>
<h2>Hope in the Time of COVID-19</h2>
<p><em>Members only; sign-in required.</em></p>
<p>
"As a species, we have coexisted and survived with an immense assortment of organisms, all pushing for a niche in which they, too, can flourish. We turn out to be fantastically resourceful - both in our physical and in our social structures. Each challenge results in subtle changes to our systems. SARS-CoV-2 is just the latest of these challenges, and it, too, will require us to adapt in ways that are likely to strengthen our resilience even more. Humanity will get through this fine, but we need to be willing to make major changes in how we function and behave until either we're through the pandemic or we have mass immunization available. Our past successes give me great optimism about our future." - <em>John Bramhall, MD, PhD</em>
</p>
<p>
"I am hopeful because I have seen teammates doing everything in their power to care for patients. Health care entities have collaborated in ways we would have never imagined - embracing technology to provide care in a matter of days instead of years. The way health care is delivered will be forever changed for the better. I am hopeful because I see compassionate people step forward to lend a helping hand. This crisis could have brought out the worst in us or the best in us - I am hopeful because it did the latter." - <em>Nariman Heshmati, MD</em>
</p>
<p>
"What brings me hope is that each generation of Americans is challenged with fears and despair, but always comes through. Some call this American exceptionalism. I call it the American people. We will work together to defeat the enemy, and you can take that to the bank." - <em>William K. Hirota, MD</em>
</p>
<p>
"Being at home with my daughter and seeing life through her eyes brings me hope. Being a doctor and mommy during these times is not easy. But looking to the future is what being a doctor mom is all about. Taking care of my patients, my work family, the residents I train, and my daughter is what brings me hope. Seeing us all come together... that brings me hope." - <em>Katina Rue, DO</em>
</p>
<p>
"I am given hope by two responses that, together, give our society the strength to get through this: neighbors looking for ways to help each other even at risk to themselves, and organizations getting past corporate inertia to respond rapidly and appropriately to a crisis." - <em>Tom Schaaf, MD, MHA</em>
</p>
<p>
"I find hope in my teammates in the emergency department where we see some of the darkest moments in people's lives. We provide compassion and hope to our patients, while caring for each other as a team. As we endure this season of COVID on the front lines, it is our ED family and those at home that help us through." - <em>Nathaniel Schlicher, MD, JD, MBA</em>
</p>
<p>
"I'm impressed by the generosity of our patients who are obviously feeling poorly and suffering from chronic illness but are willing to forgo or delay treatment so that others who are more urgent can get the care they need. Stressful and life-changing events like this bring out the best in people. I see that in my patients. I also see hope in everyone pulling together and getting the job done. In this crisis, we've learned to keep nimble and not make simple things overly complicated." - <em>Mika Sinanan, MD, PhD</em>
</p>
<p><em>
This article was featured in the May/June 2020 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="[@]WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:22:59 AM | 5/5/2020 11:40:18 AM | 5/5/2020 12:00:00 AM |
| what_are_we_spending_on_health_care | What Are We Spending on Health Care? | WSMA_Reports | Shared_Content/News/Latest_News/2020/May/what_are_we_spending_on_health_care | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/Reports/2020/COVER-WSMA_MayJune-2020-645x425px.jpg" class="pull-right" alt="WSMA Reports cover - May/June 2020" /></div>
<h5>May 5, 2020</h5>
<h2>What Are We Spending on Health Care?</h2>
<p>
By Pat Curry
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
When Washington State Rep. Eileen Cody started her career as a nurse more than 40 years ago, "insurance wasn't that big of a deal," she said. "A lot of people didn't have insurance. You could go into a hospital without being insured."
</p>
<p>
Today, with health care costs, insurance premiums, and out-of-pocket expenses higher than ever, some 400,000 Washingtonians are uninsured. For the tens of thousands more who buy insurance from the state's health benefit exchange, the out-of-pocket expenses are so high they can't afford to use it. It's insurance in name only. With the outbreak of COVID-19, access to high-quality, affordable health insurance is more important now than ever.
</p>
<p>
Cody, who represents the 34th Legislative District (Vashon Island, West Seattle, White Center, and Burien), chairs the House Health Care and Wellness Committee. The most senior Democrat in the state House of Representatives, she has been a state legislator since 1994; with her decades of medical experience, Cody is a health policy leader in Washington state's legislature.
</p>
<p>
WSMA Reports spoke with her about the recent legislative session and her vision for reducing health care costs in Washington state. The starting point for achieving that goal, Cody said, is getting a clear grasp of how much health care actually costs in the state. For that reason, she co-sponsored House Bill 2457 to establish a state health care cost transparency board.
</p>
<p>
The purpose of the board is to calculate and analyze information and trends related to all health care costs in Washington. The board also must annually establish the health care cost growth benchmark for increases in total health expenditures and analyze provider and facility cost increases. At press time, the bill had passed both houses of the Legislature and was awaiting Gov. Jay Inslee's signature.
</p>
<p>
"I'm trying to look at what we're really spending on health care across the state," Cody said. "It'd be nice to know what (health care) should cost. ... The CEO of a hospital said in front of our committee, 'Our billing has nothing to do with cost.' I've been saying that for 26 years! That's the problem."
</p>
<p>
With a goal of reducing health care costs for the state's residents, the first thing Cody said she would like to do is to raise the Medicaid reimbursement rate and to lower reimbursement on other health plans, namely those for teachers and state employees. The health care cost transparency board will provide the data to make a case for that.
</p>
<p>
The new panel, which will consist of public- and private-sector health insurance purchasers, will be responsible for annually calculating and releasing information on health care costs in Washington, including increases statewide for each health care provider, system, and payer. As in other states, the panel also will establish benchmarks for future health care cost increases and track expenditures against the annual benchmark. (The WSMA will nominate a physician to participate on an advisory committee that informs the panel's work.)
</p>
<p>
"First we need to find out what we're spending and then look at how it's spent," Cody said. "We don't know what people are paying. If we can get [information on] the spend, then we can see where the cost drivers are."
</p>
<h3>Gaining insight from other states</h3>
<p>
Washington is not the first state to tackle total cost of care or implement a method of tracking health care expenses. Massachusetts, which enacted a health care cost containment law in 2012, is furthest along, Cody said. They established a new agency, the Massachusetts Health Policy Commission, to oversee health care system performance and provide policy recommendations regarding health care delivery and payment system reform. Its sister agency, the Center for Health Information and Analysis, collects health care information from payers, providers, provider organizations, and third-party administrators and is a primary source of health care analytics that support policy development.
</p>
<p>
Cody said she doesn't want that kind of system for Washington state.
</p>
<p>
"In Massachusetts, they have a whole commission and did a whole big hoopla," she said. "I didn't want another agency looking at health care costs."
</p>
<p>
Data Washington state gets now from its all-payer claims database provide most pricing information but don't address total health care spending or the cost drivers behind the prices.
</p>
<p>
"The question has been raised how much is regulation driving cost," Cody said. "That's a little down the road. First, let's find out what we're spending and then we can look at how it's spent."
</p>
<h3>The public option compromise</h3>
<p>
Looking back on the 2019 session, Cody readily admits that the state's public insurance option—the nation's first, which is set to go into effect next year— diverged from what she proposed in her initial bill. That was a plan that capped reimbursement at Medicare rates. In the bill that ultimately passed and was signed into law, the state-sponsored plan will cap reimbursement to providers and facilities at 160% of Medicare.
</p>
<p>
"I always start out very aggressive knowing we'll have to compromise," she said. "The good thing is we have a standardized benefit package on the exchange. If nothing else happens, that's a good thing. It lowers the out-of-pocket expense and the deductible. That was outrageous; that's not really insurance."
</p>
<p>
The state estimates the standardized benefit package, coupled with the reimbursement cap, could lower premiums by 5-10%. That's not a huge savings, but given the massive premium increases on the health benefit exchange plans (35% in 2018), any drop in the premium would be cause for celebration. (The WSMA participated in public option negotiations throughout the 2019 session. We opposed the final bill due to concerns that physicians and health care facilities would not be able to contract to participate in the plan under the terms envisioned in the law, resulting in health plans that don't have adequate access to care for enrollees.)
</p>
<p>
The range of options being discussed at the state and national levels run from market-rate coverage to Medicare for All, "but there's no discussion about the rates," Cody said. "People still want choice, but they want everything for nothing and it just doesn't work too well that way.
</p>
<p>
"I think it's great to have the total cost of care discussion to own up to how much does it cost for things," she said.
</p>
<p>
Noting that prescription drug prices play a significant role in driving up health care costs, Cody noted that is one area that needs to be addressed at a federal level. It is ludicrous, she said, that the same drugs in other countries cost a fraction of the price than they do in the United States.
</p>
<p>
"The U.S. does the research and everyone enjoys that benefit," she said. "We can't allow that to continue."
</p>
<p>
State legislators passed a bill this session to cap the monthly out-of- pocket expense of insulin to $100 per month; at press time, that bill also was awaiting the governor's signature. Cody also favors legislation and/or regulation that would require insurers to apply prescription costs—and prescriptions bought using discount coupons—toward their customers' deductible and out-of- pocket expenses.
</p>
<p>
"It's ridiculous they aren't counting the cost of drugs toward the deductible," she said. She noted that her former patients, who had multiple sclerosis, needed prescription drugs that cost $7,000-$8,000 a month.
</p>
<h3>Paying doctors the right amount</h3>
<p>
Asked whether recent and proposed tax increases on physicians and health care entities, such as the business and occupation tax, run counter to the push to make health care more affordable, Cody said she agreed that it "doesn't help, necessarily. That's designed to make sure we have the next generation of doctors through college and practicing."
</p>
<p>
Given the opportunity to share what she wants Washington state doctors to know, Cody said, "We have to figure out how to get people paid the right amount of money for the work they do," she said. "It's wrong that doctors might get their bonuses from Press Ganey [patient satisfaction] scores. It tells them they can't say 'no' to a patient. That's not the way patient care should be measured. It should be patient outcomes. I appreciate a crusty doctor who does the right thing.
</p>
<p>
"In my 40 years as a nurse and 26 years as a legislator, I have seen a lot
of changes in health care," she said. "We still haven't made any headway
on [addressing the cost]. There used to be an incentive to order tests; now, it's the other way around. I personally like more global budgeting, which increases payment if you do a good job. It's very hard to make those kinds of changes."
</p>
<p>
<em>Pat Curry is senior editor of WSMA Reports.</em>
</p>
<p><em>
This article was featured in the May/June 2020 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="[@]WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:24:04 AM | 5/5/2020 11:40:24 AM | 5/5/2020 12:00:00 AM |
| a_virtuous_cycle | A Virtuous Cycle | WSMA_Reports | Shared_Content/News/Latest_News/2020/March/a_virtuous_cycle | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/Cover-WSMA_MarApril-2020-v6-645x425px.jpg" class="pull-right" alt="WSMA Reports cover" /></div>
<h5>March 4, 2020</h5>
<h2>A Virtuous Cycle</h2>
<p>
By Nicholas Rajacich, MD
</p>
<p><em>Members only; sign-in required.</em></p>
<p>
I was surprised to hear a colleague express hesitation when I suggested that her practice, struggling with caseloads and administrative work, hire a physician assistant. After all, at my orthopedic practice, we were preparing to hire even more PAs (which will mean more than one PA per doctor).
</p>
<p>
For our practice, it's simple: PAs help us increase access to our services (more care for more people) and help manage many of our day-to-day tasks (fewer hours spent by our physician specialists on administrative work and less-complex procedures). Put even more simply, the bottom line is that our PAs are good for our practice's bottom line - both for patient care and practice revenue.
</p>
<p>
With most PAs trained in primary care, few come to us with experience or training in our surgical specialty. Some choose to do an additional year of specialized training, which we have found to be quite valuable. While it requires a significant commitment of time to train them both in the clinic and in the OR, the returns on this investment accrue rapidly.
</p>
<p>
For example: In the OR, our PAs prep the patients for surgery, handle the post-op orders, apply tourniquets during the operation and, in the case of a PA who's been around a while, close and dress incisions. Complicated patient discharges? Our PAs have us covered, arranging follow-up visits, DME prescriptions, and so on.
</p>
<p>
As their training moves along, and as the individual PA gains more experience, we give them expanded independence in our practice. With experience, we allow our PAs to see an independent panel of patients, saving the complex patients for our physicians.
</p>
<p>
And of course, a PA can do many of the tasks that doctors are being tasked with (more and more...and more) these days. With the development of EMRs and increasing regulatory requirements, there's a large burden of administrative material that a PA can help me with.
</p>
<p>
At this point, our investment in teaching these PAs has more than paid off. Our physicians are now freed up to practice at the highest level of our training and to see more new patients, which is a win-win for everyone.
</p>
<p>
We do at times allow PAs to run clinics offsite. In most situations when a PA is seeing patients in clinic, there is a physician available, either by phone (with the ability to review X-rays via PACs) or in person, to answer questions or provide advice as needed.
</p>
<p>
There are some relatively simple legal hurdles that one must address before hiring a PA, most of which can be navigated with the help of staff at the WSMA and the Washington Academy of Physician Assistants. Promising work is being done by those organizations at the state level to modernize the requirements around the PA delegation agreement - the document describing what training and supervision will be provided and what duties delegated to the PA. Ultimately, what's important is to clearly define and document the clinical partnership and to regularly revisit and revise as needed. This is key to building a successful physician-PA team and to ensure the highest quality of care for our patients.
</p>
<p>
At our practice, the use of PAs has led to greater access to care, which, in turn, has led us to hire more PAs (I envision a day when we may well have two PAs per doctor). It's a virtuous cycle if there ever was one, and one I'll continue to recommend to other physician colleagues.
</p>
<p>
<em>Nicholas Rajacich, MD, is a pediatric orthopedic surgeon at Mary Bridge Children's Orthopedic Clinic.</em>
</p>
<p>
<em>This article was featured in the March/April 2020 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 7/7/2020 10:25:19 AM | 3/4/2020 12:41:00 PM | 3/4/2020 12:00:00 AM |