6 September 2019
Dear Interested Readers,
Did You Like It? Do You Want To Try It?
I was thrilled with Joe Knowles’ contribution to Tuesday’s post, “Guns In Homes: Time for a Safe Home Credit.” I hope that you have read it. If not, please do. Just click here. Once again, I want to thank Joe for his willingness to offer his idea to you through these notes. If you haven’t ever had the pleasure of meeting Joe, just scroll down to the bottom of this post, and there you will find his smiling face. I hope that it will not be long before Joe has another idea to share with us.
How about you? Do you have an idea, an opinion, a story from practice, a celebration, or a concern that you would like to share? It is easy. Just drop me a line at drgenelindsey@gmail.com and we will get started on your posting.
I Look Forward To Getting My New England Journal Each Week
There is an editorial in this week’s New England Journal of Medicine that is entitled “Thank You.” It was written by Jeff Drazen who has been the editor of this most important journal for the last nineteen years. This week’s edition will be the last edition of the “Drazen era.”
I do not know Jeff well, although I was a junior resident at the old Peter Bent Brigham Hospital when he began his internship there in June of 1972. All my memories of Jeff are characterized by his amazing fund of knowledge, his great sense of humor and big smile, his sincere concern for patients and the improvements that are possible in practice, and his contributions as a clinical scientist. Having once known Jeff is a perfect example of one of the real benefits of training and spending most of your career in an institution like the Brigham. You get to meet a lot of impressive young people who will go on to make big contributions to both the science and the culture of our profession.
I get the meaning of Jeff’s brief title. He is thanking all of those who have made contributions to the success of the NEJM over the almost two decades of his leadership, but I think the “thank you” is backwards, or at the least should be bidirectional. My professional benefit from reading the journal has grown immensely during the years that Jeff has been its leader and editor. When Jeff announced his impending retirement about a year ago Stat published a review of his tenure. All was not roses for Jeff during his time of leadership. There have been challenges, but I think that anyone who has the nerve to assume such a critical role will always encounter problems. As I see it, “All’s well that ends well.” Stat was accurate when they summarized Jeff’s 19 years.
Along the way, despite the fact that some researchers hate NEJM the way baseball fans hate the Yankees, its stature has grown. Its impact factor, a loose — and some would say deeply flawed — measure of publishing glory in science, is now brushing up against 80, far outstripping its rivals The Lancet (53) and the Journal of the American Medical Association (47). NEJM’s Perspectives section has grown and matured, and has become a critical part of the conversations around both health care policy and clinical medicine.
I bolded the last sentence of the paragraph because I believe that the impact of the “Perspectives” section over the last eighteen years has been enormous. I get my Journal at my post office box. I am often reading the Perspectives section of the journal in the post office parking lot. I can not wait to get home to read it. My wife picked up the mail on Tuesday when the journal arrived, but I was reading it within minutes of her return home. As is often the case, there were three important articles. Jeff’s last edition was noteworthy for more than his goodbye “Thank you.”
I know that many of my interested readers were not born in 1973, or if they were alive, they may have been watching Big Bird on Sesame Street which began in November 1969 and have had no direct experience in a world where abortion is illegal. Almost everyone alive today knows of the Holocaust from stories told to them about the era, visits to a museum, watching Hollywood movies, or from history they have read. As time moves on from a dark era, it is easy to forget the misery and suffering that was experienced, especially if it was never an event or experience that we personally shared or witnessed.
It is startling to realize that very few of our current practitioners have ever practiced in an era when women did not have the protection of Roe v. Wade. That is the initial point in Dr. Lisa Rosenbaum’s article “Perilous Politics — Morbidity and Mortality in the Pre-Roe Era.” This is a must read for every care professional, whether you were in practice, in diapers, or not even born yet in 1973. For 46 years the specter of death from illegal abortions has been dramatically lifted by Roe. Rosenbaum seems to be making the case that if you were not around before Roe it is understandably hard for you to realize just how awful it would be, especially for women without resources, if it is repealed.
There is an accompanying interview with Dr. Michael Baden, who is a forensic pathologist, now 85 years old, who was in practice in New York City in the sixties and participated in the evaluation and documentation of the tragedies of the pre Roe era. Stephen Morrissey, the Executive Managing Editor of the Journal, does a great job of leading Dr. Baden through this grizzly history that we must never relive. This interview is a must for every healthcare professional to hear. It is only 11 minutes long. Rosenbaum finishes her article with a few sentences worth reading and re-reading. The bolding is my addition for emphasis.
….a common conundrum in medicine: our technical limitations are sometimes more readily overcome than our social ones. Today, though we have learned so much about how best to support patients through critical illness, we struggle to address deeply rooted social ills, such as poverty and racism, that leave people vulnerable to sickness in the first place. Unavailability of safe and legal abortion need not be added to this list of intractable societal afflictions. It is unconscionable that we may soon once again condemn women to a fate that we could so easily prevent.
Dr. Rosenbaum’s article is followed by another interesting offering, “Toppling the Ethical Balance — Health Care Refusal and the Trump Administration,” by Elizabeth Sepper, J.D. This article is most interesting to me in that it represents another example of President Trump’s willingness to “pay off” a small part of his base for their loyalty in a way that compromises established precedent and our collective best interest, both now and in the future. The proposed rule change would deny practices and organizations the right to demand that all employees participate in necessary care when an employee refuses because the patient had made, or was considering, a choice that violated some personal belief. Lifting the professional and legal responsibility of every individual and institution from participating in emergency medical care from individuals who have an objection on the basis of religious conviction is really not much different than his continuing support of the gun lobby, his roll back of environmental laws, his tax relief for the super wealthy, or his efforts to undermine public education. All of these actions are designed to benefit some part of his base, or are conceptualized as a counter to progressive social policy.
Attorney Sepper goes into great detail to describe the difficulties for the organization of care that this new change in regulations could bring down on all of us. She sums it up:
…the rule creates a wide-ranging right to refuse to provide health care services..
The negative impact of this new rule on members of the LGBTQ/ trans community, or women seeking reproductive care could be significant. As she says:
The new rule instead introduces a near absolute duty of accommodation.
By that she means that any hospital, any practice, must accommodate the refusal of any person in their employment from providing service to some individual, or for some process, for which they hold an objection. To reiterate this convoluted point, the change would prevent any organization from disciplining any professional, or any employee, even one working in a role that did not have patient facing responsibilities, who refuses to participate in emergency care, or to help provide access or referral to other providers, when the care desired by the patient violates the professional’s or employee’s religious or personal views.
Sepper points out that the impact on staffing for emergency services could be huge. For example, since it would be impossible for a hospital to discipline an employee for refusing to participate in the emergency care of a woman who is miscarrying and in need of a D&C, they would need to staff to that accomodation. What is the solution that would fix the reality that it would also no longer be necessary for a physician who refuses to provide an abortion to reveal other options, or give the patient who wants other options a referral to someone who would be willing to provide the desired care? It is hard to fully protect patients, especially those whose options are limited by scarce resources. The extent of the ways harm could occur is magnified by the reality that the potential conflicts could go unnoticed by many of us until a moment of refusal occurred. I do not think it is an exaggeration to say that this rule, which is being challenged in the courts, could change the nature of practice, especially in an era of critical staff shortages in rural and inner city environments. Again, I suggest that you read the article. I would suggest that after reading the article you ask a question, “When will attempts to unravel the progress that has been made in equitable care delivery end?”
The final article in this week’s “Perspectives” section, “Primary Care First — Is It a Step Back?” by Sessums, Basu, and Landon, contains some interesting speculations. The first paragraph restates a truth that is generally accepted, followed by a terse statement of current reality.
Evidence of the value of primary care to the U.S. health care system continues to grow. Supporting primary care is a major goal of the Centers for Medicare and Medicaid Services (CMS), which has added new billing codes to pay for previously uncompensated care (e.g., long-term care and transitional care management) and new programs such as the Comprehensive Primary Care Plus (CPC+) initiative, in which CMS partners with payers in 18 regions of the country to pay for advanced population-based care in nearly 3000 practices. Yet primary care has not flourished in the United States, and it often fails to achieve the ideal of first-contact care that is comprehensive, continuous, and coordinated.
They go into some detail about the latest CMS program to support primary care.
To further support delivery of primary care to Medicare beneficiaries, in April CMS announced two new payment models, to be implemented in January 2020. The Direct Contracting model is designed for large organizations willing to assume full risk and represents an evolution of Medicare’s accountable care organization programs that incorporates new payments for primary care. The Primary Care First (PCF) model, for individual practices, is loosely based on CPC+. Whether these programs will truly support improved primary care delivery remains unclear. Given the PCF’s broad applicability to primary care practices nationally, it’s worth examining the uncertainties surrounding its likely effectiveness.
They discuss those uncertainties, and then conclude that four major challenges may hinder PCF’s ability to support primary care.
- The model does not fulfill the critical need to devote additional resources to primary care practices with already marginal income.
- PCF may move toward population-based payment before primary care practices have the capacity or willingness to enter such an arrangement.
- Under PCF, less than half the practices will receive incentive payments, and the method used to determine the amount of these payments could have unintended consequences.
- CPC+ and its predecessor were multipayer programs, which support practice success consistent with the hypothesis: that physicians adopt a single approach to care that best matches the overall incentives across all payers.
The article may become a little wonky for many readers, as the list suggests, but the authors are presenting the concern that the new program may introduce risk to practices and hospitals that are not prepared to accept it, and that the sum total of the outcomes of the program may be to reduce payments for many groups and hospitals. They are concerned that the inadequate population health infrastructure in these organizations, and their lack of experience with risk products coupled with inadequate payments increases will prevent them from being successful. They sum up their concerns in the last final paragraph.
PCF reveals the administration’s vision for supporting primary care across practices, and both its prospective payment and the potentially large performance incentive are ideas worthy of rigorous evaluation. Yet the program ignores the low level of current Medicare payments for primary care, the need for greater investment, and lessons from the managed-care era about financial incentives tied predominantly to utilization reduction. Although PCF is a bold attempt to transform payment approaches, several features raise concerns that it will not lead to improvement in primary care.
I don’t doubt the reality of their conclusion. But, I have a dilemma. I have little sympathy for the organizations that are “at risk” while I have great sympathy for the patients and communities that they serve. For more than two decades there has been clarity about the need for change. The fourth point that they make is a reality. Doctors do treat all patients the same, and it is usually the way that they get paid the most. As a result, when organizations have “dabbled” in risk contracts while building their strategies on the concepts of FFS payment, they have little to show for these weak efforts to prepare for a future that will be dominated by value based reimbursement. The knee jerk response as demonstrated by the article is to say, “Whoa, not so fast we aren’t ready!” I counter by saying “Shame on them!” The concepts they needed to master were articulated in 2001 in Crossing the Quality Chasm. That publication was widely discussed, and it gave us data and suggested pathways for improvement. They ignored the challenge to prepare for the inevitable. Any board or leadership team that ignored that signal failed in their fiduciary responsibilities to their enterprise and the patients it serves.
The authors are suggesting that most primary care providers are like the student who had two months to write a term paper, and waited to began the task until the night before the paper was due, and then complained to the teacher that they did not have enough time. I am certain that the PCF methodology could be improved, and I am just as certain that until there is no other choice, the majority of our providers and institutions will continue to resist doing the real multi year work that is necessary to make practice that is based in the principles of population health their practice methodology. They have demonstrated that they will cling to FFS payment, and the waste and excesses that drive revenue for them and costs for everyone else. We need to support them through their evolution for the sake of the patients they serve, but it is irresponsible to further delay the transformations in payment that seem to be necessary to produce desperately needed improvements.
The Triple Aim reiterated the broad objectives that we should adopt. Through all of this time when they should have been developing the necessary infrastructure for success, the majority of practices and institutions have continued to tolerate practices patterns that are inconsistent with our understanding of quality and safe practice. Our tolerance for waste has persisted. Our ability to look away from our complicity in healthcare inequities has persisted. Our primary concern for ourselves, and our support for the persistence of a pattern of Fee For Service payment that serves us well at the expense of those who pay for care has not really changed. We have had pilots. We have had a few brave organizations show us what is possible, but as a national system of care, our problems persist. We are not ready for change, and we don’t seem to want to change even as we hear how the sum total of our collective lack of concern is an increasing burden for those for whom we have a professional responsibility. My question to the authors is, “What is necessary to get us ready for what must eventually happen?” It is a truth that if something can’t go on forever, it won’t.
Dr. Drazen has done a great job. We owe him great thanks for heading a publication that both presents us the latest scientific accomplishments and advances in therapeutics while reminding us of our changing professional responsibilities and our ever increasing challenges.
When The Moon Comes Over The Mountain
The full moon for August was on the fifteenth, but the moon was huge and looked full on the night of the fourteenth. That night my wife and I joined friends for a relaxing evening cruise around Pleasant Lake. Pleasant Lake is the “other lake” in my little town. Our town has lots of water. Messer Pond is a lovely little body of water that is full of bass, and surrounded by comfortable homes. The northern end of “big” lake Sunapee, Herrick Cove, with its historic lighthouse, lies within our town’s boundaries. “My lake,” Little Lake Sunapee, lies just a half mile east of Herrick Cove. Pleasant Lake is a few acres larger than my lake. The two lakes are like bookends for the town. My lake is part of the watershed that empties into the Connecticut River. Pleasant Lake’s waters become part of the Merrimack River that flows through Concord, Manchester, Nashua, and Lowell. Both rivers played big roles in the history and development of the American Industrial revolution.
Pleasant Lake lives up to its name. Perhaps it should be called “really Pleasant Lake.” It is ringed by homes that have progressively evolved from “camps” and cabins toward multimillion dollar properties. The boat that we were “cruising” on was a one hundred year old electric boat. It was like riding around in your grandmother’s mahogany sideboard. It is a fine piece of furniture that happens to be a well restored antique from a more refined and genteel era. It’s quite a contrast to jet skis or a big party barge.
Pleasant Lake is a long oval that runs from north to south. Looking south the view is dominated by Mount Kearsage. There is a special place near the end of Morgan Hill Road where I like to go every few months to watch the view change with the seasons. From that choice spot, which is also near the trailhead of a great hike, I am looking down the entire length of the lake, right at Mount Kearsage. The view never disappoints me.
I was not expecting anything extra special when we got on board the boat and passed around horderves and libations as we began our slow sunset circumnavigation of the lake. It was a beautiful summer evening. We were about three quarters of the way around the lake at twilight. As luck would have it, or as our host had planned, we were looking down the length of the lake at Mount Kearsage just as the nearly full moon began to peak over the top of the mountain and begin its slow rise into the southern sky.
That was when our host said, “You know, Kate Smith’s theme song, ‘When the Moon Comes Over the Mountain,’ was inspired by this view.” As you can see in today’s header, the scene was spectacular. My friend was short on specifics, and a brief Internet search gives me no evidence that he is right except that the songwriter, Howard Johnson, the lyricist whom Kate Smith helped write the song, was born in Hartford, Connecticut. There have always been many summer visitors from Connecticut in our little town, so it may be true that Johnson, or perhaps Smith herself, had visited Pleasant Lake, and had seen the same view. I need to do some more research. The song was a number one hit for Kate Smith in 1931, and after that it was her theme song. Click here to hear something that your grandmother might have loved.
In the song, the moon conjures up pleasant memories of a relationship for someone who is now alone. Is the relationship over and all that is left are the memories of cherished moments that will never come again, or is the singer just using those pleasant memories to get through a temporary period of painful separation? We have all had that misery. I would prefer to think that it is just an interrupted relationship, and not one that has been lost forever. What do the words tell you? Does the song emerge from memories of the lyricist who long ago enjoyed a lovely evening on Pleasant Lake, just like the one we experienced? I would like to think so.
All by myself at twilight
Watching the day depart
And with the fading twilight
Happiness fills my heart
When the moon comes over the mountain
Every beam brings a dream dear, of you
Once again we stroll ‘neath the mountain
Through that rose-covered valley we knew
Each day is gray and dreary
But the night is bright and cheery
When the moon comes over the mountain
I’m alone with my memory
Of you
The view from Pleasant Lake of the moon coming over Mount Kearsage thrilled me, and reminded me of the joy that can occur with a planned or unexpected venture into a “thin place” where we can be restored by surprises from the beauty we encounter. In thin places we know that we are very close to a source of energy and that can sustain us and renew us as we struggle through the issues that feel like such a heavy load. I hope that you will be free to search for your own thin places and moments of inspiration this weekend.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
