JAMA Forum: Using Community Health Trusts to Address Social Determinants of Health

By Dave A. Chokshi, MD, MSc; Prabhjot Singh, MD, PhD; and Nicholas W. Stine, MD

tjf-logo-stack-feature-345x210As an increasing body of research demonstrates, there’s a link between “social determinants”—such as poverty, low educational attainment, unemployment, and housing instability—and the propensity for poor health. Many chronic diseases, such as diabetes, cancer, and heart disease, may be preventable or more readily manageable with community-based interventions addressing social determinants and fundamental risk factors such as diet and tobacco use.

But although health care systems deliver care for patients with chronic diseases, most medical centers are ill-equipped to tackle the social determinants of health themselves. This is a significant blind spot for the vision of a patient-centered, population health–driven system, and one that community health trusts could help address.

The idea of a financial trust to support community-based prevention isn’t novel. David Kindig, MD, PhD, and others have argued for “health outcomes trusts” to organize local public-private partnerships around common investment in better health. In Massachusetts, for example, the Prevention and Wellness Trust Fund makes grants to community organizations, municipal collaborations, and employers supporting workplace wellness. The fund was started with a $60 million allocation through the state’s health care cost-containment legislation, fueled by the notion that financing evidence-based programs that address costly preventable health conditions could save money.

Whatever the name, the concept of community health trusts is buoyed by the current policy milieu. For instance, nonprofit hospitals are required to provide benefits to the communities they serve, and the Affordable Care Act (ACA) established new standards relating to community health needs assessment, financial assistance policies, and hospital charges and billing. The ACA requirement, as enforced by the Internal Revenue Service (IRS), is expected to bring about greater accountability and transparency for US nonprofit hospitals’ tax exemption (estimated in 2002 to total $13 billion annually), although much depends on how the regulation is enforced.

Defining Community Benefit

Traditionally, community benefit has been interpreted expansively: it includes certain types of patient care, research, and education, as well as community health activities. In recent years, the IRS has designated categories of “community health improvement” (such as support to school-based health centers) and “community-building” (such as housing and local workforce development). One study based on 2009 IRS filings showed that 85% of community benefit expenditures went to charity care and other patient care services, and about 8% was allocated for community health improvement and community building. Some argue that the coverage expansion wrought by the ACA will shift community benefit expenditures away from patient care to community health, although the magnitude of that change is unclear.

The most salient health issues in any community—such as obesity and tobacco use—are likely to require collective action across health systems. However, at the local level, individual hospital systems attempting to address community benefit requirements may result in somewhat arbitrary and uncoordinated health improvement efforts. Instead of siloed efforts, a modest proportion of total funds dedicated by each hospital to community benefit could be put toward a common investment in proven, evidence-based public health priorities, such as those recommended by the Community Preventive Services Task Force.

Beyond Hospitals and Health Care

Some proponents of community health trusts suggest that hospital contributions could form the nucleus of a trust, providing a stable funding base that could be used to attract financing from health insurance plans, philanthropic monies, additional federal resources, or other community investment strategies being pioneered by the Federal Reserve. To invest funds with the goal of maximizing population health, there should be a mix of short-, medium-, and long-term securities that represent the spectrum from disease management to local development. For example, short-term investments, perhaps by health insurance plans, might focus on care coordination for patients who use a disproportionately high amount of health care services across multiple health care systems. Medium-term job creation programs for community health workers, meanwhile, could help a broader population achieve longer-term lifestyle changes in diet and physical activity.

Performance measures for trusts should be relevant to community organizations, local businesses, and potential investors. The assessment process should include analysis of both health improvement and effects on social determinants, such as job creation potential, improvement in education programs, and impact upon physical environment.

Creating a Framework

Creating a community health trust requires leadership from local and state elected officials. Mandatory contributions of some proportion of nonprofit hospitals’ community benefit dollars might be required to seed a trust. A more voluntary version, as described by Sara Rosenbaum, JD, and colleagues, could designate community health trusts as regulatory “safe harbors” for hospitals’ contributions. In either case, IRS rulemaking—for example, specifying that a minimum percentage of community benefit dollars must be dedicated to community health improvement or community building—would help facilitate greater public health investment by hospitals. Care should be taken to avoid unintended consequences for safety-net providers and health systems with robust and effective community programs already in place.

The concept of community health trusts is not without critics. Hospitals may be reluctant to cede authority over community benefit resources or subject themselves to what may be perceived as more burdensome regulation. Skeptics may question whether community health trusts will be able to attract broader investment, particularly from nonhealth and private sectors. And some argue that there’s insufficient evidence to warrant collective financing of community prevention strategies, characterizing these efforts as well intentioned but inconsequential.

These concerns are worth consideration, but as individual communities experiment with diverse ways to organize community health funding, they may prove soluble. Local, state, and federal policy change could help accelerate and expand incipient efforts. For example, New York has indicated an interest in shoring up state-level regulatory oversight of community benefit—including tying hospital community service plans to the State Prevention Agenda, its blueprint for reducing health disparities and improving population health.

There’s an emerging realization that our most intractable health problems, including obesity, mental illness, and tobacco use, require multifaceted solutions that cross health systems’ boundaries and require addressing the social determinants of health. Just as payment reform encoded in the ACA is beginning to transform health care delivery, community health trusts could help spur a transformation in population health.

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About the authors:

Dave A. Chokshi, MD, MSc

Dave A. Chokshi, MD, MSc

Dave A. Chokshi, MD, MSc, (@davechokshi) is Director of Population Health Improvement and Assistant Professor of Medicine and Population Health at NYU Langone Medical Center.  He practices primary care at NYU Internal Medicine Associates.  During 2012-2013, he served as a White House Fellow at the US Department of Veterans Affairs.

 

 

 

 

 

Prabhjot Singh, MD, PhDPrabhjot Singh, MD, PhD, (@prabhjotsinghNY) is an Assistant Professor of International and Public Affairs at Columbia University, Director of Systems Design at the Earth Institute, and a part-time resident in Internal Medicine at Mount Sinai Health System. Prabhjot is a Robert Wood Johnson Foundation Young Leader, lead advisor to City Health Works and a member of Mayor Bill DeBlasio’s Child Well-Being advisory group.

 

 

 

Nicholas W. Stine, MDNicholas W. Stine, MD, is Chief Medical Officer of the HHC Accountable Care Organization at the New York City Health & Hospitals Corporation, the country’s largest municipal health system. He is also an Attending Physician at Bellevue Hospital and an Assistant Professor at the NYU School of Medicine in the Departments of Population Health and Medicine.

 

 

 

 

About The JAMA Forum:  JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

 

JAMA Forum: Hiding in Plain Sight: Medical Boards and the Public’s Health

By Jesse X. Yang, MD, and Joshua M. Sharfstein, MD

tjf-logo-stack-feature-345x210The last few years have not been easy for a number of state medical boards. In December 2010, the New Haven Independent faulted the Connecticut Medical Board for permitting physicians to practice who had lost their licenses elsewhere. That same month, the St. Louis Post-Dispatch criticized the Missouri Medical Board for sending frequent, confidential “letters of concern” that “go in a physician’s file but carry no repercussions” in lieu of more serious disciplinary actions.

 In February 2012, the Minneapolis Star Tribune reported that since 2000, the Minnesota Board of Medical Practice failed to discipline at least 46 Minnesota physicians“after authorities in other states took action against their licenses for such missteps as committing crimes, patient care errors or having sexual or inappropriate relationships with patients.” The story also noted that “more than half of the 74 physicians who lost their privileges to work in Minnesota hospitals and clinics over the past decade were never disciplined by the Minnesota board.”

 These reports led Senators Chuck Grassley (R, Iowa) and Orrin Hatch (R, Utah) and former Senator Max Baucus (D, Montana) to request that the Department of Health and Human Services Office of Inspector General conduct an evaluation of “state medical board performance, including the timeliness and consistency of decision making.” Subsequently, challenges facing medical boards were identified in other states, including Massachusetts, California, and Maryland.

Physician licensure is a critical link in the health quality chain. One dangerous physician can injure scores of patients directly through poor care, or indirectly, through careless prescribing that leads to substantial drug diversion. Yet despite the front-page stories, there is far less professional or academic attention paid to medical boards than there is of more complicated questions of medical errors.

Maryland provides a case study in challenges facing medical boards—and in how engagement of academic medicine and the broader physician community can lead to progress.

In Maryland, a 2011 legislative audit of the Maryland Board of Physicians found that the number of cases not resolved within 18 months was more than 150 per year. For cases in which the state board recommended charges, the average number of days between a case being opened and final board action was 1013 days.Other deficiencies included a lack of transparency, inconsistent record keeping, and unclear sanctioning guidelines.

The report sparked negative media stories and a strong response from policymakers. Soon afterwards, the executive director of the board of physicians retired. Legislators passed a new provision allowing the governor to appoint the board chair instead of having the chair elected from within the board. In addition, legislators deferred the planned reauthorization of the board for a year to provide an opportunity for a more comprehensive external review.

Released in July 2012, this review was led by University of Maryland at Baltimore President Jay Perman, MD, and involved a team of experts from the University of Maryland Francis King Carey School of Law and the Kentucky Board of Medical Licensure. Key recommendations included:

Splitting the board into 2 panels. In this model, both panels investigate separate cases. Then, to prevent biased investigators from being involved in the adjudication of a case, the results of the investigation are passed to the other board where final decisions are made. This model results in twice as many case resolutions and a fairer process.

Better training for board members. One goal of formal training would be to handle complex cases more expeditiously.

Improved transparency. The report recommends that more information be made available to the public, including “the annual report, open meeting agendas, minutes . . . the website should also include more informative guidance about the complaint process, the different types of discipline, the charging process, and time limits on what can be investigated.”

 Adoption of clear guidelines for case resolution. Guidelines will “ensure transparency for licensees and the public and accountability for the Board’s actions.”

To its credit, Maryland’s largest physician organization, MedChi, largely supported these recommendations. Local medical leaders recognized that a better organized board would produce more fair and timely outcomes for physicians.

With the support of physician groups and the academic expert team, legislators adopted the expert recommendations during the 2013 legislative session. Changes at the board are under way. Sanctioning guidelines are now in place, the board has 2 panels, and board training is part of routine practice. The website is improving, the backlog is eliminated, and monthly performance data on licenses, complaints, and disciplinary actions are now made available through StateStat. Maryland’s medical board is even receiving some favorable media coverage.

There is much more work yet to be done, in Maryland and elsewhere. Beyond fixing issues with physician discipline, medical boards can play an important role in preventing problems such as inappropriate prescribing of pain medications. Well-functioning boards play a critical role in protecting and promoting public health.

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About the authors:

Jesse Yang, MD

Jesse Yang, MD

 

Jesse X. Yang, MD, is a resident in internal medicine at Columbia University Medical Center.

 

 

 

 

Joshua M. Sharfstein, MD

Joshua M. Sharfstein, MD

 

Joshua M. Sharfstein, MD, (@drJoshS) is Secretary of the Maryland Department of Health and Mental Hygiene. He has previously served as the Principal Deputy Commissioner of the US Food and Drug Administration and as Commissioner of Health for Baltimore. A pediatrician, he lives with his family in Baltimore.

 

 

 

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

 

Growing Concern Over Procedure for Hysterectomies and Fibroid Removal

Image: JAMA, ©AMA

Posted today on JAMA:

Two articles have been posted that examine a procedure for hysterectomies and fibroid removal known as electric uterine morcellation, which involves the use of an instrument for fragmenting fibroids or uterine tissue into smaller pieces for easier removal through a laparoscopic port. There is growing concern that this procedure has important risks, including:

  • Inadvertent dispersion and ectopic implantation of small tissue fragments during the procedure, causing symptoms and illness requiring intervention;
  • Dissemination of fragments of undetected and confined malignant tumors throughout the abdominal cavity, upstaging the cancer;
  • Injuries or death caused by damage from the blade of the instrument to organs.

A Viewpoint (available at this link) and JAMA Medical News & Perspectives article (available at this link) discuss the risks, potential alternatives, informed consent process and recommendations for addressing this issue.

JAMA Forum: Fixing the (Un)Sustainable Growth Rate Formula: Shifting From Volume to Value

By Darshak Sanghavi, MD; John O’Shea, MD; and Mark McClellan, MD, PhD

Darshak Sandhavi, MD. (Image:  Robert Carlin Photography)

Darshak Sandhavi, MD. (Image: Robert Carlin Photography)

Although much media coverage around health care reform recently focused on the Obamacare rollout, another profound but far less publicized change could be coming. Congress is closer than ever to correcting the sustainable growth rate (SGR) formula, an ill-conceived policy that annually threatens physicians with indiscriminate cuts in fees to control Medicare spending.

In a previous post, we explained the origins of the SGR in the 1997 Balanced Budget Act and reasons it failed to work as planned. Now, there are 2 congressional proposals intended to fix the problem.

If passed, such legislation would make the biggest changes to Medicare physician payments in more than a generation. The proposals would repeal the SGR-mandated cuts and essentially eliminate roughly $140 billion in planned physician fee rollbacks. In return, Medicare would largely change its way of paying physicians. Most importantly, Medicare would move away rapidly from traditional fee-for-service payments and hold physicians more accountable for quality. Such an approach could help physicians change practices to deliver better and less expensive care—reshaping health care delivery across the nation. However, major areas of uncertainty remain.

The Big Picture

Two congressional proposals, one jointly from the House Ways and Means and Senate Finance Committees and the other from the House Energy and Commerce Committee, would cancel the 24.4% SGR-imposed cut. The first completely freezes existing Medicare fee-for-service rates; the second offers only 0.5% annual increases to these rates for the next decade. Payment rates will continue to decrease in real dollars because they won’t keep up with overall inflation. Thus, as the years go by, fee-for-service models will become progressively less viable.

Between the proposals, there are 2 major strategies for physicians to handle this, both of which try to push them to provide greater value and less volume. First, both congressional proposals would create a new rewards program comparable with those in other service-oriented professions: physicians would get paid a base amount but have the chance to earn bonuses based on the quality and overall efficiency of the services. In many ways, this isn’t a big change for hospitals and physicians. The Medicare program, through the Centers for Medicare & Medicaid Services, created various “pay-for-reporting” rewards for hospitals (the Hospital Quality Initiative since 2003), physicians (the Physician Quality Reporting System since 2006), and other providers for reporting certain metrics, such as how many patients are counseled for smoking cessation.

The rewards program consolidates the patchwork affecting physicians into a unified program, with different weights for quality measuring and improvement, resource use, and meaningful use of electronic health records. It will replace the existing programs, such as the Physician Quality Reporting System, Electronic Health Record Meaningful Use, and the Value-Based Modifier. In the joint proposal from the House Ways and Means and Senate Finance Committees, the bonus program is zero-sum (high-performing physicians get a bonus and low performers can get docked 4% beginning in 2017, then up to 10% by 2020), but in the House Energy and Commerce Committee’s proposal, all physicians could earn up to a 1% bonus. To support primary care, Medicare also will pay for care-coordination services (like phone calls and other patient outreach) and encourage practices to achieve certification as medical homes.

Still, this first strategy does little that is truly novel and indeed could be viewed by many physicians as more micromanagement of how they practice. The second, more innovative way for physicians to earn more is switching to alternative payment models, which is pushed strongly by the joint House Ways and Mean and Senate Finance proposal. Such models could include payment bundles (for example, fixed pricing for a heart surgery, with a several-month “warranty” against complications) or shared savings programs (whereby a large health network assumes all aspects of a patient’s care and gets a bonus if budget targets are hit). All of these payment models discourage overuse because physicians don’t get paid more for simply doing more. Further, because they give physicians more flexibility in how they use resources for individual patients, bundled payments could support better cooperation between various care settings (see Figure) as well as telemedicine, web-based support services, care teams, and other services that are paid poorly—if at all—under Medicare fee-for-service.

Care for common problems is highly fragmented across various providers, creating opportunities for better coordination. From a RAND report to US Department of Health and Human Services (http://aspe.hhs.gov/health/reports/09/mcperform/report.pdf). (AMI indicates acute myocardial infarction; COPD; chronic obstructive pulmonary disease; DME; durable medical equipment; IRF, inpatient rehabilitation facilities; SNF, skilled nursing facility.) Source: Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.

Care for common problems is highly fragmented across various providers, creating opportunities for better coordination. From a RAND report to US Department of Health and Human Services (http://aspe.hhs.gov/health/reports/09/mcperform/report.pdf). (AMI indicates acute myocardial infarction; COPD; chronic obstructive pulmonary disease; DME; durable medical equipment; IRF, inpatient rehabilitation facilities; SNF, skilled nursing facility.) Source: Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.

The proposed shift into alternative payment models would happen fairly quickly. The House Ways and Means draft, for example, offers full 5% bonuses only if physicians switch one-quarter of all their Medicare billing to such payments within 3 years and then up to three-quarters of all billing by 2021. (The precise details of the most recent draft are somewhat more complicated and can be seen here.)

Will the Proposed Changes Help?

The shift into alternative payment models makes intuitive sense—emphasizing value over volume—and many studies have found improvements in quality. But no one really knows if they work to reduce costs on a country-wide scale. For example, while some individual reforms have led to savings in the private sector, the Congressional Budget Office in 2012 found that Medicare’s small value-based payment pilots generally failed to save money within a few years, with the exception of a cardiac surgery bundled payment.

Even bundled payments have many complexities. As a RAND report commissioned by the Department of Health and Human Services showed, it’s hard to know who should be in charge of a patient’s care, how to adjust payments for a patient’s preexisting conditions (called risk-adjustment), and how to measure quality. Currently, the Centers for Medicare & Medicaid Innovation has started to implement a new round of bundled-payment pilots, but results are not yet available.

Population-wide efforts to both improve quality and control costs also have limited evidence. The ambitious Pioneer accountable care organization pilot, in which 669 000 Medicare patients entered a type of shared-saving program, showed significant quality improvements but only limited overall cost savings in its first year. Moreover, all of these reforms require significant investments of effort and money by physicians to redesign practices.

In addition, if fee-for-service payments promote too much medical care, alternative payment models can have the opposite problem: they incentivize physicians to cut corners. For example, if every extra referral to a specialist or imaging test could ultimately come back to hurt a physician’s bottom line, he or she may not go the extra mile. Part of the solution is to measure quality and to help patients identify high-quality practices, to ensure that changes in practice don’t mean worse care. However, existing quality measures have been strongly criticized for not capturing what really matters to patients. Another part is to watch carefully for other indications that the changes in payment really do promote the professionalism that physicians often find missing in fee-for-service payments today. In this regard, it is encouraging that many providers in alternative payment models report higher satisfaction in practice and more confidence that patients are getting the care they need.

The Next Steps

Although challenges remain, an accelerating shift away from fee-for-service Medicare payments is inevitable. Prior major changes in Medicare payments, such as the switch to diagnosis-related group bundles for inpatient care, the transition to a relative value unit–based physician fee schedule, and the creation of the Medicare Part D prescription drug program, all had to be implemented with incomplete evidence. No large pilot programs were practical, and the reforms were modified along the way with experience. It is highly likely that the permanent SGR fix will proceed similarly, although it’s likely a brief temporary patch may precede a permanent fix.

What is clear is that these reforms will create a lot more opportunity for clinicians. For years, the SGR has sucked energy away from reform efforts, and tightening fee-for-service payments have made it difficult to make ends meet in practice, let alone lead the implementation of real reforms in care. If the payment system is permanently fixed, clinicians will face some new challenges but could then concentrate on real innovations.

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About the authors:

SanghaviDarshakDarshak Sanghavi, MD, is the Richard Merkin Fellow and Managing Director of the Engelberg Center for Health Care Reform at the Brookings Institution. He is also associate professor of pediatrics and recent chief of pediatric cardiology at the University of Massachusetts Medical School. His research interests range from tuberculosis in Latin America to the molecular biology of cell death. He writes regularly on health topics for Slate, the New York Times, Parents, and the Boston Globe and appears often on NBC’s Today. He speaks widely on health topics, advises federal and state health departments, and is a former visiting media fellow of the Kaiser Family Foundation. He tweets at @darshaksanghavi.

OSheaJohnJohn O’Shea, MD, MPA, MS, is currently a Visiting Scholar in the Engelberg Center for Health Care Reform, Economic Studies, at the Brookings Institution in Washington, DC. Prior to that, he was Senior Health Policy Advisor to the Energy and Commerce Committee, US House of Representatives, where he worked on a number of health care issues, including Medicare physician payment reform. A practicing general surgeon for more than 25 years, he completed his surgical training in New York City and has a Masters in Public Administration from the Harvard Kennedy School of Government and a Masters in the History and Sociology of Science from the University of Pennsylvania.

McClellanMarkMark McClellan, MD, PhD, a physician and economist by training, is a senior fellow and director of the Initiative on Value and Innovation in Health Care at the Brookings Institution, where his work focuses on promoting quality and value in patient-centered health care. His record in public service includes serving as a senior director for health care policy at the White House, administrator of the Centers for Medicare & Medicaid Services, and commissioner of the US Food and Drug Administration (FDA), where he developed and implemented the Medicare prescription drug benefit, the FDA’s Critical Path Initiative, and public-private initiatives to develop better information on the quality and cost of care. He is a member of the Institute of Medicine.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

M. Therese Southgate, JAMA Physician-Editor Who Connected Art, Medicine, and Life, Dies at 85

M. Therese Southgate, MD (Image: Norris McNamara)

M. Therese Southgate, MD (Image: Norris McNamara)

Marie Therese Southgate, MD, a senior editor at JAMA for nearly 5 decades who was widely admired for her essays about the fine art on the covers of the journal, died at her home in Chicago on November 22 after a short illness. She was 85.

Dr Southgate was born in Detroit, Michigan, on April 27, 1928; the family moved to Chicago in the 1930s. She attended the College (now University) of St Francis in Joliet, Illinois, graduating with a degree in chemistry in 1948. She earned her MD degree from Marquette University School of Medicine (now the Medical College of Wisconsin) in 1960, one of only 3 women in her graduating class. She completed her rotating internship at St Mary’s Hospital in San Francisco in 1961.

Dr Southgate accepted the position of senior editor at JAMA, headquartered in Chicago, in 1962, the first woman to hold that position. Two years later, the editors of JAMA made the bold and unprecedented decision to feature a work of fine art on the journal’s cover. In 1974, Dr Southgate was promoted to deputy editor, the second-highest position at the journal. That same year, she began to select all of the works of fine art as well as to write an eloquent accompanying essay. “The Cover” became a hugely popular and much-admired weekly feature until the journal was redesigned in 2013. Although she had no formal art education, she had a keen appreciation of the fine arts and crafted “highly insightful, lyrical essays,” according to the US National Library of Medicine (NLM).

Dr Southgate semiretired from JAMA in 2008 and spent much of her time at her Marina City writing studio in Chicago, polishing her memoirs and finishing a murder mystery set in a medieval English town.

Survivors include her brother Clair (Marie) Southgate of San Diego, California, as well as 2 nieces and 5 grandnieces and grandnephews.

Many readers—physicians and nonphysicians alike—often asked why a preeminent journal in clinical and scientific medicine would reproduce a renowned work of fine art on its front cover each week. The answer was clear: “The visual arts have everything to do with medicine,” Dr Southgate said. “There exists between the two an affinity that has been recognized for millennia. Art is a uniquely human quality. It signifies the unquenchable human quality of hope. Long and loving attention is at the heart of painting. It is also at the heart of medicine, at the heart of caring for the patient.”

“Terry Southgate became the most beloved of all JAMA editors as a supremely sensitive humanist who selected the world’s greatest art with which to educate countless physicians about the intense humanity of their calling,” said former JAMA editor in chief George D. Lundberg, MD. In a 2007 Medscape interview, Dr Southgate stated: “What has medicine to do with art? I answer: Everything.”

JAMA Editor in Chief Howard Bauchner, MD, stated, “One of the great strengths of JAMA for decades has been its inclusion of the humanities—and no one epitomized that effort more than Terry Southgate, who orchestrated the wonderful art in JAMA for more than 40 years.”

In 1997, 2001, and 2010, Dr Southgate published 3 successive collections of her essays and the accompanying images that had appeared in JAMA over the years—The Art of JAMA—to critical acclaim. She was the 2008 recipient of the Nicholas E. Davies Memorial Scholar Award for Scholarly Activities in the Humanities and History of Medicine from the American College of Physicians. She was chosen by the NLM as a Local Legend, “honoring the remarkable, deeply caring women doctors who are transforming medical practice and improving health care for all across America.”

Catherine D. DeAngelis, MD, MPH, editor emerita, JAMA, stated: “The world has lost a warm, soft-spoken, unpretentious icon who taught so many physicians and others the value of art in life and who now exemplifies her motto, Ars longa, vita brevis.”

~ By Roxanne K. Young

Additional information about Dr Southgate and her work is available here.

Is the Time Right for a Permanent Fix to Medicare’s Formula for Physician Payment?

By Darshak Sanghavi, MD; John O’Shea, MD; and Mark McClellan, MD, PhD

Darshak Sandhavi, MD. (Image:  Robert Carlin Photography)

Darshak Sandhavi, MD. (Image: Robert Carlin Photography)

The annual panic affecting the nation’s physicians is in full swing. “Medicare docs face 24% pay cut… again,” reported CNN Money this month.

But after almost a decade of kicking the can down the road, Congress is closer than ever to solving one of Medicare’s most vexing problems. Recently, 3 congressional committees with jurisdiction over Medicare physician payment made progress towards replacing the Medicare Sustainable Growth Rate (SGR), a mechanism intended to help control Medicare spending. On July 31, 2013, the House Energy and Commerce Committee unanimously reported favorably on HR 2810, a measure to repeal the SGR, and on October 30, 2013, the Senate Finance and House Ways and Means committees released a joint proposal also to repeal the SGR formula and replace it with payment reform. Impressively, there appears to be bipartisan agreement to link SGR repeal with a strategy to move away from traditional fee-for-service payments to physicians.

This recent congressional activity may be the best opportunity to fix the SGR permanently, and the physician community can and should take a leadership role, especially because any SGR fix would demand strong clinician innovation to identify payment and delivery reforms.

In this post, we describe the origins of the SGR and reasons for renewed optimism for a permanent fix.

What Is the SGR?

At its inception in the 1960s, Medicare Part B simply paid what physicians charged, in a practice called the customary, prevailing, and reasonable (CPR) system, which quickly resulted in unbridled spending. Later attempts to curb spending failed, including linking price increases to medical inflation in the 1970s and creating the relative value unit (RVU) system to standardize payments in 1989.

Enter the SGR, when Congress passed the Balanced Budget Act of 1997. It seemed like a good idea at the time. Here’s how it works: physician services, like reading x-rays, performing office visits, or doing operations, earn a predetermined number of RVUs based on the time, energy, and effort of the physician. Medicare multiplies the RVUs by a conversion factor to get a price in dollars and pays the physician. This system considers only the cost side and ignores the quality side of the value equation, paying the same for good and bad outcomes.

The key is that the SGR limits spending on Medicare Part B by setting a spending target, which is linked to the nation’s gross domestic product (GDP). Actual spending on physician services (the total number of RVUs times the conversion factor) is then compared with this global target. To control future spending, Medicare adjusts the conversion factor up or down for the next year so all physicians take a proportional increase or reduction to their fees.

Between 1998 and 2001, strong economic growth led to high targets—and higher conversion factors. Physicians made out well. But when the economy stalled in 2002, expenditures exceeded the target, and physician fees across the board were cut 4.8%. When additional SGR-mandated cuts were set for 2003, Congress worried more cuts would drive physicians out of Medicare and postponed them. This was the first of many “patches.”

This has happened year after year. That is, the money for each short-term fix was borrowed from future physician payment and not recorded as an ongoing federal expenditure. By repeatedly overriding cuts over a decade, Congress compounded the gap between actual Medicare spending and where the SGR formula says it should be—to the cumulative total of hundreds of billions of dollars by early 2012.

To address the gap, the SGR mandates a huge 24.4% cut in the conversion factor in January. This is unrealistic, would disrupt care for Medicare beneficiaries, and is causing major anxiety among physicians. But past efforts to repeal the SGR for good, either as part of the 2010 Affordable Care Act or as separate legislation, have failed because repeal would count as a big deficit increase.

Why the SGR Failed

Prices of Medicare services have never explained cost growth, as the lower line in the graph shows; physicians’ fees almost flatlined after 2000, not even keeping up with inflation (shown by the middle line). Spending per patient, shown by the top line, skyrocketed. The explanation is clear: Medicare costs are driven by physicians simply doing more and more. Medicare growth is all about volume. Yet the SGR addresses only price, which perversely makes incentives to expand volume, which triggers additional SGR-mandated cuts, which pressures physicians to further expand volume.

11 18 13 graph

Data from Medicare Payment Advisory Committee, 2011. (MEI, or Medicare Economic Index, is a measure of inflation.)

 The SGR also fails to create any incentives to practice efficiently. Suppose a physician is more judicious about her services. She gets paid less that year, is treated no differently than others, and faces later fee cuts. She gets hit twice.

Last year, economists showed that California, Tennessee, and Massachusetts physicians kept Medicare growth below targets from 2003 to 2009, while Florida, New York, and Texas physicians exceeded targets by almost 50% to 80%. In other words, doctors in certain areas performed many more services per patient, without measurable improvements in quality. Even within states with low overall physician spending growth, the Institute of Medicine showed big variation. The same was true in subspecialties. Psychiatrists, general surgeons, and anesthesiologists more than kept their costs under SGR targets, while cardiologists, radiologists, and radiation oncologists far outstripped them. Despite this variation, all physicians get cut the same by the SGR formula.

Embedded in the Balanced Budget Act, therefore, was a perverse set of incentives leading to higher Medicare costs. There was no reward for collaboration, no incentive to use resources better, and no incentive to provide better care.

An Opportunity

Last year, due to unexpectedly lower increases in Medicare growth, the Congressional Budget Office reduced the expected cost of a permanent SGR repeal to $140 billion over 10 years—a discount of more than $100 billion compared with prior estimates. It’s likely that this amount might be recouped from the other parts of Medicare, such as postacute care, hospital charges, and prescription drug costs. The continuing focus on an alternative to “sequestration” to address federal budget deficits may also create a legislative opportunity to address this issue as part of a larger fiscal package.

Although finding the precise ways to pay for the fix is not clear, there are potential areas of bipartisan agreement. For example, work from MedPAC, our center at the Brookings Institution, and others has identified areas of potential savings to offset a permanent SGR repeal. In principle, the Obama Administration proposed potential Medicare savings to offset the cost of the SGR repeal, as have congressional Republicans.

Finally, there also appears to be growing recognition on the part of the physician community of the need to reconsider the role of traditional fee for service and the increasing importance of value-based purchasing and alternative payment models. This recognition is important, because physician leadership will be critical to moving the bipartisan SGR reform proposals forward.

This post is part of the Richard Merkin Initiative on Payment Reform and Clinician Leadership and the Bending the Curve Project at the Engelberg Center for Health Care Reform, The Brookings Institution, Washington, DC.

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About the authors:

SanghaviDarshakDarshak Sanghavi, MD, is the Richard Merkin Fellow and Managing Director of the Engelberg Center for Health Care Reform at the Brookings Institution. He is also associate professor of pediatrics and recent chief of pediatric cardiology at the University of Massachusetts Medical School. His research interests range from tuberculosis in Latin America to the molecular biology of cell death. He writes regularly on health topics for Slate, the New York Times, Parents, and the Boston Globe and appears often on NBC’s Today. He speaks widely on health topics, advises federal and state health departments, and is a former visiting media fellow of the Kaiser Family Foundation. He tweets at @darshaksanghavi.

OSheaJohnJohn O’Shea, MD, MPA, MS, is currently a Visiting Scholar in the Engelberg Center for Health Care Reform, Economic Studies, at the Brookings Institution in Washington, DC. Prior to that, he was Senior Health Policy Advisor to the Energy and Commerce Committee, US House of Representatives, where he worked on a number of health care issues, including Medicare physician payment reform. A practicing general surgeon for more than 25 years, he completed his surgical training in New York City and has a Masters in Public Administration from the Harvard Kennedy School of Government and a Masters in the History and Sociology of Science from the University of Pennsylvania.

McClellanMarkMark McClellan, MD, PhD, a physician and economist by training, is a senior fellow and director of the Initiative on Value and Innovation in Health Care at the Brookings Institution, where his work focuses on promoting quality and value in patient-centered health care. His record in public service includes serving as a senior director for health care policy at the White House, administrator of the Centers for Medicare & Medicaid Services, and commissioner of the US Food and Drug Administration (FDA), where he developed and implemented the Medicare prescription drug benefit, the FDA’s Critical Path Initiative, and public-private initiatives to develop better information on the quality and cost of care. He is a member of the Institute of Medicine.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

Author Insights: Problem-Solving Intervention May Reduce Stress for Mothers of a Child With Autism

 Emily Feinberg, CPNP, ScD, of Boston University School of Public Health, and her colleagues found that an intervention that helped mothers boost their problem-solving skills helped reduce parental stress following a child’s autism diagnosis.  Image: Boston University School of Public Health


Emily Feinberg, CPNP, ScD, of Boston University School of Public Health, and her colleagues found that an intervention that helped mothers boost their problem-solving skills helped reduce parental stress following a child’s autism diagnosis. Image: Boston University School of Public Health

Mothers of a child with autism may face stress and depression as they cope with the challenges of getting appropriate care for their offspring. But offering training in problem-solving skills may help such mothers navigate these challenges with reduced stress, suggest results from a small study published today in JAMA Pediatrics.

Many mothers with a child who has been diagnosed with an autism spectrum disorder report levels of stress that may impair their health, relationships, sense of wellbeing, or parenting (40%) or symptoms of depression (33%-59%), according to the authors. They may face challenges in navigating the health system to secure appropriate and timely care for their child and are often called on to act as “adjunct therapists,” providing intensive one-on-one therapy for their child, according to the authors. Yet few interventions for autism focus on the needs of parents.

The authors probed whether an intervention that has been shown to help reduce stress in mothers with an infant born prematurely or with congenital defects requiring early intervention may also help mothers who have a child with an autism spectrum disorder. The researchers recruited mothers at 1 autism clinic and 6 community-based early intervention centers. Eighty-three percent of those approached (122) agreed to participate and were randomized to receive a half dozen 30-minute problem-solving education sessions by staff at these facilities or usual care, which may include a family or individual service plan but no parent-specific interventions. More three-quarters of the mothers in the intervention group completed the full course.

At follow-up 3 months after completion, mothers in the intervention group were less likely to report parental stress affecting their health or interactions (3.8% vs 29.3%). There was not a significant difference in the risk of having depressive symptoms between the 2 groups, but there was a significant reduction in average score for depressive symptoms (Quick Inventory of Depressive Symptomatology score) among the mothers in the intervention group compared with the usual-care group.

Emily Feinberg, CPNP, ScD, associate professor at Boston University School of Public Health, discussed the findings with news@JAMA.

news@JAMA: What were you trying to address with the intervention?

Dr Feinberg: Let’s start with what we weren’t trying to address. We were not addressing the treatment of the child. That’s a wonderful goal, but there is a gap in support for parents. We thought our intervention might fill a need in supporting parents and giving them the skills they need to deal with a challenging service system and the changes in the parent’s life associated having a child with this diagnosis.

news@JAMA: What was the intervention?

Dr Feinberg: It was a problem-solving education program to help parents feel more power and control in their lives and give them skills to solve problems they may encounter in everyday life. The parent sits down with the interventionist to think about the problems they are facing, to strategize on how to deal with them, to weigh the pros and cons of each approach, and to choose a plan of action. It also involved planning positive activities for parents to do something for themselves.

news@JAMA: What do you think are the main take-away messages from the results?

Dr Feinberg: Parents engaged in the intervention and it can be delivered easily by staff in existing programs. When we first started, we didn’t think parents would be interested because they are too busy. But parents who participated were very persistent. It speaks to the feasibility and acceptability of the intervention to families. Parents seem to be interested in services that address the needs they have, in addition to the needs of their child.

The intervention seemed to be effective at helping parents deal with the stresses in their daily lives. Our hope would be that these services would be available in the settings where the child is already receiving services, such as early intervention clinics.

news@JAMA: Is this intervention available now?

Dr Feinberg: It is not available now. We are conducting clinical trials to show whether the intervention is effective. We plan to try to secure funding to expand the trial to multiple sites to confirm and replicate the findings.

We were encouraged that problem-solving education doesn’t require someone with extensive mental health training to work with parents. If it works [in further studies], it could be widely disseminated and integrated into a variety of settings.

news@JAMA: Do you have any suggestions for parents who are interested in receiving these types of support services?

Dr Feinberg: They are not alone in feeling the kinds of stressors they are experiencing. I suggest they speak with their clinicians or their child’s clinicians to find supports that exist in their area. Clinicians should speak with parents who have a child with autism about the support they need and connect them with services in their area.