Michael A. Fishman, MD, MBA

The Sequence for the week of 4/29-5/5 talks about a previously unreported repeat expansion founder mutation causing Spinocerebellar ataxia type 4 (SCA4). SCA4 is a rare subtype of SCA characterized by ataxia and nerve pain and numbness that has never before been associated with repeat expansions. This could mean an entirely new way to utilize testing and treatments for SCA4! #genetics, #publicpolicy, #geneticcounseling, #precisionmedicine, #translationalmedicine, #genetictesting, #geneticresearch, #genomesequencing, #spinocerebellarataxia, #SCA, #SCA4

4

Thoughts from the Wild Health Summits Burning GP Summit: Should there be a salaried GP model to provide for patients that aren't fit for fee-for-service? Repeatedly throughout the day, there are examples of the current funding models failing complex patients that don't fit into the fee-for-service paradigm. This has been a problem for years, and despite advocacy from lots of different groups, patients with complex health needs continue to be failed by the fee-for-service model. We are in a situation where GPs are subsidizing these patients' care with their own income, and their own families suffer a drop in financial wealth as a direct result of GP altruism. Are we now at the point where we should consider a truly publicly funded, universally accessible, primary care GP-led system? The single employer model could be a soft landing for this idea. In reality small GP clinics are continuing to fail in low socioeconomic areas due to the inability of patients to pay a gap alongside poor Medicare rebates, I'd argue the government should be stepping in to nationalize these clinics when requested by practice owners and GPs. I know there are a lot of younger GPs who would be quite happy to spend part of the week in a salaried role doing altruistic work and spending another part of the week in a different role l/clinic doing private fee-for-service work. Is it time for a discussion about what this looks like? We’ve already seen councils and other funding bodies stepping to rescue small rural clinics. Maybe it’s time for a national approach. Jeremy Knibbs Michelle O'Brien The Royal Australian College of General Practitioners (RACGP) Australian Medical Association

18

5 Comments

Value Based Care (VBC) has a left brain problem. When you strip away the flowery adjectives in VBC definitions, you are left with its real intention, which is that value-based health care is a framework for restructuring health care systems with the overarching goal of value for patients, with value defined as health outcomes per unit of costs. Who defines value? VBC protagonists, using the imagery of Dr. Ian McGilchrist, cede this responsibility to the Emissary (the left brain). VBC antagonists, on the other hand, prefer the Master (right brain) maintain authority over this definition. Who is right? Who is wrong? The answer = both. The reality is in order to achieve maximum balance between costs and outcomes, both the Master and the Emissary must play central roles in defining value and creating proper balance between costs and outcomes. Tom Morgan brilliantly captures the essence of all of this in this short video discussing the work of Dr. McGilchrist and the importance of ensuring the Master remain in full control, less we burn down the village to save it. Scroll to 24:35 in the video to watch Tom's 5-minute talk. https://lnkd.in/gSDcqPdz Enjoy.

7

2 Comments

Endpoints News summarizes some of the findings by the #FTC report om #PBMs that came out this morning. While disappointed that no anti-trust action is being taken - the FTC report is described as an "interim" product. It lists many of the PBM actions that are raising prices for the system and patients alike, and driving independent pharmacies out of business, all for the sake of profit. It is stated that more scrutiny and investigations are warranted. As expected the FTC is not getting much information from the big 3's rebates aggregators (GPOs) 2 of which are off shore. This not surprising as it appears these may have been created in response to much of the legislation that is demanding transparency. Let's hope that anti-trust actions will be taken by the FTC in the future.

35

7 Comments

Despite diligent efforts, CDI programs, in my view, not infrequently generate clinical validation denials while performing “appropriate review” activities: · 1) The most frequent example is the “late” query such that a DX is established in the D/C Summary only. This is particularly an issue when DX is a high-severity medical condition like sepsis, acute-on-chronic respiratory failure, acute-on-chronic CHF, severe protein-calorie malnutrition, etc. 2) Failing to ensure that a clinically cogent clinical story is reflected in the medical record (i.e. a complete and accurate interdisciplinary clinical communication tool) 3) Issuing high numbers of queries such that the attending physician becomes inured to the query process and less likely to respond in a meaningful fashion 4) Failing to truly partner with the attending physician as a documentation partner (i.e. missing the opportunity to “shepherd” the clinical documentation process via brief mentoring in-person interactions). Solution- Restructure, rebrand, refocus, reinvent, and redesign CDI processes to facilitate opportunities to partner with attending physicians and drive better communication of patient care through physician documentation training that focuses upon strong fundamentals and principles of documentation. Educate physicians vs "Queryrating" & annoying physicians with repetitive rapid-fire queries. Stop relying on KPIs that fail to correlate with documentation improvement. Contact me for a list of valid reliable KPIs for CDI performance measurement. I am honored to work with Open Source MD, Inc. hospitalists and David Rosen, providing group & one-on-one physician documentation training in a meaningful way with the achievement of sustainable improvement & denials reduction.

40

25 Comments

The role of AI and new technology to aid cardiology “As cardiology starts to face staffing shortages and continued decreases in CMS payments, Biga believes technology advances need to be leveraged in cardiology to help improve outcomes, make workflows more efficient to do more with less, and to help cut costs.” “Many of the solutions that can help were displayed on the expo floor, including telehealth and real-time remote monitoring systems. "I think this area will experience an explosion in use," Biga said. Another major area that will likely see an explosion of use is artificial intelligence (AI). She said AI will begin playing a rapidly growing role in cardiology in the coming years to augment cardiologists and other clinical staff. And not just on the front lines of patient care, but also in the back offices where AI will play a growing role in IT systems, smoothing workflow, analytics, automated quality metrics capture and many other areas. "We must use AI to reduce administrative burdens and improve patient outcomes," Biga explained. “

17

1 Comment

I have always believed there were important patterns hidden in plain sight. For a couple of decades I have wondered if machines could do a better job of interpreting EEGs and detecting important patterns that our humans brains can not 👀 "see." The same is true for fetal ❤️ heart rate monitoring. The new era of #AI in #healthcare is making pattern recognition from complex data a reality. I work in the #Neonatal #ICU in which seizures in #newborns and #infants are not uncommon, but difficult to detect and manage. Continuous video EEG in the NICU for seizure management is now gold standard, but we still do not use the data as well as we could or should-- seems like that is changing. This study at the Duke University Pratt School of Engineering and Duke University Health System is more than a step in the right direction. Multi-modal AI which will take into account patient movement, sounds, vital sign changes over time in conjunction with EEG data will allow us to uncover important changes in our patients which will allow for better neurological care and outcomes. #UsingWhatWeHaveBetter https://lnkd.in/gP7xHZsJ.

3

Very important points about hospital consolidation. ⏺ Has led to the majority of physicians now being employed by a system. ⏺ A hospital system may have different priorities than physicians (in private practice). ⏺A system in which physicians have very little leverage to negotiate or change factors important to patients and clinical care. The real reason highlighted around 2 minutes 50 seconds. Short interview with beneficial insight. ⏺Physicians have joined unions not for wage negotiation but to focus on changes that affect clinical care. We as physicians do not have a unified voice. We have not organized ourselves well to create a unified voice. I am not sure that a union is the right path, but uniting to have a common voice, leverage, and negotiation power is needed. At 9 minutes Kevin Schulman highlights how this could be done without creation of a union (we need a system clinical strategy, not a market strategy) based on thoughts by @atul gawande. #UsingWhatWeHaveBetter https://lnkd.in/g5YTjFbD

8

1 Comment

Building strong physician referrals isn't just about waiting for patients to come to you—it's about actively increasing your visibility and effectively communicating with your peers. Try these steps and see how they help you get more referrals! More of this in my newsletter: https://pxl.to/AD/arbfg5e #drarianademers #Orthobiologics #Physicians

12

Transition from Medicaid to Commercial Insurance Reduces Major Amputation Risk in Diabetic Foot Ulcer Patients, Study Finds https://lnkd.in/gAiB8Y9v

5

1 Comment

Introducing POCUS into a medical practice may seem daunting. Some concerns include lack of time, negative patient perception, and malpractice. How do you introduce POCUS safely and effectively? In a recent webinar by EchoNous, I was fortunate to discuss POCUS adoption with Dr. James McLenna and William Steelman, DO, FACOI. They both successfully implemented POCUS into their #familymedicine and #directprimarycare practices respectively. Here are 5 practical tips from our discussion: 1. Be humble and patient. Most patients will appreciate your commitment to expanding your clinical skills. Mastery takes time – American College of Emergency Physicians POCUS guidelines recommend at least 25 scans of each exam type for competency. 2. Start small by focusing on 1 or 2 POCUS applications initially. No need for advanced measurements when learning basic ultrasound. 3. Order a confirmatory test while learning POCUS and use every imaging test as an opportunity to practice. 4. Learn from other ultrasound users in your field – techs, cardiologists, sports medicine doctors, etc. 5. Stay focused on the benefits of POCUS: enhancing patient care, experience, and provider satisfaction. Small setbacks are part of the learning process. Access the full recording of the webinar for insights on reimbursement, training, and use cases at this link: https://lnkd.in/eg8mWFZD #POCUS #MedicalPractice #PatientCare #ClinicalSkills #ProviderSatisfaction #patientexperience #ultrasound

7

“Patients with persistent atrial fibrillation (AFib) who undergo transcatheter aortic valve replacement (TAVR) may face a heightened risk of long-term mortality, according to new findings published in the American Journal of Cardiology.[1] However, this does not appear to be the case when patients present with preoperative paroxysmal AFib. The study’s authors focused on data from nearly 3,000 TAVR patients treated at a single high-volume medical center in the United States. A total of 38% of patients included in the analysis had with a history of AFib at the time of treatment. While approximately half of those patients presented with paroxysmal AFib—meaning it was spontaneous and could be controlled with treatment—the other half presented with persistent AFib that “failed to terminate within seven days.” After one year, AFib patients were associated with higher rates of all-cause mortality (9.0% vs. 6.1%) and hospital readmission (13.1% vs. 8.8%) than those with no history of AFib. AFib patients also had significantly lower Kansas City Cardiomyopathy Questionnaire (KCCQ) Scores. However, there were not significant differences in all-cause mortality, hospital readmission or KCCQ score between patients with persistent AFib and those with paroxysmal AFib after one year.”

18

1 Comment

This recent article by the WSJ is shocking to say the least. Everyone should read this article and understand the naked fraud that is being committed by behemoth private health insurers (United, Humana, Cigna, et al.) who are abusing Medicare Advantage, CMS, the federal government, and more importantly patients and taxpayers. If there is a modicum of truth to this, and my gestalt tells me this article is representative of the facts, this is absolutely infuriating and disturbing. These massive commercial insurers are lining their pockets at the expense of our government, taxpayers, and patients. They should absolutely be held accountable and their consolidation and power in the market busted apart. $50 billion of fraudulent Medicare payments to these insurers may seem like a drop in the bucket considering the national deficit briskly approaching $35 trillion and increasing by $1 trillion every 100 days; however, drops in the bucket will eventually fill the entire pail...... This has to stop, and other sources of fraudulent and wasteful government spending must stop. Vanquishing this fraud and corruption committed by the commercial insurers who are ripping off Medicare Advantage in particular is one lever that needs to be manipulated to alter the course of fiscal unsustainability. Please share if you are so inclined.

26

3 Comments

There's an arms race happening between radiation providers and insurance companies. Just this week, I spoke with a radiation oncology chair who's spending 80% of her time justifying treatments instead of delivering care. New PA requirements have made the issue worse over the last two years (as Gracie, Jiminez, and Winkfield just published on.) Most of these PAs get approved anyway. But we're making physicians jump through hoops, delaying patient care, when we could be using AI to automate these reviews and let doctors focus on treatment. 50% of cancer cases involve radiation, but it only makes up 3-4% of total costs. Something's not working when the most cost-effective cancer treatment faces the highest PA burden. Medicare gets it–they've dropped PA requirements for radiation. Private insurers need to catch up. #healthcare #AI #priorauth

19

5 Comments

This is an interesting talk that challenges a basic assumption that more spending in healthcare leads to better outcomes. They defined health value by looking at mortality rates across 6 diaseases and healthcare spending per capital. Florida ranked 3rd and Vermont 46th. While healthcare spending was correlated with lower heart disease it was not correlated with opioid use disorder. This sheds light upon the fact that social determinants of health have a big impact on outcomes. #healthcare #healthspending

7

There's a lot to unpack in this 2023 snapshot of obesity rates in the US. Further monitoring and investigation is needed to fully understand the causal impact of GLP-1s, the effects on cardiovascular risk and long-term health, the extent of rebound weight gain after discontinuation, and a wider range of appropriate use cases across cardiometabolic health. #obesity #glp1 #healthcareonlinkedin

7

1 Comment