TSR's Small Incisions - 9/29/2024
Hot healthcare takes from the Surgeon's Perspective
A rundown of stories from across the healthcare ecosystem — health tech, health policy, digital health, value-based care, and more — with commentary.
Presented by Commons Clinic
This week:
I’ve Got this Epic Problem
Physician Compensation is Up*
CMMI: The Venture Studio
Amazon’s Burgeoning IDN
I challenge anyone to clearly define “unnecessary”
Putting VBC in the pocket — and leaving it there?
Family medicine
Epic reminds me of 90's-era Microsoft/Windows. Both companies leveraged market dominance to push a ubiquitous operating system that many find convoluted, cumbersome, and user unfriendly. Updates include features no one asked for, unnecessary changes, and fixes to things that aren’t broken. Extremely high switching costs ensure lock-in.
To be fair, Epic isn't completely to blame for the EMR mess. Mandatory (spurious) policies and procedures created the monster and continue to feed it. Medical records are supposed to be a repository of high value information facilitating communication and crafting a clear picture of a patient's history. Instead, they've lowered the barrier to over-protocolization, brainless check-box healthcare, and death by 1,000 clicks. Epic didn't create these problems, but it helps perpetuate them.
The Epic-Particle dispute is more complicated than the “EMRs are terrible” debate. It centers around the most coveted healthcare prize — patient data — and again raises questions around who controls it, how it’s used, and how privacy is protected. I couldn’t come anywhere close to breaking this down as well as the incomparable Health API Guy, Brendan Keeler.
Increases in provider compensation, in 3 charts (Advisory Board)
Stop whining about payment cuts docs, your median compensation has gone up 3-5% per year over the last 3 years. What’s that you say — compensation increases are the result of increased productivity? Inflation adjusted numbers look less favorable? Primary care continues to lag other specialties? Oh.
As usual, the hamster wheel speeds up, and we run faster. It’s Economics 101 — if you’re getting paid less per unit of work, you have to do more work. Overhead costs continue to rise, medical education debt remains high, and inflation (though cooling) still looms. Physicians are being pushed to do more, either to maintain independence or satisfy employer productivity goals. Equally as insidious — there’s grumblings of AI being used to increase clinic volumes, offsetting any easing of administrative burdens. This was a predictable development. AI is expensive, and improving job satisfaction for healthcare providers doesn’t pay the bills.
Improvement Science and Value-Based Payment Models (Health Affairs)
Failure of VBC models is linked to three factors: insufficient population-level data, misaligned/insufficient incentives, infrastructural inertia. A better understanding of external risk factors and social drivers of health can solve the data gap. A holistic approach is key to creating proper incentives that lead to better integration. Inertia can be overcome by plan-do-study-act (PDSA) cycles — healthcare’s version of iteration that involves rapid evolution of care practices. The authors call on CMMI to “encourage the spread of better practices by launching cycles of testing and learning.” Basically, CMMI needs to explore and support innovative, less traditional care models and disseminate learnings. CMMI as venture studio, incubator, or accelerator? It might be crazy enough to work.
Amazon adds Talkspace to digital health benefits program (Fierce Healthcare)
Talkspace, an online behavioral health provider, joins Omada as the inaugural virtual care providers to be offered through Amazon’s Health Conditions Program (HCP). Adding a virtual MSK provider would be a logical next step. HCP assists employees in surfacing company-offered benefits of which they might not be aware. Does Amazon have eyes on creating its own wellness benefits marketplace? The Health Conditions Program joins One Medical, Amazon Clinic, and Amazon Pharmacy as part of the company’s broader health services offerings. If you squint, you can see the makings of an integrated care delivery network (of sorts). Brick-and-mortar primary care, virtual urgent care, pharmacy, and now a benefits-lite offering. How (or if) all this coalesces remains to be seen. But it’s fair to say that Amazon’s strategy is working better than its retail health competitors.
Surgical Precision: Cuts Like a Knife… (On the Flying Bridge)
I understand the desire to “reduce and/or eliminate and/or delay the need for expansive [sic] invasive surgical procedures.” When you look at interventions associated with a certain condition or diagnosis, procedures are the biggest cost driver. But we can’t lose the forest through the trees. Unnecessary delaying definitive treatment, even if that treatment is surgery, drives up costs, perpetuates low value non-procedural care, and potentially harms patients. Reducing, eliminating, and delaying surgeries creates large cost savings from a relatively small population. But there is also opportunity to save money through a larger volume of smaller wins — fewer low value diagnostic tests and interventions, better health optimization, and improved preventive care. Also, let’s define what “unnecessary” really means and who makes that determination. Chances are, it’s different for payer, patient, and provider. For all the talk of unnecessary treatment, few understand the nuances involved.
Thinking beyond value-based care (Out-of-Pocket)
As VBC fatigue sets in, what comes next? Probably some middle ground that incorporates elements of VBC and FFS. Nikhil is correct that no payment system is inherently good or bad — each comes with tradeoffs. FFS can achieve value by providing transparently superior outcomes at a reasonable cost. VBC doesn’t always create proper incentives — there’s cherry-picking and lemon-dropping — and we still struggle to define value. The alternative is to put down the notion that high-quality, cost-effective care is going to be driven by carrots and sticks. It’s about the care process, not the payment model. I’m a believer in a condition-specific focus and more comprehensive, holistic approach. Such a model contains elements of FFS (nested surgical episodes for MSK) and elements of VBC (global subcapitation for costs related to a diagnosis). Creating a more open, free market and giving patients the tools and incentives to find high quality care helps too. The anger and angst towards FFS as the root of all healthcare evils (and VBC as the savior) has watered down the conversation and impaired critical thinking about what will work best.
Generational Spine Surgeons: Like Father, Like Son (The Surgeon’s Record)
I must admit, becoming a podcast host was not on my 2024 To-Do list. And, while my skills are still in their infancy, I do enjoy it. An early lesson: let the conversation breathe. People are great at telling their own stories if you provide a gentle prompt and give them space. That’s why I really enjoyed this conversation between father and son, Sarbpaul and Amandeep Bhalla. Many of us pursue careers in healthcare to follow in the footsteps of parents, grandparents, or siblings. (My father was a hospital administrator, my mother a nurse). There’s been a lot of debate recently about whether a career in medicine is a calling. After this conversation, I’m not sure it matters. Each person’s career path is their own, subtly shaped by both conscious and subconscious factors.
Ben Schwartz, MD, MBA
Editor-in Chief, The Surgeon’s Record
Commons Clinic Senior Clinical Fellow
