TSR's "Small Incisions" - 9/8/2024
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:
The flipside of utilization management and prior authorization
Death by a thousand value metrics
“American Greed” — Steward Health Care Edition
Shrinkflation, a consequence of perverted healthcare markets
An argument that LLMs should be treated like med students
Mr. Wonderful “discovers” outpatient hip replacement
Evidence-based medicine is a lie
Her Surgeon Said She Needed The Operation. UnitedHealthcare Said No. (HEALTH CARE un-covered)
During the height of the pandemic, I spent some time doing utilization review for a healthcare startup. I had experienced my fair share of treatment denials and peer-to-peer calls, but I didn’t really understand the other side of UM and prior authorizations. The month I spent doing UM/PA work was an educational experience. I learned that insurance companies use a system of established treatment guidelines (either third party or developed in house) to determine if a treatment will be covered. I found the guidelines often vague, broad, and random — and, therefore, prone to subjectivity. Frequently, they didn’t seem to match scenarios commonly encountered in real world clinical situations. The bottom line: care decisions often boil down to an individual’s interpretation of non-specific rules. (In many cases, that individual doesn’t have expertise in the condition or proposed treatment). That said, a non-trivial number of the cases I reviewed featured clinical care that was poorly documented, low value, or both. The PA/UM system is deeply flawed — on both sides of the aisle. If we can get there, VBC will largely solve this issue. (Another insider secret: insurance companies get around the liability issue by not “denying” care but refusing to pay for it. Semantics for the loss.)
Value-Based Contracting in Clinical Care (JAMA)
In this study, PCPs involved in VBC faced on average 57 quality measures across 7.62 contracts. The biggest offender? Medicare, which had 13.42 quality measures per contract. In comparison, commercial payors had 10.07 and Medicaid plans 5.37. For PCPs, VBC contracts have become death by metrics. Look, I get it. There has to be some way of measuring impact. Metrics are the most straightforward way to tie an incentive to an outcome. But they’re limited and unsophisticated. Worse, they overwhelm docs who end up just chasing numbers. It’s no surprise this approach has failed to produce impactful, sustainable results. It’s time to re-think how we measure, track, and determine value. It starts by achieving clarity around what the goals are — better access, higher quality, lower costs. Value must be defined not just from the payor perspective, but also the patient and clinician perspective. We must develop valid outcomes measures that are simple, practical, and easy to administer. This is an area where I believe technology, including AI, will play a significant role.
Steward Health Care news: Globe Spotlight on Ralph de la Torre (Boston Globe)
Are you feeling angry right now? If not, read this article. Steward Health Care was (supposedly) founded on the idea of building an innovative and efficient healthcare system to challenge stale, lumbering incumbents. Oh well. As the saga continues to unwind, it’s shocking how far off course Steward went. Or maybe it isn’t. Steward is an egregious case of healthcare greed, but there are plenty of more insidious examples. Conflicts of interest, self-dealing, wasteful corporate spending, lack of administrative accountability — Steward isn’t alone here. It’s easy to be cynical about the state of healthcare. Doctors and patients always seem to be the biggest losers in these misadventures. But we shouldn’t let perversion of ideals change the mission.
Health shrinkflation: Patients wait more for less (Axios)
If healthcare were subject to normal market forces, a problem like “health shrinkflation” would solve itself. When demand for a service outstrips the market’s ability to provide it, suppliers should thrive. In today’s American healthcare system, cost efficient, high value service providers should be doing extremely well. To meet demand, they should be compelled to become more efficient and innovative. New entrants should be flooding in to fill the unmet need — even in a higher barrier of entry field like healthcare. Instead, we have burnout, an exodus of medical professionals, declining pay (despite increasing workload), and “innovation” that is anything but. Many point to current healthcare struggles as evidence that medicine shouldn’t be treated like a business. This argument ignores the core issue — healthcare markets are inefficient because the business of medicine has been distorted by ineffective regulation and legislation. We are far afield from the principles of free market competition. Until we fix these issues, it’s more of the same.
How to Regulate Generative AI in Health Care (Harvard Business Review)
An interesting idea to regulate Generative AI by treating models like medical trainees. Under this proposal, LLMs would be subjected to standardized testing and supervision by senior physicians before being allowed to “treat” patients. (Wonder if ChatGPT or Gemini would have a tough time sleeping the night before the MCAT, USMLE Steps 1, 2, and 3, or Ortho Boards like I did). The models would also be required to undergo Continuing Medical Education (CME) and a Maintenance of Certification (MOC) processes like physicians. (Docs have been fighting these requirements for years due to their costs, time commitment, and dubious impact on clinical care.) Business idea: a company that tests and certifies medical LLMs. Or, better yet, the Joint Commission for Generative AI. Actually, never mind.
Kevin's Hip Surgery - HRH Documentary (YouTube)
Shark Tank’s Kevin O’Leary had his hip replaced. I appreciate Kevin's enthusiasm for Humbolt Regional Health Center in Toronto and their coordinated, efficient, tech-forward approach to care. As I've often argued, high value care is a byproduct of high-quality people and processes (not payment mechanisms or convoluted VBC programs). The concept of joint replacement has evolved rapidly since I started practicing 15 years ago. As highlighted in Kevin's full video documentary on YouTube, some of the biggest advances in same day arthroplasty include improved anesthetic and surgical techniques, better patient optimization, and rapid mobilization protocols. TBH, while the tech is nice, it's secondary to the hard work and skill of the teams that have honed their craft and made a commitment to constant refinement. Hip and knee replacement surgeries remain two of the highest value treatments in all medicine -- at both the patient level and the societal level. What's presented in the documentary occurs in ambulatory centers across the US every day. It's nice to see it get some much-deserved attention.
Evidence-Based Medicine is a Lie (Journal of Orthopaedic Experience & Innovation)
Many thanks to Ira Kirschenbaum and JOEI for featuring my article on EBM. As part of the push for patient-centered, high value care, we need better mechanisms to capture, record, and report outcomes. Healthcare innovation should include novel ways of tracking impact. The healthcare community is at its strongest when experience is shared, and knowledge disseminated in a practical, accessible way. EBM is a lie in part because the journal publishing machinery has superseded the goals of medical literature — to foster learning through clinically relevant insights. This doesn’t excuse spurious research or self-serving, manipulated study outcomes. Nor does it absolve startups of their obligation to demonstrate effectiveness. But the time is nigh time for a paradigm shift in EBM.
Ben Schwartz, MD, MBA
Editor-in Chief, The Surgeon’s Record
Commons Clinic Senior Clinical Fellow
