Delivery of Care

Warning: Speed bumps ahead

The coronavirus disruptions are remaking health care delivery in real time

Image courtesy of Coastal Medical Twitter feed

Illustration of the empty medical office in a recent story about the office visit as becoming a dinosaur.

By Richard Asinof
Posted 8/10/20
The office visit may become a victim of the coronavirus, but the need to measure and benchmark health outcomes as health care delivery becomes more dependent on digital platforms has emerged as a key metric.
When will the role of nurses in the health care delivery system become part of the analysis of how care is actually delivered in Rhode Island? Why is there no coordinated program for testing children in Rhode Island, both symptomatic and asymptomatic, three weeks before the planned reopening of schools? What are the cost savings that can be achieved by changing the concept of the office visit? What happens if the analysis underway by the consortium looking at costs related to the All Payer Claims Database shows that the concept of “Choosing Wisely” turns out to be a nothing burger? What are the sources of data collection being used for the preparation of the second annual Rhode Island Life Index, being produced by Blue Cross & Blue Shield of RI? How is the connection between toxic contamination of air and water resources and racial disparities in health outcome being calculated? When will Rhode Island compile an integrated database for the deaths of despair, alcohol, suicide, drugs, and gun violence?
At the heart of many of the disparities and inequities in clinical health care is the tilted playing field for insurance reimbursements – who gets paid, how much, for what services, and what are the co-pays for patients? The work by the Senate commission on insurance reimbursements by Sen. Josh Miller unearthed important documentation of the existing disparities, from behavioral health to dental care to women’s health.
Moving forward, the question is: what will prompt the R.I. General Assembly to take action on correcting the imbalance in reimbursements? Will it require the R.I. Attorney General’s office to become involved through an investigation?

PROVIDENCE – The changes to the health care delivery landscape in Rhode Island keep occurring at a fast and furious pace, the result of constant disruption caused by the coronavirus pandemic. A fundamental tectonic shift has occurred, a sea change, in the way that providers and patients are talking to each other – and how providers are reimbursed for the care they deliver.

The sea change has made visible many of the dangerous reefs and barriers that had always existed but were often lurking just below the surface – the huge health disparities for African-American and Latinx populations, an unsustainable business model for hospitals, a crumbling public health infrastructure, and the extreme difficulties in accessing primary care for many, despite health insurance regulations and policies promoting patient-centered care.

Translated, the coronavirus does not pay attention to policies, regulations, bureaucratic authority or political invective. If you don’t wear a mask and do not practice social distancing, you are at risk, regardless of the fine print.

Recently, Medium published a provocative piece entitled, “COVID Has Made The Office Visit a Dinosaur,” written by the Boston-based Institute for Healthcare Improvement leadership team, including Dr. Doug Eby of the Southcentral Foundation Alaska Native Medical Center, Dr. Edward McGookin, Chief Medical Officer at Coastal Medical, and Jill Duncan, RN, MS, MPH, executive director at the Institute for Healthcare Improvement.

The article begins: “The office visit has been central to modern medicine. Long-held truths include the necessity of meeting with patients in person, lining up patients to see them in order, and care team members efficiently doing their part to maximize the physician’s precious time and skills. COVID has shown that this choreography is often unnecessary.”

The article continues, describing the changes that have occurred as a result of the disruptions from the coronavirus: “Once basic evaluation has occurred and a relationship of trust is in place, weaving medical expertise into patients’ lives when, where, and how they want it with no delay – and using ongoing virtual conversations – has proven to be better in many ways. Suddenly, the office visit no longer seems central to caring.”

Further, the article makes the case that “visit-based medicine” comes at a significant cost to patients. “Visits take time from work, a particular difficulty for those who most need clinical support and a burden that falls hardest on lower-income families. Patients travel, check into a front desk, wait, and go through a fairly long standardized ritualized process with various staff before sitting alone in a room on an exam table, waiting, again, for the precious few minutes with the clinician expert. Often, the professional, not the patient, drives the encounter, which is directive and produces a plan designed mainly by the professional.”

Translated, the pandemic has disrupted most of the paradigms of modern health care delivery. As much as there is a lot of lip service given to the concept of patient-centered care and accountable care entities, the reality has been that the policies have often been focused on the office visit and the needs of providers, not the actual needs of patients.

Here in Rhode Island, the rapid growth of telehealth digital platforms has met, for the most part, with effusive praise and little resistance – save by some representing the commercial insurance industry, including Neighborhood Health Plan of Rhode Island and the Rhode Island Business Group on Health, which have lobbied the R.I. General Assembly against efforts to expand telehealth beyond monthly executive orders by the Governor, even attacking the “authority” of the R.I. Office of the Health Insurance Commissioner to create a stakeholder group to analyze the data results form the practice of telehealth. [See link below to ConvergenceRI story, “What we have here is a failure to communicate.”]

Translated, in a time of pandemic, the status quo is becoming more and more difficult to preserve.

Another sign of the sea change underway was the announcement of the new collaboration between Brown and Lifespan to create a Center for Digital Health, led by Dr. Megan Ranney, the center’s founding director, with the goal “to take digital health innovation to the next level here in Rhode Island.”

As Ranney explained in a recent interview with GoLocalProv, “We’re working on things ranging from working with companies that are doing predictive analytics to decide if you actually have COVID symptoms or not; we’re working on projects with social media to try and identify when teens are in distress and need some extra help.”

Ranney, an emergency room doctor and a frequent contributor to cable new shows on CNN and MSNBC, talked with GoLocal about some of the projects in the pipeline: “We have projects using wearables – Fitbits and Apple watches – to try and identify folks at risk of falls, to try to deliver in the moment interventions to help people be healthier.”

In a recent tweet, Ranney wrote: "If anyone tells you they will fix physician burnout with yoga & welness appsthey are lying. It will be fixed when we create a system that makes it easier to do the right thing for the patient."

Will that same sentiment be applied to Google, owners of Fitbit, and Apple, when they produce algorithms that exploit their ability to predict consumer and patient behavior that may not be about doing the right thing for the patient?

The new digital health program will also need to answer the question: Who will own and manage the data being collected by wearable devices, the entrepreneur, the health system, the university, or the patient?

[ConvergenceRI has made two formal requests for interviews with Ranney but has not yet received a response. Stay tuned.]

Who is getting tested and what do the numbers mean?
At the same time, the often-improvised efforts to develop testing protocols and contact tracing programs for the coronovirus pandemic have made visible the long-term failure by the R.I. General Assembly to invest in the state’s public health infrastructure during the last four decades.

Some of the problems reflect the lack of a national coordinated program for testing; others reflect the tendency to create a top-down corporate approach to health care.

Tracking the data
With so much rapid change, ConvergenceRI wondered: who, if anyone, is currently keeping track of the data of the digital transformation during the coronavirus pandemic? Is there a systematic approach to analyzing the data being undertaken, or is it haphazard in nature?

The Governor and her team often invoke the concept that science, data, and public health will drive decision-making around policies such as re-opening the public schools for the fall. But who is keeping the data? And who is doing the analysis?

Given the plethora of digital platforms that are now “competing” with each other in the marketplace, what kinds of standards are there for interoperability?

What safeguards are in place to prevent, for example, three months of testing data being lost by an agency because the wrong fax number was being used?

To get some answers, ConvergenceRI reached out to Healthcentric Advisors, one of the major players in policy and data analysis in Rhode Island, an organization that serves as the quality improvement organization for Medicare for much of New England.

Here are the responses from Lauren Capizzo, director of Practice Transformation at Healthcentric Advisors, which reflect the organization’s own experiences and priorities.

ConvergenceRI: What kind of data analysis, if any, is being done through surveys with providers about how telehealth platforms are changing the interactions with patients? If you were to design a survey, would you include both doctors, nurses and patients?
CAPIZZO: Whenever we deliver digital solutions we always survey clinicians to make sure that we’re meeting their needs. For instance, both clinicians and patients report high satisfaction rates when using our digital solution for self-measured blood pressure.

The project had high patient activation with more than half of participants reducing their blood pressure to <140/90. The average amount of time it took for them to control their blood pressure was less than four weeks. Of all participating patients, 92 percent indicated the system was easy to use.

And for participating providers, 100 percent of clinicians indicated that using our portal was a good use of their time, that using it accelerated hypertension control with their patients, and would be a system they would refer to a colleague.

Healthcentric Advisors also sits on the planning committee for this project, led by Care Transformation Collaborative, and would encourage you to reach out to them since they’re doing this very work.

ConvergenceRI: Medium has just published a provocative piece entitled, “COVID has made the office visit a dinosaur." It is written by the IHI Leadership Alliance, including Drs. Doug Eby, Edward McGookin, and Jill Duncan, RN, MS, MPH. [See link below.] Is there a way to analyze the way that the pandemic has changed the cost structure of the delivery of care? What questions should be asked?
CAPIZZO: The COVID-19 pandemic has accelerated the adoption of telemedicine and remote physiological monitoring [RPM] to both support the health and safety of all patients [reducing risk and exposure of patients and staff to the virus] and to develop workflows that effectively monitor and manage patients remotely [for COVID-19 and other patient encounters] outside of the in-office visit.

New and expanded billing codes and increased payment schedules have been temporarily put in place by Center for Medicare and Medicaid Services and the private payer community to support telemedicine and RPM.

Many predict that the pandemic has brought a “shift change” to health care delivery modalities and funding for telehealth visits and remote data collection will continue as an extension of traditional face-to-face visits.

We support hundreds of practices throughout New England that serve rural and vulnerable communities and with shifts of this size due to the pandemic, it’ll be easier for some than others.

We’ve held online trainings and personalized technical support to assist providers in the adoption of telehealth, telemedicine, and RPM. For instance, in April of 2020 we hosted a six-week Project ECHO series [a free, practical, case-based tele-education] called: “Expanded Telehealth Services for COVID-19: Making sense of the new rules.”

Additionally, we’ve created a Medicare Telehealth and Remote Patient Monitoring Services Guide.

ConvergenceRI: Brown and Lifespan have launched a new Digital Health program, which seems to be Brown’s and Lifespan’s entry into claiming its disproportionate fair share of the emerging digital market, tied to collaborations with wearable devices. Did they do any outreach to you regarding the launch of this program? What are the questions that need to be asked about how data will be owned, shared, and used?
CAPIZZO: It's always exciting to hear partners forging new initiatives that will impact the digital health landscape locally and nationally. The initiative looks academic- and research-focused, which makes sense considering the many kinds of work the school and medical center engage in – but we look forward to seeing what’s to come.

Given our relationships with Lifespan, Coastal Medical, and Brown Medicine [the latter two have experience with some of our digital products], we would welcome future collaboration.

Our focus has been on creating digital health tools and resources for primarily ambulatory-based providers to improve their patient quality measures and clinical outcomes. This becomes more important as more community-based providers are operating within accountable care organization umbrellas and risk-based reimbursement systems that focus on cost reduction and quality improvement.

When it comes to data collection for our digital tools, we have "baked in" security measures. Our blood-pressure self-management platform uses a secure, HIPAA compliant portal that gives providers access to responses at the patient and practice level. Information from the tool can be downloaded and attached to their electronic [or paper] medical record.

Our system is opt-in, so the patient is digitally enrolled by their practice following an in-person, telephonic or virtual encounter. The first text message a patient receives asks them agree to participate; and patients can easily opt out at any time. The information goes securely into our portal, which has a login requirement specifically for care team members.

ConvergenceRI: How do patients' voices get heard in the post-pandemic world?
CAPIZZO: Providers have a number of ways to ensure the patient and family voices are heard and inform practice workflows for optimal care including telehealth. These strategies work both today and post-pandemic. In addition to what was referenced above, providers can survey patients, electronically, telephonically, or even through paper surveys.

Many quality and advanced payment models require a comprehensive patient experience survey such as Consumer Assessment of Healthcare Providers and Systems [CAHPS] with varied frequency, often annually. CMS incorporates patient engagement measures into their advanced payment models to support an emphasis on a patient-centered approach.

Another way care delivery is guided by person-centered principles is with a Patient and Family Advisory Council [PFAC]. Many providers across the state have incorporated PFACs into their work to shape the delivery of the care from the patients they directly serve. PFACs can be a meaningful approach to keeping the patient voice at the center of it all.

In fact, Healthcentric Advisors has a PFAC that shapes our own materials and resources that we’ve been actively working with for six years. It has representation from across New England, and we’re committed to making sure they have a say in the work we do.

We can’t meet in person now, but because of our PFAC has been meeting virtually for many years, we’re lucky to have infrastructure set up to continue to meet. We’re always looking to add voices to the fray and encourage folks to reach out to us to learn more.

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