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No, you still can’t diagnose Trump
On the morning of July 25, I scrolled through my Twitter account to see tweets flying: Psychiatrists can now defy the Goldwater Rule! Oops, wrong organization; no ,they can’t. Over the course of the day, articles appeared in Scientific American, the Los Angeles Times, Newsweek, International Business Times; and statements were issued by both the American Psychiatric Association and the American Psychoanalytic Association.
So what happened?
On July 6, 2017, the ApsaA had sent an email to all its members informing them of this decision. The email also stated: “However, it is important to note that members of APsaA are free to comment about political figures as individuals. The American Psychiatric Association’s ethical stance on the Goldwater Rule applies to its members only. The APsaA does not consider political commentary by its individual members an ethical matter.” (Bolding per the email). This was not considered to be a change in its policy.
Citing that email, on July 25, STAT reporter Sharon Begley wrote an article titled, “Psychiatry group tells members they can ignore ‘Goldwater rule’ and comment on Trump’s mental health.” The article was linked to on Twitter, and the retweets and comments started to fly. As a single example, Josh Marshall, editor and publisher of Talking Points Memo, tweeted out to his 215,000 followers: “Truly amazing am psych assoc says Trump so f’ing nuts they’re lifting Goldwater Rule.” The APA issued several statements over the course of the day, notably: “We are the largest psychiatric organization in the world with more than 37,000 members. The Goldwater Rules applies to our members.” Commenters expressed frustration with the Goldwater Rule, and suggested that the APA had a duty to warn.
Shortly after noon that day, the APsaA put a statement on its website to clarify information in the STAT article: “In an email to association members, our leadership did not encourage members to defy the “Goldwater Rule” which is a part of the ethics code of a different mental health organization, the American Psychiatric Association (APA). Rather, it articulated a distinct ethics position that represents the viewpoint of psychoanalysts. The field of psychoanalysis addresses the full spectrum of human behavior, and we feel that our concepts and understanding are applicable and valuable to understanding a wide range of human behaviors and cultural phenomenon.”
Later in the afternoon, I spoke with Wylie Tene, director of pubic affairs for the APsaA. He noted: “The article in StatNews had a misleading and sensational headline. It didn’t represent what our email was about.”
I found it interesting that a sensational headline on STAT’s website could lead to so much comment and so many articles in major news outlets. July 25, 2017, was not a slow news day: John McCain (R-Ariz) returned to the Senate that day and voted to proceed with the debate to repeal Obamacare. A single vote cast by Vice President Mike Pence broke the tie, allowing the debate to go forward.
Like many, I feel conflicted about the Goldwater Rule but for a single reason: I am a strong believer in free speech, and the rule squelches psychiatrists. But as I noted in a column in August 2016, I don’t believe that our opinions should, would, or could change our political environment. Psychiatric treatment is about compassion and healing, and diagnoses are based on symptoms that patients often tell us about in a setting of intimacy and trust. Diagnosing celebrities, on the other hand, is often about name calling; it risks insulting our patients and perpetuating stigma.
Regarding Mr. Trump, I’m going to finish with the same words I wrote back in August, prior to his election as president. You’ll note that my insights in Clinical Psychiatry News and circulated on the Internet – devoid of a diagnosis – did not influence the outcome of the general election. Psychiatric diagnoses are made by observing a constellation of symptoms that occur together.
Mr. Trump has given the whole world years of data – he’s lived his life in a very public way. As a real estate developer, he has had countless employees who all know how they’ve been treated. We’ve seen him through three marriages and watched how he interacts with his children. We’ve seen him take out full-page ads calling for the death penalty for a group of young men who were wrongly convicted in the rape and assault of the Central Park jogger in 1989. If that’s not enough, he has hosted his own reality television show, and we’ve now seen him countless times in debates and rallies. We know how he treats his running mates, journalist Megyn Kelly, a news reporter with a disability, and the parents of a fallen soldier. We’ve watched him allude to the size of his genitals during a primary debate. Every individual is free to decide if Mr. Trump’s widely viewed patterns of behavior represent much-needed spunk and change with political beliefs that align with their own, or if his words and behaviors represent cruelty, impulsivity, poor judgment, and a pattern of actions that some might not feel is dignified enough for our country’s leader. No degree is required to observe and draw conclusions.
Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).
On the morning of July 25, I scrolled through my Twitter account to see tweets flying: Psychiatrists can now defy the Goldwater Rule! Oops, wrong organization; no ,they can’t. Over the course of the day, articles appeared in Scientific American, the Los Angeles Times, Newsweek, International Business Times; and statements were issued by both the American Psychiatric Association and the American Psychoanalytic Association.
So what happened?
On July 6, 2017, the ApsaA had sent an email to all its members informing them of this decision. The email also stated: “However, it is important to note that members of APsaA are free to comment about political figures as individuals. The American Psychiatric Association’s ethical stance on the Goldwater Rule applies to its members only. The APsaA does not consider political commentary by its individual members an ethical matter.” (Bolding per the email). This was not considered to be a change in its policy.
Citing that email, on July 25, STAT reporter Sharon Begley wrote an article titled, “Psychiatry group tells members they can ignore ‘Goldwater rule’ and comment on Trump’s mental health.” The article was linked to on Twitter, and the retweets and comments started to fly. As a single example, Josh Marshall, editor and publisher of Talking Points Memo, tweeted out to his 215,000 followers: “Truly amazing am psych assoc says Trump so f’ing nuts they’re lifting Goldwater Rule.” The APA issued several statements over the course of the day, notably: “We are the largest psychiatric organization in the world with more than 37,000 members. The Goldwater Rules applies to our members.” Commenters expressed frustration with the Goldwater Rule, and suggested that the APA had a duty to warn.
Shortly after noon that day, the APsaA put a statement on its website to clarify information in the STAT article: “In an email to association members, our leadership did not encourage members to defy the “Goldwater Rule” which is a part of the ethics code of a different mental health organization, the American Psychiatric Association (APA). Rather, it articulated a distinct ethics position that represents the viewpoint of psychoanalysts. The field of psychoanalysis addresses the full spectrum of human behavior, and we feel that our concepts and understanding are applicable and valuable to understanding a wide range of human behaviors and cultural phenomenon.”
Later in the afternoon, I spoke with Wylie Tene, director of pubic affairs for the APsaA. He noted: “The article in StatNews had a misleading and sensational headline. It didn’t represent what our email was about.”
I found it interesting that a sensational headline on STAT’s website could lead to so much comment and so many articles in major news outlets. July 25, 2017, was not a slow news day: John McCain (R-Ariz) returned to the Senate that day and voted to proceed with the debate to repeal Obamacare. A single vote cast by Vice President Mike Pence broke the tie, allowing the debate to go forward.
Like many, I feel conflicted about the Goldwater Rule but for a single reason: I am a strong believer in free speech, and the rule squelches psychiatrists. But as I noted in a column in August 2016, I don’t believe that our opinions should, would, or could change our political environment. Psychiatric treatment is about compassion and healing, and diagnoses are based on symptoms that patients often tell us about in a setting of intimacy and trust. Diagnosing celebrities, on the other hand, is often about name calling; it risks insulting our patients and perpetuating stigma.
Regarding Mr. Trump, I’m going to finish with the same words I wrote back in August, prior to his election as president. You’ll note that my insights in Clinical Psychiatry News and circulated on the Internet – devoid of a diagnosis – did not influence the outcome of the general election. Psychiatric diagnoses are made by observing a constellation of symptoms that occur together.
Mr. Trump has given the whole world years of data – he’s lived his life in a very public way. As a real estate developer, he has had countless employees who all know how they’ve been treated. We’ve seen him through three marriages and watched how he interacts with his children. We’ve seen him take out full-page ads calling for the death penalty for a group of young men who were wrongly convicted in the rape and assault of the Central Park jogger in 1989. If that’s not enough, he has hosted his own reality television show, and we’ve now seen him countless times in debates and rallies. We know how he treats his running mates, journalist Megyn Kelly, a news reporter with a disability, and the parents of a fallen soldier. We’ve watched him allude to the size of his genitals during a primary debate. Every individual is free to decide if Mr. Trump’s widely viewed patterns of behavior represent much-needed spunk and change with political beliefs that align with their own, or if his words and behaviors represent cruelty, impulsivity, poor judgment, and a pattern of actions that some might not feel is dignified enough for our country’s leader. No degree is required to observe and draw conclusions.
Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).
On the morning of July 25, I scrolled through my Twitter account to see tweets flying: Psychiatrists can now defy the Goldwater Rule! Oops, wrong organization; no ,they can’t. Over the course of the day, articles appeared in Scientific American, the Los Angeles Times, Newsweek, International Business Times; and statements were issued by both the American Psychiatric Association and the American Psychoanalytic Association.
So what happened?
On July 6, 2017, the ApsaA had sent an email to all its members informing them of this decision. The email also stated: “However, it is important to note that members of APsaA are free to comment about political figures as individuals. The American Psychiatric Association’s ethical stance on the Goldwater Rule applies to its members only. The APsaA does not consider political commentary by its individual members an ethical matter.” (Bolding per the email). This was not considered to be a change in its policy.
Citing that email, on July 25, STAT reporter Sharon Begley wrote an article titled, “Psychiatry group tells members they can ignore ‘Goldwater rule’ and comment on Trump’s mental health.” The article was linked to on Twitter, and the retweets and comments started to fly. As a single example, Josh Marshall, editor and publisher of Talking Points Memo, tweeted out to his 215,000 followers: “Truly amazing am psych assoc says Trump so f’ing nuts they’re lifting Goldwater Rule.” The APA issued several statements over the course of the day, notably: “We are the largest psychiatric organization in the world with more than 37,000 members. The Goldwater Rules applies to our members.” Commenters expressed frustration with the Goldwater Rule, and suggested that the APA had a duty to warn.
Shortly after noon that day, the APsaA put a statement on its website to clarify information in the STAT article: “In an email to association members, our leadership did not encourage members to defy the “Goldwater Rule” which is a part of the ethics code of a different mental health organization, the American Psychiatric Association (APA). Rather, it articulated a distinct ethics position that represents the viewpoint of psychoanalysts. The field of psychoanalysis addresses the full spectrum of human behavior, and we feel that our concepts and understanding are applicable and valuable to understanding a wide range of human behaviors and cultural phenomenon.”
Later in the afternoon, I spoke with Wylie Tene, director of pubic affairs for the APsaA. He noted: “The article in StatNews had a misleading and sensational headline. It didn’t represent what our email was about.”
I found it interesting that a sensational headline on STAT’s website could lead to so much comment and so many articles in major news outlets. July 25, 2017, was not a slow news day: John McCain (R-Ariz) returned to the Senate that day and voted to proceed with the debate to repeal Obamacare. A single vote cast by Vice President Mike Pence broke the tie, allowing the debate to go forward.
Like many, I feel conflicted about the Goldwater Rule but for a single reason: I am a strong believer in free speech, and the rule squelches psychiatrists. But as I noted in a column in August 2016, I don’t believe that our opinions should, would, or could change our political environment. Psychiatric treatment is about compassion and healing, and diagnoses are based on symptoms that patients often tell us about in a setting of intimacy and trust. Diagnosing celebrities, on the other hand, is often about name calling; it risks insulting our patients and perpetuating stigma.
Regarding Mr. Trump, I’m going to finish with the same words I wrote back in August, prior to his election as president. You’ll note that my insights in Clinical Psychiatry News and circulated on the Internet – devoid of a diagnosis – did not influence the outcome of the general election. Psychiatric diagnoses are made by observing a constellation of symptoms that occur together.
Mr. Trump has given the whole world years of data – he’s lived his life in a very public way. As a real estate developer, he has had countless employees who all know how they’ve been treated. We’ve seen him through three marriages and watched how he interacts with his children. We’ve seen him take out full-page ads calling for the death penalty for a group of young men who were wrongly convicted in the rape and assault of the Central Park jogger in 1989. If that’s not enough, he has hosted his own reality television show, and we’ve now seen him countless times in debates and rallies. We know how he treats his running mates, journalist Megyn Kelly, a news reporter with a disability, and the parents of a fallen soldier. We’ve watched him allude to the size of his genitals during a primary debate. Every individual is free to decide if Mr. Trump’s widely viewed patterns of behavior represent much-needed spunk and change with political beliefs that align with their own, or if his words and behaviors represent cruelty, impulsivity, poor judgment, and a pattern of actions that some might not feel is dignified enough for our country’s leader. No degree is required to observe and draw conclusions.
Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).
Do you talk about marijuana with your patients?
Do you talk about marijuana with your patients?
In medical school, I had a roommate. He was a smart law school graduate, good looking, outgoing, had lots of friends, was funny, and he was a great cook.
I should tell you another thing about my friend: He was a heavy, daily user of marijuana.
I believe that most of us, at a certain point of our lives, have met someone like my friend. The combination of a high-stress lifestyle, high self-expectations, and lack of appropriate skills to tackle life’s obstacles when encountered with failure frequently leads to addiction or a behavioral problem. In most cases, that will cause a pathological relationship with an outside substance or stimuli (Internet overuse/shopping too much/overeating or drinking, and so on).
Living a life filled with severe trauma and pain, especially at a developmental stage, often leads to an addiction. We frequently see people escape to the sweet narcotic-induced sleep via opioid abuse. On the other hand, for people who did not suffer trauma and are highly functional, marijuana offers a means of emotional detachment from pain, in its different form, and existential depression. That is the main benefit my patients who live with marijuana addiction get.
My friend serves as a rather stereotypical – and some may say – subjective, simplistic example of what is becoming more and more common in our society. I’m willing to bet that a good number of clinicians who read this have a similar example in mind.
With its intoxication state perceived as benign and the limited medicinal advantages, marijuana rapidly is gaining more and more legitimacy in the eyes of the general public (Addict Behav. 2008 Mar;33:397-411), (Monitoring the Future: National Results on Drug Use: 1975-2016). The risk of addiction is perceived as negligible and often nonexistent.
Almost no one knows about the potential risk of addiction (around 9%) (Drug Alcohol Depend. 2011;115:120-30). No one knows about about tolerance and withdrawal states – or about the real risk of psychosis (N Engl J Med. 2014 Jun 5;370:2219-27) or about the possible risk of schizophrenia in vulnerable populations (Schizophr Res. 2016 Mar;171:[1-3]:62-7). No one talks about the fact that it’s often used with tobacco. (How many times have you been told during history taking that a patient doesn’t smoke tobacco, only to find that in drug history he smokes 3-5 joints with tobacco daily?)
[polldaddy:9796432]
Throughout my journey in the psychiatric world (studying and working on three different continents) another typical marijuana user is the patient living with chronic mental illness. My Israeli mentor often complained about not having a single “clean” patient with schizophrenia anymore. I now see the same phenomena in Philadelphia and was also exposed to the same reality in Europe during medical school.
As physicians, and especially as psychiatrists, I believe we are obligated to educate our patients by telling them about the risks in their behaviors. Educating patients about marijuana in today’s atmosphere can be a very important preventive measure, and awareness is an important step toward change.
The current generation of psychiatrists is dealing with an opioid epidemic. Let’s educate ourselves and our patients so this current epidemic won’t be followed by another, severe cannabis epidemic.
Dr. Shilo is a second-year PGY in the department of psychiatry at Einstein Medical Center, Philadelphia.
Do you talk about marijuana with your patients?
In medical school, I had a roommate. He was a smart law school graduate, good looking, outgoing, had lots of friends, was funny, and he was a great cook.
I should tell you another thing about my friend: He was a heavy, daily user of marijuana.
I believe that most of us, at a certain point of our lives, have met someone like my friend. The combination of a high-stress lifestyle, high self-expectations, and lack of appropriate skills to tackle life’s obstacles when encountered with failure frequently leads to addiction or a behavioral problem. In most cases, that will cause a pathological relationship with an outside substance or stimuli (Internet overuse/shopping too much/overeating or drinking, and so on).
Living a life filled with severe trauma and pain, especially at a developmental stage, often leads to an addiction. We frequently see people escape to the sweet narcotic-induced sleep via opioid abuse. On the other hand, for people who did not suffer trauma and are highly functional, marijuana offers a means of emotional detachment from pain, in its different form, and existential depression. That is the main benefit my patients who live with marijuana addiction get.
My friend serves as a rather stereotypical – and some may say – subjective, simplistic example of what is becoming more and more common in our society. I’m willing to bet that a good number of clinicians who read this have a similar example in mind.
With its intoxication state perceived as benign and the limited medicinal advantages, marijuana rapidly is gaining more and more legitimacy in the eyes of the general public (Addict Behav. 2008 Mar;33:397-411), (Monitoring the Future: National Results on Drug Use: 1975-2016). The risk of addiction is perceived as negligible and often nonexistent.
Almost no one knows about the potential risk of addiction (around 9%) (Drug Alcohol Depend. 2011;115:120-30). No one knows about about tolerance and withdrawal states – or about the real risk of psychosis (N Engl J Med. 2014 Jun 5;370:2219-27) or about the possible risk of schizophrenia in vulnerable populations (Schizophr Res. 2016 Mar;171:[1-3]:62-7). No one talks about the fact that it’s often used with tobacco. (How many times have you been told during history taking that a patient doesn’t smoke tobacco, only to find that in drug history he smokes 3-5 joints with tobacco daily?)
[polldaddy:9796432]
Throughout my journey in the psychiatric world (studying and working on three different continents) another typical marijuana user is the patient living with chronic mental illness. My Israeli mentor often complained about not having a single “clean” patient with schizophrenia anymore. I now see the same phenomena in Philadelphia and was also exposed to the same reality in Europe during medical school.
As physicians, and especially as psychiatrists, I believe we are obligated to educate our patients by telling them about the risks in their behaviors. Educating patients about marijuana in today’s atmosphere can be a very important preventive measure, and awareness is an important step toward change.
The current generation of psychiatrists is dealing with an opioid epidemic. Let’s educate ourselves and our patients so this current epidemic won’t be followed by another, severe cannabis epidemic.
Dr. Shilo is a second-year PGY in the department of psychiatry at Einstein Medical Center, Philadelphia.
Do you talk about marijuana with your patients?
In medical school, I had a roommate. He was a smart law school graduate, good looking, outgoing, had lots of friends, was funny, and he was a great cook.
I should tell you another thing about my friend: He was a heavy, daily user of marijuana.
I believe that most of us, at a certain point of our lives, have met someone like my friend. The combination of a high-stress lifestyle, high self-expectations, and lack of appropriate skills to tackle life’s obstacles when encountered with failure frequently leads to addiction or a behavioral problem. In most cases, that will cause a pathological relationship with an outside substance or stimuli (Internet overuse/shopping too much/overeating or drinking, and so on).
Living a life filled with severe trauma and pain, especially at a developmental stage, often leads to an addiction. We frequently see people escape to the sweet narcotic-induced sleep via opioid abuse. On the other hand, for people who did not suffer trauma and are highly functional, marijuana offers a means of emotional detachment from pain, in its different form, and existential depression. That is the main benefit my patients who live with marijuana addiction get.
My friend serves as a rather stereotypical – and some may say – subjective, simplistic example of what is becoming more and more common in our society. I’m willing to bet that a good number of clinicians who read this have a similar example in mind.
With its intoxication state perceived as benign and the limited medicinal advantages, marijuana rapidly is gaining more and more legitimacy in the eyes of the general public (Addict Behav. 2008 Mar;33:397-411), (Monitoring the Future: National Results on Drug Use: 1975-2016). The risk of addiction is perceived as negligible and often nonexistent.
Almost no one knows about the potential risk of addiction (around 9%) (Drug Alcohol Depend. 2011;115:120-30). No one knows about about tolerance and withdrawal states – or about the real risk of psychosis (N Engl J Med. 2014 Jun 5;370:2219-27) or about the possible risk of schizophrenia in vulnerable populations (Schizophr Res. 2016 Mar;171:[1-3]:62-7). No one talks about the fact that it’s often used with tobacco. (How many times have you been told during history taking that a patient doesn’t smoke tobacco, only to find that in drug history he smokes 3-5 joints with tobacco daily?)
[polldaddy:9796432]
Throughout my journey in the psychiatric world (studying and working on three different continents) another typical marijuana user is the patient living with chronic mental illness. My Israeli mentor often complained about not having a single “clean” patient with schizophrenia anymore. I now see the same phenomena in Philadelphia and was also exposed to the same reality in Europe during medical school.
As physicians, and especially as psychiatrists, I believe we are obligated to educate our patients by telling them about the risks in their behaviors. Educating patients about marijuana in today’s atmosphere can be a very important preventive measure, and awareness is an important step toward change.
The current generation of psychiatrists is dealing with an opioid epidemic. Let’s educate ourselves and our patients so this current epidemic won’t be followed by another, severe cannabis epidemic.
Dr. Shilo is a second-year PGY in the department of psychiatry at Einstein Medical Center, Philadelphia.
Student Hospitalist Scholars: The importance of communication
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
Quality improvement in clinical practice has recently become very important to me. What use is clinical knowledge if it cannot be appropriately used to benefit patients in a clinical setting?
Throughout my 1st year at medical school, my interest in communication continued to grow. In one of my classes, Essentials of Clinical Reasoning, we were taught to continually consider how to effectively translate our thought processes and potential diagnoses to our patients. To begin crafting effective HPIs, we created complete, whole histories from visit to visit.
At this time, I discovered the subfield of research concerning strategies surrounding handoffs as transition of care changes, with patients often suffering due to breakdowns in communication.
With my interest in handoffs, and with direction from the Society of Hospital Medicine, I reached out to Dr. Vineet Arora, a leading academic hospitalist at the University of Chicago with a highly impressive history of research concerning quality of care toward hospitalized adults. Under the supervision of Dr. Arora and Dr. Juan Rojas, a pulmonary critical care fellow, I will help investigate whether receiving floor physicians and intensive care unit physicians possess similar shared mental models in regards to the most pertinent point of care – when patients are transferred out of the ICU.
We seek to identify if there are any associations present between readmission from the general floor, the providers’ rated likelihood of the patient returning to the ICU, and whether floor and ICU physicians are on the same page concerning condition management while on the floor.
I believe the experience I gain at the University of Chicago Medical Center will be invaluable to my future as a physician. I am very excited to get to know the various clinicians at UChicago, to gain clinical experience by observing the management of the general ward, and to identify how effective physicians communicate.
Above all, I hope to use any knowledge I gain this summer to become an efficient, knowledgeable, and compassionate physician capable of providing the highest quality of care to my future patients.
Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago, Ill. He received his B.S. in Biology from Loyola University in Chicago in 2015 and his Master of Biomedical Science from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
Quality improvement in clinical practice has recently become very important to me. What use is clinical knowledge if it cannot be appropriately used to benefit patients in a clinical setting?
Throughout my 1st year at medical school, my interest in communication continued to grow. In one of my classes, Essentials of Clinical Reasoning, we were taught to continually consider how to effectively translate our thought processes and potential diagnoses to our patients. To begin crafting effective HPIs, we created complete, whole histories from visit to visit.
At this time, I discovered the subfield of research concerning strategies surrounding handoffs as transition of care changes, with patients often suffering due to breakdowns in communication.
With my interest in handoffs, and with direction from the Society of Hospital Medicine, I reached out to Dr. Vineet Arora, a leading academic hospitalist at the University of Chicago with a highly impressive history of research concerning quality of care toward hospitalized adults. Under the supervision of Dr. Arora and Dr. Juan Rojas, a pulmonary critical care fellow, I will help investigate whether receiving floor physicians and intensive care unit physicians possess similar shared mental models in regards to the most pertinent point of care – when patients are transferred out of the ICU.
We seek to identify if there are any associations present between readmission from the general floor, the providers’ rated likelihood of the patient returning to the ICU, and whether floor and ICU physicians are on the same page concerning condition management while on the floor.
I believe the experience I gain at the University of Chicago Medical Center will be invaluable to my future as a physician. I am very excited to get to know the various clinicians at UChicago, to gain clinical experience by observing the management of the general ward, and to identify how effective physicians communicate.
Above all, I hope to use any knowledge I gain this summer to become an efficient, knowledgeable, and compassionate physician capable of providing the highest quality of care to my future patients.
Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago, Ill. He received his B.S. in Biology from Loyola University in Chicago in 2015 and his Master of Biomedical Science from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
Quality improvement in clinical practice has recently become very important to me. What use is clinical knowledge if it cannot be appropriately used to benefit patients in a clinical setting?
Throughout my 1st year at medical school, my interest in communication continued to grow. In one of my classes, Essentials of Clinical Reasoning, we were taught to continually consider how to effectively translate our thought processes and potential diagnoses to our patients. To begin crafting effective HPIs, we created complete, whole histories from visit to visit.
At this time, I discovered the subfield of research concerning strategies surrounding handoffs as transition of care changes, with patients often suffering due to breakdowns in communication.
With my interest in handoffs, and with direction from the Society of Hospital Medicine, I reached out to Dr. Vineet Arora, a leading academic hospitalist at the University of Chicago with a highly impressive history of research concerning quality of care toward hospitalized adults. Under the supervision of Dr. Arora and Dr. Juan Rojas, a pulmonary critical care fellow, I will help investigate whether receiving floor physicians and intensive care unit physicians possess similar shared mental models in regards to the most pertinent point of care – when patients are transferred out of the ICU.
We seek to identify if there are any associations present between readmission from the general floor, the providers’ rated likelihood of the patient returning to the ICU, and whether floor and ICU physicians are on the same page concerning condition management while on the floor.
I believe the experience I gain at the University of Chicago Medical Center will be invaluable to my future as a physician. I am very excited to get to know the various clinicians at UChicago, to gain clinical experience by observing the management of the general ward, and to identify how effective physicians communicate.
Above all, I hope to use any knowledge I gain this summer to become an efficient, knowledgeable, and compassionate physician capable of providing the highest quality of care to my future patients.
Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago, Ill. He received his B.S. in Biology from Loyola University in Chicago in 2015 and his Master of Biomedical Science from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.
Lupus classification criteria need input from dermatologists
Editor’s note: This commentary relates to the story, “ New classification system for systemic lupus erythematosus moves forward .”
The ACR/EULAR committee that is developing new classification criteria for systemic lupus erythematosus (SLE) has done the field a service by releasing its draft version in a presentation at the recent EULAR meeting. Releasing the draft version facilitates comments before the new classification criteria become finalized.
Many in the derm-rheum field, ourselves included, classify patients with skin-predominant lupus as lupus, but the new draft classification would place a significant percentage of these patients outside of lupus.
The presentation by Dr. Johnson at EULAR stated, “... a patient can’t be classified on skin findings alone. There is concern that skin findings by themselves may not be lupus, but something else, and some people even consider that cutaneous and systemic lupus are two different things.”
Abundant data indicate instead that lupus is a spectrum that includes skin-predominant lupus. For example, the histology is identical between discoid lupus erythematosus whether or not there is SLE. Moreover, we and others have published significant rates of progression of cutaneous lupus erythematosus (CLE) to SLE. By not viewing CLE in the lupus spectrum, we have a false sense that the patients won’t progress to SLE, yet many of them do.
Importantly, patients respond similarly to therapies when they have either CLE or SLE, so removing this subset of lupus hurts their inclusion in trials and access to new treatments.
When criteria are devised by one group without input from experts who see a specific subset of the disease, that is also a problem. We went down that path in dermatomyositis and missed a lot of patients with the disease when criteria were devised that said the patient had to have muscle involvement. Those criteria have now finally been revised as the ACR/EULAR myositis criteria.
We and others from the derm-rheum community would be happy to speak with the ACR/EULAR committee about these concerns.
Victoria P. Werth, MD, is professor of medicine and dermatology at the University of Pennsylvania, Philadelphia. Joseph F. Merola, MD, is codirector of the Center for Skin and Related Musculoskeletal Diseases at Brigham and Women’s Hospital, Boston. Andrew G. Franks, MD, is a clinical professor in the departments of medicine and dermatology at New York University. Benjamin F. Chong, MD, is an assistant professor of dermatology at the University of Texas, Dallas.
Editor’s note: This commentary relates to the story, “ New classification system for systemic lupus erythematosus moves forward .”
The ACR/EULAR committee that is developing new classification criteria for systemic lupus erythematosus (SLE) has done the field a service by releasing its draft version in a presentation at the recent EULAR meeting. Releasing the draft version facilitates comments before the new classification criteria become finalized.
Many in the derm-rheum field, ourselves included, classify patients with skin-predominant lupus as lupus, but the new draft classification would place a significant percentage of these patients outside of lupus.
The presentation by Dr. Johnson at EULAR stated, “... a patient can’t be classified on skin findings alone. There is concern that skin findings by themselves may not be lupus, but something else, and some people even consider that cutaneous and systemic lupus are two different things.”
Abundant data indicate instead that lupus is a spectrum that includes skin-predominant lupus. For example, the histology is identical between discoid lupus erythematosus whether or not there is SLE. Moreover, we and others have published significant rates of progression of cutaneous lupus erythematosus (CLE) to SLE. By not viewing CLE in the lupus spectrum, we have a false sense that the patients won’t progress to SLE, yet many of them do.
Importantly, patients respond similarly to therapies when they have either CLE or SLE, so removing this subset of lupus hurts their inclusion in trials and access to new treatments.
When criteria are devised by one group without input from experts who see a specific subset of the disease, that is also a problem. We went down that path in dermatomyositis and missed a lot of patients with the disease when criteria were devised that said the patient had to have muscle involvement. Those criteria have now finally been revised as the ACR/EULAR myositis criteria.
We and others from the derm-rheum community would be happy to speak with the ACR/EULAR committee about these concerns.
Victoria P. Werth, MD, is professor of medicine and dermatology at the University of Pennsylvania, Philadelphia. Joseph F. Merola, MD, is codirector of the Center for Skin and Related Musculoskeletal Diseases at Brigham and Women’s Hospital, Boston. Andrew G. Franks, MD, is a clinical professor in the departments of medicine and dermatology at New York University. Benjamin F. Chong, MD, is an assistant professor of dermatology at the University of Texas, Dallas.
Editor’s note: This commentary relates to the story, “ New classification system for systemic lupus erythematosus moves forward .”
The ACR/EULAR committee that is developing new classification criteria for systemic lupus erythematosus (SLE) has done the field a service by releasing its draft version in a presentation at the recent EULAR meeting. Releasing the draft version facilitates comments before the new classification criteria become finalized.
Many in the derm-rheum field, ourselves included, classify patients with skin-predominant lupus as lupus, but the new draft classification would place a significant percentage of these patients outside of lupus.
The presentation by Dr. Johnson at EULAR stated, “... a patient can’t be classified on skin findings alone. There is concern that skin findings by themselves may not be lupus, but something else, and some people even consider that cutaneous and systemic lupus are two different things.”
Abundant data indicate instead that lupus is a spectrum that includes skin-predominant lupus. For example, the histology is identical between discoid lupus erythematosus whether or not there is SLE. Moreover, we and others have published significant rates of progression of cutaneous lupus erythematosus (CLE) to SLE. By not viewing CLE in the lupus spectrum, we have a false sense that the patients won’t progress to SLE, yet many of them do.
Importantly, patients respond similarly to therapies when they have either CLE or SLE, so removing this subset of lupus hurts their inclusion in trials and access to new treatments.
When criteria are devised by one group without input from experts who see a specific subset of the disease, that is also a problem. We went down that path in dermatomyositis and missed a lot of patients with the disease when criteria were devised that said the patient had to have muscle involvement. Those criteria have now finally been revised as the ACR/EULAR myositis criteria.
We and others from the derm-rheum community would be happy to speak with the ACR/EULAR committee about these concerns.
Victoria P. Werth, MD, is professor of medicine and dermatology at the University of Pennsylvania, Philadelphia. Joseph F. Merola, MD, is codirector of the Center for Skin and Related Musculoskeletal Diseases at Brigham and Women’s Hospital, Boston. Andrew G. Franks, MD, is a clinical professor in the departments of medicine and dermatology at New York University. Benjamin F. Chong, MD, is an assistant professor of dermatology at the University of Texas, Dallas.
Lupus classification criteria effort is going in the wrong direction
Editor’s note: This commentary relates to the story, “New classification system for systemic lupus erythematosus moves forward.”
While work to develop a new set of lupus classification criteria more suitable for clinical research is important, the Lupus Foundation of America believes the current work is going in the wrong direction.
Increasingly, key opinion leaders understand lupus to be a spectrum of disease, and there is ample justification of this from scientific evidence (Nat Rev Rheumatol. 2015;11[7]:385-6) The criteria being worked on by ACR and EULAR draws upon an archaic concept with the musty name of “systemic lupus erythematosus,” which relies on a 19th century approach to categorizing disease by counting the signs and symptoms instead of by modern concepts of pathophysiology and prognostic severity. This imposes a homogeneity on the population that simply does not exist. Attempts to re-order obsolescent arrays of organs and autoantibodies to classify lupus will be futile, especially if the aim is to improve the rationale for clinical trial recruitment. Recent clinical trials and modern immunologic methods have already demonstrated, beyond a doubt, that subsets of patients, definable by gene expression patterns or state of the art pharmacodynamic responses, do or do not respond to individual targeted treatments. We now know that patients who require different treatments may well share many of their symptoms in many of the same organs, and this fact defies the outmoded, abacus-based approach to disease classification.
We are concerned that redefining SLE by weighting all disease in one organ as more or less impactful than all disease in another organ flies in the face of current scientific knowledge. If this is the direction in which the effort is going, there is the potential for a negative impact on drug development, clinical care, and access to treatment. The term itself, “SLE,” interferes with selecting appropriate lupus patients for participation in trials. Many people have moderate and even severe lupus syndromes who do not meet enough criteria to be labeled “SLE” (for example, immune thrombocytopenia, hemolytic anemia, discoid lupus, or subacute cutaneous lupus, which can cause severe rashes covering wide areas of the body). In this iteration, assigning less weight to cutaneous lupus as currently proposed is not just problematic, it will set the field back.
By not viewing cutaneous lupus as part of the lupus spectrum, we develop a false sense that this subset of people with lupus will not progress to “SLE,” yet many of them do. Even those who do not later develop features in other organs besides the skin may have more severe disease than other patients who do. Minimizing the “score” for cutaneous lupus will lead to individuals who carry a significant burden of disease being barred from trials, and from access to the treatments they need, once approved.
Conversely, people who do meet criteria for “SLE” under any algorithm, past or present, may have a range of severity, from very severe to very mild. The very mild patients (who may have, in their lifetime met the multiorgan criteria) are entering trials in large numbers and contributing to the high placebo responses which have stopped many promising investigational treatments from further development. Additionally, the common misuse of the current classification criteria as diagnostic criteria has become an unacceptable norm in the lupus community. This leads us to believe that new criteria will continue to be misused, further disenfranchising a huge segment of the population who have lupus from access to state-of-the-art research and care.
Advancing the development new classification criteria deserves a wider discussion among the field’s stakeholders, particularly those with expertise in clinical trial outcomes and the clinical care of the full spectrum of lupus patients.
Sandra C. Raymond is CEO and President, Leslie M. Hanrahan is VP of Education and Research, and Joan Merrill, MD, is the Chief Adviser for Clinical Development at the Lupus Foundation of America. Dr. Merrill is also the Oklahoma Medical Research Foundation Professor of Medicine at the University of Oklahoma, Oklahoma City.
Editor’s note: This commentary relates to the story, “New classification system for systemic lupus erythematosus moves forward.”
While work to develop a new set of lupus classification criteria more suitable for clinical research is important, the Lupus Foundation of America believes the current work is going in the wrong direction.
Increasingly, key opinion leaders understand lupus to be a spectrum of disease, and there is ample justification of this from scientific evidence (Nat Rev Rheumatol. 2015;11[7]:385-6) The criteria being worked on by ACR and EULAR draws upon an archaic concept with the musty name of “systemic lupus erythematosus,” which relies on a 19th century approach to categorizing disease by counting the signs and symptoms instead of by modern concepts of pathophysiology and prognostic severity. This imposes a homogeneity on the population that simply does not exist. Attempts to re-order obsolescent arrays of organs and autoantibodies to classify lupus will be futile, especially if the aim is to improve the rationale for clinical trial recruitment. Recent clinical trials and modern immunologic methods have already demonstrated, beyond a doubt, that subsets of patients, definable by gene expression patterns or state of the art pharmacodynamic responses, do or do not respond to individual targeted treatments. We now know that patients who require different treatments may well share many of their symptoms in many of the same organs, and this fact defies the outmoded, abacus-based approach to disease classification.
We are concerned that redefining SLE by weighting all disease in one organ as more or less impactful than all disease in another organ flies in the face of current scientific knowledge. If this is the direction in which the effort is going, there is the potential for a negative impact on drug development, clinical care, and access to treatment. The term itself, “SLE,” interferes with selecting appropriate lupus patients for participation in trials. Many people have moderate and even severe lupus syndromes who do not meet enough criteria to be labeled “SLE” (for example, immune thrombocytopenia, hemolytic anemia, discoid lupus, or subacute cutaneous lupus, which can cause severe rashes covering wide areas of the body). In this iteration, assigning less weight to cutaneous lupus as currently proposed is not just problematic, it will set the field back.
By not viewing cutaneous lupus as part of the lupus spectrum, we develop a false sense that this subset of people with lupus will not progress to “SLE,” yet many of them do. Even those who do not later develop features in other organs besides the skin may have more severe disease than other patients who do. Minimizing the “score” for cutaneous lupus will lead to individuals who carry a significant burden of disease being barred from trials, and from access to the treatments they need, once approved.
Conversely, people who do meet criteria for “SLE” under any algorithm, past or present, may have a range of severity, from very severe to very mild. The very mild patients (who may have, in their lifetime met the multiorgan criteria) are entering trials in large numbers and contributing to the high placebo responses which have stopped many promising investigational treatments from further development. Additionally, the common misuse of the current classification criteria as diagnostic criteria has become an unacceptable norm in the lupus community. This leads us to believe that new criteria will continue to be misused, further disenfranchising a huge segment of the population who have lupus from access to state-of-the-art research and care.
Advancing the development new classification criteria deserves a wider discussion among the field’s stakeholders, particularly those with expertise in clinical trial outcomes and the clinical care of the full spectrum of lupus patients.
Sandra C. Raymond is CEO and President, Leslie M. Hanrahan is VP of Education and Research, and Joan Merrill, MD, is the Chief Adviser for Clinical Development at the Lupus Foundation of America. Dr. Merrill is also the Oklahoma Medical Research Foundation Professor of Medicine at the University of Oklahoma, Oklahoma City.
Editor’s note: This commentary relates to the story, “New classification system for systemic lupus erythematosus moves forward.”
While work to develop a new set of lupus classification criteria more suitable for clinical research is important, the Lupus Foundation of America believes the current work is going in the wrong direction.
Increasingly, key opinion leaders understand lupus to be a spectrum of disease, and there is ample justification of this from scientific evidence (Nat Rev Rheumatol. 2015;11[7]:385-6) The criteria being worked on by ACR and EULAR draws upon an archaic concept with the musty name of “systemic lupus erythematosus,” which relies on a 19th century approach to categorizing disease by counting the signs and symptoms instead of by modern concepts of pathophysiology and prognostic severity. This imposes a homogeneity on the population that simply does not exist. Attempts to re-order obsolescent arrays of organs and autoantibodies to classify lupus will be futile, especially if the aim is to improve the rationale for clinical trial recruitment. Recent clinical trials and modern immunologic methods have already demonstrated, beyond a doubt, that subsets of patients, definable by gene expression patterns or state of the art pharmacodynamic responses, do or do not respond to individual targeted treatments. We now know that patients who require different treatments may well share many of their symptoms in many of the same organs, and this fact defies the outmoded, abacus-based approach to disease classification.
We are concerned that redefining SLE by weighting all disease in one organ as more or less impactful than all disease in another organ flies in the face of current scientific knowledge. If this is the direction in which the effort is going, there is the potential for a negative impact on drug development, clinical care, and access to treatment. The term itself, “SLE,” interferes with selecting appropriate lupus patients for participation in trials. Many people have moderate and even severe lupus syndromes who do not meet enough criteria to be labeled “SLE” (for example, immune thrombocytopenia, hemolytic anemia, discoid lupus, or subacute cutaneous lupus, which can cause severe rashes covering wide areas of the body). In this iteration, assigning less weight to cutaneous lupus as currently proposed is not just problematic, it will set the field back.
By not viewing cutaneous lupus as part of the lupus spectrum, we develop a false sense that this subset of people with lupus will not progress to “SLE,” yet many of them do. Even those who do not later develop features in other organs besides the skin may have more severe disease than other patients who do. Minimizing the “score” for cutaneous lupus will lead to individuals who carry a significant burden of disease being barred from trials, and from access to the treatments they need, once approved.
Conversely, people who do meet criteria for “SLE” under any algorithm, past or present, may have a range of severity, from very severe to very mild. The very mild patients (who may have, in their lifetime met the multiorgan criteria) are entering trials in large numbers and contributing to the high placebo responses which have stopped many promising investigational treatments from further development. Additionally, the common misuse of the current classification criteria as diagnostic criteria has become an unacceptable norm in the lupus community. This leads us to believe that new criteria will continue to be misused, further disenfranchising a huge segment of the population who have lupus from access to state-of-the-art research and care.
Advancing the development new classification criteria deserves a wider discussion among the field’s stakeholders, particularly those with expertise in clinical trial outcomes and the clinical care of the full spectrum of lupus patients.
Sandra C. Raymond is CEO and President, Leslie M. Hanrahan is VP of Education and Research, and Joan Merrill, MD, is the Chief Adviser for Clinical Development at the Lupus Foundation of America. Dr. Merrill is also the Oklahoma Medical Research Foundation Professor of Medicine at the University of Oklahoma, Oklahoma City.
Lupus classification criteria effort is going in the wrong direction
Editor’s note: This commentary relates to the story, “New classification system for systemic lupus erythematosus moves forward.”
While work to develop a new set of lupus classification criteria more suitable for clinical research is important, the Lupus Foundation of America believes the current work is going in the wrong direction.
Increasingly, key opinion leaders understand lupus to be a spectrum of disease, and there is ample justification of this from scientific evidence (Nat Rev Rheumatol. 2015;11[7]:385-6) The criteria being worked on by ACR and EULAR draws upon an archaic concept with the musty name of “systemic lupus erythematosus,” which relies on a 19th century approach to categorizing disease by counting the signs and symptoms instead of by modern concepts of pathophysiology and prognostic severity. This imposes a homogeneity on the population that simply does not exist. Attempts to re-order obsolescent arrays of organs and autoantibodies to classify lupus will be futile, especially if the aim is to improve the rationale for clinical trial recruitment. Recent clinical trials and modern immunologic methods have already demonstrated, beyond a doubt, that subsets of patients, definable by gene expression patterns or state-of-the-art pharmacodynamic responses, do or do not respond to individual targeted treatments. We now know that patients who require different treatments may well share many of their symptoms in many of the same organs, and this fact defies the outmoded, abacus-based approach to disease classification.
We are concerned that redefining SLE by weighting all disease in one organ as more or less impactful than all disease in another organ flies in the face of current scientific knowledge. If this is the direction in which the effort is going, there is the potential for a negative impact on drug development, clinical care, and access to treatment. The term itself, “SLE,” interferes with selecting appropriate lupus patients for participation in trials. Many people have moderate and even severe lupus syndromes who do not meet enough criteria to be labeled “SLE” (for example, immune thrombocytopenia, hemolytic anemia, discoid lupus, or subacute cutaneous lupus, which can cause severe rashes covering wide areas of the body). In this iteration, assigning less weight to cutaneous lupus as currently proposed is not just problematic; it will set the field back.
By not viewing cutaneous lupus as part of the lupus spectrum, we develop a false sense that this subset of people with lupus will not progress to “SLE,” yet many of them do. Even those who do not later develop features in other organs besides the skin may have more severe disease than other patients who do. Minimizing the “score” for cutaneous lupus will lead to individuals who carry a significant burden of disease being barred from trials, and from access to the treatments they need, once approved.
Conversely, people who do meet criteria for “SLE” under any algorithm, past or present, may have a range of severity, from very severe to very mild. The very mild patients (who may have, in their lifetime, met the multiorgan criteria) are entering trials in large numbers and contributing to the high placebo responses which have stopped many promising investigational treatments from further development. Additionally, the common misuse of the current classification criteria as diagnostic criteria has become an unacceptable norm in the lupus community. This leads us to believe that new criteria will continue to be misused, further disenfranchising a huge segment of the population who have lupus from access to state-of-the-art research and care.
Advancing the development of new classification criteria deserves a wider discussion among the field’s stakeholders, particularly those with expertise in clinical trial outcomes and the clinical care of the full spectrum of lupus patients.
Sandra C. Raymond is CEO and President, Leslie M. Hanrahan is VP of Education and Research, and Joan Merrill, MD, is the Chief Adviser for Clinical Development at the Lupus Foundation of America. Dr. Merrill is also the Oklahoma Medical Research Foundation Professor of Medicine at the University of Oklahoma, Oklahoma City.
Editor’s note: This commentary relates to the story, “New classification system for systemic lupus erythematosus moves forward.”
While work to develop a new set of lupus classification criteria more suitable for clinical research is important, the Lupus Foundation of America believes the current work is going in the wrong direction.
Increasingly, key opinion leaders understand lupus to be a spectrum of disease, and there is ample justification of this from scientific evidence (Nat Rev Rheumatol. 2015;11[7]:385-6) The criteria being worked on by ACR and EULAR draws upon an archaic concept with the musty name of “systemic lupus erythematosus,” which relies on a 19th century approach to categorizing disease by counting the signs and symptoms instead of by modern concepts of pathophysiology and prognostic severity. This imposes a homogeneity on the population that simply does not exist. Attempts to re-order obsolescent arrays of organs and autoantibodies to classify lupus will be futile, especially if the aim is to improve the rationale for clinical trial recruitment. Recent clinical trials and modern immunologic methods have already demonstrated, beyond a doubt, that subsets of patients, definable by gene expression patterns or state-of-the-art pharmacodynamic responses, do or do not respond to individual targeted treatments. We now know that patients who require different treatments may well share many of their symptoms in many of the same organs, and this fact defies the outmoded, abacus-based approach to disease classification.
We are concerned that redefining SLE by weighting all disease in one organ as more or less impactful than all disease in another organ flies in the face of current scientific knowledge. If this is the direction in which the effort is going, there is the potential for a negative impact on drug development, clinical care, and access to treatment. The term itself, “SLE,” interferes with selecting appropriate lupus patients for participation in trials. Many people have moderate and even severe lupus syndromes who do not meet enough criteria to be labeled “SLE” (for example, immune thrombocytopenia, hemolytic anemia, discoid lupus, or subacute cutaneous lupus, which can cause severe rashes covering wide areas of the body). In this iteration, assigning less weight to cutaneous lupus as currently proposed is not just problematic; it will set the field back.
By not viewing cutaneous lupus as part of the lupus spectrum, we develop a false sense that this subset of people with lupus will not progress to “SLE,” yet many of them do. Even those who do not later develop features in other organs besides the skin may have more severe disease than other patients who do. Minimizing the “score” for cutaneous lupus will lead to individuals who carry a significant burden of disease being barred from trials, and from access to the treatments they need, once approved.
Conversely, people who do meet criteria for “SLE” under any algorithm, past or present, may have a range of severity, from very severe to very mild. The very mild patients (who may have, in their lifetime, met the multiorgan criteria) are entering trials in large numbers and contributing to the high placebo responses which have stopped many promising investigational treatments from further development. Additionally, the common misuse of the current classification criteria as diagnostic criteria has become an unacceptable norm in the lupus community. This leads us to believe that new criteria will continue to be misused, further disenfranchising a huge segment of the population who have lupus from access to state-of-the-art research and care.
Advancing the development of new classification criteria deserves a wider discussion among the field’s stakeholders, particularly those with expertise in clinical trial outcomes and the clinical care of the full spectrum of lupus patients.
Sandra C. Raymond is CEO and President, Leslie M. Hanrahan is VP of Education and Research, and Joan Merrill, MD, is the Chief Adviser for Clinical Development at the Lupus Foundation of America. Dr. Merrill is also the Oklahoma Medical Research Foundation Professor of Medicine at the University of Oklahoma, Oklahoma City.
Editor’s note: This commentary relates to the story, “New classification system for systemic lupus erythematosus moves forward.”
While work to develop a new set of lupus classification criteria more suitable for clinical research is important, the Lupus Foundation of America believes the current work is going in the wrong direction.
Increasingly, key opinion leaders understand lupus to be a spectrum of disease, and there is ample justification of this from scientific evidence (Nat Rev Rheumatol. 2015;11[7]:385-6) The criteria being worked on by ACR and EULAR draws upon an archaic concept with the musty name of “systemic lupus erythematosus,” which relies on a 19th century approach to categorizing disease by counting the signs and symptoms instead of by modern concepts of pathophysiology and prognostic severity. This imposes a homogeneity on the population that simply does not exist. Attempts to re-order obsolescent arrays of organs and autoantibodies to classify lupus will be futile, especially if the aim is to improve the rationale for clinical trial recruitment. Recent clinical trials and modern immunologic methods have already demonstrated, beyond a doubt, that subsets of patients, definable by gene expression patterns or state-of-the-art pharmacodynamic responses, do or do not respond to individual targeted treatments. We now know that patients who require different treatments may well share many of their symptoms in many of the same organs, and this fact defies the outmoded, abacus-based approach to disease classification.
We are concerned that redefining SLE by weighting all disease in one organ as more or less impactful than all disease in another organ flies in the face of current scientific knowledge. If this is the direction in which the effort is going, there is the potential for a negative impact on drug development, clinical care, and access to treatment. The term itself, “SLE,” interferes with selecting appropriate lupus patients for participation in trials. Many people have moderate and even severe lupus syndromes who do not meet enough criteria to be labeled “SLE” (for example, immune thrombocytopenia, hemolytic anemia, discoid lupus, or subacute cutaneous lupus, which can cause severe rashes covering wide areas of the body). In this iteration, assigning less weight to cutaneous lupus as currently proposed is not just problematic; it will set the field back.
By not viewing cutaneous lupus as part of the lupus spectrum, we develop a false sense that this subset of people with lupus will not progress to “SLE,” yet many of them do. Even those who do not later develop features in other organs besides the skin may have more severe disease than other patients who do. Minimizing the “score” for cutaneous lupus will lead to individuals who carry a significant burden of disease being barred from trials, and from access to the treatments they need, once approved.
Conversely, people who do meet criteria for “SLE” under any algorithm, past or present, may have a range of severity, from very severe to very mild. The very mild patients (who may have, in their lifetime, met the multiorgan criteria) are entering trials in large numbers and contributing to the high placebo responses which have stopped many promising investigational treatments from further development. Additionally, the common misuse of the current classification criteria as diagnostic criteria has become an unacceptable norm in the lupus community. This leads us to believe that new criteria will continue to be misused, further disenfranchising a huge segment of the population who have lupus from access to state-of-the-art research and care.
Advancing the development of new classification criteria deserves a wider discussion among the field’s stakeholders, particularly those with expertise in clinical trial outcomes and the clinical care of the full spectrum of lupus patients.
Sandra C. Raymond is CEO and President, Leslie M. Hanrahan is VP of Education and Research, and Joan Merrill, MD, is the Chief Adviser for Clinical Development at the Lupus Foundation of America. Dr. Merrill is also the Oklahoma Medical Research Foundation Professor of Medicine at the University of Oklahoma, Oklahoma City.
Lupus classification criteria need input from dermatologists
Editor’s note: This commentary relates to the story, “ New classification system for systemic lupus erythematosus moves forward .”
The ACR/EULAR committee that is developing new classification criteria for systemic lupus erythematosus (SLE) has done the field a service by releasing its draft version in a presentation at the recent EULAR meeting. Releasing the draft version facilitates comments before the new classification criteria become finalized.
Many in the derm-rheum field, ourselves included, classify patients with skin-predominant lupus as lupus, but the new draft classification would place a significant percentage of these patients outside of lupus.
The presentation by Dr. Johnson at EULAR stated, “... a patient can’t be classified on skin findings alone. There is concern that skin findings by themselves may not be lupus, but something else, and some people even consider that cutaneous and systemic lupus are two different things.”
Abundant data indicate instead that lupus is a spectrum that includes skin-predominant lupus. For example, the histology is identical between discoid lupus erythematosus whether or not there is SLE. Moreover, we and others have published significant rates of progression of cutaneous lupus erythematosus (CLE) to SLE. By not viewing CLE in the lupus spectrum, we have a false sense that the patients won’t progress to SLE, yet many of them do.
Importantly, patients respond similarly to therapies when they have either CLE or SLE, so removing this subset of lupus hurts their inclusion in trials and access to new treatments.
When criteria are devised by one group without input from experts who see a specific subset of the disease, that is also a problem. We went down that path in dermatomyositis and missed a lot of patients with the disease when criteria were devised that said the patient had to have muscle involvement. Those criteria have now finally been revised as the ACR/EULAR myositis criteria.
We and others from the derm-rheum community would be happy to speak with the ACR/EULAR committee about these concerns.
Victoria P. Werth, MD, is professor of medicine and dermatology at the University of Pennsylvania, Philadelphia. Joseph F. Merola, MD, is codirector of the Center for Skin and Related Musculoskeletal Diseases at Brigham and Women’s Hospital, Boston. Andrew G. Franks, MD, is a clinical professor in the departments of medicine and dermatology at New York University. Benjamin F. Chong, MD, is an assistant professor of dermatology at the University of Texas, Dallas.
Editor’s note: This commentary relates to the story, “ New classification system for systemic lupus erythematosus moves forward .”
The ACR/EULAR committee that is developing new classification criteria for systemic lupus erythematosus (SLE) has done the field a service by releasing its draft version in a presentation at the recent EULAR meeting. Releasing the draft version facilitates comments before the new classification criteria become finalized.
Many in the derm-rheum field, ourselves included, classify patients with skin-predominant lupus as lupus, but the new draft classification would place a significant percentage of these patients outside of lupus.
The presentation by Dr. Johnson at EULAR stated, “... a patient can’t be classified on skin findings alone. There is concern that skin findings by themselves may not be lupus, but something else, and some people even consider that cutaneous and systemic lupus are two different things.”
Abundant data indicate instead that lupus is a spectrum that includes skin-predominant lupus. For example, the histology is identical between discoid lupus erythematosus whether or not there is SLE. Moreover, we and others have published significant rates of progression of cutaneous lupus erythematosus (CLE) to SLE. By not viewing CLE in the lupus spectrum, we have a false sense that the patients won’t progress to SLE, yet many of them do.
Importantly, patients respond similarly to therapies when they have either CLE or SLE, so removing this subset of lupus hurts their inclusion in trials and access to new treatments.
When criteria are devised by one group without input from experts who see a specific subset of the disease, that is also a problem. We went down that path in dermatomyositis and missed a lot of patients with the disease when criteria were devised that said the patient had to have muscle involvement. Those criteria have now finally been revised as the ACR/EULAR myositis criteria.
We and others from the derm-rheum community would be happy to speak with the ACR/EULAR committee about these concerns.
Victoria P. Werth, MD, is professor of medicine and dermatology at the University of Pennsylvania, Philadelphia. Joseph F. Merola, MD, is codirector of the Center for Skin and Related Musculoskeletal Diseases at Brigham and Women’s Hospital, Boston. Andrew G. Franks, MD, is a clinical professor in the departments of medicine and dermatology at New York University. Benjamin F. Chong, MD, is an assistant professor of dermatology at the University of Texas, Dallas.
Editor’s note: This commentary relates to the story, “ New classification system for systemic lupus erythematosus moves forward .”
The ACR/EULAR committee that is developing new classification criteria for systemic lupus erythematosus (SLE) has done the field a service by releasing its draft version in a presentation at the recent EULAR meeting. Releasing the draft version facilitates comments before the new classification criteria become finalized.
Many in the derm-rheum field, ourselves included, classify patients with skin-predominant lupus as lupus, but the new draft classification would place a significant percentage of these patients outside of lupus.
The presentation by Dr. Johnson at EULAR stated, “... a patient can’t be classified on skin findings alone. There is concern that skin findings by themselves may not be lupus, but something else, and some people even consider that cutaneous and systemic lupus are two different things.”
Abundant data indicate instead that lupus is a spectrum that includes skin-predominant lupus. For example, the histology is identical between discoid lupus erythematosus whether or not there is SLE. Moreover, we and others have published significant rates of progression of cutaneous lupus erythematosus (CLE) to SLE. By not viewing CLE in the lupus spectrum, we have a false sense that the patients won’t progress to SLE, yet many of them do.
Importantly, patients respond similarly to therapies when they have either CLE or SLE, so removing this subset of lupus hurts their inclusion in trials and access to new treatments.
When criteria are devised by one group without input from experts who see a specific subset of the disease, that is also a problem. We went down that path in dermatomyositis and missed a lot of patients with the disease when criteria were devised that said the patient had to have muscle involvement. Those criteria have now finally been revised as the ACR/EULAR myositis criteria.
We and others from the derm-rheum community would be happy to speak with the ACR/EULAR committee about these concerns.
Victoria P. Werth, MD, is professor of medicine and dermatology at the University of Pennsylvania, Philadelphia. Joseph F. Merola, MD, is codirector of the Center for Skin and Related Musculoskeletal Diseases at Brigham and Women’s Hospital, Boston. Andrew G. Franks, MD, is a clinical professor in the departments of medicine and dermatology at New York University. Benjamin F. Chong, MD, is an assistant professor of dermatology at the University of Texas, Dallas.
Small community hospitals need antibiotic stewardship programs
Antibiotic use and misuse is driving drug resistance. Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year as a result of these infections, according to the Centers for Disease Control and Prevention.
Over 70% of U.S. hospitals are small community hospitals with 200 beds or fewer; however, our understanding of antibiotic use in these facilities is extremely limited. Most of the existing data on antibiotic use rates come from larger academic medical centers. Describing antibiotic usage patterns in small facilities is a high priority, given they constitute the majority of acute care hospitals and national antibiotic stewardship is forthcoming.
Intermountain has a long history of antibiotic use measurements and digital data support. All facilities use an electronic medical record system that transmits data to a centralized enterprise data warehouse. Since 2011, antibiotic use reports have been collected from the data system and submitted to the CDC’s National Healthcare and Safety Network Antimicrobial Use (NHSN AU) module.
Using data from the NHSN AU module from January 2011 through December 2013, we calculated monthly and 3-year antibiotic use rates for each facility, care unit type, and antibiotic category. Data included in the NHSN AU modules include:
• Patient care location.
• Facility-wide antibiotic use.
• Use of individual antibiotics.
• Classes of antibiotics.
• Days of therapy.
• Patient-day data.
Antibiotic agents were categorized into five groups based on antibiotic spectrum and ability to treat multidrug-resistant organisms (MDROs). Category one antibiotics are narrower-spectrum agents, and category five antibiotics are the broadest-spectrum antibiotics or associated with treating MDROs. Categories four and five were classified as broad-spectrum antibiotics. Hospital care units were categorized as intensive care, medical/surgical, pediatric, or miscellaneous.
Antibiotic use rates, expressed as days of therapy per 1,000 patient-days (DOT/1000PD), were calculated for each small community hospital and compared with rates in large community hospitals. Negative-binomial regression was used to relate antibiotic use.
The key findings of the study include:
• Total antibiotic use rates varied widely across the 15 small community hospitals and were similar to rates in four large community hospitals.
• The proportion of patient-days spent in the respective care unit types varied substantially within small community hospitals and had a large impact on facility-level antibiotic use rates.
• Broad-spectrum antibiotics accounted for 26% of use in small community hospitals, similar to the proportion in large community hospitals.
• Significant predictors of antibiotic use include case mix index, proportion of patient-days in specific care unit types, and season.
• Small community hospitals need to become a focus of antibiotic stewardship efforts.
All hospitals in 2017 are required to have an antibiotic stewardship program in place according to Joint Commission guidelines. Small community hospitals in the United States face significant challenges meeting the national antibiotic stewardship requirements. These challenges include: limited access to infectious diseases physician and/or pharmacist leadership, limited information technology support, and lack of antibiotic guidance.
In order to holistically address the growing problem of antibiotic-resistant bacteria, the infectious disease community must respond to antibiotic use in ALL hospitals, not just the large academic medical facilities. Small hospitals are least likely to have stewardship programs even though antibiotic usage patterns are similar to larger facilities. We need to bring stewardship support to ALL hospitals, but the challenges come in knowing how to do that.
To address the challenges, researchers at Intermountain Healthcare are currently conducting a study to identify recommendations that will help build antibiotic stewardship programs for these facilities.
Eddie Stenehjem, MD, is an infectious disease physician and researcher at Intermountain Medical Center, Salt Lake City, the flagship facility for the Intermountain Healthcare system.
Antibiotic use and misuse is driving drug resistance. Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year as a result of these infections, according to the Centers for Disease Control and Prevention.
Over 70% of U.S. hospitals are small community hospitals with 200 beds or fewer; however, our understanding of antibiotic use in these facilities is extremely limited. Most of the existing data on antibiotic use rates come from larger academic medical centers. Describing antibiotic usage patterns in small facilities is a high priority, given they constitute the majority of acute care hospitals and national antibiotic stewardship is forthcoming.
Intermountain has a long history of antibiotic use measurements and digital data support. All facilities use an electronic medical record system that transmits data to a centralized enterprise data warehouse. Since 2011, antibiotic use reports have been collected from the data system and submitted to the CDC’s National Healthcare and Safety Network Antimicrobial Use (NHSN AU) module.
Using data from the NHSN AU module from January 2011 through December 2013, we calculated monthly and 3-year antibiotic use rates for each facility, care unit type, and antibiotic category. Data included in the NHSN AU modules include:
• Patient care location.
• Facility-wide antibiotic use.
• Use of individual antibiotics.
• Classes of antibiotics.
• Days of therapy.
• Patient-day data.
Antibiotic agents were categorized into five groups based on antibiotic spectrum and ability to treat multidrug-resistant organisms (MDROs). Category one antibiotics are narrower-spectrum agents, and category five antibiotics are the broadest-spectrum antibiotics or associated with treating MDROs. Categories four and five were classified as broad-spectrum antibiotics. Hospital care units were categorized as intensive care, medical/surgical, pediatric, or miscellaneous.
Antibiotic use rates, expressed as days of therapy per 1,000 patient-days (DOT/1000PD), were calculated for each small community hospital and compared with rates in large community hospitals. Negative-binomial regression was used to relate antibiotic use.
The key findings of the study include:
• Total antibiotic use rates varied widely across the 15 small community hospitals and were similar to rates in four large community hospitals.
• The proportion of patient-days spent in the respective care unit types varied substantially within small community hospitals and had a large impact on facility-level antibiotic use rates.
• Broad-spectrum antibiotics accounted for 26% of use in small community hospitals, similar to the proportion in large community hospitals.
• Significant predictors of antibiotic use include case mix index, proportion of patient-days in specific care unit types, and season.
• Small community hospitals need to become a focus of antibiotic stewardship efforts.
All hospitals in 2017 are required to have an antibiotic stewardship program in place according to Joint Commission guidelines. Small community hospitals in the United States face significant challenges meeting the national antibiotic stewardship requirements. These challenges include: limited access to infectious diseases physician and/or pharmacist leadership, limited information technology support, and lack of antibiotic guidance.
In order to holistically address the growing problem of antibiotic-resistant bacteria, the infectious disease community must respond to antibiotic use in ALL hospitals, not just the large academic medical facilities. Small hospitals are least likely to have stewardship programs even though antibiotic usage patterns are similar to larger facilities. We need to bring stewardship support to ALL hospitals, but the challenges come in knowing how to do that.
To address the challenges, researchers at Intermountain Healthcare are currently conducting a study to identify recommendations that will help build antibiotic stewardship programs for these facilities.
Eddie Stenehjem, MD, is an infectious disease physician and researcher at Intermountain Medical Center, Salt Lake City, the flagship facility for the Intermountain Healthcare system.
Antibiotic use and misuse is driving drug resistance. Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year as a result of these infections, according to the Centers for Disease Control and Prevention.
Over 70% of U.S. hospitals are small community hospitals with 200 beds or fewer; however, our understanding of antibiotic use in these facilities is extremely limited. Most of the existing data on antibiotic use rates come from larger academic medical centers. Describing antibiotic usage patterns in small facilities is a high priority, given they constitute the majority of acute care hospitals and national antibiotic stewardship is forthcoming.
Intermountain has a long history of antibiotic use measurements and digital data support. All facilities use an electronic medical record system that transmits data to a centralized enterprise data warehouse. Since 2011, antibiotic use reports have been collected from the data system and submitted to the CDC’s National Healthcare and Safety Network Antimicrobial Use (NHSN AU) module.
Using data from the NHSN AU module from January 2011 through December 2013, we calculated monthly and 3-year antibiotic use rates for each facility, care unit type, and antibiotic category. Data included in the NHSN AU modules include:
• Patient care location.
• Facility-wide antibiotic use.
• Use of individual antibiotics.
• Classes of antibiotics.
• Days of therapy.
• Patient-day data.
Antibiotic agents were categorized into five groups based on antibiotic spectrum and ability to treat multidrug-resistant organisms (MDROs). Category one antibiotics are narrower-spectrum agents, and category five antibiotics are the broadest-spectrum antibiotics or associated with treating MDROs. Categories four and five were classified as broad-spectrum antibiotics. Hospital care units were categorized as intensive care, medical/surgical, pediatric, or miscellaneous.
Antibiotic use rates, expressed as days of therapy per 1,000 patient-days (DOT/1000PD), were calculated for each small community hospital and compared with rates in large community hospitals. Negative-binomial regression was used to relate antibiotic use.
The key findings of the study include:
• Total antibiotic use rates varied widely across the 15 small community hospitals and were similar to rates in four large community hospitals.
• The proportion of patient-days spent in the respective care unit types varied substantially within small community hospitals and had a large impact on facility-level antibiotic use rates.
• Broad-spectrum antibiotics accounted for 26% of use in small community hospitals, similar to the proportion in large community hospitals.
• Significant predictors of antibiotic use include case mix index, proportion of patient-days in specific care unit types, and season.
• Small community hospitals need to become a focus of antibiotic stewardship efforts.
All hospitals in 2017 are required to have an antibiotic stewardship program in place according to Joint Commission guidelines. Small community hospitals in the United States face significant challenges meeting the national antibiotic stewardship requirements. These challenges include: limited access to infectious diseases physician and/or pharmacist leadership, limited information technology support, and lack of antibiotic guidance.
In order to holistically address the growing problem of antibiotic-resistant bacteria, the infectious disease community must respond to antibiotic use in ALL hospitals, not just the large academic medical facilities. Small hospitals are least likely to have stewardship programs even though antibiotic usage patterns are similar to larger facilities. We need to bring stewardship support to ALL hospitals, but the challenges come in knowing how to do that.
To address the challenges, researchers at Intermountain Healthcare are currently conducting a study to identify recommendations that will help build antibiotic stewardship programs for these facilities.
Eddie Stenehjem, MD, is an infectious disease physician and researcher at Intermountain Medical Center, Salt Lake City, the flagship facility for the Intermountain Healthcare system.
From Obamacare to Trumpcare – implications for gastroenterologists
The June issue of CGH was the final column under my management. I have enjoyed the opportunity to provide you with information about practice management and health care reform. I also have enjoyed working with the Clinical Gastroenterology and Hepatology board of editors, and Erin Landis and Brook Simpson from AGA headquarters. Beginning in July 2017, this section will become the responsibility of Ziad Gellad, MD, MPH, AGAF, from Duke University. I have worked with Ziad for many years, and he serves on my board of editors for GI & Hepatology News. I have great confidence in his knowledge and ability.
During the last 5 years, we have published 58 columns beginning with an article where I made several broad predictions. I have tried to present important concepts and management tools related to private and academic clinical practice, health care reform, and health economics. This article was written in early January 2017 just before the inauguration of Donald Trump. As I wrote, we did not know the full extent or the pace of “Repeal and Replace,” as Obamacare becomes Trumpcare (www.healthaffairs.org/obamacare-to-trumpcare).
The extent of current Republican control of federal and state governments is unprecedented in modern political history. Per Newt Gingrich (The Economist, Jan. 7, 2017, p. 25), this will be the third attempt, after Ronald Reagan’s election in 1980 and Gingrich’s “Contract with America” in 1994, to break free from a “Big Government” mindset initiated by Franklin Roosevelt’s New Deal. In this article, I will speculate how a right-leaning shift in American health care policy might impact the business model of gastroenterology. No matter how government regulations or funds flow change, we (physicians) will ultimately be responsible for digestive care provided to our patients. In the words of Martin Luther King Jr. (as he paraphrased Theodore Parker), “The arc of the moral universe is long, but it bends toward justice.” What is remembered by fewer people, however, are words he then added during his speeches: “but only if we march.”
John I. Allen, MD, MBA, AGAF
Editor in Chief
The first column was published in July 2012.1 I wrote about five dominant themes that would alter our gastroenterology practices in the ensuing years. They were 1) an increasing requirement for us to demonstrate value, 2) the need to think about population management in addition to individual patient care, 3) consolidation that would occur at all levels of health care delivery, 4) increasing cost pressure, and 5) how medical decisions would be linked to reimbursement (now called value-based payment). I fully expected the Patient Protection and Affordable Care Act (ACA) would shape the health care landscape for the rest of our careers. After the article’s publication, I was invited to speak about health care reform at many academic centers and private practices. My last talk before the election was in Pasadena, Calif. (Oct. 28, 2016) where I confidently spoke about the implications of President Clinton’s cementing ACA into the fabric of U.S. medicine.
Donald Trump is now the 45th President of the United States. Republicans hold a 52-48 majority in the Senate and a 241-194 majority in the House. As of January 2017, one Supreme Court seat was available, and three more may open because of retirements (Justice Ginsburg is 83 years old, Justice Kennedy is 80, and Justice Breyer is 78). Republicans control all three branches of government in 25 states and dominate in 8 others. Conservative politicians control a large majority of county and city boards.
Until this year, Republicans have controlled all three branches of government only twice since 1945 (modern political history), and only once (George Bush in 2005) did the president have a Senate majority.2 With his win, Mr. Trump can lead a conservative revolution to reverse key initiatives begun when the Democratic Party held majority power. Repeal of the ACA, signed into legislation on March 23, 2010, is the Republican Party’s top priority.
Equally important, Congress can alter previously implemented federal regulations. Each year about 3,000 regulations are written by federal agencies that act with authority delegated by Congress (albeit Congress retains power to overturn them). Regulations are published in the Federal Register as preliminary rules during each year, and Final Rules are published after a public comment period and implemented shortly thereafter. Regulations carry the force of law and are codified in the Code of Federal Regulations. The Code of Federal Regulations is divided into 50 sections (Titles), with Title 42 (Public Health) and Title 45 (Public Welfare) most pertinent to us.
Other policies are created through executive orders, issued by the president (federal) or governors (states), without involvement of legislative or judicial branches (they were not mentioned in the Constitution, by the way). Executive orders issued by President Obama could, theoretically, be overturned by new executive orders.
Repeal and replace
Destruction of the ACA is a top priority of President Trump and Republican leaders of both houses of Congress. The ACA was a Democratic bill (passed with no Republican support), although it had many similarities to previous Republican legislative ideas dating from 1993.3
Although outright repeal could be blocked by a Democratic filibuster, the law could be drastically modified through budget reconciliation whose passage takes only a simple Senate majority. Thus, a simple budget-related bill could serve as a vehicle to defund many parts of ACA, including money for Medicaid expansion, insurance risk corridors, money to offset out-of-pocket expenses and individual premium subsidies, for example.4,5
There would be substantial problems if ACA were repealed even with a 2- or 3-year delay, a scenario proposed to provide time for a replacement bill. On Jan. 4, 2017, the House Republican Study Committee introduced the American Health Care Reform Act (AHCRA) as a replacement proposal, with the stipulation that ACA would be repealed as of Jan. 1, 2018. This initial bill hinted at Republican intent and was detailed in a Health Affairs blog.6 Importantly, there were distinct similarities between this and prior Republican proposals put forward by Representative Tom Price (nominated to head the Department of Health & Human Services under President Trump) and Speaker of the House Paul Ryan.7,8
Consistently, Republicans have advocated for expansion of health savings accounts, altering the tax code to allow individuals to deduct health insurance premiums, establishment of association risk pools, imposition of malpractice limits, protections for people with preexisting conditions, and further restrictions on abortion coverage. The AHCRA changes financial subsidies for purchasing insurance from a tax credit (which can be paid to people even if they do not pay taxes) to a tax deduction (only applicable to people who pay taxes). Analysis of a similar proposal made by President Trump during the campaign found that this plan would increase the number of uninsured people by more than 15 million.
If ACA is repealed, effects would be broader than just factors related to insurance coverage.9 ACA provides for preventive care (including colonoscopy) without copays, education of additional medical personnel, closing the donut hole for Medicare Part D (medications), approval of generic biologics, and Medicaid expansions, among other initiatives. If ACA were defunded without restoring pre-ACA support for Disproportion Share Hospital charity care, research, and graduate medical education, then safety-net hospitals and many academic medical centers (AMCs) could face enormous funding cuts.10 Defunding Medicaid expansion would adversely affect states in many ways, as pointed out by Ayanian et al.11 Medicaid expansion had broad economic impact in states that accepted federal money to expand. In Michigan for example, 30,900 jobs were added to the state in 2016 because of Medicaid expansion, with two-thirds outside of the health care industry. President Obama defined his view about the effects of ACA repeal in the New England Journal of Medicine.12
Lessons learned
Economic principles and unique characteristics of United States health care help explain why solutions to its high cost and uneven coverage are so difficult to achieve. These include higher prices for goods in the United States compared with other countries, variation in price (unrelated to quality), restraints on government price negotiations, inefficiencies due to variation in size of delivery systems, and “moral hazard” related to rich insurance coverage, which are some of the factors that doom any simple solutions. These are reviewed by Victor Fuchs13 in an excellent article in Annals of Internal Medicine. Payment methods for health care services also distort resource use and efficiencies. Understanding the eight basic payment methodologies in health care and current predictions about future health care spending will be important in shaping reimbursement policies.14,15
Disruptions in health care are unpopular and, as Uve Reinardt stated: “Our health care financing system will always remain a horrendous mess and a fountain for such dismay among the providers of health care as well as among patients.”4 Lessons to inform the next iteration of health care policy, learned from the 2009-2010 experience, might be as follows:
1. If a bill is to be passed, the president must personally lead in explaining the bill to the public in simple terms.
2. Even the threat of repeal may disrupt the current market and force insurance companies to exit quickly.
3. Coverage must be affordable to individuals, state budgets, and health care providers. Because expansion states saw positive impacts to state budgets8 and mental health and substance abuse services became part of Medicaid benefits, how will a replacement bill maintain coverage and compensate for new state moneys used now for other imperatives such as education and infrastructure?
4. Health care is like a massive cargo ship, not a sports car, so a bill to replace the ACA may take a long time (and might never be passed).
5. Health care is intensely personal, so it will always be politically charged.
Ultimately, physicians will need to make strategic guesses and rapid adjustments to sustain financial viability and provide high-value care. Strategies differ depending on your practice situation. Keep in mind the five principles listed in the opening paragraph of this article. It is likely that the most important principle to factor into your practice strategy is continuing reduction in reimbursements. No matter what model is adopted to reform the ACA, the financial pot (Medicare, Medicaid, commercial insurance, bundled payments, fee-for-service payments) will be reduced, and the number of uninsured patients will increase. How would you change your practice if Medicare was your best payer (“manage to Medicare”)?
Independent practices
Physicians in small- to medium-size independent practices continue to struggle with reducing reimbursements, reporting burdens, increasing overhead expenses, crushing regulatory requirements, and provider burnout. Trumpcare will favor small practices more than Obamacare from a policy (not necessarily a financial) perspective. Regulations on small business and reporting burdens may ease, but the move toward value-based reimbursement as outlined in the MACRA (passed with overwhelming bipartisan support) will not end.16 Practices in small communities continue to thrive because they give excellent care with limited competition and low overhead. Some practices in suburban and urban centers struggle because payers tend to favor (with enhanced managed care rates) larger practices and health systems. Large, horizontally integrated, efficient gastroenterology practices will continue to thrive because they can develop a “must-have” position with payers. Building remote patient monitoring, teleconsulting, and capabilities around value demonstration will be strategically advantageous.
Options for independent physicians include 1) maintaining status quo, 2) retiring, or 3) exiting the independent business model through a practice sale. Traditionally, physicians who wanted to sell their practices turned to hospitals or health systems. Recently, a physician-run model funded by venture capital has emerged where reduced overhead (through centralization of services) is combined with enhanced power during payer negotiations (because of scale). This model has allowed practices to merge into a physician organization and remain free from health system employment.17
Large health systems
Physicians employed by large health systems, whether they are nonprofit, for-profit, or AMCs, will see their future tied directly to health system success. If bundled payment, alternative payment, and capitation models of health care financing continue to grow in popularity, then success will be determined by a health system’s market share and its ability to form true clinical integration. In a capitated environment, expansion of market share (especially of relatively healthy patients) will help support margins. However, financial success will come from a system’s ability to manage high-cost patients, those 5% of patients who consume 50% of health care resources.18
Hospitals with a financially challenged patient base (safety-net hospitals) will have enormous financial pressures going forward. Repeal of ACA without restoration of pre-ACA funding will affect directly the financial health of systems including AMCs. AMCs and other health systems will be forced to reduce fixed overhead, enhance productivity of faculty, and restrict nonfunded activities (teaching for example). Although most AMCs are now in an active acquisition mode, this strategy is naturally limited by the number of remaining acquisition targets. Traditional high managed care rates enjoyed by AMCs will shrink, as will federal research funding (which typically comes with high indirect financial support). Health systems and GI societies will need to dedicate much more attention to state policy makers as Trumpcare progresses.
Finally, all providers will need to manage the business implications of retail health. As people assume higher deductibles and copays and health savings accounts grow, patients will change their patterns of purchasing services. Reputation counts for less when people are facing large price differences, so attention to patient-centric amenities, price, patient engagement, and patient satisfaction will become even more important.
Conclusion
The United States has undergone a massive and rapid political transformation. The mandate felt by conservative politicians, perhaps not supported by numbers, will carry a conservative platform forward. In areas where progressive Democrats emphasized federal power and socialized regulation (religion, education, civil rights, income security, and health policy), conservatives will transfer decision power as much as possible to states, local communities, and individuals. Maintaining the concept of “health as a right” will test the conscience of all of us.
References
1. Allen, J.I. The road ahead. Clin Gastroenterol Hepatol. 2012;10:692-6.
2. Gill KE. Visual guide: the balance of power between Congress and the Presidency (1901-2016). Wired Pen. November 2016. Available from http://wiredpen.com/resources/political-commentary-and-analysis/a-visual-guide-balance-of-power-congress-presidency/. Accessed Dec. 30, 2016.
3. Mertens M. Chart: comparing health reform bills – Democrats and Republicans 2009, Republics 1993. Kaiser Health News. Feb. 24, 2010. Available from http://khn.org/022310-bill-comparison/. Accessed Jan. 8, 2017.
4. Hotchkiss M. Q&A: what a Trump presidency means for the Affordable Care Act. Nov. 16, 2016 News at Princeton. Princeton University. Available from https://www.princeton.edu/main/news/archive/S47/93/09C11/index.xml?section=topstories. Accessed Dec. 30, 2016.
5. Jost T. Taking stock of health reform: where we’ve been, where we’re going. Health Affairs Blog. Available from http://healthaffairs.org/blog/2016/12/06/taking-stock-of-health-reform-where-weve-been-where-were-going/. Accessed Dec. 30, 2016.
6. Jost T. The Republican Study Committee’s ACA replacement proposal (updated). Health Affairs Blog. Available from http://healthaffairs.org/blog/2017/01/05/the-republican-study-committees-aca-replacement-proposal/. Accessed Jan. 10, 2017.
7. Price T. Empowering patients first. Available from http://tomprice.house.gov/sites/tomprice.house.gov/files/HR%202300%20Empowering%20Patients%20First%20Act%202015.pdf. Accessed Dec. 30, 2016.
8. Ryan P. A better way. Available from https://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf. Accessed Dec. 30, 2016.
9. Oberlander, J. The end of Obamacare. N Engl J Med. 2017;376:1-3.
10. Goodnough A. Hospitals in safety net brace for health care law’s repeal. New York Times. Dec. 28, 2016. Available from http://www.nytimes.com/2016/12/28/health/hospitals-medicaid-obamacare-trump.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0. Accessed Jan. 10, 2017.
11. Ayanian, J.Z., Ehrlich, G.M., Grimes, D.R., et al. Economic effects of Medicaid expansion in Michigan. N Engl J Med. 2017;376:407-10.
12. Obama, B.H. Repealing the ACA without a replacement: the risks to American health care. N Engl J Med. 2017;376:297-9.
13. Fuchs, V.R. Major concepts of health economics. Ann Intern Med. 2015;162:380-3.
14. Quinn, K. The 8 basic payment methods in health care. Ann Intern Med. 2015;163:300-6.
15. Schoenman JA. A detailed look at US health care spending: a presentation from the National Institute for Health Care Management (NIHCM). Oct. 25, 2012. Available from http://www.nihcm.org/images/stories/Health_care_spending_slides_-_MILI_-_Schoenman.pdf. Accessed Dec. 30, 2016.
16. Allen, J.I., Allen, C.C., Brill, J.V. Gastroenterology 2020: no time for WIMPs. Gastroenterology. 2016;150:295-9.
17. Sciacca R. Weekly Byte: GI roundtable and navigating uncharted waters in health care. The PMD Blog. Available from https://www.pmd.com/blog/post/weekly-byte-gi-roundtable-and-navigating-uncharted-waters-in-health-care. Accessed Jan. 10, 2017.
18. Powers, B.W., Chaguturu, S.K. ACOs and high-cost patients. N Engl J Med. 2016;374:203-5.
Dr. Allen is professor of medicine, University of Michigan School of Medicine, Institute for Health Care Policy and Innovations, and associate medical director of Network Strategy and Business Development – Michigan Medicine, Ann Arbor. He discloses no conflicts.
The June issue of CGH was the final column under my management. I have enjoyed the opportunity to provide you with information about practice management and health care reform. I also have enjoyed working with the Clinical Gastroenterology and Hepatology board of editors, and Erin Landis and Brook Simpson from AGA headquarters. Beginning in July 2017, this section will become the responsibility of Ziad Gellad, MD, MPH, AGAF, from Duke University. I have worked with Ziad for many years, and he serves on my board of editors for GI & Hepatology News. I have great confidence in his knowledge and ability.
During the last 5 years, we have published 58 columns beginning with an article where I made several broad predictions. I have tried to present important concepts and management tools related to private and academic clinical practice, health care reform, and health economics. This article was written in early January 2017 just before the inauguration of Donald Trump. As I wrote, we did not know the full extent or the pace of “Repeal and Replace,” as Obamacare becomes Trumpcare (www.healthaffairs.org/obamacare-to-trumpcare).
The extent of current Republican control of federal and state governments is unprecedented in modern political history. Per Newt Gingrich (The Economist, Jan. 7, 2017, p. 25), this will be the third attempt, after Ronald Reagan’s election in 1980 and Gingrich’s “Contract with America” in 1994, to break free from a “Big Government” mindset initiated by Franklin Roosevelt’s New Deal. In this article, I will speculate how a right-leaning shift in American health care policy might impact the business model of gastroenterology. No matter how government regulations or funds flow change, we (physicians) will ultimately be responsible for digestive care provided to our patients. In the words of Martin Luther King Jr. (as he paraphrased Theodore Parker), “The arc of the moral universe is long, but it bends toward justice.” What is remembered by fewer people, however, are words he then added during his speeches: “but only if we march.”
John I. Allen, MD, MBA, AGAF
Editor in Chief
The first column was published in July 2012.1 I wrote about five dominant themes that would alter our gastroenterology practices in the ensuing years. They were 1) an increasing requirement for us to demonstrate value, 2) the need to think about population management in addition to individual patient care, 3) consolidation that would occur at all levels of health care delivery, 4) increasing cost pressure, and 5) how medical decisions would be linked to reimbursement (now called value-based payment). I fully expected the Patient Protection and Affordable Care Act (ACA) would shape the health care landscape for the rest of our careers. After the article’s publication, I was invited to speak about health care reform at many academic centers and private practices. My last talk before the election was in Pasadena, Calif. (Oct. 28, 2016) where I confidently spoke about the implications of President Clinton’s cementing ACA into the fabric of U.S. medicine.
Donald Trump is now the 45th President of the United States. Republicans hold a 52-48 majority in the Senate and a 241-194 majority in the House. As of January 2017, one Supreme Court seat was available, and three more may open because of retirements (Justice Ginsburg is 83 years old, Justice Kennedy is 80, and Justice Breyer is 78). Republicans control all three branches of government in 25 states and dominate in 8 others. Conservative politicians control a large majority of county and city boards.
Until this year, Republicans have controlled all three branches of government only twice since 1945 (modern political history), and only once (George Bush in 2005) did the president have a Senate majority.2 With his win, Mr. Trump can lead a conservative revolution to reverse key initiatives begun when the Democratic Party held majority power. Repeal of the ACA, signed into legislation on March 23, 2010, is the Republican Party’s top priority.
Equally important, Congress can alter previously implemented federal regulations. Each year about 3,000 regulations are written by federal agencies that act with authority delegated by Congress (albeit Congress retains power to overturn them). Regulations are published in the Federal Register as preliminary rules during each year, and Final Rules are published after a public comment period and implemented shortly thereafter. Regulations carry the force of law and are codified in the Code of Federal Regulations. The Code of Federal Regulations is divided into 50 sections (Titles), with Title 42 (Public Health) and Title 45 (Public Welfare) most pertinent to us.
Other policies are created through executive orders, issued by the president (federal) or governors (states), without involvement of legislative or judicial branches (they were not mentioned in the Constitution, by the way). Executive orders issued by President Obama could, theoretically, be overturned by new executive orders.
Repeal and replace
Destruction of the ACA is a top priority of President Trump and Republican leaders of both houses of Congress. The ACA was a Democratic bill (passed with no Republican support), although it had many similarities to previous Republican legislative ideas dating from 1993.3
Although outright repeal could be blocked by a Democratic filibuster, the law could be drastically modified through budget reconciliation whose passage takes only a simple Senate majority. Thus, a simple budget-related bill could serve as a vehicle to defund many parts of ACA, including money for Medicaid expansion, insurance risk corridors, money to offset out-of-pocket expenses and individual premium subsidies, for example.4,5
There would be substantial problems if ACA were repealed even with a 2- or 3-year delay, a scenario proposed to provide time for a replacement bill. On Jan. 4, 2017, the House Republican Study Committee introduced the American Health Care Reform Act (AHCRA) as a replacement proposal, with the stipulation that ACA would be repealed as of Jan. 1, 2018. This initial bill hinted at Republican intent and was detailed in a Health Affairs blog.6 Importantly, there were distinct similarities between this and prior Republican proposals put forward by Representative Tom Price (nominated to head the Department of Health & Human Services under President Trump) and Speaker of the House Paul Ryan.7,8
Consistently, Republicans have advocated for expansion of health savings accounts, altering the tax code to allow individuals to deduct health insurance premiums, establishment of association risk pools, imposition of malpractice limits, protections for people with preexisting conditions, and further restrictions on abortion coverage. The AHCRA changes financial subsidies for purchasing insurance from a tax credit (which can be paid to people even if they do not pay taxes) to a tax deduction (only applicable to people who pay taxes). Analysis of a similar proposal made by President Trump during the campaign found that this plan would increase the number of uninsured people by more than 15 million.
If ACA is repealed, effects would be broader than just factors related to insurance coverage.9 ACA provides for preventive care (including colonoscopy) without copays, education of additional medical personnel, closing the donut hole for Medicare Part D (medications), approval of generic biologics, and Medicaid expansions, among other initiatives. If ACA were defunded without restoring pre-ACA support for Disproportion Share Hospital charity care, research, and graduate medical education, then safety-net hospitals and many academic medical centers (AMCs) could face enormous funding cuts.10 Defunding Medicaid expansion would adversely affect states in many ways, as pointed out by Ayanian et al.11 Medicaid expansion had broad economic impact in states that accepted federal money to expand. In Michigan for example, 30,900 jobs were added to the state in 2016 because of Medicaid expansion, with two-thirds outside of the health care industry. President Obama defined his view about the effects of ACA repeal in the New England Journal of Medicine.12
Lessons learned
Economic principles and unique characteristics of United States health care help explain why solutions to its high cost and uneven coverage are so difficult to achieve. These include higher prices for goods in the United States compared with other countries, variation in price (unrelated to quality), restraints on government price negotiations, inefficiencies due to variation in size of delivery systems, and “moral hazard” related to rich insurance coverage, which are some of the factors that doom any simple solutions. These are reviewed by Victor Fuchs13 in an excellent article in Annals of Internal Medicine. Payment methods for health care services also distort resource use and efficiencies. Understanding the eight basic payment methodologies in health care and current predictions about future health care spending will be important in shaping reimbursement policies.14,15
Disruptions in health care are unpopular and, as Uve Reinardt stated: “Our health care financing system will always remain a horrendous mess and a fountain for such dismay among the providers of health care as well as among patients.”4 Lessons to inform the next iteration of health care policy, learned from the 2009-2010 experience, might be as follows:
1. If a bill is to be passed, the president must personally lead in explaining the bill to the public in simple terms.
2. Even the threat of repeal may disrupt the current market and force insurance companies to exit quickly.
3. Coverage must be affordable to individuals, state budgets, and health care providers. Because expansion states saw positive impacts to state budgets8 and mental health and substance abuse services became part of Medicaid benefits, how will a replacement bill maintain coverage and compensate for new state moneys used now for other imperatives such as education and infrastructure?
4. Health care is like a massive cargo ship, not a sports car, so a bill to replace the ACA may take a long time (and might never be passed).
5. Health care is intensely personal, so it will always be politically charged.
Ultimately, physicians will need to make strategic guesses and rapid adjustments to sustain financial viability and provide high-value care. Strategies differ depending on your practice situation. Keep in mind the five principles listed in the opening paragraph of this article. It is likely that the most important principle to factor into your practice strategy is continuing reduction in reimbursements. No matter what model is adopted to reform the ACA, the financial pot (Medicare, Medicaid, commercial insurance, bundled payments, fee-for-service payments) will be reduced, and the number of uninsured patients will increase. How would you change your practice if Medicare was your best payer (“manage to Medicare”)?
Independent practices
Physicians in small- to medium-size independent practices continue to struggle with reducing reimbursements, reporting burdens, increasing overhead expenses, crushing regulatory requirements, and provider burnout. Trumpcare will favor small practices more than Obamacare from a policy (not necessarily a financial) perspective. Regulations on small business and reporting burdens may ease, but the move toward value-based reimbursement as outlined in the MACRA (passed with overwhelming bipartisan support) will not end.16 Practices in small communities continue to thrive because they give excellent care with limited competition and low overhead. Some practices in suburban and urban centers struggle because payers tend to favor (with enhanced managed care rates) larger practices and health systems. Large, horizontally integrated, efficient gastroenterology practices will continue to thrive because they can develop a “must-have” position with payers. Building remote patient monitoring, teleconsulting, and capabilities around value demonstration will be strategically advantageous.
Options for independent physicians include 1) maintaining status quo, 2) retiring, or 3) exiting the independent business model through a practice sale. Traditionally, physicians who wanted to sell their practices turned to hospitals or health systems. Recently, a physician-run model funded by venture capital has emerged where reduced overhead (through centralization of services) is combined with enhanced power during payer negotiations (because of scale). This model has allowed practices to merge into a physician organization and remain free from health system employment.17
Large health systems
Physicians employed by large health systems, whether they are nonprofit, for-profit, or AMCs, will see their future tied directly to health system success. If bundled payment, alternative payment, and capitation models of health care financing continue to grow in popularity, then success will be determined by a health system’s market share and its ability to form true clinical integration. In a capitated environment, expansion of market share (especially of relatively healthy patients) will help support margins. However, financial success will come from a system’s ability to manage high-cost patients, those 5% of patients who consume 50% of health care resources.18
Hospitals with a financially challenged patient base (safety-net hospitals) will have enormous financial pressures going forward. Repeal of ACA without restoration of pre-ACA funding will affect directly the financial health of systems including AMCs. AMCs and other health systems will be forced to reduce fixed overhead, enhance productivity of faculty, and restrict nonfunded activities (teaching for example). Although most AMCs are now in an active acquisition mode, this strategy is naturally limited by the number of remaining acquisition targets. Traditional high managed care rates enjoyed by AMCs will shrink, as will federal research funding (which typically comes with high indirect financial support). Health systems and GI societies will need to dedicate much more attention to state policy makers as Trumpcare progresses.
Finally, all providers will need to manage the business implications of retail health. As people assume higher deductibles and copays and health savings accounts grow, patients will change their patterns of purchasing services. Reputation counts for less when people are facing large price differences, so attention to patient-centric amenities, price, patient engagement, and patient satisfaction will become even more important.
Conclusion
The United States has undergone a massive and rapid political transformation. The mandate felt by conservative politicians, perhaps not supported by numbers, will carry a conservative platform forward. In areas where progressive Democrats emphasized federal power and socialized regulation (religion, education, civil rights, income security, and health policy), conservatives will transfer decision power as much as possible to states, local communities, and individuals. Maintaining the concept of “health as a right” will test the conscience of all of us.
References
1. Allen, J.I. The road ahead. Clin Gastroenterol Hepatol. 2012;10:692-6.
2. Gill KE. Visual guide: the balance of power between Congress and the Presidency (1901-2016). Wired Pen. November 2016. Available from http://wiredpen.com/resources/political-commentary-and-analysis/a-visual-guide-balance-of-power-congress-presidency/. Accessed Dec. 30, 2016.
3. Mertens M. Chart: comparing health reform bills – Democrats and Republicans 2009, Republics 1993. Kaiser Health News. Feb. 24, 2010. Available from http://khn.org/022310-bill-comparison/. Accessed Jan. 8, 2017.
4. Hotchkiss M. Q&A: what a Trump presidency means for the Affordable Care Act. Nov. 16, 2016 News at Princeton. Princeton University. Available from https://www.princeton.edu/main/news/archive/S47/93/09C11/index.xml?section=topstories. Accessed Dec. 30, 2016.
5. Jost T. Taking stock of health reform: where we’ve been, where we’re going. Health Affairs Blog. Available from http://healthaffairs.org/blog/2016/12/06/taking-stock-of-health-reform-where-weve-been-where-were-going/. Accessed Dec. 30, 2016.
6. Jost T. The Republican Study Committee’s ACA replacement proposal (updated). Health Affairs Blog. Available from http://healthaffairs.org/blog/2017/01/05/the-republican-study-committees-aca-replacement-proposal/. Accessed Jan. 10, 2017.
7. Price T. Empowering patients first. Available from http://tomprice.house.gov/sites/tomprice.house.gov/files/HR%202300%20Empowering%20Patients%20First%20Act%202015.pdf. Accessed Dec. 30, 2016.
8. Ryan P. A better way. Available from https://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf. Accessed Dec. 30, 2016.
9. Oberlander, J. The end of Obamacare. N Engl J Med. 2017;376:1-3.
10. Goodnough A. Hospitals in safety net brace for health care law’s repeal. New York Times. Dec. 28, 2016. Available from http://www.nytimes.com/2016/12/28/health/hospitals-medicaid-obamacare-trump.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0. Accessed Jan. 10, 2017.
11. Ayanian, J.Z., Ehrlich, G.M., Grimes, D.R., et al. Economic effects of Medicaid expansion in Michigan. N Engl J Med. 2017;376:407-10.
12. Obama, B.H. Repealing the ACA without a replacement: the risks to American health care. N Engl J Med. 2017;376:297-9.
13. Fuchs, V.R. Major concepts of health economics. Ann Intern Med. 2015;162:380-3.
14. Quinn, K. The 8 basic payment methods in health care. Ann Intern Med. 2015;163:300-6.
15. Schoenman JA. A detailed look at US health care spending: a presentation from the National Institute for Health Care Management (NIHCM). Oct. 25, 2012. Available from http://www.nihcm.org/images/stories/Health_care_spending_slides_-_MILI_-_Schoenman.pdf. Accessed Dec. 30, 2016.
16. Allen, J.I., Allen, C.C., Brill, J.V. Gastroenterology 2020: no time for WIMPs. Gastroenterology. 2016;150:295-9.
17. Sciacca R. Weekly Byte: GI roundtable and navigating uncharted waters in health care. The PMD Blog. Available from https://www.pmd.com/blog/post/weekly-byte-gi-roundtable-and-navigating-uncharted-waters-in-health-care. Accessed Jan. 10, 2017.
18. Powers, B.W., Chaguturu, S.K. ACOs and high-cost patients. N Engl J Med. 2016;374:203-5.
Dr. Allen is professor of medicine, University of Michigan School of Medicine, Institute for Health Care Policy and Innovations, and associate medical director of Network Strategy and Business Development – Michigan Medicine, Ann Arbor. He discloses no conflicts.
The June issue of CGH was the final column under my management. I have enjoyed the opportunity to provide you with information about practice management and health care reform. I also have enjoyed working with the Clinical Gastroenterology and Hepatology board of editors, and Erin Landis and Brook Simpson from AGA headquarters. Beginning in July 2017, this section will become the responsibility of Ziad Gellad, MD, MPH, AGAF, from Duke University. I have worked with Ziad for many years, and he serves on my board of editors for GI & Hepatology News. I have great confidence in his knowledge and ability.
During the last 5 years, we have published 58 columns beginning with an article where I made several broad predictions. I have tried to present important concepts and management tools related to private and academic clinical practice, health care reform, and health economics. This article was written in early January 2017 just before the inauguration of Donald Trump. As I wrote, we did not know the full extent or the pace of “Repeal and Replace,” as Obamacare becomes Trumpcare (www.healthaffairs.org/obamacare-to-trumpcare).
The extent of current Republican control of federal and state governments is unprecedented in modern political history. Per Newt Gingrich (The Economist, Jan. 7, 2017, p. 25), this will be the third attempt, after Ronald Reagan’s election in 1980 and Gingrich’s “Contract with America” in 1994, to break free from a “Big Government” mindset initiated by Franklin Roosevelt’s New Deal. In this article, I will speculate how a right-leaning shift in American health care policy might impact the business model of gastroenterology. No matter how government regulations or funds flow change, we (physicians) will ultimately be responsible for digestive care provided to our patients. In the words of Martin Luther King Jr. (as he paraphrased Theodore Parker), “The arc of the moral universe is long, but it bends toward justice.” What is remembered by fewer people, however, are words he then added during his speeches: “but only if we march.”
John I. Allen, MD, MBA, AGAF
Editor in Chief
The first column was published in July 2012.1 I wrote about five dominant themes that would alter our gastroenterology practices in the ensuing years. They were 1) an increasing requirement for us to demonstrate value, 2) the need to think about population management in addition to individual patient care, 3) consolidation that would occur at all levels of health care delivery, 4) increasing cost pressure, and 5) how medical decisions would be linked to reimbursement (now called value-based payment). I fully expected the Patient Protection and Affordable Care Act (ACA) would shape the health care landscape for the rest of our careers. After the article’s publication, I was invited to speak about health care reform at many academic centers and private practices. My last talk before the election was in Pasadena, Calif. (Oct. 28, 2016) where I confidently spoke about the implications of President Clinton’s cementing ACA into the fabric of U.S. medicine.
Donald Trump is now the 45th President of the United States. Republicans hold a 52-48 majority in the Senate and a 241-194 majority in the House. As of January 2017, one Supreme Court seat was available, and three more may open because of retirements (Justice Ginsburg is 83 years old, Justice Kennedy is 80, and Justice Breyer is 78). Republicans control all three branches of government in 25 states and dominate in 8 others. Conservative politicians control a large majority of county and city boards.
Until this year, Republicans have controlled all three branches of government only twice since 1945 (modern political history), and only once (George Bush in 2005) did the president have a Senate majority.2 With his win, Mr. Trump can lead a conservative revolution to reverse key initiatives begun when the Democratic Party held majority power. Repeal of the ACA, signed into legislation on March 23, 2010, is the Republican Party’s top priority.
Equally important, Congress can alter previously implemented federal regulations. Each year about 3,000 regulations are written by federal agencies that act with authority delegated by Congress (albeit Congress retains power to overturn them). Regulations are published in the Federal Register as preliminary rules during each year, and Final Rules are published after a public comment period and implemented shortly thereafter. Regulations carry the force of law and are codified in the Code of Federal Regulations. The Code of Federal Regulations is divided into 50 sections (Titles), with Title 42 (Public Health) and Title 45 (Public Welfare) most pertinent to us.
Other policies are created through executive orders, issued by the president (federal) or governors (states), without involvement of legislative or judicial branches (they were not mentioned in the Constitution, by the way). Executive orders issued by President Obama could, theoretically, be overturned by new executive orders.
Repeal and replace
Destruction of the ACA is a top priority of President Trump and Republican leaders of both houses of Congress. The ACA was a Democratic bill (passed with no Republican support), although it had many similarities to previous Republican legislative ideas dating from 1993.3
Although outright repeal could be blocked by a Democratic filibuster, the law could be drastically modified through budget reconciliation whose passage takes only a simple Senate majority. Thus, a simple budget-related bill could serve as a vehicle to defund many parts of ACA, including money for Medicaid expansion, insurance risk corridors, money to offset out-of-pocket expenses and individual premium subsidies, for example.4,5
There would be substantial problems if ACA were repealed even with a 2- or 3-year delay, a scenario proposed to provide time for a replacement bill. On Jan. 4, 2017, the House Republican Study Committee introduced the American Health Care Reform Act (AHCRA) as a replacement proposal, with the stipulation that ACA would be repealed as of Jan. 1, 2018. This initial bill hinted at Republican intent and was detailed in a Health Affairs blog.6 Importantly, there were distinct similarities between this and prior Republican proposals put forward by Representative Tom Price (nominated to head the Department of Health & Human Services under President Trump) and Speaker of the House Paul Ryan.7,8
Consistently, Republicans have advocated for expansion of health savings accounts, altering the tax code to allow individuals to deduct health insurance premiums, establishment of association risk pools, imposition of malpractice limits, protections for people with preexisting conditions, and further restrictions on abortion coverage. The AHCRA changes financial subsidies for purchasing insurance from a tax credit (which can be paid to people even if they do not pay taxes) to a tax deduction (only applicable to people who pay taxes). Analysis of a similar proposal made by President Trump during the campaign found that this plan would increase the number of uninsured people by more than 15 million.
If ACA is repealed, effects would be broader than just factors related to insurance coverage.9 ACA provides for preventive care (including colonoscopy) without copays, education of additional medical personnel, closing the donut hole for Medicare Part D (medications), approval of generic biologics, and Medicaid expansions, among other initiatives. If ACA were defunded without restoring pre-ACA support for Disproportion Share Hospital charity care, research, and graduate medical education, then safety-net hospitals and many academic medical centers (AMCs) could face enormous funding cuts.10 Defunding Medicaid expansion would adversely affect states in many ways, as pointed out by Ayanian et al.11 Medicaid expansion had broad economic impact in states that accepted federal money to expand. In Michigan for example, 30,900 jobs were added to the state in 2016 because of Medicaid expansion, with two-thirds outside of the health care industry. President Obama defined his view about the effects of ACA repeal in the New England Journal of Medicine.12
Lessons learned
Economic principles and unique characteristics of United States health care help explain why solutions to its high cost and uneven coverage are so difficult to achieve. These include higher prices for goods in the United States compared with other countries, variation in price (unrelated to quality), restraints on government price negotiations, inefficiencies due to variation in size of delivery systems, and “moral hazard” related to rich insurance coverage, which are some of the factors that doom any simple solutions. These are reviewed by Victor Fuchs13 in an excellent article in Annals of Internal Medicine. Payment methods for health care services also distort resource use and efficiencies. Understanding the eight basic payment methodologies in health care and current predictions about future health care spending will be important in shaping reimbursement policies.14,15
Disruptions in health care are unpopular and, as Uve Reinardt stated: “Our health care financing system will always remain a horrendous mess and a fountain for such dismay among the providers of health care as well as among patients.”4 Lessons to inform the next iteration of health care policy, learned from the 2009-2010 experience, might be as follows:
1. If a bill is to be passed, the president must personally lead in explaining the bill to the public in simple terms.
2. Even the threat of repeal may disrupt the current market and force insurance companies to exit quickly.
3. Coverage must be affordable to individuals, state budgets, and health care providers. Because expansion states saw positive impacts to state budgets8 and mental health and substance abuse services became part of Medicaid benefits, how will a replacement bill maintain coverage and compensate for new state moneys used now for other imperatives such as education and infrastructure?
4. Health care is like a massive cargo ship, not a sports car, so a bill to replace the ACA may take a long time (and might never be passed).
5. Health care is intensely personal, so it will always be politically charged.
Ultimately, physicians will need to make strategic guesses and rapid adjustments to sustain financial viability and provide high-value care. Strategies differ depending on your practice situation. Keep in mind the five principles listed in the opening paragraph of this article. It is likely that the most important principle to factor into your practice strategy is continuing reduction in reimbursements. No matter what model is adopted to reform the ACA, the financial pot (Medicare, Medicaid, commercial insurance, bundled payments, fee-for-service payments) will be reduced, and the number of uninsured patients will increase. How would you change your practice if Medicare was your best payer (“manage to Medicare”)?
Independent practices
Physicians in small- to medium-size independent practices continue to struggle with reducing reimbursements, reporting burdens, increasing overhead expenses, crushing regulatory requirements, and provider burnout. Trumpcare will favor small practices more than Obamacare from a policy (not necessarily a financial) perspective. Regulations on small business and reporting burdens may ease, but the move toward value-based reimbursement as outlined in the MACRA (passed with overwhelming bipartisan support) will not end.16 Practices in small communities continue to thrive because they give excellent care with limited competition and low overhead. Some practices in suburban and urban centers struggle because payers tend to favor (with enhanced managed care rates) larger practices and health systems. Large, horizontally integrated, efficient gastroenterology practices will continue to thrive because they can develop a “must-have” position with payers. Building remote patient monitoring, teleconsulting, and capabilities around value demonstration will be strategically advantageous.
Options for independent physicians include 1) maintaining status quo, 2) retiring, or 3) exiting the independent business model through a practice sale. Traditionally, physicians who wanted to sell their practices turned to hospitals or health systems. Recently, a physician-run model funded by venture capital has emerged where reduced overhead (through centralization of services) is combined with enhanced power during payer negotiations (because of scale). This model has allowed practices to merge into a physician organization and remain free from health system employment.17
Large health systems
Physicians employed by large health systems, whether they are nonprofit, for-profit, or AMCs, will see their future tied directly to health system success. If bundled payment, alternative payment, and capitation models of health care financing continue to grow in popularity, then success will be determined by a health system’s market share and its ability to form true clinical integration. In a capitated environment, expansion of market share (especially of relatively healthy patients) will help support margins. However, financial success will come from a system’s ability to manage high-cost patients, those 5% of patients who consume 50% of health care resources.18
Hospitals with a financially challenged patient base (safety-net hospitals) will have enormous financial pressures going forward. Repeal of ACA without restoration of pre-ACA funding will affect directly the financial health of systems including AMCs. AMCs and other health systems will be forced to reduce fixed overhead, enhance productivity of faculty, and restrict nonfunded activities (teaching for example). Although most AMCs are now in an active acquisition mode, this strategy is naturally limited by the number of remaining acquisition targets. Traditional high managed care rates enjoyed by AMCs will shrink, as will federal research funding (which typically comes with high indirect financial support). Health systems and GI societies will need to dedicate much more attention to state policy makers as Trumpcare progresses.
Finally, all providers will need to manage the business implications of retail health. As people assume higher deductibles and copays and health savings accounts grow, patients will change their patterns of purchasing services. Reputation counts for less when people are facing large price differences, so attention to patient-centric amenities, price, patient engagement, and patient satisfaction will become even more important.
Conclusion
The United States has undergone a massive and rapid political transformation. The mandate felt by conservative politicians, perhaps not supported by numbers, will carry a conservative platform forward. In areas where progressive Democrats emphasized federal power and socialized regulation (religion, education, civil rights, income security, and health policy), conservatives will transfer decision power as much as possible to states, local communities, and individuals. Maintaining the concept of “health as a right” will test the conscience of all of us.
References
1. Allen, J.I. The road ahead. Clin Gastroenterol Hepatol. 2012;10:692-6.
2. Gill KE. Visual guide: the balance of power between Congress and the Presidency (1901-2016). Wired Pen. November 2016. Available from http://wiredpen.com/resources/political-commentary-and-analysis/a-visual-guide-balance-of-power-congress-presidency/. Accessed Dec. 30, 2016.
3. Mertens M. Chart: comparing health reform bills – Democrats and Republicans 2009, Republics 1993. Kaiser Health News. Feb. 24, 2010. Available from http://khn.org/022310-bill-comparison/. Accessed Jan. 8, 2017.
4. Hotchkiss M. Q&A: what a Trump presidency means for the Affordable Care Act. Nov. 16, 2016 News at Princeton. Princeton University. Available from https://www.princeton.edu/main/news/archive/S47/93/09C11/index.xml?section=topstories. Accessed Dec. 30, 2016.
5. Jost T. Taking stock of health reform: where we’ve been, where we’re going. Health Affairs Blog. Available from http://healthaffairs.org/blog/2016/12/06/taking-stock-of-health-reform-where-weve-been-where-were-going/. Accessed Dec. 30, 2016.
6. Jost T. The Republican Study Committee’s ACA replacement proposal (updated). Health Affairs Blog. Available from http://healthaffairs.org/blog/2017/01/05/the-republican-study-committees-aca-replacement-proposal/. Accessed Jan. 10, 2017.
7. Price T. Empowering patients first. Available from http://tomprice.house.gov/sites/tomprice.house.gov/files/HR%202300%20Empowering%20Patients%20First%20Act%202015.pdf. Accessed Dec. 30, 2016.
8. Ryan P. A better way. Available from https://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf. Accessed Dec. 30, 2016.
9. Oberlander, J. The end of Obamacare. N Engl J Med. 2017;376:1-3.
10. Goodnough A. Hospitals in safety net brace for health care law’s repeal. New York Times. Dec. 28, 2016. Available from http://www.nytimes.com/2016/12/28/health/hospitals-medicaid-obamacare-trump.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0. Accessed Jan. 10, 2017.
11. Ayanian, J.Z., Ehrlich, G.M., Grimes, D.R., et al. Economic effects of Medicaid expansion in Michigan. N Engl J Med. 2017;376:407-10.
12. Obama, B.H. Repealing the ACA without a replacement: the risks to American health care. N Engl J Med. 2017;376:297-9.
13. Fuchs, V.R. Major concepts of health economics. Ann Intern Med. 2015;162:380-3.
14. Quinn, K. The 8 basic payment methods in health care. Ann Intern Med. 2015;163:300-6.
15. Schoenman JA. A detailed look at US health care spending: a presentation from the National Institute for Health Care Management (NIHCM). Oct. 25, 2012. Available from http://www.nihcm.org/images/stories/Health_care_spending_slides_-_MILI_-_Schoenman.pdf. Accessed Dec. 30, 2016.
16. Allen, J.I., Allen, C.C., Brill, J.V. Gastroenterology 2020: no time for WIMPs. Gastroenterology. 2016;150:295-9.
17. Sciacca R. Weekly Byte: GI roundtable and navigating uncharted waters in health care. The PMD Blog. Available from https://www.pmd.com/blog/post/weekly-byte-gi-roundtable-and-navigating-uncharted-waters-in-health-care. Accessed Jan. 10, 2017.
18. Powers, B.W., Chaguturu, S.K. ACOs and high-cost patients. N Engl J Med. 2016;374:203-5.
Dr. Allen is professor of medicine, University of Michigan School of Medicine, Institute for Health Care Policy and Innovations, and associate medical director of Network Strategy and Business Development – Michigan Medicine, Ann Arbor. He discloses no conflicts.
Student Hospitalist Scholars: Preventing unplanned PICU transfers
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experiences on a biweekly basis.
I’m a rising second year medical student working this summer on a project to determine predictors for pediatric clinical deterioration and unplanned transfers to the pediatric ICU.
We’re hoping to identify characteristics of the pediatric population that is more prone to these unplanned transfers, as well as determine what clinical signs serve as reliable warnings so that an intervention can be designed to prevent these emergency transfers.
So far, I have been searching the literature for what current interventions exist to prevent pediatric clinical deterioration. I have been reading about rapid response teams and their effectiveness in preventing codes, as well as what measures are used to evaluate the condition of a pediatric patient who is at risk for clinical deterioration. It is clear that more investigation is needed to identify reliable predictors that indicate a possible ICU transfer for the child patient.
I was interested in this project, and in quality improvement, because of its power to directly improve patient care and safety. It is vital to identify and fix problems that are preventable. It is directly related to the work of the physician, and the interprofessional collaboration aspect is key to improve communication that directly affects the patients’ outcomes.
I was introduced to the field during the past year in medical school, and this prompted me to start looking for research projects in the hospital medicine department at Cincinnati Children’s Hospital. I was connected with Patrick Brady, MD, an attending physician in the division of hospital medicine at Cincinnati Children’s, whose work involves studying patient safety. His goals of investigating how to prevent clinical deterioration in pediatric patients aligned with what I wanted to learn during my research experience.
After partnering with my primary mentor, Dr. Brady, we discussed how the Student Hospitalist Scholar Grant would be a good fit for me, so I decided to apply.
I am excited to continue this experience this summer, as I believe it would not only educate me about applying interventions to better patient care but also about medicine in general. I plan to carry on and apply these lessons learned during my third year of medical school for rotations.
Farah Hussain is a second year medical student at the University of Cincinnati and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care in vulnerable populations.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experiences on a biweekly basis.
I’m a rising second year medical student working this summer on a project to determine predictors for pediatric clinical deterioration and unplanned transfers to the pediatric ICU.
We’re hoping to identify characteristics of the pediatric population that is more prone to these unplanned transfers, as well as determine what clinical signs serve as reliable warnings so that an intervention can be designed to prevent these emergency transfers.
So far, I have been searching the literature for what current interventions exist to prevent pediatric clinical deterioration. I have been reading about rapid response teams and their effectiveness in preventing codes, as well as what measures are used to evaluate the condition of a pediatric patient who is at risk for clinical deterioration. It is clear that more investigation is needed to identify reliable predictors that indicate a possible ICU transfer for the child patient.
I was interested in this project, and in quality improvement, because of its power to directly improve patient care and safety. It is vital to identify and fix problems that are preventable. It is directly related to the work of the physician, and the interprofessional collaboration aspect is key to improve communication that directly affects the patients’ outcomes.
I was introduced to the field during the past year in medical school, and this prompted me to start looking for research projects in the hospital medicine department at Cincinnati Children’s Hospital. I was connected with Patrick Brady, MD, an attending physician in the division of hospital medicine at Cincinnati Children’s, whose work involves studying patient safety. His goals of investigating how to prevent clinical deterioration in pediatric patients aligned with what I wanted to learn during my research experience.
After partnering with my primary mentor, Dr. Brady, we discussed how the Student Hospitalist Scholar Grant would be a good fit for me, so I decided to apply.
I am excited to continue this experience this summer, as I believe it would not only educate me about applying interventions to better patient care but also about medicine in general. I plan to carry on and apply these lessons learned during my third year of medical school for rotations.
Farah Hussain is a second year medical student at the University of Cincinnati and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care in vulnerable populations.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experiences on a biweekly basis.
I’m a rising second year medical student working this summer on a project to determine predictors for pediatric clinical deterioration and unplanned transfers to the pediatric ICU.
We’re hoping to identify characteristics of the pediatric population that is more prone to these unplanned transfers, as well as determine what clinical signs serve as reliable warnings so that an intervention can be designed to prevent these emergency transfers.
So far, I have been searching the literature for what current interventions exist to prevent pediatric clinical deterioration. I have been reading about rapid response teams and their effectiveness in preventing codes, as well as what measures are used to evaluate the condition of a pediatric patient who is at risk for clinical deterioration. It is clear that more investigation is needed to identify reliable predictors that indicate a possible ICU transfer for the child patient.
I was interested in this project, and in quality improvement, because of its power to directly improve patient care and safety. It is vital to identify and fix problems that are preventable. It is directly related to the work of the physician, and the interprofessional collaboration aspect is key to improve communication that directly affects the patients’ outcomes.
I was introduced to the field during the past year in medical school, and this prompted me to start looking for research projects in the hospital medicine department at Cincinnati Children’s Hospital. I was connected with Patrick Brady, MD, an attending physician in the division of hospital medicine at Cincinnati Children’s, whose work involves studying patient safety. His goals of investigating how to prevent clinical deterioration in pediatric patients aligned with what I wanted to learn during my research experience.
After partnering with my primary mentor, Dr. Brady, we discussed how the Student Hospitalist Scholar Grant would be a good fit for me, so I decided to apply.
I am excited to continue this experience this summer, as I believe it would not only educate me about applying interventions to better patient care but also about medicine in general. I plan to carry on and apply these lessons learned during my third year of medical school for rotations.
Farah Hussain is a second year medical student at the University of Cincinnati and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care in vulnerable populations.