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July 2019 • Vol.10 No.4

Primary care in CMS’s spotlight Primary Cares Initiative is a further step in physician payment reform

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CONTENTS »» JULY 2019 2 What does real innovation look like?

It’s time we examine healthcare innovation from the ground up

8 Primary care in CMS’s spotlight Primary Cares Initiative is a further step in physician payment reform

20 Pitt leads creation of global infectious disease data system 22 Health news and notes

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The Journal of Healthcare Contracting | July 2019

1

TRENDS

By Bruce Stanley

What does real innovation look like?

It’s time we examine healthcare innovation from the ground up

Have you ever wondered how all these innovations stack up to each other? Will they ignite the course of better health, or are they just other vehicles to extend the life of an existing idea, product or company? Do they lead to real reform of the system? Is innovation just a buzzword for more costs, more operat-

2

Technological innovations are surfacing all across our

ing challenges, more work for clinicians

healthcare world. Many entrepreneurs, clinicians and patients

and just plain old more of everything

are searching and waiting for the holy grail of cures to appear.

(except, often, for more care)?

July 2019 | The Journal of Healthcare Contracting

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TRENDS

Opinions differ on how healthcare innovations actually

up. Our industry needs to embrace

affect systemic costs. What most patients experience is that

and encourage a real innovation chal-

their costs usually go up and rarely come down. The prevail-

lenge. Why not encourage our lead-

ing rationale is that the inventors need to be compensated

ing-edge innovators to create an en-

for all their expensive research and development. Over time

tirely new economic model that sets

even the cost of generic products ends up moving higher.

our healthcare system and structure

While many innovations lead to improved care, they can be-

on a futuristic course better suited for

come so costly that patients are unable to afford them and

the 21st century?

decide not to undergo the treatments or take medications as prescribed.

More than 50 years ago, the United States set an aggressive and even somewhat naïve space exploration

More than 50 years ago, the United States set an aggressive and even somewhat naïve space exploration strategy. That effort led to more innovation and new technology than anyone could have imagined. Why can’t we do the same with healthcare, rather than constantly arguing the merits of an old model?

strategy. That effort led to more innovation and new technology than anyone could have imagined. Why can’t we do the same with healthcare, rather than constantly arguing the merits of an old model?

We should envision a new system of economics, clinical training, technology, product creation, delivery and sales, and innovation design that starts at the heart of all patients’ care. This new economic healthcare model should be accessible and affordable for patients and still be profitable for the industry.

This idea is not to be confused with government-provided healthcare in the current framework. Some of the potential new core clinical competencies and technologies may not even exist today.

It has become a binary system choice of picking either A or B, all the while using the same tired economic models for

4

The discussion need not be socialism or capitalism, just healthcare.

creating, delivering and paying for care. When we debate

To be fair, many product innova-

universal care, does it really matter, since the economic

tions do save lives and do affect the

model never changes?

care and costs in the system. Industry

Given that our delivery and economic model for health-

developers create some pretty terrific

care came about after World War II, one would think it’s time

robotics, techno devices, software and

to re-exam how we approach the issue from the ground

apps. However, when industry leaders July 2019 | The Journal of Healthcare Contracting

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TRENDS

discuss these innovations, they inevitably talk about how

What I am suggesting is that in and of

about sales projections and financial opportunities for in-

itself, these activities don’t drive sys-

vestors. What they rarely talk about is how these ideas might

temic economic innovation.

revolutionize care and lower costs in the entire system, and

So where do we look for the real

specifically for each patient. We are expected to believe

economic innovation in healthcare?

that profitable returns equal better patient outcomes. Im-

Any clinician will tell you we need to

plementing change using a tired model is just less effective

stop and reevaluate what is really oc-

clinically and economically.

curring. We’ve never answered the fundamental question: Is healthcare a privilege or a right, or for that matter,

Is innovation just a buzzword for more costs, more operating challenges, more work for clinicians and just plain old more of everything?

is it like breathing air and necessary to sustain our society? We need to flip the process on its end and challenge how we can fundamentally change the system. Real transformation of care and economics may be uncovered when examining the industry through a completely new lens. That said, the question remains: Can the economic underpinning materially change, and

Many times, the self-described innovations produce results of care that are mixed. EHR is one example. Even with

is innovation in that new model evolutionary or non-existent?

this technology, patient records are lost or corrupted, clini-

Can this industry rally in support of its

cians are exhausted from the tedious hours of data manip-

own headline – Health and Care? When

ulation, and insurance coding confusion grows at unprec-

the industry better balances this with

edented rates while patient healthcare is declining. Creating

profitability, then quite possibly a new

a new healthcare economic model won’t be easy. But with

model will emerge where innovative

all the energy being put on “innovation of things,” one has to

healthcare will lead all aspects of care

wonder, are we afraid of what a new economic model might

while guaranteeing its own long-term

look like? I’m not criticizing the investments or the innovators.

economic viability.

Bruce Stanley is a global supply chain, business development and contracting operations advisor and consultant with over 30 years in the healthcare industry. In 2011, he co-founded The Stanley East Consulting Group, a consulting practice specializing in supply chain, contracting, business development, order fulfillment and project management for small and mediumsized companies, startups, and companies in transition or divestiture. He is also a published author of many commentaries on healthcare processes, and an adjunct MBA professor teaching global supply chain, contracting and healthcare informatics and regulations. He previously served as senior director, contracting operations, for Becton Dickinson. He can be reached at brucejstanley@gmail.com

6

July 2019 | The Journal of Healthcare Contracting

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July 2019 | The Journal of Healthcare Contracting

Primary care in CMS’s spotlight Primary Cares Initiative is a further step in physician payment reform

Primary care physicians are cautiously optimistic about a new primary-care payment program unveiled in April by the Centers for Medicare & Medicaid Services. The new model – Primary Cares Initiative – is intended to build on CMS’ prior programs to reimburse primary care physicians on the basis of health and outcomes rather than on a per-procedure basis.

“APC members have expressed a lot of interest and desire to participate in these types of innovative new payment models that reward clinicians for keeping patients healthy,” says Robert McLean, M.D., FACP, president of the American College of Physicians, a specialty organization for internal medicine physicians. “Up until now, one of the main criticisms we've heard and one that we've repeatedly relayed to CMS is that we need more [alternative payment models]. So, at a high level,

1.

Primary Care First (PCF)

2.

Primary Care First – High Need Populations

3.

Direct Contracting – Global

4.

Direct Contracting – Professional

“ These models will test out paying for health and outcomes rather than procedures on a much larger scale than ever before.”

5.

Direct Contracting – Geographic

– Alex Azar

we're certainly excited to see the CMS Innovation Center start to come out with new models, and hope that is just the tip of the iceberg and we have more coming.”

The CMS Primary Cares Initiative will provide primary care practices with five new payment model options under two paths: Primary Care First (PCF) and Direct Contracting (DC). The five options are:

The Journal of Healthcare Contracting | July 2019

9

PRIMARY CARE

Primary Care First

Direct Contracting option

The Primary Care First model will be tested for five

While the two PCF models are focused on individual

years and is scheduled to begin in January 2020.

primary care practice sites, the three Direct Contracting

(A second application round is planned for partici-

payment model options aim to engage organizations

pants starting in January 2021.) Eligible practitio-

that have experience taking on financial risk and serv-

ners are those in internal medicine, general medi-

ing larger patient populations, such as accountable care

cine, geriatric medicine, family medicine, and/or

organizations, Medicare Advantage plans, and Medic-

hospice and palliative medicine. CMS says it will

aid managed care organizations, according to CMS.

encourage other payers – including Medicare Ad-

The DC options are designed to financially reward

vantage Plans, commercial health insurers, Medic-

organizations that offer greater efficiencies and bet-

aid managed care plans, and State Medicaid agen-

ter quality of care, the agency says. The options

cies – to align payment, quality measurement, and

include a focus on care for patients with complex,

data sharing with CMS in support of Primary Care

chronic needs and seriously ill populations, as well

First practices.

as a voluntary option that allows beneficiaries to

Both paths under PCF are intended to incen-

align with the healthcare provider of their choosing.

tivize providers to reduce hospital utilization and

Depending on the DC payment option in which

total cost of care by potentially rewarding them

an organization is participating, the model partici-

through performance-based payment adjust-

pant will receive a fixed monthly payment that can

ments, says CMS. These models seek to improve

range from a portion of anticipated primary care

quality of care, specifically patients’ experiences

costs to the total cost of care. Participants in the

of care and key outcomes-based clinical qual-

global payment model option will ultimately bear

ity measures, which may include controlling high

full financial risk, while those in the professional pay-

blood pressure, managing diabetes mellitus, and

ment model option will share risk with CMS.

screening for colorectal cancer.

PCF payment model options “will test whether

CMS anticipates these five payment model options

financial risk and performance-based payments

administered under the Primary Cares Initiative will:

that reward primary care practitioners and other

• Provide better alignment for over 25 percent of

clinicians for easily understood, actionable out-

all Medicare fee-for-service beneficiaries. More

comes will reduce total Medicare expenditures,

than 11 million Medicare beneficiaries would

preserve or enhance quality of care, and improve

potentially be included (5 million beneficiaries

patient health outcomes,” said CMS in a statement.

in the DC payment model options and 6.4 mil-

PCF will provide payment to practices through a

lion in PCF payment model options).

total monthly payment. It will also include a payment model option that provides higher payments

for an estimated one in four primary care prac-

to practices that specialize in care for high-need

titioners as well as other healthcare providers.

patients, including those with complex, chronic

• Create new coordinated care opportunities for

needs and seriously ill populations.

10

• Offer new participation and payment options

a large portion of the 11-12 million beneficiaries July 2019 | The Journal of Healthcare Contracting

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PRIMARY CARE

dually eligible for Medicare and Medicaid, spe-

CMS is seeking public comment on one DC pay-

cifically those in Medicaid managed care and

ment model – the Geographic Population-Based op-

Medicare fee-for-service.

tion – with an expected launch in January 2021. The

Builds on CPC+

option is designed to offer organizations the opportunity to assume responsibility for the total cost of care

Primary Care First borrows underlying principles from

and health needs of a population in a defined target

the Comprehensive Primary Care Plus (CPC+) model,

region. Driving accountability to a local level empow-

which was introduced in January 2017, says CMS:

ers communities to devise strategies best designed to

• Prioritizing the doctor-patient relationship

meet their health care needs, according to CMS.

• Enhancing care for patients with complex chronic needs and high need, seriously ill patients • Reducing administrative burden • Focusing financial rewards on improved health outcomes More than 2,900 primary care practices and 56 aligned payers participate in CPC+ in 18 regions: Arkansas, Colorado, Hawaii, Greater Kansas City Region of Kansas and Missouri, Louisiana, Michigan, Montana, Nebraska, North Dakota, Greater Buffalo Region of New York, North Hudson-Capital Region of

Twenty-six regions for new program

New York, New Jersey, Ohio and Northern Kentucky

Primary Care First model options will be offered in 26 regions for a 2020 start date:

Region, Oklahoma, Oregon, Greater Philadelphia Region of Pennsylvania, Rhode Island, and Tennessee.

What’s next?

“For years, policymakers have talked about building an American healthcare system that focuses on primary care, pays for value, and places the patient at the center,” said Health and Human Services Secretary Alex Azar, when the Primary Cares Initiative was unveiled in April. “These new models represent the biggest step ever taken toward that vision.

“Building on the experience of previous models and ideas of past administrations, these models will test out paying for health and outcomes rather than

Alaska (statewide) Arkansas (statewide) California (statewide) Colorado (statewide) Delaware (statewide) Florida (statewide) Greater Buffalo region (New York) Greater Kansas City region (Kansas and Missouri) Greater Philadelphia region (Pennsylvania) Hawaii (statewide) Louisiana (statewide) Maine (statewide) Massachusetts (statewide) Michigan (statewide)

Montana (statewide) Nebraska (statewide) New Hampshire (statewide) New Jersey (statewide) North Dakota (statewide) North Hudson-Capital region (New York) Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky) Oklahoma (statewide) Oregon (statewide) Rhode Island (statewide) Tennessee (statewide) Virginia (statewide)

procedures on a much larger scale than ever before.”

12

July 2019 | The Journal of Healthcare Contracting

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PRIMARY CARE

An internists’ view of new payment model Editor’s note: Robert McLean, MD, FACP, president of the American College of Physicians, says ACP is enthusiastic about the Primary Cares Initiative from CMS, but that the organization is reserving judgment until it can see more details. His comments to The Journal of Healthcare Contracing have been lightly edited for brevity.

The Journal of Healthcare Contracting: In announcing the Primary Cares Initiative, CMS refers to lessons learned from and experiences of the previous models, (presumably, CPC, CPC+).

From the American College of Physicians’ perspective, what are some of those “lessons learned?”

Robert McLean: The first CPC+ comprehensive annual report (based on 2017 performance) came out around the same time the Primary Care First model was announced. According to the report, there were "few" and "small" differences in service use and quality outcomes. The report itself notes that with any model, downstream outcomes and spending changes take time to realize, so it's not surprising that the results were modest in the very first performance year of the model.

ACP remains supportive of this model and the positive changes that investments in enhanced primary services and other advanced patient care can have on downstream health outcomes and costs. That said, with any alternative payment model, getting the details right – from setting financial benchmarks, to risk adjusting, to attributing patients – is what matters. ACP is still waiting on a lot of those details and we look forward to evaluating them.

JHC: In what ways do you expect the Primary Cares Initiative to take ACP members (as well as payers and patients) beyond the Comprehensive Primary Care Plus program?

14

McLean: The separate track for clinically complex and/or high-risk patients could be an important addition that doesn't exist in CPC+. As CMS points out, these types of patients absorb a disproportionate proportion of practice resources and finances, so targeting these particularly vulnerable patient populations is really important when we discuss ways to improve value.

From the quality measure side, CMS can stand to improve the validity, accuracy, and clinical relevance of the individual quality and outcomes measures it uses – something ACP has repeatedly called for.

CMS notes more generally that the new models will focus on relevant, actionable and outcomes-focused measures.

We hope they will, but it’s hard to tell if measures really meet the mark until we actually see them. There is a real risk of patients experiencing poor outcomes and even harm if they are making decisions based on potentially flawed or unclear information. Additionally, patient participation in such programs should be voluntary, and participants should not have financial penalties imposed simply for failing to achieve health goals and outcomes.

ACP has repeatedly argued that if CMS wants clinicians to participate in these models, they need to make a compelling value proposition, particularly when we're talking about higher risk models. The type of asymmetric reward-to-risk that we see in the Primary Care First model seems like a promising

way to go about that, but we need a more complete picture of the payment amounts before we can make that assessment. Harold Miller [president and CEO of the Center for Healthcare Quality and Payment Reform] recently raised some red flags that the level of reimbursement for these models might actually come in below previous models for the vast majority of participants, which is obviously a concern. The 50% sharing rate is only useful if participants are actually achieving it, and that all comes down to the benchmark. It is premature to say whether in fact these models make a compelling value proposition until we have that type of information.

CMS has said it is considering beneficiary incentives for Primary Care First, which were not a piece of CPC+. ACP feels that engaging the patient in his/her own care is critical when talking about value and improving outcomes. Incorporating some type of beneficiary incentives could be another powerful way to make any [alternative payment model] more effective.

Of course, with any patient incentives, it is important that patient choice is not restricted. Certainly we hope patients can benefit from positive incentives to align with the model … such as additional services and better care or increased access … that they would not otherwise have through traditional Medicare. But it is important that these models do not swing the pendulum the other way and design payment or coverage structures in a way that restricts patient access to certain clinicians or treatment options.

JHC: CMS has said the Primary Cares Initiative will “test out paying for

July 2019 | The Journal of Healthcare Contracting

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Brief Summary of Prescribing Information INDICATIONS AND USAGE Treatment of Hypoxic Respiratory Failure INOmax® is indicated to improve oxygenation and reduce the need for extracorporeal membrane oxygenation in term and near-term (>34 weeks) neonates with hypoxic respiratory failure associated with clinical or echocardiographic evidence of pulmonary hypertension in conjunction with ventilator support and other appropriate agents.

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July 2019 | The Journal of Healthcare Contracting

PRIMARY CARE

health and outcomes rather than procedures on a much larger scale than ever before.” Do you expect that to be the case? Why or why not?

McLean: Primary Care First has 26 regions versus 18 for CPC+. That alone would hopefully mean wider participation, but of course it will depend on the level of uptake. We will need more information on the payment methodology, attribution, and other core elements of the model before we can have a full sense of how attractive this model will be to potential participants. As with the existing CPC+ model, we’d like to see models generally available on a national scale to promote innovation and better patient care in all areas of the country.

Another important element of this question is control groups. ACP understands the importance of being able to evaluate the effectiveness of a program where Medicare dollars are at stake. However, we urge the Innovation Center to consider options other than the way they approached it for CPC+, which unnecessarily restricts participation by sorting willing participants into a control group and depriving them, and more importantly their patient populations, from participating in and benefiting from the program.

JHC: CMS says that Primary Care First “seeks to improve quality of care, specifically patients’ experiences of care and key outcome-based clinical quality measures, which may include controlling high blood pressure, managing diabetes mellitus and screening for colon cancer.” Given all the quality benchmarking programs that already exist, does ACP consider Primary Care First to be a new way to improve quality of care?

McLean: Improving patient outcomes through reporting meaningful quality metrics is not a new concept, but ACP believes it is important to keep in mind

The Journal of Healthcare Contracting | July 2019

that the effectiveness of the model or performance program is only as good as the metrics you are using.

ACP's Performance Measurement Committee has reviewed internal medicine performance measures for the MeritBased Incentive Payment System [MIPS] and found half of them to be inappropriate for use. Physicians are also dealing with “noise” from being evaluated on dozens of quality and cost metrics. ACP firmly believes in the importance of aligning syncing metrics across alternative payment models and performance-based programs from all payer types. Intending PCF to be a multi-payer model is a great step in that direction, but it also depends on how many payers actually sign up to participate in PCF first.

JHC: CMS says that Primary Care First will reduce administrative expenses or time on the part of the primary care physician. How do you feel about that?

McLean: Through our “Patients Before Paperwork” initiative, ACP has consistently advocated for reducing administrative burden in billing, compliance, documentation, and value-based program reporting, and has noted that alternative payment models in which clinicians are already being held financially accountable for cost and utilization outcomes are a particularly viable vehicle to make this happen.

It’s encouraging to hear that CMS seems to be listening and has at least expressed a desire to leverage these models to streamline billing. That said, they also note that fee-for-service billing will continue, so it remains to be seen how much of an actual burden reduction these models will entail. ACP is certainly hopeful that any model that is already holding clinicians accountable for outcomes, utilization and costs in a substantial way, particularly capitation models, can and

should be leveraged as an opportunity to drastically reduce billing, reporting, and other administrative burdens.

It's also important to keep in mind that Medicare is just one payer. For this to really make a meaningful dent in reducing administrative burden, we'll need more payers to come to the table and agree to revise their own billing and reporting requirements.

JHC: How prepared are ACP members to embrace the concepts behind the Primary Cares Initiative, namely, delivering value-based care using population health management techniques? Will the Primary Cares Initiative help them be more prepared?

McLean: ACP members have expressed a lot of interest and desire in participating in these types of innovative payment models, which reward clinicians for keeping patients healthy. Up until now, one of the main criticisms we've heard – and one that we've repeatedly relayed to CMS – is that we need more alternative payment models. So, at a high level, we're certainly excited to see the CMS Innovation Center come out with new models and hope that is just the tip of the iceberg and we have more coming. We're also encouraged to see alternative payment models, particularly in the primary care space, recognizing the critical role internists play in delivering high-value medicine, and how investing in advanced, comprehensive preventative services can contribute to improved outcomes, reduce the risk of downstream complications, and achieve utilization and cost savings.

Additionally, there is a lack of availability of even existing models (like CPC+) in many areas of the country.

That said, with any model, a lot of the devil is in the details, so ACP is looking forward to reviewing all the facts before we can say for certain exactly how much interest there will be in these new models.

17

PRIMARY CARE

Report card for CPC+ In April 2019, the Centers for Medicare & Medicaid Services issued a report covering the first year of the Comprehensive Primary Care Plus (CPC+) program, which CMS calls the largest and most ambitious primary care payment and delivery reform ever tested in the United States.

In 2017, CMS partnered with 63 public and private payers and 2,905 primary care practices in 14 regions across the United States. The practices included 13,209 primary care practitioners, which together served approximately 15 million patients. Participating practices were diverse, ranging in size from one to 80 primary care practitioners. CMS expanded the program to an additional four regions in 2018, partnering with a total of 79 public and private payers.

CMS and other payers agreed to provide CPC+ practices with enhanced and alternative payments, data feedback, and learning activities to support primary care transformation. Health information technology (health IT) vendors also partnered with CPC+ practices to help them use health IT to improve primary care.

The goal of CPC+ is to increase access to – and improve the quality and efficiency

of – primary care, ultimately resulting in better health outcomes at lower cost.

CPC+ also aims to enhance primary care practitioners’ experience. To meet this goal, CMS requires CPC+ practices to transform across five Comprehensive Primary Care Functions: • Access and continuity • Care management • Comprehensiveness and coordination • Patient and caregiver engagement • Planned care and population health In 2017, the median care management fees practices received for participating in CPC+ from CMS and other payers – over and above what they already receive for providing care – exceeded $88,000 per Track 1 practice, which translates to $32,000 per practitioner on average; and $195,000 per Track 2 practice, which translates to $53,000 per practitioner on average. (Compared to Track 1, practices

in Track 2 are required to make more advanced care delivery changes to improve the care of complex patients and, to support that work, they receive more financial support and a greater shift from fee-for-service toward population-based payment.)

CMS paid higher care management fees per patient than other payers, in part to compensate for the higher needs of Medicare fee-for-service beneficiaries.

Some CPC+ practices, known as “deep-dive practices” were selected for intensive qualitative study. The deep-dive practices reported that enhanced payments were the most critical support for improving primary care in 2017. Most deep-dive practices reported that they used CPC+ care management fees to improve their care delivery, most commonly by hiring new staff such as care managers. However, on the 2018 CPC+ Practice Survey, only 41 percent of Track 1 practices and 51 percent of Track 2 practices indicated that CPC+ funding from Medicare FFS was adequate or more than adequate for them to complete the work required by CPC+.

Practices were more concerned about payment levels from non-Medicare FFS payers. Only one-third of practices in each track reported that payments from these payers were adequate. Deep-dive practices noted that non-Medicare FFS payers often did not provide additional support unique to CPC+ and that their care management fees were generally lower than practices anticipated.

To view the report, “Independent Evaluation of Comprehensive Primary Care Plus (CPC+): First Annual Report,” go to https://www.mathematica-mpr.com/our-publications-and-findings/publications/independent-evaluation-of-comprehensiveprimary-care-plus-cpc-first-annual-report

18

July 2019 | The Journal of Healthcare Contracting

Employed physicians outnumber self-employed AMA reports that younger physicians and women physicians are more likely to be employed For the first time in the United States, employed physicians outnumber self-employed physicians, according to a study released in May by the American Medical Association. This milestone marks the continuation of a long-term trend that has slowly shifted the distribution of physicians away from ownership of private practices, according to AMA. Employed physicians were 47.4% of all patient care physicians in 2018, up 6% points since 2012. In contrast, self-employed physicians were 45.9% of all patient care physicians in 2018, down 7% points since 2012. Changes of this magnitude are not unprecedented, said AMA. Older AMA surveys show the share of self-employed physicians fell 14% points during a six-year span between 1988 and 1994.

Given the rate of change in the early 1990s, it appeared a point was imminent when employed physicians would outnumber self-employed physicians, but the shift took much longer than anticipated, according to AMA. The majority of patient care physicians (54%) worked in physicianowned practices in 2018 either as an owner, employee, or contractor. Although this share fell from 60.1% in 2012, the trend away from physicianowned practice appears to be slowing since more than half of the shift occurred between 2012 and 2014.

Concurrently, there was an increase in the share of physicians working directly for a hospital or in a practice at least partly owned by a hospital. Physicians working directly for a hospital were 8% of all patient care physicians, an increase from 5.6% in 2012. Physicians in hospitalowned practices were 26.7% of all patient care physicians, an increase from 23.4% in 2012. In the aggregate,

The Journal of Healthcare Contracting | July 2019

compared to 38.2% of physicians age 55 and over. Among female physicians, more were employees than practice owners (57.6% vs. 34.3%).

The reverse is true for male physicians: More were practice owners than employees (52.1% vs. 41.9%).

As in past AMA studies, physicians’ employment status varied widely across medical specialties in 2018. The surgical subspecialties had the highest share of owners (64.5%) followed by obstetrics/gynecology (53.8%) and internal medicine subspecialties (51.7%). Emergency medicine had the lowest share of owners (26.2%) and the highest share of independent contractors (27.3%). Family practice was the specialty with the highest share of employed physicians (57.4%).

Despite challenges posed by dynamic change in the health care landscape, most physicians still work in small practices, says AMA. This share has fallen slowly but steadily

Family practice was the specialty with the highest share of employed physicians.

34.7% of physicians worked either directly for a hospital or in a practice at least partly owned by a hospital in 2018, up from 29% in 2012.

Younger physicians and women physicians are more likely to be employed. Nearly 70% of physicians under age 40 were employees in 2018,

since 2012. In 2018, 56.5% of physicians worked in practices with 10 or fewer physicians compared to 61.4% in 2012. This change has been predominantly driven by the shift away from very small practices, especially solo practices, in favor of very large practices of 50 or more physicians.

19

INNOVATION IN HEALTHCARE

Pitt leads creation of global infectious disease data system “The scientific community is increasingly recognizing that sharing research data and software not only benefits individual research projects, but increases the impact of science and innovation on the greater good. However, nobody’s figured out exactly how to do this for global infectious diseases,” Van Panhuis said. “What we’re going to do is leverage that interest in ‘open science’ to create a framework that will make it easy to share, find and use research data and software to combat infectious diseases.”

In its first year, the MIDAS Network Coordination Center will largely conWilbert van Panhuis

centrate on standardizing and uploading hundreds of existing infectious disease datasets into its platform, as well as

The University of Pittsburgh Graduate School of Public

reaching out to scientists who use such

Health plans “to lead a culture shift in data-sharing rippling

data to ask how MIDAS data and soft-

through scientific fields and harness it to improve global knowl-

ware can best serve them.

edge of infectious diseases.” The initiative will be backed by a five-year, $6.7 million NIH grant.

20

“Our hope is that after that first year, the MIDAS network will be able to dem-

Pitt Public Health will lead a multidisciplinary group of com-

onstrate the benefits of open science and

puter scientists, biostatisticians and biomedical informatics ex-

open data for making new discoveries,”

perts to direct the inaugural Network Coordination Center for

Van Panhuis said. “We’ll also be going after

the Models of Infectious Disease Agent Study (MIDAS), a collab-

new data ourselves, on behalf of MIDAS,

orative research network originally launched by the NIH in 2004

collecting datasets from health organiza-

to assist the nation in preparing for infectious disease threats.

tions and government entities worldwide,

Wilbert van Panhuis, MD, PhD, assistant professor of epidemi-

so that the scientists have to spend less

ology at Pitt Public Health and biomedical informatics at Pitt’s

time obtaining data and can instead con-

School of Medicine, will lead the new center.

centrate on making discoveries with it.”

July 2019 | The Journal of Healthcare Contracting

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HEALTH NEWS

Health news and notes How much screen time?

sels in the retina – the light-sensing tissue

How much screen time – smartphones, videos, online games –

at the back of eye. Diabetic macular edema

should little kids have? The World Health Organization says that

is the result of fluid build-up in the central

kids in their first year of life should have ZERO time in front of a

area of the retina, called the macula, which

screen, and very little in year 2. Those aged 2 to 4 should spend

is important for sharp vision. Swelling of

no more than an hour a day in front of a screen, says WHO. The

the macula can distort vision required for

international health agency drew on emerging – but as yet un-

reading and driving.

settled – science about the risks screens pose to the development of young minds, reports The Washington Post. Experts in

Lightning strikes

child development say the acquisi-

Just as lightning can strike the same tar-

tion of language and social skills, typically by interacting with parents and others, are among the most important cognitive tasks of childhood.

But there is disagreement about how screen time interferes with that. “The more guidelines we give, it just seems like there’s going to be more of a mismatch between what experts say …

A study published in Diabetes Care found that the company’s technology could detect 97 percent of developing foot ulcers an average of five weeks before they could be detected otherwise.

get more than once in a given storm, hip fractures can and do happen again to the same person, according to New York Times health writer Jane Brody. Yet, more often than not, people who fracture a hip do not get follow-up treatment that could prevent another fracture. Anyone who breaks a hip, unless from a severe trauma like a car accident, is considered

and what it feels like to be a parent in

at high risk for further fractures, includ-

the real world every day,” said University of Michigan pediatri-

ing breaking the other hip. To reduce the

cian Jenny Radesky, author of 2016 screen-time guidelines for

risk, orthopedic experts recommend that

the American Academy of Pediatrics.

following a fracture, patients should have

Wait and see

a bone density test, evaluation of calcium and vitamin D levels and, in nearly all cas-

People with good vision despite having center-involved diabetic

es, medication to protect against further

macular edema can safely forego immediate treatment of their eye

bone loss. Writing in JAMA Geriatrics last

condition as long as they are closely monitored, and treatment be-

year, University of California San Fran-

gins promptly if vision worsens, according to clinical trial results.

cisco internist Dr. Douglas Bauer wrote

The findings were published in the Journal of the American Medical

about “really depressing, hocking data”

Association. Diabetic macular edema is the most common cause of

revealing that only a small – and steadily

vision loss among people with diabetic eye disease in the United

declining – fraction of hip fracture pa-

States. Diabetes can result in the development of leaky blood ves-

tients are being treated with medication that might forestall future broken bones.

22

July 2019 | The Journal of Healthcare Contracting

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PATIENT CARE

ENVIRONMENT OF CARE

INTERVENTIONAL CARE

HEALTH NEWS

HPV vaccine has impact

other substances really lead to a longer,

Cervical cancer is the most common human papillomavirus

healthier life? A nationwide study pub-

(HPV)-associated cancer in women, and high-grade cervi-

lished in the Annals of Internal Medicine

cal lesions (CIN2+) have been used to monitor HPV vaccine

suggests it doesn’t. Based on an analy-

impact, reports the CDC. During 2008–2016, CIN2+ rates in a

sis of survey data gathered from more

population-based surveillance system declined in women aged

than 27,000 people over a six-year pe-

18–24 years, the agency reported. The estimated numbers of

riod, an NIH-funded study found that

U.S. CIN2+ cases were 216,000 (2008) and 196,000 (2016), with

individuals who reported taking dietary

an estimated 76% attributable to 9-valent HPV vaccine types.

supplements had about the same risk of

“The reduction in CIN2+ attributable to vaccine types in young

dying as those who got their nutrients

women demonstrates impact of the HPV vaccination program,”

through food. What’s more, the mortal-

says CDC. “Continued efforts to increase coverage and encour-

ity benefits associated with adequate

age vaccination at the routine ages (11–12 years) can increase

intake of vitamin A, vitamin K, magne-

vaccine impact on cervical disease in the United States.”

sium, zinc, and copper were limited to

Sickle cell therapy is tested An experimental gene therapy being tested at the National

Sensor for diabetic foot ulcers

Institutes of Health Clinical Center in Bethesda, Maryland, has

Somerville, Massachusetts-based Podi-

shown some positive results in eliminating sickle cell disease

metrics is tackling the problem of dia-

(SCD). The approach involves using gene editing to increase

betic foot ulcers through a smart sensor

levels of fetal hemoglobin (HbF) in the red blood cells of peo-

mat that is designed to be placed in a pa-

ple with SCD. Significant quantities of HbF have been found

tient’s home and can analyze foot tem-

to provide protection against sickling. Sickle cell disease is

perature variations to predict and pre-

caused by a specific point mutation in a gene that codes for

vent the occurrence of a potential ulcer,

the beta chain of hemoglobin. People with just one copy of

according to MedCity News. Podimetrics

this mutation have sickle cell trait and are generally healthy.

users stand on the mat for about 20 sec-

But those who inherit two mutant copies of this gene suf-

onds, and the data gets analyzed and

fer lifelong consequences of the presence of this abnormal

sent to the Podimetrics care team, which

protein. Their red blood cells – normally flexible and donut-

examines and triages the data and works

shaped – assume the sickled shape that gives SCD its name.

with the patient’s physician on preven-

The sickled cells clump together and stick in small blood ves-

tative treatments and coaching. A study

sels, resulting in severe pain, anemia, stroke, pulmonary hy-

published in Diabetes Care found that

pertension, organ failure, and far too often, early death.

the company’s technology could detect

How valuable are vitamins?

24

food consumption.

97 percent of developing foot ulcers an average of five weeks before they could

More than half of U.S. adults take dietary supplements, accord-

be detected otherwise. Podimetrics has

ing to Dr. Francis Collins, director of the National Institutes of

reportedly raised around $16 million in

Health. But does popping all of those vitamins, minerals, and

funding since its founding in 2011.

July 2019 | The Journal of Healthcare Contracting

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