How do we improve the value of care delivered in primary care? with John Mafi

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All of us like to think that we provide high-value care for our patients; but the truth is, just like the rest of the health care system, primary care provides a lot of low value care too – and we drive a lot of overuse. John Mafi joins us this week to talk about his leading research into these thorny, complex issues.

We talk about the definitions of high-value and low value care, his 2016 study in Annals of Internal Medicine examining rates of high and low value care among physicians, NPs, and PAs in the primary care setting, how practice setting may affect the delivery of high and low value care, and the essential truth that there is no free lunch in trying to solve some of the challenges in fixing primary care in the US. You can find Shah et al, which John referenced here; a recent study relevant to our conversation by Hong et al looking at clinician characteristics and frequent ordering of low-value imaging studies; and an extremely important new paper that John published recently in Health Affairs looking at the the impact of low-cost, high-volume studies on unnecessary health spending.

A little bit more about our guest:  John N. Mafi, MD, MPH is an assistant professor of medicine in the Division of General Internal Medicine and Health Services Research at the David Geffen School of Medicine at UCLA where he also practices and teaches. He also serves as an Affiliated Natural Scientist in Health Policy at RAND Corporation. Dr. Mafi trained in internal medicine at Beth Israel Deaconess Medical Center in 2012, where he also served as Chief Medical Resident and completed the Harvard Medical School Fellowship in General Internal Medicine and Primary Care in 2015. Dr. Mafi’s research focuses on quality and value measurement and how electronic health records can improve the value of care.

If you enjoy the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

 This interview has been lightly edited for length and clarity.

Lori Tishler of Commonwealth Care Alliance – Caring for the Most Vulnerable Patients

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Have you ever felt lonely and overwhelmed in a clinic room with a patient whose needs are far beyond your skills and ability to meet? I have, many times, and so has our guest this week, Dr. Lori Tishler. Dr. Tishler is the Vice President of Medical Affairs at Commonwealth Care Alliance, a not-for-profit organization that cares for more than 20,000 of the most vulnerable patients in Massachusetts, duals, or individuals who have both Medicare and Medicaid.

We talk about how CCA’s member-centered approach (as opposed to a physician-centered approach) has helped her feel more effective in caring for these vulnerable patients. We talk about the range of services that CCA offers, the role of their care partners, and the freedom that their financial model permits – for example, they provide 90% of care to patients in their homes.

You can find the Atlantic Magazine article we referenced featuring CCA here, and find a few Health Affairs blogs featuring CCA here, and a blog post focusing on building the business case for a community paramedicine program here.

A bit more about our guest: Lori Tishler is the Vice President of Medical Affairs at Commonwealth Care Alliance, a not-for-profit organization that cares for more than 20,000 of the most vulnerable patients in Massachusetts, people who have both Medicare and Medicaid.  She oversees CCA’s physicians and is involved with clinical aspects of quality, utilization, and pharmacy.  In addition, she is an Assistant Professor at Harvard Medical School and an active member of the General Medicine Faculty at Brigham and Women’s Hospital, As a caring and connected physician leader, mentor, and educator, Dr. Tishler’s passion has been providing care for the medically and socially vulnerable and making a difference in health systems for all.   Tishler has found that the most rewarding way to help change and grow our health care systems is to mentor learners who are interested in clinical care, leadership, and innovation.

Her leadership roles have extended outside of the clinic and outside of primary care.  She served on the Partners Healthcare Board of Directors, the Board of Directors for the Office for Women’s Careers, and the Board of the Schwartz Rounds while at the Brigham.  At Commonwealth Care Alliance, she teaches and presents nationally about our care model and innovations.

In addition to her leadership work, she continues to provide clinical care  Tishler feels that working as a clinician informs her choices and decisions as a leader.  Outside of work, Dr. Tishler loves to spend time with her husband and teenaged daughter, to travel, read, and knit.  She is honored to have been interviewed on Review of Systems.

If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @rospodcast and check out our facebook page at www.facebook.com/reviewofsystems. Or, you can email us at audreyATrospod.org. We’d love to hear from you, and thanks for listening.

Tom Bodenheimer – Building Blocks of High-Performing Primary Care and the Quadruple Aim

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Dr. Tom Bodenheimer is one of the world’s foremost experts in primary care re-design, having recently written about high-performing primary care clinics and the Quadruple Aim, which are articles consistently in the most-read list for the Annals of Family Medicine and among his most cited work.  We focused much of our conversation on his work visiting 23 high-performing primary care practices, what he and co-authors learned, how resident teaching sites can also be high-performing, and why we should be seeking a fourth aim in addition to IHI’s famed Triple Aim.

A general internist who received his medical degree at Harvard and completed his residency at the University of California-San Francisco, Dr. Tom Bodenheimer spent 32 years in primary care practice in San Francisco’s Mission District, a primarily low-income, Latino community—ten years in community health centers and 22 years in private practice.  He is currently Professor of Family and Community Medicine at UCSF and Founder and Co-Director of the Center for Excellence in Primary Care.  He has written extensively in journals such as the New England Journal of Medicine, JAMA, Annals of Family Medicine, and Health Affairs, on health policy and health care delivery for chronic disease management, including patient self-management, health coaching, and team-based care. He is also co-author of the books Improving Primary Care: Strategies and Tools for a Better Practice, and the health policy text book Understanding Health Policy.

Listen at the end of the episode for a promo code to receive 15% off registration fees for an upcoming conference from the Harvard Center for Primary Care: Primary Care in 2020 – Future Challenges, Tips for Today.

This interview has been lightly edited for length and clarity.

Journal Club – Do On-Site Mental Health Professionals Change Pediatricians’ Responses to Children’s Mental Health Problems?

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On our journal club this week, we talk about an article published in September 2016 in the journal Academic Pediatrics: Do On-Site Mental Health Professionals Change Pediatricians’ Responses to Children’s Mental Health Problems? By Sarah McCue Horwitz and colleagues.

If you like the show, please rate and review us on itunes or stitcher, which makes the show easier for others to find; and share us on social media. We tweet at @rospodcast and are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you.

Gail D’Onofrio, Initiation of Suboxone Treatment for Opiate Use Disorder in the ED

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This week we are again looking at the opioid crisis, but this time from the perspective of an emergency room physician. Gail D’Onofrio, MD, MS is Physician-in Chief of Emergency Services at Yale-New Haven Hospital; she and her colleagues published a randomized controlled trial in JAMA in April 2015 looking at an intervention initiating suboxone treatment for patients with substance use disorders in the ED.  Gail is Professor and Chair of the Department of Emergency Medicine at Yale University and is internationally known for her work in substance use disorders, women’s cardiovascular health, and mentoring physician scientists in research careers, and she is a founding board member of the American Board of Addiction Medicine.

We talk about her perspective on the opioid epidemic as an ED physician; her RCT; how people could set up a similar program in their local ED and community; and her thoughts on ED utilization for primary care complaints, which is the subject of a recently issued report from the Massachusetts Health Policy Commission.

Please rate and review us on iTunes or Stitcher and share us on social media. Tweet us your thoughts @RoSpodcast and check out our Facebook page at www.facebook.com/reviewofsystems. Or, you can email us at contact@rospod.org. We’d love to hear from you.

Journal Club – Los Angeles Safety Net Program eConsult System Was Rapidly Adopted and Decreased Wait Times to See Specialists

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For this week’s journal club, we are talking about a recent paper from Health Affairs entitled: Los Angeles Safety Net Program eConsult System Was Rapidly Adopted and Decreased Wait Times to See Specialists  by Michael Barnett, Hal F. Yee Jr, Ateev Mehotra, and Paul Giboney. The paper describes and analyzes data from an e-consult system that was rolled out to a network of hundreds of safety-net clinics in Los Angeles County. We are thrilled to have the lead author, Michael Barnett, join us for our discussion! Michael is an Assistant Professor at Harvard T.H. Chan School of Public Health and a primary care physician at Brigham and Women’s Hospital. He publishes prolifically on a variety of topics, and is particularly interested in the primary care-specialty care interface.

Do you use e-consults in your practice? Or do you wish you had access to such a system? Please tweet us your thoughts @RoSpodcast, or drop us a line at contact@rospod.org. And, let us know what manuscripts you think we should look at in future journal clubs or who we should have on to talk about their work. We look forward to hearing from you, and thanks for listening.

Reprise – David Buck, Caring for High-Need, High-Cost Patients

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This week, Thomas Kim hosts the show and interviews Dr. David Buck, a family physician and professor of family and community medicine at the Baylor College of Medicine.  He is the founder and president of Patient Care Intervention Center (PCIC), an organization that uses advanced population health methods to target super-utilization of the health care system and intervenes through intensive care coordination and case management. It’s based in Houston, Texas and recently opened a branch in Dallas, and they were recently featured on PBS NewsHour. Prior to Dr. Buck’s work at PCIC, he founded Healthcare for the Homeless – Houston (HHH), now a federally qualified health center for over 7,000 homeless in Harris County, as well as the associated Houston Outreach Medicine Education and Social Services (HOMES) clinic, a student-managed clinic at HHH in conjunction with BCM and the University of Texas Health Science Center. He is a co-founder of the Houston-based physician advocacy group Doctors for Change, and founded the Houston-Galveston Albert Schweitzer Fellowship. He helped found the international street medicine institute, and was appointed to the 15-member Consumer Operated and Oriented Plan Program advisory board created as part of the Patient Protection and Affordable Care Act in 2012.

You can find some CDC resources about Adverse Childhood Experiences, or ACEs here, and a New Yorker article about the effects of ACEs on health here.
Dr. Buck is a graduate of the Baylor College of Medicine and the University of Texas School of Public Health, as well as family medicine residency at the University of Rochester.

Lauren A Taylor – Integration of Healthcare and Social Services

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Today we’re joined by Lauren A Taylor, a health services researcher based at Harvard Business School, where is she is earning her doctorate in health policy and management. Prior to joining HBS, Lauren co-authored The American Health Care Paradox, which has become required reading at a variety of medical and public health schools across the country. Our discussion spans a range of topics and should excite clinician and policymaker listeners alike, especially those interested in addressing upstream factors that affect health in our American society.

We start with reviewing the initial research paper that lay the groundwork for her book and what other countries show us about how government spending on social services can affect health outcomes, as well as what she learned interviewing caregivers and social services workers in the US.  We also talk on how American sociopolitical factors influence our discourse on the distribution and allocation of resources as well as how research is done in her field. We discuss whether health systems are moving in the right direction addressing social determinants of health through ACOs, why management gets overlooked and undervalued as a key ingredient in healthcare delivery, and why it’s just so hard to get all of this right.

Lauren’s work focuses on organizational theory and strategy in health care, with a particular emphasis on the integration of health and social services. She holds a BA in the History of Medicine and a Master in Public Health from Yale University. She has also worked as a health care chaplain and studied ethics as a Presidential Scholar at Harvard’s Divinity School.

If you like the show, please subscribe on our website www.rospod.org, and rate us on iTunes and Stitcher and share us on social media. Get in touch via twitter @RoSpodcast or drop us a line at contact@rospod.org. Thanks for listening!

Seth Berkowitz – Food Insecurity and Chronic Disease

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This week we are joined by Seth Berkowitz to talk about his research examining the associations between food insecurity and health outcomes. Seth is a primary care physician, Instructor of Medicine, and is on faculty in the Division of General Internal Medicine and the Diabetes Research Center at Massachusetts General Hospital.

Seth’s research interests include population management, food insecurity, cost-related medication underuse and the impact of adverse social circumstances on chronic disease management. His goal is to develop and disseminate interventions and care delivery models that address social and economic needs.

Today he joins us to talk about a recent collaboration, funded by an award from the Robert Wood Johnson Foundation Evidence for Action Program, with Community Servings. Community Servings is a Boston-based non-profit organization dedicated to bringing medically tailored meals to chronically ill adults. The study aims to assess whether individuals receiving the medically tailored meals have lower rates of inpatient hospitalization, ED utilization, and medical expenditures.

You can find a piece co-authored by Seth and David Waters, the CEO of Community Servings here, and the Health Affairs article Seth and I talked about examining the effect of eliminating use of SNAP, or food stamps, for sugary sweetened beverages here.

Lastly, if you like the show, please rate and review us on itunes or stitcher, which makes the show easier for others to find; and share us on social media. We tweet at @rospodcast and are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you.

 

Less AND More Are Needed to Assess Primary Care – Rebecca S. Etz et al

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On this week’s journal club, David Rosenthal, Audrey Provenzano, and Thomas Kim discuss Less AND More are Needed to Assess Primary Care, which was recently published in the Journal of the American Board of Family Medicine by Rebecca Etz, PhD, Martha M. Gonzalez, BS, E. Marshall Brooks, PhD, and Kurt C. Stange, MD PhD.

The study utilized surveys to assess the lacuna between current quality measures and attributes of high quality primary care, and make the case that as policymakers and payers work to reduce the administrative burden of quality measurement more attention should be paid to measuring domains of high quality primary care.

What do you think? How do you know good primary care when you see it? How should the quality of primary care be assessed?

Please tweet us your thoughts @RoSpodcast, or drop us a line at contact@rospod.org. And, let us know what manuscripts you think we should look at in journal clubs and who we should have on to talk about their work. We look forward to hearing from you, and thanks for listening!