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Editor’s note: Comments from the American Medical Association were added to the original article.

The patients underwent elective surgery with primary surgeons and in facilities that were in their private insurer’s network. Yet, one in five got a surprise bill after their procedure for out-of-network services, according to a new study.

The patients were left with an average potential balance of $2,011, according to the JAMA study released today.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

As politicians in Washington look at how to address the problem of surprise bills, researchers examined claims data from a large health insurer to examine how often patients unexpectedly received out-of-network bills after having in-network elective surgery. In 20% of the surgeries, patients received out-of-network charges, the study found.

Members of Congress have been grappling with ways to end surprise medical bills. The House Ways & Means Committee on Friday released largely provider-friendly legislation as a bid to end an impasse over how to handle surprise billing with a proposal to use a “mediation” process to handle disputes.

In the study, most commonly, the out-of-network bills occurred when patients received care from anesthesiologists and surgical assistants who were not part of their insurance network, which happened in 37% of the cases where patients received a surprise bill, the study found.

In cases where a surgical assistant was not in the insurance network, patients faced an average potential bill of $3,633. With out-of-network bills that resulted from the anesthesiologist being out of the patient’s network, the average potential bill was $1,219, the study found.

The analysis included almost 350,000 commercially insured patients who underwent one of seven common elective surgeries at in-network facilities with in-network primary surgeons between 2012 and 2017. Researchers said one limitation of their study was that the claims data came from only on insurer.

Patients had a greater risk of receiving an out-of-network bill when they were members of a health insurance exchange plan. Risks were also significantly higher when there were surgical complications, the study found.

In an accompanying editorial, JAMA editors said it’s time to stop surprise medical bills, which they described as “both common and potentially financially devastating.”

“Such billing practices are particularly pernicious because patients usually have no knowledge that they will occur, and no way to avoid them,” wrote Karen E. Joynt Maddox, M.D., of the Washington University School of Medicine and associate editor of JAMA, and Edward Livingston, M.D., deputy editor at JAMA.

It’s up to both clinicians and policymakers to act to end surprise billing, they said, arguing that surgeons have an ethical responsibility to speak out.

“When feasible, surgeons should ensure that all the personnel involved in the care team that they are leading accept the same insurance plans and should consider refusing to work in facilities that allow surprise billing,” they wrote.

The American Medical Association, the country’s largest physician organization, Tuesday came out in support of the bipartisan efforts of the House Ways and Means Committee to craft legislation to protect patients from surprise medical bills.

The legislation creates a two-step process for resolving disputes over reimbursement, first through a 30-day negotiation process that encourages parties to resolve their differences before using a mediation process administered by a third party.

“We support the underlying mechanism for resolving these disputes, including the eligibility of all disputed claims for negotiation and mediation. We also appreciate that the mediator must consider a wide range of supporting information submitted by physicians in rendering a final determination,” said Patrice A. Harris, M.D., AMA president, in a statement.

Harris said the AMA plans to work with the committee and others to refine the legislation so it is fair to everyone involved.

While hospitals and physicians support the legislation, payers have pushed to link out-of-network payments to a benchmark rate, rather than the arbitration process favored by providers.

Florida-based AdventHealth plans to replace its Cerner electronic health record (EHR) system with rival Epic’s.

One of the largest faith-based health systems in the country, AdventHealth operates 50 hospital campuses across a dozen states. The health system employs more than 80,000 people who serve more than 5 million patients annually and reports nearly $20 billion in annual revenue.

The health system first signed a deal with Cerner in 2002 when it was known as Adventist Health System.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

AdventHealth will begin the transition in March and will eventually roll Epic’s EHR out to 1,200 care sites. The work is expected to be completed in about three years, the health system said.

In a press release issued Tuesday, AdventHealth said it plans to install a single, integrated Epic EHR and revenue cycle management system across all of its acute care, physician practice, ambulatory, urgent care, home health and hospice facilities.

Epic’s Community Connect program will also allow AdventHealth to extend its EHR system to affiliated providers as part of the integrated platform, according to AdventHealth.

“Our journey to become a consumer-focused clinical company requires a fully connected network throughout our entire enterprise,” Terry Shaw, president and CEO for AdventHealth, said in a statement. “Connecting our network with a robust, integrated health record platform will give our caregivers access to the clinical information they need at the point of care and ultimately advance our consumer promises through a more seamless experience for those we serve.”

In an emailed statement, Cerner confirmed the changeover. “AdventHealth has made the business decision to transition over the next few years management of its EHR and revenue cycle management system to another supplier. The shift is expected to take up to five years and Cerner is committed to working closely with AdventHealth to continue delivering superior health care technology solutions throughout the transition,” the company said.

Anonymous Reddit posters predicted the change months ago, saying that the health system was frustrated with integration issues with Cerner’s ambulatory solution and revenue cycle functionalities. HIStalk first reported the Reddit posts regarding Cerner and AdventHealth.

One Reddit user said AdventHealth staff felt the health system was on the “back burner” since Cerner signed massive projects with the departments of Defense and Veterans Affairs.

It’s unclear what the loss of a big EHR client will mean for health IT company Cerner’s annual revenue or earnings.

The company continues efforts to turn its financial picture around and improve its operating performance.

Almost a year ago, activist investor Starboard Value stepped in, and Cerner reached a settlement with the hedge fund to add new directors to its board and buy back more of its shares. Cerner also agreed to take steps to improve operations and committed to hitting certain operating targets.

The new agreement between Cerner and Starboard Value, which has a 1.2% stake in the company, was seen as welcome news by many financial analysts as a plan to increase the company’s profitability.

Cerner’s full-year 2019 bookings were down 11% compared to 2018 bookings, from $6.72 billion to $5.99 billion. Company executives said during their full-year and fourth-quarter earnings call that the decline in bookings was primarily driven by the company being more selective in the types of contracts it pursues, which led to fewer large, long-term outsourcing contracts.

Congressional Democrats said they felt blindsided by the Department of Veterans Affairs’ (VA’s) decision this week to push off its go-live date for a new $16 billion medical records system.

The House Veterans’ Affairs Subcommittee on Technology Modernization plans to hold a hearing in the next few weeks to scrutinize the VA’s decision to delay the platform’s rollout, Susie Lee, D-Nevada, chairwoman of the subcommittee, announced.

The VA had planned to flip the switch on the new electronic health record (EHR) at its first site—Mann-Grandstaff VA Medical Center in Spokane, Washington—on March 28. But the VA announced this week it’s delaying plans to commence end-user training, which may impact “going live” with its EHR in March in Washington.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

“After rigorous testing of our new EHR, the department will need more time to complete the system build and ensure clinicians and other users are properly trained on it,” VA spokesperson Christina Mandreucci told FierceHealthcare in an emailed statement.

“We believe we are 75-80% complete in this regard and will be announcing a revised ‘go-live’ schedule in the coming weeks,” she said.

Lee said during a hearing on VA’s data privacy policies Wednesday that the VA needs to be “forthright about its progress, identify concerns, and notify Congress about any challenges.”

“I’ve long said that getting it right is far more important than hitting a date on a calendar. If there needs to be a delay to get the system to a place where veterans’ lives are not at risk and VA staff are ready to use it, that’s the right thing to do,” she said.

She added, “However, I’m concerned that as we have moved closer to the go-live date, we were told repeatedly there were no show-stoppers in implementation, that testing was going great, and that things were on track.”

Politico reported that the committee’s staff said the VA had not mentioned the possibility of delay in recent meetings. When the department informed Lee of the decision, VA officials employed inconsistent explanations, committee staff told Politico.

Lee acknowledged that software development and testing conditions can change rapidly, but the committee requires “transparency and for the VA to be accountable for its actions.” 

She also noted that President Donald Trump’s proposed budget would “speed up” the EHR project rollout.

The VA signed a $10 billion deal with Cerner in May 2018 to move from the VA’s customized VistA platform to an off-the-shelf EHR to align the country’s largest health system with the Department of Defense, which has already started integrating Cerner’s MHS Genesis system.

For the VA, the Cerner EHR will replace the approximately 130 operational instances of VistA currently in use across the department. While the initial EHR contract signed with Cerner was for $10 billion, the VA has pushed the estimated 10-year cost for implementing the system past $16 billion.

The VA’s delay comes a week after a key VA EHR project leader, former VA Deputy Secretary James Byrne, was abruptly dismissed. In his five months at the agency, Byrne was a key leader updating members of Congress on the progress and challenges of the implementation.

Lawmakers on both sides of the aisle want more answers on why the department pushed off its go-live date for the multibillion dollar medical records system.

Rep. Jim Banks, R-Indiana, ranking member of the committee, said during the hearing that he supported VA Secretary Robert Wilkie’s decision to delay the EHR launch but was disappointed that no VA officials in charge of the EHR project attended Wednesday’s hearing, as lawmakers had requested.

Rep. Phil Roe, M.D., R-Tennessee, the ranking member of the House Committee on Veterans’ Affairs and a member of the subcommittee, said VA’s decision to delay the project highlighted the need for lawmakers to ramp up oversight of the project.

Sen. Jon Tester, the ranking member of the Senate Veterans’ Affairs Committee, said in a statement that, “VA must establish stable leadership to provide sufficient accountability and robust oversight of this process.”

Mark Takano, D-California, chairman of the House Veterans’ Affairs Subcommittee on Technology Modernization, said he supported VA leadership taking the time they need to get the $16 billion dollar implementation right, but leaders need to be transparent with Congress.

During Wednesday’s hearing, Paul Cunningham, the VA’s deputy assistant secretary and chief information security officer, testified that he was made aware of the EHR project delay on Tuesday.

The delay was more a “tactical decision” than a result of a lack of resources, he said, while acknowledging that the project was “outside his purview.”

“Change is the only constant in life.” – Heraclitus, Greek philosopher

While the universal flux theory is 2,700 years old, in oncology, it is as applicable today as it was when the “weeping philosopher” first uttered his paradoxical doctrine.

Oncology has experienced more constant change in the last 30 years than from the late 20th century to the time cancer was first identified in 440 B.C. 

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

The rapid pace of innovation in oncology has been fueled by an immense knowledge explosion about cancers, how they grow and how to treat them in different subpopulations. In fact, from May 2018 to May 2019, the U.S. Food and Drug Administration (FDA) approved almost 60 new oncology drugs.

And while the advances we see in oncology today—targeted therapies, precise diagnostics and a better patient experience—are powering a consistent drop in cancer death rates, they also require oncologists to know more than any one person possibly can.

How, then, should medical oncologists and their practices stay up to speed on advancements to ensure patient receives the right treatment at the right time?

  • Harness technology: Oncologists and their practices cannot get overwhelmed by the promise of artificial intelligence or any other aspect of technology and instead should focus on two vital deliverables: 1) an agile platform that turns data clinical, operational and financial data inputs into actionable insights; and 2) a platform for real-time peer-to-peer communication offering a virtual second opinion. Technology must work to improve physician workflow and efficiency. By engaging physicians and focusing on meeting their needs, technology and the analytical insights it reveals should help oncologists, not exacerbate physician burnout.
     
  • Stay flexible locally: Former House Speaker Tip O’Neill’s adage about all politics being local applies to healthcare, too. Every market in the U.S. is different, and it requires practices looking to thrive to have the flexibility to form partnerships that make sense locally. One-size-fits-all does not work for oncology practices or their patients today. Rather, practices need flexibility to form relationship with hospitals or other provider networks that make sense for their patient populations.
     
  • Having scale to negotiate: While flexibility is important locally, practices cannot survive without the scale to negotiate on drug purchasing, payer contracts or employer relationships. Practices don’t have to sacrifice independence for scale, but they cannot go it alone and expect to be able to offer their patients services along the continuum of care from clinical trials to palliative treatments. Practices must figure out partnerships that work so care options, most notably access to clinical trials, are expanded for patients. 
     
  • Embrace value: Fee-for-service care will soon be akin to skiing in jeans—a relic of the 20th century. Medicare’s voluntary—and risk free—value-based payment model in oncology will soon give way to a two-sided risk model. And while entering into two-sided risk now might not be right for every practice immediately, ignoring the tectonic shift in payment comes with peril. Practices need to understand value-based models through implementing them so their patients can benefit from better care coordination, drug utilization and communication between the care team and their patients outside the clinic. 

The practice of oncology has changed immensely since I’ve been treating patients.

My overarching advice to practices trying to negotiate the constant change that oncology offers is to not be complacent, because your patients are receiving the best care possible today. Understand where oncology is headed and how today’s trends will impact your ability to deliver care tomorrow. Do what makes the most sense for your patients and colleagues by always anticipating change rather than reacting to it.   

Jeff Patton is acting CEO and president of physician services at OneOncology. He is also a member of FierceHealthcare’s Editorial Advisory Council.

WASHINGTON, D.C.—Federal health IT leader Donald Rucker, M.D., said an upcoming interoperability rule will include “solid” privacy protections for patients as they share their medical data. 

Speaking at Health Datapalooza on Tuesday, Rucker—who is the head of the Office of the National Coordinator for Health IT (ONC)—acknowledged that privacy in a digital world is a challenging issue. But he reiterated his perspective that patients should be able to easily access and share medical data.

“It is our human right as patients to have access to our data,” he said.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

Rucker was pushing back on health IT vendor Epic’s lobbying efforts against the proposed rules, including an email Epic CEO Judy Faulkner sent to customers encouraging them to sign an opposition letter. The letter cited risks to patient privacy and intellectual property if the rules are finalized now.

According to reporting from CNBC’s Chrissy Farr, about 60 health systems signed the letter.

“Most of their customers did not sign on to that letter,” Rucker said. “If you parse out the big academic medical centers, only three out of 100 AMCs signed on.”

He also called out hospitals that signed the opposition letter due to their claims about data privacy concerns but then disregard patient privacy when filing lawsuits for unpaid medical bills.

“One of the signers of the letter is known for taking thousands of patients to court. If you take someone to court, that information becomes public discovery. Their medical care is now public. It’s part of the court record,” he said. “Looking at protecting privacy, we need to walk the walk here as we look at who is saying what and letter-writing campaigns.”

Almost a year ago, ONC issued a proposed interoperability and information-blocking rule that defines the demands on healthcare providers and electronic health record (EHR) vendors for data sharing. The rule also outlines exceptions to the prohibition against information blocking and provides standardized criteria for application programming interface (API) development. 

Department of Health and Human Services (HHS) leaders have not offered a timeline for when the rule will be published, but many have speculated it will be released during the Healthcare Information and Management Systems Society conference in March.

While Epic and many hospitals have come out against the interoperability rules, many technology vendors, including Apple and Microsoft, along with health plans and consumer advocacy groups have urged HHS to move forward with publishing the rule.

Four healthcare leaders recently penned an op-ed in Health Affairs calling for ONC to publish the rule immediately. Omada Health’s Lucia Savage and University of California, San Francisco’s Aaron Neinstein, Julie Adler-Milstein and Mark Savage said the ONC rule will not make the current consumer privacy protections worse.

“All health care stakeholders who are concerned about that issue should raise it with Congress and state legislatures, which have authority to act, rather than request to delay the ONC’s rule, delaying critical improvements to interoperability, access, innovation, and ending information blocking,” the authors wrote.

APIs are the technology used to link IT systems, such as EHRs, with apps and will help bring healthcare into the modern app economy, according to Rucker.

ONC’s vision is for patients to choose what apps to use, he said

“We’ve often looked at interoperability in a narrow view, which is just as a replacement for moving the patient’s chart. Modern computing and APIs offer a vastly richer and more empowering global computing environment. Well-built APIs can do almost anything that your creativity allows,” he said.

Before Rucker took the stage at Health Datapalooza, HHS Secretary Alex Azar also addressed the upcoming interoperability rules and the Trump administration’s commitment to putting “patients in charge of their data” and called out industry stakeholders who are “defending the status quo.” They are protecting a health records system that is “segmented and Balkanized,” he said. 

“We have a serious problem—and scare tactics are not going to stop the reforms we need,” Azar said.

Health technology company Seqster is focused on helping patients bring all their health information into one place.

The San Diego-based company, which launched in 2016, announced Thursday it secured backing from Japanese pharmaceutical giant Takeda Pharmaceutical. 

The companies did not disclose the funding amount.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

The funds will be used to accelerate the adoption of the company’s interoperability technology for enhancing clinical trials, patient engagement and outcomes, the company said.

“Seqster’s technology is a very unique platform that addresses interoperability on not only a nationwide scale but also globally. Interoperability is one of the biggest barriers to applying precision medicine to clinical trials and patient engagement,” Bruce Meadows, head of investments at Takeda Digital Ventures, said in a statement.

Seqster’s platform retrieves, parses and harmonizes multidimensional data sets to help accelerate the entire drug development process and provides clinical trial participants a platform to share their data with investigators in real time creating a longitudinal health record, according to the company.

Before the Takeda investment, the company raised at least $4 million in seed funding.

The company’s name, Seqster (pronounced seekster), comes from the idea that everyone is “seeking” health data, company CEO and co-founder Ardy Arianpour told FierceHealthcare during Health Datapalooza this week.

Arianpour said he was motivated to launch the startup as a result of his mother’s experience as a cancer patient and the challenge of aggregating health data from multiple providers and hospitals.

As a health technology entrepreneur, Arianpour has a background in genomics and big data. Prior to starting Seqster, he helped bring next-generation DNA sequencing to the clinic as chief strategy officer of Pathway Genomics as well as senior vice president of Ambry Genetics, which Konica acquired for $1 billion in 2017.

Seqster aims to provide “person-centric interoperability,” he said.

“When I started on this journey I didn’t know what interoperability was,” he said. “Recently a former executive from a large EHR vendor came to us and said: ‘You cracked interoperability.”

The platform is designed to pull together episodic clinical electronic health record (EHR) data, baseline genetic DNA results and continuous fitness/wearable device data all in one place. The company’s technology standardizes and harmonizes different data sources on the back end and then organizes and visualizes those health data in an easily accessible format.

Arianpour compares the platform to the personal finance management platform Mint.com, which was designed to be a platform that brought all of an individual’s financial information together to a single place.

Seqster is not a consumer-facing platform, but licenses it to enterprise customers such as providers and payers. The platform currently connects users to more than 3,600 healthcare providers and over 150,000 hospitals and clinics nationwide.

Other companies taking a stab at aggregating patient records include Picnic Health, which collects and digitizes health records, and PatientBank, which offers online medical record sharing. Apple also launched its Health Records feature that is now supported by hundreds of hospitals, medical clinics and specialty practices.

One distinction from Apple Health Records is that Seqster is platform-agnostic, the company says. It also enables families to aggregate health data to form a multigenerational health record, an idea that has raised privacy concerns. 

In January, the company added new interoperability features it says will help its customers more easily share longitudinal health information across various sources. Seqster improved its connectivity to providers by adopting the Fast Healthcare Interoperability Resources (FHIR) standard through the FHIR application programming interface, the company said.

The company says the new platform can help healthcare providers and health plans come into compliance with upcoming federal interoperability regulations to be released by the Office of the National Coordinator for Health IT and the Centers for Medicare & Medicaid Services.

As we wait for final rules that will enable consumers to freely access their health data, electronic health record (EHR) giant Epic is saying breaking down the silos where this information lives will create a privacy hazard for patients.

While privacy concerns over health data sharing are always legitimate, they can’t stem the tide of the inevitable: Patients and consumers are demanding access to their data, and new proposed government rules supporting a consumer-directed, seamless flow of medical information will likely go into effect as soon as this month.

When they do, it will accelerate the race among technology companies to offer consumers the end-to-end healthcare experience and outcomes we’ve all been missing. At the same time, they will force the government to move quickly to establish a new privacy framework that will replace HIPAA’s limited reach and work to benefit all stakeholders.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

We could be in for a wild ride. But when the dust settles, we will have what we should have had all along: a healthcare system where consumers sit at the center and are empowered by ownership of their own health data.

A snapshot of health IT’s bumpy history

In 2004, the Office of the National Coordinator for Health IT released a framework for strategic action, the decade of health information technology: delivering consumer-centric and information-rich care (PDF).

I worked for David Brailer at the time, who was appointed by President George W. Bush to be the country’s first information “czar” for healthcare. Dr. Brailer is still an advocate for information-sharing, recently calling on healthcare CEOs to lean into, not away from, the opportunity to engage the patient in a more meaningful way. If healthcare CEOs fall short, tech companies will fill the void (more on that later). 

We envisioned a system where important health data would follow the individual by building interoperability into EHRs from the start—a vision that tragically has yet to be realized. 

ELATED: Epic’s Judy Faulkner: ONC data blocking rule undermines privacy, intellectual property protections

We imagined health data would function as a powerful currency for consumers, but to date, this valuable asset has stayed in the hands of EHR companies who keep it under lock and key. 

Consumers will soon hold this currency in their hands for the first time. If they seek to understand and apply their health data like they have with their genetic information—consider the explosion of tech companies like 23andMe and others—we’ll see dramatic shifts in the health tech landscape.

Consumers are most likely to share their health information with companies that have proven they can offer a powerful, secure and user-friendly experience: companies like Amazon, Apple, Google and a host of established and emerging technology players.

We must now endeavor to build the necessary security and privacy frameworks that ensure the consumer will always be protected and in control of their personal health information.

Where to go from here

We’re entering a new era, one where healthcare providers, payers, solutions providers and technology companies will create a superior healthcare experience and deliver improved patient outcomes.

The days of medical information being walled off and guarded by EHR vendors are coming to an end.

We can expect three things to occur once the rules are finalized:

  •  EHR companies will see their business models disrupted: As consumers control their health data, the silos created by EHR companies will gradually erode. This will change these companies’ business models permanently. No longer the central gatekeepers of the country’s medical information, EHR companies will scramble to build new capabilities and services in a bid to remain important players in healthcare.
  • Technology companies that build trust will earn their moment in the sun: Consumers have shown a willingness to share sensitive information with technology companies in exchange for insights about their health. With new rules in place that turn loose volumes of health data, incumbent tech giants and newcomers will compete to create compelling new healthcare experiences and superior outcomes. Consumers will decide the winners by preferentially sharing their data with companies whose products and services are both transparent and secure.
  • New privacy laws must take shape: As tech companies compete to win the trust of consumers, the government will develop updated rules of the road for our new, consumer-centric health system. This effort is already underway thanks to multi-stakeholder groups like the CARIN Alliance and the work that the Robert Wood Johnson Foundation is doing with Manatt. We can expect these efforts to ramp up quickly.

HIPAA doesn’t cover many of the new digital products and services that can benefit consumers, but that doesn’t mean consumers and technology companies cannot hold this data. It means we need to modernize HIPAA.

When these trends come to pass, it will be the consumer—newly empowered with their health data—who will drive our country toward value-based care. Top-down decisions by healthcare providers, insurers and government agencies haven’t accomplished this vision—consumers can and will.

As a consumer, a health tech entrepreneur, a mother and a former federal and state official, I am eager to bear witness as consumers take the driver’s seat, which was the intention all along.

Lori Evans Bernstein is a co-founder and the president and chief operating officer of HealthReveal. She was a senior advisor to the first National Coordinator for Health IT in the U.S. Department of Health and Human Services and served as deputy commissioner of the New York State Department of Health’s Office of Health IT Transformation. 

Burnout among physicians and advanced practice providers (APPs) is one of the most critical issues in healthcare.

Roughly half of these professionals reported at least one burnout symptom, such as emotional exhaustion and detachment from patients, in a Mayo Clinic survey. 

When burnout strikes, a health professional’s ability to provide quality care is diminished, and the likelihood of a safety mishap or medical error rises. Physician burnout costs the U.S. health system approximately $4.6 billion annually in turnover, reduced productivity and other costs.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

In extreme cases, burnout leads to suicide. A physician commits suicide every day in this country—twice the national average. The trauma of a colleague’s suicide has touched the lives of most U.S. physicians and APPs.

Years ago, a colleague of mine committed suicide—and I still wonder if that could have ended differently, if attention were focused on this problem like it is now, if a support network was in place and if we had understood more about stressors and how organizations can help reduce them.  

We ask physicians and APPs to be productive and efficient, to prevent safety mishaps and medical mistakes, to provide incredible care despite grueling schedules and to do all this at an affordable price. Documentation and complex new technologies add to this already significant burden. 

We did not get here through a single cause, and no single solution will fix it. Burnout is a constellation of symptoms, requiring a multipronged strategy. A leading voice in this effort, Stephen Swensen, M.D., professor emeritus, Mayo Clinic College of Medicine and Science, created a holistic model to combat burnout. 

At Banner Health, our burnout strategy—Cultivating Happiness in Medicine (CHIM)—is based on that model, tailored for a large, multistate health system. It includes incorporating burnout into our enterprisewide operating plan and strategic initiatives, annual measurement and designating a team to oversee these efforts.

As part of CHIM, for example, we have a support program for “second victims,” providers involved in an adverse patient event or injury. Recognizing second victims in no way lessens the focus on the patient, but it is essential to help professionals recover and to learn and acknowledge what was their fault and what was not, to help them be ready for other patients who need their help.

Measurement is also essential. We previously used surrogate measures of physician/employee engagement: is this a great place to work, a great place to receive care, etc. In 2018, we began more specific measurement using the Maslach Burnout Survey. From 2017 to 2018, we saw 60% improvement in physician engagement, 36% less physician turnover and 46% improvement in electronic health record speed.

Our experience, over the last 18 months, gives me great optimism.

But the call to action applies to all of us: A decade from now, physician burnout should be rare. We owe it to clinicians to build workplaces where they can thrive and focus on the mission of healing that brought them here. 

Marjorie Bessel, M.D., chief clinical officer for Phoenix-based Banner Health, has made ending physician burnout her top priority.

Small physician-led Accountable Care Organizations (ACOs) have shown success in reducing costs while improving quality. But they need more support to continue down that road, according to a new report.

Those ACOs would benefit from more guidance and support from the Centers for Medicare & Medicaid Services (CMS), private insurers and other sources as they take on greater financial risk and move farther away from traditional fee-for-service payments, according to a new report (PDF) from the Duke-Margolis Center for Health Policy.

Case Study

Across-the-Board Impact of an OB-GYN Hospitalist Program

A Denver facility saw across-the-board improvements in patient satisfaction, maternal quality metrics, decreased subsidy and increased service volume, thanks to the rollout of the first OB-GYN hospitalist program in the state.

See how

“ACOs, especially smaller ones and those in more resource-deprived settings, need additional support in building the organizational competencies (such as clinical care redesign and forecasting costs) to take on increased risk,” authors of the report, who conducted interviews with ACO leaders, concluded.

ACO leaders interviewed by researchers have concerns about meeting the new requirements of Medicare’s “Pathways to Success” program that shifts financial risk from CMS to ACOs more quickly, the report indicated. 

“By asking physician-led ACOs to take on more financial risk, CMS is trying to encourage better care at a lower cost,” said Robert Saunders, research director for payment and delivery reform at Duke-Margolis. “Transitioning to new payment models is always challenging, and CMS should do all it can to support smaller physician groups in joining effective ACOs at this pivotal time or risk their longer-term sustainability.”

Some of the challenges faced by small physician-led ACOS in taking on more risk include the structure of their ACO contracts—including the cost benchmark they are expected to improve on, their limited capital reserves and their need for advance investment and technical assistance, the report said.

The report noted that many small physician-led ACOs are partnering with third-party companies, what they called “ACO enablers,” such as Aledade, Caravan, Evolent and others, to access needed upfront capital and additional services to help them participate in risk-bearing models.

Others have dropped out of ACO programs at high rates in recent years, the report said.

CMS is pushing ACOs to more quickly transition to downside risk under its Medicare Shared Savings Program, or in new ACO-type programs, such as the Direct Contracting program or complementary programs, such as the Primary Care First program.

The report, which was prepared with funding from the Robert Wood Johnson Foundation, recommended three steps CMS can take to assist these ACOs:

  • Reduce regulatory burdens. For instance, ACO leaders interviewed by researchers said that regulations such as the Stark Law and Anti-Kickback Statutes limited their ability to coordinate and manage care effectively. CMS has proposed changes to both rules to provide greater flexibility for organizations in value-based payment arrangements
     
  • Provide more support for ACOs to develop technical capabilities. The report said CMS can identify and share successful strategies used by ACOs to improve the cost and quality of healthcare.
     
  • Simplify program rules. ACO leaders expressed difficulty keeping up with changing policies and priorities, the report said. Smaller organizations will be more likely to participate in new tracks or programs when the rules are certain and simpler to understand.

When Carol Pak-Teng, M.D., an emergency room doctor in New Jersey, hosted a fundraiser in December for Democratic freshman Rep. Tom Malinowski, her guests, mostly doctors, were pleased when she steered the conversation to surprise medical bills.

This was a chance to send a message to Washington that any surprise billing legislation should protect doctors’ incomes in their battle over payments with insurers. Lawmakers are grappling over several approaches to curtail the practice, which can leave patients on the hook for huge medical bills, even if they have insurance.

As Congress begins its 2020 legislative session, there is evidence the doctors’ message has been received: The bills with the most momentum are making more and more concessions to physicians.

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See how

As surprise medical billing has emerged as a hot-button issue for voters, doctors, hospitals and insurers have been lobbying to protect their own money flows. All that lobbying meant nothing got passed last year.

Television and internet ads are the most visible manifestation of the battle. But in taking their cause to politicians, doctors like Pak-Teng have waged an extraordinary on-the-ground stealth campaign to win over members of Congress. Their professional credentials give them a kind of gravitas compared with other lobbyists, who are merely hired guns.

Ending the practice of billing patients for the amount of their treatment not covered by insurance—sometimes triggered by unwittingly seeing a doctor out of network—is ultimately a fight between doctors and insurers over rate-setting and reimbursement. But as more patients balk at surprise bills—or suffer the enormous financial strain—lawmakers are under pressure to protect patients. In turn, powerful lobbying forces have activated to protect doctors and insurers who don’t want to pay the price for a fix.

The main message physicians are using to bring lawmakers into their corner? “We just want to be paid a fair amount for the services rendered,” Pak-Teng said.

Her congressman, Malinowski, has not endorsed any surprise billing legislation. In congressional testimony in July, he cited the “extra $420 million” in medical debt patients in New Jersey reckon with each year.

“There are many things that Republicans and Democrats sincerely disagree about in this body,” he said. “I don’t think that this is one of them. I don’t see any philosophical difference amongst us about whether people should be stuck with massive surprise medical bills.”

Doctors say they are taking the brunt of the criticism.

But little has been as powerful in shaping surprise billing legislation as the clout of hospitals and their doctors, many of whom are, in fact, employed by private equity-backed companies and armed with years of experience shaping surprise billing legislation at the state level.

 

They are throwing in a lot of money, too, funneling millions to lawmakers ahead of the 2020 elections. Four physician organizations that have heavily lobbied on surprise medical bills and have private equity ties—the American College of Emergency Physicians, Envision Healthcare, US Acute Care Solutions and U.S. Anesthesia Partners—gave roughly $1.1 million in 2019 to members of Congress, according to a Kaiser Health News analysis of Federal Election Commission records.

The biggest recipients, from all four PACs combined, were Reps. Donna Shalala and Stephanie Murphy, Florida Democrats who got $26,000 each. Sen. Thom Tillis (R-N.C.) took in $25,500, Senate Majority Leader Mitch McConnell got $25,000, and Rep. Brett Guthrie (R-Ky.) received $22,500.

That was in tandem with a ground game led by local doctors. ER doctors, anesthesiologists, radiologists and other specialists who most often charge out-of-network prices—and also are among the highest-compensated practitioners—fanned out to shape legislation in a way that maintains their pay, and to voice their concern to lawmakers that insurance companies would have too much leverage to control their compensation.

“We by necessity place a tremendous amount of trust in our physicians,” said Zack Cooper, an assistant professor at Yale University who has extensively researched surprise medical bills. “Frankly, they have an easier time lobbying members [of Congress] than the folks who are affected by surprise billing.”

Arguing over the fix

Lawmakers in both parties appear unified on the need to resolve the problem of surprise billing. But as was clear when all the air blew out of legislative proposals on the table at year’s end, that is largely where the agreement ends.

Fixing the problem comes down to settling on a system for deciding how much to pay for a disputed bill. One approach is to set up an outside arbitration process, in which doctors and insurance companies would negotiate payment—this is the model preferred by doctors, who contend it puts them on better footing against insurance companies. Another option would be to resolve surprise billing disputes by having insurance companies pay doctors based on the median in-network rate for the service, an approach known as benchmarking. Large employers, labor unions and insurance companies prefer this.

The failure to get legislation through Congress set up a potentially explosive battle in an election year. Republicans and Democrats who have vowed to do something about healthcare costs must reckon with powerful industry groups whose influence transcends party lines.

Meanwhile, physicians and hospitals have made their case in Washington and back home through in-person meetings and phone calls with lawmakers and congressional staff. They’ve hosted dinners and fundraisers and organized fly-ins to swarm Capitol Hill with in-person meetings. They’ve even led tours of their emergency rooms.

Pak-Teng is among them, coming to Washington this month with other physicians to petition lawmakers. She is employed by Envision, a physician staffing company backed by private equity firm KKR. She’s also on the board of the American Academy of Emergency Medicine, a trade organization representing ER doctors.

“There is a lot of anti-physician rhetoric out there,” said Pak-Teng, who is pushing her physician colleagues to be more active in shaping public policy by sharing stories about the reality of caring for patients.

The lobbying by hospitals and physicians trying to protect their reimbursements has divided key lawmakers, compounding disagreements among senior House Democrats over the policy details of a bill and turf wars in Congress. Three House committees have now unveiled legislation to ban surprise medical bills, each with different details.

“We are not trying to stop legislation. We are trying to stop bad legislation,” said Anthony Cirillo, M.D., an emergency medicine physician who describes a “bad” bill as one that favors insurance companies over doctors.

Cirillo is also a lobbyist for US Acute Care Solutions, a physician staffing company backed by private equity firm Welsh, Carson, Anderson & Stowe. WCAS, which manages $27 billion in assets and is focused on healthcare and technology investments, is based in New York City and co-founded US Acute Care Solutions in 2015.

In an interview, Cirillo said he met with lawmakers and their aides about “10 to 12 times” in Washington last year. Financial disclosures show he spent $340,000 between July and September lobbying on surprise billing on behalf of US Acute Care Solutions. USACS’ political committee also contributed $134,500 to lawmakers in 2019, according to FEC records.

Tilt toward doctors

Before the private equity-fueled dark-money group Doctor Patient Unity started running ads warning of the dangers of government price controls as an argument against legislation, surprise billing legislation being drafted in one of Congress’ most powerful healthcare committees was already tilting to be more favorable to doctors.

“People on the Hill are very sympathetic to hospitals and physicians because they’re actually providing the care itself,” said one Democratic aide, speaking on the condition of anonymity to candidly describe sensitive political dynamics. “Nobody wants to defend the insurers.”

In May, a House Energy and Commerce Committee draft proposal included no mention of outside arbitration. The same was true for a bill the Senate Health, Education, Labor and Pensions Committee approved in June. Instead, under those proposals, surprise billing disputes would be resolved by insurance companies paying doctors based on similar rates in that area.

By mid-July, though—roughly a week before Doctor Patient Unity registered as a business in Virginia—the Energy and Commerce legislation was amended to allow doctors to appeal to an independent arbiter if their payments exceed $1,250. The revision was pushed by two physicians on the committee—Democrat Raul Ruiz, M.D., of California and Republican Larry Bucshon, M.D., of Indiana—and was a moment Sherif Zaafran, M.D., a Texas anesthesiologist, describes as a “turning point” in negotiations over the bill.

“It’s all about fairness,” said Zaafran, who works for private equity-backed U.S. Anesthesia Partners. He has been involved for a decade in surprise billing fights in Texas, which enacted a new law with an arbitration process last year. U.S. Anesthesia Partners gave $197,900 in campaign contributions to members of Congress last year.

Zaafran chaired another coalition of medical specialists, Physicians for Fair Coverage, in 2019, and pressured Congress to pursue a surprise billing approach modeled on a New York law under which insurers and providers rely on arbitration. Under that process, if there is a payment dispute between doctors and insurers, the two sides submit a proposed dollar amount to an independent mediator, who then selects one.

In New York, the mediators were told to base their decisions on the 80th percentile of the prices set by the hospital or physician. Research has suggested that the model is broadly making healthcare more expensive for state residents because of higher payments to doctors, according to findings from the USC-Brookings Schaeffer Initiative for Health Policy.

Still, on Capitol Hill, doctors complained that many procedures would fail to cost enough to qualify for arbitration as proposed in the Energy and Commerce bill, bolstered by data ER doctors presented to lawmakers showing that prices mainly fall below $1,250.

“It’s largely out of reach,” said Laura Wooster, a lobbyist with the American College of Emergency Physicians, whose political action committee contributed $708,000 to lawmakers in 2019. “The problem with a threshold is, you just have one threshold. It’s going to impact different specialties so differently.”

By December, House Energy and Commerce Committee leaders and Sen. Lamar Alexander, a Republican who chairs the Senate HELP Committee, agreed to lower the arbitration threshold to $750 as part of a bipartisan agreement on a bill. Notably, several hospital lobbying organizations, such as the American Hospital Association and the Greater New York Hospital Association—the latter a strong financial backer of Senate Minority Leader Chuck Schumer—refused to back the deal.

Pak-Teng and other physicians also say that arbitration threshold is still too high. The House Education and Labor Committee has unveiled surprise billing legislation with a similar framework.

“I’m open to listening to all sides on this,” Rep. Greg Walden of Oregon, the top Republican on the House Energy and Commerce Committee, said in an interview. “We want to make sure doctors are adequately compensated.”

Walden had harsh words for private equity firms that have attacked the Energy and Commerce legislation in a series of TV and internet ads, saying they were “misleading and scaring people” and just made lawmakers dig in deeper. The ads prompted a bipartisan probe from Walden and committee Chairman Frank Pallone (D-N.J.) into how the companies have influenced surprise billing practices.

“I’m not trying to hurtle a rock at them, but they’ve been throwing a few my way,” he said.

What’s coming

Arvind Venkat, M.D., a Pittsburgh emergency physician employed by US Acute Care Solutions, traveled to Washington multiple times last year to meet with congressional offices representing Pennsylvania. But he also made sure to bring up surprise bills on his home turf, giving his congressman, freshman Democrat Conor Lamb, a tour of the emergency room at Allegheny General Hospital last summer.

“There are two issues here,” said Venkat, who leads the Pennsylvania chapter of the American College of Emergency Physicians and has practiced at Allegheny General for 12 years. “Patients need to be protected, [and] we need to avoid anything that disrupts in-network relationships between insurers and clinicians.”

The call seems to have been heard: Legislation is likely to change further this year as the House Ways and Means Committee pushes an approach that is friendlier to hospitals and doctors. It builds off a one-page document committee leaders issued Dec. 11 that blunted momentum for a bipartisan deal that was to be included in a December spending bill.

The latest proposal from the committee includes an arbitration process to resolve payment disputes, with no minimum dollar amount needed to trigger it, and doesn’t ban surprise billing from air ambulance companies—a win for yet another special-interest lobbying group. The patient protections would not take effect until 2022.

Richard Neal, a Massachusetts Democrat who chairs the committee, remains an ally of Massachusetts hospitals. He released the brief December surprise billing document two days after the Massachusetts Medical Society and Massachusetts Hospital Association wrote a joint op-ed in The Boston Globe arguing that benchmarking physician payments—as the Senate HELP and Energy and Commerce deal would do—would wreck the state’s healthcare system.

“The heavy hand of government would create an unfair imbalance in the healthcare marketplace and insurers would have no incentive to engage physicians in building robust healthcare networks. The connected system of care we have all been working toward in Massachusetts would immediately become fragmented and disjointed,” the two groups wrote in The Boston Globe.

“They weren’t asking for favorable treatment. They were asking for fair treatment, and there’s a big difference,” Neal said in an interview. “I don’t want to rule anything out, but I think that the momentum right now is arbitration.”

“We need to get a little bit more balance,” added Shalala, who endorsed the Ways and Means legislation unveiled earlier this month.

Shalala has at least two hospitals in her Miami-area district that rely on private equity-supported physician staffing companies.

“I’m worried about the hospitals,” she said. “And the providers obviously include the docs.”

Victoria Knight contributed to this story.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.