[dropcap]R[/dropcap]ecently, I gave a capstone speech for the 4th World Congress on Ultrasound. It was one of the most interesting conferences that I have attended in a very long time. For most people, ultrasound is another of the miracle technologies of medicine that are mysterious and not widely understood. Most people about to have their first child have seen those images that confirm there’s a baby on the way and maybe even give clues as to the sex of that child. Most people don’t know that ultrasound was actually discovered a dozen years before the x-ray in 1883, but it has just recently found a place as a promising application in medicine.
POINT OF CARE ULTRASOUND (POCUS)
Ultrasound scanning, also called sonography, is a non-invasive diagnostic imaging tool that works by transmitting high-frequency sound waves into the body. It produces images of internal organs such as the uterus, ovaries, liver, kidneys, thyroid gland, scrotum, pancreas, gallbladder, bladder, lungs and heart. It can detect abnormal structures like stones, cysts and tumors, or it can show blockages in blood flow and other fluids. It can be done in real time or stored and viewed later in 2D, 3D and in dynamic motion. It can be used to guide invasive procedures such as needle biopsy or aspiration. It is a relatively simple way to examine symptoms of swelling, pain or infection and harmless, unlike x-rays, CT scans and MRIs that involve the use of radiation.
By now, you are probably thinking that this sounds like a Tricorder from “Star Trek.” Well, you’re not far off. It’s pretty similar in concept and applications. Ultrasound has become extremely portable, and handheld machines are commonly used in teaching medical and other professionals and will soon be as common in practice as the stethoscope. When I first saw an ultrasound machine, it was the size of a large filing cabinet and had its own motorized cart to propel it to patient rooms in the hospital. It cost several thousands of dollars. Today, that same machine — well actually a better version with color-flow Doppler and voice-recording for patient information — weighs less than a pound and is about the size of an iPhone. It’s cost is around $2,500, and for a bit more one can purchase a “smart version” that perfects and verifies the location and quality of the image.
DISRUPTIVE TECHNOLOGIES ARE COMMON IN THE MARKET
So what we have in ultrasound is a disruptive technology. A disruptive technology is one that displaces an established technology or so shakes the status quo of medicine that it completely creates a new culture, industry or set of practices. We all know of disruptive technologies that impact our lives daily. Things like personal computers that displaced the typewriter, cell phones that have radically altered the telecom industry or email that has transformed communications and the postal industry. Handheld ultrasound will do the same in medicine, but I think it will go further.
To understand what I mean, let me use an example from the hotel industry. In business there are four fundamental questions that underlie every successful business. These are: How is value created? How is value consumed? How is quality controlled for the value created? How does value scale? Consider AirBNB and how it forced a restructuring of the value chain and operating model for the hotel industry.
AirBNB allows anyone with a spare mattress or room to run their own “bed and breakfast” by giving them access and tools to market them to a potentially global clientele. AirBNB also changed consumption behavior. It wasn’t common for travelers to stay in a stranger’s place until the demand for a “good deal” room rate became a factor and changed the very design of a traditional trip. Since hotel chains are known and branded for their service quality and the reliability of the customer experience, AirBNB changed the quality paradigm by relying on a peer-curation system that ensured consumers had information from fellow travelers on the quality and reliability of the property they were considering. Traditional hotels would scale their product by adding more rooms by either buying or building new sites. But AirBNB scales by improving its ability to match travelers, by leveraging better data. Of course, other disruptive technology have led to similar changes in other industries. Ever heard of Uber?
Let’s explore how ultrasound might disrupt an area of medicine. Consider prenatal uses of handheld ultrasound. This is an arena of life that has in most places in the world not been a domain of medicine but rather of the doula or midwife. Considering that US home births increased by 29 percent from 2004 to 2009, a trend that continues and now stands at about one percent of all births, a technology such as handheld ultrasound could revolutionize the birth industry. The fastest growing segment of home-birthers, about 1 in every 90 births, is non-Hispanic white women, mostly affluent. These are women who can afford the ever falling price of handheld ultrasounds and who have the means to share their experience with that innovation throughout social circles, especially in this age of social media.
I could imagine that initially someone with a handheld ultrasound might learn to do only a few things but do them very well. As the machines get smarter, that set of things could easily expand. What if that someone were a well-known doula or midwife, or a nurse practitioner? Isn’t it reasonable to expect the word to spread in that community and well beyond? With the price of the technology falling and with patients curating with their own sense of quality control and reliability, as in the AirBNB example, the birth market would be changed rapidly. Even if more traditional healthcare providers become proficient in the use of ultrasound, that too would scale the technology by making it easily accessible for application across every applicable dimension of health service.
TRIPLE AIM OF HEALTH REFORM
Health care has always been about quality and, more recently, about access to care, especially for rural areas. With the advent of the Patient Protection and Affordable Care Act of 2010 (Obamacare), it has been about those two aims and another, which is the costs of care. The picture to the left shows these triple aims, how they are interrelated, and highlights how they are going to lead to four disruptive innovations. Those disruptions are improved quality, greater value, more technology, and a greater focus on population health initiatives.
Consider this proposition: When society values something it defines it, and when it defines it then it scales it, and when it scales it then it measures it, and when it measures it then it improves it. The corollary is true as well; namely, when something is shown to be improved it is more easily monetized and payment systems will reflect that. In fact, under Obamacare, the idea is to ensure that all citizens have access to care through health insurance. The notion is that payment mechanisms will reward better outcomes which will put in place the value proposition that will lead to smarter spending.
I wonder how many of us would agree that health care would be more accessible if it were obtainable anywhere, at any time, by anyone. It would likely be better if we could add that consultation with another trained mind would probably make it better, thus adding a quality dimension. Many readers are probably thinking that type of health transaction would be much less expensive, more affordable and, if time is money, convenience would be a key. This may seem a bit disturbing to some readers. Change is uncomfortable, and with all new technologies there are hazards like misuse. In places like rural West Texas, we face a triple threat of another kind that will be fertile ground for the growth of disruptive technologies like POCUS.
THE RURAL TRIPLE THREAT
The triple threat in rural West Texas is distance, health workforce shortages, and an aging population with comorbidities. What is it that the Affordable Care Act can do to ensure people have access to care? When you sign up for the exchanges – what do you get? You purchase insurance. And if you live in an urban area of the country, access to care is often determined by whether or not you have an insurance card because the infrastructure of health providers is much denser in urban centers.
However, if you live in rural America, if you live in most places in West Texas, you can have 100 insurance cards and still not have access to health care.
The fact is that 85 percent of the US population lives in an urban or suburban area. Care is focused on the 85 percent of the folks that live in urban areas. As I write this, the first day of open enrollment in the ACA plans has started and the news is that most rural Americans will face much higher premiums and many fewer insurance plan options. That has been more the norm in rural areas since the inception and passage of the ACA.
HEALTH CARE AND THE ECONOMY
There must be innovations that provide new ways to take care of the folks that live in rural regions. The reasons are simple. The 15% of the population that lives in rural America provides food, fiber, and fuel for the nation.
When healthcare is not readily available to rural residents, the impact on the local economy can be dramatic.
Take the case of Bowie, Texas where the Critical Access Hospital closed about a year ago. Within weeks, the largest employer in town closed its operation and moved to a town less than an hour away that kept its hospital afloat.
The impact is felt in Bowie as depressed employment opportunities and a lost tax base for schools and the hospital. If the pattern holds, within 10 years what was a viable downtown business district will be boarded up, restaurants will give way to fast food sold in a gas station, and all that will remain are those who could not make a new start, mainly the elderly and poorer residents. If the school continues — not likely as busing is already used in rural regions — it will have many fewer teachers, counselors, and related services.
Many in rural areas will find that one promising option for continued care will be telemedicine, used to provide routine primary care, behavioral health and counseling, and for managing acute and chronic conditions by employing remote monitoring equipment that regularly and reliably sends information on biomedical parameters (e.g., heart rate, blood pressure, glucose, weight, etc.) to caregivers who will manage medications and other aspects of care using virtual technologies.
For those of us who live in places like West Texas, distance is a fact of life as are shortages in nearly every type of healthcare provider. In our region, most of it is classified as a Frontier area with ten or fewer residents per square mile. We definitely live with health disparities in such areas.
Rural residents tend to be poorer. On average, per capita income is $7,417 lower than in urban areas and rural Americans are more likely to live below the poverty level. The disparity in income is even greater for minorities living in rural areas. Nearly 24 percent of rural children live in poverty. Rural residents also tend to be older and have more health issues than their urban counterparts.
We can’t forget that health professions shortages extend to mental health professionals in a time when the mental health issues in society are obvious. Consider some of the key reasons – large numbers of returning veterans with PTSD, children from poor and single parent homes, and older people isolated by dementia, distance and disease. Telemedicine is a technology we are using to make things better on all these fronts.
PIONEERS AND THEIR ABIDING SPIRIT
M. C. Overton was born in Morganfield, KY in 1878, the fifth of six children. He left high school after two years to work various odd jobs, including four years with the Bell Telephone Company, before resigning to enter medical school. While interning in Kentucky, a classmate informed him of a shortage of physicians in the Plains area, so he entertained the idea of setting up practice in Texas. Dr. Overton visited Lubbock in 1901. On the second day he weathered a violent sandstorm, but it didn’t deter his determination to set up practice here upon completion of his internship. From 1902 – 1906 he was the only licensed physician in the area. His practice encompassed 23 counties, 21,477 square miles, and a population of 16,342.
Dr. Overton made house calls by horse and buggy until 1908 when he bought the first privately-owned automobile. Despite the vast amount of acreage to encompass, Dr. Overton managed to stay in touch with his office. He carried a phone receiver with him that had a long wire attached to it. When he came across an overhead phone line, he would throw the wire across it, and contact an operator to check in with his office. This enabled him to reduce the number of miles between patients.
Telemedicine has advanced from Dr. Overton’s time. Today, a telemedicine visit is very much like a traditional office visit, simply with technology involved. There is still patient-clinician interaction, communication of the patient’s need to the clinician, and steps taken towards resolution by the clinician. This disruptive innovation, telemedicine technology, does not supplant patient-clinician interaction. It is changed by that technology and the future will tell whether it has been more influenced by market forces or healthcare forces. I know my hope is that whichever prevails we optimize success and do not harm.
Real and lasting innovation with new technologies like point-of-care ultrasound and telemedicine come when those technologies roll out into use and add value to healthcare encounters, while maintaining safety and security. It is our obligation in the F. Marie Hall Institute to create a competency based standard of education around new technologies if we want to lead in creating a standard of competency in care delivery with those technologies. For us, it’s the pragmatism that accompanied the pioneering that made it all happen, and that’s the stuff we’re all about.
The MACRA Effect
As the United States is shifting to a value-based care model, “MACRA” has become a popular buzzword among healthcare providers this last year. MACRA, which stands for the Medicare Access and CHIP Reauthorization Act, is a historic Medicare reform law that permanently repealed the sustainable growth rate (SGR) methodology for determining updates to the Medicare physician fee schedule.
The replacement payment program is known as the Quality Payment Program, which rewards the delivery of quality patient care through either the Merit-based Incentive Payment System, known as MIPS, or Alternative Payment Models, known as APMs.
With over 2,000+ pages of policy that make up this complex rule, it is no surprise that many clinicians are not quite sure the effect MACRA will have on their practices. However, despite the fact that many do not know of this rule, just like the mantra that “ignorance of the law is no excuse,” clinicians will need to adhere to the guidelines this next year whether they are ready or not.
MIPS ties payments to performance based on a compilation of quality measures:
MIPS will focus on quality and practice-based improvement activities to award an overall score to clinicians, called the Composite Performance Score (CPS), which will determine what kind of payment adjustment, either penalty or bonus, that a clinician will get for the corresponding payment year. Top performers will have the potential for bonuses as high as 14 percent in 2019.
Those who do not perform will be financially penalized, with the lowest 25 percent seeing revenue cut by 9 percent by 2022. Initially, MIPS eligible clinicians will includes physicians, PAs, NPs, clinical nurse specialists, certified registered nurse anesthetists; however, this may be expanded to other groups starting in year three of program implementation. MIPS does not apply to hospitals or facilities at this time.
APMs move providers towards true value-based payments, which go beyond the MIPS quality scores by incorporating quality with shared risk to the providers. A qualified APM includes a Medicare Shared Savings Program Accountable Care Organization; a Center for Medicare & Medicaid Innovation Center model (CMMI); a Medicare Health Care quality Demonstration Program; or a demonstration program required by federal law.
Several requirements exist for successful provider participation in APMs. Providers who meet these requirements will receive a 5 percent annual lump sum bonus every year from 2019 to 2024 and will be exempt from the MIPS program.
Below are some aspects of the rule to consider as clinicians ramp-up for program implementation.
2017 is a transition year to allow providers time to ramp-up the program and performance thresholds. CMS has also envisioned that calendar year 2018 will be a transitional year as well.
FLEXIBLE IMPLEMENTATION OPTIONS
For the transition year, clinicians may choose a variety of ways to participate in a way that is best for them, their practice, and their patients. This includes three options to submit data to MIPS and a fourth option to join Advanced APMs in order to become qualifying APM Participants.
CMS is selecting contractors to implement technical assistant program for small practices, rural practices, and practices in medically underserved health professional shortage areas.
SMALL PRACTICE EXCLUSION
Many small practices will be excluded from the requirements in 2017 due to the low-volume threshold, which is less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients. For providers at a CAH, only the portion of charges paid under the Medicare physician fee schedule counts toward the $30,000 threshold, not the facility payment to the CAH.
VIRTUAL GROUP OPTION
Solo and small practices may join virtual groups (consisting of no more than 10 clinicians) and combine their MIPS reporting; however, this will not be implemented in the 2017 transition year.
Some providers that are excluded from MIPS include clinicians that are newly enrolled in Medicare, Qualifying APM Participants (QPs), certain Partial Qualifying APM Participants, Rural Health Clinics and Federally Qualified Health Centers.
For those clinicians who have not yet taken steps to prepare for MACRA, there is a chance that a Trump presidency will dismantle the Affordable Care Act, significantly impacting MACRA, which may result in a windfall for those that did not want to participate and have held out.
However, “undoing” the existing regulations will take some time, so it is still up in the air how this will all play out. For those that take the risk of a “wait and see” approach and decide to do nothing, the final rule did confirm that if a MIPS eligible clinician chooses to not report even one measure or activity in 2017, they will receive the full negative 4 percent payment adjustment in 2019.
The question that will need to be asked is whether gambling the potential negative 4 percent adjustment is worth it. Although there might be some interest in avoiding the performance pressure under MACRA in taking the chance that a Trump presidency may do away with it altogether, not participating wipes out the chance to gain a bonus for high performance, which may be a considerable funding source for some clinicians.