Category Archives: Medical School

I first met Wes Ely in 2016, when I wrote about ICU delirium and Elys attempts, as a critical-care physician at Vanderbilt University Medical Center, to urge fellow health care workers to rethink the use of heavy sedation in ICUs. His research was an attempt to limit the crippling cognitive and physical impairments he saw develop in many critical-care patients long after they left the hospital, something he came to call post intensive care syndrome, or PICS.

Well, a lots happened since 2016. I thought of Elys work often as ICU care became a mainstay of the Covid-19 pandemic and wondered about the long-term prognosis of people who were so sickened by the virus theyd been heavily sedated and placed on ventilators to survive. Then long Covid showed up, and became something Ely grappled with as well.

Through a new book, op-eds, and a steady stream of TikToks, Ely has become a leading voice on the recovery that can take place after trauma or grueling illness and on the importance of preventing new Covid infections. As the pandemic marches on, hes increasingly concerned about the resulting epidemic of chronic disease society may face. I spoke with Ely about his concerns, what he initially got wrong about long Covid, what he finds humbling about medicine, and, why, despite all the suffering he sees and treats, he still holds hope. The conversation has been lightly edited for length and clarity.

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In your book Every Deep-Drawn Breath, you describe how you came to understand that ICU treatment may harm patients even as it allows them to survive. Can you describe this awakening you had and how it started you on your research trajectory?

I had the opportunity to care for a woman in her 20s named Tracy Martin. She had made a mistake and found herself, after an overdose, in the ICU. I was the primary doctor helping to take care of her. We worked so hard, with all the technology that we had, to try to get her through. At the end of the day, I thought, What a great doctor I am, I helped you survive this. When she came back to clinic weeks later, I was expecting a high-five, but I saw a woman who couldnt walk, who couldnt go to the bathroom, who couldnt shower. Her mother said, Wheres my daughter? What happened to her? She looks like an old woman now.

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As a physician, I had to face the fact that none of that stuff she was suffering was what she came into the ICU with and that I was complicit. I felt guilty about it. I knew that something that Id done had injured her but I didnt even know what. I started grappling with that and became kind of obsessed with figuring out how to get people off the ventilator sooner so they didnt get so much injury in the ICU. And thats what started me on a 25-year journey in this area.

Can you describe these issues you work on: post-intensive care syndrome and ICU delirium?

What happens with people who get critically ill and live in an ICU is they come in with one problem and under our noses, in the ICU, under our care [and due to sedation, ventilation and immobilization], they accrue problems in their brain, such as acquired dementia, PTSD, and depression. And then they accrue profound problems neck down in their muscles and nerves which leave them unable to walk, climb stairs, and live a normal life physically. So they become very disabled, cognitively, mentally, and physically. Thats what PICS is. ICU delirium is one of the strongest predictors of the development of post-ICU syndrome.

Like so many ICU physicians and other staff, you were on the front lines of the first Covid waves. What were your first impressions, and how did those evolve during the pandemic?

Taking care of the most critically ill patients who were on ventilators, dialysis, and other forms of life support was just an immensely profound experience. And I knew that those patients were going to leave the hospital, those who survived, with an immense amount of acquired disease, that this was going to be PICS to the extreme. So when people started talking about being long haulers and having long Covid, I just thought, those are the ICU survivors who have PICS. Through our CIBS (Critical Illness, Brain Dysfunction, and Survivorship) center, we started offering Covid survivor support groups we didnt even call it long Covid in the beginning. We started finding people who got out of the ICU and had PICS. And we had patients, and this was shocking to me, who got out of the ICU, their PICS was in a strong state of recovery, then 100 days later they would fall off a cliff. And I thought, What is that? That is not PICS.

Then there was a third group that never came to the ICU at all, went through a mild case of Covid but then came to our support group and said, I didnt have a problem until three months after Covid and now my life is ruined. I cant think well anymore, and I cant work. I have all these heart-racing problems and GI disturbances. I had originally thought, this is PICS and all these people dont know about PICS yet, but then I realized that long Covid was something completely different.

That must have been startling because your research focuses on people post-ICU?

Yes, I had to admit I was wrong. And I was so sure I was right. It was super humbling. But thats what I love about medicine: The second we think we know what we are doing, we fall flat on our face.

Youve spent two decades trying to get people to realize that being released from the ICU may not necessarily be the end of their medical or mental health issues. Do you see an analogy with Covid that just because you test negative after an infection, your problems are not necessarily over?

Absolutely. The rapid antigen test tells you when you have that virus active in your body, and when it starts going negative, you think, this has passed. But now we know that the virus can persist as a viral ghost in your GI tract, brain, and cardiovascular system, and that it can also alter your immune reactions. What happens is that over ensuing weeks and months, your body takes on a new set of diseases that you did not have at the end of acute Covid. Thats what we call long Covid.

Unfortunately way too many people with this are not being believed about their illness. And this has happened before, with long Lyme, and CFS, and fibromyalgia. And I will tell you, as a medical insider, that I used to think that those werent real. I was taught in medical school that they werent real. I was just with some medical students last week, and I talked to them about a patient of mine who had long Lyme. And they said we were taught that thats not real and these are current med students. This is something the ivory tower medical profession needs to realize long Covid is going to push us to get outside of our comfort zone with illnesses that we cant define. Because we dont like it when we cant understand something, but we have to get over that.

In your book, you describe saying to patients, I will not leave you. Its not something you typically hear doctors saying to patients, even in movies. Can you talk about how you communicate with patients, especially those with PICS and long Covid?

If a person is suffering pain, fear, illness with uncertainty about where theyre going to be going with this illness and they are seeking somebody who can help, they want to be cuddled and lifted up and have things explained on their level. And by cuddled, I dont mean physically holding because some people wouldnt want that. What I mean is paid attention to at an intimate level. You know, if somebody was in the streets and they were broken, Im not going to stand 20 feet away from that person and minister to them at a distance. And yet, when patients come into the ICU and theyre super, super sick, that distance caring is exactly what our culture evolved into, where instead of being at the bedside and holding their hands, looking in their eyes, oftentimes were caring for them from the door. Were looking at their monitors. Were adjusting their life support machines at a distance. And throughout Covid, we literally were outside their room with the glass door shut, a worst-case scenario. Thats why Ill whisper in their ear and say, Im present. Im your doctor. Im not leaving you.

Whats your message to doctors, not just in critical care but in any speciality, who are seeing patients with these complicated symptoms that are difficult to understand, let alone treat?

The first thing I say to my fellow physicians and nurses and health care providers is were busy. We dont have a lot of extra time, I get that. But it does not take that much time to be at eye level with a patient, look them in the eyes, hold their hands, and give them this compassionate message of your presence and the fact that you will not abandon them during this illness. And also to say, I dont have all the answers for you. For example, for long Covid, theres no treatment yet, but you can say to them, Ill stick with you as we learn more in the months and years ahead and well figure this out together.

Why did you decide to write your book?

As a physician who is also a scientist, I have an intense amount of discomfort at the bedside when I see that we do things that dont have evidence to back them up. As a scientist, Ive conducted 25, 30 years of research and I realized there was a story evolving that no matter how many papers I published was never going to reach the lay public or other health care professionals who dont really keep up with the literature. Growing up in Louisiana with my mom, we read poetry, she edited my essays, she taught me to love words. So I love writing and reading and literature and thats why I thought, Why dont I use the stories of my patients, with their permission, to leverage the power of literature to show people how we can be caring for people in the most humanistic way.

I asked each patient for permission to use their story. And one patient said, OK, but I dont want you to make any money off my story. After she said that to me, we decided that every penny in proceeds from Each Deep-Drawn Breath would go into an endowment to help people with long Covid. Weve hired social workers and are helping people find disability services all over the country and the world.

On a very different end of the communication spectrum, theres your TikTok account. Why did you start that?

So, Im 58 years old. You know, an old doctor. And if you had told me two years ago that I was going on social media and Twitter, I would have said, Youre crazy. Theres no way. But two things happened. One was that at the beginning of the pandemic, a lot of doctors around the world were writing me and saying, theres so much ICU delirium, weve got to study this. And they said if you get on Twitter, we can find the patients faster. I said fine. Ill open a Twitter account and we will advertise for the study on Covid delirium. We enrolled 2,100 patients in two weeks. And so I decided to stay on Twitter to share and validate peoples stories and spread good science about long Covid and brain dysfunction and PICS and such.

And then about six months ago, people in the office said you need to get on TikTok and I said, No, Im drawing the line. But theres this crazy set of misinformation being spread on TikTok, misinformation so egregious that I thought, You know what, Im just going to try five videos and see what happens. So all I do is I sit in my office, flip my phone around, and give a two to three minute message on some topic, and I post it. I dont spend any time on it, theres no production. Its super old school. But if its helping people, then Ill keep doing it.

Entering the third year of the pandemic, there is so much anguish and strife right now, and possibly a wave of chronic disease that patients, health workers, and society at large will be facing. Yet you remain hopeful. Can you explain why people with long Covid should hold similar hope?

They can absolutely heal. The brains capacity to heal is so much greater than what people give it credit for. We have trillions and trillions of neurons and connections, and these things can regrow. So, if a patient gets this brain fog and they think, Oh, my gosh, Im never going to get back again, I always tell them, do not lose hope because you will find recovery. And whether its mitochondrial disease or glial cells that have died, or vascular clotting that develops into long Covid, your body has this capacity to recover, and you must remain hopeful that you can get through this. And we are working hard as scientists to do the right trials to find answers. I just want people to hang on and know were going to stick with them and not abandon them during the process.

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'Long Covid is going to push us to get outside of our comfort zone' - STAT - STAT

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This is the fourth installment of a five-part series,Reclaiming Control: The History and Future of Choice in Our Health, examining how healthcare in the US has been built on the principle of imposing control over body, mind, and expression. However, that legacy stands alongside another: that of organizers, healers,and care workers reclaiming control over health at both the individual and systems levels.Published in five monthly installments from July to November 2022, this series aims to spark imagination amongstNPQs readers and healthcare practitioners by speaking to both histories, combining research with examples of health liberation efforts.

In their new book, Inflamed, doctors Rupa Marya and Raj Patel explore how colonialism makes us sick while also shaping our core beliefs about how healthcare providers should make us better. For example, Lakota elders in the book describe the forces that led to widespread prevalence of diabetes in their communities: colonizers arrived and dammed a river that traditionally fertilized a rich river valley where nutritious food and medicinal plants utilized by local peoples grew. As this ecosystem was erased, and as the impacts of erasure and assimilation took hold, the Lakota became less active and were forced to rely on the food and medicine of their oppressors, rather than their ancestors. Marya and Patel point out that skeletal evidence backs up these claims, showing a marked difference in Indigenous remains excavated before and after European invasion. However, they also point out a paradox that comes with this data, writing:

If you find yourself more convinced by studying skeletal remains than by listening to the oral histories of Indigenous people, youre a participant in a colonial system of organizing truth. Reconstructing history through bones misses much that oral histories capture. Yet, in a colonial world, stories passed down by Indigenous elders cannot be considered true until they are validated by the empires that colonized them.

This tenet applies not only to our society writ large, but also to healthcare professionals. As physicians, the authors grapple with their own training, pointing out that modern clinical professionals are taught to be biomedical technicians rather than healers. Inevitably, they fall short when root causes of poor health, from structural racism to food insecurity, present themselves.

The COVID-19 pandemic and the national uprisings on race that took place in summer 2020 further exposed the shortcomings of our current paradigm for training, recruiting, and deploying healthcare workers. Coverage of the harrowing experiences that healthcare workers endured over the past two and a half years highlights not only the trauma that the pandemic inflicted on such workers as they cared for surges of critically ill patients with limited supplies and equipment; it also shows the stress caused by underpayment and overwork, divisive, politically driven policy shifts, and the disproportionate morbidity and mortality burden that low-income and BIPOC communities face. BIPOC healthcare workers, as well as frontline support staff, home care workers, and service staff, all of whom are deprioritized within the medical hierarchy, experienced additional layers of threat: racism and xenophobia inside and outside of their institutions and a compounded mental health toll. Since the pandemic began, 20 percent of healthcare workers in the US have quit their jobs, and healthcare labor shortages are now a major challenge for the sector.

Healthcare staffs feelings of powerless in the face of broader societal forces, however, are not unique to the pandemic. Almost two decades ago, as an undergraduate patient advocate, I experienced this dynamic up close. At clinics in East and West Baltimore, I had the opportunity to partner with individuals and families who presented not just with individual health issues like asthma and lead poisoning, but also with social issues: a crumbling rowhome with asbestos dust; limited fresh food options in the neighborhood; a bureaucratic social services system quick to judge Black and Brown families. Many of the clinics I worked in had one social worker for every 5,000 patients, presenting an impossible capacity challengeeven when medical staff asked about patients life situations and referred patients to social work or our advocacy program to identify helpful resources. While not all the clinics physicians, nurses, or medical staff felt obliged to address the impacts of social forces on their patients lives, most didbut they had limited training, resources, and time to do so.

In the first few articles of this series, we covered the political history of our healthcare system and the role that organizers and healers play in imagining what the future could hold. But what role will healthcare workers have in that future? As actors who benefit from the existing healthcare system while facing harsh challenges within it, healthcare professionals hold a specific positional power and can play a unique role. Even for those of us that have faced trauma inside healthcare institutions, or who have reason to distrust the system as a whole, healthcare workers can still act as trusted messengers and crucial lifelines during the uncertainty of seeking care for ourselves or loved ones.

Much of medical educations current pillarsthe separation of public health and medicine, a focus on treatment rather than preventioncan be traced to a 1910 report prepared by Abraham Flexner. In an effort to standardize curricula across medical schools, the report prioritized a biomedical care model that excludes social and environmental factors. It reinforced a healthcare model, including a paternalistic doctor-patient complex, adopted by institutions that only white males could access. That prioritization also led to the closure of many historically Black medical colleges.

What would it look like to reimagine the tenets of healthcare education through a host of lenses, voices, and teachers who take a more holistic, healer-rooted approach? Many training programs are now adding anti-racism frameworks and a focus on health equity to their classrooms. The Institute for Healing Medicine and Justice, launched in 2020 by a community of medical and graduate students at the Joint Medical Program of UCSF School of Medicine and UC Berkeley School of Public Health, envisions a new medicine that centers healing, community, and justice. They seek to bridge their own educational experiences with multidimensional healing paradigms that have long been promoted by women, people of color, disability activists, queer organizers, and healers across cultures.

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With a community of more than 3,000 people representing 300 institutions, the institute focuses on establishing a new, ground-up praxis for medicine, consisting of interdisciplinary research working groups, community healing gatherings, a justice hub, and a peer-reviewed publication. Along with the Othering and Belonging Institute and the Center for Race and Gender at UC Berkeley, the group published Toward the Abolition of Biological Race in Medicine: Transforming Clinical Education, Research, and Practice, which traces the history of white supremacy and racism in healthcare training. The publication also points out that epigenetics, the study of how the environment can alter gene expression, promises to deepen understanding of how racismand not raceimpacts health outcomes. The also launched the Freedom School for Intersectional Medicine and Health Justice, a community organizing effort led by Bernie Lim and Nicole Carvajal, both women of color in the Joint Program. The Freedom School re-imagines medical praxis and creates community for women of color in medicine, offering a community organizing model, an alternative syllabus populated by critical studies frameworks, and a fellowship for people interested in intersectional healing, medicine, and/or public health initiatives.

One additional effect of the Flexner recommendations was that advocacy training is largely absent from clinical curricula. While this has started to shift in the past 20 years, such training is still rarely seen in clinical classrooms, and when included, it varies from program to program: some programs focus on social determinants of health policy, while others focus more on advocacy to ensure the healthcare professions viability as a whole. This lack of training contributes to missed opportunities for the sizable healthcare workforce trusted experts with a front row view of the challenges involved in improving patients healthto leverage their collective power to enact change.

People Power Health, which trains health professionals in community organizing skills in order to set them up to redress power and resource inequities, aims to agitate healthcare workers to co-create just systems for communities, caregivers, and clinicians alike via trainings and fellowships targeted at different sections of the healthcare worker ecosystem, including clinicians interested in health justice, immunization professionals, climate health organizers, healthcare professionals focused on civic engagement and voting, and more.

Pedja Stojicic, executive lead of People Power Health and a physician by training, shares the role that a power-building community for healthcare professionals can play in moving physicians from an individualistic, passive mindset to one of collective action:

Right now, many [medical residency programs] are thinking about health equity tracks. But what is still problematic is its [just] awareness generation. Medical education itself is organized in such a way that is focused on individuals. The fact that [participants in People Power Health programs] often need us to see their colleagues as a sense of solidarity in pursuit of change is mind blowing. These are the facts of the system: a session outside of it can bring solidarity, hope, etc.

A collectivist approach may also enable healthcare professionals to move beyond defensiveness about their role in a system that often causes harm and to leverage their power beyond the context of an individual patient. Sam Gonzales, a member of the People Power Health core team, points out the value of the relational organizing on which the organization is focusing. Such organizing can be built upon to identify institutional or policy-level campaigns that members want to engage inan antidote to project proliferation, in which healthcare trainees identify an initiative they want to engage patients or community members in, but without first building rooted relationships. When I was in high school, I had a cancer diagnosis, and that helped me to see some of the health inequities that were in the Mexican health system. and when I went into medical school, I saw that it was more than just a drug or a treatment that was involved, shares Gonzales. Racism, classism, poverty. That is how I came to politics, policy to organizing. And then wow, to meet other professionals who are working on these topics was incredible.

Significant work remains to be done if we are to shift the healthcare systems core pedagogy. These efforts, however, point to a small but growing movement that is underway, spearheaded by a growing number of healthcare professionals who refuse to accept the status quo. Often lifted up as heroes, healthcare staff are in reality humans frequently tasked with doing challenging jobs in a system with a long history of harmand are increasingly also challenged to examine their own agency within that system. These models provide an emerging vision of how these individualscharged with caring for the rest of uscan move from healthcare to healing.

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Decolonizing Healthcare Education and Practice - Non Profit News - Nonprofit Quarterly

Des Moines Register staff| Des Moines Register

From 2022 races to caucus action, what to watch for in Iowa politics

It's an election year: Look for no shortage of news from Gov. Kim Reynolds' and Sen. Chuck Grassley's reelection races to early Iowa caucus action.

Megan Bridgeman, Wochit

Republican Jerry Cheevers is running against Democrat Megan Srinivas to represent Des Moines' south side in the Iowa Legislature.

The two are seeking to succeed Democratic state Rep. Bruce Hunter, who is retiring at the end of his term, for the seat in the redrawn Iowa House District 30. Cheevers has run unsuccessfully against Hunter in two previous campaigns. Srinivas won June's Democratic primary, defeating Democrat Eddie Mauro.

To help voters, the Des Moines Register sent questions to all federal, statewide and Des Moines area legislative candidates running for political office this year. Their answers have been lightly edited for length and clarity.

Cheevers did not respond to the Register's request to fill out a questionnaire.

Early voting begins Oct. 19 for the Nov. 8 election.

More:A guide to voter rights in Iowa. What you need to know before you cast a ballot

Age:No response

Party: Republican

Where did you grow up? No response

Current town of residence: Des Moines

Education: No response

Occupation: No response

Political experience and civic activities: No response. Cheevers previously ran for the Iowa House in 2018 and 2020.

Age:35

Party:Democrat

Where did you grow up?Fort Dodge

Current town of residence:Des Moines

Education:

Occupation:Physician

Political experience and civic activities:

Cheevers: Did not respond.

Srinivas:I became a doctor to help my community, but so many of the challenges that my patients and neighbors face are systemic problems that I cannot solve with my prescription pad. The reason Im running is to address those issues, the social determinants of health that keep people from living the quality of life they deserve. This includes making sure people have access to the things that they need to succeed, such as food, housing, transportation, good jobs, and education. All of these factors are critical to ones health, and I will advocate for my community using this holistic approach.

More:Where Sonya Heitshusen & David Young stand on key issues in the House District 28 race

Cheevers: Did not respond.

Srinivas:We need to bolster our small businesses, especially after the economic hardship of the last few years. Ill also work for all Iowans to have access to a living wage protect pensions, including IPERS and 411, so workers enrolled in these plans remain secure in their retirement. Additionally, affordable childcare is a hurdle for many in the workforce. We must support childcare businesses in the face of rising operational costs that caused many to close over the pandemic. We can also adopt an income-based tax credit to create affordable childcare options. These upfront investments to create viable childcare options will spur economic growth for the state.

Cheevers: Did not respond.

Srinivas:As a physician, I strongly believe that an individuals healthcare decisions are their own and should only be discussed with their medical team. Ill advocate for an individuals right to abortion care. Ill also fight against efforts to remove insurance coverage for contraception and family planning. In 2017, our state stripped family planning health centers of public funding if they are affiliated with an abortion provider or even discuss abortion as a healthcare option. One of my goals is to reverse this policy and improve delivery of reproductive health services in every part of our state.

More:Where Iowa House District 27 candidates Kenan Judge & Kristen Stiffler stand on key issues

Cheevers: Did not respond.

Srinivas:We need to increase our supplemental state aid (SSA funding) to public schools to not just meet inflation, but to make up for the underfunding of the last decade. We need to change the narrative from our legislative leaders about our teachers and school staff, recognizing the critical and hard work they do rather than attacking them. We can improve teacher recruitment and retention by increasing teacher pay and creating programs to help with education loans for individuals teaching in high-need areas. We also must properly fund our public universities and community colleges. Additionally, I'll advocate to reinstate vocational curricula into schools.

More:Meet Todd Halbur & Rob Sand, running for Iowa state auditor in the 2022 election midterms

Cheevers: Did not respond.

Srinivas:

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Where Iowa House District 30 candidates stand on the issues - Des Moines Register

Rebecca Baum, chief, section of Development, Behavior, and Learning at the University of North Carolina, Hillsborough, North Carolina; and Katherine Wu, MD, FAAP, Pediatric Health Care Associates in Cambridge, Massachusetts began their presentation, Promoting relational health during health supervision visits with an anecdote of a mother sitting in a pediatricians office with 2 of her children, one rather unruly. If you dont stop misbehaving, Im going to get the doctor to give you a shot, the very stressed mother warned her child.

Comical or concerning? Using the Bright Futures Guidelines, 4th edition, a book that offers principles, strategies, and tools to improve the health and well-being of children through culturally appropriate interventions, the 2 practitioners went on to explain relational health, how the pediatric HCP can promote relational health during office visits, and offered both strategies and resources for attendees.

Baum and Wu explored 4 concepts during their session: adverse childhood experiences (ACEs); toxic stress; relational health; and strength-based approach. ACEs were categorized into 3 different types; neglect, abuse and household challenges, such as substance misuse, divorce, etc) along with other adversity (bullying, community violence, etc). ACEs can increase the risk for disease, early death, and poor social outcomes, Baum stated.

Toxic stress was explained as biological processes that occur after the extreme or prolonged activation of the bodys stress response in the absence of safe, stable, and nurturing relationships (SSNRs), the crux of this conversation. With SSNRs, children, even in the face of ACEs, can still grow up to be mentally and emotionally stable adults.Relational health, in essence is what creates these SSNRs, and the focus is on finding patient, family, and community capacities that can promote these SSNRs. How to create, though? As the presenters explained, the strength-based approach shifts the focus from a deficient model (emphasizing problems and disease detection) to health promotion and disease prevention, acknowledging the patient and familys particular skills that can promote family (and particularly patient) overall well-being.

Baum and Wu then shared examples through videos of doctors and parents discussing challenges in the family that could be impacting the patient. The key takeaways here:--the clinician should echo the mothers concerns (I am sorry to hear that you are going through the challenge of a divorce right now)-- then through positive reinforcement, help the parent to strategize additional solutions to the problem (It is great that you can work with your ex-husband in that way; would it be OK if I help you explore some additional options to come up with a solution to your childs misbehaving?).

If a family is successfully executing SSNRs, it will reap positive benefits; the child will demonstrate interest and curiosity to learn new things; complete tasks; and (one of the most important), stay calm and in control when faced with a new challenge (ie, moving to a new school).

Additionally, Baum and WU shared both screening tools and resources, and offered these final suggestions:--Assess a childs level of relational health as part of pediatric health supervision visits--Support families by utilizing the common factors approach (using hope, empathy, lay language, support; ask the family for permission to delve further with questions; and partner with family for solutions)--Provide prevention and treatment counseling and guidance to children and adolescents and their parents/families--Refer to local parent/child services when relationships are strained--Advocate for effective opportunities for focusing on relational health in schools, communities, and hospitals--Incorporate relational health in medical school curricula

ReferenceBaum R, Wu K. Promoting relational health during health supervision visits. 2022 AAP National Conference & Exhibition. October 9, 2022. Anaheim, California.

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What is relational health, and why is it so important? - Contemporary Pediatrics

Survey shows that alternative sites for care are gaining popularity with consumers

When it comes to where Americans prefer to receive their care, retail clinics, virtual health, and community centers are all growing in popularity, according to a survey from the Deloitte Center for Health Solutions. These changes reflect patient preferences to have health care be more similar to other consumer retail experiences.

There is a growing desire to use retail clinics, and this is especially true among underserved populations, according to the survey. Only 10% of consumers have used a retail clinic in the past year, but many more say the would be likely to or maybe would use retail clinics for preventive care (55%) or mental health care (47%). Black, Asian, and Hispanic respondents were more likely than White respondents to use retail clinics, and urban respondents were more likely than rural ones.

Virtual care, which became popular during the worst months of the pandemic, continues to be popular with patients. Nearly three in four consumers with Medicaid (74%) or HIX plans (73%) would use virtual health for mental health visits, and nearly two-thirds of all consumers would use virtual visits for preventive care.

According to the report, health care organizations looking to stay relevant need to take several steps. They should create more access points and include opportunities to address the drivers of health. They need to develop diverse care teams, ensure care continuity, and invest in virtual health technology and training.

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Is the doctor's office heading for extinction? - Medical Economics

Study looks at how prior auths help and hurt health care - and how they can be made better

A study from the University of Colorado and Johns Hopkins University on the prior authorization process for Medicare Advantage plans identified several areas for improvement.

The study, published in JAMA, examined the benefits and problems with prior authorizations, which 99% of MA plans use for at least some medical services. The goal of prior authorization is to ensure appropriate use criteria are met and the right care is provided to the patient to reduce unnecessary spending. This also can benefit the patient through reduction in premiums and lower out-of-pocket costs through better care allocation and reduced denials. The study also notes that when applied to medications, prior auths can provide an additional level of safety review.

On the other hand, patients must content with inappropriate denials due to omissions or errors in the medical record, or inappropriate application of clinical practice guidelines. An HHS report in 2018 found that 56% of audited MA contracts inappropriately denied prior auth requests. Approximately 75% of audited denial appeals were successful, raising concerns that MA plans were denying services and payments that should have been approved, according to the report.

Prior auths can also cause delays in care, which for serious conditions, can cause possible harm to the patient, according to the report. Prior auths create a substantial administrative burden, with 93% of physicians reporting care delays and 82% reporting abandonment where the patient does not follow through because of prior authorization policies, and can contribute to physician burnout.

Because of these issues, the report notes that calls for reform have resulted in Congressional bills to establish requirements for MA plans with respect to the timeliness and efficiency of prior auths.

The report outlines the following proposed measures that may help improve the use of prior authorization in Medicare:

Plans should use an electronic-based prior authorization process with time-bound requirements for initial and appeal decisions.

Plans should be mandated to report guidelines used to make prior authorization decisions and seek input from respective medical societies and stakeholder groups on an annual basis.

In addition, to expand the congressional legislation, the following proposed measures could be considered:

The relative benefits and costs of prior authorization should be reviewed by the CMS at the procedure level. Such review could consider evidence from other care rationing mechanisms, including price. All else equal, unnecessary care is less of a concern in clinical scenarios for which demand is inelastic and there is little price sensitivity (eg, high-cost chemotherapy when there is not a lower-cost alternative). In such cases, restrictions on access due to prior authorization will introduce little change in wasteful or unnecessary care while still generating additional administrative costs.

Medicare Advantage insurers should report approval and denial rates annually to the CMS based on beneficiary sociodemographic characteristics and by procedure type so that the CMS can monitor whether prior authorization policies may be increasing disparities in access to care.

Drawing upon MA insurersubmitted data on denial rates, the CMS should audit the denials of plans with high-denial rates. Setting thresholds for audit could be based on a comparison with other MA plans, as well as in consultation with patient, caregiver, clinician, and insurer stakeholders.

The authors conclude that by improving transparency and accountability of the process, prior authorization can better function as a tool to improve high-value care for Medicare beneficiaries.

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How to improve the prior authorization process for Medicare Advantage - Medical Economics