EPtalk by Dr. Jayne 6/14/18

Mr. H has mentioned the rise of private equity in healthcare, most recently in this week’s news and morning headlines. I’ve seen it both from the consulting side and from the trenches as I’ve watched several of my friends sell their independent practices.

It’s amusing to watch their thought process. These are the same physicians who wouldn’t consider selling their practices to a local health system for fear of being beholden to “the man,” yet they’ll get in bed with private equity. Even before the ink is dry, some of them have seen their worlds completely reorganized with less of a focus on clinical quality and patient care and more of a focus on profits. I’m not sure why my colleagues are surprised when this happens. By definition, private equity firms are investment management companies,. Not healthcare companies, not charities, and certainly not physician-led organizations.

Allowing private equity investments puts you on a slippery slope, but selling to private equity moves you squarely into the realm of being a for-profit business, whether you want to put an altruistic healthcare face on it or not. I’ve been in consulting engagements (working for physician groups) where the PE firm brings in its own consultants and starts slashing and burning before even trying to understand the practice’s culture, patient population, and what they’ve tried to do already. I’ve watched dermatology practices converted to almost exclusively cosmetic enterprises over the protests of the former controlling physicians who actually want to practice dermatology.

There’s only so much money out there. It’s tempting to think that the PE firm is actually going to invest in you and grow your business the way you might have done on your own, but in reality, they’re likely to drastically change your way of life and profit will be the driving force behind most decisions moving forward. Caveat emptor!

I got a kick out of Jacob Reider’s comments about potential suitors for Athenahealth following the departure of Jonathan Bush. He discounts the possibilities of Apple, Cerner, and Microsoft, but gives 10 percent odds to Salesforce. He also throws the possibility of Roper/Strata Decision into the mix. I agree with Jacob that Strata CEO Dan Michelson gets the EHR market, and the last time I saw him in action, it made me want to go home and learn more about cost accounting – something you don’t hear too many people hankering to do in their free time.

From No Surprise Here: “Re: HDHPs. Check out this article about high-deductible plans keeping patients from accessing preventive care services. No surprise, right?” The link is from the American Academy of Family Physicians and cites a study from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. The study found that patients who have high-deductible health plans but who do not have health savings accounts to go with them are less likely to receive preventive care or care from primary physicians or subspecialty service providers. The authors looked at data from 2011-2014 for almost 26,000 privately insured adults in four categories: no deductible, low deductible, high-deductible plan with savings account, and high-deductible plan without savings account. Those in the latter category were 7 percent less likely to receive breast cancer screening and 8 percent less likely to receive a flu vaccine. Screenings for hypertension were slightly (4 percent) less.

Under the Affordable Care Act, preventive care is supposed to be exempted from out-of-pocket charges, including deductibles, but this only applies to certain identified preventive services. It definitely doesn’t apply to my breast MRI, which is indicated due to my very high lifetime cancer risk, and fortunately as a physician, I can afford to pay for it. But for those services that are explicitly exempted — such as well visits, screening tests, and vaccinations — many patients don’t realize they have access without a deductible, so they don’t seek care.

As I’ve said before, there’s not the greatest incentives for insurance companies to advertise all the services they cover at minimal cost to the patient since the return on investment is likely to be years down the road when the patient may be with another payer. One would hope the payers could adopt the attitude of “we’re all in this together” since the number of patients moving around is likely to impact all of them, but I haven’t seen much education to patients in this regard. Failure to have patients take advantage of preventive services that are shown to be cost-effective illustrates the lack of attention to public health efforts in our nation. We’re relying on the primary care workforce to identify all these gaps in care and take care of them, but if the patients don’t have a primary to see (the wait in my community is well over six months), aren’t eligible to be seen at a clinic, or just don’t go, then no one is handling it for the patient.

I’ve always found the AAFP to be a solid source of information, both as a physician and as a patient. I was sad to see their writeup on increased suicide rates across the US. Looking at data through 2016, the suicide rate has increased nearly 30 percent, with 45,000 Americans age 10 or older taking their own lives. We hear about the celebrities, but we don’t hear about the others, and we don’t hear enough about the people who tried and didn’t succeed.

One of the most heartbreaking situations I ever encountered was a pre-teen who tried to hang himself and was found by his parents, but not quickly enough, resulting in severe anoxic brain injury. I cared for him several years later due to some complications of his multiple medical issues. It’s never to early to talk about mental health.

In the times that suicide has touched me personally, for most, there was no warning. This is borne out by data that shows that in states reporting complete information for 2015, 54 percent of the time there were no known mental health conditions. The data also shows an increase in visits for non-fatal self-harm, rising 42 percent between 2001 and 2016. Firearms were used in 48 percent of cases.

Suicide is preventable. The article lists key strategies:

• strengthening economic supports (housing stabilization policies, household financial support)
• teaching coping and problem-solving skills to manage everyday stressors and prevent future relationship problems, especially in early life
• promoting social connectedness to increase a sense of belonging and access to informational, tangible, emotional and social support
• identifying and better supporting people at risk (military veterans, people with physical or mental health conditions)

As a side note, the next to last bullet does not refer to Facebook, Snapchat, Instagram, or other social media that can actually increase feelings of decreased self-worth and hopelessness. We’re talking real, interpersonal connections that might be made when people are actually together interacting like human beings. I see a lot of people who are well “connected” but have no one they can really turn to. Reach out to your friends, your neighbors, and the people you know and consider getting to know them better.

I’ll get off my soapbox now and get back to the business of working on a lab interface. Thanks for listening.

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