Michael Romano Installed as New President

Date of Publication May 1, 2018

During the IMS President’s Reception on April 27, 2018, Joyce Vista-Wayne, MD, installed Michael Romano, MD, MHA, as the 169th IMS President.

Here is the full transcript of Dr. Romano's speech.

Health care in the United States is nearing a state of crisis. We have over 23 million diabetic patients, an increase of over 250% from 20 years ago. Almost 40% of adults are obese, which will further drive increases in diabetes. More than 115 people die daily from opioid overdoses. Every day, 10,000 baby boomers turn age 65, adding new Medicare beneficiaries to a program already fiscally unsustainable. In 2016, our per capita spending on health care hit the dubious benchmark of $10,000 per person. Electronic health records, once thought to be a tool for dramatically improving patient care and patient safety, have become an administrative albatross around the neck of our physicians.

Our healthcare system is in desperate need of reform, but the situation is hampered by an additional barrier to improvement. Our physician workforce is overburdened and overwhelmed, making healthcare reform just one more task taking their time and attention. We’re experiencing a substantial level of physician burnout, the severity of which is summarized by our very own Steenblock Report: “A 2015 Iowa Physician Survey found that 79.3% of physician respondents reported some level of professional burnout. Coupled with low professional morale — just 41% of Iowa respondents expressed positive feelings about the state of the medical profession — these growing rates of burnout paint an image of a profession in crisis.”

Solutions have been proposed for healthcare reform, most notably by the Centers for Medicare & Medicaid Services (CMS). When we distill the proposals down to basic concepts, CMS is exactly on target. Reform of the healthcare system means we should be rewarding value — the improvement of quality, patient experience and cost. And we should move away from a system that pays only for volume. Unfortunately, the CMS proposals are complex and sometimes convoluted, and that is problematic. Physicians cannot embrace a solution they do not understand.

Healthcare reform should be relevant and understandable for both physicians and patients. Many physicians haven’t engaged with the CMS-proposed solutions because they’re too difficult: too many payment programs, too many quality measures, too many acronyms. Healthcare needs and healthcare costs are not equally distributed in our patient populations; chronic disease and high costs are concentrated in a relatively small percent of the population. Yet we haven’t made enough effort to allocate our most valuable healthcare resources to address this concentrated distribution of healthcare needs. In fact, we can easily argue that we’ve misallocated our most valuable resources to focus on areas that don’t address the healthcare needs or costs of our patients.

But there is hope for simplification. According to CMS: “. . . Administrator Seema Verma launched the ‘Patients over Paperwork’ initiative . . . to ‘cut the red tape’ to reduce burdensome regulations. Through ‘Patients over Paperwork,’ CMS established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience. In carrying out this internal process, CMS is moving the needle and removing regulatory obstacles that get in the way of physicians spending time with patients.”

There it is — the secret to success: physicians spending time with patients. If we have any hope of success in healthcare reform, it’s about physicians spending more time with their patients. From my perspective, healthcare reform isn’t as much about transformation of clinical practice as it is about reclamation of clinical practice. We need to reclaim the role that physicians have traditionally held in healthcare delivery: spending the bulk of their time face to face and engaged with patients. That’s the role we are uniquely trained for. And it’s the role physicians most desire to fulfill — caring for the health and healthcare needs of our patients.

So how do we get there? I would propose six achievable steps for success in healthcare reform. These steps need to be applied universally across all patient populations, across all payers, and across all physicians. The Iowa Medical Society can initiate this dialogue, but we’ll need engagement of all the stakeholders with whom we share the same goal: assuring the highest-quality health care in Iowa.

Here are the six steps:
  1. We must focus on patients with the highest healthcare needs. In most populations, about 20% of the patients utilize about 80% of the healthcare resources. These patients have difficult, complex diseases. They have difficult medication regimens and they have difficult diagnostic dilemmas. These patients need the full benefit of the skills and training of a physician. Even an incremental improvement in managing the disease burden of this population will begin to solve the cost conundrum of our healthcare system.
  2. Physicians need access to meaningful data. By meaningful, I mean data that is clinically relevant and clinically actionable. This data falls into three categories:
    a. Risk stratification of patient populations. This will identify the 20% of patients that utilize 80% of healthcare resources.
    b. Identification of clinical care gaps. Primary care visits are an important factor for keeping our healthy patients healthy and for managing our chronic disease patients. Making sure our patients get appropriate primary care visits gives us a much better chance of success in managing the health of our populations.
    c. Predictive analytics. These analytics can help us identify patients who are predicted to have worsening disease in the next 6–12 months. Intervention with primary care visits gives us an opportunity to mitigate the factors causing their disease to worsen.
  3. We must seek community engagement and support. As we begin to focus our attention on patients with the greatest healthcare needs, we’ll find that clinical care is responsible for only a small percentage of improved health outcomes. In this population, the biggest influence on health outcomes is the social determinants of health. Solutions for these social determinants will only be found in resources provided by our communities. Iowa takes care of its own, so I’m optimistic that we can begin to successfully engage with our communities.
  4. We must work for simplification in quality reporting. Too much time and resources are spent tracking and reporting quality measures. Unfortunately, the care processes that dominate quality measurement may not actually reflect quality health care. There are patient outcome measures that can be easily tracked by payers through claims data, relieving the burden of quality reporting with perhaps a more accurate reflection of healthcare quality. For instance, tracking newly diagnosed, advanced cancer patients through diagnosis codes might better reflect success or failure of early cancer screenings. Tracking diabetic patients initiating dialysis or undergoing amputations through procedure codes might better reflect disease management versus the tracking of hemoglobin A1C control. Tracking ED visits or hospital admissions would be an excellent measure of the success or failure of chronic disease management./li
  5. We need access to value-based contracts. If physicians perform well in managing quality and costs, they should be allowed to share in the savings that are generated. Our current system relies heavily on accountable care organizations to manage value-based contracts. This works well for physicians who are part of larger health systems, but doesn’t work well for small, independent practices in rural locations. Rural physicians have high levels of patient and community engagement, which should give them an opportunity to perform well in value- based contracts. Costs are easily tracked in any practice. If quality can be just as easily tracked through claims-based measures, it would put us in a position to reward high-value care wherever it occurs, including rural locations.
  6. We need to open the tent. If physicians focus on caring for just 20% of their population, who’s going to care for the other 80%? This is the reality of many scope of practice discussions: The majority of our patients don’t always need physicians to care for them. The majority of our patients are reasonably healthy, but they need providers to keep them healthy. Advanced practice providers can manage many acute illnesses. They have familiarity with preventive care guidelines. They can recognize and mitigate risk factors for developing chronic disease. And they generally have excellent patient engagement skills. In order to be successful, we need everyone on the healthcare team functioning to the full extent of their licensure. And we must ensure that members of the healthcare team have sufficient training to maintain patient safety.

I think Iowa can do this. I would challenge our Medical Society to take advantage of its relationships with key stakeholders in all areas of the care continuum to convene discussions and to start meaningful change in our state. Success in healthcare reform benefits our patients, our physicians, and our economy.

Michael Romano, MD, MHA, Friday, April 27, 2018

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