More Than Half of US Doctors Now Part of Healthcare Systems

More than half of US physicians now work for or contract with fewer than 700 healthcare systems across the country, according to a new study in Health Affairs.

Between 2016 and 2018, the percentage of physicians affiliated with a healthcare system — defined as an organization that includes at least 50 physicians, 10 primary care doctors, and one nonfederal acute care hospital — increased by 11 percentage points, jumping from 40% to 51%. The proportion of primary care physicians affiliated with healthcare systems rose from 38% to 49%, the study found.

The researchers, led by Michael F. Furukawa, PhD, the acting director of the Division of Healthcare Delivery and Systems Research in the Center for Evidence and Practice Improvement at the Agency for Healthcare Research and Quality (AHRQ), used AHRQ data on healthcare systems as well as data from IMS Health and IQVIA to identify system-affiliated physicians.

Their findings confirm and extend earlier research showing a major increase in physician employment by hospitals over the past decade. For example, a survey by the American Medical Association (AMA) found that in 2018, 8% of doctors worked directly for a hospital, and nearly 27% worked for a hospital-owned practice, up from 5.6% and 23% in 2012, respectively. Another study, by Avelere Health and the Physicians Advocacy Institute (PAI), found that in 2018, 44% of physicians were employed by hospitals and health systems, up from 41.7% in 2016.

The authors of the current study note that they did not measure the full extent of industry consolidation, partly because they excluded hospitals that employed fewer than 50 doctors. So why did their results show that so many more doctors were working for hospitals than earlier studies did?

One reason is that not all of the physicians affiliated with healthcare systems are employed by them, Furukawa told Medscape Medical News. For example, he said, physicians in the Sharp Community Medical Group in San Diego do not work directly for Sharp Healthcare. They receive their paychecks from the group, which contracts with the healthcare system for their services. (That arrangement is in line with California’s corporate practice of medicine law, which bars most hospitals from directly employing doctors.)

The AMA and Avelere/PAI studies also used different kinds of data, Furukawa added. The AMA survey, for instance, relied on member reports that aren’t frequently updated, he said.

Michael La Penna, a healthcare consultant based in Grand Rapids, Michigan, told Medscape Medical News that he isn’t surprised that a majority of doctors are affiliated with hospitals. The study’s results, he said, “told us what we already knew” from observing facts on the ground. In some cities, he noted, it’s hard to find independent practices.

La Penna, whose clients include hospitals that employ physicians, said that healthcare systems have continued to add more physicians to their networks since 2018. In some cases, he said, efforts by private equity firms to acquire high-ticket specialty practices have spurred the hospitals to defensively buy out specialists such as orthopedic surgeons.

Vertical vs Horizontal Consolidation

Healthcare systems’ hiring of additional doctors follows a phase in which hospitals joined together into systems. According to the new study, the percentage of hospitals in healthcare systems increased by just two percentage points, rising from 70% to 72%, during the study period. Looked at in a slightly different way, in 2018, 91% of hospital beds were in system-affiliated hospitals — a small increase from the 88% in 2016.

During the same period, the number of healthcare systems that fit the study criteria increased from 626 to 637. Of the 626 systems in 2016, 556 were operating in 2018. The difference is partly explained by mergers of systems, the authors note.

The most common type of healthcare system ownership was nonprofit, which included 440 systems in both 2016 and 2018. The number of public/government hospital systems increased from 108 to 127. In contrast, the number of church-operated systems decreased from 59 to 53, and the number of for-profit systems dropped from 19 to 17.

Among the 556 systems that remained under the same ownership throughout the study period, the median number of affiliated physicians increased by 29%, from 285 to 369. Similarly, the median number of affiliated primary care physicians increased by 32%, from 106 to 140.

In for-profit systems, the median number of doctors more than doubled, from 519 to 1127, while the median number of hospitals grew by 156%, from nine to 23. These systems had by far the highest median number of employed doctors, the authors note.

Church-owned systems increased their median number of physicians by 32%, which is about the same as other not-for-profit systems; but in absolute numbers, they had the second highest median number of physicians. The 49 church-operated organizations employed a median of 820 physicians in 2018, up from 622 in 2016.

“Big church-operated healthcare systems like Ascension and Trinity Health and for-profit systems had the biggest growth in acquiring practices and the biggest percentage increases in affiliated doctors, partly because they were doing catch-up,” Furukawa explained. “Their baseline was lower than that of other types of systems.”

In addition, for-profit systems were aggressive in acquiring practices, partly because of government regulatory changes, such as the implementing of alternative payment models, he suggested.

La Penna agreed that the church-sponsored chains, which are in multiple states, have been acquiring more practices to compete with nonprofit systems that usually focus on single markets. The for-profit chains, which are few in number, are contending with all of the other systems to corral the remaining independent physicians, he said.

Driving Up Costs

A number of studies have shown that industry consolidation has raised costs by giving healthcare systems leverage over private insurance companies. This is true of both hospital mergers and physician employment. With more doctors aboard, healthcare systems can negotiate higher rates for their employed physicians.

They’ve also been able to take advantage of Medicare regulations that pay provider-based outpatient departments — physician offices affiliated with hospitals — at higher rates for evaluation and management services than independent practices are paid. The Centers for Medicare & Medicaid Services has tried to change this with “site-neutral” payments, but that policy change is currently tied up in court.

The coronavirus pandemic is putting further pressure on independent practices, which have seen revenues plunge 30% or more. According to a recent report from Merritt Hawkins, a physician recruiting firm, up to 35% of practices may close in some markets.

What that will mean for industry consolidation is up in the air. Merritt Hawkins noted that physician searches have dropped by 30%, an indication that healthcare systems are hiring fewer doctors than in the past because of the pandemic. At this point, there are far more doctors seeking jobs than there are available positions, Travis Singleton, executive vice president of Merritt Hawkins, told Medscape Medical News.

But La Penna said that despite the COVID-19 crisis, hospitals in New York City and along the East Coast are looking for bargains as practices start to go under. Some doctors, he said, are now knocking on hospital doors after resisting their entreaties for years.

The study was funded by AHRQ. The authors and La Penna have disclosed no relevant financial relationships.

Health Aff. Published online August 3, 2020. Full text

https://www.medscape.com/viewarticle/935249#vp_1

Brain Death: What Does it Mean?

New international recommendations aim to bring worldwide consensus to determining brain death in adults and children.

The guideline is an effort to “improve the rigor of and minimize diagnostic errors in brain death, or death by neurologic criteria,” said Gene Sung, MD, MPH, of the University of Southern California, who is the corresponding author of the World Brain Death Project consensus statement published in JAMA.

“One of the most fundamental concepts of medicine is life and death, but how do you determine if someone has died?” he asked.

This is the first time five different world federations have come together to help develop and endorse a consensus statement about brain death or death by neurologic criteria (DNC), Sung told MedPage Today.

Multiple professional societies including the Society of Critical Care Medicine have endorsed it. The American Academy of Neurology, which called for uniform brain death laws, policies, and practices in its 2019 position statement, affirmed the value of the statement as an educational tool for neurologists.

In the U.S., death by neurologic criteria has been incorporated into legal standards for death in every state following the Uniform Determination of Death Act (UDDA), a model state law approved in 1981.

“Notwithstanding this very important legal innovation, there have been recurrent philosophical and religious objections to DNC,” noted Ariane Lewis, MD, of New York University Langone Medical Center in New York City, and co-authors, in an editorial published in JAMA Neurology.

The most common objection is that the only “true death” is death by cardiopulmonary criteria, they said. “Some have argued that continuing hormonal functions in an individual who is comatose, has absent brainstem reflexes, and is unable to breathe spontaneously indicates that person is not dead under the UDDA, because they have not lost ‘all functions of the entire brain,'” Lewis and co-authors wrote.

Clinicians have contributed to the growing controversy by failing to ensure consistency among hospital DNC guidelines, they added: “As a result, a person could be declared dead at one hospital yet alive at another.”

To create their consensus statement, Sung and co-authors conducted literature searches from January 1992 through April 2020. Because high-quality data from randomized clinical trials or large observational studies were lacking, their recommendations also relied on the consensus of contributors and medical societies representing critical care, neurology, neurosurgery, and other fields.

“The determination of brain death/DNC is a clinical diagnosis, and given the implications and consequences of this diagnosis, a conservative approach and criteria are recommended,” they wrote.

The diagnosis begins by establishing that the clinical history, etiology, and neuroimaging demonstrate the person has experienced an irreversible devastating brain injury leading to loss of all brain functions, and there are no confounders that could make the person appear to have irreversible brain injury when that’s not the case, they said.

Determining brain death/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea, they continued. This is seen when:

• There’s no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation
• Pupils are fixed in a midsize or dilated position and are nonreactive to light
• Corneal, oculocephalic, and oculovestibular reflexes are absent
• There’s no facial movement to noxious stimulation
• The gag reflex is absent to bilateral posterior pharyngeal stimulation
• The cough reflex is absent to deep tracheal suctioning
• There’s no brain-mediated motor response to noxious stimulation of the limbs
• Spontaneous respirations aren’t seen when apnea test targets reach pH below 7.30 and PaCO₂ equal to or above 60 mm Hg

“If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing,” the authors wrote. “Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability.”

The guidelines recommend that consent not be required for apnea testing because of concerns over prolonged somatic support, challenging an emerging trend of families objecting to apnea tests, noted Wade Smith, MD, PhD, of the University of California San Francisco, in another JAMA Neurology editorial. “By doing so, families preclude the diagnosis of death, leading in some instances to prolonged somatic support that many physicians consider unethical,” he wrote.

The trend is highlighted in a law under discussion in Michigan called Bobby’s Law: if passed, physicians may be required to gain consent from surrogates before testing for apnea, Smith said. The proposed legislation is predicated on Simon’s Law — now adopted in Missouri, Kansas, and Arizona — that requires physicians to involve family members in end-of-life decisions, “an ethic that is sensible,” he wrote.

“Ostensibly, families should be asked to provide consent because the apnea test may lead to cardiovascular collapse in some patients, classifying it as procedure with risk,” Smith added. “Physicians have argued that apnea testing is part of the neurological examination and it should be performed to establish an important diagnosis (death), allowing them to communicate an honest prognosis.”

The World Brain Death Project guidelines “serve as a foundational report for all clinicians involved in determining brain death,” observed Robert Truog, MD, MA, of Harvard University, and co-authors in an editorial published in JAMA.

Two steps are necessary to bring these recommendations to the entire international community, they pointed out. “First, evidence to support the existing tests needs to be bolstered, and this may require greater use of advanced neurodiagnostic techniques,” Truog and colleagues wrote.

“Second, since much of the world does not have access to advanced technologies, the World Brain Death Project will need to focus on development and validation of tests that rely on the clinical examination and widely available diagnostic tools,” they continued. “This will be essential if the capacity for accurately diagnosing brain death/DNC is to become accessible to all clinicians around the world.”

One important limitation to this consensus document is that a “lack of high-quality data from randomized clinical trials or large studies prevented the use of GRADE, AGREE, or other formal analytic techniques,” Sung and co-authors noted. Another is that the group developed recommendations without including patient partners or direct input from diverse social and religious groups.

Disclosures

World Brain Death Project members reported relationships with Canadian Blood Services, Gift of Life of Michigan Foundation, Lifecenter Northwest, and the American Association of Neurological Surgeons.

Editorialists reported relationships with Sanofi, Covance, and the American Academy of Neurology.

Primary Source

JAMA

Source Reference: Greer DM, et al “Determination of brain death/death by neurologic criteria: the World Brain Death Project” JAMA 2020; DOI: 10.1001/jama.2020.11586.

Secondary Source

JAMA Neurology

Source Reference: Lewis A, et al “Is there a right to delay determination of death by neurologic criteria?” JAMA Neurol 2020; DOI: 10.1001/jamaneurol.2020.1815.

Additional Source

JAMA Neurology

Source Reference: Smith WS “Standardizing brain death globally” JAMA Neurol 2020; DOI: 10.1001/jamaneurol.2020.1243.

Additional Source

JAMA

Source Reference: Truog RD, et al “Brain death—moving beyond consistency in the diagnostic criteria” JAMA 2020; DOI: 10.1001/jama.2020.11665.

https://www.medpagetoday.com/neurology/generalneurology/87882

3 Diets Cut Seizures in Kids with Intractable Epilepsy

Three major methods of providing ketogenic diet therapy reduced seizures in children with drug-resistant epilepsy, the randomized DIET trial showed.

Median reduction in seizure burden was similar with the ketogenic diet, the modified Atkins diet, and the low glycemic index therapy diet, though neither the modified Atkins nor low glycemic index therapy diet met criteria for non-inferiority to the ketogenic diet, reported Sheffali Gulati, MD, of All India Institute of Medical Science in New Delhi, and co-authors, in JAMA Pediatrics.

Most research in the past has focused on the ketogenic diet, Gulati noted. “The ketogenic diet is a high-fat diet, and some families and patients find it challenging to adhere to and also experience serious adverse effects,” she and first author Vishal Sondhi, DM, also of All India Institute, said in an email to MedPage Today.

DIET was the first trial to compare the three primary dietary therapies, Gulati and Sondhi added. “The seizure burden decreased by greater than 50% in 67% of patients receiving the ketogenic diet, 52% of patients receiving the modified Atkins diet, and 59% of patients receiving the low glycemic index therapy diet,” they wrote. “Hence, clinicians have two more modalities in their armamentarium — the modified Atkins and low glycemic index therapy diets — when they are managing children with drug-resistant epilepsy.”

While the low glycemic index and modified Atkins diets “were slightly less likely to work in this study, the low glycemic index therapy had fewer side effects,” noted co-author Eric Kossoff, MD, of Johns Hopkins University in Baltimore.

The important message is that parents, patients and centers should continue to make individualized decisions regarding which of the three major diets to use,” he told MedPage Today. “They are different and have different pros and cons.”

The trial included children ages 1 to 15 who had four or more seizures a month, had not responded to two or more anti-seizure drugs, and had not been treated previously with one of the three diets. Patients were enrolled between April 2016 and August 2017 at a tertiary care referral center in India and were randomly assigned to receive one of the diets in addition to their ongoing anti-seizure drugs.

A total of 158 children completed the trial: 52 in the ketogenic diet group, 52 in the modified Atkins diet, and 54 in the low glycemic index therapy diet. Diets were supplemented with vitamins and minerals, and each patient’s caregiver kept a daily log of meals, seizure frequency, urinary ketones, and dietary intolerance symptoms.

A gradual nonfasting protocol was used to start the ketogenic diet. The modified Atkins diet group followed the Johns Hopkins protocol. The low glycemic index diet restricted foods with a glycemic index higher than 55 and limited carbohydrates to approximately 10% of daily calories. While the modified Atkins and low glycemic index diets were started in outpatient settings, children were admitted to start the ketogenic plan.

The primary outcome was percentage change in seizure frequency after 24 weeks in the ketogenic diet group compared with each of the others. The trial had a predefined, noninferiority margin of −15 percentage points.

After 24 weeks, intention-to-treat analysis showed that the median change in seizure frequency was −66% in the ketogenic diet group, −45% in the modified Atkins group, and −54% in the low glycemic index therapy group (P = 0.39).

The median difference in seizure reduction between the ketogenic and modified Atkins groups was −21 percentage points (95% CI −29 to −3 percentage points). Between the ketogenic and low glycemic index therapy groups, it was −12 percentage points (95% CI −21 to 7 percentage points). Neither diet met noninferiority criteria.

Treatment-related adverse events were similar in the ketogenic (31 of 55; 56.4%) and modified Atkins groups (33 of 58; 56.9%), but were significantly less in the low glycemic index group (19 of 57; 33.3%).

The most common clinical adverse event was vomiting. Two patients on the low glycemic index diet and one on the ketogenic diet had thrombocytopenia at 24 weeks; both were receiving sodium valproate (Depakote). Ten patients, all receiving concomitant zonisamide ‎(Zonegran), had hypercalciuria at 24 weeks. Two patients on the modified Atkins diet developed scurvy. Three patients developed a prolonged QTc interval.

“The risk profiling illustrated that the low glycemic index therapy diet was associated with the least number of and least severe adverse events, while the other two diets were more likely to be associated with severe and life-threatening events,” Gulati and Sondhi noted.

The study had blinding limitations because the diets required close parental interaction. Daily logs might have missed some seizures and may include subjective errors. This was a single-center study and selection bias may have occurred.

Disclosures

Kossoff reported receiving support from Nutricia outside the submitted work. No other disclosures were reported.

Primary Source

JAMA Pediatrics

Source Reference: Sondhi V, et al “Efficacy of Ketogenic Diet, Modified Atkins Diet, and Low Glycemic Index Therapy Diet Among Children With Drug-Resistant Epilepsy: A Randomized Clinical Trial” JAMA Pediatrics 2020; DOI: 10.1001/jamapediatrics.2020.2282.

https://www.medpagetoday.com/neurology/seizures/87914