Michigan Medicine®, Volume 121, No. 2

Page 1


March/April 2022




your malpractice insurance? Unlike other medical liability insurers, which are investor-owned companies, The Doctors Company remains fiercely independent and dedicated to your interests. Ask yourself, “Do I want an insurer founded by and for physicians that’s guided by my peers? Or do I want a profit-focused insurer that’s directed by Wall Street?” Join us and discover why delivering the best imaginable service and unrivaled rewards is at the core of who we are. Endorsed by

p resident 's Dear Colleagues, “The future cannot be predicted, but futures can be invented.” For more than a half-century, those words from a Nobel Prizewinning physicist have impacted the way leaders around the globe approach the responsibility and the opportunity of leadership. The future of medicine is in our hands, and it’s going to be what we make it. Last year, the Michigan State Medical Society partnered with Public Sector Consultants to conduct in-depth survey analysis of what


that future might look like, and the answers crafted a brilliant road map towards a better health care delivery system that continues to put patients first. In this edition of Michigan Medicine®, you’ll hear from some of the

“The future

roughly 60 physicians and health care leaders who participated in

of medicine is

the research, you’ll learn about where medicine is headed, and – we hope – you’ll be inspired to help build the future one patient

in our hands,

outcome at a time.

and it’s going

Thank you for your leadership.

to be what

Thank you for reading.

we make it.”




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FEATURES & CONTENTS January / February 2022


12 The Future of Medicine On a daily basis, physicians are inventing new technologies and approaches to improving, protecting, and restoring the human body—and shaping our tomorrows. That's no small responsibility. (Story begins on page 12.)

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Michigan Supreme Court Greatly Expands Damages Available In Medical Malpractice and Other Wrongful Death Cases DANIEL J. SCHULTE, J.D


It’s Round Up Time! Let’s Circle our Wagons and Get Kids Up to Date on Vaccines BY SARAH DE RUITER, BSN, RN, MA


MSMS On-Demand Webinars and Education Events MICHIGAN STATE MEDICAL SOCIETY

MICHIGAN MEDICINE® VOL. 121 / NO. 2 Chief Executive Officer JULIE L. NOVAK Managing Editor KEVIN MCFATRIDGE KMcFatridge@msms.org Publication Design STACIA LOVE, REZUBERANT! INC. rezudesign.com Printing FORESIGHT GROUP staceyt@foresightgroup.net Publication Office Michigan Medicine® PO BOX 950 East Lansing, MI 48826 517-337-1351 www.msms.org All communications on articles, news, exchanges and advertising should be sent to above address, ATT: Kevin McFatridge. Postmaster: Address Changes Michigan Medicine® Kevin McFatridge PO BOX 950 East Lansing, MI 48826


Attracting Qualified Candidates in a Tight Labor Market JODI SCHAFER, SPHR, SHRM-SCP


What U.S. Health Care Will Look Like in 2032: Executive Summary RICHARD E. ANDERSON, MD, FACP



Michigan Medicine®, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan. The MSMS Committee on Publications is the editorial board of Michigan Medicine® and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors. Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine® reserves the right to accept or reject advertising copy. Products and services advertised in Michigan Medicine® are neither endorsed nor warranteed by MSMS, with the exception of a few. Michigan Medicine® (ISSN 0026-2293) is the official magazine of the Michigan State Medical Society, published under the direction of the Publications Committee. In 2022 it is published in January/February, March/April, May/ June, July/August, September/October and November/December. Periodical postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110. Single copies, $10. Printed in USA. ©2022 Michigan State Medical Society

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Michigan Supreme Court Greatly Expands Damages Available In Medical Malpractice and Other Wrongful Death Cases


It was recently reported that our Supreme Court

refused to hear a case that greatly expanded the damages available to plaintiffs in wrongful death cases (arising from medical malpractice or other claims). Can you explain this decision? Is it significant?


he case that you refer to is Estate of Langell v McLaren Port Huron. The plaintiff estate alleged medical malpractice against several defendants. The issue on appeal was whether the plaintiff estate was entitled to recover as damages an amount approximating all the potential future earnings of the decedent or only an amount approximating the future financial support obligation of the decedent (a more limited amount).

The Court of Appeals held that the plaintiff estate was entitled to recover all the future earnings of the decedent without regard to whether the decedent had a financial support obligation. Defendants filed an application for leave to appeal to the Supreme Court. MSMS and the AMA filed an amicus brief supporting the defendants’ application and arguing that this element of the plaintiff estate’s damages should be limited to the decedent’s financial support obligation. The applicable section of Michigan’s Wrongful Death Act, MCL 600.2922(6), provides: In every action under this section, the court or jury may award damages as the court or jury shall consider fair and equitable, under all the circumstances including reasonable medical, hospital, funeral, and burial expenses for which the estate is liable; reasonable compensation for the pain and suffering, while conscious, undergone by the deceased during the period intervening between the time of the injury and death; and damages for the loss of financial support and the loss of the society and companionship of the deceased. This statute specifically states that “damages for the loss of financial support” are recoverable. It does not provide that all the future earnings of the decedent are recoverable. Despite this choice of language by the Michigan

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legislature, our Supreme Court decided to let stand a Court of Appeals decision allowing and award of damages including a loss of all future earnings without regard for whether the decedent owed anyone an obligation of financial support. The Supreme Court’s 5-2 decision was contained in an order denying defendants’ application for leave to appeal. The majority (Justices Bernstein, Clement, Cavanagh Welch and McCormack) included no substantive explanation supporting their denial in the order. Justices Viviano and Zahra dissented and provided an explanation. They believed the Supreme Court should have granted leave to appeal to fully consider this “significant and recurring question of law involving a complicated statute.” Justices Viviano

This statute specifically states that “damages for the loss of financial support” are recoverable. It does not provide that all the future earnings of the decedent are recoverable. and Zahra further stated their opinion that the Court should have heard the appeal to consider the applicable precedent, Baker v Slack, 319 Mich 703 (1948). In Baker the Supreme Court held that the previous version of MCL 600.2922(6) limited a plaintiff estate’s recovery to the amount of the decedent’s support obligation and did not allow all the future earnings of the

decedent to be recovered as damages. Justices Viviano and Zahra openly questioned whether Baker remains “good law” and would have heard this appeal and addressed that question. The denial of the application for leave to appeal in Langell is significant. In future medical malpractice cases involving the death of a patient and other cases brought pursuant to Michigan’s Wrongful Death Act plaintiffs will now seek the full loss of the earnings capacity of the decedent whether the decedent had a support obligation or not. This will be the case until the Supreme Court decides to hear an appeal which fully interprets MCL 600.2922(6) considering its history and Baker.

Convergence — Detroit From Above by Brian Day

Trusted Advisors to Michigan Physicians

A successful practice requires physicians focused on treating Apatients. successful practiceto requires physicians focused on treating patients. As counsel the MSMS community for over 70 years, As to the MSMS community years, we know how to wecounsel know how to help physicians. Letfor usover help70 you protect, help physicians. Letyour us help you protect, manage, and grow your practice. manage, and grow practice.

kerr-russell.com Daniel J. Schulte, dschulte@kerr-russell.com | Patrick J. Haddad, phaddad@kerr-russell.com | Kathleen A. Westfall, kwestfall@kerr-russell.com


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Attracting Qualified Candidates in a Tight Labor Market By Jodi Schafer, SPHR, SHRM-SCP HRM Services | www.WorkWithHRM.com


Like many employers in this job market, we are struggling to recruit new staff. We have many positions unfilled including nurses, medical assistants and office staff. What are some new strategies we might try to stand out from our competitors and attract qualified candidates to our practice?

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ou are right. It is a tight labor market right now. The “great resignation” that started in 2021 and continues into 2022 is leaving many jobs

unfilled and employers struggling. Michigan currently has 190,000 fewer people in the workforce as compared to prepandemic numbers and a labor force participation rate of 59.5%; 41st lowest in the nation. These trends mean that the labor shortage is unlikely to change anytime soon.

“With a tight labor market, employees can be choosier on where they want to work. Employees want to work at practices that treat their staff and patients well.”

So, how can your practice stand out from others and attract qualified candidates? There are several strategies you might consider beyond what you may already do as part of your traditional recruiting process. This job market is forcing employers to adapt their way of doing business.

Offer more part-time positions Providing more part-time options may be attractive for several reasons including offering flexibility with child care arrangements and supporting more work-life balance. Women make up the majority of medical practice and office staff. Women are still primarily responsible for handling home and child care arrangements for their families and after becoming a parent, women are more likely to switch to a job with greater flexibility. Offering part-time positions may appeal to trained staff that left the workforce previously, enticing them to rejoin. Also, don’t forget about your current employees. Offering a parttime option may help retain existing staff who are experiencing burnout. Of course, there are additional considerations when offering part-time options, including decisions on what benefits to offer and scheduling considerations, but these costs and logistical details may pay off in recruiting and retaining talent. Start by talking with your existing employees about their interest in part-time options. You can also test out the option with a couple of staff to assess how it works and then decide to expand from there.

Consider offering evening appointments. You may be thinking, what does evening scheduling have to do with recruiting and retaining staff? Along with part-time options, there are a segment of workers who may appreciate working non-traditional hours, including those who have someone at home able to provide child care in the evening. You may have patients who appreciate this option too!

Provide additional benefits. Support with child care costs and continuing education may give you the edge as compared with other practices. If you don’t already offer retirement match and/or student loan payment assistance, these can set you apart too.

Pay attention to your image. With a tight labor market, employees can be choosier on where they want to work. Employees want to work at practices that treat their staff and patients well. If your patient reviews are not positive overall (more than just a periodic bad review), it could mean that there are other issues happening in the practice that need attention. Discontent in a practice not only impacts patient satisfaction, but employee recruitment and retention as well. And if there are other employment options that look more attractive as a place to work, high quality employees will choose to apply somewhere else.

In addition to paying attention to online reviews, spend some time marketing your practice online via social media and your website. Potential employees are researching your practice and you want them to see a place that looks like

Build your future workforce. Do you have office staff who are interested in learning a clinical role or clinic or medical assistants who are burned out with direct patient care and interested in working in business operations? Do you partner with your local high school career institute, community college or advanced degree programs by providing internships, clinical rotations or other shadowing opportunities for students/residents? Building up your talent pipeline is a long-term strategy to cultivate your future workforce. While these strategies may not be an immediate fix, together they can help build and retain a high-quality workforce for the long term.

REFERENCES 1 https://crcmich.org/unemployment-is-down-but-michigans-shrinking-labor-force-is-still-a-problem 2 https://www.jec.senate.gov/cards/__employment-updates/ Michigan%20Employment%20Report.html 3 Germano, Maggie. Women Are Working More Than Ever, But They Still Take On Most Household Responsibilities. Forbes, March 27, 2019.


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It’s Round Up Time! Let’s Circle our Wagons and Get Kids Up to Date on Vaccines By Sarah de Ruiter, BSN, RN, MA, Immunization Nurse Educator Michigan Department of Health and Human Services, Division of Immunization


pring in Michigan is just around the corner, and schools are getting ready for Kindergarten Roundup. This year, instead of corralling incoming students at an in-person kindergarten readiness rodeo, many schools are assembling the necessary registration forms into electronic packets to go out to families. When kids come into your practice for any reason, especially those between 4 and 6 years of age, don’t forget to talk about vaccines and assess immunization status at every visit. Your kindergarten eligible patients are not only vulnerable to infectious disease but are efficient carriers as well. Never has it been more important to ensure kids are up to date on routine vaccinations. The COVID-19 pandemic triggered a significant decline in vaccination rates in kids as parents and their children didn’t just stay home—they stayed away from doctors’ offices. To avoid illness and spread in close group settings such as classrooms, buses, and cafeterias, kids need to be up to date on vaccines. It is important to assess immunization records at every visit to see which vaccines are needed to protect them and others from communicable disease. For the best protection, health care providers should vaccinate their pediatric patients from vaccine-preventable diseases according to the recommended

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child and adolescent immunization schedule from the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP). Every year in the United States, people get diseases that vaccines can prevent. Infants and children need to get vaccinated to prevent diseases like hepatitis, measles, varicella, and pertussis. Strategies to make sure more children get vaccinated — like requiring vaccination for children who are in school — are key to reducing rates of infectious diseases. Michigan requires all incoming kindergarteners and 4-6-year-old transfer students to have appropriate documentation of vaccines protecting against diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, hepatitis B, and varicella. For some of these diseases, appropriate documentation of immunity from the disease is acceptable in lieu of vaccination. By vaccinating children according to the ACIP schedule, your patients will receive all the vaccines required for school and daycare entry. To help understand school and daycare vaccine requirements, the Michigan Department of Health and Human Services (MDHHS) has created easyto-read handouts that target health care providers, schools and daycares, and parents. These documents are available on the MDHHS Immunization Information for Families and Providers website. As a reminder, patients requesting a non-medical waiver for school should be referred to their Local Health Department (LHD). Health care providers should only provide parents with a medical immunization waiver (i.e., true medical contraindication to vaccine(s)) when needed. Remember to check the Michigan Care Improvement Registry (MCIR) for every patient at every well and sick child visit to determine which vaccines are needed to best protect them. All vaccines administered to persons less than 20 years of age, including flu vaccine, are required to be entered into MCIR within 72 hours of vaccine administration. By protecting your patients with all ACIP-recommended vaccines, you are helping young Michiganders stay

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ennis Gabor won the Nobel Prize for Physics

in 1971 after a lifetime developing, studying, and expanding the world’s knowledge of the

During many of the darkest days of the 20th century, he tackled some of the universe’s toughest challenges with eyes firmly set on tomorrow. He survived enlistment during World War I, fled the Nazis ahead of World War II, and remade his life with a foreign language in a foreign land. The industrial world had presented both challenges and opportunities, and Dennis Gabor was a futurist. “We are still the masters of our fate,” Gabor wrote in 1963. “Rational thinking, even assisted by any conceivable electronic computers, cannot predict the future. All it can do is to map out the probability space as it appears at the present and which will be different tomorrow when one of the infinity of possible states will have materialized. Technological and social inventions are broadening this probability space all the time; it is now incomparably larger than it was before the industrial revolution—for good or for evil.

sciences and holography.

“The future cannot be predicted, but futures can be invented.”

His work as an inventor,

We’re all inventors. What kind of future are we going to create?

communicator and theoretician changed the world—and our global concepts of what’s possible.

The 21st century will present different challenges than those confronted by Gabor and his peers, but there will be new opportunities as well. Health care is revolutionizing our quality of life, how long we live, and how we consume information. Its role in scientific, political, and broader popular culture have thrust physicians into the roles of advisors, guides, and statesmen. On a daily basis, physicians are inventing new technologies and approaches to improving, protecting, and restoring the human body—and shaping our tomorrows. That’s no small responsibility.

The Future of Medicine The practice of medicine has changed substantially in recent years, due to rapidly changing technologies, fresh research, and a renewed focus on racial equity and the social determinants of health (SDOH). As Michigan physicians and caregivers work to address these transformations, there’s never been a better time for us to look ahead and determine what kind of health care future Michigan’s physician leaders are working to build. Last year, the Michigan State Medical Society invited Lansing-based Public Sector Consultants to conduct interviews with health care leaders, with a focus on physician voices, to gather input on the most pressing issues in health care, how to address those issues, and the policies needed to support those changes. The Society also investigated opportunities to support Michigan physicians and improve health care over the coming years. Researchers found physicians in Michigan already imaging a future designed to deliver better results for patients. The future of health care is in capable hands, and they’re hard at work. Public Sector Consultants is a local organization that’s served hundreds of government agencies, nonprofits, associations, and industries for more than 40 years. They’ve built a reputation in Lansing as non-partisan, no-nonsense investigators who can cut through the clutter and deliver results. PSC compiled their findings in a new report called The Future of Medicine, available now free for physicians at MSMS.org. CONTINUED ON PAGE 14


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As one might imagine, their research identified roadmaps Michigan’s physician community are following—and carving out of the wilderness of the health care universe. Physicians and health policy experts identified hundreds of unique threads being woven into the fabric of better patient care.

A meta-analysis of the data found seven major themes and finding:

• Inventing the Future of Medicine • Key Findings and Major Themes • Team-based and integrated care models • Multidisciplinary and cross-sector collaboration • Value-based and risk-based contracting • Electronic health record improvements • Social determinants of health and health equity • Payer alignment and transparency Physicians are building a future based on team-based and integrated care models, because collaboration delivers the best outcomes. That includes multidisciplinary and cross-sector collaboration that expands the team. Health insurers, pharmaceutical purchasers, Michigan businesses and patients themselves all have a role to play on the team. Value-based and risk-based contracting, health care leaders told researchers, decreases variability in care and leads to better results. They’re also leading the charge to put more information in the hands of patients and their providers. Electronic health record (EHR) improvements will

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support clinical decision-making when it comes to diagnosing challenges and identifying the best evidence-based treatments. Interoperability will take the team dynamic to the next level, allowing providers in different practices, health systems, and locations to pull together in the same direction. Payer alignment and transparency, experts said, is about a lot more than accounting and paying the bills. It’s about reducing administrative burdens, reducing prior authorization requests, and putting physicians back alongside patients instead of stuck behind a desk. Physicians are also tackling opportunities to better identify and address social determinants of health and health equity. Tying the entire effort together, researchers claim, is expanding physician leadership. The last two years have driven home the key role physicians play in the health and wellness of their patients and their broader communities. There’s a trust factor between a doctor and his or her patient that can save a life. Building that trust within health systems, physician organizations, with payers, and even on the public policy battlefield represents a challenge and an opportunity to improve patient outcomes on a broader scale. Physician leadership can accomplish a lot—and that’s a lot of responsibility. Thomas J. Veverka, M.D. is a general surgeon practicing in Midland, Michigan, and the President-elect of the Michigan State Medical Society. A member of the board of the Michigan Health Improvement Alliance and a member of clinical faculty at both Michigan State University and Central Michigan University, Doctor Veverka’s work places him smack-dab in the middle of the physician efforts to build a better future.

“As leaders and advocates, it is incumbent upon all of us to spend time with these findings,” said Dr. Veverka. “Ultimately, it is our work with one another and with MSMS that will help us achieve the results we want for our patients and our practices. We’ve identified the battle plan for a much healthier Michigan. Now it’s time to do the hard work one patient, one practice, and one conversation at a time to build it.” Michigan’s health care leaders are already on the job.

Team-based and Integrated Care Models Public Sector Consultants’ central finding, after consultation with nearly 60 health care leaders from across the state, should come as great comfort but no surprise. Physicians view the future of medicine through the lens of better patient outcomes. “We will continue to be in the business of treating patients; medicine may be pulled in different directions—public health, advocacy—but it all comes back to treating patients,” one Michigan provider told researchers. “We need to recapture the fundamental nature of what medicine is about and for—treating people and staying patient centered.” Patients’ future will be brightest through the development and enhancement of team-based and integrated care models. Contributors expressed broad support for these physician-led models, which allow practices to address their patients’ needs more holistically while allowing everyone on the team to practice at the top of their license. Working together, patients gain access to the right provider—and the right part of the team—at the right time. It’s an approach that also focuses the entire team on delivering the best

patient outcomes. The physician remains accountable, and everyone on her or his team remains responsible. Integrating that care across settings, leaders told researchers, means a focus on prevention, stronger relationships between patients and providers, and better identifying challenges outside a single provider’s specialty—especially challenges that may impact a patient’s broader care. Breaking down barriers between treating physical and behavioral health issues separately and tying in challenge resolution with preventative care can make a world of difference for patients. It can save a life. Michigan physicians recognize that, and they’re building those bridges.

Multidisciplinary and Cross-Sector Collaboration Stronger working relationships and communications among physicians and between a physician and his or her health care team are identifying challenges and opportunities faster than ever before. A focus in the coming years on stronger multidisciplinary and cross-sector collaboration will send that progress through the roof.

Physicians and other health care providers need to work directly with payers, experts told PSC. Payers. Purchasers. Businesses. Patients. Each plays a unique role in public and private health. “In our practice, we have really driven hard to build a multidisciplinary team: social work, behavioral health, care management, and quality experts built into infrastructure in our clinic,” one Michigan provider told researchers. “We need a whole lot more of that. If we’re going to adopt new models, we need to reach outside the (practice or) clinic. “The practice model of the future is community integrated. Live, direct communications with multiple philanthropies so we can drive grants into areas that need it. Engaging with local political leaders. Liaisons with grocery stores and work with grocers to identify food deserts to champion and actively politicize the need for transformational change.” When patients have access to housing, food, and clean water, they’ll encounter fewer health challenges. Collaborating with community organizations to improve access to those services isn’t providing something “extra.” It’s often a critical first step.

““The practice model of the future is community integrated. Live, direct communications with multiple philanthropies so we can drive grants into areas that need it. Engaging with local political leaders. Liaisons with grocery stores and work with grocers to identify food deserts to champion and actively politicize the need for transformational change.”

Value-based and Risk-based Contracting Better health for Michigan patients also means an evolution toward value-based and risk-based contracting, according to researchers. It’s an approach that helps decrease variability in care and get patients the biggest bang for the health care buck. Focusing on value-based contracting would have an added benefit—more providers in family practice, where care is so often desperately needed. “The payment model has to move,” providers told PSC. “If we build one that benefits patients, it will support physicians too. It needs to incentivize value and addressing the social needs of patients and have the infrastructure to do so, too.”

EHR Improvements Patients, of course, value control over their health care experience, and access to the diagnoses, test results, and battle plans their providers identify. Again and again, Michigan physicians told researchers that they’re fighting for a future that puts health care information and electronic health records in the hands of their patients—and their peers in other settings and specialties. “Everything already exists for universal electronic health records and marrying that with artificial-intelligence enhanced decision support,” one provider said, borrowing an approach from futurists like Dennis Gabor. “It’s already out there, we just have to implement it. Leveraging these tools will hardwire best practices and evidence-based guidelines to immediately improve quality (of care).” It’s an approach that would also allow patients to have a better say and a bigger stake in the management of their own health care. It’s time to put those tools in the hands of patients and providers alike. MARCH/APRIL 2022 |

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Social Determinants of Health and Health Equity Health care leaders often pointed researchers to the ways proposed advancements to practice models, payment models, and technology would also enable medicine to better identify and address social determinants of health and health disparities. It was a concern of providers in every part of the state. “We need a more personalized approach to medical care that is individualized for patients, where patients and providers work together with patients as the driver of their medical care, including in addressing social determinants of health and behavioral health needs,” one physician leader said. Whether it’s a history of smoking or a family home located in a food desert, physicians recognize the path to a healthier future means better understanding the patients they’re walking alongside. They told researchers that means identifying patient needs through a conversation, assessments, and better knowledge of available resources and how to connect those resources to those patients. It’s the kind of support that’s best and most effectively delivered through a team-based care model. Sometimes that may even mean including a social worker or care manager who are expertly suited and trained to support patients in addressing their social service needs. Michigan physicians are leading the charge with an approach that’s deeper than a questionnaire and an exam, because prioritizing patients means creative and more holistic thinking.

Payer Alignment and Transparency Too often, still, paperwork and payers stand in the way of the best and most timely care.

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Physician leaders identified improvements in payer alignment, transparency, and additional simplification of prior authorization processes as central features of health care’s future. They’re going to bat for patients at their practices, and with payers, too. Better alignment among payers regarding the metrics they use to monitor quality of care. More transparency surrounding payment models they use to incentivize value-based care. Fewer hoops to jump through to get patients access to the treatment and medicine they need to overcome a challenge or live a healthier life. They’re the kind of fixes physicians have the least control over, but that hasn’t stopped them from using their voice or identifying the path to a healthier future. Fixes would reduce administrative burdens, they’d hasten care, they’d keep physicians in the exam room and operating suites instead of behind their desks, and they’d lower costs for patients and payers. Clearing bureaucratic hurtles outside the world of providers has never been easy, though, but Michigan’s health care leaders refuse to shrink from the challenge.

Physician Leadership The pandemic’s taught us the need for physician leadership is critical both amongst their patient populations and in the broader public policy world. Their voice in health systems, physician organizations, with payers, and with policymakers makes a huge and lasting difference. “No one understand the needs of the patients and the resources available to meet those needs as well as physicians,” one respondent told researchers. “I don’t think anyone understand the opportunities for waste reduction and cost reduction as well as physicians.

No one has a leadership perspective both within health care and in politics like physicians have. It is a unique perspective.” The stakes couldn’t be higher. We’re only talking about the future. When Vincent Gabor invented holography, he created a new way to look at the world. He ushered in a revolution that’s benefited patients and physicians around the globe. X-ray holography is used for imaging of internal parts of the body and living biological specimens. It’s used for biomedical measurements. Noncontact high resolution 3D imaging and nondestructive measurements of internal organs has become possible, impacting endoscopic and other medicine. The list goes on and on. Prakash Mehta writing for Integraf, a holographic supply expert serving providers in 55 countries, has identified and dissected the evolution of Gabor’s work in ophthalmology, dentistry, otology, orthopedics and so much more. Gabor’s work was ahead of its time and his wisdom, timeless. The Governor of Illinois in a major speech even recently misattributed the physicist’s quotes to former President Abraham Lincoln. His legacy, though, is carried by physician leaders across the state of Michigan and around the world. The future of medicine is dynamic, it’s revolutionary, and at the same time it’s incredibly simple. It’s about what medicine’s always been about—patients. Let’s get building.

Readers can now review Public Sector Consultants full report on the Future of Medicine online at www.MSMS.org.

Convenient access to specialists at


• Make appointments • Transfer patients • Consult with physicians



24 hour s a day, 7 days a w eek

• Get patient information


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MSMS ON-DEMAND WEBINARS The MSMS Foundation has a library of on-demand webinars available, many of which are free, making it easy for physicians to participate at their convenience to meet their educational needs.

Webinars that Meet Board of Medicine Requirements: A Day of Board of Medicine Renewal Requirements Human Trafficking Medical Ethics – Conscientious Objection among Physicians Medical Ethics – Confidentiality: An Ethical Review Medical Ethics – Decision Making Capability Medical Ethics – Eliminating Disparities in Health Care What Can You Do? Medical Ethics – Just Caring: Physicians and Non-Adherent Patients

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Medical Ethics – Racial Disparities in Maternal Morbidity and Mortality: A Persisting Crisis Medical Ethics – Reclaiming the Borders of Medicine: Futility, Non-Beneficial Treatment, and Physician Autonomy Pain and Symptom Management – Naloxone Prescribing Pain and Symptom Management – Balancing Pain Treatment and Legal Responsibilities

To register or to view full course details, please visit: msms.org/OnDemandWebinars

Grand Rounds Series

Other Webinars:

A Review of COVID-19 Variants

2021 ASM – Cardio-Oncology: Enhancing the Cardiac Care of the Cancer Patient

Changes to Michigan’s Auto No-Fault Act for Physicians

2021 ASM – Updates in Endocrinology

Coronavirus Relief – Overview and Updates

2021 ASM – Update in Infectious Disease

CURES Act – What is Information Blocking and How Do I Comply?

2021 ASM – Updates in Otolaryngology

Cyber Preparedness & Response for Medical Practices

2021 SSM – Contemporary Management of Nephrolithiasis

Domestic Violence and Sexual Assault (Intimate Partner Violence)

2021 SSM – Neuroscience: Central Nervous System and Neuromuscular Junction Inflammatory Disorders

Federal Information Blocking Rules Harm Reduction in Practice and Policy Strategies Henry Ford Health System COVID-19 Requirement for Employees MDHHS Update from New Director Elizabeth Hertel Navigating the No Surprises Act Recovery Audit Contractor (RAC) Region 1 Sharing Clinical Notes With Patients – A New Era of Transparency in Medicine Update on COVID-19 from Joneigh Khaldun, MD, Chief Medical Executive

Monday Night Medicine Series Creating a Manageable Cockpit for Clinicians 100% Virtual Collaborative Care for Behavioral Health Outcomes Practicing Wisely – Save 2 Hours Each Day AMA Strategic Plan to Advance Health Equity

2021 SSM – Updates in Allergy, Asthma and Immunology 2021 SSM – Updates in Dermatology 25th Annual Conference on Bioethics Health Care Providers' Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities HEDIS Best Practices In Search of Joy in Practice: Innovations in Patient Centered Care Integrating Pharmacists into Practice: The Missing Link for Comprehensive Medication Therapy Management Legalities and Practicalities of HIT - Cyber Security: Issues and Liability Coverage Legalities and Practicalities of HIT - Engaging Patients on Their Own Turf: Using Websites and Social Media Medical Marijuana Law Medical Necessity Tips on Documentation to Prove it

Implicit Bias and Racial Disparities

Non-Pharmacologic Management of Musculoskeletal Pain Syndromes

“Then when you know better, do better.” Next Steps in the Journey of Dismantling Systemic Racism Within Health Care and Beyond

Section 1557: Anti-Discrimination Obligations

A Team Based Approach Training Modules – • Module 1: How to Develop a Pharmacist-Physician Collaboration • Module 2: Medication Therapy Management Reimbursement and ROI

Update on Chronic Fatigue Syndrome Part 1: Clinical Diagnostic Criteria for Chronic Fatigue Syndrome/CFS now called Myalgic Encephalomyelitis or ME/CFS

• Module 3: Best Practices for Addressing Workflows, Resources, Challenges

Sexual Misconduct – Prevention and Reporting

Update on Chronic Fatigue Syndrome Part 2: Uniting Compassion, Attention and Innovation to treat ME/CFS

Once registered, you will receive an email within 15 minutes with links to watch the on-demand webinar and to complete the survey evaluation. Contact: Beth Elliott at 517/336-5789 or belliott@msms.org


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Grand Rounds Date(s): February 11, February 23, March 9, April 13, May 11, June 8, September 14, October 5, November 9, and December 14, 2021 Time: 12:00 - 12:45 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

A Day of Board of Medicine Renewal Requirements Date: September 23, 2021 Time: 9:00 am – 4:00 pm Location: In-Person Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Practice Management

Annual Scientific Meeting

Date(s): February 23, March 9, April 13, May 11, June 8, September14, October 5, November 9, and December 14, 2021 Time: 12:00 – 12:45 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Date: September 22, October 20-21, and November 17, 2021 Time: September and November 3:00- 6:00 pm, October 8:30 am - 4:30 pm Location: September and November Virtual Conference, October In-Person Intended for: Physicians and all other health care professionals Contact: Brenda Marenich at 517/336-7580 or bmarenich@msms.org

Monday Night Medicine

A Day of Board of Medicine Renewal Requirements

Date(s): March 7, April 4, October 3, and November 7, 2021 Time: 6:30 – 8:00 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Date: November 4, 2021 Time: 9:00 am – 4:00 pm Location: In-Person Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org

Spring Scientific Meeting

24th Annual Conference on Bioethics

Date(s): April 7-8, May 12-13, and June 9-10, 2021 Time: 8:00 – 11:00 am Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Brenda Marenich at 517/336-7580 or bmarenich@msms.org

Date: November 5, 2021 Time: 8:45 am – 4:00 pm Location: In Person Intended for: Physicians and all other health care professionals

Implicit Bias Series Date(s): May 13, June 10, July 8, August 12, September 9, October 14, November 11, and December 9 Time: 12:00 – 1:00 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Brenda Marenich at 517/336-7580 or bmarenich@msms.org

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For more information or to register, please visit: MSMS.org/EO Questions? Contact Beth Elliott: email belliott@msms.org or call 517/336-5789





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What U.S. Health Care Will Look Like in 2032 EXECUTIVE SUMMARY Richard E. Anderson, MD, FACP, Chairman and Chief Executive Officer, The Doctors Company and TDC Group

Now that so many aspects of the U.S. health care system have been tested by near-battlefield conditions, we can see the emerging risks and opportunities that have developed over nearly two years of disruption.


n one hand, despite extraordinarily trying circumstances, those on our clinical frontlines have delivered some of the finest hours of contemporary medicine, finding innovative ways to deliver care to millions of patients despite distancing restrictions and life-threatening conditions. Decades of development of digital medicine has accelerated the adoption of remote, personalized care, which encouraged massive investment in medicine by new corporate entrants. Concurrently, medical science has countered the existential threat of a global pandemic fueled by a new and terrifying virus by creating remarkably effective vaccines and delivering billions of doses—all in a year’s time. However, in 2020 we experienced more than 500,000 excess deaths caused by delayed, deferred, or disrupted care for patients with non-COVID illness, and the National Cancer Institute (NCI) is predicting thousands of additional

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The following top 10 predictions suggest how U.S. health care will change over the next 10 years. Most medical history forms will include questions about COVID-19, as its longtail effects will still linger over all aspects of medicine.

deaths over the next decade caused by postponed or canceled checkups and cancer screenings in 2020.

Postponements of care during COVID-19 may be followed by delayed diagnoses of cancer and other major diseases.

The pandemic has also unearthed serious fault lines in American health care. Access to care, health equity, health literacy, and an epidemic of health misinformation have all been highlighted as life-and-death issues unresolved in this country.

Health care providers will become more consumer oriented in response to large non-legacy corporate entities playing a greater role in delivering care.

What Will Health Care Look Like in a Decade? As we look forward at TDC Group, we are discussing health care over the next decade while focusing on trends, challenges, key lessons, and emerging risks. We remain committed to serving those who provide care by delivering insights into the evolution of health care to help guide the actions of medical leaders making critical decisions. This examination, though certainly not exhaustive, lays out some of the most pressing issues medical professionals must address as we look ahead.

The cost of health care will continue to rise— and continue to be a critical issue—despite the increasing prevalence of value-based care models.

Advanced practice clinicians (APCs) will become the primary care providers for many Americans, reserving MDs and DOs for complex cases. Digital advances, including wearable technologies, will account for more than half of global health care investment. Most systems for electronic health care records (EHRs) will be interoperable, enabling data to move as a patient moves—without the Herculean lifts often currently required to make systems work together. Critical progress in data integration will bring about major improvements in health care. Health care providers will find it easier to treat patients across state lines via telehealth, which will become a routine part of health care in virtually every setting.

Physician burnout rates will decrease.

PREDICTION ONE: Most medical history forms will include questions about COVID-19, as its longtail effects will still linger over all aspects of medicine. The short-term effects of severe COVID19 cases have been discussed extensively, but now more researchers and clinicians are delving into long COVID and the insidious symptoms that linger after the infection has cleared. While this list includes symptoms that affect nearly every major organ system in th – just as the severity level of initial COVID-19 infections has varied. However, the severity of acute and longtail symptoms in a patient are not necessarily proportionate. Even previous mild COVID-19 cases that did not require hospital visits can result in symptoms surfacing a year later. Many have been treatable, but an increasing number of COVID-19 patients are experiencing dysautonomia, which affects the nervous and immune systems, leaving them more vulnerable to other recurring and chronic illnesses that can lead to longterm disability.

“Post-acute sequelae SARS-CoV-2 (PASC) is recognized as a disability under the Americans with Disabilities Act as of July 2021. While there are varying degrees of disability due to illness, the sheer number of possible cases in the general population means there will be a large impact both in the U.S. and around the world. The increase in health care costs, as well as the associated decrease in productivity by those afflicted, will likely escalate with increased incidence.” – Zijian Chen, MD, Medical Director of the Mount Sinai Center for Post-COVID Care

In studying COVID-19’s long-term effects, some neurology reports have indicated similarities in the brain chemistry of COVID-19 patients and Alzheimer’s patients.

Scientists are unsure yet if the link is definite, but the suggestion that COVID19 has changed body chemistry adds to a growing list of longtail symptoms that must be understood and addressed.

CASE STUDY (From email correspondence with Zijian Chen, MD, Medical Director of the Mount Sinai Center for PostCOVID Care, November 2021) A previously active and healthy physician in her mid-30s presents for the management of symptoms developed after her exposure and illness with COVID-19. During her acute illness three months ago, she had symptoms consisting of shortness of breath and fever. This waxed and waned, and slowly improved over the course of two weeks. After her acute illness, the physician resumed work, only to note that she is now having difficulty concentrating and completing tasks that she usually performs. Additionally, her ability to work through the day is now gone, replaced by the need to take frequent breaks during her work shift, as well as naps after her shifts. Finally, she also has a lingering sensation of food and drinks tasting not right, sometimes even foul. As she is seen by specialists within the Mount Sinai Center for Post-COVID Care in New York City, she is offered treatment regimens that show promise with similar patients. However, the improvement is frustratingly slow and she quickly becomes unable to participate in patient care at work. She eventually applies for an indefinite leave of absence from her duties. This physician and many other patients like her are suffering the same fate.

PREDICTION TWO: Postponements of care during COVID-19 may be followed by delayed diagnoses of cancer and other major diseases.

across medicine since the advent of the pandemic, but missed opportunities in cancer and cardiac care and detection are particularly troubling: An American Association for Cancer Research poll of women never diagnosed with cancer and women diagnosed with breast cancer found that approximately 30 percent of each group reported delays in screenings or active treatment. We are seeing the impacts now as oncologists are seeing more patients with advanced stages of disease than pre-pandemic. The scenario most likely to lead to litigation is one in which the patient is acutely aware of delays. In such cases, liability risks may exist even if care was available, but the patient was too worried about COVID-19 to come into the provider’s office. Providers who do not identify and prioritize patients with serious medical conditions, proactively contact them about coming in for screenings or checkups, and keep meticulous records are putting themselves at risk. Documenting efforts to reach these patients will reduce the likelihood of a malpractice claim. This brings us to one of the biggest unanswered questions that will loom as we look toward the future: Will there be a delayed surge in claims related to COVID-19 itself? We are not certain at this time. However, claims could arise from issues including: • Delayed or missed COVID-19 diagnoses. • Delayed immunization, care, and/or testing. • Failure to detect medical contraindications to the vaccines. • Failure to follow proper infection control procedures. Potential delayed diagnoses of new conditions or delayed treatment of existing conditions because of health care disruptions related to COVID-19.

Postponed care for conditions other than COVID-19 has been a problem


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“An estimated 15,000 COVID-related lawsuits have been filed nationally as of mid-2021. While the majority of these initial lawsuits were against long-term care facilities, it was thought the next targets would be providers and other facilities, including some hospitals. But here we are 18 months into the pandemic, and we have not seen that. The Doctors Company, with 80,000 members, has had 22 COVID-related claims as of October 31, 2021, and has not paid any indemnity. A physician is more likely to have a complaint made to a licensing board for a COVID-related incident than to have a medical malpractice claim. We may have many more actions reported to us that involve complaints to medical boards for COVID treatment that are opened as investigations to which our policy offers a defense” – Robert E. White Jr., Chief Operating Officer, The Doctors Company and TDC Group

Prediction Three: The cost of health care will continue to rise–and continue to be a critical issue–despite the increasing prevalence of value-based care models In 2019, the most recent year with 12-month statistics, health care costs comprised nearly 18 percent of U.S. gross domestic product (GDP). The Centers for Medicare and Medicaid Services (CMS) project that U.S. health care spending will grow 1.1 percent faster than the annual GDP, and by 2028 will reach $6.2 trillion—almost 20 percent of GDP. According to research sponsored by the Peter G. Peterson Foundation, Americans will not be rewarded with better health outcomes in exchange for the higher spend. Furthermore, these figures do not account for the impacts of the pandemic. Numerous factors contribute to the spending increases, but already-high

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administrative costs are a major factor. The swamp of usage and billing requirements from multiple payers through which providers must wade requires expensive administrative help. The ever-growing cost of prescription drugs and long-term care is another key factor, as well as an increasingly elderly population, high provider salaries, and defensive medicine. Tests and screenings are also much costlier in the U.S. than in other countries. Today, the consolidation of health care is being driven principally by economics, with two fundamental perspectives in conflict: Providers wish to protect revenue streams and market share, and payers seek to decrease health care costs and simplify access. The fee-for-service system is gradually being replaced by value-based care. In the value-based care model, providers are generally paid a global fee for each patient, supplemented by incentive payments based on the quality of care—not the quantity. One argument for a value-based model is that it will provide better care for individuals and chronically underserved communities, lowering health care costs by rewarding providers for efficiency and effectiveness. According to Cleveland Clinic, “With its core based on overall wellness and preventive treatments, value-based care improves health care outcomes and reduces costs.” Yet, while we attempt to implement new financing and delivery models to increase quality and reduce costs, we will need to account for growing demand for extraordinarily expensive specialty drugs. These medications are unaffordable without excellent health insurance, intensifying the fight for affordable health care as a social justice issue. Consequently, the overall percentage of health care funded by government is likely to continue to increase, though most care will continue to take place in the private sector.

Another factor in the continued increase in the cost of health care is the rising cost of malpractice litigation nationwide. From 2010 to 2019, the average of the top 100 jury awards for medical malpractice cases rose by nearly 50 percent. This disturbing trend foretells medical malpractice rate increases while adding to burgeoning health care costs. At The Doctors Company, we saw a 33 percent increase in the cost of the average claim from 2010 to 2019. Several factors will continue to drive severity higher. The consolidation of health care creates larger corporate defendants, almost always with very high policy limits, making attractive deep pockets in the eyes of sympathetic juries. Monetary desensitization is another driver. The public has become so accustomed to large numbers, from the national debt to professional athletes’ salaries, that paid indemnities in the hundreds of thousands of dollars may appear less impressive. Batch or cluster claims, lawsuits in which plaintiffs bring multiple claims against one defendant based on the same behavior, also play a role. Social media is a potent facilitator of these claims. One patient can post online about a bad outcome with a provider, which attracts others with similar experiences to join the batch claim. Unless jurors’ attitudes change, batch claims decrease, and caps on noneconomic damages are protected, outlier verdicts will continue to grow and become more common. Another driver of health care costs is fragmented care. Patients today often must navigate through disconnected appointments with multiple specialists, labs, and imaging facilities—each like its own island, with no bridge between them. Patients must make uncoordinated individual appointments at different times and places, then scramble

to get and/or share their test results— and then receive separate bills. This is not a sustainable situation for patients or providers. This lack of coordination puts patients into a complex obstacle course of time requirements, transportation needs, and administrative hassles. Clinicians, meanwhile, face additional liability risks if fragmented care leads to a delayed or incorrect diagnosis. All parties can benefit from the improved patient safety and provider job satisfaction, leading to reductions in professional liability, that will come from a path out of the maze.

“Fragmented care is akin to buying 30,000 individual car parts, assembling them yourself, and expecting to have a better, cheaper car than you can readily obtain from your dealer. That's pretty much how we've tried to purchase medical care in the U.S. for a long time. It has never made much sense and makes even less today.” – Richard E. Anderson, MD, FACP, Chairman and Chief Executive Officer, The Doctors Company and TDC Group

Coordinated care models reduce duplicative tests and use an integrated and accessible EHR. Problems are more likely to be addressed, and patient satisfaction increased, resulting in patients less inclined to sue those who are working as a team to help them get better.

“Integrated care makes a value-based payment mechanism more feasible. It's very hard to come up with a capitated model when medicine is atomized the way it has been. Better integration is required for a better health care system.” – Richard E. Anderson, MD, FACP, Chairman and Chief Executive Officer, The Doctors Company and TDC Group

Changes in care models are not limited to physician-directed medical care. The challenges faced by nursing homes over the course of the last two years have been overwhelming.

“Many hope that pressures on health care costs, along with the broader evolution of health care services and financing in the U.S., will drive in-home care and community-based options for elder care—developed on neighborhood-oriented models—as alternatives to heavy reliance on the current institutional model. This transition will require significant government investment and a substantial restructuring of the current reimbursement system over the next decade, but the proliferation of broader value-based care models will likely add to forces driving this change.” – Paul Romano, President, TDC Specialty Underwriters, Part of TDC Group

Prediction Four:

Health care providers will become more consumer oriented in response to large non-legacy corporate entities playing a greater role in delivering care. The trend of patient-centered care morphing into consumer-driven care will accelerate, but there will remain a distinction between medicine’s definition of “patient-centered care” and retail’s perspective on “customer service.”

“Amazon Care is really quite extraordinary. Amazon has a reputation for customer service that's really unmatched almost anywhere, but the particular matchup here is the medical profession's notion of patient-centered care versus Amazon's reputation for customer service. That's an uneven conflict, and we are going to have to do much better to meet the expectations of our patients for what medical services in the 21st century ought to be like.” – Richard E. Anderson, MD, FACP, Chairman and Chief Executive Officer, The Doctors Company and TDC Group

The corporate giants, from big tech to consumer retail, have moved aggressively into medicine with a focus on consumer convenience. Retail medicine is now an important part of primary care delivery in the U.S. and is poised to become even more so. Powerful partnerships between traditional integrated delivery systems and some of the large pharmacy chains make data from millions more people available to expand the database for retail medicine:

» WALGREENS With its VillageMD partnership, Walgreens is the first national pharmacy chain to offer full-service provider offices co-located at its stores on a large scale. Covering 30-plus markets, the goal is to open 500 to 700 physician-led primary care clinics in the next five years, with hundreds more to come. The service will include primary care telehealth and at-home visits around the clock, 365 days a year. Meanwhile, competitors Walmart and Sam’s Club are offering $40 health visits for primary and urgent care, and telehealth visits for only $1 per visit after a $135 per year subscription.

» CVS Capitalizing on the immense amount of patient data gained through its Aetna merger, CVS planned to have 1,500 HealthHUBs associated with its pharmacies by the end of 2021. These will play an important role in managing patients' chronic diseases between primary care visits. Unlike its MinuteClinics, the hubs will focus more on chronic disease management, with services including blood tests and sleep apnea assessment. CVS wants to focus on the 25 percent of health care spending for chronic conditions that is avoidable, and these hubs will allow the company more control over which drugs are prescribed


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while increasing the total number of prescriptions they fill. The idea of virtual visits, on-site pharmacists, primary care, doctors, and medical supplies all under one umbrella is raising the bar for consumer-focused care, and other providers and health care systems will need to adapt.

» AMAZON The online retail giant recently opened its online pharmacy and is preparing to acquire and manage provider networks. In other words, it's aggressively recruiting people who can manage a health care practice. Customers can now have their provider directly send their prescription for most medicines (though not high-risk drugs like opioids) to Amazon and have it delivered to their front door as easily as they can other products. The stock prices of Rite Aid, Walgreens, and CVS fell by as much as 16 percent the day of Amazon’s announcement, largely because these stores need their pharmacies to do well to bring shoppers inside. Smaller drugstores that lack Amazon’s purchasing power and/or deals with insurers will likely feel the greatest impact.

» APPLE HEALTH The more than 1.4 billion Apple Health apps cannot be deleted from our iPhones, iPads, and Apple Watches. This technology trio is an incredibly efficient mobile system for clinical use and is being widely adopted in health care facilities nationwide. The Apple Health app now allows consumers to download their EHR data from some of the major EHR companies, including Epic and Allscripts. More than 500 U.S. institutions participate in this program, including the Department of Veterans Affairs.

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Apple recently announced a new data-sharing feature for Apple Health Records that allows users to choose a participating organization and select health metrics to share with their doctor—from vitals to immunization histories to lab results. From there, the platform will periodically collect a snapshot of the user’s health information that doctors can open within a patient's EHR. The fall 2021 launch was supported by six EHR companies.

» MICROSOFT Microsoft is moving aggressively into health care with several partnerships, including one with the Mount Sinai Health System. Its key initiatives are to help health care move into the Microsoft Azure cloud and to thoughtfully apply AI to medical data. Data42, a partnership with Novartis, will mine 2 million patient-years of clinical data from hundreds of Novartis studies over the past 20 years to find previously unknown correlations between drugs and diseases. This data could lead to the design of new drugs for challenging conditions like Alzheimer’s, as well as innovative treatments for rare diseases for which there are currently no effective treatment options. It may also lead to greater collaboration between medical scientists and data scientists.

“Amazon Pharmacy is up and running and basically promises a 48-hour delivery of your pharmaceuticals at home with the kind of service that you've come to expect from Amazon. My guess is that the pricing will be somewhat better than average retail pricing. Walmart is the one company of a scale that can compete head-on with Amazon, and it's moving actively in health care. There now are 37 state licenses for Walmart health care. They're doing some things that

we can all applaud, including financing a private-label version of analog insulin, bringing down the high cost of insulin today.” – Richard E. Anderson, MD, FACP, Chairman and Chief Executive Officer, The Doctors Company and TDC Group

Prediction Five

Advanced practice clinicians will become the primary care providers for many Americans, reserving MDs and DOs for complex case. More and more care will be administered in outpatient settings, expanding the role of advanced practice clinicians (APCs). Encompassing nurse practitioners (NPs), nurse anesthetists, midwives, and physician assistants (PAs), APCs are becoming the frontline for patient care in both primary and specialty settings, as well as retail clinics. Consequently, they will continue to perform everything from pelvic exams and electrocardiograms to psychotherapy and trauma care—likely becoming the primary care providers for most healthy Americans. An examination of Medicare and Medicaid payments to health care providers shows these professionals represent an expanding presence in medicine. Through 2030, Conning strategic studies show that physicians, dentists, chiropractors, and podiatrists are each projected to grow at a compound annual growth rate (CAGR) of less than 1 percent, while the CAGR for NPs is forecasted at 6.8 percent, and a CAGR of 4.3 percent is forecasted for PAs. This will place them among the fasting growing of all professions, doubling over this decade. The rise of APCs is attributed in part to expanding doctor shortages and a growing number of patients gaining insurance through the Affordable Care Act.

Currently, APCs are either covered by the supervising physicians’ insurance policy or they have their own. In 2022, The Doctors Company will launch an insurance product specifically for APCs, as there is a growing trend for APCs to work independently. “APCs have been integral to health care delivery and will grow increasingly so as the demand for patient care increases. However, independent APCs will face higher stakes than their employed counterparts. They will have risks and exposures similar to physician practices. For some, such autonomy may require greater patient safety / risk management access and 24/7 resources in the early years as they build their practices. They will want the industry’s leading litigators, claims professionals, and proven defense strategies when their care is questioned." —Laura Kline, MBA, CPCU, Senior Vice President, Business Development, The Doctors Company and TDC Group The integration of APCs into health care systems can improve access to care, particularly for underserved populations. Research has shown that patient outcomes are similar to those achieved by physicians treating patients with similar maladies. In fact, one study has shown that utilizing advanced practice nursing in the emergency and critical care settings improves patient outcomes. Improved care access conveys a business benefit to practices as well as a health benefit to patients. In addition to increasing patient satisfaction and retention, improved access offers better care and less visit lag. As a lower-cost resource, APCs help meet the needs of chronic care patients in terms of patient education and lifestyle adjustments, reducing unnecessary emergency department (ED) visits and hospital admissions.

Most states already explicitly identify NPs as primary care providers (PCPs), but 10 states do not. PAs, on the other hand, are currently required to be supervised by physicians in all states. That said, as physician shortages grow more severe, we predict that PAs will graduate to a more independent scope of practice. An indication of this trend toward greater independence is the American Academy of Physician Associates—formerly American Academy of Physician Assistants—House of Delegates’ vote to change their profession’s title to physician associate—although recognition of their title change can only come by statute. Today, NPs and PAs practice along a continuum ranging from required supervision to complete independence. Over the next decade, we predict that physician shortages, combined with recognition of the competencies of APCs, will drive more widespread independence in practice for APCs.

Prediction Six:

Digital advances, including wearable technologies, will account for more than half of global health care investment. The highest-impact trend in health care over the next decade will be the further acceleration of the digitization of medicine. Far beyond just using telehealth as an in-person visit replacement, digital transformation will include hospital at home, health apps, remote monitoring devices, new medical-grade sensors, cloud computing, and data analytics. Digital initiatives were a key driver of the increase in global health care investment in 2021, with digital health startups comprising 40 percent of the deals and fundraising. This trend will accelerate over the next decade.

“Data analytics will significantly improve health outcomes, because with greater access to data, there will be more customized care. This will help cut the cost of health care and the cost of insurance.” – Robert A. Kauffman, President, Health care Risk Advisors, Part of TDC Group

Increasingly, health metrics like blood pressure, cardiac rhythm, glucose, weight, and more will be monitored remotely via wearable devices that can be plugged into a smartphone and connected through Wi-Fi and Bluetooth. For instance, the future of remote patient monitoring is here when it comes to patients with diabetes. At UCSF Medical Center in San Francisco, CA, hospitalized patients with diabetes are being monitored remotely through a virtual glucose management service (vGMS) developed by the medical center. And at UCHealth’s Virtual Health Center, outpatients’ glucose levels are being monitored remotely.

“The vGMS and similar inpatient-services leveraging technology may also become economically important for cost savings, as medicine moves toward bundled care.” – Robert Rushakoff, MD, MS, Professor of Medicine at UCSF and Medical Director for Inpatient Diabetes at UCSF Medical Center

Beyond COVID-19, increased demand for digital wellness stems from health care cost inflation, improved research and development, a rapidly aging global population, and improved integration with the Internet of Things (IoT). These wearables can either transmit information to health providers or allow patients to self-monitor wellness measures through personal electronic devices.


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The technology goes far beyond smartwatches and consumer-grade IoT; it involves devices woven into clothing, sensors placed on specific areas of the body to communicate with an overall body area network (BAN) system (such as devices placed in the inner ear to monitor heart rate). There are even implantable devices that can automatically track blood sugar and other levels, so that a patient need not be actively involved in monitoring. Researchers studying teenagers with type 1 diabetes found that interventions combining software and devices for tracking fluctuating glucose levels led to improvements, both in the number of patients in range of target glucose levels and in patients’ quality of life. Meanwhile, Google has launched its first medical device, Derm Assist, a smartphone app that helps dermatologists diagnose skin conditions without having to see the patient in person. These technologies can save providers valuable time and improve access to care by allowing clinicians to reach patients who live far from a hospital or clinic. They can also empower patients to better understand their own health. Likewise, patients with asthma, for instance, equipped with certain accessible home health technologies, are better able to advocate for themselves and have more meaningful conversations with their providers about how their own data connects to their health goals. For all their benefits, however, wearables do generate risks for patients and physicians alike. These include poor data quality, as some consumer wearables may not be sufficiently reliable for medical use, security and privacy risks, and the threat of data overload if important data signals are lost in a sea of noise. Moreover, digital health tools, which have the power to increase access to care, paradoxically have the power

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to increase disparities. Creators of solutions can mitigate these risks by accounting for health equity requirements during the design phase, rather than as an afterthought.

Prediction Eight:

Prediction Seven:

Data integration will grant patients access to their complete longitudinal health records on their phones and will drive the tech giants to use machine learning and artificial intelligence (AI) to create accurate, human-readable summaries.

Most systems for electronic healthcare records (EHRs) will be interoperable, enabling data to move as a patient move – without the Herculean lifts often currently required to make systems work together. The maturation and integration of EHRs will accelerate remote care, making it a reality for millions. As interoperability continues to advance, EHRs will help some of the large, nationwide systems move beyond ex post facto data mining and start building real-time analytics into EHRs. Health plans will continue to consolidate or “associate” with other plans and will expand relationships with front-line care providers including urgent care centers and health systems, crossing into the direct provision of care. Others will consolidate or merge with technology companies to aggregate and parse massive amounts of data to drive utilization decisions, benefitting device design.

“Interoperability has been a goal since the digitization of health records began, and by 2023, EHRs must meet a higher standard of interoperability under the Cures Act than many are prepared to meet. Some EHRs are not currently compatible with the digital ecosystem, so meeting the 2023 standard is not only a matter of health care providers and staff members learning to use new EHR technologies—it’s a matter of EHR vendors innovating to alter their technology itself. In any event, the 2023 deadline will be a forcing function in this effort to evolve and integrate EHRs.” – Chad Anguilm, MBA, Vice President, In-Practice Technology Services, Medical Advantage, Part of TDC Group

Critical progress in data integration will bring about major improvements in health care.

“The potential for AI in medicine is immense, as it benefits the relationships between doctors and patients while unlocking incredible amounts of valuable data. When we see patients, instead of typing at a keyboard and looking at a screen, natural language processing can take a synthetic note that's far better than any notes we have today. [The technology] also introduces the ability to review all of a patient's data at every level. Not just their electronic record but the wearable sensors that they're using, all their biologic layers, their environment sensor data— [AI applications can bring us to a point at which all this] is being continuously assessed with the entire corpus of medical literature relevant to that patient.” – Eric Topol, MD, Founder and Director of the Scripps Research Translational Institute, Professor, Molecular Medicine, and Executive Vice President of Scripps Research

The evolution of digital health care demands improvements in the management of data, but it seems as if no entity is currently in a position—or willing—to properly integrate it. Consequently, patient health summaries are often incomplete or otherwise inaccurate because of the lack of coordination among providers, health systems, health devices, EHRs, pharmacies, health plans, etc. With the current system too fragmented to get EHRs to talk to each other, coordinating all the

operational and institutional elements with the financing necessary to integrate data is still in the future. Machine learning and AI are already contributing to numerous advances across health care, and AI’s use as a tool will continue to be critical to data integration. Applications in radiology are already helping clinicians in busy hospital settings prioritize their interpretation of critical findings, leading to a faster review of cases for patients with more significant risks for adverse outcomes. During the hospital overcrowding in 2020 in New York, the Mount Sinai Health System used an algorithm to help identify patients ready for discharge.

“Our AI model was developed by an internal team and identifies patients most likely to be discharged in the next 48 hours. Such advances in health care allow hospitals to remove barriers to discharge in advance, so when a patient is medically ready, nothing is delaying the transition to the next care setting. Mount Sinai will continue to innovate with AI over the next decade to improve the delivery of health care.” – Robbie Freeman, RN, MSN, Vice President of Clinical Innovation and Chief Nursing Informatics Officer at the Mount Sinai Health System

Such systems can assist overburdened hospitals in managing personnel and supply flow to mitigate effects on quality patient care, even in a crisis. The use of AI can also help in rapidly spotting new virus outbreaks: The platform BlueDot, for instance, identified a cluster of pneumonia cases in Wuhan, China, before the World Health Organization (WHO) issued its first warning about COVID-19. Most sophisticated medical AI applications rely on machine learning that uses historical patient data to recognize

patterns. AI is only as good as its input data, and for many experts, concerning unknowns remain—including the potential for worsening risks to patients from pre-existing bias, plus liability risks for providers: How do physicians know that the data sets guiding their AI-assisted interventions are cohesive and complete?

“You have to ask: What was the data set in which the algorithm trained? Was the data set appropriate? If you're looking at an unrepresentative cross-section of the population, you may get an algorithm that's blind to racial differences or blind to socioeconomic differences, or blind to other things.” – Richard E. Anderson, MD, FACP, Chairman and Chief Executive Officer, The Doctors Company and TDC Group

What happens when a patient alleges that an error occurred because the AI was faulty?

“If AI suggests a path that's different than the standard of care, and it turns out to be right, that's great for the patient, and there's no liability. But if it turns out to be wrong: Who's liable for that? Is it the algorithm? The developer of the algorithm? The doctor who deviated from the recognized standard of care in order to follow the black box? And how do you sue a black box? All of these things remain to be to be worked out.” – Richard E. Anderson, MD, FACP, Chairman and Chief Executive Officer, The Doctors Company and TDC Group

In a clinical environment of ever-increasing digital interactions, how will doctors acquire the knowledge traditionally gained by discussing patient cases and data with peers?

“Digitized medical data has the potential to flow freely and to be readily accessible wherever and whenever it is needed. On the other hand, it means clinicians may have fewer direct interactions with each other,

reducing opportunities to collaborate, share insights, and confer on complicated cases. We see this already in the era of digital radiology, where it has become unusual for clinicians to visit the radiologist for personal review and discussion of the day’s x-rays.” – Richard E. Anderson, MD, FACP, Chairman and Chief Executive Officer, The Doctors Company and TDC Group

Prediction Nine: Health care providers will find it easier to treat patients across state lines via telehealth, which will become a routine part of health care in virtually every setting. Telehealth was already a vital part of the health care landscape, but the pandemic has rapidly accelerated adoption. Digital transformation initiatives share common goals of increasing access to care and improving the patient experience. Currently, three-quarters of health care organizations are investing in telehealth.

“Digital medicine represents a fundamental shift for health care. In the same way that digital payment platforms and online banking apps transformed financial services —we now only go to a physical bank for complex transactions—the revolution of telehealth and digital health care will drive this change in medicine. In 10 years, medical practices will serve as a control center—monitoring, coordinating, and delivering care through technology. A patient coming into a practice will be the exception rather than the rule. Consumers will view their phone as the center of their care. In-person care will be for emergencies and serious illnesses.” – Paul MacLellan, President, Medical Advantage, Part of TDC Group


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During the pandemic, virtually every state passed legislation (some temporary) to remove licensing obstacles. In addition, 35 states have adopted the Interstate Medical Licensure Compact Commission (IMLCC), which streamlines the process for physicians to practice across state lines. Opening care across state lines will continue to be accomplished by state action with federal support and, perhaps, the adoption of the Uniform Law Commission’s Model Telehealth Act. This would create a national telehealth provider registry to allow health care providers with a clean disciplinary record to offer limited telehealth-only services across state lines. To date, members of The Doctors Company have been involved in very few malpractice claims related to telehealth. However, claims involving mental health—an area in which telehealth is heavily used—have seen a slight uptick recently. As telehealth becomes even more common across the board, more claims related to remote treatment modalities may emerge.

“While medical malpractice claims involving telemedicine have been minimal in the past, these claims are likely to increase as telehealth—which includes telemedicine, remote monitoring, asynchronous data collection, and a variety of other incorporations of technology into nonclinical patient and professional health–related areas—continues to gain popularity.” – David L. Feldman, MD, MBA, FACS, Chief Medical Officer for The Doctors Company and TDC Group

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Prediction Ten:

Physician burnout rates will decrease. “The occupational health definition of burnout is what occurs when the job demands exceed the resources. Of course, since the onset of the pandemic, the issue of physician burnout has been raised repeatedly: Factors like excessive workload, unmanageable schedules, inadequate staffing, and administrative burden. There are also external system factors like inadequate technology support, time pressure, and moral distress, but health care is a human factors engineering problem. So how do we get people to come to work with the best of themselves? Some of it is about obvious things like allowing work/life balance and support for childcare, but it’s also a lot about how we treat each other and how we think about the flexibility of the roles within the workforce that might really help people.” – Christine Cassel, MD, Professor of Medicine, University of California, San Francisco

The high rate of burnout among frontline clinicians dealing with COVID-19, amplifying the high rate of clinician burnout that already existed before the pandemic, could be a key factor impacting health care outcomes in the near future. A recent study showed that U.S. health providers have the highest rate of burnout among the 60 countries studied. A survey of more than 15,000 U.S. physicians representing 29 specialties shows that more than 40 percent report signs of burnout, with higher rates for female providers and those in certain specialties.

Integrated systems can be better for providers, as well as patients, because they address the epidemic of physician burnout. One study found that providers in fully integrated care settings report higher levels of personal accomplishment and lower levels of depersonalization compared to providers in minimal-collaboration settings. Help is on the way, as the expanded roles of APCs, combined with increased interest in the medical profession, will provide a much-needed staffing boost, allowing physicians more time with seriously ill patients. Nursing schools recently reported rises of up to 25 percent in applications, a trend known as the “Fauci effect” as students are inspired by such people as Anthony Fauci, MD, Director of the National Institute of Allergy and Infectious Diseases. According to the Association of American Medical Colleges, the supply of advanced practice registered nurses (nurses with postgraduate education and training in nursing, also known as APRNs) and PAs is predicted to more than double over the next 15 years. Ideally, this change will enable physician specialists to focus their efforts where they are most needed.


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