ADVOCATING for HEALTH SERVICES RESEARCH and AHRQ Thomas Kingsley, MD, MPH

VOL. 41 n NUMBER 10 n OCTOBER 18

HEALTH POLICY ADVOCATING FOR HEALTH SERVICES RESEARCH AND AHRQ Thomas Kingsley, MD, MPH

Dr. Kingsley ([email protected]) is a senior associate consultant and instructor of medicine at Mayo Clinic.

n 2000, the Institute of Medicine (IOM) released system. The Agency for Healthcare Research and Quality “To Err Is Human,” a report that awoke the medical (AHRQ) funds a large portion of the health services re- Icommunity and the public to a startling reality: health search in the United States. The importance of the agen- care too often harms. Eighteen years after this land- cy’s work is evident. Since 2010 AHRQ-funded research is mark report, there has been evidence of improvement, estimated to have decreased hospital acquired conditions but one troubling reality remains—we still harm too by 21%, prevented 3 million adverse events, and saved many patients. This fact is unavoidable. Medical errors 125,000 lives.3 continue to be one of the leading causes of death in the AHRQ has also created the Consumer Assessment of United States. A Johns Hopkins study found that medical Healthcare Providers and Systems (CAHPS) surveys, the errors killed 250,000 people in 2013, making it the third Healthcare Cost and Utilization Project (HCUP) databas- leading cause of death behind heart disease and cancer.1 es, and the Medical Expenditure Panel Survey (MEPS). Although the study’s methods may have led to overesti- These publicly available datasets have been invaluable to mates of the number of deaths caused by medical errors, our understanding of patients’ experiences with care and the estimates are nevertheless alarming. Another startling the delivery and costs of care in the United States and the example of health care’s harm is the opioid epidemic. For effects of various health policies on care and outcomes. decades, physicians uninhibitedly prescribed opioids to Primary care research, often underfunded compared their patients with pain. Not too long ago, I was sitting with research focused on specialty care, has been another in a medical school lecture given by a renowned professor beneficiary of AHRQ. For example, EvidenceNow is a who explained to a group of attentive medical students $112-million-dollar project to fund 1,500 primary care that opioids were “not that addictive” and “pain should clinics to implement cardiovascular evidence-based care never go untreated.” Unfortunately, this professor as well and study how this impacts outcomes.4 as most of the medical community got this wrong. Today, It may come as a surprise then that AHRQ’s future towns throughout the United States are being crippled by has been precarious. Proposals for eliminating AHRQ the opioid crisis that kills more than 100 lives every day.2 have been brought forth in Congress several times in the Thus, we arrive at the following question asked after recent past. None have succeeded, yet. In February 2018, “To Err Is Human” was published—how do we improve the President’s FY19 budget proposal was released to our healthcare system so that it does not harm those it in- Congress, and it recommended a major funding cut to tends to heal? An answer to this question will take further AHRQ from $322 million to $256 million, an approxi- investment in health services research; researching how mately 20% decrease from FY18 (see figure on page 13).5 we deliver care, its quality and safety, and evaluating the Beyond the expected budget cuts, the President’s proposal impact of newly implemented value-based methods. also recommended moving AHRQ from a free-standing To the public, health services research is an obscure agency in the Department of Health and Human Services term, but to many clinicians, researchers, and policy (HHS) to a component of the National Institutes of makers, it is an essential part of improving our healthcare continued on page 13

1 CONTENTS FROM THE EDITOR 1. Health Policy...... 1 2. From the Editor...... 2 TALK AMONGST 3. President’s Column...... 3 4. Best Practices...... 4 YOURSELVES Joseph Conigliaro, MD, MPH, Editor in Chief, SGIM Forum 5. Technology...... 6 6. Perspective: Point/Counterpoint Part I...... 8 7. Perspective: Point/Counterpoint Part II...... 10 s I write this month’s Forum editorial, the details and unfortunate controversy surrounding Senator AJohn McCain’s memorial service, and his lega- cy, are just two days old. When I heard of his passing, I SOCIETY OF GENERAL INTERNAL MEDICINE was reminded of his “nay” vote rejecting a scaled-down OFFICERS Republican plan to repeal parts of the Affordable Care President Act, after returning to the Senate following a recent diag- Giselle Corbie-Smith, MD, MSC | Chapel Hill, NC [email protected] nosis of brain cancer.1 Certainly, it was only one of many Immediate Past-President Thomas H. Gallagher, MD | Seattle, WA votes and actions in his remarkable life and career but the [email protected] one that I, as a general internist, will always remember. President-Elect Karen B. DeSalvo, MD, MPH, MSc | Austin, TX The struggle to provide a workable plan that provides [email protected] every American with affordable healthcare has been long Treasurer Mark D. Schwartz, MD | New York, NY with a profound gap among policy makers and stakehold- [email protected] ers as to how it should be accomplished. Secretary Somnath Saha, MD, MPH | Portland, OR This month’s Forum highlights a related debate that [email protected] many of us have joined in in our work institutions, our Secretary-Elect Mitchell D. Feldman, MD, MPhil | San Francisco, CA homes, and, for some of us, in the public arena—the [email protected] United States adopting a single payer system and whether COUNCIL April S. Fitzgerald, MD | Baltimore, MD or not SGIM should advocate for it. Drs. Mark Earnest [email protected] and Daniel McCormick each respectively make cogent Maria G. Frank, MD | Denver, CO [email protected] and compelling arguments reflecting their points of view Reena Karani, MD, MHPE | New York, NY [email protected] and of those they represent. To be sure, there are many in Eboni G. Price-Haywood, MD, MPH | New Orleans, LA the organization who would love to see the Society take [email protected] Luci K. Leykum, MD, MBA, MSc | San Antonio, TX a definitive stand on this, one way or another. Many in [email protected] the Society also stress caution, arguing that the Society Monica E. Peek, MD, MPH, MSc, FACP | Chicago, IL [email protected] should continue to take a broader view in this debate and EX OFFICIO COUNCIL MEMBERS focus our efforts in incremental ways in the discussion of Chair of the Board of Regional Leaders how best to improve the health, and health care of our Shelly-Ann Fluker, MD, MPH | Atlanta, GA [email protected] nation such that it is of the highest quality, and of the ACLGIM President greatest value yet fairly and and equitably distributed. Carlos Estrada, MD, MS | Birmingham, AL [email protected] The debate can be made on moral grounds, economic Associate Member Representative outlooks, or societal beneficence. Read the articles and Madeline R. Sterling, MD, MPH | New York, NY [email protected] make your own conclusion. I welcome reader comments Co-Editors, Journal of General Internal Medicine in upcoming issues to keep the discourse going. Steven M. Asch, MD, MPH | Palo Alto, CA [email protected] Further in this issue, Dr. Giselle Corbie-Smith, in her Carol Bates, MD | Boston, MA [email protected] President’s Column, continues the conversation around Jeffrey L. Jackson, MD, MPH | Milwaukee, WI SGIM’s sabbatical year. The word sabbatical literally [email protected] means a rest from work, or a break. Many of us in aca- Editor, SGIM Forum Joseph Conigliaro, MD, MPH | Hempstead, NY demic medicine know it as any extended absence in your [email protected] career whereby you achieve something. Dr. Corbie-Smith Chief Executive Officer Eric B. Bass, MD, MPH | Alexandria, VA explains the rationale and the process of our sabbatical [email protected] year to ensure that SGIM’s organizational structure and Deputy Chief Executive Officer Kay Ovington, MD, MPH | Alexandria, VA focus align with our mission, vision, and values. The [email protected] Health Policy Consultant long-term effects from this sabbatical year will enable Lyle Dennis | Washington, DC SGIM to play a role in the health care debate by support- [email protected] Director of Communications and Publications ing member development, informing the membership and Francine Jetton, MA | Alexandria, VA continued advocacy. [email protected] continued on page 15

2 PRESIDENT’S COLUMN STARTING WITH “WHY?” Giselle Corbie-Smith, MD, MSC, President, SGIM

Our current political and social landscape is changing quickly and unpredictably, and SGIM needs to focus our activities to address issues at the forefront of our field in the coming years. We want to respond. . . but we do not have the organizational bandwidth to do so. This is why Council and staff are engaged in an indepth strategic planning effort. . . .

ome of you may be familiar with been stretched too thin and have had many “WHATs” Simon Sinek. His 2009 TED talk that were not integrated into an organizational strategic S(available on YouTube) focused on plan. Our current political and social landscape is chang- helping individuals find their why—their ing quickly and unpredictably, and SGIM needs to focus purpose, cause, or set of beliefs that our activities to be in a better position to address issues inspire them to do what they do. Sinek at the forefront of our field in the coming years. We want introduced a model of three concentric to be able to respond to these types of cutting-edge issues circles with WHY at the center, HOW that define who we are as an organization and profession, in the middle circle, and WHAT in the outer circle.1, 2 but we do not have the organizational bandwidth to do so. He calls this the Golden Circle and has since applied This is why Council and staff are engaged in an indepth the same model to organizations. The work our SGIM strategic planning effort in this, our “sabbatical year.” Council and staff are doing during our “sabbatical year” Coming out of the June Council retreat, our commit- focus very much on our why, how, and what. ment as a Council for the coming year is to ensure that In my first Forum column as your president, I spoke SGIM’s organizational structure and focus align with of the need for us to have a clear vision as an organiza- our mission, vision, and values. We took the findings and tion—SGIM’s WHY. Having a well-defined focus will recommendations from the Pyramid audit of our society’s allow us to concentrate our efforts on initiatives we are communications quite seriously—the issues raised in the uniquely positioned to lead successfully and enable us to report were sobering and required what may seem to be respond to the important challenges that face us as a pro- drastic action.3 fession. SGIM’s reality is that as an organization we have continued on page 12

SGIM Forum

Editor In Chief Managing Editor Joseph Conigliaro, MD, MPH, FACP Frank Darmstadt [email protected] [email protected]

Editorial Board Maria Gaby Frank, MD Somnath Mookherjee, MD Irene Alexandraki, MD, MPH [email protected] [email protected] [email protected] Kittu Garg, MD Avital O’Glasser, MD Yousaf Ali, MD, MS [email protected] [email protected] [email protected] Shanu Gupta, MD Tanu Pandey, MD, MPH Seki Balogun, MD, MBBS, FACP [email protected] [email protected] [email protected] Patricia Harris, MD, MPH Shobha Rao, MD Alfred P. Burger, MD [email protected] [email protected] [email protected] Jeffrey Jaeger, MD Jorge Rodriguez, MD Amanda Clark, MD [email protected] [email protected] [email protected] Francine Jetton, MA Justin J. Roesch, MD Ricardo Correa, MD [email protected] [email protected] [email protected] Tiffany Leung, MD Gaetan Sgro, MD Utibe Essien, MD [email protected] [email protected] [email protected] Megan McNamara, MD, MS Elisa Sottile, MD Michele Fang, MD [email protected] [email protected] [email protected]

The SGIM Forum, the official newsletter of the Society of General Internal Medicine, is a monthly publication that offers articles, essays, thought-pieces, and editorials that reflect on healthcare trends, report on Society activities, and air important issues in general internal medicine and the healthcare system at large. The mission of the Forum is to inspire, inform, and connect—both SGIM members and those interested in general internal medicine (clinical care, medical education, research, and health policy). Unless specifically noted, the views expressed in the Forum do not represent the official position of SGIM. Articles are selected or solicited based on topical interest, clarity of writing, and potential to engage the readership. The Editorial staff welcomes suggestions from the readership. Readers may contact the Editor, Managing Editor, or Associate Editors with comments, ideas, controversies, or potential articles. This news magazine is published by Springer. The SGIM Forum template was created by Howard Petlack.

3 BEST PRACTICES ACUTE PAIN AND SYMPTOM MANAGEMENT FOR HOSPITALIZED PATIENTS WITH OPIOID-USE DISORDER Annie Massart, MD; Theresa E. Vettese, MD; Julie Hollberg, MD

Dr. Massart ([email protected]) is assistant professor of medicine at Emory University Division of Hospital Medicine. Dr. Vettese ([email protected]) is associate professor of medicine at Emory University Division of General Medicine and Geriatrics. Dr. Hollberg ([email protected]) is associate professor of medicine at Emory University Division of Hospital Medicine.

Case Presentation no increased risk of relapse.3 Instead, multiple studies 48-year-old woman with a history of intrave- have shown that these patients are usually undertreated4 nous heroin use presents with fevers and wors- and are more likely to have poor outcomes when their A ening lower back pain for two weeks. She has acute pain is not well managed.2 had chronic neck pain for seven years stemming from a There also seems to be a poor understanding of how motor vehicle accident. Her chronic pain was managed opioid dependent patients experience pain. Although with opioid pain medication for five years through a pain studies have shown that these patients have less toler- management clinic. Two years ago, she lost her insurance ance for pain than opioid-naive patients, a minority of and turned to intravenous heroin. She usually uses five physicians know that to be true.4 This leads to missed “bags” per day but increased to seven “bags” per day for opportunities to manage pain. With precise calculations the last two weeks because of increasing pain. and careful monitoring of symptoms, opioid-depen- On examination, she is extremely uncomfortable but dent patients can have acute pain safely and effectively neurologically intact. A spine MRI reveals osteomyelitis addressed in the hospital. Table 1 outlines an effective of the L4 vertebra. Blood cultures are positive with 2/2 approach to opioid analgesia for this patient with hero- bottles growing gram positive cocci. She was initiated on in-use disorder who is experiencing severe, acute pain. morphine 2 mg IV q4h prn severe pain which she reports is not relieving her pain. Opioid Withdrawal Opioid withdrawal may occur in hospitalized, opioid-de- Management of Acute Pain pendent patients who are not receiving adequate opioid The opioid epidemic continues to expand in the United therapy. Common symptoms include: diffuse pain, States, with increasing numbers of deaths related to abdominal cramps, nausea, vomiting, diarrhea, yawning, opioid use. While the number of prescriptions for opi- rhinorrhea, lacrimation, with elevations in heart rate oid pain medication has decreased since 2012, opioid and blood pressure seen in more severe cases. There are overdose deaths due to heroin and synthetic opioids have scoring systems available to help further categorize the continued to increase, as have hospital admissions due severity of withdrawal and guide treatment.2 The timing to opioid-use related complications.1 Opioid-dependent of the onset of symptoms depends upon the opioid used. patients admitted to the hospital with acute pain have Acute withdrawal from short-acting opioids begins after complex pharmacologic needs and require a systemat- 8-12 hours, peaks at 36-72 hours, and lasts 7-10 days ic approach to analgesia. Managing their acute pain is while acute withdrawal from long-acting opioids begins often complicated because of their opioid dependence. at 36-72 hours, peaks at 4-6 days, and lasts 14-21 days.2 Long-term opioid use changes the neurobiology of pain Opioid withdrawal is best managed through the sensation, creating tolerance to opioids.2 These patients administration of opioids in conjunction with symp- have a lower pain tolerance than opioid-naïve patients tom-directed therapy. In general, symptom-directed and often require higher doses of opioids for analgesia.2 treatment without opioids is not as effective5 and should Physicians may be hindered by biases when caring be avoided if possible. For acute opioid withdrawal, you for patients on long-term opioid therapy or with a histo- may start methadone or buprenorphine as part of an ry of opioid-use disorder. Physicians have reported anx- inpatient detoxification versus initiation with linkage to iety about being manipulated by patients to get opioids an outpatient clinic at discharge. When deciding which that are not medically indicated.2 Physicians have also to start, considerations include cost, access to follow up expressed worry that using opioids may induce a relapse care (methadone clinic versus any physician with bu- of addiction.3 There is no data to suggest that this is prenorphine training certification), risk for medication true. Several small studies have looked at this and found continued on page 5

4 BEST PRACTICES (continued from page 4)

Table 1. Acute Pain Management in Heroin-use Disorder drugoverdose/pdf/pubs/2017- 100 mg IV heroin = 15-30 mg IV morphine cdc-drug-surveillance-report. 15 mg IV morphine = 45 mg PO morphine pdf. Published August 31, 2017. Ms. Smith has been using ~700 mg IV heroin daily for the last 10 days without Accessed September 1, 2018. adequate analgesia = 105 mg IV morphine 2. Donroe JH, Holt SR, Tetrault Oral SR opioid for basal with IV or oral short acting JM. Caring for patients with opioid for breakthrough opioid use disorder in the 1. Calculate baseline opioid use in oral morphine equivalents hospital. CMAJ. 2016 Dec (OME) 6;188(17-18):1232-1239. 100 mg IV morphine/24 hours = 300 mg oral morphine/24 hours 3. Kantor TG, Cantor R, Tom E. 2. Reduce dose by ~25-50% to account for incomplete cross tolerance A study of hospitalized surgical Oral morphine 150 mg/24 hours patients on methadone mainte- nance. Drug Alcohol Depend. 3. Convert reduced dose to long acting agent for baseline pain control 1980;6(3):163-173. Morphine SR 45 mg q 8 hour or morphine SR 75 mg q 12 hours 4. Bounes V, Jouanjus E, Roussin 4. Use short acting IV opioid agonist or start opioid PCA for rapid titration to A, et al. Acute pain management address acute pain for patients under opioid main- Morphine 5-7.5 mg IV q 3 hours PRN breakthrough tenance treatment: what physi- • Emphasize non-opioid and non-drug treatments cians do in emergency depart- ments? Eur J Emerg Med. 2014 • Convert to oral opioids asap Feb:21(1):73-76. • Opioids will be tapered as acute pain improves 5. Gowing L, Ali R, Mbewe D. • The goal is to effectively treat acute pain, improve function and prevent with- Buprenorphine for managing drawal symptoms opioid withdrawal (review). • Discharge plan: Cochrane Database of Syst Rev. • Refer for MAT or initiate in hospital if able 2017 Feb 21;2:CD002025. doi: Harm-reduction strategies 10.1002/14651858.CD002025. pub5. SGIM interactions, patient preference, and References whether the patient has a pre-exist- 1. Centers for Disease Control and ing prolonged QTc (which would be Prevention. Annual Surveillance increased by methadone). Table 2 Report of Drug-Related Risks outlines recommended dosages and and Outcomes—United States, schedules for both medications. 2017. https://www.cdc.gov/

Table 2. Buprenorphine and Methadone Tapering Protocols2 Buprenorphine Detoxification Buprenorphine/naloxone 2/0.5 mg SL film or tab: • QID x 2 days • then TID x 2 days • then BID x 2 days • then daily x 2 days then stop Buprenorphine Induction (with planned linkage to outpatient clinic) Buprenorphine/naloxone 8/2mg SL film or tab: • Day 1: 1/2 film or tab; reassess 1-2 hours - ? film or tab; repeat until cravings and withdrawal resolve; max dose day 1=8 mg • Day 2: Day one dose + ? film or tab; reassess 1-2 hours; max dose 16 mg * if nauseated only or over sedated, the dose is too high Methadone • DAY 1: Methadone 10 -30 mg; reassess in 2 hours; if patient still having distress- ing withdrawal symptoms provide a one-time additional dose of 5-10 mg (maxi- mum dose = 40 mg) • Taper by 5-10 mg daily over 10-14 days * check ECG at baseline; avoid in patients with QTc Prolongation

5 TECHNOLOGY CLINICAL UPDATE IN CLINICAL INFORMATICS—PART II Tiffany I. Leung, MD, MPH, FACP, Jorge Rodriguez, MD, Stephen Morgan, MD, FAAP

Dr. Leung ([email protected]) is an assistant professor at the Faculty of Health, Medicine and Life Sciences at Maastricht University in The Netherlands. Dr. Rodriguez ([email protected]) is medical director of clinical informatics, Lawrence General Hospital. Dr. Morgan ([email protected]) is chief information officer at Pediatric Associates of Greater Salem and instructor of medicine at Harvard Medical School.

n the August 2018 SGIM Forum, we coauthored ics experts to outline “goals and near-term achievable the first of a series on Clinical Informatics, inspired actions...to enable the health IT ecosystem to meet the Iby a live Clinical Update session at this year’s 2018 acute needs of modern health care delivery.” SGIM Annual Meeting. In brief, each article in this series Adler-Milstein et al. describe the needs of the health summarizes key papers in clinical informatics for gener- IT ecosystem from the perspective of multiple stakehold- alists published within approximately the last year. The ers: patients, physicians, researchers, and innovators. For complete methods for journal and article selection are example, the authors go beyond identifying gaps in the described in the August 2018 article.1 patient experience, such as having online scheduling ca- In the previous article, “Clinical Update in Clinical pabilities, electronically transmitting personal health re- Informatics—Part I,” we summarized publications in cords, or collecting health data (patient-generated health the year prior the annual meeting that were relevant to a data, or PGHD); to enable these types of functionalities, currently popular topic: desktop medicine. In this article, the authors suggest policy updates, such as clarifying we focus on policy recommendations for electronic health HIPAA requirements to ease patient access to their health records and health information technology. In the dis- records or to their PGHD from wearables and apps. In cussion, we highlight real examples of high-level policy the vignette, supportive IT infrastructure, incentivized by changes that impact the health data ecosystem. appropriate policy, would facilitate Mr. Shah’s access to his health records and their transmission electronically to Case Vignette his new physician; further, he could easily track his own Mr. Shah is a 55-year-old male, with essential hyperten- biometric data and provide medication and health status sion on lisinopril, who moves to Denver, and is experienc- updates electronically to his new physician. ing shortness of breath a few times in the past week. He This paper is aligned with but broader in scope selects a new primary care physician and schedules an ap- than a position paper that the AMIA EHR Task Force pointment. He does not have his medical records from his published in 2015 describing the current state of EHRs last physician. He receives a letter in the mail welcoming and making five high-level recommendations about the him to the new practice, containing information about future of EHRs.3 Many of those recommendations, such his new doctor and the practice group. Enclosed also is a as those pertaining to a call for simplifying documenta- paper form that has questions about his medical history. tion, refocusing regulation of EHRs, ensuring that EHRs He is to complete this and bring it to his upcoming visit. support patient-centered care, and other recommendations, have also been reframed in the 2017 paper partly Policy Recommendations as issues concerning physicians2 and discussed in other The vignette describes a common clinical scenario in other organizations’ position papers.4 Concerning re- which a patient and physician express several information searchers and innovators as stakeholders, Adler-Milstein needs towards a common task of having an in-person of- et al. recommend the development of a policy framework fice visit to establish primary care. This vignette is loosely that assures that appropriate data is used for appropriate based on one presented in a key paper published by reasons, with appropriate patient consent and agreed Adler-Milstein et al. in April 20172 that presents high-lev- upon terms. el policy recommendations as a potential roadmap for Finally, an editorial by Labkoff and Sittig in June health information technology (IT) and electronic health 2017 focuses on needed safety surveillance of EHRs record (EHR) policymaking. The paper is the result of a and clinical decision support (CDS) knowledge sourc- policy invitational of the American Medical Informatics es by proposing the concept of a Health Information Association (AMIA), which assembled clinical informat- continued on page 7

6 TECHNOLOGY (continued from page 6)

Technology Safety Center.5 That is, and apply best evidence in the provi- Acknowledgement they comment that with the rapid sion of high-value, patient-centered The authors thank Michel and widespread usage of EHR and care, driving scientific discovery as Dumontier, Ph.D., Distinguished CDS systems, a health IT safety an natural extension of patient care Professor of Data Science at center could collect, investigate, and and ensuring innovation, quality and the Institute of Data Science at disseminate learnings from challeng- safety in health care. The learning Maastricht University for contribut- ing EHR-related safety issues. health system should include infra- ing important intellectual content to structure and policies supportive of this article regarding the FAIR data Discussion secondary uses of EHR and other principles. A real-life example of a policy patient data—importantly, with a framework relating to appropriate focus on value for each patient and References consent for data usage, enacted in without undue burden on clini- 1. Leung, T., Rodriguez, J., May 2018, is the European Union’s cians—such as quality measurement Morgan, S. (2018) Clinical up- General Data Protection Regulation and improvement, safety monitoring, date in clinical informatics: Part (GDPR). The GDPR applies not public health surveillance and man- 1. SGIM Forum 41 (8):4-5. only to health data but also to all agement, basic and clinical research, 2. Adler-Milstein J, Embi PJ, consumer data in the EU—including and healthcare innovation. Middleton B, et al. Crossing the non-EU organizations who engage FAIR data principles, published health IT chasm: Considerations in the collection and usage of data in 2016, can accelerate the achieve- and policy recommendations from EU-based users. According to ment of the learning health system. to overcome current challeng- the European Commission, with FAIR defines a set of principles to en- es and enable value-based GDPR in place, the general prin- hance the Findability, Accessibility, care. J Am Med Inform Assoc. ciple is that no data processing is Interoperability, and Reusability of 2017;24:1036–1043. done unless necessary, for example, all types of digital objects, such as 3. Payne TH, Corley S, Cullen for reasons of public interest or electronic health care records, clini- TA, et al. Report of the AMIA where the subject has given explic- cal guidelines, and predictive algo- EHR-2020 Task Force on the it consent. In practice, this means rithms.6 The FAIR principles sug- status and future direction of that companies offering mobile gest, for instance, that such digital EHRs. J Am Med Inform Assoc. apps, devices, and other healthcare resources should have high quality 2015;22:1102–1110. technologies collecting data from metadata, unambiguous licensing, 4. Erickson SM, Rockwern B, EU users must comply with GDPR adhere to data standards, and follow Koltov M, et al. Medical Practice or risk facing very expensive fines. community expectations. The FAIR and Quality Committee of the This includes hospitals and health- principles have been widely adopted American College of Physicians. care systems. In the United States, across global communities, includ- Putting patients first by re- California governor Jerry Brown ing governments, governing bodies, ducing administrative tasks in signed the Consumer Privacy Act, publishers, and funding bodies. health care: A position paper also a digital privacy law, in June Consequently, these principles offer a of the American College of 2018; considered a Californian ver- sensible framework for the design of Physicians. Ann Intern Med. sion of GDPR, the law is expected to digital infrastructures to support the 2017;166:659–661. go into effect in January 2020. learning health system and its com- 5. Sittig D, Labkoff S. Who watch- All of these papers touch upon ponents, towards meeting the data es the watchers. Appl Clin components of a key concept in clin- needs of healthcare stakeholders— Inform. 2017;08:680–685. ical informatics: the learning health patients first and foremost, but also 6. Mons B, Neylon C, Velterop J, system. According to an Institute healthcare professionals, researchers, et al. Cloudy, increasingly FAIR; of Medicine report on Digital and innovators. revisiting the FAIR Data guid- Infrastructure for the Learning The next article in this series will ing principles for the European Health System, a learning health focus on clinical decision support Open Science Cloud. Inf Serv system is designed to both generate systems and population health. Use. 2017;37:49–56. SGIM

continued on page 14 7 PERSPECTIVE: POINT/COUNTERPOINT PART I SGIM SHOULD SUPPORT A SINGLE-PAYER NATIONAL HEALTH INSURANCE PROGRAM Danny McCormick, MD, MPH; Oliver Fein, MD; Christopher J. Wong, MD; Scott Goldberg, MD; Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD

Dr. McCormick ([email protected]) is associate professor, Harvard Medical School/Cambridge Health Alliance, Cambridge, MA. Dr. Fein ([email protected]) is professor, Weill Cornell Medical College, New York, NY. Dr. Wong ([email protected]) is associate professor, Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA. Dr. Goldberg ([email protected]) is resident physician, University of California San Francisco, San Francisco, CA. Dr. Woolhandler ([email protected]) is distinguished professor, City University of New York at Hunter College, New York, NY. and lecturer in medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, MA. Dr. Himmelstein ([email protected]) is distinguished professor, City University of New York at Hunter College, New York, NY, and lecturer in medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, MA.

espite improvements in health insurance coverage clinical care, and ethics. This allows SGIM to play an under the Affordable Care Act (ACA), 29 million important role in guiding the public and policy makers DAmericans remain uninsured and millions with on which specific policy options to select to address key coverage are also unable to afford care. Meanwhile, in policy problems. Through its committees and the Council, our healthcare institutions, the drive for profit increasing- SGIM works hard to advance its mission “to achieve ly trumps clinical imperatives, and even in not-for-profit health care delivery that is comprehensive…[and] is orga- organizations, mounting bureaucracy drains both funds nized and financed to achieve optimal health outcomes and joy from patient care. None of the incremental re- and maximize equity”. SGIM’s stated values include “so- forms currently being debated would fix these problems. cial responsibility and equity in health and healthcare”. SGIM has supported the goals of universal access to care In addition, SGIM’s Health Policy Committee affirms a and health equity, but has never taken a position on how commitment to “universal health care access”. to achieve these goals. The time has come for our orga- SGIM regularly supports specific policies, even nization to endorse and advocate for the only viable way controversial ones, by issuing white papers or public to ensure universal access to comprehensive care at an statements. As an organization, we have taken strong po- affordable price—a single-payer reform. sitions against physicians’ participation in torture and in support of providing care for undocumented immigrants. Current State of Coverage and Access in the USA However, SGIM has yet to advocate clearly on how to The ACA implemented the largest health insurance achieve universal and equitable access to care. We believe expansion since the start-up of Medicare and Medicaid it should now publicly support a single-payer program for in 1966. Since 2013, 15.5 million Americans have gained the United States. coverage, with larger gains among the poor, Hispanics and African Americans, although these groups continue Why Should SGIM Support a Single-Payer to suffer higher-than-average rates of uninsurance.1 Yet, Healthcare System? 9.1% of Americans remain uninsured, and 13.0%—in- Merits of Single-payer cluding 16.3% of black and 20.3% of Hispanic people— A single-payer reform would replace the current welter of can’t afford a needed physician visit currently.2 private and public insurance plans with one public plan But we have likely seen all the coverage gains achiev- covering everyone for all medically necessary care—in able under the ACA. Unfortunately, the current admin- essence, an expanded and upgraded version of the tradi- istration is seeking to undercut the law, implementing tional Medicare program. The potential health benefits policies that will erode existing coverage levels.3 Even of this approach are substantial. Numerous studies, many without these setbacks, the Congressional Budget Office from SGIM members, have shown that being uninsured estimated that no further increases in coverage would carries mortal consequences. Covering the 29 million occur through 2026. Americans who are currently uninsured would likely save many thousands of lives annually, and would reduce the SGIM’s Mission, Previous Work, and Role in Medicine risks borne by many more patients who delay seeking SGIM is an association of the world’s leading academic care and skimp on medications to save costs. general internists whose members have expertise in health The economic case for single-payer reform is also services and policy research, healthcare administration, continued on page 9

8 PERSPECTIVE: POINT/COUNTERPOINT PART I (continued from page 8) compelling. Private insurers’ over- The Moral Argument larger proportion of general inter- head averages 12.4% versus 2.2% Universal access to care is, funda- nists—favor a single-payer system. in traditional Medicare. Reducing mentally, a moral issue. As scientists, Others may view an incremental insurance overhead to Medicare’s we must be attentive to research strategy as a more practical route level would save approximately evidence, policy details and economic to universal coverage, citing nations $220 billion this year. Even larger necessities. Ultimately, however, we such as Switzerland and Germany savings would accrue by sharply must be guided by our conscience. that have retained multiple insurers reducing provider overhead, includ- Access to health care should not be while achieving universal covering the substantial costs of billing dependent on one’s age, employer, age. Yet those nations’ insurers are and paperwork required to deal with wealth, or zip code; it is a moral fail- fundamentally different from ours. multiple payers. By paying hospitals ure that we do not guarantee the clear In Switzerland, for example, only lump-sum operating budgets rather common good that is health care. A non-profit insurers can offer the than forcing them to bill per patient, strong body of research in the United tightly regulated mandatory coverage Scotland and Canada have held States and experience in other nations and are required to pay providers hospital administrative costs to ap- give clear evidence that a single-payer identical rates. Transitioning to proximately 12% of revenues versus system would dramatically expand this or similar models would entail 25.3% in the United States.4 Further, access to care, including treatments converting our for-profit insurers to a single-payer program could use its for millions with chronic illnesses, heavily-regulated non-profits, a re- bargaining clout to sharply reduce saving thousands of lives annually. form that insurers would vehemently drug prices. Single-payer’s savings on As physicians, we have an obligation oppose. Moreover, both insurance bureaucracy and drug profiteering to advocate for policies that evidence overhead and providers’ administra- would fully offset the added costs of indicates are in the best interest of tive costs in multi-payer systems are providing universal, comprehensive the public’s health. In light of this, we far higher than under single-payer. first-dollar coverage. Indeed, even believe that advocacy for single-payer While the incremental approach may critics of single-payer estimate that reform is a professional duty. sound appealing, it would sacrifice such reform would cut overall health much of the administrative savings expenditures by $2 trillion over a Arguments against SGIM’s that makes universal coverage under decade.5 Support for Single-Payer a single-payer system affordable and Some suggest that advocating it would still require a head-on con- Single-payer and SGIM’s single-payer reform would commit frontation with America’s for-profit Organizational Objectives SGIM to supporting a fringe pro- insurance giants. Single-payer aligns well with SGIM’s posal that would isolate us from the organizational goals. We agree with mainstream of political debate. Yet, Conclusion SGIM’s support of the broad princi- recent surveys indicate that most SGIM supports universal access ples of access and equity. However, Americans favor such reform. Single- and the elimination of disparities lacking any plan for how these goals payer bills in Congress have gained in access to care. The only plau- can be realized effectively undermines co-sponsorship from 123 members of sible way to achieve these goals is advocacy efforts. SGIM’s not provid- the House and 16 in the Senate. All through adoption of a single-payer ing specific recommendations, leaves the leading Democratic party con- national health insurance program. the impression that it believes that tenders for the presidency in 2020 Single-payer would cover 100% of incremental reform is a plausible way openly call for single-payer reform. Americans, dramatically expand to achieve universal coverage. The Some may also worry that SGIM access to care, and improve access to evidence does not support this belief. support for single-payer could alien- needed treatments for millions with We are also convinced that sin- ate some current or potential mem- chronic illnesses, saving thousands of gle-payer is the best way to address bers, or isolate us from other phy- lives annually. Popular and political SGIM’s mission of “improving the sician groups. Yet, as noted above, support for single-payer is growing. work and practice environment for SGIM has not shied away from SGIM should provide leadership in general internists” and reducing taking stands on other controversial advocacy for such reform. physician burnout. The simplified, and potentially divisive issues when uniform billing procedures under a it was clearly in the interest of the References* single-payer system would reduce the public’s health. Moreover, past polls 1. Cohen RA, Zammitti EP, time and effort physicians currently of SGIM’s membership have found Martinez ME. Health insur- waste arguing with private, prof- substantial support for “a single, ance coverage: Early release of it-driven insurers and providing doc- consolidated financing mechanism,” estimates from the National umentation that is clinically superflu- and recent surveys indicate that a Health Interview Survey, 2017. ous but essential to justify payment. majority of physicians—and an even continued on page 14

9 PERSPECTIVE: POINT/COUNTERPOINT PART II WHY SGIM SHOULD NOT ADVOCATE FOR SINGLE PAYER Mark Earnest, MD, PhD

Dr. Earnest ([email protected]) is the GIM division head at the University of Colorado and current chair of SGIM’s Health Policy Committee. He is a former Soros Physician Advocacy Fellow and served as the Vice President for the Colorado Coalition for the Medically Underserved for a decade. He is the founding director of the University of Colorado’s Student and Resident Program in Leadership and Advocacy (LEADS) and their interprofessional education program.

“Our lives begin to end the day we become silent about things that matter.” —Martin Luther King Jr.

ealthcare reform matters. SGIM should advocate we can. Our commitment to this ideal lends our voices firmly for a just healthcare system that cares authority and forms the backbone of our profession. We Hequally for everyone as one of our top priorities. have more latitude speaking publicly as physicians, but Physicians, both individually and collectively through our we still carry that authority with us and some expecta- professional societies, have a critical, public role to play tion that we manage our biases and represent the best in ensuring that the American healthcare system delivers interest of others. Speaking as individuals, without the universal, equitable access. No one else can speak with mantle of our profession, our obligations are no different the same authority and experience of the consequences of than anyone else. our current chaotic and inequitable system. Our deep- My solution was to make some distinctions. In front ly flawed healthcare system breeds corruption, forces of a grand rounds audience or a classroom, I would speak unethical choices on us daily, and contributes mightily as a physician and address the problems of access and to the growing inequalities that sap our nation’s health equity with passion, but would also offer dispassion in and vitality. It must change. As a solution to all of these evaluating the spectrum of responses. There were viable problems, a single payer system is undeniably elegant. alternatives. Speaking as a physician, I would respectfully Nevertheless, it would be a mistake for SGIM to endorse allow for their consideration and enable my audience to single payer health reform. make a fully informed decision. I would be less con- This position is far from where I started. Twenty-five strained at a backyard barbeque or a party caucus, but years ago, as a junior faculty member, I delivered my first speaking in my professional capacity, it was improper to departmental grand rounds entitled “The Case for Single present my preference as if it were the only reasonable Payer Health Reform.” I was among those loudly calling choice. for SGIM to endorse single payer. In the years since, I’ve SGIM as a professional society needs to make these continued to speak on health reform. I’ve given scores of same distinctions when we advocate for policy. SGIM talks to professional and lay audiences on the topic, but can never speak as freely as any of us can as individuals. over time, my approach has changed. To maintain our credibility and effectiveness as an orga- The change began with polite questions from physi- nization, we need to stay at the professional end of the cian audiences. “Aren’t there health systems that perform spectrum when we speak. We should be absolutely clear well and have private insurance?” Initially, I was com- about the ends we pursue, but when there are multiple pletely unprepared to answer the question and left with means to achieve a particular end, we should speak as a a sense of discomfort. Reflecting on that moment and doctor would. We should rigorously evaluate how well those that followed, I realized I was struggling to locate different options would accomplish the goals we have ar- my voice and my role. Was I speaking as a physician in ticulated and help policy-makers and the public make an equipoise—like I should at a patient’s bedside—or as informed decision. We should hold the process account- a citizen-activist with the goal of moving people to my able to acceptable outcomes, but we should not make the point of view? Which voice should I use and where? choice for them. As physicians, we have a great deal of latitude to As the gentleman in my grand rounds audience not- determine how we speak along a spectrum stretching ed, single payer is not the only way. A quick scan of the from our purely professional roles, to our roles as private globe reveals several high performing health systems that individuals and citizens. At the bedside we speak as phy- deliver universal, equitable, high quality care, through sicians—putting aside our biases and self-interest as best continued on page 11

10 PERSPECTIVE: POINT/COUNTERPOINT PART II (continued from page 10) models that include private insur- bers). This would reduce our ability what policies they will support. We ers. Among the many examples are to influence their opinions on future should each support candidates who Germany, Switzerland, and Japan health reform proposals and alienate can move us forward, and oppose who all deliver better population support we will need for other crit- those who will undermine reform ef- outcomes at a fraction of the cost of ical items on our advocacy agenda. forts. Each of us has the opportunity the United States. There are many voices advocating for to challenge, engage, educate and Replacing private insurers with single payer, but we are almost alone reason with our students, residents, a government program would have in advocating for academic GIM. colleagues, friends and family. We been much simpler 40 or 50 years Our research, education, and clinical should be writing editorials and ago when health care as a percent of care agendas are vitally important, supporting organizations that apply the economy was still in single digits and we should be very cautious political pressure in ways we agree and most insurers were not-for-prof- about anything that compromises with. it. It is much more complicated now them. As a society, we cannot be that nearly 1 dollar out of every 5 Our position now will also silent about this thing that matters. that change hands in this country is determine our role in future re- SGIM’s principles and goals must be spent on health care, and a sizeable form. The ACA passed without a firm and clear. Healthcare reform is proportion of that passes through single Republican vote; “repeal and an urgent national priority. We have the coffers of U.S. insurance com- replace” became one of the most an important role to play as a trust- panies. While we can question the potent rallying cries through the last ed, objective, non-partisan resource value these companies add, the facts four election cycles. I hope we will in the coming debate. That is how remain that they employ hundreds of have another shot at reform soon. SGIM will move hearts and minds thousands of people in good paying Health care will be one of the toward the solution we have so long jobs, and many Americans own a top issues of the 2020 presiden- sought and so desperately needed. piece of these companies through tial election. Meaningful, durable Perhaps that solution will be a single their retirement plans. There may be reforms—that Congress can build payer system, but we should be pre- many salutary benefits to adopting and improve upon rather than tear pared to do all we can to ensure the a single payer system, but we should down when another party takes best outcome, even if it’s not. be clear, there will be side effects. power—will need bipartisan sup- SGIM In evaluating the choices we face in port. Adopting single payer now will health reform, SGIM can highlight reduce our influence on that debate. the effectiveness and elegance of sin- Perhaps the political landscape will gle payer as a solution and enumerate evolve in such a way that single-pay- its many advantages, but we should er reform is possible. What if it does recognize the consequences and be not? What if the only model that will open to discussing them with the attract enough support to pass is a people who worry about them. If we bill to fix the ACA? If we are all in endorse single payer as the model of on single payer, we are by definition reform, we imply it is the only model opposed to other options. We might and we compromise our voice and find ourselves on the sidelines with reduce our influence. some strange bedfellows, when we Unfortunately, health reform could be working to ensure that a has become highly politicized and compromise proposal meets the criti- partisan and single-payer generates a cal needs of our nation. lot of heat. While single payer’s star Just because SGIM maintains may be on the rise in this political equipoise doesn’t mean our members moment, let’s be clear about what should. Our membership includes that looks like: single payer is red some of the most articulate and meat for Democrats and kryptonite effective voices in support of single for Republicans. SGIM cannot as a payer as well as many of the inves- society adopt active advocacy toward tigators who have developed the single payer without creating the evidence for its efficacy. Those voices impression we are a partisan orga- are important and should be heard. nization. If we appear partisan, we We should all make our votes count. will instantly alienate a majority of As citizens, we should pressure can- current members of the House and didates to commit to support health Senate (and many of our own mem- reform and even pledge in advance to

11 PRESIDENT’S COLUMN (continued from page 3)

I want to commend the Council members and SGIM staff who par- ticipated in these discussions—we had very intense and rigorous con- versations. These strategic goals will form the backbone for identifying/ refining tactics and articulating high level performance metrics for SGIM so we can chart our path as an organization. In service of this strategic planning process, we will tackle four major initiatives in the “sabbatical year” focused on organizational renewal:

1. SGIM leadership will continue to respond to the recommendations from the Pyramid communications audit. An oversight committee chaired by Tom Gallagher has started working I want to share with you how in academic general internal on our implementation strategy. the planning efforts are proceeding. medicine 2. The Finance Committee, chaired During the June retreat, Council by Mark Schwartz, has been and Staff took a considerable Promote high-value, evidence-based, working on a long-term strategic amount of time to review and revise person-centered, population-orient- plan for financial sustainability the mission and vision statements ed approaches to improving health. and growth for SGIM. They are that I shared with you in my • Strengthen and leverage the examining and developing tar- September column. Our next step organizational infrastructure gets for all sources of revenue, was to reexamine the strategic goals for catalyzing and disseminating keeping well within our external and priorities for the organization evidence-based innovations in funds policy. to further identify how we could be clinical practice, research, advo- 3. A steering committee, chaired most effective in the work we do as cacy, and education by Mitch Feldman, will reas- an organization and how we can sess our career development best serve our members. Advocate for our vision of a just programs in order to develop a In developing the strategic plan, health system that brings optimal more cohesive overall strategy we revisited the strategic priorities health for all people. and sustainable business mod- developed in 2015 and used them as • Conduct advocacy with an em- el for these programs. As you the starting point to develop a set phasis on vulnerable and under- may have seen in my message of organizational goals (HOW) and served patients and communities in GIM Connect, SGIM has current tactics (WHAT) to achieve • Advocate for policies supporting declared a temporary hold on these goals.4 Below are the current the ability of general internists to new enrollments in existing working goals and tactics in the provide optimal care in ambula- career development programs. SGIM strategic plan: tory and hospital settings We have outstanding content to • Develop advocacy-related educa- which many of you have contrib- Foster the development of future tion messages to communicate to uted and for which SGIM has leaders in academic general internal members become known. We are at a key medicine. time-point to ensure coordina- • Develop an integrated, com- Ensure SGIM financial health and tion and synergy in the pedagog- prehensive portfolio of career employee satisfaction. ical approaches and logistics of development initiatives • Align organizational structure implementing these programs. • Run programs to stimulate inter- and workload to make effec- We will be calling on commit- est in careers in general internal tive use of resources and foster tees and commissions to help us medicine growth as we get into the details of this • Offer awards to recognize in- • Enhance employees’ satisfaction work. novators, scholars, and leaders and fulfillment with work continued on page 14

12 HEALTH POLICY (continued from page 1)

towards rewarding value... Nobody at first blush would say they are against value but there are a lot of people who are gaining by working in this current volume-based system, and thus it’s hard to find support for increasing incentives towards a value-based care system, and therefore funding health services research.

Me: How can groups like SGIM help support health services research, and make the key stakeholders aware of its value in improving our healthcare system?

Andy Bindman: It’s not just about having stakeholders support health services research, it’s about having stakeholders seeing health services research as one of its top priorities… When I was first director of AHRQ I went to Health (NIH) and renaming it the Me: What are the benefits of having a meeting at the AAMC [Association National Institute of Research on health services research at the NIH? of American Medical Colleges], who Safety and Quality (NIRSQ). The is a big stakeholder, and they listed President’s FY18 proposed budget Andy Bindman: Right now, the NIH their top three priorities for Congress also made this recommendation, but has already been funding tremendous that year. The NIH was on the list, but it never gained traction. efforts in health services research in AHRQ and health services research The FY19 proposals from the projects such as the National Institute was not. My goal was to have AHRQ House and Senate Appropriations of Aging and the National Cancer and health services research get on Committees recommend no change Institute. Yet, I don’t know if their that list. Doing so helps Congress and in AHRQ’s budget compared with efforts are well coordinated for the other stakeholders wake up to the FY18, although the funding legis- larger efforts made in health services importance of this work. One issue lation is still pending at the time of research, which AHRQ is very good in achieving this goal is that health this writing. Looking forward, the at. But it’s been hard to bridge these services researchers often talk amongst President is already threatening a efforts with AHRQ being a separate themselves but not to the end users... government shutdown by vetoing any institute. A benefit of having AHRQ at When a drug gets discovered and cures spending bill that does not include the NIH would be better coordination a disease its easy to draw a line from funds for building his wall. This of health services research between de- biomedical research to the outcome. could once again put AHRQ in dan- partments in the NIH and a dedicated This helps emphasize the importance ger of funding cuts if the legislation department where this type of research of biomedical research. But when you is not passed. is the main focus. prevent a medical error or improve the Foreseeing the political battle quality of a healthcare treatment, who over the budget and the impact it Me: Why does health services research, knows that health services research may have on the future of health which is so critical to improving our lead to this outcome? Health services services research, it’s important to healthcare system, not get the same researchers and groups like SGIM better understand the president’s support as biomedical research? need to focus on making stakeholders proposal to move AHRQ to the NIH aware of the impact of health services and understand why health services Andy Bindman: Biomedical research research, if they want to see continued research funding, which is crucial to funds projects that are tied with support and become a top priority the success of our healthcare system, industry and leads to new drugs that among important stakeholders. continues to be threatened. go into the market place to be sold… I spoke with Dr. Andy Bindman, Health services research helps make The possibility of moving former AHRQ director under our healthcare system more intelli- AHRQ to the NIH is uncertain, and President Obama, to help answer gent. But most of our incentives in the would require authorizing legisla- these questions. market place are not geared that way, continued on page 14

13 PRESIDENT’S COLUMN (continued from page 12)

4. Council will complete the strate- information about the process the tion. Posted September 2009. gic planning work by identifying Council is using to do this work. We Accessed August 24, 2018. tactics and metrics for each stra- expect this strategic planning process 2. Sinek S. Start with why: How tegic goal. As part of this effort, to strengthen the organization so great leaders inspire everyone Council will ask committees and that it is better able to serve our to take action. New York, N.Y.: commissions to map their cur- members and pursue new opportuni- Portfolio, 2009. rent programs and initiatives to ties to keep SGIM at the cutting edge 3. Corbie-Smith G, Jetton F, Bass this plan, articulating measures of issues in general internal medicine. E. Looking inward and moving that would help us benchmark forward: Results of SGIM’s our progress in meeting these References communications audit. SGIM goals. 1. Sinek S. Start with why: How Forum. 41(6):3,15. great leaders inspire everyone 4. Chin M. Who is SGIM? In the coming months, we will to take action. https://www. Focusing on six strategic priori- share the outcomes of these four ted.com/talks/simon_sinek_ ties. SGIM Forum. 38(8):3,13. initiatives and continue to share how_great_leaders_inspire_ac- SGIM

PERSPECTIVE: POINT/COUNTERPOINT PART I (continued from page 9)

https://www.cdc.gov/nchs/data/ org/blog/2018/first-look-health- far. Health Aff (Millwood) . nhis/earlyrelease/insur201711. insurance-coverage-2018-finds- 2014;33(9):1586-94. pdf. Published November 2017. aca-gains-beginning-reverse?re- 5. Blahous C. The costs of a Accessed September 1, 2018. direct_source=/publications/ national single-payer health- 2. BRFSS Web Enabled Analysis blog/2018/apr/health-cover- care system. https://www. Tool. https://nccd.cdc.gov/weat/ age-erosion. Published May 1, mercatus.org/system/files/ index.html#/crossTabulation. 2018. Accessed September 1, blahous-costs-medicare-mer- Accessed September 1, 2018. 2018. catus-working-paper-v1_1.pdf. 3. Collins SR, Gunja MZ, Doty 4. Himmelstein DU, Jun M, Published July 2018. Accessed MM, et al. First look at health Busse R, et al. A compari- September 1, 2018. insurance coverage in 2018 finds son of hospital administra- SGIM ACA gains beginning to reverse. tive costs in eight nations: *A full set of references is available upon http://www.commonwealthfund. US costs exceed all others by request from the authors.

HEALTH POLICY (continued from page 13) tion, which does not appear likely for AHRQ and the crucial research Agency for Healthcare Research in the immediate future. However, it funds. and Quality (AHRQ) research threats of funding cuts should re- summit on improving diagnosis: mind us that health services research References a proceedings review. Diagnosis. is not on the priority list of enough 1. Makary MA, Daniel M. 2016. 2017;4(2):57-66. important stakeholders. By following Medical error-the third leading 4. Meyers D, Miller T, Genevro T, Dr. Bindman’s advice, clearly sum- cause of death in the US. BMJ. et al. EvidenceNOW: Balancing marizing our successes in health ser- 353:i2139. doi: 10.1136/bmj. Primary Care Implementation vices research and their associations i2139. and Implementation Research. with improved healthcare outcomes, 2. Seth P, Rudd RA, Noonan RK, Ann Fam Med. 16 (Suppl 1):S5- we will better acknowledge its sig- et al. Quantifying the epidemic S11. doi: 10.1370/afm.2196. nificance. Wanting to end the opioid of prescription opioid overdose 5. Department of Health and epidemic or prevent another medical deaths. Am J Public Health. Human Services. FY 2019 HHS error from taking a life is not a parti- 2018 Apr;108(4):500-502. doi: Presidents Budget Proposal. san debate; neither should be sup- 10.2105/AJPH.2017.304265. https://www.hhs.gov/sites/default/ porting health services research and Accessed September 1, 2018. files/fy-2019-budget-in-brief.pdf. AHRQ. The members of groups such 3. Henriksen K, Dymek C, Last updated February 19, 2018. as SGIM, who can inform policy Harrison MI, et al. Challenges Accessed September 1, 2018. makers, need to continue to advocate and opportunities from the SGIM

14 FROM THE EDITOR (continued from page 2)

The rest of this issue is a great regarding the difficult topic of References example of what and who we are providing adequate pain relief to 1. Pear R, and Kaplan T. G.O.P. in and what we stand for. Dr. Tom patients that are opioid dependent. Senate trims ambitions to start Kingsley describes the history Finally, Drs. Tiffany Leung, Jorge voting. New York Times. https:// around and the role that AHRQ Rodriguez, and Stephen Morgan www.nytimes.com/. Published plays in the funding of health ser- provide us with the second part of July 28, 2017. (Subscription vices research. Drs. Annie Massart, their Clinical Update in Clinical needed to download article.) Theresa Vettese, and Julie Hollberg Informatics taken from the 2018 SGIM educate us on the best practices Annual Meeting.

Academic Primary Care Positions at Beth Israel Deaconess Medical Center in Boston

The Division of General Medicine and health providers, as well as anticoagulation, account, use the search term “Academic Primary Care at Beth Israel Deaconess HIV, diabetes, hypertension and substance Primary Care Physician,” and apply to req- Medical Center, a teaching hospital of use disorder management services. uisition # 171439. Primary care physicians Harvard Medical School, seeks highly moti- Residents and Harvard medical students are employed by Harvard Medical Faculty vated board eligible and certified internists are integrated into the overall practice and Physicians (HMFP), the faculty practice to join our hospital-based, academic prima- team structure, and we have a cutting edge plan for all physicians at Beth Israel ry care practice. We are an NCQA certified primary care residency program. A Harvard Deaconess Medical Center, Inc. level III patient-centered medical home, appointment will be offered commensurate We are an equal opportunity employer with a strong track record of high quality, with academic qualifications. We offer a and all qualified applicants will receive innovative patient care, excellent popula- highly-competitive salary, incentives close- consideration for employment without tion-health tools and an abiding commit- ly aligned to the diverse mix of elements regard to race, color, religion, sex, sexual ment to excellence in teaching, research, required in providing quality care and a orientation, gender identity, national or- quality improvement and work-life balance. generous benefits program. igin, disability status, protected veteran Our practice delivers team-based care with Candidates should visit http://www. status, or any other characteristic protect- integrated on-site support from mental hmfphysicians.org/careers, create an ed by law.

Research Faculty Position Division Of General Medicine

The Division of General Medicine at Boston’s Beth Israel MID-CAREER/SENIOR POSITION—The successful appli- Deaconess Medical Center (BIDMC, major teaching affili- cant will be prepared to lead a new research program ate of Harvard Medical School), seeks junior and mid-ca- within the Division, garner significant external research reer/senior research faculty. The Division is home to the funding, and mentor fellows and junior faculty members Sections of Primary Care and Hospital Medicine, with within his/her area of expertise. Resources will be avail- research focusing on improving the health of vulnerable able to establish a research program, including potential populations and those with chronic conditions, fostering recruitment of additional faculty or fellows. We seek to patient-centered care, improving clinical decision making, grow breadth in our present lines of inquiry, and therefore and developing, implementing, and testing innovations welcome investigators focused on new topics relevant to in primary care and hospital medicine. Eighteen M.D. general medicine. Such topics include (but are not limited and Ph.D. investigators conduct research, seek external to) health disparities, healthcare policy and organization, funding, and provide mentoring within Harvard’s general and substance use disorders. medicine and integrative medicine fellowships. M.D. and/or Ph.D. required, with general medicine JUNIOR POSITION—For junior positions, we seek to grow (including hospital medicine) research interests. M.D.s depth in established research areas as listed above. The practice in BIDMC’s faculty inpatient and outpatient Section for Research takes particular pride in our men- settings. Under-represented minorities, women, and per- toring of junior faculty members; most senior faculty sons with disabilities encouraged to apply. EEO/AA/M/F/ are recipients of individual awards for excellence in Vet/Disability. Please apply by going to https://hmfphy- mentoring, and our Section has been recognized with sicians.org/. Please enter 171454 in keyword search to Harvard Medical School’s Program Award for a Culture of locate the job posting to apply. Excellence in Mentoring.

15 Society of General Internal Medicine 1500 King Street, Suite 303, Alexandria, VA 22314 202-887-5150 (tel) / 202-887-5405 (fax) www.sgim.org

Boston University School of Medicine / Boston Medical Center— Medical Director for Primary Care

The Section of General Internal Medicine at Boston grams in Office-Based-Addiction-Treatment (e.g., This is an exciting time to join the Section Medical Center and Boston University School of buprenorphine), Women’s Health, Refugee Health, of General Internal Medicine at New England’s Medicine is seeking an innovative and inspirational patient navigator programs, Care Coordinator pro- largest safety-net hospital and make a real impact. faculty leader to serve as Medical Director for gram, Clinical Pharmacist Program, and TOPCARE The Section is comprised of a diverse, energetic Primary Care, providing overall leadership respon- for safe opioid prescribing. and committed group of Primary Care Faculty sibility for Primary Care Operations, Transformation The Primary Care Medical Director will oversee Members. Boston Medical Center is committed to and Innovation. Practice Team and Leadership Development by growing and strengthening Primary Care, and the Working with an Associate Medical Director, creating a culture of continuous performance im- Section of General Internal Medicine has embarked Administrative Director and Clinic Operation provement, responsible stewardship of resources, on an effort to further transform our NCQA- Managers, the Director has responsibility for and career development of our talented clinical certified patient centered medical home into a lead- Primary Care operations, transformation, and in- faculty. The Director will also have an important ing primary care practice with a focus on providing novation. The Director will have important roles in role in ensuring that the primary care practice high-value, team-based care consistent with our ensuring the success of our very exciting Medicaid facilitates effective educational environment for mission for caring for Boston’s underserved. Accountable Care Organization as well leading our our students, residents, and fellows in primary Boston University is an Affirmative Action and primary care clinicians to continue to excel in all care. The Director will report to the Chief, Section Equal Opportunity Employer. Salary and faculty aspects of high value, patient-centered care. The of General Internal Medicine and the Vice Chair rank will be commensurate with prior experience primary care practice in the Section of General for Clinical Affairs in the Department of Medicine, and qualifications. Interested candidates - please Internal Medicine has 70 faculty and responsibility and will be expected to work collaboratively with send a cover letter and CV via email to Jeffrey for approximate 38,000 patients. In addition, the the BMC leadership team in formulating strategic Samet, Section Chief of General Internal Medicine: practice has critically important specialized pro- plans for the practice. [email protected]

Boston University School of Medicine / Boston Medical Center— Associate Medical Director for Primary Care Transformation and Innovation

The Section of General Internal ular, the Associate Medical Director make real impact. Boston Medical Medicine at Boston Medical will lead a multidisciplinary team in Center is committed to growing and Center is seeking an innovative conceptualizing and implementing strengthening Primary Care, and the and inspirational leader to join the a care delivery model for complex Section has embarked on an effort Primary Care Leadership team as and high-risk care management to further transform our NCQA- the Associate Medical Director for from the ground up. Successful certified patient centered medical Primary Care Transformation and applicants will have experience in home into a leading primary care Innovation. This is a faculty position change management, project imple- practice with a focus on providing in the Department of Medicine and mentation, process improvement, high-value, team-based care consis- the Boston University School of and managing diverse teams. This tent with our mission for caring for Medicine. leader will serve on key quality and Boston’s underserved. This position will combine direct strategy committees, interact di- Boston University is an Affirmative patient care with significant admin- rectly with Hospital and Department Action and Equal Opportunity istrative time to lead change and of Medicine leadership, and will Employer. Salary and faculty rank quality improvement in key prior- have leadership development and will be commensurate with pri- ity areas. The Associate Medical mentorship opportunities tailored to or experience and qualifications. Director will work closely with the the applicant’s interests. There will Interested candidates—please Medical Director to lead the efforts be an expectation of teaching and send a cover letter and CV via to drive changes in primary care scholarship related to primary care email to Jeffrey Samet, Section as the hospital transforms into an quality and innovation work. Chief of General Internal Medicine: Accountable Care Organization for This is an exciting time to join [email protected] the safety-net population. In partic- General Internal Medicine and

The ISSN for SGIM Forum is: Print-ISSN 1940-2899 and eISSN 1940-2902.