December 7, 2018

The Weekly Gist: The Pomp and Circumstance Edition

by Chas Roades and Lisa Bielamowicz MD

It’s been a somber week here in the nation’s capital, following the passing of former President George H.W. Bush. Washington is a city accustomed to hosting national events, and one that delivers pomp and circumstance like no other. Other than Presidential inaugurations, there are few events that compare to a state funeral. This one provided an up-close look: our offices are just down the street from the National Cathedral. Whatever your politics, you had to be moved by the spectacle of our great democracy engaging in one of its national traditions. That, coupled with the remembrance of a life lived in service to the country, left us feeling optimistic about America, despite our polarized times. Safe home, President Bush.


What happened in healthcare this week—and what we think about it.

Seeing a slowdown in healthcare spending growth

The Centers for Medicare & Medicaid Services (CMS) released its annual report on National Health Expenditures (NHE) this week, reporting that total healthcare spending in the US grew by only 3.9 percent in 2017, the slowest rate of growth since 2013. Slower growth was observed across all major categories of spending—hospital care, physician services, and retail pharmacy. As a percentage of gross domestic product (GDP), healthcare spending was down slightly in 2017, at 17.9 percent, although per capita spending hit its highest level yet, at $10,739 per person. Total national spending on healthcare in 2017 hit $3.5T. The slowdown in spending was in part attributable to changes in the level of insurance coverage, which expanded rapidly in 2014 and 2015, but declined slightly last year. In particular, the growth of spending in Medicaid continued its three-year decline, following the Obama-era expansion in 2014. Also contributing was a slowdown in household healthcare expenditures, caused by slower growth in out-of-pocket spending in the face of higher deductibles, copays and coinsurance borne by those who get coverage through their employer.

The government’s share of spending held steady at 45 percent, with the Federal government shouldering 28 percent of the total, and state and local governments paying for 17 percent. Of note, Medicare spending now accounts for 20 percent of NHE, with two-thirds of that in traditional Medicare fee-for-service (FFS) and a third in private Medicare Advantage (MA) plans. Medicare FFS spending grew at 1.4 percent, while MA spending grew at 10.0 percent—with nearly all of that difference accounted for by enrollment growth: flat for fee-for-service, up 8.0 percent for MA. It would seem that the continued growth of private Medicare coverage is allowing the Federal government to constrain spending growth to 1.7 percent per enrollee, even despite a 2.5 percent increase in overall enrollment. That, according to CMS, is because MA enrollees “tend to use more physician and less hospital services.”

As always, there’s a lot of data to absorb in this year’s report on NHE. In particular, the perennial debate over what drives increases in health spending in the US—price growth, demographics, or “intensity” of services—seems to be continuing its swing toward price, meaning that the amount we pay for each unit of service accounts for a larger share of spending growth than our increased use of services or the kind of services we use. Surely this latest report will be used as additional evidence that we pay too much for healthcare services—and we do, in the form of prices that are higher than they should be. Amid these arguments, however, it’s worth remembering that the definitions of price and intensity are complex and determining whether we’re getting value for our healthcare dollars is not as straightforward as comparing this year’s spending to last year’s. That said, given the findings of the latest NHE report, we seem to have settled into a more moderate rate of spending growth that puts healthcare more in line with the rest of the economy, after years of outsized healthcare inflation.

A new vision for competition in healthcare

In a report developed over the course of the past year in response to an Executive Order by President Trump, and released this week, three Cabinet secretaries jointly offered more than 50 recommendations for “Reforming America’s Healthcare System Through Choice and Competition”. The report lays out a blueprint for continuing the Trump administration’s efforts to deregulate the healthcare marketplace and encourage private market competition to lower the cost of care. Focusing on reforms to the provider and insurance sectors, as well as to laws and regulations governing the healthcare workforce and use of health information technology, the document calls for sweeping changes to be made by Federal and state governments. Some of these could be achieved unilaterally by the administration, others would require major legislative action. Among the proposals:

  • Toughening enforcement of antitrust laws governing provider mergers;
  • Broadening scope of practice laws and regulations to allow nurses, pharmacists and others to extend their services;
  • Loosening state medical licensure laws to allow for greater workforce mobility;
  • Modifying payment and regulatory restrictions to allow for greater use of telemedicine;
  • Easing restrictions on foreign-trained doctors and streamlining funding for graduate medical education;
  • Repealing certificate-of-need laws; and,
  • Eliminating restrictions on physician-owned hospitals.

Also included in the proposal are suggestions for increasing IT interoperability, bolstering price transparency, loosening insurance regulations, and streamlining provider quality reporting requirements.

On the whole, the report, signed by Secretary of Health and Human Services Alex Azar, Secretary of Labor Alexander Acosta, and Secretary of the Treasury Stephen Mnuchin, reinforces the Trump administration’s bias toward harnessing the power of private market competition and consumer choice as the primary means of improving value in healthcare. While parts of the document simply rehash long-standing, anti-Obamacare ideas, others (such as the scope of practice and medical licensure ideas) represent an aggressive vision for deregulation, one that comes at a moment when the healthcare industry seems on the brink of disruption from a number of new entrants. After the recent midterm elections, major new legislation in healthcare is unlikely, but the new report provides a useful roadmap for predicting future regulatory action and policy proposals. To its credit, the Trump administration may have moved past its “repeal and replace” rhetoric and seems poised to advance its own vision of healthcare reform.

A status report on telemedicine in the US

As we’ve written, telemedicine is at a tipping point, with growing consumer awareness, provider adoption and payer coverage laying the groundwork for dramatic growth. Medicare has long lagged commercial payers and state Medicaid plans in paying for telemedicine. But next year for the first time, nearly all Medicare beneficiaries will have access to some telehealth services, thanks to expanded coverage in the 2019 Physician Fee Schedule and with the passage of the CHRONIC Care Act in February. With that in mind, we were excited to dive into the December issue of Health Affairs, which is devoted to telehealth, and takes a deep look into the state of telemedicine access, utilization, efficacy and regulatory issues today.

Both patient use of telemedicine and the number of providers offering telehealth services are growing rapidly. While overall use rates today are lower than many providers anticipated, researchers found that telehealth use more than quadrupled between 2010 and 2015, rising to 113 users per 10,000 enrollees in the commercial population. The same study found an interesting split in mode of utilization between urban and rural markets. Urban telemedicine visits were more often for minor primary care needs and likely to be consumer-initiated, whereas telemedicine use in rural areas was more often provider-initiated, and focused on access to specialty care, particularly behavioral health. On the supply side, researchers found that only 15 percent of doctors practice in a group that offers direct-to-patient telemedicine, with 11 percent reporting that their group offers provider-to-provider telehealth consults. Rates vary significantly by specialty, with the highest use seen in radiology and psychiatry. Unsurprisingly smaller practices face barriers in telehealth adoption, which will only increase given the expansion of insurers and retailers into the space, as evidenced by an analysis showing the numerous virtual health technology and provider acquisitions by these players.

Other studies in the new Health Affairs issue evaluate the efficacy of telehealth for a range of primary and specialty care conditions, with the key takeaway that care provided with telemedicine is largely equivalent to in-person evaluation; however, data on telemedicine’s effect on utilization is mixed. For at-risk and rural populations, telehealth provides an important access boost, particularly for specialty care needs. In accountable care organizations, telehealth use decreased the use of in-person visits by a third, but telehealth users had more visits with providers overall. Remote monitoring for heart failure increased the number of ED visits—but decreased six-month mortality, perhaps by more quickly identifying symptoms needing treatment. Taken together these studies suggest a need to reframe the goal of telemedicine from simply substituting for in-person visits to providing more comprehensive, accessible care across a spectrum of care needs—and for many patients, a way to increase, not reduce, the number of interactions they have with the health system.


A key insight or teaching point from our work with clients, illustrated in infographic form.

Widening the “front door” of the health system

Last week in this space, we began to share our framework for helping health systems rethink their approach to investment in delivery assets, built around a functional view of the enterprise. Briefly, we’ve urged our clients to take a consumer-oriented approach to planning, starting by asking what consumers need and working backward to what services, programs and facilities are required to meet those needs. That led us to break the enterprise into component parts that perform different “jobs” for the people they serve. We think of each of those parts as a “business”, located at either the market, regional or national level depending on where the best returns to scale are found (and on the geographic scale of any particular system). Over the coming weeks we’ll be sharing thoughts on each one of those businesses, starting here with the “access business”.

The access business—serving as the “front door” to care delivery—has been a hot space for innovation and investment, and for good reason. Most obviously, it’s the top of the funnel for delivery organizations, through which most patients first pass as they move through whatever episodes of care they’re consuming. It’s also the site of the most “shoppable” services offered by a health system, meaning that consumerism has been most pronounced here, with patients often choosing whether and where to consume care based on price, convenience, and service. Much of the “primary” care delivered across the access business serves as a lower-cost substitute for expensive and unnecessary emergency department visits—critical in the world of population health and cost reduction. And it’s the business most involved in caring for millennials today, making it an important early focus for building loyalty and engagement among a large population whose healthcare spending still mostly lies ahead.

We advise clients to over-invest in resources here, blanketing the market with access points to the extent possible. The goal is to be able to meet the consumer in every channel, with a set of services that provides an attractive balance of benefits and price. In the context of managing the larger cost profile of the health system, we don’t believe every access point should be viewed as a profit center; rather, the best systems view low-priced access as an investment in building consumer loyalty that will pay off over time. We’re not fans of strategies that look to leverage high hospital pricing in non-hospital settings, as some systems have tried to do in owned physician clinics and freestanding emergency departments. Instead, systems should run toward (not away from) site-neutral pricing wherever possible. (Unfortunately, the hospital industry seems to still be motivated by the opposite instinct, as this week’s lawsuit demonstrates.)

Two additional components of the access business are not depicted below but should be integral parts of any system’s “front door”. The first is telemedicine, which we believe is best scaled and operated at a regional or national level (perhaps in partnership with specialized telemedicine providers) but should be deployed at a local level in support of broader access strategies. And the other, related, is home-based care. We are bullish on the prospect for much care to be delivered in the patient’s home—often using a telemedicine approach but sometimes even with in-person home visits. This component may best be deployed through partnership, although (as with telemedicine) the premium on integration with the broader system’s clinical enterprise is high. In general, the ethic across the access business should be one of delivering the right care at the right level—often at lower cost.

Next week: the postacute, or “senior care” business.


Here’s what we heard from you.

Telemedicine poised for expansion?

Despite growing consumer demand and widespread provider investment in virtual care, policy and reimbursement barriers have kept telemedicine use rates low. However, this year has brought a number of policy changes which could potentially break down barriers to access. Health policy expert Julie Barnes responded to our questions about how these changes could expand access to telemedicine services for millions of patients.

Gist Healthcare: How robust is telemedicine utilization today, and how is it poised to grow?

Julie Barnes: Despite lots of publicity and hype, telemedicine use rates today are much lower than many believe. A new report issued in November from the Centers for Medicare & Medicaid Services (CMS) said that 90,000 Medicare fee-for-service beneficiaries used over 275,000 telehealth services between 2014 and 2016.

Telemedicine is more popular with the non-elderly population—but the people who like it the most will be eligible for Medicare soon: younger Baby Boomers and “Generation X” consumers. FAIR Health, a non-profit organization that analyzed telehealth trends in recent years, released a study of its database of over 25 billion private claims showing that telehealth use has grown by 960 percent between 2011 and 2016, and the largest portion of this growth was from by people aged 41 to 60.

And while telehealth is still very uncommon—fewer than 7 annual visits per 1,000 people, compared to 313 physician office visits per 100 individuals—there is a marked uptick in use by people in bigger cities. While many policies have been adopted to support telemedicine as an access alternative for rural patients, a research letter published last month in JAMA reports that 83 percent of telehealth users lived in urban areas.

[Read the rest of our Q&A with Julie Barnes here.]


What we learned this week from our work in the real world.

Debating the value of academic medicine for consumers

Over the past few months we’ve had the chance to work with executives and physician leaders at a health system that’s in the early stages of launching a four-year medical school, building from a position of market-leading tertiary care services and growing residency training programs. As they plan to expand their academic faculty and launch a formal practice plan, they asked for our help in understanding the value provided by an academic medical group, and laying out a plan for how the group should be structured and relate to other closely-aligned employed and independent physician groups across the health system.

With any discussion around physician alignment and medical group structure, it’s easy to get mired in the mechanics. What “model” should we use for governance? How should compensation plans be structured? Who will report to whom? Before any of these decisions could be made, we realized the group needed to be grounded in a common definition of system success and aligned with strategy within the market. Executive leaders agreed with our assertion that health systems need to organize around consumer value, so we spent a day with the group applying our framework for consumer-focused strategy toward answering the question: how should academic medicine and an academic medical group provide value to consumers?

There was no disagreement among the doctors and executives about what their customers want: care that is accessible, reliable, affordable and personal—and a handful of leaders were admittedly a little dispirited by the hurdles the group faced. Trainees can make visits take longer. Wait times for specialist appointments are longer than market average, and hospital-based clinics less convenient. And like most academic centers, their costs are higher. However, others were skeptical, feeling that patients would continue to come based on group’s reputation and academic portfolio. We reminded leaders that they couldn’t rest on their reputation alone: the vast majority of services provided in academic centers do not require quaternary-care expertise, and patients will judge them by the same quality, cost and experience standards as they do other providers.Moreover, the value of academic medicine—cutting-edge research, specialized care services, and training new providers—can seem amorphous and far-removed to the average patient. The right operating model for the academic medical group will need to merge the value of academic medicine—producing the best doctors, clinical knowledge, clinical care and brand reputation—with the accessible, affordable and reliable care that consumers increasingly demand. 

Facing a talent gap in health system leadership

There’s a fine line between provocative and insulting, and I was afraid I’d crossed that line recently during a meeting with the executive team of a health system client. We’d been talking about the potential for big, new entrants to disrupt the traditional delivery business: Amazon, CVS, and so forth. I commented that one of the things that worries me is that health systems just don’t have the level of leadership talent to keep up with these fast-moving innovators as they look to push aggressively into care delivery. No sooner had the words left my mouth than I realized I had just told a room full of client executives that they’re not talented enough. Oops. As quickly as I could, I added, “Present company excepted, of course!”

It turned out that the CEO and his team—to their credit, one of the sharpest, most progressive group of leaders we work with—were in complete agreement. As we dug into the issue, the group discussed the factors that contribute to what they concurred is a growing leadership gap between traditional health systems and would-be disruptors. For starters, many health system executives “came up through the ranks”, having worked their way up from entry-level jobs in hospitals or physician groups. That’s pretty uncommon among other corporate executives, who often move laterally across organizations and across types of businesses. That leaves many health system execs with a relatively narrow frame of reference and experience base upon which to draw. Also, delivery organizations tend to reward stability over risk-taking (especially bond-funded, not-for-profit systems)—which may make running a health system less attractive to high-potential talent compared to other career options.

Further, many health systems have grown significantly in complexity and scale over the past two decades, leaving veteran executives leading very different organizations from when they started. Some have simply reached the limits of their ability to keep up. Yet the talent pool from which to recruit new leaders for these larger organizations is much more competitive, and costly. As much as we hear criticism of health system executives for receiving exorbitant salaries, the reality is that systems are probably underpaying for talent, relative to the demands of the job (especially as complexity increases). Giant disruptors like CVS ($184B revenue), UnitedHealth Group ($201B revenue) and Amazon ($178B revenue) can afford a very different caliber of talent than even the largest of health systems (HCA at $41B revenue), let alone the typical $1B-$5B health system. As we’ve written elsewhere, hospital CEO salaries are probably too low, not too high (though they must be more transparent and value-based). The executives I was with are feeling all of these challenges, and it’s a testament to their commitment that they’ve maintained their progressive posture in the market so consistently. But they’re right to worry—as we do—that the talent gap in healthcare delivery is going to present a growing challenge as the pace of innovation and disruption quickens.


What we’ve been writing about this week on the Gist Blog.

Understanding Medicare’s New Drug Proposals

Late last month the Centers for Medicare & Medicaid Services (CMS) released a proposed rule that makes changes to the regulations governing Medicare Part D and Medicare Advantage drug plans. The changes come as part of the Trump administration’s ongoing focus on addressing high pharmaceutical spending. We asked our friend and colleague Layne Oliff, who knows the Medicare pharmacy space well, to share some context on the proposed rule, and to provide guidance on the impact of the proposal.

What is the goal of the proposed rule announced by CMS?

The proposed rule follows up on the Drug Pricing Blueprint that was announced in May 2018 by the current administration. The overall goal is to lower medication costs for Medicare beneficiaries while continuing to provide medication choice. The Blueprint has four key components:

  • Improve competition
  • Negotiate better drug prices
  • Incentivize plans and payers to provide lower list prices
  • Lower Medicare beneficiary out-of-pocket costs

[Read the rest of the post on the Gist Blog.]


We said it, they quoted it.

The doctor who founded CityMD and sold it for $600 million explains how a new kind of medical clinic is changing how Americans get healthcare
Business Insider; December 4, 2018.

“Urgent care is catching on as Americans increasingly seek convenient ways to get healthcare. According to the Urgent Care Association, the industry’s trade group, there were 8,154 urgent care centers in the US in 2017, up 25% from 2014. Urgent care visits have climbed rapidly, too, according to one study.

‘They’re definitely popping up everywhere,’ Dr. Lisa Bielamowicz, the president of Gist Healthcare, which consults with health systems, told Business Insider. ‘There’s a huge amount of competition for the convenient-care space.’”


Give this a spin, you might like it.

One of the great pleasures of this twilight moment in the history of rock has been the recent output of the vanguard generation of art rockers, many of whom are now approaching their 70s. Constantly reinventing themselves but still driven by the same instinct for the cutting edge, these elders of alternative music—think David Byrne, Peter Gabriel, Patti Smith, Brian Eno, and of course the late David Bowie—have produced some of the most interesting work of the past decade. To that list, add Bryan Ferry. The legendary front man of Roxy Music has built a remarkable body of solo work over the years, moving from art rock to synth pop to orchestral jazz. His latest, released in November, is Bitter-Sweet, a collection of reworkings of earlier songs from his solo and Roxy Music catalogue, arranged in the style of 1930s cabaret music. The album draws on his soundtrack for last year’s German interwar noir series Babylon Berlin, in which he appeared as a cabaret singer. Working again with his full orchestra, with whom he produced the 2012 instrumental album The Jazz Age, Ferry croons darkly through a set that sounds for all the world like it came straight from a Weimar nightclub—though most of these numbers saw their first renditions as new wave tracks. Compare the treatment of “While My Heart is Still Beating” here compared to the original from 1982’s Avalon. Ferry’s voice is an ideal match to the smoky aesthetic of cabaret, and it’s fascinating to listen to him wander through clarinets and muffled trumpets where once were synths and electric guitars. It was a fun surprise to see him briefly on stage in the Netflix series—this release delivers the full musical realization of that guest appearance.


Stuff we read this week that made us think.

The first look inside Medicare’s new bundled payment program 

Medicare’s newest bundled payment program, Bundled Payments for Care Improvement-Advanced, or BPCI-Advanced, went live on October 1st for over 1,500 participating hospitals and physician groups. A piece this week on the Health Affairs blog provides the first look into the makeup and focus areas of the BPCI-Advanced cohort, and finds robust participation from across the country. Here’s a quick refresher on BPCI-Advanced: participation is voluntary, and open to hospital and physician groups. Participants can choose from a list of 29 inpatient and three outpatient episodes (this is the first time Medicare has offered bundled payments for services initiated in the outpatient space) and are accountable for total costs across a 90-day episode. And unlike its predecessor program, “BPCI-Classic”, BPCI-Advanced participants will bear downside risk from day one of the program. [Read our early analysis of the program here.]

Contrary to the predictions of some policy experts, the mandatory downside risk of BPCI-Advanced does not seem to have deterred providers from joining. 1,547 providers, divided almost equally between hospitals and physician groups (54 versus 46 percent, respectively), have joined. 85 percent of all markets in the US are participating, with over two-thirds of markets having two or more participants. The average provider is participating in eight episodes, and the authors found that episode selection does vary between hospitals and doctor groups. While lower extremity joint replacement is the most commonly selected episode overall, it ranks tenth for hospitals, for whom congestive heart failure and sepsis are the most common episodes. Physician groups were also more likely to participate in the three outpatient care episodes.

With BPCI-Advanced, providers are signaling continued strong interest in bundled payments, with the next indicator of the program’s success to come in Mach 2019, when participants have their first chance to opt out of episodes. Previous bundled payment programs have delivered mixed results, and policymakers will be watching to see if mandatory downside risk enhances savings. While we remain a bit skeptical of the scalability of bundled payments across different clinical areas, managing an efficient, seamless episode of care is a capability all health systems must develop—and BPCI-Advanced will provide a critical window into the ability of a large cohort of providers to execute against that challenge.

Penalizing nursing facilities for excess readmissions

We’re always interested to read the work of Kaiser Health News reporter Jordan Rau, who has been tracking the impact of value-based care reforms for several years and is one of the most data-driven journalists in healthcare. His new piece this week is worth a look: drawing on an analysis of data from CMS, he looks at the results from the first year of Medicare’s Skilled Nursing Facility (SNF) Value-Based Purchasing (VBP) program. Implemented as part of 2014’s Protecting Access to Medicare Act, the program evaluates the rate at which SNFs readmit patients to inpatient hospitals within 30 days of discharge, comparing their performance to how they did in previous years, and how other SNFs are performing. A follow-on to the Hospital Readmissions Reduction Program, which has been in place since 2012, the SNF VBP program puts in place a scheme of bonus payments and penalties for SNFs, aiming to reduce unnecessary readmissions. Starting this October, and lasting through the end of next September, SNFs will receive extra payments or have payment withheld for services based on their 2017 rates of readmissions. According to Rau’s analysis, nearly 11,000 SNFs will be penalized across the coming year, with another 4,000 receiving bonuses. Payments amounting to $316M will be shifted from poor-performing SNFs to high-performing ones.

In the states with the best-performing SNFs, which include Washington, Idaho, Alaska and Hawaii, the redistribution of payment will be close to equal—half receiving bonuses, half being penalized (with the exception of Alaska, where 7 of the state’s 9 SNFs will earn bonuses). On the other end of the scale, more than 85 percent of Arkansas, Louisiana and Mississippi SNFs can expect to see their reimbursement docked in 2019 as a result of 2017 performance. Next up for a similar value-based reimbursement program are home health agencies, which have been a test-bed for Medicare VBP since 2016.

Overall, Medicare’s effort to reduce readmissions has been successful, with the rate of 30-day readmissions falling for several years following the 2012 implementation of the hospital-based VBP program. One concern we have: Medicare’s focus on controlling readmissions using incentives may be leading to a “squeezing the balloon” effect: readmissions “corrected” after 2012 because hospitals traded off lower length of stay (the primary incentive of the DRG system) for lower readmission rates (often letting patients stay longer to avoid bounce-backs). Will SNFs “correct” their readmissions level by refusing to admit sicker patients who might be more at risk for readmission? If so, we’ve merely traded one problem for another. A better solution—one that’s part of accountable care organization (ACO) and bundled payment approaches—is to build the incentives around a longer episode or period of time, rather than a single metric. Those may prove to be more reliable vehicles to achieve sustainable reductions in unnecessary readmissions.

Let your patients sleep 

Writing for the New York Times’ Upshot column, healthcare economist Austin Frakt reminds us of something that seems like common sense: patients recovering from illness or surgery need a good night’s sleep, even more than the rest of us. The science is well-documented: short sleep duration is associated with hypertension, mood disorders, delirium and increased use of sedatives, which carry their own risks including increased falls and addiction. But given the noise level in hospitals and routinized nature of clinical care, it’s next to impossible for even stable patients to get several hours of uninterrupted sleep while in the hospital. Frakt points to an excellent piece by physician Dr. Peter Ubel, who shares his experiences as a patient recovering from kidney surgery. Ubel recalls being awakened every hour by a beeping alarm or staff drawing blood or taking vitals. Most frustrating was knowing, as a doctor, that these middle-of-the-night tasks were almost entirely unnecessary for a stable patient and merely a vestige of hospital routine and culture.

A handful of hospitals have started to implement (rather obvious) solutions. Don’t clean the floors at 3 am. Install sound-dampening tiles and flooring. Schedule vitals checks around patient needs, not staff shift changes. Consider a nighttime “quiet period” for stable patients, which has been shown to reduce the need for sedatives in elderly patients by 62 percent. While these may all seem like common sense measures, it’s easy to see the tension with entrenched hospital operational practices. Standardized vitals checks allow for better use of nurses’ time. Getting a midnight CT scan is good use of expensive equipment during a slow shift. Use of specialized staff prevents drawing blood and dispensing medication at the same time. Some of these routines have been created with the goal of standardizing care or reducing labor costs—but many are done because that’s how they’ve always been done. Reworking routine care and operations to allow for needed rest during recovery is more complex than a lay person would expect, but it is a necessary and important element of patient-centered care.

Many thanks for taking time out to read the Weekly Gist. (It was a long one this week!) As always, we’re deeply appreciative of your feedback, your support and the opportunity to share ideas and engage in dialogue with so many of you. We’d be grateful if you’d share this with a friend or colleague who might find it of interest, and even better if you’d encourage them to subscribe!

And of course, don’t hesitate to reach out if there’s anything we can do to be helpful with whatever you’re working on. You’re making healthcare better—we want to help!

Best regards,

Chas Roades
Co-Founder and CEO

Lisa Bielamowicz, MD
Co-Founder and President