Telehealth Policy, Practice, and Education: a Position Statement of the Society of General Internal Medicine.

Telehealth services, specifically telemedicine audio-video and audio-only patient encounters, expanded dramatically during the COVID-19 pandemic through temporary waivers and flexibilities tied to the public health emergency. Early studies demonstrate significant potential to advance the quintuple aim (patient experience, health outcomes, cost, clinician well-being, and equity). Supported well, telemedicine can particularly improve patient satisfaction, health outcomes, and equity. Implemented poorly, telemedicine can facilitate unsafe care, worsen disparities, and waste resources. Without further action from lawmakers and agencies, payment will end for many telemedicine services currently used by millions of Americans at the end of 2024. Policymakers, health systems, clinicians, and educators must decide how to support, implement, and sustain telemedicine, and long-term studies and clinical practice guidelines are emerging to provide direction. In this position statement, we use clinical vignettes to review relevant literature and highlight where key actions are needed. These include areas where telemedicine must be expanded (e.g., to support chronic disease management) and where guidelines are needed (e.g., to prevent inequitable offering of telemedicine services and prevent unsafe or low-value care). We provide policy, clinical practice, and education recommendations for telemedicine on behalf of the Society of General Internal Medicine. Policy recommendations include ending geographic and site restrictions, expanding the definition of telemedicine to include audio-only services, establishing appropriate telemedicine service codes, and expanding broadband access to all Americans. Clinical practice recommendations include ensuring appropriate telemedicine use (for limited acute care situations or in conjunction with in-person services to extend longitudinal care relationships), that the choice of modality be done through patient-clinician shared decision-making, and that health systems design telemedicine services through community partnerships to ensure equitable implementation. Education recommendations include developing telemedicine-specific educational strategies for trainees that align with accreditation body competencies and providing educators with protected time and faculty development resources.

Changes in coverage among non-elderly adults with chronic diseases following Affordable Care Act implementation.

IMPORTANCE: Changes in insurance coverage after the Affordable Care Act (ACA) among non-elderly adults with self-reported chronic conditions across income categories have not been described. OBJECTIVE: To examine changes in insurance coverage after the ACA among non-elderly adults with chronic conditions across income categories, by geographic region. DESIGN: We compared self-reported access to health insurance pre-ACA (2010-2013) and post-ACA (2014-2017) for individuals 18-64 years of age with ≥ 2 chronic conditions, including hypertension, heart disease/stroke, emphysema, diabetes, asthma, cancer, and arthritis, across regions using a logistic regression approach, adjusted for covariates. We also assessed U.S. Census regional differences in insurance coverage post-ACA using modified Poisson regression models with robust variance and calculated the risk ratio (RR) of being uninsured by region, with the Northeast as the reference category. Within each region, we then examined changes in insurance coverage by income level among non-elderly individuals with any chronic condition. SETTING: 2010-2017 household component of the nationally representative Medical Expenditure Panel Survey (MEPS). PARTICIPANTS: All members of surveyed households during five interviews over a two-year period. INTERVENTION: Start of insurance coverage expansion under the ACA. MAIN OUTCOMES: Health insurance status. RESULTS: On average nationwide, non-elderly adults with self-reported chronic conditions experienced increased insurance coverage associated with the ACA (diabetes: +6.41%, high-blood pressure: +6.09%, heart disease: +6.50%, asthma: +6.37%, arthritis: +6.77%, and ≥ 2 chronic conditions: +6.39%). Individuals in the West region reported the largest increases (diabetes +9.71%, high blood pressure +8.10%, and heart disease/stroke +8.83 %, asthma +9.10%, arthritis +8.39%, and ≥ 2 chronic conditions +8.58). In contrast, individuals in the South region reported smaller increases in insurance coverage post-ACA among those with diabetes, heart disease/stroke, and asthma compared to the Midwest and West. The Northeast region, which had the highest levels of insurance coverage pre-ACA, exhibited the smallest increase in reported coverage post-ACA. Reported insurance coverage improved across all regions for adults with any chronic condition across income levels, most notably for very low- and low-income individuals. A further cross-sectional comparison after the ACA demonstrated important residual differences in insurance coverage, despite the gains in all regions. When compared to the Northeast, adults with any self-reported chronic conditions living in the South were more likely to report no insurance coverage (diabetes: RR 1.99, p-value <0.001, high blood pressure: RR 2.02, p-value <0.001, heart diseases/stroke: RR 2.55, p-value <0.001, asthma RR 2.21, p-value <0.001, arthritis: RR 2.25, p-value <0.001), and ≥ 2 chronic condition (RR 2.29, p-value <0.001). CONCLUSION AND RELEVANCE: The ACA was associated with meaningful increases in insurance coverage for adults with any self-reported chronic condition in all US regions, most notably in the West region and among those with lower incomes, suggesting a nation-wide trend to improved access to health insurance following implementation. However, intra-regional comparisons after ACA implementation showed important differences. Individuals with ≥2 chronic conditions in the South were 2.29 times less likely to have insurance coverage in comparison to their peers in the Northeast. Though the post-ACA improvements in reported access to health insurance coverage affected all US regions, the reported experience of those with multiple chronic conditions in the South point to continued barriers for those most likely to benefit from access to health insurance coverage. Medicaid expansion in the South would likely result in increased insurance coverage for individuals with chronic conditions and improve health care outcomes.

Primary Care Practice Transformation in the Era of COVID-19 and Beyond: Key Principles for General Internal Medicine Practitioners.

As members of the Clinical Practice Committee (CPC) of the Society for General Internal Medicine (SGIM), we support practice innovation and transformation to achieve a more just system by which all people can achieve and maintain optimal health. The COVID-19 pandemic has tested the US healthcare delivery system and sharpened our national awareness of long-standing and ingrained system shortcomings. In the face of crisis, SGIM members innovated and energetically mobilized to focus on the immediate needs of our patients and communities. Reflecting on these experiences, we are called to consider what was learned from the pandemic that applies to the future of healthcare delivery. CPC members include leaders in primary care delivery, practice finance, quality of care, patient safety, hospital practice, and health policy. CPC members provide expertise in clinical practice, serving as primary care doctors, hospitalists, and patient advocates who understand the intensity of care needed for those with severe COVID-19 infections, the disproportionate impact of the pandemic on Black and Brown communities, the struggles created for those with poor access to care, and the physical and emotional impact it has placed on patients, families, and clinicians. In this consensus statement, we summarize lessons learned from the 2020-2021 pandemic and their broader implications for reform in healthcare delivery. We provide a platform for future work by identifying many interactive elements of healthcare delivery that must be simultaneously addressed in order to ensure that care is accessible, equitably provided, patient-centered, and cost-effective.

Geographic variations in specialty distribution and specialty-related mortality.

Using data from the Centers for Disease Control and Centers for Medicare and Medicaid Services, we analyzed the relationship between specialty physician location and specialty-specific mortality rates for diagnoses where access to specialty expertise could plausibly reduce death rates. After adjustment for demographic and health indicators, counties with the highest quartile specialty physician density had lower mortality rates compared to counties with the lowest quartile. The observed association in endocrinology, infectious disease, and neurology was 10.7, 2.9 and 7.2 fewer deaths per 100,000 residents, respectively. There is an inverse correlation between the distribution of select specialties and population-level mortality.

Differences in the Complexity of Office Visits by Physician Specialty: NAMCS 2013-2016.

BACKGROUND: Specialty-to-specialty variation in use of outpatient evaluation and management service codes could lead to important differences in reimbursement among specialties. OBJECTIVE: To compare the complexity of visits to physicians whose incomes are largely dependent on evaluation and management services to the complexity of visits to physicians whose incomes are largely dependent on procedures. DESIGN, SETTING, AND PARTICIPANTS: We analyzed 53,670 established patient outpatient visits reported by physicians in the National Ambulatory Medical Care Survey (NAMCS) from 2013 to 2016. We defined high complexity visits as those with an above average number of diagnoses (> 2) and/or medications (> 3) listed We based our comparison on time intervals corresponding to typical outpatient evaluation and management times as defined by the Current Procedural Terminology Manual and specialty utilization of evaluation and management codes based on 2015 Medicare payments. MAIN OUTCOME AND MEASURES: Proportion of complex visits by specialty category. KEY RESULTS: We found significant differences in the content of similar-length office visits provided by different specialties. For level 4 established outpatient visits (99214), the percentage involving high diagnostic complexity ranged from 62% for internal medicine, 52% for family medicine/general practice, and 41% for neurology (specialties whose incomes are largely dependent on evaluation and management codes), to 34% for dermatology, 42% for ophthalmology, and 25% for orthopedic surgery (specialties whose incomes are more dependent on procedure codes) (p value of the difference < 0.001). High medication complexity was found in the following proportions of visits: internal medicine 56%, family medicine/general practice 49%, and neurology 43%, as compared with dermatology 33%, ophthalmology 30%, and orthopedic surgery 30% (p value of the difference < 0.001). CONCLUSION: Within the same duration visits, specialties whose incomes depend more on evaluation and management codes on average addressed more clinical issues and managed more medications than specialties whose incomes are more dependent on procedures.

Amino acid sequence of Japanese quail (Coturnix japonica) and northern bobwhite (Colinus virginianus) myoglobin.

Myoglobin has an important physiological role in vertebrates, and as the primary sarcoplasmic pigment in meat, influences quality perception and consumer acceptability. In this study, the amino acid sequences of Japanese quail and northern bobwhite myoglobin were deduced by cDNA cloning of the coding sequence from mRNA. Japanese quail myoglobin was isolated from quail cardiac muscles, purified using ammonium sulphate precipitation and gel-filtration, and subjected to multiple enzymatic digestions. Mass spectrometry corroborated the deduced protein amino acid sequence at the protein level. Sequence analysis revealed both species' myoglobin structures consist of 153 amino acids, differing at only three positions. When compared with chicken myoglobin, Japanese quail showed 98% sequence identity, and northern bobwhite 97% sequence identity. The myoglobin in both quail species contained eight histidine residues instead of the nine present in chicken and turkey.

The undervaluation of evaluation and management professional services: the lasting impact of current procedural terminology code deficiencies on physician payment.

The Resource-Based Relative Value Scale (RBRVS) is fundamentally undermined by the following foundational errors: (1) The full range of office-based evaluation and management (E/M) activities are not captured by the Current Procedural Terminology (CPT) code choices, (2) it places relatively high values on procedural services, (3) there is no measure of intensity for complex outpatient E/M care, and (4) its maintenance and update have been delegated to select professional societies. Limitations imposed on the development of the RBRVS dating back to the early 1980s have not been corrected. The repertoire of codes for physician office-based E/M work must be expanded to create a new topology of choices with new outpatient code families with discrete service code levels, such as comprehensive outpatient consultation care, comprehensive outpatient primary care, and limited outpatient consultation care. Service code relative values must be based on representative samples and reliable survey data, draw from the broader literature on work intensity, and be developed with accountable and representative professional engagement.

Patient Protection and Affordable Care Act: promise and peril for primary care.

The Patient Protection and Affordable Care Act (PPACA) of 2010 brings both promise and peril for primary care. This Act has the potential to reestablish primary care as the foundation of U.S. health care delivery. The legislation authorizes specific programs to stabilize and expand the primary care physician workforce, provides an immediate 10% increase in primary care physician payment, creates an opportunity to correct the skewed resource-based relative value scale, and supports innovation in primary care practice. Nevertheless, the peril is that the PPACA initiatives may not alter the current trend toward an increasingly specialized physician workforce. To realize the potential for the PPACA to achieve a more equitable balance between generalist and specialist physicians, all primary care advocates must actively engage in the long rebuilding process.

Evaluation of a video-based error correction procedure for teaching a domestic skill to individuals with developmental disabilities.

We evaluated a video-based error correction procedure for teaching four adults with developmental disabilities to set a table. Video clips were initially used as an antecedent prompt. However, only one of the adults learned to set the table with this procedure. Consequently, the remaining three adults received intervention in which the video clips were also used as part of an error correction procedure. Specifically, if the participant did not complete the step correctly after an initial viewing of the video clip, they were prompted to watch the same video clip a second time and the trainer completed that step of the task if necessary. All three adults reached 100% correct on the task analysis when the error correction procedure was implemented. This error correction procedure may be useful for individuals who fail to learn with video prompting alone.