Primary Cares Initiative Tests Value-Based Pay—Will It Work for You?

By Krishnan Narasimhan M.D.
May 8, 2019

The road from fee-for-service payments to value-based care has been a bumpy one for the entire health system. Current models have not found the most effective way to pay and incentivize primary care.

At an April 22, 2019 event in Washington, DC, the US Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) announced new payment models that aim to transform primary care through value-based options. This Primary Cares Initiative 1 will also test financial risk and performance-based payments for primary care physicians. The voluntary initiative includes five new payment models under two paths—Primary Care First (PCF) and Direct Contracting (DC). These models will be rolled out in 20 states starting in 2020. Continue reading “Primary Cares Initiative Tests Value-Based Pay—Will It Work for You?”

The Physician Side of the Medicare-For-All Debate

By Krishnan Narasimhan M.D.
February 28, 2019

As the 2020 presidential campaign is getting into high gear with a host of candidates, health care continues to take center stage. Specifically, the Medicare-for-all proposals from Democratic candidates and members of Congress have become a key issue. These proposals could represent the biggest access change in health policy since the Affordable Care Act.

It pays for physicians to understand and be engaged in health policy as it will dictate their practice life, their patient’s health, and the future of health care. However, unraveling competing proposals is not always easy. Let’s take a deeper look. Continue reading “The Physician Side of the Medicare-For-All Debate”

Why Physician Leaders Can No Longer Ignore Health Policy

By John E. McDonough
January 24, 2019

For most physicians and physician leaders, health policy is an annoyance and distraction that happens “over there” in Washington DC, state capitals, and elsewhere.  The ways and means of politics and policy making are mysterious and not worth the bother.

In today’s U.S. health care system, that attitude makes less and less sense from institutional, professional, and personal points of view. Continue reading “Why Physician Leaders Can No Longer Ignore Health Policy”

Making sense of opioid prescribing in the midst of the overdose crisis

By Sarah Wakeman, MD
September 18, 2018

In the face of a growing crisis of overdose deaths, predominantly driven by opioid-related fatalities, there has been a tremendous focus on decreasing the prescribing of opioid pain relievers. The reason for the drive to reduce prescribing is pretty simple; when we looked at the onset of the current crisis of opioid-related deaths, it was strongly correlated with rising rates of prescription opioids and treatment admissions for prescription opioid use disorder. As policy makers and clinicians looked at this correlation, a simplistic narrative emerged. If increased prescribing rates “caused” the overdose crisis, then reducing prescribing should curtail deaths. Unfortunately, as the saying goes, “For every complex problem there is an answer that is clear, simple and wrong.” As prescribing rates have decreased over the past five years, we have seen opioid-related deaths increase significantly. Continue reading “Making sense of opioid prescribing in the midst of the overdose crisis”

Improving Health Outcomes by Healing Our Communities

By Ted A James, MD, MHCM, FACS
May 31, 2018

The Paradox of U.S. Health Care

We are not as good as we should be. Despite incredible technological advances and high-levels of spending, compared to other countries, the U.S. health care system fails to achieve superior outcomes on many key health indicators including life expectancy, infant mortality, and preventable disease. Although we are capable of delivering some of the most exceptional care in the world, we do not do so reliably or in a well-coordinated manner. According to recent studies from the Commonwealth Fund, the U.S. tends to excel in doctor–patient relationships, wellness counseling, shared decision making, and chronic disease management. However, we operate in a system plagued with major disparities in access to primary care and gross social inequities. Innovations in our approach to health care are required in order to address these challenges and remove the barriers they present to providing reliable and sustainable care for all patients.  Continue reading “Improving Health Outcomes by Healing Our Communities”

Gun Violence as a Public Health Issue

By Ajay K. Singh, MBBS, FRCP, MBA
November 21, 2017

An interesting viewpoint about gun violence was recently advanced by Nicholas Kristof (with Bill Marsh) in the New York Times.

Kristoff argues that a blanket opposition to guns hasn’t worked and that an alternative approach of regulating guns should be considered. He advocates a “public health approach.”

The article cites some staggering facts:

  1. Guns per 100 people—for the US, 88.8; the next closest Switzerland at 44.7; Canada comes in at 30.8 and Japan 0.6.
  2. Murders per 100,000 people—the US 3.0; the next closest Italy at 0.7; Canada comes in at 0.5.
  3. Research on guns: from 1974 through 2012, the NIH funded just three research awards.

The Kristof article makes some sensible recommendations that seem to resonate with Americans. Here are three that caught my eye:

  1. Background Checks—93% of Americans surveyed agree and yet 1 in 5 guns are obtained without one. Nearly 90% of Americans agree that the mentally ill shouldn’t be buying guns.
  2. Safe storage—making sure guns are inaccessible to children and have trigger locks.
  3. Banning under-21-year-olds from purchasing guns—we don’t let them drink, but allowing a teenager to buy a semi-automatic gun seems sensible?

Other ideas that we could consider with a public health approach include taking a systems approach. How can the health system help reduce gun violence?

  • Could the primary care doctor ask patients about gun ownership, and perhaps even counsel them about safe gun use?
  • Does integrating educating patients about safe storage and making sure guns can’t be fired accidentally seem to make a lot of sense?
  • Could research be funded that predicts which individuals are prone to gun violence? Perhaps, high-risk individuals could be screened and then offered help by the health system?
  • Could sensible controls be built-in that, on the one hand preserve privacy, but at the same time regulate access to guns in people with mental illness? Should people with personality disorders or a history of psychotic illness be allowed to buy guns without undergoing some secondary screening? On a related note, merging databases that screen people as a part of a “background check” with databases that record diagnoses around mental health could be developed.

Whether gun violence abates in the US is a complicated question. At one level, solutions are a function of societal trends, politics, and the power of the gun lobby. Still, thinking about novel ways to frame an important problem isn’t a bad idea. Gun violence kills people, and as Kristof suggests, emphasizing and framing it as a public health issue makes sense. Has anything else worked?

Learn more about Health and Health Care Disparities from a panel of HMS experts.

Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

Share your thoughts on solving America’s gun violence crises in the comment section below.


HMS Responds to the Opioid Crisis with Education

Harvard Medical School’s dean, George Daley, recently hosted a panel presentation to highlight “the transformative role that education can and should play in solving the opioid crisis.” HMS speakers at the event presented a three-pronged approach taken by the medical school to address the current epidemic of opioid use and abuse which includes educating medical students, health care professionals, and the general public. Other notable invitees spoke about health care policy in our government.

The following is a summary of the event by Dean David Roberts, one of the presenting speakers:

By David Roberts, MD
HMS Dean for External Education
October 13, 2017

On October 3rd, my colleagues Todd Griswold, Bertha Madras, and I joined Massachusetts governor Charlie Baker and HMS dean George Daley to make a presentation on Harvard Medical School’s response to the opioid crisis. The live-streamed event held at the HMS Martin Conference Center was attended by a large in-person audience with an additional remote audience of more than 6,000 viewers.

For my part, I presented on the great work Harvard Medical School teams are doing creating free online learning resources for clinicians, recovery coaches, first responders, and family members who are wrestling with the opioid crisis every day. Continue reading “HMS Responds to the Opioid Crisis with Education”

Tort Reform and Health Care Costs

By Ajay K. Singh, MBBS, FRCP, MBA
August 31, 2017

The country gyrates and convolutes about whether Obamacare should be repealed and replaced, but the larger discussion should center on how to reduce health care costs.

One significant contributor to escalating health care costs is the impact of malpractice. An article published by Michelle Mello and colleagues in Health Affairs discusses the impact of medical malpractice on the US health care system. It estimates that in 2008, medical malpractice, including defensive medicine, cost $55.6 billion or about 2.4% of total health care spending.

Currently, having passed the House of Representatives, federal tort reform legislation is stuck in the US Senate . The nonpartisan Congressional Budget Office estimates that enacting federal tort reform would save approximately $14 billion over five years and $50 billion over 10 years. Some key features of the tort reform proposal languishing in Congress include a cap on non-economic damages, a three-year statute of limitations on medical liability suits from the date of injury, and a “fair-share” rule in which a defendant would be liable only for his or her share of responsibility for a medical injury.

One criticism of tort reform is whether it works, and in particular whether it could be implemented in the US. A recent article by Vishal Khetpal in Slate on reforming medical malpractice caught my eye.  The article makes two points:

  1. Tort reform that creates a no-fault compensation system has worked in several countries such as Sweden, Denmark and New Zealand.
  2. The US has implemented a system for patients harmed by the administration of a vaccine—the National Vaccine Injury Compensation Program. This system does seem to work.

The other criticism is that tort reform might reduce clinical quality and clinical outcomes. But the authors of an interesting article in the Journal of Public Economics disagree.

The President of the American Medical Association, Dr. David O. Barbe, MD, has been  quoted in Modern Healthcare by Mara Lee: “This legislation is an important step toward fixing that system—a step that reins in defensive medicine, reduces the growth of health care costs and strikes the correct balance by promoting speedier resolutions of disputes—while maintaining an injured patient’s access to just compensation.”

Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.


Supervised Injection Sites: A Boston Doctor Speaks Out

(photo: Massachusetts General Hospital, Boston. Ma.)

June 29, 2017

Dr. Sarah Wakeman speaks about the process that informed her opinion on supervised injection facilities:

Opening supervised injection sites to address the opioid crisis in America is a controversial subject. Dr. Sarah Wakeman, the medical director of Massachusetts General Hospital’s Substance Use Disorder Initiative and Addiction Consult Team, has something to say about it.

As a staunch supporter of evidence-based treatment for patients with substance use disorders, you may hear her expert opinion by clicking on the brief video below…

Do you have an opinion to share as well, or questions for Dr. Wakeman? Use the comment section to start a conversation about supervised injection sites.

Read more posts by Dr. Sarah Wakeman:

Waiting for Addiction Treatment: A Deadly Proposition
Summary: Dr. Wakeman discusses the results of a randomized pilot study of interim buprenorphine dosing for individuals with opioid use disorder.

Harvard Medical School is offering free online accredited CE/CME courses in identifying and treating opioid use disorder for physicians, physician assistants, nurse practitioners, nurses, and social workers. Each course contains additional resources to assist health care providers in treating patients with opioid use disorder. Select a course below to learn more and enroll:

Understanding Addiction

Identification, Counseling, and Treatment of OUD

Collaborative Care Approaches for Management of OUD

Dr. Sarah Wakeman is medical director of the Substance Use Disorder Initiative and the Addiction Consult Team at Massachusetts General Hospital (MGH), co-chair of the Mass General Opioid Task Force, and clinical lead for the Partners Healthcare Substance Use Disorder Initiative. Dr. Wakeman is also an assistant professor in medicine at Harvard Medical School and course director for Understanding Addiction. Twitter

(photo credit:


Waiting for Addiction Treatment: A Deadly Proposition

By Sarah E. Wakeman, MD, FASAM
May 3, 2017

In a 2016 research letter to the New England Journal of Medicine, Dr. Sigmon and colleagues describe the results of a randomized pilot study of interim buprenorphine dosing for individuals with opioid use disorder.1 Interim buprenorphine dosing means offering medication alone to people on a waiting list to get into a buprenorphine treatment program, which generally involves medication plus counseling. This study randomized patients to either staying on the waiting list or getting just the buprenorphine administered at home by an automated and locked pill dispenser. The results were compelling. All of the participants who remained on the waiting list continued to use illicit opioids. In contrast, the majority of those treated with buprenorphine stopped using opioids completely, with abstinence rates of 88%, 84%, and 68% at 4, 8, and 12 weeks (P<0.001 for all comparisons). Continue reading “Waiting for Addiction Treatment: A Deadly Proposition”