Tag Archives: Primary

Eric Adams Wins Democratic Primary for NYC Mayor

Mr. Adams held off Kathryn Garcia after a count of 118,000 absentee ballots saw his substantial lead on primary night narrow to a single percentage point.

Eric L. Adams, who rose from poverty to become an iconoclastic police captain and the borough president of Brooklyn, won the Democratic nomination for mayor of New York City on Tuesday, according to The Associated Press, putting him on track to become the second Black mayor in the history of the nation’s largest city.

The contest was seen as one of the city’s most critical elections in a generation, with the winner expected to help New York set a recovery course from the economic devastation of Covid-19 and from the longstanding racial and socioeconomic inequalities that the pandemic deepened.

But as the campaign entered its final months, a spike in shootings and homicides drove public safety and crime to the forefront of voters’ minds, and Mr. Adams — the only leading candidate with a law enforcement background — moved urgently to demonstrate authority on the issue.

Mr. Adams held an 8,400-vote lead over Kathryn Garcia, a margin of one percentage point — small enough that it was not immediately clear whether she or any of his opponents would contest the result in court. All three leading candidates had filed to maintain the option to challenge the results. If no one does so, Mr. Adams’s victory could be certified as soon as next week.

The results came after the city’s Board of Elections counted an additional 118,000 absentee ballots and then deployed a ranked-choice elimination system — the first time New York has used it in a mayoral election.

Kathryn Garcia moved ahead to second place on the strength of ranked-choice balloting but could not surpass Mr. Adams.
Desiree Rios for The New York Times

Thirteen Democratic candidates were whittled down one by one, with the candidate with the fewest first-place votes eliminated, and those votes were redistributed to the voters’ next-ranked choice. Maya Wiley, a former counsel to Mayor Bill de Blasio who emerged late in the primary as a left-wing standard-bearer, was eliminated following the seventh round of tabulations.

Ms. Garcia won far more of Ms. Wiley’s votes than Mr. Adams did, but not quite enough to close the gap.

Still, it was a striking result for Ms. Garcia, a candidate who until recently was little known and who lacked the institutional support and the political operation that helped propel Mr. Adams, a veteran city politician.

In heavily Democratic New York City, Mr. Adams will be the overwhelming favorite in the general election against Curtis Sliwa, the Republican nominee and the founder of the Guardian Angels.

“While there are still some very small amounts of votes to be counted, the results are clear: An historic, diverse, five-borough coalition led by working-class New Yorkers has led us to victory in the Democratic primary for mayor of New York City,” Mr. Adams, 60, said in a statement.

“Now we must focus on winning in November so that we can deliver on the promise of this great city for those who are struggling, who are underserved and who are committed to a safe, fair, affordable future for all New Yorkers,” he added.

Neither Ms. Garcia nor Ms. Wiley has conceded, and their campaigns noted that the results were not yet completely final.

“Today, we have nearly final results for Democratic primary for mayor,” a Garcia campaign statement said. “We are currently seeking additional clarity on the number of outstanding ballots and are committed to supporting the Democratic nominee.”

The final-round matchup between Mr. Adams and Ms. Garcia illustrated sharp divisions within the Democratic Party along the lines of race, class and education.

Mr. Adams, who cast himself as a blue-collar candidate, led in every borough except Manhattan in the tally of first-choice votes and was the strong favorite among working-class Black and Latino voters. He also demonstrated strength with white voters who held more moderate views, especially, some data suggests, among those voters who did not have college degrees — a coalition that has been likened to the one that propelled President Biden to the Democratic nomination in 2020.

Ms. Garcia, a former sanitation commissioner who ran on a message of technocratic competence, had strong appeal to white moderate voters across the five boroughs.But she was overwhelmingly the candidate of Manhattan, dominating in some of the wealthiest ZIP codes in the country. She strongly appealed to highly educated and more affluent voters across the ideological spectrum there and in parts of brownstone Brooklyn, even as she struggled to connect with voters of color elsewhere in the kinds of numbers it would have taken to win.

The results capped a remarkable stretch in the city’s political history: The race began in a pandemic and took several unexpected twists in the final weeks. Most recently, it was colored by a vote-tallying disaster at the Board of Elections, leaving simmering concerns among Democrats about whether the eventual outcome would leave voters divided and mistrustful of the city’s electoral process. In a statement Tuesday night, Ms. Wiley thanked her supporters and expressed grave concerns about the Board of Elections.

“We will have more to say about the next steps shortly,” the statement said. “Today we simply must recommit ourselves to a reformed Board of Elections and build new confidence in how we administer voting in New York City. New York City’s voters deserve better, and the B.O.E. must be completely remade following what can only be described as a debacle.”

Under the ranked-choice voting system, voters could rank up to five candidates on their ballots in preferential order. Because Mr. Adams did not receive more than 50 percent of first-choice votes on the initial tally, the winner was decided by ranked-choice elimination.

Ms. Garcia came in third place among voters who cast ballots in person on Primary Day and during the early voting period, trailing both Mr. Adams and Ms. Wiley. But on the strength of ranked-choice voting, she surged into second place, with significant support from voters who had ranked Ms. Wiley and Andrew Yang, a former presidential candidate, as their top choices.

Ms. Garcia and Mr. Yang spent time during the final days of the race campaigning together and appearing on joint campaign literature, a team-up that plainly benefited Ms. Garcia under the ranked-choice process after Mr. Yang, who began the race as a front-runner but plummeted to fourth place on Primary Day, dropped out.

Hilary Swift for The New York Times

Ms. Wiley, a favorite of younger left-wing voters, had sought to build a broad multiracial coalition, and she earned the support of some of New York’s most prominent Democratic members of Congress.

Mr. Adams and Ms. Garcia both ran as relative moderates on policy issues, including policing, education and their postures toward the business and real estate communities.

Mr. Adams especially put issues of public safety at the center of his campaign, pushing for urgent action to combat a rise in gun violence and troubling incidents of subway crimes as well as bias attacks, especially against Asian Americans and Jews. While crime rates are nowhere near those of more violent earlier eras, policing still became the most divisive subject in the mayoral race.

Mr. Adams took a more sweeping view of the Police Department’s role in ensuring public safety than a number of rivals did.

But some older voters had first heard about Mr. Adams when he was a younger member of the police force, pushing to rein in police misconduct.

That background helped him emerge as a candidate with perceived credibility on issues of both combating crime and curbing police violence. And some Democrats, aware that national Republicans are eager to caricature their party as insufficiently concerned about crime, have taken note of Mr. Adams’s messaging — even if his career and life story are, in practice, difficult for other candidates to automatically replicate.

“What Eric Adams has said quite well is that we need to listen to communities that are concerned about public safety, even as we fight for critical reforms in policing and racial justice more broadly in our society,” said Representative Sean Patrick Maloney, a New York Democrat and the chairman of the Democratic House campaign arm, who endorsed Mr. Adams the day before the primary.

While Mr. Adams was named the winner on Tuesday night, he faces significant challenges in unifying the city around his candidacy. He has faced scrutiny over transparency issues concerning his tax and real estate disclosures; his fund-raising practices and even questions of residency, issues that may intensify under the glare of the nominee’s spotlight, and certainly as mayor, should he win as expected in November.

Michael Gold, Dana Rubinstein and Emma G. Fitzsimmons contributed reporting.

Author: Katie Glueck
Read more here >>> NYT > Top Stories

Bragg Holds Lead in Manhattan District Attorney Primary

Mr. Bragg and Ms. Farhadian Weinstein both have substantive legal pedigrees. Mr. Bragg graduated from Harvard Law School, clerked for a federal judge in New York and worked as a defense and civil rights lawyer. He first worked as a prosecutor in the state attorney general’s office, became a federal prosecutor in Manhattan and then returned to the attorney general’s office, where starting in 2013, he led a unit charged with investigating police killings of unarmed civilians. He eventually rose to become a chief deputy attorney general.

Erin E. Murphy, a law professor at New York University who supports Mr. Bragg, said that the combination of the candidate’s policies and his racial identity was key to understanding how he might lead the office.

“When we’re in this moment of racial reckoning, it’s really important the leader of the Manhattan D.A.’s office understands the real concerns about public safety that exist in our communities but also that they understand that the police themselves can be a harm-causing agent in the community,” she said.

Ms. Farhadian Weinstein graduated from Yale Law School, clerked on the Washington, D.C., Court of Appeals and the Supreme Court, served as counsel to the former United States attorney general, Eric H. Holder Jr., and after a stint as a federal prosecutor in Brooklyn was on the leadership team in the Brooklyn district attorney’s office.

The district attorney’s office has had only two leaders in close to 50 years, and the current officeholder, Cyrus R. Vance Jr. has held his seat for more than a decade. He was considered one of the most progressive prosecutors in the United States when he was first elected in 2009. But since he took office, a wave of prosecutors have won elections by pledging to make their offices less punitive and less racist, a trend that has changed the way that such races are run.

In the opening months of this year, it looked as if the Democratic primary for Manhattan district attorney would follow suit, with Ms. Aboushi, Ms. Orlins and Mr. Quart tipping the balance of the race toward the left. But as Ms. Farhadian Weinstein emerged as a financial powerhouse and gun violence rose in certain areas of the city, the focus of the race changed, and she and Mr. Bragg began to be seen as front-runners.

Author: Jonah E. Bromwich
This post originally appeared on NYT > Top Stories

Primary Day in New York: Rain, Short Lines and a New Kind of Ballot

It appeared ranked choice was having an unusual effect on some New Yorkers: They were civil. Political rancor had no place on the street corner, the two volunteers agreed — particularly when voters could select both of the candidates.

“Be rude?” Mr. Bruce said. “Who, moi?”

On the pavement outside of a polling place in the Chelsea neighborhood of Manhattan, Evelyn Yang, the wife of Andrew Yang, a candidate for mayor, was making her own ranked choice, of sorts: In chalk, she wrote her husband’s name on the concrete — just above a chalk doodle in support of Kathryn Garcia, one of his rivals. Over the weekend, the pair of opponents had formed an alliance and campaigned together.

“I love ranked-choice voting; I think it should be the future, not just here in New York City but around the country,” Mr. Yang said. “In some cases that might require a little more time to tabulate the results. But every vote should be counted, and I’m willing to be patient.”

“New Yorkers are not a very patient lot,” Mr. Yang said with a laugh.

Not everyone agrees: Eric Adams, the presumed front-runner, has criticized the ranked-choice system and said that Mr. Yang’s alliance with Ms. Garcia, though a typical tactic in such elections, was intended to dilute Black voting power.

After voting at Brooklyn Arbor Elementary School in Williamsburg, Vismar Dominguez, 40, was heading with his godsons to Zeff’s Pizzeria across the street to celebrate. He was hopeful about his preferred candidates’ chances, but said he felt like the ranked-choice voting was a waste of time.

“I think it’s useless because I only wanted to vote for the guy I wanted,” Mr. Dominguez said. “Before it would have taken me two minutes to vote. That took me 10, and it felt pointless.”

As Josh Klinski, 43, a grant writer, left P.S. 84 José de Diego in Brooklyn, he said he felt good about his choices for mayor — but utterly mystified at the actual tallying process.

Author: Sarah Maslin Nir
This post originally appeared on NYT > Top Stories

Yang concedes as Adams takes lead following chaotic New York primary

Polls closed at 9 p.m in the primary, New York City’s first ranked-choice mayoral election. Yang was trailing well behind Adams, the Brooklyn borough president, who had a comfortable lead in first-choice votes by 11 p.m., followed by Kathryn Garcia and Maya Wiley. The two are now neck and neck for second place.

The winner of Tuesday’s Democratic primary will face Republican nominee Curtis Sliwa in the general election. But the Democrat is almost certain to become mayor and will arrive at City Hall during a time of unique challenge: Recovering from high unemployment, flattened tourism and a chaotic school year of remote learning spurred by the Covid-19 pandemic.

At the same time, if a sustained rise in violent crime continues apace, Mayor Bill de Blasio’s successor will confront a rash of shootings and hate crimes that continue to threaten the city’s recovery.

Crime frequently topped polls as a leading concern among voters, vaulting Adams — a former police captain who ran almost singularly on a promise of restoring safety to the city — into first place and minimizing the impact of the “defund NYPD” movement that got a foothold in city politics last year.

“New Yorkers are feeling this energy,” Adams told reporters in Manhattan Tuesday morning, repeating his campaign pledge to drive down shootings.

Yang, the former presidential candidate, Garcia, the former sanitation commissioner, and Wiley, former counsel to Mayor Bill de Blasio, formed the top-tier of the crowded race in recent weeks. Yang and Garcia were the only ones to form a late alliance in the race, a common move in other ranked-choice campaigns around the country.

The Democratic nominee will not be officially determined until the city Board of Elections releases its tally of absentee ballots on July 6. Further extending the ballot count is the advent of ranked-choice voting, which allows New Yorkers to select up to five candidates for each position. The system kicks in when no candidate attains 50 percent of votes on the first pass. The board plans to issue preliminary results of ranked ballots on June 29.

Yang spent months in first place after bursting into the primary with high name recognition and a relentlessly positive message. He filmed an ad riding the famous Cyclone roller coaster to tout the city’s comeback, made a show of buying movie tickets with his wife when theaters reopened and took on the powerful teacher’s union over school closures.

But the city’s steady reopening throughout the spring took some of the wind out of Yang’s sails, and his campaign faltered amid a series of public mistakes that critics said demonstrated what they had feared all along: A candidate who never voted in a mayoral election during his 25 years in the city lacked the municipal know-how for the job.

Sensing the public’s growing concern over crime, Yang adopted a strong anti-crime posture, but it was difficult to wrest the issue from Adams, who boasted 22 years on the police force and spoke openly about being assaulted by cops as a Black teenager in Queens.

The two developed a bitter rivalry, which was on full display during televised debates. Yang has recently taken to questioning Adams’ true residence following a story by POLITICO detailing confusing answers and botched paperwork about where he lives.

Adams and his surrogates went as far as accusing Yang and Garcia of attempted voter suppression of Black New Yorkers by teaming up in the final days of the race. They said their joint appearances were part of a strategy to appeal to one another’s supporters, but Adams slammed the arrangement, at one point invoking poll taxes that were employed to suppress Black votes.

Garcia, the city sanitation commissioner under de Blasio for seven years, made a surprising surge in her first bid for public office. She was lagging in the polls and facing difficulty fundraising, but the coveted endorsement of the New York Times and Daily News editorial boards helped propel her to the top tier late enough in the race that she did not sustain many negative attacks. In recent weeks, Adams began airing ads attacking her.

Wiley, the leading progressive candidate, competed for attention and endorsements with city Comptroller Scott Stringer and nonprofit CEO Dianne Morales, and didn’t pick up sufficient steam until each of their campaigns imploded.

Wiley decided to join the race last summer, as the city was gripped by police accountability protests that matched her passion and experience. But the ground shifted under her and her law enforcement reform agenda did not end up matching the wishes of a majority of voters.

As they chose their candidates Tuesday, voters also weighed in on the new voting system and offered a variety of reactions.

“I like having the option,” said Shannon Sciaretta, 24, of Queens. “Instead of picking one candidate I can pick a bunch of them, and maybe one of them will stick.”

Others were less enthused.

“I thought the whole thing sucked,” said retiree R. Reiser, 66, after casting his ballot on Manhattan’s Upper East Side. “There’s so many candidates and there are so many offices and the information available was really tough to get … You don’t know what anybody stands for.”

Author: Sally Goldenberg and Tina Nguyen
This post originally appeared on Politics, Policy, Political News Top Stories

Three tricky primary school maths questions that leave adults scratching their heads

And the third and final problem involves another picture.

The picture features different pieces of fruit and sums and asks people to work out how many pieces of fruit are left.

The first sum shows that three apples equals 60.

The next one shows that cherries plus two bananas equals 20.

An apple plus two bananas equals 38.

So what is the sum of an apple plus cherries plus a banana?

You have to work backwards through each sum to reveal the numeric value of each fruit.

Here’s a look at the answers to the questions.

1. 12

2. There are 12 triangles.

3. The answer is 31.

The value of the apples is 20 (60 divided by three), bananas are nine (18 divided by two) and cherries are two.

So how did you do? Let us know in the comments below.

Author:
This post originally appeared on Daily Express :: UK Feed

In a Possible First, Primary Care Practice Opens in Cancer Center

Dr Nicholas Petrelli

Patients with cancer will now be offered primary care in the same place as they have their cancer treatment and management, in a development in Delaware that appears to be a first in the United States.

This combination of primary care and multidisciplinary cancer care “all under one roof is highly unusual among major cancer centers,” said Nicholas Petrelli, MD, medical director at the Helen F. Graham Cancer Center, Newark, Delaware, in a press statement.

The organization, which is a National Cancer Institute-designated center and part of the regional ChristianaCare system, said it was “among the first…in the nation” to do so. But that claim was a cautious hedge. “We believe we are the very first to actually do this,” a spokesperson told Medscape Medical News in an email.

Like most major US cancer centers, Graham already offers “urgent” or acute primary care to patients who have suddenly arising cancer-related complications such as neutropenic fever, pain, and dyspnea. The goal of such care is to avoid costly — and uncomfortable — emergency department admissions for sick patients.

However, the new offering consists of “nonurgent” primary care for chronic illness such as hypertension, diabetes, and other conditions that every internist and family practitioner sees — and which can impact cancer treatment in some cases.

The news was met with hope, enthusiasm, support, and skepticism by a number of experts asked for comment by Medscape Medical News.

“That’s absolutely outstanding,” said William Dunson, MD, of Huntsman Cancer Institute in Salt Lake City, Utah, about Graham’s initiative. “If they really have the intent to do full primary care, I’m impressed.”

Dunson, who is medical director of acute care service, said this effort is a “very noble undertaking” because primary care generally “isn’t financially viable.”

Leading centers such as MD Anderson in Houston and Memorial Sloan Kettering in New York City have “massive” acute care clinics, he observed. “But none of the bigger centers are claiming they are doing primary care or would want to do primary care. Most cancer centers don’t want to be in that business,” he added.

Dunson also questioned whether Graham’s service would follow patients temporarily or “longitudinally,” with the latter being a hallmark of primary care.

Ana Maria Lopez, MD, MPH, a medical oncologist at Jefferson Health New Jersey and president-emeritus of the American College of Physicians, likes the concept at Graham. “Cohabiting the same physical space would help facilitate coordinated care,” she said. “High blood pressure or diabetes don’t take a break while cancer is a focus. They impact each other,” Lopez explained.

Katherine O’Brien, a patient with metastatic breast cancer in Illinois, also saw upsides: “What Graham is doing can only help primary care providers gain a more in-depth understanding of cancer, its treatment, and cancer patients’ realities.”

Patients can be alienated by a provider’s lack of familiarity with cancer, said O’Brien, who has traveled as far as Boston for care.

There are many, many fine PCPs with an excellent grasp of oncology Katherine O’Brien, patient with breast cancer

A few years into her treatment, O’Brien told her local primary care physician in suburban Chicago that she had recently gone to Dana Farber for a consult. “He asked me if Dana Farber was any relation to Bill Farber in Rockford.”

She eventually switched to a provider at Chicago’s Northwestern University where her primary care is in the same complex as the Lurie Comprehensive Cancer Center, but not in the same building or suite of offices.

O’Brien, who had a de novo breast cancer diagnosis in 2009, also praised primary care physicians in a very personal way. “There are many, many fine PCPs with an excellent grasp of oncology…like my mom’s doc who instantly realized she had inflammatory breast cancer, a rare presentation.” Her mother was diagnosed in 1981 and died in 1983.

Whether or not the Graham Cancer Center in Delaware can actually provide full primary care (without big financial losses), improve provider coordination, and deepen their primary care provider’s understanding of cancer remains to be seen.

The program just started about 6 weeks ago, medical director Petrelli said.

What the organization describes as a “primary care practice” is modest, occupying a single office in their oncology express unit, an urgent care service for cancer and treatment-related complications. The practice footprint is a small sliver of the 270,000 square foot Graham Cancer Center, which occupies two multistory buildings.

The practice is staffed by a single nurse practitioner and runs from 8 AM to noon, Monday to Friday, with plans to extend hours eventually.

The nurse practitioner, Debra Delaney, RN, MSN, who has a background in trauma and acute care, had seen “a couple of patients last week,” said Petrelli. “We’re advertising it slowly,” he explained, to avoid “opening the floodgates.”

In an informal survey of patients, the center concluded that “as many as 30%” of its patients with cancer did not have a primary care physician. But Petrelli said the number could be as low as 15%; either way, the pilot program is worth doing, he said.

The center has approximately 3300 new cancer cases a year, so at most they could accrue between 495 to 990 new primary care patients.

“I’m fairly certain it’s going to work in view of what we’ve seen so far,” said Petrelli.

How Urgent Care Makes Money

There is a clear, documented need for urgent care clinics at cancer centers — unlike, perhaps, onsite primary care for chronic conditions.

For example, at the Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas, after the urgent care clinic was established in 2012, emergency department visits among its patients fell by half, research shows.

That matters because patients with cancer are among the highest healthcare resource users in the United States, which was one of the drivers behind the creation of these less costly acute care clinics, which are widely credited as being effective.

Urgent care is not true primary care, said Dunson from the Huntsman Cancer Institute. He and a team of four advanced practice clinicians tend to primary care issues like hypertension, but only when they are “out of control.” And patients are liaised back to their primary care provider as soon as safe and possible.

Dunson, who is an internist, also said he would one day like to run a primary care practice at a cancer center, but it does not seem feasible at this time.

What is feasible is acute care. Huntsman’s service is available 8 AM to 7 PM, Monday to Friday, and is “like a clinic, ER, and ICU all combined into one service,” with the goal of not just avoiding ER visits but admissions to hospital, he said.

“Our service costs the [University of Utah] hospital money, but we make it up in other areas,” he observed. Laboratory tests, CT scans, MRIs, EKGs, echocardiograms, intravenous antibiotics and fluids for acute care patients allow the hospital to generate revenue in other departments like radiology and compensate for operating loss of the service.

There are many acute care clinics in the United States but “all are slightly different,” he said.

Moffitt Comprehensive Cancer Center in Tampa, Florida, has been closest in combining acute care and primary care but probably still doesn’t qualify as doing so, according to Dunson.

Moffitt urgent care has 27 dedicated beds and is open 24 hours a day, 7 days a week for cancer and treatment-related complications.

However, the Florida provider explicitly says that potential urgent care patients “are advised to call their primary care provider first if they have medical [noncancer-related] concerns.”

Also, Moffitt has an ambulatory internal medicine clinic, which sees a mix of patients, including those who are “high-risk” and need to be assessed prior to surgery as well as patients actively receiving cancer treatment who also need smoking cessation, diabetes or blood glucose management, thyroid care, or blood pressure management, said a spokesperson.

Thus, there is a limit to exactly what Moffitt provides in its primary care clinic.

Jefferson’s Lopez says that these various models are all “great” because they seek to integrate care, which is especially helpful when other illnesses impact cancer treatment.

The “old model” of a primary care physician simply referring a patient to a cancer center or oncologist “may not work so well anymore” because of the potential for “disjointed” care in many cases, she added.

The Black Box Effect

 Misunderstanding between oncologists and primary care providers regarding management of comorbidities in patients with cancer may occur in the realm of the finer details, research indicates.

For example, a 2019 study of staff at three academic hospitals in New York City showed primary care providers and medical oncologists agreed that diabetes should be actively managed during cancer treatment. But more primary care providers felt looser glycemic control was allowable (56.8% vs 37.5%; P = .05) and that it was okay for patients to miss some diabetes-related visits (80.6% vs 56.3%; P = .01).

The “main advantage” with having primary care linked to a cancer center is that it facilitates communication to address such issues, commented Archana Radhakrishnan, MD, an internist at Michigan Medicine in Ann Arbor in an email to Medscape Medical News.

However, even when there is “team-based” cancer care that includes primary care, patients “often don’t know who to turn to” said Radhakrishnan, who has practiced in clinic settings with various models of cancer survivorship care.

“When there is better communication between the providers, such as identifying which provider will do what, that then can be passed down to the patient. Patients then know who to turn to, and this avoids a lot of uncertainty,” she said.

Trust between referring primary care physicians and oncologists about sharing a patient is also important, said Huntsman’s Dunson.

“We call it the black box effect — you send your patient as a primary care doc to the cancer center or major academic center and the patient disappears into a black box and you never see them back,” he acknowledged.

“It’s not always the cancer center’s fault. Sometimes it’s the patient who grows attached to their oncologist and is fearful to leave that embrace.”

In the past in the United States, there has been a blurring of the lines between urgent care, primary care, and cancer care, suggested Dunson.

“Historically, prior to the subspecialization of cancer care, the medical oncologist would not only treat the cancer, but the complications, and would also fill in as a surrogate primary care provider at the same time. Those old school oncologists are a dying breed now,” he commented.

Healthcare reform has limited oncologists’ time with patients and now “they don’t even very often handle the complications of cancer and treatment,” he said, referring to growing role of advanced practice clinicians in urgent care.

Delaware’s ChristianaCare sees another opportunity in the relationship between oncology and primary care. “We also are looking at the possibility of eventually establishing a fellowship training program in cancer medicine for our family medicine providers,” said Cydney Teal, MD, chair of the Department of Family & Community Medicine, adding that “to our knowledge, there are no fellowships or specialty training for providers who specialize in both primary as well as oncologic care.”

Nick Mulcahy is an award-winning senior journalist for Medscape, focusing on oncology, and can be reached at [email protected] and on Twitter: @MulcahyNick

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This post originally appeared on Medscape Medical News Headlines

Changes in Primary Care Could Improve Blood Pressure Outcomes

Operational changes are linked to improvements in smoking and blood pressure outcomes in primary care practice settings, new research indicates.

The qualitative analysis, published in Annals of Family Medicine, included smoking and blood pressure as separate outcome measures.

The outcomes were calculated using Clinical Quality Measure improvements, with targets of at least 10-point absolute improvements in the proportion of patients with smoking screening, if relevant, counseling, and in the proportion of hypertensive patients with adequately controlled BP. The results were obtained from practices participating in Evidence-NOW, a multisite cardiovascular disease prevention initiative. Configurational Comparative Methods were used to evaluate the joint effects of multiple factors on outcomes.

The majority of practices in the analysis were clinician owned, small (fewer than six clinicians), and/or in an urban location. The researchers sampled and interviewed practice staff from a subset of 104 primary care practices across 7 Cooperatives and 12 states, ranging from small to medium in size, having 10 or fewer clinicians. The interview data were analyzed to identify operational changes, then transformed into numeric data.

Operational Changes Led to Improvements in Specific Contexts

In clinician-owned practices, process improvement, documentation, and referral to resources, combined with a moderate level of facilitation support, led to an improvement of at least 10 points in smoking outcomes.

However, the researchers found that these patterns were not observed in system–owned practices or Federally Qualified Health Centers.

In solo practices, training medical assistants to take an accurate blood pressure led to an improvement of at least 10 points in blood pressure outcomes.

Among larger, clinician-owned practices, measurement of blood pressure a second time when the first was elevated, and documentation of this reading in the electronic heath record, also led to a 10-point or greater improvement in BP outcome when combined with a large amount (50 hours or more) of facilitation.

“There was no magic bullet for improving smoking cessation counseling and blood pressure outcomes across the diverse primary care practices studied,” lead author Deborah J. Cohen, PhD, of Oregon Health & Science University, Portland, said in an interview. “Combinations of operational changes among practice sizes and types led to improvements.”

Smaller Practices More Nimble, Experts Say

Results of the qualitative data analysis suggest that smaller and clinician-owned practices are more likely to have the capacity for change and improvement compared with larger, hospital/health system–owned practices.

Commenting on the study, Noel Deep, MD, regional medical director at Aspirus Clinics, Ironwood, Mich., said solo or small private practices have a distinct advantage over larger hospital or system-owned practices when implementing new operational changes to improve clinical outcomes.

“A smaller independent practice is nimble, with the physician [or physicians] able to make a quick decision at analyzing the scientific data, planning the changes, implementing them quickly, and doing a rapid cycle review of the results and tweaking the program to attain the targets,” said Deep, a member of the editorial advisory board of Internal Medicine News.

Kate Rowland, MD, MS, assistant professor in the department of family medicine at Rush Medical College, Chicago, also noted that smaller practices have unique advantages over larger health organizations.

“Larger organizations should replicate the benefits of the smaller office, providing as much local decision-making and autonomy as possible to the site where the changes are happening,” Rowland explained in an interview.

“The clinicians at these sites are mostly likely to know what is going to be successful for achieving measurable change in the patients they care for,” she added.

The study was funded by the Agency for Healthcare Research and Quality. The authors and other experts interviewed for this piece reported having no conflicts of interest.

This story originally appeared on MDedge.com, part of the Medscape Professional Network.

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This post originally appeared on Medscape Medical News Headlines

Medicare, Not AMA, Should Set Values for Primary Care Pay

Tucked within a new federal report on the future of primary care is a challenge to an influential panel whose approach to valuing US physician pay has been criticized for being skewed toward specialists.

The Centers for Medicare & Medicaid Services (CMS) should independently value physicians’ services, given the limits of the existing Relative Value Scale Update Committee (RUC) of the American Medical Association, according to a new report from the National Academies of Sciences, Engineering, and Medicine (NASEM).

The report, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,” released on May 4, also recommends raising the profile of primary care in the eyes of policymakers and the public.

With respect to the valuation of services, the authors of the report say it will not be possible to overhaul the current makeup of the RUC to fully overcome what they see as its deficiencies. Currently, the RUC plays an outsized role in divvying up the funds that Medicare, the nation’s largest purchaser of healthcare, spends on clinicians’ services, according to the report. CMS has had to rely too heavily on the findings of the RUC, which has “drifted away from science-based estimates toward interest group input,” the report says.

There is no regulatory or institutional block that would prevent CMS from valuing physician services independently of the RUC, the report says. Building such a base of knowledge within CMS would help move Medicare payments toward a system that does more to peg payments to patient outcomes, according to the report.

“In fact, it is hard to imagine that it could do so in the absence of an independent valuing mechanism within or external to the agency, such as the Medicare Payment Advisory Commission,” the authors of the report write.

Building this capacity would require “a relatively modest level of resources and staff” and would not prevent the RUC from continuing to make recommendations to CMS about physician pay, the report says.

Person-Centered, Relationship-Oriented Care

The recommendation regarding CMS’s need to develop new expertise in Medicare pay for clinicians was a specific recommendation included in the wide-ranging report.

Primary care should be promoted as a “common good,” the report stresses. It argues for making efforts to allow more Americans to build a partnership with a primary care clinician, which the authors depict as a bedrock of improving outcomes in the United States.

“Everyone in the country should have easy access to high quality primary care that is person-centered, relationship-oriented, and responsive to the needs of the community,” said Christopher Koller at a Tuesday press conference announcing the report. Koller is president of the Milbank Memorial Fund, an endowed foundation, and is a member of the committee that produced the report.

The wide-ranging report also offers many suggestions for elevating the profile of primary care within federal policymaking circles. These include a call for the creation of an Office of Primary Care Research at the National Institutes of Health and a recommendation that the Department of Health and Human Services establish a Secretary’s Council on Primary Care.

The report also says CMS should continue policies instituted during the COVID-19 pandemic that allowed greater use of telehealth and virtual visits.

At the press conference, Koller argued for a dramatic shift in how advocates for primary care seek funds for their field.

Too often, attempts are made to justify spending money on primary care on the view that doing so would lead to future savings in healthcare costs. Studies have not backed up such claims, which detract from more relevant arguments for expanding access to primary care, he said.

“We think it’s an unreasonable ask” to demand savings, Koller said.

Instead, advocates for primary care should argue that the field’s ability to increase life spans and preserve health is worth the investment, he said.

Challenge to AMA’s RUC

Many of the report’s recommendations center on ways to boost pay for primary care specialists.

It calls on CMS to shift away from the fee-for-service (FFS) payment model to hybrid models, which could be part FFS and partly capitated. This approach would reward clinicians who secure better outcomes and would grant payment per patient, rather than per visit or procedure, which would make them the default payment method over time. CMS should aim to increase physician payment rates for primary care services by 50%, to identify overpriced healthcare services, and to reduce their rates to accomplish this.

A key component of efforts to boost pay for primary care would be to change Medicare’s approach to reimbursement for different specialties, the report argues.

Over the years, the RUC has tilted in favor of directing higher pay to specialists who perform procedures, in part because of the composition of this panel, the report says.

“These deficiencies in the RUC process compound over time because changes to Medicare’s fee schedule must be budget neutral. As a result, primary care services generally, and evaluation and management [E/M] codes specifically, have become passively devalued in the PFS [physical fee schedule] as their relative prices fall as a result of other service prices (including new technologies) increasing.”

Primary care and other fields of medicine that focus on managing complex conditions scored at least a partial win last year when CMS opted to stick with its plans for an overhaul of Medicare’s E/M codes. The E/M overhaul reflected changes made through the AMA’s RUC. The panel responded to long-standing criticism about pay disparities.

Over the objections of many specialty groups that focus on procedures, such as surgeries, CMS finalized a 2021 payment rule intended to raise pay for primary care while making compensatory cuts in other fields.

But Congress then took steps to delay some of these changes, said Bob Phillips, MD, co-chair of the NASEM committee that wrote the report. Thus, it’s unclear at this time how meaningful the E/M overhaul will prove in addressing claims of pay disparity between primary care and procedure-focused specialties.

“There’s an embedded tragedy there and then as the rest of the RUC community thinks they’ve solved our problem…. The appetite for reopening conversations about how to redistribute resources to primary care may not be there,” said Phillips, who is also director of the Center for Professionalism and Value in Health Care at the American Board of Family Medicine.

That could leave primary care starved of resources and “anemic in its capacity to improve health and health equity,” Phillips told Medscape Medical News.

Primary care receives less than 5% of the money spent on healthcare but provides more than one third of all healthcare visits. Boosting compensation for primary care is critical to maintaining the workforce for this field of medicine, he said. Many clinicians who might otherwise stay in the field switch career paths to boost their income.

“It’s not just physicians. It’s physicians and nurse practitioners and physician assistants,” Phillips said. “The evidence shows that trainees in those areas are choosing other careers because they’ve got loans. They’ve got kids they want to put through college. They’ve got homes to buy, and the difference in income potential and the risk of burnout are both just such powerful messages to them that they’re not coming into the field, and some are leaving.”

Sean Cavanaugh, a former director of the Center for Medicare at CMS in the Obama administration, reviewed the NASEM report at the request of Medscape. In an interview, he recalled how CMS officials would try to counter the imbalances in physician payment introduced by the RUC.

He credits CMS with having begun to raise pay for primary care through the E/M overhaul. Like Phillips, he says more work is needed. He expects there will be a drift back toward distributing money from the Medicare physician fee schedule with a bias toward specialties that focus on procedures.

“I don’t think we can leave it to the RUC. We need a fundamentally different process,” said Cavanugh, now chief policy officer and chief commercial officer at Aledade, a firm that helps independent physicians participate in accountable care organizations.

When asked about the new report’s recommendation to move away from the current RUC-based system, the American Medical Assocation said in a statement, “The RUC process is credible and transparent, and relies on an evidence-based approach for making fair and objective recommendations that the government may consider in establishing Medicare payment policies. For decades, the RUC has offered recommendations that led to improved primary care payment, such as the recently implemented significant increases in payment for office visits.”

However, in an interview with Medscape Medical News, George M. Abraham, MD, president of the American College of Physicians, emphasized support for having CMS more directly assess the value of clinician services.

There’s widespread agreement in healthcare policy circles about a need for better coordinated medical care and for a reduction in the delivery of fragmented, often expensive services. Having a more “neutral” entity such as CMS review the data on costs would likely produce better outcomes, Abraham said. CMS could still consult with RUC, but it would also be taking into account the interplay of medical services and the larger goal of coordinated patient care.

“CMS could look at its overall priorities and drive the final decision in terms of how to prioritize resources,” Abraham said. He noted that Medicare has a pool of funds for paying clinicians.

“The pie is the same size. It’s just how the slices are cut,” Abraham said. “CMS is probably in the best position to decide this, because CMS sees how resources are currently spent and what all the expenses are that CMS pays for.”

ACP was among the funders of the NSEM research that led to the report. Other backers were the Academic Pediatric Association, the Agency for Healthcare Research and Quality, the Alliance for Academic Internal Medicine, the American Academy of Family Physicians, the American Academy of Pediatrics, the American Board of Pediatrics, the American Geriatrics Society, Blue Shield of California, the Commonwealth Fund, Family Medicine for America’s Health, the Health Resources and Services Administration, the New York State Health Foundation, the Patient-Centered Outcomes Research Institute, the Samueli Foundation, the Society of General Internal Medicine, and the US Department of Veterans Affairs.

Kerry Dooley Young is a freelance journalist based in Washington, D.C. She earlier covered health policy and the federal budget for Congressional Quarterly/CQ Roll Call and the pharmaceutical industry and the Food and Drug Administration for Bloomberg. Follow her on Twitter at @kdooleyyoung.

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This post originally appeared on Medscape Medical News Headlines