Consulo Indicium - 9/14/18

Information for your Consideration…

 Breastfeeding And Stupidity – At the July World Health Assembly in Geneva the delegates barely passed a resolution promoting breastfeeding.  What?  Barely?  Why?  Because the USA delegation – by completely ignoring all available scientific evidence on the benefit of breastfeeding – put forward a resolution to remove language asking the governments of the world to “promote, support, and protect” breastfeeding.  These same USA delegates also wanted a resolution which discouraged the promotion of food products (i.e. infant formulas mixed with untreated water in developing nations) that have deleterious health effects on infants. Just one small statistic among the extensive body of literature on the benefits of breastfeeding suffices.  In a 2016 study reported in The Lancet, universal breastfeeding was highlighted as the approach that would save the lives of more than 823,000 children and 20,000 mothers with an overall savings in excess of $300B worldwide.  In my book, those are real savings across the board.  As a Family Physician I always, always, always tried to get the Moms I cared for to adopt breastfeeding and almost all did so…  Let’s not let the stupidity of delegates rein unharnessed.  I’m apoplectic and – that’s after nearly four weeks of waiting to write about it…  Argh!!

Should We Get Excited?  Or? – In a step that could very well move data sharing in a new direction for the health care community, Alphabet, Amazon, IBM, Microsoft and Salesforce recently announced that they intend to put energy and resources into solving the incorrigible problem of “interoperability.”  While I have many complaints about the health care system and how we could fix them – this singular issue is the elephant in the room of all problems facing health care.  Here’s the joint statement that they released:

 “We are jointly committed to removing barriers for the adoption of technologies for healthcare interoperability, particularly those that are enabled through the cloud and AI.  We share the common quest to unlock the potential in healthcare data, to deliver better outcomes at lower costs.”

Unfortunately, the bulk of money in information technology support was used over the last decade in making our filing systems electronic rather than addressing the core problem of moving information around seamlessly.  As a result, the big winners have been the big EMR companies, among them Cerner and Epic as two notable examples.  Data from one does not move seamlessly to the other.  While their effort is to be applauded, there is a need for one more change if interoperability is to be realized in the short-term.  We need to address incentives.  The healthcare system needs to move toward value-based reimbursement instead of fee-for-service models.  Why?  Because in value-based systems, the results are measured based on “results” or “outcomes” rather than just “doing”.  Without that shift, the front lines will not be incentivized to get behind the IT company’s quest.  It takes more than a bunch of IT companies making a statement of commitment  to realize interoperability.  What are your thoughts?

Leadership Through Walking – I got a notice recently from The Wharton School about an old tool that has gotten new support as part of the armamentarium of effective leaders – walking. It actually seems to be the rediscovery of something Nietzche said over a century ago: “All truly great thoughts are conceived by walking.”  Read the study to get the details but it’s compelling.  The folks at Wharton even offer up places that help you engage in active walking, including: 1) walk in the city, 2) walk in nature (NOTE: that must be “rural” as compared to city?); and, 3) walk in the forest (also, mostly rural 😊).  The study also noted that even walking on a treadmill increased creativity by 60% and that backpackers scored 50% better on creativity tests during a wilderness trip (again, rural 😊) compared to their pre-trip performance. It seems to be the New Old Thing.  Consider it.  Enjoy it.  Take your dog along. My faithful companion – Toto – loves it!!

Follow The Money – The Medicare Payment Advisory Commission (MedPAC) recently reviewed a Medicare staff proposal that would create a unified payment system for skilled nursing facilities (SNFs), long-term care hospitals (LTCHs), home health agencies (HHAs); and, inpatient rehabilitation facilities (IRFs).  Under the new payment model, payments would be based on patient characteristics rather than the site location where services are provided.  In addition, the model would create two payment tiers – a basic tier for “typical patients” (yet to be fully identified); and, an advanced tier for “patients with highly specialized care needs” (e.g. post-hospital stroke rehabilitation, ongoing cancer care treatment, ventilator care, etc.).  The intent is to reduce the disparities in payment for equivalent services that are provided by the different agencies. For example in 2016, HHAs received only $18.1 billion for 6.5 million episodes versus SNFs receiving $29.1 billion for 2.3 million stays.  In addition, the new payment model would stipulate requirements for patient care regardless of location. The full Medicare report is available for review. The report is now out for review.  Expect the health care community to weigh in with financial losers complaining and financial winners championing the changes.

What Is The House Of Medicine And Health Care Doing To Stop The Anti-Vaccine Movement? – In a harbinger of things to come here in the USA, the Wall Street Journal recently reported that Romania has been combating a measles outbreak since 2016.  In fact, the London School of Hygiene and Tropical Medicine in a 2016 survey reported that 7 out of the 10 countries with the strongest skepticism about vaccination safety were in Eastern Europe. The Romanian outbreak has resulted in more than 15,000 people with measles infections resulting in 59 deaths.  The anti-vaccine movement is alive and well here in the USA as well.  It’s spread by specious arguments that seem to drift hither and yon on various web sites.  As I read the article, it occurred to me that we – the medical and health care professions – are NOT doing enough to combat bad information.  And, it’s not just about vaccines.  There are a whole host of issues that are percolating up with inaccurate and even dangerous mis-information.  The professions should ban together to prevent this type of spurious information.  

Fighting Back…Finally! – It’s all too common.  Whether it’s IV bags, Lidocaine, tetracycline or some other common product – the shortage of common tools and products used in the treatment of problems is becoming all too common.  In an effort to solve the problem, Intermountain Healthcare along with HCA, Mayo and other providers plus support from a number of foundations have decided to get into the generic drug production business by starting a company Civica Rx.  And, it’s not just the shortages that are a problem.  It’s also the outrageous cost for some of these medications, devices and products despite their longstanding use in the medical community.  It’s simply a matter of price gouging.  The new company is going to focus its initial efforts on producing and marketing 14 common generic drugs that are in short supply or whose prices have abruptly increased in recent years. Applause, applause!!  Even better, the Association for Accessible Medicines – a generic drug manufacturer trade group – issued a statement extending support to the initiative by stating that it "welcomes into the generic drug manufacturing community any entity that shares our commitment to bring safe, effective and affordable treatment options to patients, providers and payers."

Consulo Indicium - 8/17/18

Information for your Consideration…

Drug Overdose Deaths: Moving From Shrugging Shoulders To Action – The death toll from drug overdose – in particular, opioids – continues to climb, increasing to more than 72,000 Americans in 2017 or, about a 10% over the prior year. The deaths from drug overdoses even exceeds the highest recorded levels for car accidents and gun-related deaths and outpacing influenza, pneumonia and suicide – which makes the tragedy all that much worse.  So, the question is Why?  According to the CDC, the cause is because “…overdose deaths involving synthetic opioids rose sharply, while deaths from heroin, prescription opioid pills and methadone fell.”  Furthermore, certain areas of the country have been hit harder than others.  The New England states and Appalachia have been particularly hard hit with West Virginia at the top – tipping the scale at nearly 59 overdose deaths per 100,000 residents.  But, something can be done that’s not being done.  As Patrice A. Harris, M.D., chair of the AMA Opioid Task Force, noted, “We know what works. We can point to states where making access to medication assisted treatment (MAT) has been a priority, and the mortality rates are doing down.”  Such programs need to be uniformly available across the entire country.  The hold up is primarily with state legislatures making the investments. Now is the time for the medical community to step forward and aggressively push for programs at the state level. 

Meanwhile, at the state level, one example of state action is the lawsuit by New York state which was filed against Purdue Pharma.  The reason?  The state alleges that the pharma manufacturer of fentanyl misled physicians on the safety of the drug which has been linked to the addiction, overdose and deaths of many people throughout the nation.  In announcing the lawsuit, Governor Andrew Cuomo stated: “The opioid epidemic was manufactured by unscrupulous distributors who developed a $400 billion industry pumping human misery into our communities.”

In The Nick Of Time Or, So We Hope – The Alzheimer’s research world was abuzz recently when Eisai, a Japan-based drug company, and Biogen announced the results of BAN2401.  The drug was used in a trial involving 856 patients from across the USA, Europe and Japan who exhibited early signs and symptoms of cognitive decline with a diagnosis of either mild cognitive impairment or mild Alzheimer’s dementia.  The key issue is that all of the patients had significant accumulations of the amyloid protein, the clumps or plaques which are present in brain for those people with the disease.  The essence of their finding was that for the first time in a large clinical trial, a drug was able to both reduce the presence of plaques and slow the progression of dementia in patients with the disease.  In prior research with other drugs, amyloid levels have been reduced but the memory decline and other cognitive difficulties continued so there was, in essence, no relief.  However, for this study – at the high dose given – both amyloid levels and cognitive loss declined compared to patients who had received the placebo.  Now, to be cautious, this was a Phase 2 study and other drugs have shown promise at this stage only to fail at Phase 3 trials.  So, we shall wait and see – but, with anticipation!!  For those of us with Alzheimer’s in our family history (the cause is unknown), we are continuously vigilant and anxious about what comes next…

Believe It Or Not – A new study by the Brookings Institute revealed that ACA (= ObamaCare) “premiums would likely be decreasing next year if the Trump administration and congressional Republicans had left the law alone”.  The data from the study showed that the premiums would be 4.3% lower.  Why?  Because the healthier people leave the individual market which raises premiums for those who stay and keep their insurance in place because they are most likely at higher risk.  For those of us who are cynics – these are the “intended consequences” of dismantling the program.  But, I’m taking the long view.  My prediction: we will be back to something like ObamaCare in the not-too-distant future.  Remind me that I predicted this in case I forget (SEE prior note).

Shulkin’s Legacy Lives On At The VA – In a long awaited decision, the Department of Veterans Affairs finalized a new rule that will allow providers to treat patients across state lines using tele-technologies.  It’s part of the ongoing movement toward the use of virtual technologies for enhancing and delivering care.  The big obstacle to the advancement in use of virtual technologies has been state licensure laws which have required that anyone being treated at an in-state entity be licensed in the state.  The new rule finalizes a proposal from last year which laid out the approach for the VA to override state licensing restrictions so clinicians can treat veterans from anywhere in the country. It’s a legacy of David Shulkin, MD’s leadership when he announced about one year ago the VA’s Anywhere to Anywhere, telecare initiative. The VA’s leadership is a harbinger of what’s to come. 


Information for your Consideration…

 Let’s Start With Some Good (Wonderful) News – The Centers for Disease Control and Prevention (CDC) recently announced that the rate of smoking continued to drop by reaching a NEW LOW of 14% last year!!!  The prior year, in 2016, the rate was 15%.  The anti-smoking campaigns, cigarette taxes and smoking bans in cities and states across the country were major factors contributing to the decrease.  We’ve seen a drop from 42% in the early 1960s.  Wow!  That’s impressive…

 Money, Money, Money – This past week, the updated changes to the 2019 Physician Fee Schedule and Quality Payment Program were sent out by the Centers for Medicare and Medicaid (CMS).  The good news is that for several decades, physicians have billed Medicare after completely documenting the details of each patient visit with a set of evaluation and management codes.  Most clinicians would argue that the codes are onerous without contributing much value to the ongoing care of a patient.  However, next year, the E&M documentation process is going to change dramatically by through a proposed simplification of the documentation requirement process.  The intent is to provide clinicians more flexibility.  We shall see…  In addition – on a topic near and dear to my heart – CMS is also proposing that doctors be paid for the time they spend communicating with patients over the phone or via other telecommunication channels, regardless of whether a face-to-face office visit or other service has been rendered. The proposals even call for physicians to be paid for the time they spend reviewing patient images or video.  All I can say is – It’s about time!!  Now, the proof will be in the pudding as they say in the kitchen.  But, lest we think that all is sweet smelling roses with the new CMS proposals, it also appears that some specialties are going to take deep cuts in their payment schedules.  Where one part of the medical community wins, another part is gored.  We need to move to value-based payments if we want to get beyond these kinds of battles…

At the same time CMS is moving to change physician reimbursement, the US Senate Finance Committee has reported that it will be taking up reconsideration of how rural hospitals are paid under the national program.  The Committee report stated that it would, “rethink Medicare payment policy for rural hospitals”.  Committee members are evidently focused on considering a move toward the success of global budget demonstrations in contradistinction to the current Medicare payment structure which is designed around the issues related to high volume and frequency of inpatient stays.  In addition, the Committee recommended that HHS Secretary Alex Azar “…do more for rural providers, particularly when it comes to regulatory relief.”

Then, Move On To The Problem Areas – Like The Growing Urban-Rural Economic Gap – A new report was recently released by the Brookings Institute providing an analysis of metropolitan economic growth compared to their surrounding areas.  In sum, the 300 largest metros in the world accounted for 36% of global employment growth and 67% of GDP growth between 2014-2016.  At the same time, these same metros only represented 21.9% of the population growth. The disproportionate growth of these metros is causing an increased gap between them and their surrounding, more rural areas.  And, most importantly – it’s a universal phenomenon across virtually all the nations of the world (See full report here). And, increasingly, if one considers the politics as well as the economics, the divide is not just economic.  Witness the recent electoral votes in the UK, Austria, Turkey and even the US where there were clear and distinctive divides in political outcomes at both ends of the spectrum depending on where one lived.  It’s the rurals (or, “populists” or “economic have nots”) versus the urbans (or, “elites” or, “economic haves”).  As an example, what have we done to provide further education and support for the dislocation in the coal mining industry?  Promises of “bringing back” the industry are hollow at best.  But, doing nothing is also hollow at best.  We have a problem and it will only get worse in my estimation.  I suggest we get on with it…because with the growing gap there will be continued growth in dislocation, animosity and economic disadvantage.  And, over the long term that is simply not sustainable. 

The Symbiosis Of A Diminishing Workforce And Rising Health Care Costs – Now that Boomers have moved through the red wagon-, Schwinn bicycle-, college experimentation-, early mortgage-, child rearing-, empty nesting-stages of life – they are rapidly shifting gears towards retirement or a simple downshift in life at a rate of 10,000+ per day.  The impact is reshaping the USA economy with fewer workers to support a burgeoning elderly population that will substantially increase their consumption of health care services after age 65.  According to the Centers for Medicare and Medicaid Services (CMS), the data falls out accordingly:

  • Children (0 – 18) will consume $3,572 (female) to $3,680 (male) per capita
  • Working-Age Adults (19 – 64) will consume $5,353 (male) to $6,892 (female) per capita with the Medicaid spend about a third higher for women and even more for men due to the number of disabled male enrollees; and,
  • Elders (65 and older) will spend $17,530 (male) to $19,110 (female) with the larger spend for women due to a higher percentage living in nursing homes in the later year at a rate of nearly twice that of men.

These data points do not bode well for the USA economy.  Why?  Because the rate of health care spend has been outstripping the GDP growth since 1970.  We are now at nearly 19% of GDP devoted to health care.  Furthermore, in 2017 there were 25 Americans 65+ for every 100 working age folks growing to 35 by 2030 and 42 by 2060.  If we don’t do something, the burden will become unsustainable.  Either a massive backlash will occur among the Millennials who will be stuck with the costs or some other solutions will need to occur (immigration for instance…).  While I don’t anticipate reaching 2060, I hope my kids will and – I don’t want them to be burdened by bad decisions we made in the early part of the 21st century.  Make sense?  If so, we need to raise our voices…

Then, There’s Workforce Automation – It seems like every day there’s a new report on the automation of work.  From self-driving vehicles (think taxi cabs and long-haul trucks) to intelligent algorithms and predictive analytics (think statisticians and financial analysts) to machine learning and artificial intelligence (think dermatologists and hospitalist physicians) the tools which are driving workforce automation are at play.  A study done by researchers at Oxford University in 2013 suggested that nearly half of all jobs in the USA were at risk of “computerization.” More recently, the Pew Research Center surveyed experts in the field of robotics and computing and found similar predictions on the displacement of jobs over the coming decades which will have profound implications for both workers (i.e. our children and grandchildren) and society as a whole. Perhaps all this talk is having an impact on worker attitudes.  Fully two-thirds of workers feel that by 2050 their work will be done by robots!  Hmmm – that leaves a lot of time for exercise to stay healthy so that we can live better longer, engage in real human interaction that is truly connected to the person we are engaging; and, participate in other kinds of activity where robots are not so good like cooking, art, music and dance renaissance.  First, let me say that all of these areas are very, very hard professions that require a commitment just as strong as STEM, the professions or any other areas of professional pursuit.

But, the fact of the matter is that we are at the formative stages of the digital revolution which much like the Neolithic Revolution and Industrial Revolutions before it caused massive societal disruptions.  The difference was that the Neolithic lasted several thousand and the Industrial nearly 150 years.  The Digital will likely last just about another 20 years.  The data listed below from the Pew Research Center shows clearly that people are concerned.

The extent to which robots, algorithms and protocols make the human workforce more efficient and, therefore, less dependent upon sheer brute force of people power is an open question.  But, it’s safe to say that we are on the horizon of a major shift in how work will be accomplished. 

 Studies were recently completed by ShiftLabs – a collaboration between the Rockefeller Foundation and New America on the shakeup in the jobs market for Phoenix and Indianapolis.  It’s very clear from the study that people are going to be required to learn new skills that will radically reconfigure their occupation and the training/education required for it.  To give you a flavor of their findings, the study noted that restaurant workers (e.g. food service workers, waiters and cooks) will lose the most jobs, followed by retail and sales people with cashiers at a 97% risk of losing their job to automation – think going to the grocery store and those quick, automated lines or, simply the automation of the regular lines. And, the list goes on. 

In the field of health care, the risk is slightly less with the study showing that nurses had only a 50% risk of professional automation.  I actually have likened the use of these new technologies as the renaissance of health care through the use of “clinically augmented intelligence.”  I’ve said this before having once been a patient in the ICU and surrounded by the best of the best technology that medicine had to offer.  It was not the technology that made me feel “taken care of”.  Rather, it was the nurse who held my hand and reassured me that all would be well.  Such is health care.  So, we should anticipate that we will become more efficient, more effective and less reliant upon people power to manage the care delivery process.  Learning how to integrate these new capabilities will be the challenge.  Anticipate more discussion on this topic as the journey continues. 

 A Plethora Of Telehealth Information – It seems that the floodgates have been lifted.  We are awash in a rising tide of information on the use of telemedicine technologies related to the delivery of care.  While I can say, “It’s about time”, I can also say, “Let’s be diligent!”  I would encourage any executive team that is considering the use of telehealth technologies to pursue it with vigor and resolve.  It is the future.  But, go into the future with eyes wide open.  Here is a starter list of information from various websites on nuggets of information to consider related to telehealth:

Consulo Indicium 6/18/18

Information for your Consideration…

 A Diversionary Thought:  I Thought I Was Useful – As most of my readers know, I moved into executive and managerial roles some time ago and when I’m asked by those I met the question – “So, where do you practice?” – my usual response is: “On United Airlines!”  I answer that way because for the last 20+ years it seems that the clear majority of my time has been spent on planes traveling across the world.  So, you can imagine my dismay when I recently picked up The New York Times and there was an article titled: “Is There a Doctor on the Plane? Increasingly, Airlines Hope Not”.  I’ve always known that there was a company in the background someplace providing support to the flight attendants and pilots on in-flight medical emergencies.  Evidently, the major company is MedAire, Inc. which provides services to more than 100 airlines – and, by all accounts very high-quality support.  According to their data, only 1.6% of their flights are “diverted” for a landing due to an in-flight medical problem which generally costs about $200,000 – so the emphasis of the airlines is to avoid diversions.  Now the diversion results of MedAire are different than the results of a study reported in a 2013 issue of the New England Journal of Medicine which revealed that there was a medical emergency once in every 604 flights and 7.3% led to diversions.  The study also reported that 0.3% of medical emergencies on planes end in deaths. The dismaying part of the article was the statement that the airlines “hoped” that no physicians were available on the flight in large measure because in-the-air physicians have a much higher propensity for diverting a plane to land.  It got me thinking.  What were my results?  So, I did a quick tally.  Over the last 20 some years, I’ve experienced about 3 – 5 “medical emergencies” with 0 deaths and only 1 diversion – which was for a gent who was having chest pain and all the symptoms of a myocardial infarction.  But the vast majority of my clinical experience has been related to in-flight patients who either drank too much the night before or the hours before a flight or, drank too much during the flight.  These have been interspersed with “real” medical emergencies like acute asthma due to peanut dust in the air, an apparent appendicitis (although I never did get the final diagnosis), a TIA-like presentation and other assorted “real” experiences.  My most challenging was when one of the flight attendants collapsed in the cockpit and I had to work with the crew to extract her from the floor so that they could continue the flight.  We made it…  Anyway, I decided that zero deaths with one diversion is a record that’s not bad.  Hopefully, United will continue to let me fly the (increasingly less) friendly skies. I expect to continue answering the call when I hear, “Is there a doctor on board” or the flight attendant approaches me with a quiet whisper, “Dr. Fickenscher, please come with me right now!”

Politics Before Health Care So That Health Care Trumps Politics – Lancet had a very interesting article several weeks ago entitled, “The world has been warned” by Richard Horton. The essence of the article is that it makes the case for greater involvement by the health care professions in the politics of the day if we are going to be successful in continuing to make the case that investments in health care research and programs make a difference for society.  Our focus tends to be on the more immediate questions related to patient care services with strong advocacy for a proper financing and functioning of the health system. Beyond those core areas of focus, the health professions tend to scatter.  The article makes the case the we need to listen to the advice of the economist, Dambisa Moyo, Ph.D. who argues in her new book Edge of Chaos (2018) that the support for public investments in health programs and services is weakening.  Why?  She argues that it all comes back to sustainable economic growth and development – which is not the first order of concern among most health care professionals.  Without it; however, the ability of governments to provide the necessary funds for health care programs will wane even though demand is rising.  In fact, her central argument is: “politics, and not economics, will be the key driver of human progress and prosperity in years to come”.

In essence, the message is that threats to democracy, factors that diminish economic growth (e.g. growing debt, aging of the populace, natural resource depletion, deepening income disparities and a host of other “economic” considerations are key factors that will be driving the health care debate in future years.  We need to listen.  The point of the article by Horton is that “Taken together, these pathologies are laying foundations for an unprecedented period of government failure, political instability, social fracture, and community unrest.”  You definitely need to read this article and check out Moyo's conclusion that, “liberal democratic capitalism is in retreat”. There are ten prescriptions offered that could help move us back toward a position of stronger support of health care – a core offering of most governments throughout the world.  The ten prescriptions have little to do with health care and everything to do with democratic stability.  Check it out. 

Are We Prepared For Value-Based Care?  Short answer, “No!” A new study of over 900 physician organizations by Black Book, a consulting firm, reveals that physician organizations are increasingly concerned about their readiness for the move toward value-based care.  Independent and physician-led practices represented 72% of the study group. The essence of the findings; however, was that the groups felt that they were not prepared for a move toward value-based payments.  In fact, the study found that 93% of the practices did not have a strategic plan in place "for transforming [to] population health management or value-based care solutions…”  My prediction: The coming decade will be littered with also-ran medical groups that failed to prepare for a tsunami of change that is about to sweep the fiscal structure of our health care delivery models.  The current system is unsustainable from a purely financial perspective.  The Boomers (my generation) will bankrupt the nation if we continue the current course.  Change will be led by the states.  It already is!  Things need to change. 

Secondhand Smoke And Marichiwanna – A new study was recently published online in the journal Pediatrics suggesting that the warnings we’ve made about the use of cigarettes in the home by parents should also now be extended to the use of marijuana in the home.  The assessment of the study was that “an increase in parents smoking pot around their children could undo decades of effort to protect” children from the effects of secondhand smoke. The homes as risk were those where parents already smoke cigarettes.  In those families, the percent of marijuana smokers increased from 11% (2002) to 17% (2015), a notable rise versus those families where cigarette smoking did not exist with an increase of 2% to 4%, respectively.  I mean, after all, smoke is smoke…

Healthy Diets = Big Brains – In a new 10-year study from the Netherlands, it was determined that eating a healthy diet like the Mediterranean diet seems to be associated with larger brain volumes. In fact, the brain matter in these individuals had a higher volume of grey and white matter along with a larger hippocampus.  The study is consistent with my wife’s missive that I need to eat six cups of fruits and/or vegetables every day, less red meat and less fat (i.e. far less bacon).  And, potatoes are not considered a vegetable in her ruling which doesn’t make sense to a farm boy of German heritage unless I decide to become Greek – which she notes is always a good option!  But, I’m learning that I should not argue!  Besides, now I have a reason – a bigger brain.  That and $2.00 will get a Grande dark roast at Starbucks.  But, we do seem to be getting consistent results related to the impact of the Mediterranean diet.  It’s worth adopting in my estimation.

Sovereignty Of The Tribes Indirectly Challenged – The US Department of Health and Human Services is seemingly stumbling into what could become a decade long litigation nightmare as it continues down the track of requiring Native Americans to hold jobs to keep their health care.  The move by HHS directly assaults long held agreements between the US government and the tribes by challenging tribal sovereignty which has been recognized for centuries – not, decades.  The Trump Administration has put forward a proposal stipulating that the tribes are a racial group and not separate governments.  Needless-to-say, the reaction from the tribes and many members of both parties was quick and negative.  In making the preliminary ruling, the feds are passing along the implementation to the states which will no doubt result in a series of inconsistent proposals and approaches toward the tribes.  This is not an arcane legalistic argument.  Rather, it cuts to the core of agreements made between the US government and the tribal nations over the last two hundred some years.  The decision has also split the department where the political appointees have taken a seemingly softer position (i.e. let the states work it out) while the HHS Office of General Counsel have taken a distinctly opposite position (i.e. work requirements apply to everyone and the tribes are not exempt).   So, the question is whether the Trumpee discord will be resolved in the Agency or in the courts?  HHS political leaders have tried to avoid the controversy by suggesting the matter is a local issue that could be resolved as the federal government and states negotiate the parameters of their proposals. But, duly negotiated agreements between sovereign tribes and the US government would be a difficult thing to undo to say nothing of the political fallout.

Here A Tweet, There A Tweet, Everywhere A Tweet, Tweet – It was only a matter of time before academia caught on to the use and impact of Twitter.  In fact, in a recent article, Jason Frank, MD (@drjfrank), a clinician-educator at the Royal College of Physicians and Surgeons of Canada (@RoyalCollege) made a bold statement when he offered this thought: “Within the next decade, you won’t be able to be a successful scholar without having some activity on social media.”  Hmmm…  Dr. Frank’s thinking is that social media is becoming a ubiquitous tool for sharing one’s scholarship, engaging with the public on the findings of research, advocating for change in public policy and in building new social networks.  His contention is that Twitter offers a means for educators, clinicians, and researchers to communicate directly and accelerate information sharing by extending the network from a handful of conference attendees to a worldwide audience of involved researchers.  In fact, the data from a recent Pew Research Center study supports the notion that the use of social media is growing substantially among researchers (See graph below).  While I’m not going to get in the way of this rapidly moving train, I would like to point out that we need to be highly attuned to the unintended consequences of social media use as it relates to public perception and interpretation of information.  My fear is that the nuance of an issue or problem or research finding cannot be effectively conveyed in many – if not most cases – with a string of 140   characters.  So, the question for academia is: what are the ground rules for engaging in the use of social media?  How should this new communication form be integrated into traditional avenues?  And, what types of research needs to be completed to affirm the adopted approach?  It’s clear that social media can have a very positive impact on research and the sharing of research results.  We need to foster its use and support its deployment.  But, let’s also keep a watchful eye on the results…

Percentage of All American Adults and Internet-Using Adults  Using at Least One Social Networking Site

social graph

Source: Pew Research Center surveys, 2005-2006, 2008-2015. No data are available for 2007.

Far be it from me that “Dr. Change” would get in the way of “change”.  At the same time, I’ve strongly advocated for adapting to rather than resisting change, I’ve also always stated a strong belief that it is incumbent upon those of us who are change agents to monitor what we change since the unintended consequences will sneak up on us over time…

Consulo Indicium 5/11/18

Information for your Consideration…

Technology Reading Your Mind – And, you thought it was way out into the future…  Researchers at MIT Media Lab have been working on a wearable device that can read your mind – literally.  The device is like an extended ear piece for a mobile device except that it has an elongated attachment that follows your jawline and attaches to the skin just under the lower lip.  It picks up neuromuscular activity in the face and jaw which are activated by verbalizations.  The result is that this activity has been translated into the specific words, thereby allowing verbalization of your thoughts.  Dubbed the AlterEgo, the device is now at 92% when trained with a limited vocabulary of 20 words.  But, after all – it is only May 2018.  Just think what it will be able to do by Christmas!!

Cost Of Health Care Continues To Increase – It’s not too surprising but a recently released study reveals that the major drivers of high healthcare costs in the USA are essentially higher prices for nearly everything—from physician care to hospital services to diagnostic tests and on to pharmaceuticals to say nothing of the costs associated with administrative complexity. The study was completed by researchers from the Harvard Global Health Institute and the London School of Economics and published in the March 13, 2018 issue of JAMA (Journal of the American Medical Association).  The researchers compared USA health care cost data with 10 other comparable countries (i.e. Australia, Canada, Denmark, France, Germany, Japan, the Netherlands, Sweden, Switzerland, and the United Kingdom) on nearly 100 data points. 

And, the findings?  In no surprise to many of us, the study confirmed that USA health care costs are way higher with worse population health outcomes and less access to care than all of the other wealthy countries. For example, the USA percent of GDP for health care in 2016 was 17.8% and growing.  The next highest was Switzerland at 12.4% to a low of 9.6% for Australia.  In a point of further humiliation, our USA life expectancy was the lowest of the entire group at 78.8 years (range = 80.7-83.9 years); and, the percent of the USA population with health insurance coverage was 90% - again lower than all of the other nations (range: 99%-100% for the remaining 11 nations).  I recommend that you read the study.  It blows away a lot of myths about USA health care.  Folks…I keep saying it: “We’ve got a problem”.  If we continue the current course with the current demographic trends, the entire system is unsustainable.  Health care is Job #1 in America but: 1) not well understood, 2) complex, 3) system-centric rather than consumer-centric; and, 4) disconnected from the average person because of the way health insurance is structured.  Change will happen one way or the other.  Either we lead the change or change will happen to health care.  Either way – it’s moving forward… 

Not That I’m A Bearer Of Bad News, But – Since I’m on a downer today, I thought you should also be aware of that the well-being of USA citizens took a hit in 2017, according to the annual Gallup-Sharecare Well-Being Index results released last month. In fact, 2017 saw the worst decline in well-being in the 10-year history of the survey, marking the worst results since the Great Recession. The top five states in well-being included:

  1. South Dakota (64.10)
  2. Vermont (64.09)
  3. Hawaii (63.39)
  4. Minnesota (63.12)
  5. North Dakota (63.06) – we’ll stop right here :-) 

Something is going right in the Upper Midwest.  Perhaps it’s the winter storms?  Or, the prairie mentality?  Any ideas on why? 

“It’s Not The Money, It’s The Money!” – I’ve used this moniker before which I learned from a close friend and colleague nearly 30 years ago in referencing the problems with the health care system.  So, it wasn’t surprising to learn that 71% of the Medicare Shared Savings Program ACOs recently indicated that were likely to leave the program if forced to take on risk.  The results came from a survey conducted by the National Association of ACOs (NAACOS).  In responding to the survey, the ACOs noted that the three biggest reasons for their decisions were: 1) the risk is too great, 2) ACO and CMS rules are too unpredictable; and, 3) the financial projections are often unreliable. As Clif Gaus, President/CEO of NAACOS, in responding to the results of the survey noted, "It's naïve to think ACOs that aren't ready will be forced into risk in what is ultimately a voluntary program. The more likely outcome will be that many ACOs quit the program, divest their care coordination resources and return to payment models that emphasize volume over value."  Such a result would be a wrong turn at the busy intersection of health care…

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