Consulo Indicium - 11/5/18

Information for your Consideration…

Factoid – By 2020, the total volume of medical information will double every 73 days. So, the question becomes – how do we teach our young physicians, nurses and other health care providers to stay abreast of the latest and best approaches in care delivery?  It’s not just automating information.  It’s not just “augmented intelligence”.  The issue demands our immediate attention…

Factoid 02 – Medical researchers are actively studying the retina as an early-warning system for onset of not only diabetes – which is well known – but, also dementia, multiple sclerosis, Parkinson’s disease, Alzheimer’s, schizophrenia and more. I think I’ll invent a mirror that can be used for this purpose.  Darn.  I bet someone is already working on it… 

Exercise: An Old Idea Giving Shape to Better Outcomes – As we all know, falling is the bane of growing older.  Balance and proprioception become more difficult as we age.  In one of my JAMA articles that was lying on the floor waiting for me to read it – when I picked it up – I learned that an old form of aerobic training has become the new model.  In the September 10, 2018 issue of JAMA Internal Medicine, tai chi was found to be more effective than balance and strengthening exercises in preventing falls among adults.  The study came from Oregon with a randomized selection of older adults (primarily white women, average age = 78) who engaged in a twice weekly program of tai chi for 60 minutes.  After 6 months of training, the tai chi group was found to have significantly fewer falls than the traditional exercise and the control groups.  The end result: move slow, keep focused and do tai chi!!  Now, about that yoga exercise for cleansing the mind…

On The Upside-01: Healthcare Groups Oppose Rule Penalizing Use of Public Benefits by Immigrants – The Trump Administration via the Department of Homeland Security proposed a rule last month that would penalize legal immigrants for using government benefits like Medicaid.  It’s a rule that rang the alarm bells among a wide range of healthcare and public health organizations. Stepping up to the plate in opposition to the rule were the American Hospital Association, America's Essential Hospitals, the American Academy of Family Physicians and the American Academy of Pediatrics. Beyond the medical groups, there was a broad coalition of advocacy groups seeking to block the rule. According to experts in the field, literally hundreds of thousands of children and other members of low-income legal immigrant families would be forced out of participating in public programs that provide nutrition, housing and healthcare services. The opposing medical groups cited the ensuing public health dangers as a major consideration in why the rule was ill-advised.  Kudos to the health care leaders and advocates for drawing the line!!!

…And, for those who think I’m not a middle-of-the-roader…

On The Upside-02: CMS Proposes Telehealth Expansion for Medicare Advantage Plans – The Trump Administration via the Centers for Medicare and Medicaid Services made a 362-page proposal to eliminate geographical restrictions on telehealth access in Medicare Advantage (MA) plans by 2020. The change would enable those plans located in urban areas to use connected health technology services as a core component of their approach. Furthermore, the proposal would allow members access to telecare services in the home as well as through medical service locations.  The proposal was posted by CMS last week and will be available for comments through December 31st.  The proposal emanates from language in the Bipartisan Budget Act of 2018 signed into law by President Donald Trump earlier this year, which included provisions to increase the use of telehealth and telemedicine by MA plans. In issuing the proposal, CMS stated that it believes the change “…will increase access to patient-centered care by giving enrollees more control to determine when, where, and how they access benefits.” One of the benefits will be cost savings in care delivery to the tune of about $4.5 billion dollars over the next decade once implementation begins.  In other news, the Department of Agriculture announced over $39M in learning grants related to telehealth and telemedicine.  Kudos to the Trump Administration leaders at CMS!!

Rural Hospital Closures Spike – The General Accounting Office (GAO) noted recently in a late September report that a total of 64 rural hospitals closed between 2013 and 2017 which is more than twice as many closures as the previous five-year period.  The number did not include the eight that closed and then reopened.  Emily Rappleye, the Managing Editor of Becker’s Hospital Review, wrote a very concise list of “10 things” to remember about these closures.  Rather than synthesize her thoughts, I’m quoting her in the following excerpt from her article in early October.  Here are the “10 things”:

  1. “This has happened before.Between 1985 and 1988, 140 rural hospitals closed, accounting for about 5 percent of the rural hospitals in existence in 1985. These closures are credited to the then-new financial pressures of the Medicare Inpatient Prospective Payment System created in 1983.
  2. “Comparatively fewer urban hospitals closed. Forty-nine urban hospitals closed between 2013 and 2017, accounting for about 2 percent of all urban hospitals in 2013. The 64 rural closures accounted for 3 percent of rural hospitals in 2013.
  3. “Most closures – 77 percent – occurred in the South. Texas accounted for 22 percent of the closures between 2013 and 2017, more than the entire Midwest (11 percent) combined.
  4. “The hospitals that closed were predominantly for-profit. Thirty-six percent of the hospitals that closed between 2013-17 were for-profit, though for-profit hospitals accounted for just 11 percent of rural hospitals in 2013.
  5. “The hospitals that closed were also predominately designated Medicare Dependent. Of the 64 hospitals that closed between 2013-17, 25 percent were designated Medicare Dependent hospitals, though just 9 percent of rural hospitals were Medicare Dependent in 2013.
  6. “Financial issues were the root cause of most closures. The GAO notes rural hospital closures typically occurred when hospitals had negative margins and were unable to cover fixed costs.
  7. “Declining levels of inpatient care often aggravated the hospitals' financial standing. These declines stemmed from increased competition from federally qualified health systems and other larger health systems, as well as a declining rural population overall. The report notes 2010-16 was the first period of rural population decline in American history.
  8. “Medicare payment reductions were also a major factor in the closures. The GAO notes the average rural hospital in 2016 counted on Medicare for 46 percent of gross patient revenue. Medicare payment reductions across the board contribute to negative margins for rural hospitals, while reductions in Medicare bad debt payments also add financial pressure.
  9. “Medicaid payments are a boon to rural hospitals. Supporting past research, the GAO found rural hospitals in Medicaid expansion states were far less likely to close than those in states that had not expanded Medicaid as of April 2018.
  10. “More than half of the closed hospitals converted into another type of healthcare facility,such as urgent care, primary care or emergency services. Forty-seven percent ceased all services.” 

Hmmm – Social Media Use by Physicians – When I was going to medical school, we didn’t have to worry about things like social media.  Facebook, Instagram, Twitter, Snapchat and all the rest didn’t exist because there was no access to the Internet.  It’s didn’t exist, yet!  So, if you haven’t read the AMA Code of Medical Ethics  you may want to consider a closer read in lieu of yet another endless evening of “working the web”.  The Code recognizes that there is real value in the use of social media and – at the same time – a special need for caution among the physician community in how it is used. It’s becoming more and more of an issue.  The AMA is also now offering a credit-eligible CME course, Boundaries for Physicians: The Code of Medical Ethics, which provides guidance to physicians for identifying and understanding how to maintain proper boundaries with their patients and to articulate and understand the underlying importance of those boundaries to the practice of medicine. The module is not only available for CME credit but is also free to members or $20 for non-members.  It’s worth it.

Consulo Indicium - 10/11/18

Information for your Consideration…

Combatting the Opioid Menace – The US Department of Health and Human Services (DHHS) recently announced that the agency has “awarded more than $1 billion in grants to states, communities and organizations fighting the opioid crisis.” The bulk of the money ($930 million) has been allocated to support state efforts related to providing treatment and prevention services in combating the opioid problem.  DHHS also has allocated more than $350 million to community health centers throughout the nation to increase access for substance use disorder and mental health services.  The efforts are to be applauded but, we need to go beyond ex post facto treatment.  Prevention is the key and a broad strategy for engaging in prevention has yet to be put forward in an effective way.  So, let’s give the Administration credit for what’s been done but push them to do more.  The opioid problem cuts across all societal sectors.  More effort needs to be put into solving the problem…    

Health Care Leaders Group Speak Out on Top Concerns – The HealthCare Executive Group (HCEG) recently released its Top 10 list of concerns.  The group consists of provider, payor, technology and other related industry leaders who engage in a multiple day discussion before determining their consensus list of issues. The results of their list which presents challenges, issues and opportunities were as follows:

1.       Data & Analytics: Rising to the top of the list, the issue was all about leveraging the data – especially the clinical data – to manage health care more effectively and to support decision-making.

2.       Total Consumer Health: The consensus was focused on improving the overall medical, social, financial, and environmental well-being of individuals seeking health care services.

3.       Population Health Services:  There has been lots of talk about population health but not as much action.  The discussions centered on operationalizing community-based health strategies that support chronic care management, drive clinical integration, and address barriers by integrating the social determinants of health as action points.

4.       Value-based Payments: Again, another area that has gotten lots of talk and less action.  The need for systems to support the targeting of specific medical conditions to improve quality of care and manage costs rose to the top of the discussion points.

5.       The Digital Healthcare Organization: Health care is becoming a digital enterprise so literally all elements of the health care network including: portals, patient literacy, cost transparency, digital payments, mobile wearables and devices, other patient-generated data, remote monitoring, and omni-channel access/distribution of data were all issues that percolated to the top of the agenda.

6.       Rising Pharmacy Costs: Strategies to address the continuing escalation of pharma costs along with the best approaches for measuring benefits to quality of care and total healthcare costs were highlighted

7.       External Market Disruption: Suffice it to say, there was lots of discussion about the plethora of announcements emanating from new players in health care like Amazon, Chase, Apple, Walmart, Google – and, others...

8.       Operational Effectiveness: The spectrum of opportunities for creating efficiencies was discussed including: implementing lean quality programs, process efficiency (with new core business models), robotics automation, revenue cycle management, and real-/near-time point of sales transactions.

9.       Opioid Management: The struggle continues despite investments at the state and federal level for developing strategies to identify and support individuals and populations who struggle with substance abuse/addiction or are at-risk of addiction.

10.   Cybersecurity: Finally, for the fourth year in a row, cybersecurity was listed in the Top 10 list.  The protection of data by maintaining the privacy and security of consumer information and trust in sharing data were top concerns.

The Source of Academic Leadership – For the last century at least and probably longer, the USA has been a leader in academic circles.  Our research, our universities, our academicians have been the points of discovery for this little wonder we call, Earth.  It’s been the Golden Age in America.  But, we are seeing the glimmer of change on the horizon and, the challenge is coming from the East.  I remember my first visit to China in 1978 as a member of one of the very first delegations of health care professionals to visit China since before the Revolution.  We were impressed with the many public health measures that had been implemented to improve the health of the people.  It was remarkable!  But, it was also obvious that China was well behind the USA in research, acute care and much of the rest of health care.  Now, 40 years later (yes, 40 – argh), China is coming of age as a leader in the scholarly community.  In recent years, the Chinese government has shifted its focus from investments that improve agriculture and manufacturing toward more scientific efforts.  Witness the growth of investment in the technology sector as well as the fact that 11 of the top 100 universities globally are Chinese. During the ensuing period, Chinese academics have also moved to the pole position in the academic publications for math, the physical sciences and engineering where the number of academic publications has quadrupled since 2000.  For example, in Nature and Science, 20% of the publications emanate from Chinese authors based at Chinese universities. Research in health care is not far behind.  While the quality of their output is not up to par with the US, it’s not far behind either…

So, what’s the US response?  Rather than embracing the change, the US government under the Trump Administration has started tightening the rules for obtaining study or work visas for Chinese academics – which now represent 1/3 of foreign students studying in America.  The clamp down is being done on the notion that these academicians are gaining too much information and knowledge by studying in the US.  However, our US scientific community has reacted with alarm. Knowledge is porous. The good part about the Chinese studying in the US is that they get to know our culture, the way we live, the way we think and – while there are many good elements about Chinese culture – they learn the US is not some evil empire.  Scientific process absolutely requires an open collaboration. If, in fact, there are documented episodes of espionage or unsuitable behavior we have other avenues for managing such situations like criminal prosecution or academic expulsion. But, simply building a wall against academic collaboration will result in exactly the wrong result – the slow decline of research leadership in America.  Rather than closing our doors, we should open them wide and serve as the source of collaboration and collegial exchange.  At the end of the day, such an approach will yield far greater results than hiding behind our borders.

Paying It Forward – Yet another survey is out noting that workers are shouldering an ever-growing share of their medical costs because employers are simply passing along the additional health insurance costs in the form of deductibles. The non-profit Kaiser Family Foundation conducted a survey showing that health insurance premiums and deductibles for American workers continued to escalate in 2018.  But, it wasn’t just the escalation, it was also the fact that cost increases are outpacing wage growth and inflation. For example, the average cost of a family health plan is now $19,616 a year, with workers contributing $5,547, or about a quarter of the cost.  Employers pick up the balance of health plan costs for the workers as a benefit. But, the number of workers with large deductibles is increasing.  In 2009, only 7% of workers had a deductible of $2000 for single coverage.  Today, it is 26% (See Table). deductible What we’ve seen in the market place is that health insurance premium increases have moderated, increasing by about 5%.  However, deductibles have marched forward as employers adopt strategies which shift the cost burden to the workers.  With the Republican efforts in play to undo the Accountable Care Act (ACA), access to affordable insurance has become increasingly problematic.  I’ve said this before BUT – rather than undoing, we need to amend the ACA.  After all, even though neither political party seems to believe it, solutions do come to the middle.  They are not at the extremes of political agendas.  Perhaps the focus should shift toward doing something right for the American people as a whole.  The next revolution that we will see in the streets are marches about access to health care.  Mark my word – they are coming.  In 2000, 68% of the employers offered health insurance.  That dropped to just over one-half by 2017 although it has increased to 57% for 2018.  This is the one issue I get more emails on than any other – except, of course, those related to restaurants and where to eat…

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. 

Robots

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:

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