Consulo Indicium - 9/15/23

Information for your Consideration… 

Some Good News: Cigarette Smoking Rate Stable At Only 12% - Last year, smoking reached an all-time contemporary low at 11% of the American public. The most recent report is that it held firm at 12% for 2023. These are the lowest levels over the last eight decades of monitoring according to a Gallup survey done on an annual basis. These results are important for increasing the health of the nation and it’s been accomplished – in large measure – due to public initiatives such as banning smoking in public places as well as discontinuation of public advertisements and the like.

Now Some Bad News: Most American Adults Think Inhaling Marijuana Is Safer Than Tobacco – A new report published in JAMA Network Open reported that a survey of  American adults revealed that “inhaling marijuana smoke” is “safer than inhaling smoke from tobacco.” And, just as bad, those same survey respondents felt that secondhand marijuana smoke was safer than tobacco smoke especially among the younger individuals and the unmarried who were surveyed. However, what will be the result emanating from all those cannabis outlets that seem to be cropping everywhere? And, what about the “inhalation” of marijuana? Then, there’s the question of “vaping” over the longer term as well? One would think that external smoke of any type would not be good for lung tissue…

And, Some More Bad News: Physician Owned Primary Care Practice Staff Shortage Worsens – One of the downsides of the pandemic has been the loss of stable staffing across the board. For the primary care providers, the results are even more significant. The Medical Group Management Association in a recent report noted that staffing in primary care practices is off by 40% compared to pre-pandemic staffing patterns. The report notes that “physician-owned practices had just 3.0 support staff per full-time equivalent physician in 2022 compared to 5.08 per doctor in 2019.” The report highlights the results of the “Great Resignation” which although while abating somewhat in the last couple of months has affected all industries but especially the health care community. 

The Shifting Distribution of USA Wealth – A recently released Congressional Budget Office report deserves some attention from all of us. First, as one would expect, the COVID Pandemic had a marked impact on the fiscal status of the nation as well our health. It decreased the total wealth across all segments of society. The total real wealth (after accounting for inflation) for USA families tripled from 1989 to 2019 going from $38 trillion (2019) dollars (about 4X GDP) to $115 trillion (about 5X GDP). The problem? It also showed that over that same period the vast majority of accumulated wealth accrued to the Top 10% of Americans with the bottom 50% remaining stagnant over the same time period. Another important finding was the fact that the median wealth of every cohort born since 1950 was less than the preceding cohort’s median wealth when that cohort was the same age.

The Health Of The Oceans – I’ve just returned from a six week trip through Newfoundland – a beautiful, geologically unique land. It was my first visit but it will not be my last. For those who are regular readers, you’ve heard me talk about the fact that the Maine Lobster has moved – on average – about 250 miles further north due to the warming of the sea in the Gulf of Maine. I was struck by another piece of data that expands on the problems of global warming and the impact on our oceans during my Newfie visit. The Marine Institute’s Centre for Fisheries Ecosystems Research recently reported in a scientific article the very significant global impact of global warming on Arctic Cod and the Arctic ecosystem. Cod (NOTE: also an absolutely wonderful book by Mark Kurlansky) are THE most abundant food source for mammals, seabirds and other fish species – as well as for the Inuit and all of us cod lovers who love our fish and chips!  Why? Well, it’s due to habitat loss which disrupts the cod reproduction, changing food availability for Arctic cod larvae and juveniles and an increase in southern predators who are migrating north into the Arctic waters. It’s yet another sign that we’ve got a problem but, of course, there is no global warming… 

Not To Be Missed – A very important article was published a couple of weeks ago in Health Affairs. It was entitled: The Forgotten Middle: Worsening Health And Economic Trends Extend To Americans With Modest Resources Nearing Retirement. Perhaps it’s because the issue is top of mind for me and mine because we are part of the “aging US society”. The study used projection models on mortality, quality-adjusted life years (QALY), health expenditures, and income and benefits with an emphasis on looking at the difference between the upper and lower middle classes of the economic distribution. What the study revealed is that the economic disparities between the two groups of people actually widened a fair amount over the period of 1994 to 2018. In essence, the study supports other work (SEE above “Shifting Wealth”) that argues those in the lower-middle income group of retirees are likely to require more support than the current systems and structures allow. It once again speaks to the growing economic divide that is fraying the fabric of the American populace.

Value in Health Care Act of 2023 Introduced to Congress – Amid increasing recognition among some stakeholders that our payment system for health care services needs attention, a bipartisan legislation was introduced in July to make a number of reforms to support alternative payment models (APMs). Seventeen Members signed a letter encouraging Members of Congress to push forward with the notion of creating a “value-based care” model for Medicare. Legislation supporting the model was introduced in 2021 by Reps. Darin LaHood (R-Ill.), Suzan DelBene (D-Wash.), Brad Wenstrup, D.P.M. (R-Ohio), Earl Blumenauer (D-Ore.), Larry Bucshon, M.D. (R-Ind.), and Kim Schrier, M.D. (D-Wash.) but received no action. So, the legislation was again introduced this year by the same six Members. For an overview of the legislation go here. The act would make the following changes in Medicare payments:

• Create a two-year extension on the 5% advanced APM incentives program that is to expire at the end of FY23 as well as allowing Medicare to alter the incentive thresholds so that more rural, underserved, primary care and specialty practices can move toward APM models of payment,
• Eliminate disincentives for rural and safety net providers with the intent of improving health equity and access,
• Allow Accountable Care Organizations (ACOs) to take on higher levels of risk with appropriate oversight,
• Create a technical assistance program for providers who want to move toward APM reimbursement models; and,
• Conduct studies to determine how to make the Medicare program competitive with other payment models.

Medicaid Prior Authorization Denials Deemed Excessive by MCOs – In a new report by U.S. Office of Inspector General, the denial rate for prior health care services requiring “prior authorization” was deemed excessive by many Managed Care Organizations (MCOs). The report noted 1 in 8 prior authorizations were denied in 2019. The OIG reviewed 115 MCOs in 37 states with a total of nearly 30 million enrollees for the review. Of particular note was the fact that of all the MCOs involved in Medicaid services 12 had more than 25% of “all” requests denied!! In large measure it stems from the fact that the State Medicaid agencies by and large do not monitor nor collect data on such decisions. This problem is one of the banes of care provided across the board by primary care providers as well as specialists. It also speaks to the issue that there is a need for revamping our payment model(s). On the provider side, the more you do, the more you get paid. On the MCO side, the less you approve, the more you get paid. The two elements clash and the patient suffers. It’s a major reason why we need to move toward a “value-based reimbursement” model of care delivery across the board in the USA. “Prior authorizations” are used inappropriately across the board. The report had a number of suggested modifications in Medicaid policy that were proposed to ameliorate the problem.

Editorial Comment: I have a family member who requires 3L of O2 to maintain an adequate oxygen saturation level just above 90%. The member has documented chronic obstructive pulmonary disease (COPD) and – still – after 8 weeks of regular contact with the MCO, he has not been allowed to have an O2 generation device at home. In fact, he had to go to the emergency room and refuse to leave before they were even able to portal O2 for his problem due to “prior authorization” requirements. It’s a pathetic outcome that is only getting worse. Tweaking around the edges will only exacerbate the problem in my estimation. 

The Promise of Stem Cell Research – The International Society for Stem Cell Research (ISSCR) recently completed its annual meeting in Boston with some exciting news. Bit.Bio, a company focused on synthetic biology of human cells presented data related to its efforts to engineer stem cells with a high level of consistency. In sharing their approach, the company noted that their technology will accelerate stem cell biology in the same manner that CRISPR technology has done for genetics. That’s quite a statement! The Bit.Bio model is based on the research of Shinya Yamanaka, Ph.D. from Kyoto University in Japan. In 2006, he discovered how to take ordinary adult skin cells and transform them into more primitive precursor cells that are comparable to the embryonic stem cells found in the early stage of embryonic cell development in the womb. He then continued his research with mouse cells and was able to make the cells transform into whatever type of cell desired through external manipulation through a process he described as “induced pluripotent stem cells” (iPSCs). The long and short of the approach was that the cells derived from human cells were similar to the embryonic stem cells discovered at the University of Wisconsin Stem Cell and Regenerative Center in the 1980s.

And, on the same front, a recent research article in MIT Technology Review highlighted the potential for stem cell research to resolving medical problems faced by patients. While the sample size was small (n=12), the outcomes were significant. The research was supported by Bayer Pharma’s subsidiary, BlueRock Therapeutics as a demonstration project on the potential of stem cell technology. In essence, the implanted stem cells began producing dopamine in Parkinson’s Disease patients who then exhibited improvement in the symptoms – at least for some of the patients which led to some outside experts stating that the results were “inconsistent”. Clearly, the research is at the formative stages of development. At the same time, stem cell research has been moving forward very slowly for the last couple of decades and, at the same time, holds much promise for resolving many long-term medical problems associated with cellular dysfunction. Aside from the research issues, there are legal issues as well since the stem cells are derived from IVF human embryonic tissue created in the laboratory. In sum, both the research as well as the political issues have created roadblocks for the stem cell movement. The study and its results are a step forward in demonstrating the potential value of this evolving technological capability for resolving medical problems. Keep an eye on it for the foreseeable future.

So, how do these two separate findings tie together? Basically, the announcement made at the ISSCR solves the dilemma related to the use of embryonic cells. The use of human skin cells clearly takes the issues related to the use of embryonic stem cells off the table. It will be very interesting to see how the technologies come together. I am anticipating that stem cell research will finally take a dramatic leap forward in the coming years. In fact, I predict that our whole approach to “chronic” problems especially will no doubt include stem cell innovations as part of the care delivery process. Stay tuned…