Consulo Indicium - 3/30/18

Information for your Consideration…

The Opioid Problem – It’s appalling. The numbers are staggering. 175 people die every day in the USA from opioid use.  About 110 people die every day from car accidents in the USA.  Medical error cause 268 deaths per day (Institute of Medicine) and iatrogenic surgical-related deaths come in at 88 deaths per day (Agency for Health Services Research).  So, what are doing about the opioid problem?  Really?

A Correction Of The Headline – Paul Keckley – a friend, colleague and respected consultant – recently offered an alternative viewpoint to the question on whether or not there is a physician shortage.  He argues that “There Is No Physician Shortage”.  He took issue with the recent AAMC analysis which projects a shortage of 40,800-104,900 physicians by 2030.  While Keckley noted that the AAMC makes a credible case in support of a pending shortage of physicians. But, he feels that the case overstates the shortage for the following reasons:

  • Increased supply of alternatives to traditional physician services – He points to the number of urgent care and retail clinics (7400 and 2000, respectively) which are expected to double in the next five years. He also points to the use of pharmacists as primary care providers, new fitness facilities, mindfulness and yoga programs, chiropractic services, acupuncture and other initiatives that use mid-level providers of various types as substitutes for traditional physician services.
  • Consumer receptivity to physician alternatives – He makes the argument that consumer confidence in traditional medical physician providers has decreased substantially over the last several decades. With the move towards increasing co-pays and out-of-pocket requirements for consumers, they are seeking less expensive options.
  • Hospital employment of physicians – As health care becomes more consolidated, the traditional role of the physician will be eroded. The consolidation is primarily occurring with large integrated health care systems that are much more inclined to use health care providers who practice at the top of their license.  Such efforts will reduce the demand for more traditional services.
  • Clinical innovations that change how health is defined, delivered and by whom – Technology in all of its forms is altering the process and approach toward care delivery. He makes the argument that “machine learning, artificial intelligence, precision medicines and mind-numbing innovations are the future of patient care delivered virtually or on-site”. These types of capabilities are projected to alter – in very dramatic ways – our entire approach to care delivery.  Just to be clear – I absolutely agree with this point.
  • Public policies that enable new approaches to health delivery – He makes a solid argument that due to the growing allocation of society’s resources towards health care, the move toward “value-based” care is an inextricable requirement for the US economy. As such, the number of providers that will be required in a value-based model is called into question.  He summarizes that “…the public policies impacting the health industry will accelerate changes that are disruptive to enable lower costs, better care and more direct engagement of consumers.” Again, I absolutely agree with this point.

It is these last two points where Paul and I have a confluence of perspective.  The implementation of new, evolving technologies and value-based payment systems will clearly facilitate a move toward new models of care delivery.  I believe the combination of these two factors will facilitate the nation moving toward the use of “virtualist” care providers.  So, does this mean that there’s no shortage?  I’m not so sure…  We currently do not have any virtualist training programs in the nation poised to educate care providers on the nuance of virtual care delivery.  There is no standard curriculum.  There is no recognition that virtual care requires a cross-disciplinary approach for it to be successful.  In the face-to-face model – unless you are in a solo or a small-group practice – there are often a variety of professionals available to assist in the care process.  Long story short, Paul may be right in the far longer term (i.e. after 2050) but that seems a ways off. 

In fact, there is a looming shortage of primary care physicians.  Fully one-third (1/3) of the general primary physicians will either retire, become disabled or die over the next 7 – 10 years.  Why?  In large measure because they reflect the same demographic as the boomer generation.  But, as importantly, the number of young physicians moving into the primary care fields has decreased in recent years.  So, there IS a shortage of physicians AND it requires the health care community to TOTALLY rethink the approach to care delivery. 

Increasingly, however, I’m convinced that the solution will come from an “outside-in” model rather than an “inside-out” model.  We shall see…

The Longest Study of Human Aging – In Southern New Zealand in the district of Dunedin, there’s been a study going on for 45 years that is providing some very interesting results on the “health” of the population.  It’s a one-of-a-kind study.  To understand all of the details you need to read the review, which provides a more comprehensive overview of the project.  With more 1200 reports in the literature over the period of the study, there are certain facts that can be extrapolated which from a health care standpoint are quite interesting.  They include: (1) The importance of self-control – The researchers have noted in several publications that the level of “self-control” exhibited by a child was a more important predictor of physical health, wealth, life satisfaction, parenting, and levels of addiction and crime as an adult than all of the other more traditional indicators. The study has documented that the degree to which young children have less self-control is directly correlated to worse health, less wealth, and more crime as adults; (2) Ubiquitous Under-reporting of Mental Health Disorders – The researchers have documented a finding that shows the prevalence of anxiety, depression, and substance abuse in the Dunedin birth cohort is more than twice the rate that the mental health community has traditionally predicted. The Dunedin project not only recorded a much higher rate of mental problems but also identified approaches to identify the problems much earlier through cognitive testing and digital imaging.  Through earlier diagnosis, there are better treatment outcomes; (3) Identifying Aging Markers – The study has been studying “aging” at the other end of the aging continuum by looking at young people.  In particular, the study has identified a number of biomarkers related to aging, which are helping in quantifying the pace of the aging process. The study has been fodder for other studies related to higher levels of tissue inflammation and the length of telomere as signs of aging and age-related disease; and, 4) Considering “Nature Versus Nurture” – This particular issue has been a dominate consideration for many decades.   Did the genes do it? Or, did the environment do it?  For example, one study showed that genes were involved in predicting which abused children later developed antisocial violent behavior. Another study showed a correlation between one’s genes and predicting whether or not highly stressed adults developed depression.  A replication of the study is still pending.  So, the nature versus nurture question continues...

 There are any number of other findings which have evolved from the Dunedin study.  Read more about the study.  It’s quite interesting.  We should expect more…

Trending – For the first time, health care has surpassed manufacturing and retail to become the largest source of jobs in the USA.  For those of us in the health care industry it’s been obvious for some time that this would happen.  The reasons given for the trend include: 1) an aging population (= ah hum – that would be my friends and me).  In fact, by 2025 one quarter of the USA populace will be over age 55; 2)  the increased subsidies as a result of the ACA implementation (= that means we now have people that are insured rather than uninsured); and, 3) the “immunity” of health care to globalization and automation (= some of us are working on that problem).  Despite the growth, the criticisms continue.  For example, despite all the additional labor growth in the health care field, quality indicators have not improved all that much over the past 10 years.  For example, the 30-day hospital readmission rate has only gone from an average of 19% to 17.8% according to Robert Kocher, Ph.D., a senior fellow at the University of Southern California Center for Health Policy and Economics.  So, the question gets asked: Is all of the additional money thrown the way of health care getting us additional benefits, more efficiency or better results?  Well – not according to the latest statistics.  We’ve got to do a better job…

A New Movement Is Afoot So, What Do You Think? – Since I started practicing medicine in 1980, I’ve been a proponent of the “team” model of care delivery.  I got started early in my practice career using the team approach with the Nurse Practitioner in our clinic.  Initially, it was by happenstance but then we realized that each of us brought different skills to the table and that working as a “team” made us better in our delivery of services for the patients we served.  But, several decades ago, the movement to allow NPs and PAs to practice independently started to gain traction is some quarters.  And, while there are some who practice in the modality, the majority work in collaborative practices with physicians and in some states such a relationship is required.  Now, there is a new movement afoot, which has been called “Cathopathic Medicine”.  The notion of this type of medicine came to me through a notice I received on the American College of Cathopathic Physicians who purpose is defined as: “to protect the professional autonomy and advocate for a full, broad scope of practice for DNPs [Doctor of Nursing Practice] as a ‘cathopathic physician’ completely equal in every way to our MD and DO counterparts.”  My reaction was “Hmmmmm…how can one be a “Doctor of Nursing Practice” and an equal to MD/DOs?  In particular, when one considers the educational requirements for an MD vs. a DNP – there are substantial differences.  Perhaps I’m getting older and more set in my ways but it seems to me that the additional education afforded the physician provides a much deeper background in the issues related to disease than the two year addendum to a baccalaureate nursing degree.  It’s not that I’m against DNPs.  In fact, I think they offer considerable value to health care.  It’s the demarcation of these professionals as “cathopathic physicians” which is what the new College advocates – that seems to be a bit misleading.  Any thoughts from readers would be appreciated.  I think this moves us in the wrong direction.  Just as I have not believed that physicians should be in “solo” practice – unless it is absolutely necessary (e.g. rural areas). Even in those circumstances, the technology has changed so that having a “solo” practice in a rural area is no longer necessary.  In sum, the “cathopathic” movement shifts us absolutely in the wrong direction from creating truly “accountable care organizations” (ACOs) towards creating warring factions within the health care community.

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