Information for your Consideration…

The Covid-19 Pandemic of the Elderly – The New York Times recently posted an analysis by columnist David Wallace-Wells noting that the biggest challenge is among the immunologically challenged elders of society. OVERALL, since the start of the pandemic back in 2019, people 65 years and older have accounted for 75% of all American Covid deaths! But, even worse, Americans 65 years and older TODAY account for 90% of new Covid death – despite a 94% vaccination rate for these citizens! We are now seeing similar reports from China as the pandemic spreads there which exhibit the same pattern. The elderly are at highest risk! Review the article for a complete analysis. It’s got me wearing a mask again…

Health Spending Reaches $4.3 Trillion in 2021 – While health care spending only increased by 2.7% in 2021 over the prior year, it did reach a watermark of 18.3% of the overall GDP as 23 trillion according to a report by the Centers for Medicare and Medicaid Services (CMS). While the rate of increase was a clear decline from the prior year’s spending due primarily to COVID-19, it still represented an ongoing escalation as an over percent of the GDP. This is troubling! Why? Because the overall cost continues to escalate while the quality and services continue to decline across the nation in increasingly disproportionate ways. I am projecting that we will face even more rocky times down the road due to global dissociation, economic headwinds, the decline of the American empire and the factors noted in my missive above on misinformation breeding misdirection to cause misunderstanding across society. 

Primary Care First – The Centers for Medicare & Medicaid Services (CMS) released their analysis of the new Pirmary Care First (PCF) initiative in December. At 201 pages, it’s a lengthy read but – important. PCF essentially encourages practices to take an upside/downside risk in caring for patients through a value-based care delivery program. The intent is to support value and quality while simultaneously reducing administrative burden. The evaluation revealed that practices gained a 20% income advantage over traditional fee-for-service model under traditional Medicare payments. The other important aspect of the report is that the practices that failed to make equivalent or better income also failed to make the proper investments in appropriate care management strategies to support quality, decrease readmissions and maintain better health outcomes. So, looking to the future – it seems to me that practices need to be very strategic in developing the proper infrastructure and support systems to be successful under the PCF program.

The Kiwi’s Get Tough – The New Zealand Parliament in December passed a law that would raise the age of smoking from its current age of 18 by one year until the Kiwi’s born after 2008 would be ineligible for legit purchases for life!! That’s called “Phased In Prohibition”. While the sentiment is on target, I’m not sure the anticipated outcomes will become real. New Zealand already has one of the lowest smoking rates in the world with just 8% of the Kiwi’s smoking on a daily basis. The government wants to get the figure down to 5% by 2025. At present, the cost for a pack of smokes in New Zealand is running $20.00 per pack. It would seem better in my estimation to increase the tax and until the purchase of cigarettes becomes an unbearable expense AND use the tax funds to pay for health care. It would likely work better than outright prohibition…

Fentanyl Kills – While I’m big on creating a non-smoking environment, it’s even more of an imperative to begin managing the Fentanyl crisis better. In 2021, there were more than 107,000 overdoses in the USA with two-thirds related to Fentanyl. Furthermore, 196 Americans died every day in 2021 or, double the number from 2019. It is now the leading cause of death among the 18 – 49 year old crowd. The Fentanyl crisis is sucking life out of the younger crowd.

Information for your Consideration… 

Omicron Subvariants Are Shifting – In mid-November, the CDC reported that Omicron subvariants BQ.1 and BQ.1.1 were accounting for about 44.2% of all COVID for that time period. This was compared to 32.6% of cases during the first week of November. According to the CDC report, the two variants “…made up less than 10% of total cases in the country” in October. This probably explains while – yet again – despite my precautions and withdrawal from socializing except for close friends, I was again infected. Yikes!! The only good part was that I was totally boosted and with the help of Paxlovid, the symptoms did not last that long and I was back in the saddle in about 4 days and testing COVID negative.

Waning Measles Vaccinations Creates A Potential Measles Outbreak As An Imminent Threat Worldwide. Oy! Just when we are making progress worldwide with the vaccination of children, the CDC issued a Thanksgiving warning that the nations of the world  “could be on the verge of a [measles] comeback after a lull in the immediate months following the emergence of the coronavirus. The potential for a measles outbreak was described as “an ‘imminent threat in every region of the world’…” Why? Because nearly 40 million children missed their measles vaccinations in large measure because of the pandemic. The details are ominous. Worldwide there were 9 million measles infections and 128,000 deaths in 2021. The other element that adds to this problem is the fact that a recent poll revealed that while 82% of parents in the USA have discussed existing immunizations or vaccination schedules with their primary care provider, only 68% had discussed influenza vaccine and 57%, COVID-19 vaccine. 

The Burden Of Healthcare Costs – A recent ranking by Forbes on the burden of health care costs continues to point to disparities across the nation. On average in 2020, healthcare costs averaged $10,000 per person. Regardless of your personal economics that’s a chunk of change! The study also pointed to the fact the problem is worse in the eastern USA with five out of ten of the highest cost states located in that region, including: West Virginia, Florida, Maine (where I live 😊), Delaware and New Hampshire. This was in comparison to the least expensive states which were western, including: Washington, Nevada, Hawaii, New Mexico and Oregon. What was particularly disturbing from the report is that Americans are increasingly delaying care due to unaffordability. 27% of survey respondents said they have delayed a doctor’s visit, 19% delayed a medical procedure and 19% avoided a prescription refill. The data was derived from a Kaiser Family Foundation analysis. It’s increasingly clear to me that we are headed toward a financial cliff related to health care costs. The combination of the stress of high health care costs coupled with the number of elders entering the Medicare market are creating stress points across the system and moving us toward a clear focus on value-based care delivery programs that increasingly are demonstrating better outcomes and results at lower costs. 

And Now, Burnout Is A Problem – A recent Commonwealth Fund report documents one of the major factors behind the growing shortages of physicians, nurses and other care givers in the wake of the COVID-19 pandemic. Here are some of the important statistics from the study:

• Just over half of USA primary care physicians under age 55 report being burned out and 45% plan to stop seeing patients within the next three years.
• 61% of the same cohort have experienced emotional distress since the start of the pandemic
• Compounding the loss of PCP providers, medical students are less likelyto pursue a career in primary care – in large measure because of the stress conditions and, instead are opting for specialty fields. 
• As a result, by 2034 the USA will be facing a shortageof 17,800 to 48,000 primary care physicians. 

The Commonwealth Fund report is worth a review by all health care leaders that are working to create a sustainable health care delivery organization. Without adequate primary care providers, my fear is that the system could implode. We’re moving in that direction.

The SuperAgers – I recently read some work done by Marc Milstein, Ph.D., a brain health researcher based at the University of California Los Angeles and wanted to pass along his thoughts on how all of us can work to maintain good brain functioning as we get older. It’s an area of research that has caught my interest of late 😊 and – will no doubt – be an area of continuing interest in the months and years immediately ahead. Long story short, Dr. Milstein has noted that it’s not just our genes, it’s also our behaviors that can impact on our brain’s ability and functionality.  And, one of the biggest factors in maintaining good brain health is engaging inlearning behaviors. He notes that while Wordle, Soduko, crossword puzzles and the like are useful in maintaining capabilities through the use of “existing” knowledge, it is critically important to also engage in activities that “increase” our knowledge pool through learning behaviors – outside of our existing areas of expertise. He suggests that we need to approach brain health like we do physical health and create a plan for maintaining our capabilities. His first three suggestions for cross-training the brain include:

“Day 1: Learn something mentally stimulating, such as listening to a podcast or taking an online course,

“Day 2:  Do something that requires learning through movement, such as a new sport, dance or yoga pose; and,

“Day 3:  Be social. Grab coffee with a friend or go to a dinner party.”

It appears “socialization” is a good way of staving off dementia. So, I should be good to go on that front!! Other activities that come to mind are like my wife, Suzanne, who is enhancing her language skills in Greek. Or, one of my physician friends who has taken up piano. The latter is a skill that my adopted son, Michael, keeps after me to consider since we have a rather large piano sitting in the parlor that needs attention. If you want more details, I suggest that you consider reading The Age-Proof Brain: New Strategies to Improve Memory, Protect Immunity, and Fight Off Dementia by Marc Milstein, Ph.D. BTW – good luck!! 

Traditional Flu Spiking and COVID-19 May Not Be Far Behind – The flu as we’ve come to know it over the last century – the seasonal, respiratory type – is gaining speed with a more extended spread across the USA (NOTE: if you want to check the spread in your state go here). In particular, according to Dr. Peter Hotez we are facing the confluence of multiple different bugs that are becoming disseminated throughout the populace, including: rhinovirus, pneumococcus bacterial, the respiratory syncytial virus or RSV, flu virus, as well as the multiple COVID-19 variants which all seem to be the culprits. These bugs spread easily and primarily – if not exclusively – through human-to-human contact spread. In fact, the overall rate of flu (rhino and RSV types) is the highest we’ve seen in more than a decade and children are especially vulnerable. With cases on the rise, many of the flu experts are suggesting that the precautions we undertook during the pandemic (i.e. masking, reduced human-to-human contact, etc.) may have contributed to increased vulnerability toward traditional flu while at the same time protecting us from COVID-19. That may be true…but…But…BUT…that does not mean we should undo those practices – especially, the masking part. It’s an absolutely necessary precaution for preventing a resurgence of COVID-19 or its subsequent variants!! AND, MOST IMPORTANTLY – IT IS CRITICAL THAT EVEREYONE GET THEIR REGULAR FLU SHOTS, in addition to your COVID-19 booster. This is especially important for: 1) adults over the age of 65, 2) individuals who are immune compromised for any reason; and, 3) children under the age of 4. The troubling news with the ongoing surge is a recent survey shows that nearly 40% of the American public do NOT intend to become vaccinated. The misinformation, distortion and outright lies about vaccination is a very troubling phenomenon that will magnify the problem and create unnecessary disease and death. If we all do the right thing – get vaccinated and engage in appropriate protective behaviors – the resurging flu epidemic will not be a problem for our families and loved ones. Get tough. Insist on vaccination and appropriate masking!! We can make a difference if we all work together…

On the COVID-19 front, there is also some major concern. According to data released by the CDC, hospitalizations have increased by 25% in the last week. Much of the increase has been seen in the elder population – especially among those who have not been vaccinated OR who have missed getting their boosters. In fact,  less than one-third of seniors AND, we are among the lowest among the countries throughout the world with bivalent booster vaccinations. Folks – the data is absolutely clear!! Getting vaccinated PLUS maintaining your booster status is critical to preventing bad outcomes if you do become infected. Take it from me. Despite my best efforts to prevent an infection, I got COVID again for the second time but barely had the sniffles. However, I’m fully boosted and combined with Paxlovid treatment, I was up and running in about four days. 

Americans Are Increasingly Exasperated With Health Care – The Beryl Institute recently completed a survey that reported about 60% of Americans as rating the quality of their health care experiences less than “good” or “very good”. That means the vast majority believe it’s average or below average. And, to make matters worse, the results show a continuing decline in public attitudes toward health care. At the same time, the survey also revealed that about the same number rate their personal health care as “good” or “very good.” Hmmm… There are lots of reasons why these results are prevalent including: the pandemic, more generally; supply chain considerations; inflation; workforce shortages, wait times and fatigue; staffing problems; and, the like. Having interacted with the health care system of late on a personal level, I can see why patients are frustrated. Call systems put you into long queues, staff are not available, timely responses are often delayed to the point of frustration, etc. But, I also know from personal interaction with health care providers that once you connect with them – they are still, by and large, the humane people who went into health care because they wanted to help people.

The Canary In the Coal Mine – Recent reports from the Cleveland Clinic show that one of highest rated health care organizations in the country is now reporting massive financial losses for the third straight quarter. Their report is increasingly typical of health care organizations throughout the nation. Cleveland Clinic reported losses of $1.5B compared to 2021 when they realized a profit of $1.7B due in large measure to rescue funds provided by the federal government via the PRF [Provider Relief Fund], ARP [American Rescue Plan] and ERC [Employee Retention Credit] programs.

Information for your Consideration…

North Dakota – Leading The Nation!! – I’m from North Dakota and when I was growing up, it always seemed like the “Top 10” lists ignored us even though we had the bluest of blue skies, the cleanest of clean air, the flattest of flat prairie lands, the nicest of nice people and the like. I have also frequently regaled people with the fact that when I left North Dakota for my residency in New York City, I was at first intimidated and self-conscious of my origin. Why? Because I had not gone to one of those “special” East Coast schools. However, I very quickly came to the realization that my clinical skills were every bit as good – if not better in most instances – than my colleagues from those “named” medical schools. So…imagine to my surprise and excitement when I learned that North Dakota was able to capture the designation for four of the Top 10 Cities in the USA in a special survey. The North Dakota winners came in on positions: #2: Grand Forks (where I practiced for 10 years); #3: Williston; #4: Fargo; and, #8: Bismarck (where I grew up). The only problem with the rating is that it was for the Top 10 “Coldest” Cities in the USA. However, as noted above global climate change is affecting North Dakota as much as other states. In fact, I’ve predicted that if the trends continue North Dakota will be the new Napa Valley due to Global Warming. For the interim, we’ll stick with our “coldest city” status. After all, we’re proud of our ability to wear short sleeved shirts on cold winter days…😊…

American Medical Association Advocacy On Track – While I have been a vocal critic of the American Medical Association on many issues since my days as a medical student when I served as the President of the American Medical Student Association – when an organization does the right thing – it needs to be called out. So, I wanted to call attention to a policy established at the 2022 AMA House of Delegates that I only recently learned about on the issue of “government interference into the practice of medicine”. I’m simply going to restate (i.e. copy) the policy in whole. It states:

Our AMA opposes the interference of government in the practice of medicine, including the use of government-mandated physician recitations. Our AMA endorses the following statement of principles concerning the roles of federal and state governments in health care and the patient-physician relationship:

• Physicians should not be prohibited by law or regulation from discussing with or asking their patients about risk factors, or disclosing information to the patient (including proprietary information on exposure to potentially dangerous chemicals or biological agents), which may affect their health, the health of their families, sexual partners, and others who may be in contact with the patient.
• All parties involved in the provision of health care, including governments, are responsible for acknowledging and supporting the intimacy and importance of the patient-physician relationship and the ethical obligations of the physician to put the patient first.
• The fundamental ethical principles of beneficence, honesty, confidentiality, privacy, and advocacy are central to the delivery of evidence-based, individualized care and must be respected by all parties.
• Laws and regulations should not mandate the provision of care that, in the physician's clinical judgment and based on clinical evidence and the norms of the profession, are either not necessary or are not appropriate for a particular patient at the time of a patient encounter.

I agree. I support. I shout out!!

A Forewarning Of the Feast To Come – There’s a new report by a group of investigators that the timing of our meals affects hunger as well as appetite-regulating hormones, thereby causing weight gain. However, the study only included 16 obese individuals who maintained a strict schedule of a meal in the early morning and late in the evening – once a week in the lab with the remainder of their meals held to the same schedule at home. The study showed that they burned fewer calories, had an increase in fat tissue and also had increases in leptin and ghrelin – which control “hunger”. The student was published in Cell Metabolism. Long story short, don’t have a late evening Thanksgiving Dinner 😊.  Now, about that Maple Syrup Pie recipe I mentioned in my November 1, 2022 issue of The Fickenscher Files. Have you tried it yet? If not, the weight gain is worth it…

• Consumers Weigh In: Virtual Primary Care Is A Positive – A new poll/survey by Elevance Health (formerly known as Anthem, Inc.) on the attitude of consumers toward virtual primary care points in the direction of “very positive” on the convenience and accessibility side of the equation. The key findings included:
• 63% of Americans are living with or managing chronic health conditions with nearly 2/3 indicating that the believe primary care could help them with their care needs.
• 73% of the respondents indicated that virtual primary care was appealing primarily due to convenience (35%), accessibility (31%), and overall ease of use (30%).
• 31% of those who have not used telehealth services indicated that they prefer in-person visits and 21% were not sure if their health care policies covered telehealth services. 
• Of those individuals who have used telehealth services, 94% indicated they were satisfied with their virtual care experience and 79% indicated that virtual care "has allowed them to take charge of their health."

Information for your Consideration…

By A Whisker – On Saturday mornings, CNN has a broadcast by Michael Smerconish – a commentator out of Philadelphia. It always has interesting twists and perspectives on the “news”. One part of the show is where he queries his viewers on a current topic. This past Saturday (2022-1008) he tried a new twist by asking the question: “Would you trust in your physician if you knew they struggled with undergraduate organic chemistry?” It obviously got my attention right away since I did “OK” in pre-med organic chemistry but, I was not the best in the class either. There were over 20+ thousand respondents to his in-the-moment poll with 60% indicating that it would not alter their trust and 40% responding that it would. Whew! Organic chemistry is most often viewed as the washout course for undergrad pre-medical students. And, I would argue that the organic chemistry professors relish their role. If you do well, you’ll be considered for medical school. If not, you’re likely washed out. I made it by a whisker 😊. When I was admitted, the Dean for Students – Dr. Wally Nelson – pulled me aside and said with a wink and a nod, “Sometimes, we admit students because we think they’ll make a difference in medicine.” Hmmm…I hope I met the expectations!

An Increased Uptake Of COVID-19 Boosters = Potential Decrease By Almost 90K Deaths. The Commonwealth Fund did an analysis of data on the immunization rates and results of subsequent COVID-19 infections. The results? “…if 80% of eligible people receive their booster dose” nearly 950,000 hospitalizations and 90,000 deaths would be prevented. On top of that over $50B in costs would be saved. The analysis is not only compelling – it’s distressing given the mis-information that’s been spread about the vaccinations. We need to get the word out in the various forums in which we are working…

The Malicious Virus Surges Again – Are we ever going to get ahead of it? Is the end of COVID on the horizon? Yes! And, No! I have faith in the ongoing research being conducted around the world that eventually we will get a handle on the effort by COVID to cause disease among the human species. At the same time, it’s evident that the fight is not over!! In fact, you can check out the state of the COVID infectivity and hospitalization rate at the site above. You’ll note that there is actually a bit of a gentle plateau or even a slight decline in the number of cases in the USA at the present time. However, the FDA issued yet another warning that while Omicron Subvariant BA.5 seems to be causing most of the new COVID-19 cases in the USA, it is the evolving number cases related to Omicron Subvariant BA4.6 that is causing concern. Why? It’s because the BA4.6 is not as responsive to the vaccine as the other variants. Regardless, it is VERY CLEAR that everyone should not only be getting their vaccination but also lining up for their boosters on a regular basis. As of this writing (2022-10 09), only about 8 million out of 200 million USA citizens who are eligible for the booster have received the repeat immunization. As the winter months come upon us, we’re going to be spending more time inside – with one another – which will increase the likelihood of viral spread. So, vaccination is the first preventive measure and, masking will come along again if we see an upsurge. Already, researchers are beginning to notice that wastewater Omicron viral levels are up in certain part of the country especially in the Northeast.  So, stay tuned!! This could be the canary in the coal mine for yet another surge in the coming couple of months. The European findings are a harbinger of a potential surge in the USA… 

Health Equity Accreditation: The Next Step – The National Committee for Quality Assurance (NCQA) recently announced the healthcare entities that have earned accreditation from the new Health Equity Accreditation Plus evaluation program. The new program was announced last fall. The recipients include two health systems and seven insurance plans around the country. It was the first time that health systems had been included in the evaluation process as part of the NCQA program. The message? Integration of health care systems and insurance plans continues at a slow pace but, integration nonetheless. The essential components of the evaluation process include the following elements:

• Building cultures that link to external health equity initiatives,
• Collecting race, ethnicity, and language (REaL) data to support individuals' cultural and linguistic needs; and,
• Identifying health equity and related care needs such as: 1) data that assesses social risk and need, 2) in-depth patient and consumer engagement, 3) strong partnerships with community-based organizations; and, 4) social need referral systems and partners.

Guns, Again? – The use of firearms as the cause for homicides and suicides continues its ongoing growth across the USA. In 2021 compared to 2020 there was an increase in gun-related homicides (= 21,000 people or 57+ people/day) from 79% to 81% and for suicides (= 26,000 people or 71 people/day) from 53% to 55%. In fact, 2021 is now the highwater mark for gun-related deaths over the last 30 years. Gun purchases through 2021 were made by 18% of American households with about 5% purchasing a gun for the first time. Researchers who were involved in the data analysis noted that the findings “underscore the urgent need for prevention efforts…” such as more effective outreach, hospital-based interventions, and reducing access to firearms among people at risk of harming themselves or someone else. Hmmm? How about sensible gun control? When I talk with the gun owners I know, it seems that we could develop “sensible” gun control measures but, then again, the NRA would not find that acceptable.

The Path Toward Value-Based Care Delivery – In an online study published in the Annals of Family Medicine the use of “facilitators” (i.e. trained professionals in health care counseling) was shown to be effective with better outcomes for selected cardiovascular-related problems. The types of facilitated conversations included aspirin use, smoking cessation, blood pressure control and other preventive care-focused areas. The review included the assessment of 162 facilitators employed at 1,630 small- to medium-sized primary care practices. The study shows the way for possible (? probable) improvement in other clinical areas such as CHF, kidney disease, diabetes, and other clinical problems with “high value” returns through the reduction of ongoing healthcare costs. This finding totally resonates with my personal experience as a clinician. When I was in active practice – oh, so many years ago – I found that the combination of my nurse practitioner, pharmacist and social worker working in collaboration as a team with me was MUCH more effective than me working alone. However, the changes in the reimbursement system over all of those years destroyed the incentives. We need to – no, we must – move toward value-based care delivery models if we’re going to be successful in simultaneously enhancing outcomes and reducing costs. 

Extending The Obvious – The Pew Charitable Trusts recently released a report regarding the Medicare Care Choices Model (MCCM) program which extended hospice services to those individuals who were suffering from other long-term illnesses aside from a terminal disease such as dementia, respiratory diseases, and other common problems. Originally, the Medicare hospice program was set up in 1982 to provide extended home care for those with cancer. Back then – as a newly minted physician – cancer was a grim diagnosis. We’ve come so very far in our treatments in today’s world. The study included 4500+ participants who received hospice support services over the period 2016 – 2020. The results are significant. Medicare expenditures for the MCCM participants were 17% lower than non-participants (i.e. $45,976 versus $53,229) over the course of the evaluation. Why did that occur? It was due to the 26% fewer inpatient hospital admissions, 38% fewer ICU stays; and, 30% fewer days in other inpatient hospital units. The study will be a big boost to making palliative care more available and helps in the shift toward “value-based care delivery” (See note immediately above). 

More On Medicare – I’m following the Medicare data points a lot more closely this year than last. Want to know why? It’s because I’m now part of the problem due to my total reliance upon Medicare as a source of coverage for health insurance 😊.  So, I was pleased to learn of the Biden Administration announcement that Part A and B premiums will drop in 2023 Medicare premium rates will drop in 2023. The changes will also apply to the 2023 Medicare Part D income-related monthly adjustment amounts. The reason the rates are going down (a “tish” – but, an important “tish” for those on limited incomes) relates to the lower-than-expected expenditures held in the contingency for the addition of the new dementia drug, ducanumab (= Aduhelm) as well as lower-than-expected costs for Part B services. But I would caution that this does not solve the longer term problem of potential Medicare insolvency! We need to deal with the whole structure and payment methods of the program to get a grip on that one. More on this later… 

Shifting The Problem – There was a recent report in The Washington Post noting that “more than 2.5 million adolescents were current e-cigarette users in 2022, with the majority choosing flavored, disposable products”. The report comes from a federal study conducted by the Centers for Disease Control (CDC) in collaboration with the Food and Drug Administration (FDA) as part of the National Youth Tobacco Survey. Current users were grouped according to the total number among all such youth with middle school users representing 3+% and high school users at 14% of the total populace. In the latter group, a full ¼ of them were daily users!! “Use” was defined as the use of e-cigarettes at least one day in the prior month. What is most disconcerting is that the study showed that 85% of the users favored vapes in fruit, dessert, or candy flavors. Aren’t we simply shifting the problem from smokers to vapers? What are the long-term implications of vaping? I bet (no data on my side at this point) that the data will show – very clearly – that vaping causes some time of long-term health problems… We are simply shifting the problem from cigarettes to another source. For the policy makers – how stupid is that?

Telehealth Continues To Climb – FAIR Health is “…an independent nonprofit that collects data for and manages the nation’s largest database of privately billed health insurance claims and is entrusted with Medicare Parts A, B and D claims data for 2013 to the present.” The organization conducts a Monthly Telehealth Regional tracking report on telehealth. The latest report reveals a continuing increase in utilization for three of the four US census regions. FAIR Health monitors claim lines, procedure codes, and diagnostic categories derived from the billing information on care delivery. Beyond the general increase, certain specialties are the leaders in use. For example, social workers are the highest users in all of the regions. Among the medical specialties, the psychiatrists take the lead and their use increased by 8.1%. The highest users in the Midwest were primary care non-physicians and psychologists which I surmise relates to the remoteness of care delivery in the rural areas – many of which can be better served through the application of telehealth services. As for diagnosis, the most frequent problems were acute respiratory disease with COVID-19 coming in #2. However, in the Northeast, acute respiratory diseases and infections fell out of the most frequent list of diagnosis.