Consulo Indicium - 2/26/24

Information for your Consideration… 

The Changing Face Of Healthcare – I just finished an intensive two days with an immersion into the application of artificial intelligence (AI), machine learning (ML), Small Language Models (SML), and Large Language Models (LLM). Wow! My head’s a spinning. While I continue to have the perspective that we should be looking at all of the technologies that are rapidly coming down the track as useful for “clinically augmented intelligence” – it’s clear that the augmentation is getting quite good!! These systems are not only engaging the type of support that ChatGPT provides (if you’ve used it you know what I mean) but also real-time, interactive “discussions” and “empathetic support” from AI proxies in any number of areas from clinical to non-clinical. The world is changing and the healthcare community is not appropriately engaged in the topic. There are reasons to pay attention:

  • Systems are getting as good as expert clinicians in analyzing a patient’s information and providing diagnostic support.
  • Efficiencies are being provided that will help us to address the significant workforce shortage that exists within the healthcare community.
  • Effectiveness is enhanced through interventions and support that are too frequently missed by our lack of appropriate follow-up when patients are discharged from acute care.
  • Not only do the evolving systems provide “data” they also exhibit “empathy” that patients find attractive and supportive.

Wowzer!! I’m trying to keep up on all of these changes but my eyes were opened even further to the pace of change we are experiencing across the health care spectrum. From back office business to data analysis, to clinical decision support, to clinical staffing triage – and, beyond; these systems are rapidly changing the landscape of all the clinical and healthcare management fields. As a former leader of health systems, I urge all of my colleagues out there to get serious on this front and begin to actively explore, consider, and invest in these new evolving systems for helping to “make health care better” – my personal mantra for the last 50 years (whoa…is it that long? Yes, even longer but, let’s not go there…)

North Dakota In A Growth Spurt! – Even though I moved away some years ago from my home state of North Dakota, I follow the news and events – and the people – where I grew up. I was especially taken by the fact that the US CDC recently reported that the fertility rate in North Dakota came in as the second highest in the nation at 66.7, just after South Dakota at 68.6 which had the highest! But, that’s OK, we’ve always touted the fact that even with all of these second-place finishes, we know that the roads are longer and paved in North Dakota. And, the lowest? My newly adopted home state (now 10 years) at 49.9 = Maine, as well as New Hampshire. We were tied. But, in general, the Northeast has low fertility across the board. Why? It’s because so many more of us “retired” types are moving north to the good country. You see, Maine is just like North Dakota – except, it has mountains, ocean, and trees. Other than that – they’re almost identical…

It’s Back To The 50’s!! – The US CDC recently reported that the rate of syphilis increased by 80% from 2018 to 2022 with about 207,000 “reported” cases which also included 3,750 newborn infants or a 183% increase during that period. While we commonly associate syphilis with sexual transmission, it appears that a large portion of the increase was due to drug abuse associated with risky sexual behaviors. We also have way fewer sexual health programs in the schools than in prior years. We seem to be in a retrograde action since the new rate of infection is the highest since 1950!! Now, that is a sad commentary…

And, Let’s Not Forget the 60’s & 70’s – I will never forget my first – and pretty much last – experience with cannabis. I had eschewed the use of the drug because in North Dakota at the time, it was a felony that could land you in the state pen and…I wanted to go to medical school. But, one night – before medical school – I was cajoled into joining my good friend, Eddie (who shall remain anonymous). It was quite the experience. I think my lifetime “love” of pancakes came from that evening when at the local diner I consumed a whole bunch of them because of the ocean experience that exploded in my mind… But, let’s put that aside. I read an article recently that caused me great concern. It was from the last issue of Science Digest (February 10, 2024) on “Teen Brains and THC Don’t Mix Well”. For starters, I was only peripherally aware of the THC (the active agent) content of contemporary cannabis. Historically, the “weed” that my generation played with had a range of 2.5 – 5.0% (strong) potency. Now, “wax, budder, and shatter” have ranged from 20% - 95% potency ranges. As the article points out, “the availability of cannabis promotes the ideas that it’s safe.” Not so fast! So, what’s the concern?

The concern is the increasing amount of research data showing the adverse effects of cannabis consumption on the teen brain. Here’s a couple of data points for you to consider:

  • As it is inhaled, imbibed, and consumed, THC binds to a receptor CB1 in the endocannabinoid system – which influences many functions in the body such as problem-solving, pain management, memory and recall, motivation, anxiety management, and a host of other functions that are “actively” developing during the teen years. These are functions that are critical to function in the prefrontal cortex (i.e. “thinking”).
  • Use of cannabis as a teen is associated with a much higher dependency on alcohol, cocaine, nicotine, and illicit drugs as the teen ages. The increase goes from about 6% to 20% which is a very dramatic increase!!
  • Depression and anxiety are much more prevalent in the future years among those who started in their teens. This makes for difficulty in relationships and functioning.
  • While smoking among teens has decreased dramatically over the years – decreasing by 90 – 95% - vaping in recent years has increased from 25% to 34%. It’s just the tip of the iceberg since very few studies have been done on “vaping” – especially with the high potency products now available in most cannabis shops across the nation.

So, what to do? In Maine, we (the health care folks) are advocating that there should be restrictions on the presence of cannabis shops near schools but, from my perspective – while that’s a good first step, it’s not the only step. We need to step up the research on cannabis through the National Institutes of Health and other federal/state agencies to learn more before we have yet another epidemic on our hands.

Now, I still remember those pancakes from so many years ago. BUT, now I use an alternative. I use lots of Maine, Vermont, and New Hampshire (local) maple syrup on my pancakes and they are just as good as in that one experience. And, to top it off, there is no research that I’m aware of causing concern related to Maple Syrup consumption. It’s actually pure enjoyment – as long as you don’t gain too much weight. You heard it here first!!

Write It Down And Remember! – In a report from THE WEEK (February 16, 2024), it seems that those of us who continue to use cursive (writing) for taking notes did a much better job of remembering the material than those individuals who typed on a keyboard. The study comes from the Norwegian University of Science and Technology where they studied students using electroencephalogram (EEG) studies of students engaged in both types of note-taking. What was particularly interesting is that in using cursive the portion of the brain that forms memories and encodes information was more proactive in promoting learning. So, the message conveyed by the study is that we should put aside the laptops in the classroom or board room – as the case may apply – and re-adopt cursive as the format for taking notes that we want to remember. Now, what is that I was trying to say at the beginning of this short note…?

Consulo Indicium - 2/6/24

Information for your Consideration… 

The Good From AI/ML – Researchers at Microsoft have made a very significant discovery that will greatly help the extension of AI/ML capabilities. Specifically, one of the current concerns in the use of these new technologies is the dependence upon lithium ion batteries. The Microsoft researchers have created a new battery that is 70% LESS reliant upon lithium for moving the electrical charges through the battery. They were assisted by AI/ML capabilities where they examined 23.6 million candidate materials as potential replacements for the electrolytes and lithium atoms used in making such batteries. The work of the research team is moving ahead and there is hope that a viable commercial product will be available sometime in the not-too-distant future (i.e. not tomorrow, not next week, or even next year but beyond that “sometime”).

It’s Not Pontificating But ProtelyzingIn 1982 (I think that’s correct), I had an “event” that brought me to my knees at the ripe old age of 31. I was traveling in rural Montana for work on “rural health” near Cody, Wyoming when I developed chest pains and a very rapid heart rate. Being the physician that I was and inclined toward treating myself, I went to the hotel ice machine, got a bucket of ice, went back to my room, put the ice in the sink, ran some water into and stuck my face into it. Yes, my heart did slow down, but…too much. I ended up going to the hospital and being admitted with the missive that I should “cut down on my smoking.” I got home and was with one of my closest friends in life when I was smoking on a street corner and the same symptoms appeared. I vowed to quit…and, I did. You see – I was smoking four (yes, “4”) packs per day (NOTE: What a stupid doctor). So, I quit and have never regretted it but I’ve always been an evangelist for those who need to (i.e. must) stop smoking. I’ll support anything that prevents the onset of disease through passive means – like smoking.

Which takes me to my issue. Here are some myths that we need to dispose of ASAP for the good of society that relate to the use of cannabis and other similar products that offer people “other places to go” with their thoughts from smoking. Check out what the Family Physicians are sharing with patients. It’s right on the mark. The myths including the following:

  • Myth #1: E-cigs are a safer alternative to smoking cigarettes.

Fact: Makers claim that e-cigarettes don’t contain the harmful chemicals that cigarettes do. Of course, this is not true. Most devices contain nicotine. Plus, e-cigarettes may also contain ultrafine particles that can be inhaled and cause lung inflammation.

  • Myth#2: E-cigs aren’t addictive.

Fact: While there are some cartridges that don’t contain nicotine, most do. Any time a smoker inhales nicotine, they are inhaling an addictive and harmful chemical.

  • Myth #3: You can use e-cigs indoors.

Fact:  At first, makers of e-cigarettes said that e-cigarettes were appealing because they could be smoked in places that didn’t allow traditional cigarette smoking. This is no longer true. Most states have created laws that prohibit vaping in the same areas where traditional smoking is not allowed.

  • Myth #4: E-cigs are a way to quit smoking.

Fact: Marketers claim it is easier to quit smoking if you switch to vaping first. But e-cigarettes contain nicotine and may even lead to a user becoming a traditional cigarette smoker.

Now…Go out there and share the news. The harm we are causing across society is incredible. We can stop it now, if we just speak up. Now is the time. Now is the moment. Now requires action! And, it all happens at the state level. Speak up now or you may lose someone you love…

Listen Carefully – Perhaps it’s because my ears are attuned to the latest information on health care happenings but the number of ads and other forms of information flowing out to the public seems to be increasing at a dramatic rate. Of course, it could be that I’m listening carefully for “stuff” I may need as part of the aging process. But, putting that aside, there are any number of adverts that caught my eye this week. First, I was watching the National Geographic News – a politically neutral news source that often shares information you don’t hear on other channels. However, in the space of a couple of minutes there were ads for “Kardia Mobile” – a remote EKG to for individuals to check for tachycardia, afib, bradycardia, NSR or normal sinus rhythm. And, their web site had an interesting name = www.BuyBeActivePlus.com.  Then came the ad that was looking for nursing staff to provide care for individuals residing at home on www.BrightStarCar.com. These were followed by an array of other ads on various aspects of “care.” While I’m a big fan of self-care – the ads seemed to overstep the line and gave assurances for better health that did not relate to the underlying problems. Hmmm – how to deal with digital, channel and virtual information that speaks “to” the problem but does not “deal with” the problem… 

Confirmation – For a whole bunch of decades I’ve been arguing that patients having a primary care physician as the first line of defense in the care delivery process is a priority for several reasons, including the management of cost! In fact (and, I’m not overstating here), the literature is replete with articles over that period of a “whole bunch of decades” that access to primary care enhances care delivery, results in better outcomes and reduces costs. So, why am I engaging in echolalia? The NEJM Journal Watch, Vol.44 No.3 in the February 1, 2024 issue posted an article, “Another Benefit of a Primary Care Continuity Relationship” by Thomas Schwenk, MD, Associate Editor. The article outlined the results of a Canadian study of 5 million Ontario residents over the period 2021-22. Rather than put it in my own words, let me quote directly from Dr. Schwenk’s report: “After controlling for sociodemographic variables, diagnoses, and timing of virtual visits, likelihood of an ED visit was 66% higher for patients who saw physicians who were not identified FPs than for patients who were seen by their own physicians. This difference corresponds to 1 additional ED visit for every 77 virtual visits. This difference was accentuated about fivefold when virtual visits were with direct-to-consumer telemedicine clinics.” This report is yet another strong statement of support for all individuals having access to a primary care provider – and, at the same time – we’ve got a massive, looming shortage of primary care providers on the immediate horizon (i.e., within the next five years). While it’s nice to have confirmation, we also need to recognize that: “Houston, we have a problem!” Need I say more?

When Is Enough, Enough? There was a recent report on NPR.org, the media station noted a report from Oxfam outlining the fact that the five richest men in the world doubled their combined income over the period of 2020 – 2023 from $405B to $869B. During that same period almost 5 million people grew poorer across the world. I don’t know about you but an extra $464B in the pocket seems like a bit of excess retention by five (yes, “5”) individuals. I would think – but, then I’m sometimes considered pie-in-the-sky – that these five gents could do with just a bit (perhaps more than a bit) less than the mega–billions they hold in their pockets.

Value-Based Care Getting More Attention – The USA Centers for Medicare and Medicaid are continuing their march forward with an emphasis on value-based care delivery. Innovation is the key and it is getting support. Furthermore, it would appear that the managed care companies are also beginning to move toward fiscal consideration for support and reimbursement of value-based care delivery models. This is a trend that deserves the attention of all leaders in the healthcare community.

The Focus of the C-Suite – A new report was recently released by Sage Growth Partners, a healthcare advisory firm with extensive expertise in market research, strategy, and communications. The report consisted of a survey of 108 healthcare leaders from across the USA and is available at this site: The New Healthcare C-Suite Agenda: 2024-2025. The top two issues on the minds of the C-suite are: 1) investments in human resources, including technology integration of workforce needs and support. At the top of the list of workforce issues are recruitment, retention and workforce resilience of health care workers with the latter point garnering 61% of the C-suite recognizing the issues as a “top challenge”. The second issue that is highlighted in the report is the recognition of health IT investments as a way of protecting against unfavorable economic headwinds. The C-suite plans for 43% of the participants noted an increase in capital investments during 2024 which included: 20% for a new EMR, 15% for AI investments, and 13% related to virtual monitoring capacity. Of note was the fact that nearly 50% of the C-suite view AI integrations as supporting improvements in data quality and accessibility. Conversely 35% indicated that their organization had not realized any real benefit from AI investments at this point.

Vaping Declines Among High School Students – In November, the US Centers for Disease Control and Prevention (CDC) issued a report on the extent of vaping among high school students in 2023. It revealed that the use of vaping as a technique had declined from 14% in 2022 to 10% by late Spring 2023. That’s the good news. The not-so-good news was that vaping among middle school students over the same period increased from 3.3% to 4.6%. At the same time, use of tobacco products remained low at less than 2%. So, my take is that “education” matters and can have an impact since many schools have taken on the issue of educating their students on the trials and tribulations of vaping. It’s also an issue that many state legislatures are taking up in various forms by preventing access to flavored products – especially near schools.

Consulo Indicium - 1/22/24

Information for your Consideration…

Good News – It Takes Less Effort, So…Go For It! – In a new study from Washington University School of Medicine, lead author Cyrus A. Raji, MD, PhD reported in the December 7, 2023 issue of the Journal of Alzheimer’s Disease that only “moderate” levels of physical activity – such as 4,000 steps a day or even less – have a positive effect on brain health. So, while the 10,000 steps-a-day regime is excellent, you can still get a substantial benefit even with fewer steps. 4,000 steps are like walking 5 – 6 blocks. Now…isn’t that simple. So don’t just consider it. Do it!! I’m spoiled; however. My two dogs – Toto and Lole – expect it! So, I have to do it…

A Sad Commentary – A recent report in The New York Times noted that for the last year (2022-2023), Congress only passed 27 bills – yes, 27 bills out of more than 700 that were in the queue for consideration. Now one observation for those who don’t like government might be – “Thank goodness”. But, for me and mine, it means that Congress “Sure didn’t do very much”. In fact, it is the least productive Congress in more than 90 years. The 2020-2021 (117th Congress) legislative session passed 365 bills during its 2 years of work; and, to put it in perspective, the 2018-2019 (116th Congress) passed 344; and the 2016-2017 (115th Congress) passed 443 bills. So, calling it the “Do Nothing” Congress is not an exaggeration…

And A Lesson From Abroad To Prevent Sad Commentary – It seems that the USA is not the only nation dealing with the presence of “social media” as a major force in politics. Richard Correa in Estadao [NOTE: Forgive me if I got the wrong citation. My Portuguese is not so good] recently noted that it has turned politics into an ugly mud fight down in Brazil. Evidently, candidates are appealing the fringes on both the left and right social media users for support because that’s where the partisan trolls hang out. Does it sound increasingly familiar? He reported, “Your political survival depends on how you react to every fact…” so that even good conversations with colleagues from the other side of the aisle are scrutinized. He concluded that in Brazil soon the country will be “incapable of holding a rational debate.” This sounds so familiar to the recent hearings in Congress where one Member challenged a person giving testimony to a wrestling match right there in the room. Whew…We’ve all got to get a grip!!

Better Hearing = Reduced Risk of Death – Well, finally there is some good news about getting older. In a new study released by The Lancet Healthy Longevity study, it was noted that “wearing hearing aids if you need them may help protect you from early death…there was no difference in risk of death over the research period between people who used hearing aids occasionally and those who never wore them, but regular users were at a significant lower risk.” “It’s one of the few benefits of getting older.” said the author of The Fickenscher Blog.

Healthcare Employment A Major Contributor To USA Job Growth – The amount of growth occurring in the healthcare sector is really significant. In fact, 24% of all new jobs in 2023 in the USA were derived from healthcare with an average monthly job growth of 54,000 jobs. The total of 653,000 new jobs (2023) compared to 557,000 the prior year (2022) represents a 17% increase. Furthermore, half of the growth was in the ambulatory care sector. However, the unemployment rate held steady at 3.7% during the latter part of the year. The second largest growth areas were in government (52,000) and the hospitality industry (40,000).

Increased Private Equity Results In Lower Safety Performance – The alarm bells went off at a higher frequency when I heard the news about private equity where JAMA recently reported that hospitals saw a significant increase in central-line intravenous infections (an increase of 38%) and patient falls (an increase of 27%) after purchase by private equity firms. There was also an increase in infections in other areas as well (e.g. surgical sites). The research was completed by faculty from the University of Chicago and Harvard Medical School after comparing the Medicare Part A claims data for 51 equity-acquired hospitals compared to 259 non-equity-owned, matched controls. The culprit? According to the article, it would appear that staffing reductions that occurred following equity acquisition were the major factor.  For further information on this alarming study, check here. 

Sad Statistic #1: The United Nations recently reported that almost one-half of humanity live in nations where more is spent on servicing debt than on either health or education. It affects 3.3 billion people.

Sad Statistic #2: The World Health Organization reported that over 4.5 million women and babies die every year during pregnancy, childbirth or the first couple of weeks following birth primarily related to preventable and/or treatable problems if the right care was provided. This death rate is the equivalent 1 death every 7 seconds to put it in stark terms.

Ignoring A Good Thing – Nirmatrelvir/Ritonavir For Treating COVID-19: In a recent study from the NIH, it was noted that “only about 15%” of eligible individuals diagnosed with COVID-19 took medication that has been shown to make a marked difference in outcomes – and, that’s Nirmatrelvir/Ritonavir (= Paxlovid)!! BTW, I learned about the issue in New York Times. The reluctance is on both the provider (doctor) side as well as the consumer side for different reasons. Physicians have been worried about drug-drug interactions and patients about side effects like the metallic aftertaste that can evolve for some individuals. While I’m only a case of 1 – it made a huge difference for me. Within 36 hours, my COVID+ symptoms had essentially disappeared, and I was back at it (and, behind 😊) in my work. Check out the research findings here. We still have a problem with nearly 1,500 USA citizens dying each week from COVID-19. Spread the word…

And, If You Survive COVID-19 – Start A Daily Multivitamin – For those of us in the over 60 crowd (there are a few of us 😊), a new study reported in the American Journal of Clinical Nutrition shows that a “One-A-Day” (there are other brands as well…) multivitamin slows memory loss by nearly two years. That’s significant! Furthermore, the research reported in the journal is not the only one touting the benefits of a daily multi-vitamin. So, do as I do – and take one every morning. That way you’ll be able to continuing reading – and, understanding – The Fickenscher Files!! I’ll report back if I find that the results are not working very well…

 

 

 

Consulo Indicium - 12/4/23

Information for your Consideration…

The Continuing Coffee Health Saga – I know, I know – it’s another Kevy story about the continuing saga of coffee. But, it’s exciting! A new study at the University of Tsukuba in Japan has identified a naturally occurring compound found in coffee that seems to improve age-related cognitive decline, memory and spatial learning. The compound is trigonelline. It’s a substance that is found in multiple neurologic pathways throughout the nervous system. It’s also a substance that increases neurotransmitter levels while simultaneously decreasing inflammation. The only problem is that the studies – so far – have been on mice. So, the next step is to determine their application to the human brain but all human brain studies seem to start with mouse brains so the resulting studies will be important.

But, that’s not all. I learned something new this past week. There is “natural” caffeine and then, there’s also “synthetic” caffeine. The coffee giants and the energy drink resources that have become ubiquitous purchases for many of us on our way to work (e.g. Starbucks, Aroma Joes, etc.) as well as the caffeinated drinks (e.g. Red Bull, Coke, etc.) are mostly saturated with “synthetic” caffeine. The interesting finding is that research is now becoming available that shows the not all caffeine is created equal. Emerging research is demonstrating that synthetic caffeine may actually accelerate aging while naturally occurring caffeine slows the age-related decline. With more than 60% of the caffeine we consume coming from the synthetic side, the issue of which type we are consuming becomes quite important. The ongoing research is important for understanding the difference. In a study reported in Nutrition and Metabolism, high caffeine content was associated with shorter telomeres – a marker for cellular aging in adults versus an increase in coffee consumption associated with longer telomeres. That finding would suggest that something other than caffeine is at work… Since this report, there have been a number of studies reporting the same essential findings. Hmmm? What to do? One analysis suggests that because coffee and tea contain not only caffeine but also any number of polyphenols with anti-oxidative properties, it’s likely that the telomere effect is multi-factoral. So, for the moment, I would hang in there and continue with my favorite caffeinated drink as long as it's a natural occurring compound or, chocolate, of course – the other natural source 😊.

Speaking Of Dementia – There is a growing body of evidence revealing that generalized Covid-19 infections can cause neurogenerative decline, especially among the elderly. Based on a review in the Journal of Neurochemistry the problem seems to stem from neuro-inflammation.  For example, in one study there was a 69% increase in onset of Alzheimer’s type dementia for those over the age of 65 who experienced a Covid-19 infection. And, increasingly a number of viruses are showing up associating infections of varying intensity with onset of early dementia. So, to prevent the problem keep up the vaccinations and keep your ear to the ground. When warnings are issued, stay alert, wear your masks and be prudent. The long-term effects could be more of a bummer than the short-term.

Making Travel Safer – The CDC recently announced that it is partnering with Gingko Bioworks to expand the Traveler-based Genomic Surveillance Program which will be testing for more than 30 priority pathogens in airports across the USA. The testing program will include voluntary nasal swabs, sampling of wastewater both in airports and from planes, testing of international travelers from high infection rate nations, and other testing functions. We should not be surprised if testing for flu, RSV and other fall-related pathogens were to begin over the holiday season. Just remember, it’s good for the nation and helps everyone. You’re not being singled out if asked for a swab…you’re part of a group… The major international airports will be the primary targets = JFK, SFO, IAD and others. 

What Are We Doing? – The rate of vaccinations among kindergarteners is declining!! In fact, the rate of vaccine exemptions for children reached the highest level ever reported in the USA according to the CDC. That means kids are not receiving their measles, mumps, rubella (MMR) vaccine, diphtheria, tetanus and pertussis vaccines as well as their poliovirus and chickenpox vaccines. Ay Yi Yi!!! In many cases, parents are seemingly less concerned about these infections because there are no reported cases in their communities. The reason? Because kids have gotten vaccines!! I believe the medical community needs to become more aggressive about advocating the need for vaccinations. The reason these diseases have declined is because of “safe” vaccines. The diseases are still around and lurking in the background only to arise again when a sufficient number of the community lack the vaccines. Take note…

Cyberthreats Abound In Healthcare – The healthcare community is experiencing a plethora of cyberthreats across the board from business email compromise (BEC), to supply chain problems, to cloud compromise, to ransomware. A recent study by the Ponemon Institute found that 88% of the 653 health care organizations surveyed had experience a cyberattack in the last 12 months!! The average cost of each of those cyberattacks was $4.99 million dollars which represented a 13% increase over 2022. At the top of the list according to the security analysts who participated in the study was cloud compromise with 74% of respondents indicating their organization was “at risk”. In many respects that’s not unexpected since “the cloud” is where most organizations now host their healthcare information rather than on server farms within their own organizations. But, while ransomware attacks are still a concern, the degree of concern has decreased somewhat from 2022 by 12%. Long story short, diligence on the part of the IT teams at healthcare organizations across the board is essential in today’s world of digital care delivery.

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…

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