Information for your Consideration… 

You Probably Missed It? Once a year over a relatively short period of time we celebrate one of Maine’s best products. What am I talking about? The 3^rd Annual Wild Blueberry Weekend in Maine. It’s generally held the first weekend of August so you can plan for next year 😊. Why is this so important? First of all, blueberries – often referred to as a “superfood” – are an excellent source of nutrients. And, “wild” blueberries are absolutely the VERY BEST! Those tiny berries (about the size of pea) are known to help in lowering blood pressure, preventing heart disease, reducing cancer, improving memory, preventing premature aging, aiding in exercise recovery, and a whole lot more. In fact, I try to eat them as much as possible!! Factoid: Maine produces 99% of all blueberries in the country which makes the state the single largest domestic producer of the fruit. Farmers harvested nearly 78 million pounds of blueberries in 2022 and the production is expected to grow this year. But, the most important piece of information is that “wild” blueberries are exceptionally “blueberryie”, nutritious and wonderful – far better than those larger, chubby blueberries you often find from elsewhere (e.g. New Jersey). So, consider a visit to Maine next year during blueberry season. You will not be disappointed. And, “P.S.” – Maine has other attributes as well… 

Kudos To The College Board – On Thursday, August 3^rd, the College Board – which oversees the curricular offerings by colleges and universities across the nation sent a notice to the Florida State Board of Higher Education noting that they should no longer offer AP Psychology courses to entering students because a state law was passed banning the inclusion of references to human sexuality and gender identify. KUDOs to the College Board. Psychology is an important foundation for many professional degree programs. It is very clear to me that we should NOT be having state legislatures – regardless of political affiliation – defining the content of professional training. To explicitly demarcate a portion of training because some legislators don’t like it is to expunge training on issues and problems that cut across all sorts of pre-conceived notions of adequate training. Psychology is an essential part of training not just for psychologists but also physicians, nurses, social workers, nutritionists, advertising executives, business leaders and others (you get the point!). In fact, Psychology is frequently a pre-requisite for entry to many professional programs. As Arthur Evans, CEO of the American Psychological Association stated in announcing the College Board decision: “…parsing out human sexuality and gender identification is like taking division out of math training.” Well said!! Legislatures across the country are becoming micro-managers of curricular programs in all sorts of professions to the detriment of those professions. The legislatures or a state’s elected officials frequently appoint or name the participants on the state professional oversight bodies. They should allow those bodies to do their work. I could go on but…you get the point! 

Let’s Solve The Problem – The Commonwealth Fund is reporting that the United States holds the unfortunate distinction of having the biggest geographic health disparities of all countries in the developed world. As a rural health advocate, I found the rural-urban inequalities along with embedded racism concerns to be most troubling. I know for a fact – as an example – that some of the worst – if not the worst – disparities from across the entire USA reside in rural places like Pine Ridge Reservation in South Dakota where the poverty level is 53.75%!! There is a clear need for more state-based as well as a national focus on health disparities generally as well as across rural areas throughout the nation. There are certain exemplary programs such as the Equitable Neighborhoods Initiative, sponsored by the University of Alabama that are working to equip communities to become more resilient to health disparities. Specialized programs in “rural” primary care and surgery such as those offered by my alma mater at the University of North Dakota School of Medicine and Health Sciences are also needed across the nation. With much of the rural workforce dependent upon the Boomer generation, we can anticipate a significant growth in health disparities unless more focus and support are given to solving the geographic disparities problems. It’s a problem in need of a solution… 

Double Kudos for The Centers for Medicare and Medicaid Services (CMS) – One of the issues that CMS has been grappling with ever since the launch of ObamaCare is how best to create “value” in the health care delivery chain. It’s an issue that I believe can best be handled through the effective deployment of “primary care coordination” across the spectrum of care delivery. But, then again – I’m a Family Physician by training so you would expect me to be an advocate for primary care (= Family Practice, General Internal Medicine, Pediatrics, Gynecology Generalists [my definition]). CMS is finally moving forward with plans to implement value-based care delivery. Under the ObamaCare program, CMS set a goal of getting 100% of Medicare beneficiaries into “value-based arrangements” by 2030. While movement was on hold for four years, it picked up again when the Biden Administration moved to engage in a “strategic refresh“. Under the initiative, CMS is taking a hard look at the status of initiatives established under Obama and determining which directions to support going forward. CMS has been pushing internally to kick-start a focus on the value-based care delivery model. As a result, CMS in June announced the launch of a major new initiative, Making Care Primary (MCP). The focus of CMS efforts is to: "improve care management and care coordination, equip primary care clinicians with tools to form partnerships with health care specialists, and leverage community-based connections to address patients' health needs…" Good goals from my perspective. Importantly, the initiative includes a strong focus on the Social Determinants of Health (SDOH) which have been shown to represent 80% of the cost of care following discharge from hospital. In essence, it’s about transportation, nutrition, home care support, in-home medication management and other considerations. The MCP model will be deployed over the course of the coming decade to allow primary care practices time to develop the capacity and infrastructure to appropriately deploy and coordinate value-based care delivery services. In fact, one of the areas of focus is on the state Medicaid programs which are moving forward with a variety of initiatives focused on value-based care delivery. For more information on the CMS initiatives, check out an interview with John Barkett, Managing Director for Healthcare at the Berkeley Research Group.  

New Study on Private Equity Healthcare Investments = Not Good! – A recent study published in The British Medical Journal documented the upsides and downsides derived from the involvement of private equity (PE) ownership in healthcare operations. The study was not complimentary and highlighted the “harmful impacts” of PE from payers to providers to patients. It included a meta-analysis of 55 prior studies related to healthcare PE ownership. In sum, the downsides outweighed the upsides of PE ownership, particularly in institutional settings such as hospitals and nursing homes. The reason it’s an important study for consideration is that PE ownership in healthcare has grown precipitously over the last several years and is projected to experience further growth in the coming years. The authors of the study suggested that due to the growth in health care, PE investments were “…warranting surveillance, reporting and possibly increased regulation.” This is an issue that deserves every health care leader’s attention. It is especially important in follow-up to the prior Consolo Indicium note on “value-based care delivery”...

Some Important Stats On The Field of Medicine – The Federation of State Medical Boards recently completed its 7^th biennial census of physicians in the USA. The current count as of 2022 was just over one million physicians licensed to practice in the USA with 89% holding a Doctor of Medicine (MD) degree and 11% hold a Doctor of Osteopathic Medicine (DO) degree. Some other important stats include the following:

• The number of physicians who are board certified in their respective specialty has increased from 77% (2010) to 85% (2022) – a tribute to the specialty societies in emphasizing the need for board certification.
• On the downside the physician pool is getting a bit older (ahem – like me 😊) with the mean age of 51.9 years (2022) compared to 50.7 (2010).
• However, such a small increase in the media age does not quite accurately portray the profession. Why? Because over that same period there was a 54% increase in the number of physicians aged 60 years and older. This portends a very significant shortage of physicians in the not-too-distant future as the population continues to increase.

On the upside, the presence of women in the physician workforce has increased fairly dramatically from 30% in 2020 to 37% of the total physician pool in 2022 – a fact that I believe has been a very positive force for the profession.

The Microbiome and Brain Health – As a follower of brain health research, I found the research presented at the Alzheimer’s Association International Conference in Amsterdam last month to be quite interesting. There is a growing body of research demonstrating a direct link between our biome and our projected brain health. For example, one study found that chronic constipation was tied to declining cognitive abilities with the loss of up to three years of aged living for those who were so affected. Specifically, constipation resulted in a depletion of bacteria that produce butyrate which creates byproducts supporting the gut barrier and prevent the entrance of bad bugs! In another study, low levels of neuroprotective gut bacteria, Butryricicoccus and Ruminococcus, were associated with elevated levels of Alzheimer’s disease. There is clearly a growing body of evidence related to the gut microbiome and our cognitive capabilities over time. Perhaps this accounts for those population groups (e.g. certain Japanese populations) that have exceptionally good cognitive function far above the average based on simple dietary differences. I suspect we will be finding over the next decades that dietary intake and microbiome function have far more to do with our mental sustainability than is currently known. Meanwhile, eat six cups of fruits and vegetables every day!

Information for your Consideration… 

More Data Supporting The Fruits-Vegetables-Nuts-Legumes Diet – In yet another study – this time from the European Heart Journal – researchers are reporting that a diet comprised of higher amounts of fruit, vegetables, nuts, legumes, fish, and whole-fat dairy supports a lower incidence of cardiovascular disease and mortality throughout the world, including lesser developed nations. The study involved a review of multiple cohort studies across 80 countries with case-control studies from 62 countries. The results? A 6% lower incidence of major cardiovascular events and an 8% lower risk for mortality. Our mantra at home is “six cups of fruits and vegetables a day” – along with the obligatory chocolate and coffee, of course.

Consulo Indicium

Information for your Consideration…

A BEAD of Hope – The Biden Administration made a recent announcement that will have a profound impact on rural and underserved areas throughout the nation. The new program under the auspices of the US Department of Commerce has been titled the “Broadband Equity, Access and Deployment (BEAD Program (For details go here). In essence, the program will allocate over $42 billion in federal funds from the 2021 bipartisan infrastructure law to the states for support of high-speed internet access with the goal of creating equity in access across the entire nation and closing the digital divide. Specifically, the states will be charged with the responsibility for developing state-based plans and programs for how the funds will be allocated, deployed, and managed. In making the announcement, President Biden stated: “We’re talking today about a major investment that we’re making in affordable, high-speed internet, all across the country,” describing the program as “…the best thing that’s happened in rural America since the Rural Electrification Act.” As a long-time rural health advocate, I couldn’t agree more. The program has the potential for making high-speed infrastructure available on an equitable basis throughout the nation to support health care, education, communications, commerce and a host of other areas. It’s a policy I’ve been advocating for some time since eyes were opened to the inequities of care delivery for rural American when I served as the Founding Director of the Center for Rural Health at the University of North Dakota. From a health care perspective, the program will bring equity by allowing for better communication, monitoring, connectivity and actual care delivery for rural residents. Kudos to Biden for pushing this new initiative forward!

The Federal Communications Commission has been working to define the US households and business where high speed infrastructure is lacking and last month issued new maps that revealed at least 7% of US households and businesses with deficient infrastructure. The information will be used by the states as they develop their plans and program over the coming months. The states have been guaranteed a minimum of $100M in BEAD funding to support the initiative. For example, my home states of North Dakota and Maine will receive $130M+ and $271M+, respectively – a very respectable amount of start-up funds for initiating the new program. The next step will be in bringing the capabilities of the initiative to bear making sure the services are affordable as well as accessible. Congress approved the Broadband Equity, Access and Deployment program, or BEAD, along with several other internet expansion initiatives, through the infrastructure bill Biden signed in 2021.

A Cautionary Note On The Results Of Telemedicine: A Brief Analysis – When the pandemic hit in 2019, it seems that we finally saw the uptick in use of telemedicine technologies that some of us had been predicting for some time. The disappointing factor was that it took a pandemic to see it come about ☹. Regardless, the use of telemedicine and telecare has become far more normative in a relatively short period of time. However, the recent research on the effectiveness or reliability of these tools for enhancing care delivery has been mixed. Why? At least for starters, it appears that a focus on selected problems appears to offer better outcomes than on those individuals with a panoply of clinical problems. In a study on blood pressure management from Mass General Brigham researchers, there was a 22% increase in the number of patients who reached their goal which due in large measure to the fact that there was a 71% increase in home B/P measurements during the course of the study. But, it’s not just chronic problems. It also applies to acute problems such as at-home treatment for COVID-19 infections as reported in three separate studies[1]. However, the results are inconsistent as reported in the literature. Other studies have shown little correlation to the use of remote management. So, why the difference? The US Department of Health and Human Services did a review to assess the reasons for the differences in outcomes from these studies. Their analysis along with other studies can be found is here. Long story short, there seem to be several important factors, including:

• Infrastructure – As a long-time rural health equity advocate I’ve been making this argument for far too long. Without bandwidth, capacity, connectivity and a host of other issues related to “access”, people cannot be expected to use telehealth and telecare models for care delivery! In part, that’s why I was so excited about the recent announcement by the Biden Administration to establish the BEAD Initiative (SEE first item in this blog, “A BEAD of Hope”).

• Workflow Management – Simply adding in the use of technology without reassessing and redesigning the workflow of the clinical care approach is creating an incompatibility. As a clinician, I can tell you that managing face-to-face clinical work with patients is vastly different than virtual work. Trying to do the two together requires a modification of how clinicians do their work. Without such an approach, far too many workflow items simply fall to the flow and “use” of these systems will decline over time.

• Scaling – While an initial “small” cohort of patients might benefit substantially from use of the tools, how and what resources are used in scaling up to care for larger numbers of patients is an important element. I will argue that simply assigning these scaled up tasks to the very busy clinical office for following up will create a major obstacle (back to “workflow management”).

• Collaborative Capability – It is important to consider how the entire “team” of care providers in the continuum of telecare/telehealth/FTFcare will be integrated. In short, rethinking the care delivery model is required so that effective “team” with internal as well as external communication capacity are developed, supported and sustained.

• Integration of AI/ML – There are any number of evolving tools that need to be considered as part of the capacity for deploying effective telehealth and telecare tools that will require a focus on all four of the above items. For a good review of “guidelines and guardrails” on this topic, go here.

A Leading Cause of Injury Can Be Abated – As an individual who suffers from peripheral neuropathy (the diminished ability to “feel” one’s hands and feet – for starters), I recently read an article that more than a couple of my readers might find of interest. It relates to engaging in “balance exercises” for diminishing the risks associated with the falling. I was sensitized to the problem more recently not because of my own problem but because of a colleague who fell and ended up with a total hip and some other medical sequelae. It sensitized me to the problem that I was already “not feeling”. The data shows clearly that nearly 1 in 4 adults will experience a fall. In fact, for those over the age of 65 (hmmm – that’s me!), a fall is the leading cause of injury. In fact, every time I visit one of my many physicians, he always asks me first up, “Where’s your cane?” I finally relented and then discovered more recently that for those over the ae of 65, the most common cause of hip fractures and traumatic brain injuries is a fall!! So, why the problem? It’s not only the result of decreased balance from problems like peripheral neuropathy. It’s also from decreased visual acuity and muscle weakness. So, for the last couple of years, I’ve engaged the help of an exercise guru who once worked with professional athletes to help them stay in tip top condition. The only problem was their attitude – which he did not like. So, he turned to the “elder community” – which is growing by leaps and bounds ,where attitudes are more forgiving (ahem!). His approach includes some critical areas of focus training.

1. Improved coordination through balance training. When we first started, I could not for the life of me do heel-to-toe walking or stand one leg. Now I perform much better through a combination of focused exercises and practice. These types of exercises, reduce the rate of falls by 24%.
2. Selective and focused weight-lifting along with use of resistance bands. The muscles in the core, hips and legs are critical areas of focused training.

3. Tai chi and yoga exercises have been shown to be an effective approach. Through the use of controlled, slow movements with shifts in body weight a person can increase their strength and balance, demonstrating a 20% reduction in falls.

4. Flexibility training to improve one’s range of motion and reduce stiffness. These types of exercises clearly add to us older types ability to move around much more effectively and efficiently.

5. Find someone with expertise and follow their advice. As an increasingly seasoned elder this is probably the most important part of the program. And, don’t dabble. Get into it. Regular exercise does – in fact – make a difference!

Then, There’s Sleep… - Boy, you can sure see what’s been on my mind of late 😊. I noticed this article from the Sleep Disorders Center at Beth Israel Lahey Health the other day and wanted to pass along the information. It’s especially important for those of us who are burning both ends of the candle trying to “make health care better” (my personal mantra for the last 50 years). Sleep is one of the most basic of human functions the over the millennia (and before) has been fine-tuned to help us with all of our body’s daily functioning, In our modern society we face significant intrusions into the rhythm of life – intrusions like increasingly variable work lives that are no longer confined to the office but seek out time at home as well. Then there are the usual intrusions like always on smartphone, computer messages, messages from whoever to say nothing of the impact of travel through multiple time zones to get to a place like Greece 😊. According to the National Heart, Lung, and Blood Institute, sleep disruption affects an estimated 50-70 million people or just over 20% in the USA alone. If we extrapolate that number to the world, it means that roughly 1.5 billion+ people across the world are affected by sleep deprivation.

Finally – The Targeted Bans Show Results With E-Cigarette Sales Tapering Off in 2022! – The New York Times recently reported that the sale of e-cigarettes increased by “nearly 47% from January 2020, just before the pandemic hit the United States, to December 2022” according to research conducted by the US Centers for Disease Control and Prevention. The decline was attributed to several factors including the increasingly ubiquitous e-cigarettes which seemingly give the user immediate nicotine fixes with hundreds and hundreds of puffs from a single device, to state and local bans on flavored tobacco products and other government policy initiatives designed to curb tobacco use. The impact on e-cigarette use through such initiatives as the “flavor ban” was clear. During the study period, tobacco flavored products decreased from 28.4% to 20.1%; and, mint flavored productions, from 10.1% to 5.9%. If you need more information on how best to curb your patients’ use of e-cigarettes, a good sourced is available on Familydoctor.org. 

An Ominous Trend – Price Waterhouse Coopers (PwC) is projecting a potential increase of 7% in health care costs according to a report recently released by the consulting firm. Labor shortages and inflation were described as the primary culprits. The trend is ominous for several reasons. First, in the decade prior to the onset of COVID-19 health care costs had generally been on a gradual decline in comparison to overall costs for other goods and services. Health care was not the only area affected. COVID-19 was generally a culprit across the board throughout society and across all sectors. For health care the pandemic; however, saw a spike in costs due to the two factors mentioned above. The other issue inflationary factor was from the pharmaceutical side of health care where the average cost for introduction of a new medicine was in the neighborhood of $200,000. That’s a major cost factor that affects everyone. The burden for these costs will likely fall on the uninsured, the underinsured as well as those with insurance with significant deductible plans like middle-class workers private insurance and elders with Medicare Advantage plans offered by employers. Now, the big question is: Will the inflationary increases continue or abate in the next couple of years? If they continue their upward spiral – health care will no doubt consume even more of the overall Gross Domestic Product (GDP) and the federal and state budgets. Now, that’s not good for the health care delivery community! 

[1] Kaiser = https://www.thepermanentejournal.org/doi/10.7812/TPP/20.281#ref; Mayo = https://www.aha.org/aha-center-health-innovation-market-scan/2021-09-14-studies-find-remote-monitoring-advanced-care; and, VHA = https://telehealthandmedicinetoday.com/index.php/journal/article/view/281/444 

Information for your Consideration…

Alzheimer’s Disease Studies Need Patients! – A new report from the Alzheimer’s Association (AA) highlights the fact that there are presently 187 clinical trials – as of last count – for the neurodegenerative disease underway. The information was published by the association and derived from a review of the ClinicalTrials.gov database. Big Pharma seems to be engaged  seems to be engaged on the issue and more trials are expected. In addition, there was a recent piece on National Public Radio on Huntington’s disease that will no doubt boost even more research on the Alzheimer’s front. It basically describes the current drug regimes used for the treatment of Alzheimer’s as cleaning up the forest fires that occur in the brain through the accumulation of beta-amyloid deposits. The new approach described in the NPR piece was on the focus of identifying the places in the brain where the fire starts before a forest fire occurs to prevent the formation of the beta-amyloid. It’s an intriguing finding from the work on Huntington’s disease. 

Calling Uber For Healthcare Support – It was only a matter of time before we would see the onset of Uber Health. And, it’s started!! The initial focus will be providing consumers with over-the-counter medication and grocery delivery. The company started moving in this direction in 2018 when they offered nonemergency medical transportation for patients. In April, Uber Health started offering same-day medication delivery to the home and will now provide the same service for over-the-counter medications as well as groceries. The focus is different; however, in that the service is directed specifically to the care delivery side (e.g. care coordinators, payors, providers). It’s clear that their service will be an important adjunct to the ongoing effort toward moving care to the home as part of the value-based care delivery movement. In fact, Caitlin Donovan – the Global Head of Uber Health stated as much in making the announcement about the extension of Uber Health. She noted: “Value-based care is the future of healthcare, but it’s complex and labor-intensive to deliver and scale. Uber Health addresses this challenge head-on…Our platform streamlines coordination across multiple benefits—nonemergency medical transportation (NEMT), prescription delivery, and food and over-the-counter medication delivery, empowering payers and providers to support patients beyond the four walls of a medical office.” So, I’m wondering – what’s next?

But, Uber Is Not The Only Interloper – Healthcare is moving beyond the local to the ubiquitous national!! With the likes of Amazon, CVS, Walmart and others from the retail world moving into the healthcare delivery space what should we expect in the future? Stacey Malakoff, Chief Financial Officer at NYC Hospital for Special Surgery, offered her insights on a recent HealthLeaders podcast.  

The Critical Role AND Shortage Of Nurses – I’ve been working with nurses since I was a 16 year-old orderly in a nursing home and, I’ve developed a tremendous respect for their capabilities and talents. In fact, a short anecdote is in order to make the point. When I was a first-year intern at Montefiore Hospital in The Bronx in 1978, I will never forget my first night on call. It was shortly after midnight and I received a call to the Intensive Care Unit. I was asked to see and care for a patient who was in obvious respiratory distress. As the new intern – fresh from medical school – I dutifully answered my beeper, rushed to the ICU and started talking with the patient. I pulled out my stethoscope and bumbled about after a brief exam and looked at the nurse who was with me in that look of panic! The nurse calmly walked from the foot of the bed over to me, put her hand on my shoulder and quietly said, “Doctor, do you want me to save your ass?” I replied in the most humble way that I could with a quiet “Yes!”. So begat my learnings on the value of competent nurses as partners in care delivery. 

I share the story because the American Association of Colleges of Nursing recently released a very disturbing fact sheet outlining the fact over the period of 2020 to 2021 there was a drop of more than 100,000 registered nurses in the USA. Furthermore, the College projects more than 200,000 openings for RNs each year between now and 2031. Why? It’s largely because we Boomers and GenXers are moving toward retirement at a slower pace at best. Furthermore, as the USA moves from 52 million (2018) over the age of 65 to nearly 100 million (2060) the impact on care delivery will be even more dramatic. It seems clear that we will not solve the problem by simply attempting to increase numbers of nurses. While that needs to occur, it’s also clear that we need to rethink out entire approach to the care delivery process – and, I obviously believe that “augmenting” our care through the appropriate uses of technology is one avenue that will absolutely be required.

The Loneliness Epidemic – In a recent press conference, Vivek Murthy, MD – the USA Surgeon General – highlighted the “…epidemic of loneliness” as a major “…underappreciated public health crisis” in the nation. He also noted that while the COVID 19 pandemic was a major precipitating factor, there are other social dynamics at play contributing to the growth in loneliness and isolation across the nation. Why? A decline in trust of community and neighbors was a leading factor. Also, the rising tide of technology and its intrusion into our lives was another factor. Changes in family structure with the huge increase in single parent households was also cited. And, income disparities were another leading factor. The issue deserves our attention. Listen to the press conference for some insight into the growing problem that will no doubt affect the health of the populace in the years to come.