Consulo Indicium - 9/19/19

Information for your Consideration…

The Number of Holes – When I saw this picture, it caused me to pause.  A picture is worth a thousand words.  Check it out.

Remembering JFK – In the midst of our national debate on immigrants, I was sent a clip of President John F. Kennedy’s 1963 address to the Anti-Defamation League 50th Anniversary Celebration.  In the speech, the America I grew up comes to the forefront.  My Great Grandfather left Germany to get away from Bismarck’s army.  He dodged the German draft to come to America, to homestead a farm, to raise four kids who raised their kids which allowed one of them to become a doctor to help people.  That’s the essence of the American dream.  We all – except for our Native Americans – were immigrants to this wonderful land.   

Education versus Warnings – A recent report in the Washington Post noted that the Food and Drug Administration (FDA) has proposed a new requirement for cigarette packaging that would include graphic images of the injury cause by smoking “along with vivid descriptions” on cigarette packages. What type of graphic images?  Does “amputated toes”, “black-tinged lungs,” or “a sickly boy in an oxygen mask” offer an image?  In the past the FDA has been blocked from requiring such images because of the courts siding with tobacco companies arguing that such practices constitute a violation of First Amendment rights.  But, warnings have been around since 1966.  So, the question is where to draw the line?  From my perspective – as a former smoker of four packs per day in college (yes, stupidly – four packs per day), I think graphic warnings are just fine. Even better would be a short clip watching someone try to breathe due to emphysema from smoking (you might pick up on the fact that I’m an avid anti-smoker!!).  And, the same applies to vaping.  There has been precious little research on vaping and only hypothetical benefits offered.  If we want to get “in your face” about smoking and/or vaping – I’ve suggested for years that we should admit people to the hospital, give people chest pain and, the vast majority would quit smoking.  How’s that for a graphic, in-your-face approach?  In five or ten years, I bet that we will look back on vaping as a menace as deep and disheartening as the opioid crisis of today.  We are allowing it to be created.  We must get ahead of the curve…

Consulo Indicium - 8/5/19

Information for your Consideration… 

Washington, We’ve Got A Problem – Arash Mostaghimi, MD recently published information in the British Medical Journal on the exploding costs of WHO “essential medicines”.  At present, there are 265 such medications on the list which is used by Medicare Part D.  Among the essential medicines, the growth in spending went from $11.9Bn (2011) to $25.8Bn (2015) or a 116% increase over a four-year period.  Over that same period of time, out-of-pocket expenses by patients totaled $12.1Bn increasing from $2.0Bn (2011) to $2.9Bn (2015 or, a 47% increase.  In addition, the introduction of novel or new drugs accounted for about 58% of the cost increase versus 22% of the increases attributed to existing drugs.  Nonetheless, this is only for the “essential medicines”.  The cost question for drugs – largely because of federal policies which limit Medicare’s ability to negotiate with the drug companies – in an increasing problem.  We need to get much more serious about negotiating drug prices BUT, that’s not the only point.  Costs in Medicare are growing faster than ALL other elements of society’s costs – education, entertainment, transportation – pick your favorite one!!  If we don’t get a handle on the problem, my generation runs the risk of bankrupting the nation BUT, I actually don’t think the Millennials will let that happen.  So, let’s get on with the solutions…

A Distressing Trend – From 1999 to 2016, the rate of suicide in the US has increased by 28%.  It’s now the 10th most common cause of death.  More importantly, it’s a trend that seems to cut across all the demographic although there is an equally disturbing increase among young girls, age 10 – 19, by 70% according to CDC data.  Why?  No one really knows at this point although there is a phenomena referred to as “suicide contagion”.  For example, in the months following Robin Williams’ (“Nanu, Nanu”) suicide in 2014 there was a 10% spike in such suicides across the nation. Economic crisis seem to cause an increase.  But, I’m wondering about our “connectivity” as a society.  Getting together and talking things over was once a group exercise.  Now, the answer always seems to be “online”.  There is a certain disconnect by using online sources.  I remember several years ago I was at the airport awaiting a plane departure – one of my more common activities in those days – when I looked up to the laughter of a group of young people.  But, they weren’t talking with one another.  They were online, engaged in some activity together, heads turned down with all of their stimulus coming from a screen – not through interaction “real time” with people.  I wonder?  Are we becoming disconnected?  Is the technology separating us?  Now, don’t think I’m “old school” because I’m a huge fan of technology but, I’m wondering!  It’s an issue that needs to be considered…

Walking, Walking, Walking – But, It’s More Than Walking – It seems that walking is all the rage these days as a way for getting us sedentary types out of our hibernation cocoons which are attached to computers and other electronic devices – and, someplace where walking at a rapid clip is accomplished.  The earphones are elective.  But, the question is for how far?  And, for how long?  A recent JAMA Internal Medicine article reviewed the literature in an attempt to find an answer.  The data shows that while 10,000 steps is nice there is no cardiovascular improvement beyond the 7500 steps/day quota.  There was step-wise mortality improvement from 2700 to 4400 to 5900 steps but, beyond 7500, improvements leveled off.  And, if a slightly lower number stimulates you to go after it – you’ll benefit.

But, it’s not just walking that’s important.  It’s the use of weight-bearing exercise that involves the large muscles of the legs.  In a recent report, studies show that use of these muscles stimulates the production of stem cells in the brain which are thought to review our neuro-capabilities!  So, not only do we live longer but, we can also think longer.  When this study is replicated and more effectively disseminated, we’ll probably all be out there taking those big steps to lean on those big muscles. After all, without a brain – what’s it all worth?  If you still want to be a pumpkin and sit around, good luck!

Putting Job Stress Aside To Consider Job Security – There was a recent JAMA Network article on the state of the health and health care workforce in the United States. The US Bureau of Labor Statistics recently noted that the demands of an aging population and the increased rate of health insurance coverage by Americans has resulted in a large increase in demand for health care workers. Between 2014 and 2024, the increase in health care jobs will grow by 19% - the biggest increase for any occupational segment in their database. But, while numbers are important – it is equally important to consider how the workforce actually “works together”.  As we move from value-based reimbursement (I am of the opinion that is a “when” not an “if” question), collaboration becomes the watchword of health care teams.  We’re still not training for that outcome.  So beyond, “more” workers, we also need to be including “how” workers work.  

Crossing The Line Into Advocacy:  I’m Appalled! – The pediatricians have spoken and I’m with them!  In findings that were published online in JAMA Pediatrics, the pediatricians stated: “Millions of children stand to lose health and nutrition benefits if…[a]...proposed rule that influences immigrants’ legal status in the U.S. is finalized by the Trump administration.” According to the report, at least 1.3 million children with a least one existing, life-threatening condition such as asthma or cancer risk losing their benefits if the rule goes through in its current form where it designates these kids as “public charges”.  In essence, the new rule states the “public charges” are ineligible for government health benefits like safety-net programs such as Medicaid and the Children’s Health Insurance (CHIP) program.  Researchers note that even families who would not be affected are likely to pull out or not apply out of fear and confusion.  What kind of country are we evolving toward?  So, I would like anyone who disagrees with me to do the following:

  • Go to church or, to synagogue, or to your local community center, or, to your favorite gathering place where friends gather – or,
  • Go to the nearest park where your neighbors commune or, Better yet, go to the office and call a meeting

In each of these situations, I want you to either stand up and explain (no shouting is needed) your position.  Explain it thoroughly so that everyone you know will know your position.  Don’t post it because I don’t want you to hide behind the veil of social media.  Don’t sit quietly by and let those of us who are appalled take the stand and rant and rave. Simply explain – why on earth you would allow such a policy to be made the law of the land.  Make a stand and explain.  Make us listen. You can even send me a message.

Why Children? – We’ve come so very far as a nation but we seem to be backsliding a lot.  When my Great Grandfather emigrated from Bavaria, Germany in 1887 with his wife and two young children (with more on the way once he arrived) because he wanted to avoid conscription for Bismarck’s wars (i.e. he was a draft dodger), there was a paucity of health care services available.  I’m not sure what they did for health care more than a century ago upon arrival in the USA or if we had adopted the policies in place.  However, I’m confident that he had heard about the plaque on the new dedicated “Statue of Liberty” that was positioned in New York’s harbor as a welcome for emigrants from around the world (SEE “Quotes” above). 

So, it was very disturbing to learn that the Administration recently made a proposal that will increase the odds that immigrants will be deemed ‘public charges’ ineligible for government health benefits. The policy will have a hugely adverse impact on an estimated 1.3 million children throughout the nation who will likely become uninsured.  Why?  Because it is highly that many immigrants will simply disenroll their children from safety-net programs like Medicaid and the Children’s Health Insurance Program (CHIP) out of fear – “even those for those whom the rule would not apply.” I know that not everyone will believe my posts on this topics so I encourage you all to review the George W. Bush Presidential Center website on the topic of immigrants.  They provide a fair overview of the problem.  And, taking it out on children is definitely not the answer!!

 

Consulo Indicium - 6/12/19

Information for your Consideration…

Support For Seeing Another Day – Are you getting a tad older?  Is the memory slipping just a bit too much – forgotten names, missed appointments, details lost, etc.?  Want to be healthier?  Do you need some data to encourage your patients to get off their duff?  A recent study reveals that moderate exercise such as simply walking or pedaling a stationary bicycle can make a huge difference in our long-term mental sharpness.  After only six months of moderate exercise, participants in the study had marked improvements in executive function which includes our ability to focus, to organize our activities, regulate our behavior and achieve our goals – all laudable capabilities that we all want to retain.  For more information on the study, go to WebMD for references and details.

Then, there is the physical side of the house.  A recent JAMA Open Network article reported a study of >300,000 AARP members. It showed that people who engage in “leisure-time physical activity (LTPA)” and who started in midlife (35% lower mortality) had comparable results to those who maintained such activity throughout their life (36% lower mortality) – compared to those who never engaged in physical activity.  That speaks volumes to the fact that it is never too late to start!  It does not have to be excessive exercise either.  For example, walking and moderate exercise will help to turn back the clock a bit for older adults and, it seems to help in increasing mental acuity.  In support of the “moderate exercise” theme, a separate piece in The New York Times reported that “dog owners are about four times more likely than other people to meet today’s physical activity guidelines, according to a large-scale new study of dogs and exercise.”  When Toto the Wonder Dog (my constant companion when I’m home) heard this news, his tail wagged even more than usual.  He’s incredibly excited about the “more walking” part.  He loves to walk and explore.  Now, about that travel side of my life… 

On A Healthy Note – Researchers at the Beth Israel Lahey Health – a Boston-based health care academic and care delivery system – reported a compound in Brussels sprouts, broccoli or other cruciferous vegetables can block an enzyme that drives the occurrence of human cancer. That’s consistent with the message my wife gives (pretty much every day) to “eat green vegetables”.  Another consideration includes eating more fruits and vegetables.  Put the two together and studies are showing a nine-year reduction in brain age, according to James Blumenthal, Ph.D. from Duke University.  In particular, the DASH diet has been called out as a successful strategy on the dietary side.  The diet includes not only fruits and vegetables but also whole grains, reduction in healthy unsaturated fats and a low sodium, sugar, and meat but high dairy diet. The result is that walking a dog every day and eating the right stuff keeps you younger and healthier longer. So, that means potatoes don’t count. What’s a German boy from North Dakota to do?  Argh! 

And, A Long-Term Health Note – It was very disturbing to learn that scientists are reporting the monthly peak amount of carbon dioxide in the Earth's atmosphere in 2019 jumped by a near-record amount to reach 414.8 parts per million (ppm) in May.  The level is the highest level on record and – what is even more disturbing – the highest level in the past 3 million years. And, oh by the way, the accumulation of carbon dioxide in the atmosphere is due to global warming.  So, what is the data that the naysayers are citing?  And, what are the health implications?  They range from the change of ecosystems to biomes to all manner of life on earth.  And, what are we doing about it?  Not as much as what is needed.  “Health” is a broad issue.  It’s not just human health but also “health” of the place where we live.

Kudos To The Derms – I recently received a copy of the American Academy of Dermatology position paper on “artificial intelligence” (AI) and was very pleased to see that they have adopted “augmented intelligence” (AuI) as the model for big data analytics in health care.  I’ve been arguing for some time that we need to be thinking of these tools as sources for “clinically augmented intelligence”.  But, in fact, the Derms are correct.  It goes beyond the “clinical” to include all the non-clinical elements in the lives of the people for whom we provide care.  It’s where they travel, it’s what they eat, it’s the social determinants of health, and more.  So, kudos to my Derm colleagues.

When Trade Wars Might Affect Healthcare – Unbeknownst to most of us, the pharmaceutical companies over the last couple of decades have moved most of their production overseas. In particular, the US makes almost none of its own antibiotics anymore – yes, I said “none”.  That’s an ominous declaration because it creates a health risk but also a national security risk.   And, the problem is not confined to unavailability.  It is also an increasing problem with generics that are made overseas that are not equivalent to the original drugs.  The result can be devastating.  Check it out in an article that appeared in the Boston Globe by Katherine Eban.  The details are chilling.  It’s an issue that deserves the greater attention of the medical community. 

Rural Inequities Continue – A new poll reported in U.S. News & World Report and conducted by the Harvard Chan School of Public Health, the Robert Wood Johnson Foundation and National Public Radio found that 1 in 3 rural Americans struggle to afford health care. If the health care component is combined with housing and food, the figure jumps to 4 of 10 “…rural adults have struggled to afford medical bills, housing or food in recent years.” Furthermore – and, not surprising – about a fourth of rural adults “have skipped health care at some point because they lacked either financial or physical access to care.” The rural inequity – which I’ve been blogging about for over a decade now, continues.  We seem to take a couple of steps forward and then fall backwards…

 But, It’s Not Just Rural Folks: Racial Inequities Continue As Well – In testimony before the US House Ways and Means Committee, Patrice Harris, MD, President of the AMA noted that racial disparities and social determinants of health represent a “maternal mortality crisis” for the nation.  She cited studies which show that contributors to the crisis include:

  • Lack of insurance or inadequate coverage prior to, during, and after pregnancy,
  • Increased closures of maternity units in rural and urban communities,
  • Lack of inter-professional teams trained in best practices,
  • Structural determinants of health, such as public policies, laws and racism that produce inequities in the social determinants of health, such as education, employment, housing and transportation,
  • Stress exacerbated by discrimination that can result in hypertension, heart disease and gestational diabetes during pregnancy; and,
  • Clinicians not listening to black women, resulting in missed warning signs and delayed diagnosis.

Dr. Harris noted in her testimony that, “At the provider and institutional levels, there is a growing body of evidence demonstrating that implicit and explicit biases exist that negatively impact the quality of health care equity and patient safety and drive these inequities.” In citing the issues, she called for a program to address maternal mortality and depression. The AMA also called for policy to encourage local and state health departments to develop material mortality surveillance programs along with support for research on best practices to reduce poor material mortality and morbidity in racial and ethnic minorities. 

Directing Care To Improve Care – In a major move to enhance the accuracy of diagnosis of employees, Walmart recently announced that it has selected 800 imaging centers which will be used by their employees in the future. In an internal study, the company found there was a high rate of error in the readings of CT scans and MRIs at certain centers providing imaging services. In an effort to curb misdiagnosis and improve care, they decided to direct the care to selected centers across the nation.  The trend towards directing care to those organizations that have better outcomes is not confined to imaging centers nor to Walmart. It’s happening across the board.  As transparency increases, the health care industry should anticipate that the trend will only accelerate.  And, I believe, it will be good for health care across the board. 

Consulo Indicium - 5/1/19

Information for your Consideration…

When The Future Is Too Close – It was rather disturbing to receive a notice in the media this past week that if Congress does not take action soon [to quote from the report]: “…tens of millions of Americans will only receive about three-quarters of their Social Security benefits when they retire.” Hmmm.  Now, if you were only three, four or five decades into life that wouldn’t be totally alarming.  But, if the future were much nearer than the past, it could you make more than pause – which is why I paused when I read the notice.  The annual report for the Medicare and Social Security Trust funds noted that Social Security will be tapped out 2035 and Medicare by 2026.  Yikes!  That’s seven years away.  Hmmm – another pause and big deep breath.  The recent media reports media reports are noting that the major problem steps from lower-than-anticipated tax revenue (income) and higher-than-anticipated (outflow) payments to the medical system.  In fact, Medicare’s costs “…are expected to continue rising sharply over the next several decades, from about 3.7% of the total U.S. economy to 5.9%, putting a strain on the federal budget that lawmakers must act to avoid.” So, it seems that Congress – that divided group of politicians who keep pointing fingers across the aisle – is not acting to solve the problem. A whole series of policy options have been outlined to close or reduce the long-term financing problem for both Social Security and Medicare.  Furthermore, earlier action by Congress would make the problem easier to solve that delayed action.  Is it any wonder that the American public is increasingly disenchanted with the ill-will and dysfunctional state of American politics? 

The entire Medicare and Social Security funding issue is a major issue.  Together, these two federal responsibilities accounted for 45% of Federal program expenditures – excluding net interest on the debt – in FY18. The unified budget reflects current trust fund operations. The impact of drawdowns on the balances for Medicare and Society Security as well as any transfers from the general fund impact directly on the overall budget of the US government. It’s time for leadership on both sides of the aisle to shut down their Twitter accounts and put aside the name calling so that they can listen to one another and solve problems.  Now is a far better time than later.  As I have said repeatedly, if we don’t solve these two problems – my generation will bankrupt the nation or, you’re going to see a lot of very old, angry folks out on the streets making lots of noise.  Perhaps you already are seeing that happen?

The other disturbing aspect of the report is the projection that the annual cost of Social Security benefits expressed as a share of workers’ taxable earnings is growing from 13.8% (2018) to about 16.6% (2040).  In other words, Social Security will be taking away dollars from our regular earnings in an era when the economy of the US is expected to continue experiencing pressure from our international friends and foes.  But, the Medicare side of the equation is where those of us in the health care community can have an impact by advocating for changes that will increase the solvency of the program.  The most worrisome portion of the report was the projected insolvency of the Hospital Insurance (HI) Trust Fund which pays for inpatient hospital services, skilled nursing facility and home health services following hospital stays, and hospice care. With depletion just around the corner in 2026 (yes, 7 years away!), it means that we (= the health care community) need to do our part toward increasing efficiency and effectiveness of the services we provide. The report does note: “It is possible that U.S. health care practices are becoming more efficient as new payment models develop and providers anticipate less rapid growth of reimbursement rates in both the public and private sectors than has occurred during the past several decades.” From my perspective, it’s time to accelerate our efforts. My generation will thank all of you who step forward but, even more importantly, the generations that follow the Boomers will thank you even more for lifting a large anchor off of their economic shoulders. If you only want an overview, the short version is available.  If you’re so inclined, I suggest the full report. 

Sustaining Primary Care – As a primary care Family Physician, I have felt for some time that the entire specialty has been throttled for the last couple of decades.  From low reimbursements to a de-emphasis on team models of care delivery, the specialty has not been able to adequately contribute to the efficiency and effectiveness equation.  And, yet, even the most recent studies are showing the critical importance of primary care as a foundational element of care delivery.  With the move toward value-based care delivery, the need for a strong primary care component will be even more important.  To that end, HHS Secretary Alex Azar – to his credit – announced an aggressive strategy for shifting primary care from fee-for-service payments to a global fee model.  Two approaches were outlined.  First, one of the approaches will be focused on small primary-care practices with bonuses and penalties tied to their ability to keep their patients "healthy and at home." Larger practices and health systems will be given even more lucrative upside models that also pose steeper risks. The various options range from 50% of risk/reward to 100%.  There’s also a "geographic option" whereby health systems or insurance plans could assume the primary care risk for a swath of communities within a particular region.  The launch date for these initiatives is January 2020. Over the next several weeks and months, these new initiatives will no doubt receive greater scrutiny. 

In a related discussion on the future of virtual primary care, mHealth Intelligence reports that the  program must be “…more nuanced, identifying specific patient populations and offering specific services, and they’re looking beyond early numbers and revenues to focus on cost savings, downstream revenue opportunities and patient engagement and satisfaction.” Key factors to note in the primary care telehealth space include the facts that telehealth adoption is increasing, there are challenges in simply measuring success by utilization and revenues; and, the focus of such programs needs to be focused on what patients want and expect. As efforts continue to develop the virtual primary care capabilities within health care organizations, it is increasingly clear that a focus on value-based care delivery models will carry the concept forward.  I look forward to following this important movement which will dramatically alter our notion of care delivery over the coming months. 

What About Telemedicine Full Time? – A recent study published in Health Affairs surveyed physicians from the 2016 American Medical Association database and identified 15.4% of the physicians reporting the use of telemedicine in their practices.  But, the trend is growing according to recent reports in Bloomberg. The report noted that a growing number of physicians are practicing telemedicine because they “…prefer to treat patients remotely, from the comfort of their own homes.” My prediction?  By 2025, more than 50% of practices will incorporate some element of virtual care into their practice settings.  Not to be outdone by private practice, the Veteran’s Administration recently submitted requests to Congress for $1 billion in additional funding for telehealth initiatives.  

And, Then, There’s The Workforce Challenge – Anyone who is on the front lines of health care knows about the gap that is becoming increasingly evident in the adequacy of professional skills among the workforce which is making it hard for the U.S. healthcare industry to fill jobs.  A recent report outlined the major factors contributing to the problem.  They include:

  • The skills gap in the healthcare sector is larger than for any other part of the overall economy. It is in large measure due to the lengthy training and licensing required to become a healthcare professional.
  • A disparity in demand is also evident. Some healthcare roles have far more job seekers than job postings.  This includes home health aides, nursing/medical assistants, direct caregivers, and dental assistants. On the other hand, those positions that require lengthy training (e.g. RNs, PTs, speech language pathologists, NPs/PAs) are in short supply.

The report goes on to note that "…healthcare faces a greater hiring challenge than do other sectors". The authors suggested that health care organizations need to invest more in training due to the “…unique role [health care plays] in society, one that will only become more critical as the population ages." 

In Case You Missed It - Did you know that 25 states are now part of the Interstate Medical Licensure Compact? And, what does that mean?  The compact provides physicians with an expedited means of applying for a license to practice telehealth in member states.  As Humayun Chaudhry, DO, President and CEO of the Federation of State Medical Boards (FSMB) noted: “The expansion of the Compact to half of all U.S. states is an incredible achievement and testament to state medical boards’ efforts to innovate and improve license portability.”  To date, the states included in the Compact include: Alabama, Arizona, Tennessee, Colorado, Idaho, Illinois, Iowa, Kansas, Maine, Maryland, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, Oklahoma, Pennsylvania, South Dakota, Michigan, Utah, Vermont, Washington, West Virginia, Wisconsin, Wyoming, the District of Columbia and Guam. The Compact is one of those changes that brightens the future of telehealth and telecare.

 The Continuing March Of Technology – A new report in the journal Depression and Anxiety confirms work that was previously developed and supported at MITRE Corporation on behalf of the Veterans Administration.  The new study describes the use of an algorithm that identified 18 indicators from a list of 40,500 speech characteristics that were key markers for diagnosing post-traumatic stress disorder (PTSD).  The algorithm reported in the study revealed a 89% concurrence with expert diagnostic assessment.  The study marks the future direction where I’m projecting that clinicians will wear earpieces that “whisper” in their ear, “PTSD”.  But, it’s far more than PTSD.  It’s depression.  It’s Parkinson’s disease.  It’s attention deficit hyperactivity disorders (ADHD).  It’s any number of problems that present clinically with auditory cues. 

Consulo Indicium - 4/19/19

Information for your Consideration…

 In Case You Missed It – A recent article in Forbes highlighted a number of issues we are facing as a society related to the aging demographic. It’s a particular concern to some of us because of our direct involvement :-)  as well to others – like the broad swath of millennials who are inheriting the mess we’ve seemingly created in a number of areas over the last half century.  But, let’s not go there.  Instead, let’s focus on the aging issue. The article notes that there are two major considerations with an aging society.  First is the biological considerations related to our physical and mental capabilities that allow us to go about our daily lives. The second is transitions we all face as we move from being the doers, the leaders, the ones in charge, to the hang abouts, the sage advisors and the no-longer-up-to-the-taskers – as some who are younger think.  We all make the transition.  I’ve thought about “who is God” more in the last year than in the previous umpteen years of life.  Why?  Because I can feel God’s presence coming in some fashion and it’s a lot closer now than it was at the beginning of this journey! 

But, it is more than me, my aging colleagues and our personal journey.  There are also the societal considerations.  Are the changes in the environment beyond my horizon or not?  What can I do now for the sake of my children and my children’s children?  Will the Age Bubble burst the economic seams of the United States and bankrupt the nation? (NOTE:  If we don’t change course, yes it will!)  Will Social Security remain solvent?  I was with Michael Roizen, MD last week and he noted that living to an age over 100 is becoming increasingly common – and, that we should expect the average age of humans to continue climbing. Retirement as we know it came into existence in 1925 at age 65.  I’m looking at that age and responding as a total, unremitting failure.  But, when we look at it from a medical standpoint, 75 is the new 65 – today.  And tomorrow, it’s likely that 85 will be the new 75 a lot quicker than it took to make the change to 75.

Purely from a health care standpoint – there are some very serious questions we need to be asking about how much?  For what purpose?  Why? When? And, where?  And, those of us who are at the forefront of the aging issue need to lead the discussions.  I think it is time for the Boomers to step up to the plate and begin a serious societal debate on aging in America.  After all, we want to leave something better than we have or, at least that’s my philosophy.  Your thoughts appreciated.  By the way, don’t mis-interpret my comments.  I’m not saying “take away services or care” I am saying let’s have the harder discussion on what’s “appropriate” and “why”.  It’s an important debate not only for those who are aging but also for those who are just beginning their lives…

The First Line of Defense – Several weeks ago a new JAMA study reported that as the number of primary care physicians (PCPs) increased in a community there were gains in life expectancy and mortality rates improved.  Specifically, the study revealed reductions in cancer, pulmonary and cardiovascular death rates with the researchers stating that the addition of 10 primary care physicians for a population cohort of 100 000 resulting in “a 51.5-day increase in life expectancy whereas an increase in 10 specialist physicians per 100 000 population corresponded to a 19.2-day increase.”  In fact, the researchers concluded by stating: “…primary care is by far the most significant variable related to better health status.” 

Why is this important?  It’s important for three major reasons.  First, the demographics of the primary care population reveal that about 1/3 of them will either retire, become disabled or die over the next decade resulting in a shortage of between 7,300 to 43,100 over the next decade depending on how you count the numbers. Why?  Because they are Boomers.  Second, the number of young medical school graduates selecting primary care as a specialty is decreasing – an ominous trend for the US health care system.  And, third, primary care is essentially being disintermediated by the likes of CVS, Walmart, Telladoc, AmericanWell and others who are taking over the straightforward problems and leaving the more complicated primary care problems (e.g. asthma, congestive heart failure, etc.) to the face-to-face providers. At the present time, the US spends about 6% of our health care dollar on primary care which is roughly about ½ of what most other OECD countries spend.  And yet, the data is clear.  Spending more on primary care reduces the overall health care spend across the nation. 

So, why are we on this course?  I’ve said it so many times before but I’ll say it again, “The health care system is performing exactly as the incentives of the system are asking it to perform.”  If the money is put into specialties – we will get specialty services.  If the money is directed at acute care – we will get acute care.  If the focus is on “doing” things to people, you get a system that “does” things. And, finally, if prevention is not a focus and instead all of the money goes into sickness – then a sickness-oriented system will result.  The US health care system is performing exactly as it is presently incentivized.  So, if we want to change things – we need to start with the incentives. 

Value-based care delivery is a model that forces this question to the forefront so, there is hope.  My sense is that we are moving down that track.  If we don’t want to bankrupt the nation due to the weight of health care costs, it’s actually an imperative!  Health care is the #1 issue on the minds of Americans.  Now we need leadership. Actually, not just leadership but “unified” leadership.  In other words, bipartisan leadership or perhaps better put, non-partisan leadership.  Will that be forthcoming?  Yes – over the longer term. It has to be there for the sake of the country. The short term is another story…

So, What’s Happening On The Value-Based Payment Front? – First, we are definitely learning that “incentives” do matter.  Adam Boehler, the Director for the Centers for Medicare and Medicaid Innovation (CMMI) recently gave an update on the state of value-based care at the America Hospital Association meeting in Washington, DC.  He noted several important considerations. First, trying to practice in two different incentive worlds (value-based vs. fee-for-service) is “very hard”.  Second, open transparency on the results of practice is an imperative if we want providers to respond to a change in incentives. He then went on to articulate four priorities for the office: 1) supporting the patient-as-consumer, 2) creating provider accountability, 3) pay for outcomes; and, 4) prevent disease. The office is also going to be re-evaluating the criteria for evaluation and the metrics used in conducting the evaluation of results.  There was also an undercurrent of focus on telehealth and telecare as areas in need of further support and demonstration. He also noted that there will be an increasing focus on primary care models as well (SEE above commentary).  We’ll see.  The rhetoric is good.  Now we await the reality. 

 What About Specialty Care?  There was a recent article in Health Affairs that highlighted some very interesting trends among large employers.   The big employers – like Walmart – are moving toward the use of a select group of specialists for selected services (e.g. open heart, cancer care, etc.).  By having their employees use specific providers they are able to shift services to those physicians who perform at the top of their game from a clinical, quality and cost perspective.  In return the companies pay for all travel and health care costs associated with the services.  And, the result?  As an example, Walmart, Lowe’s and McKesson reported a combined savings of more than $19B under such a model that had patients using specific spine and specialty surgeons for a set of selected services.  That’s a chunk of change by any measure. Expect to see more of this strategy in the coming year…

Better To Be Late Than Never –  A large study from the US reports that people who engage in high levels of leisure activity throughout their entire lives had a 1/3 lower in their risk of death.  Tell us something we didn’t know!  The good news for the late bloomers; however, is that people were inactive in the early part of their lives but then increased their physical activity later during middle age enjoyed the same reduction in all cause mortality as if they had been exercising their entire life!  Oh, oh!  That means there’s now a very good, documentable reason to exercise as part of your daily routine.  The data is compelling.  The experts keep arguing that 80 is the new 60. So, it seems that are no more excuses… The lucky one is Toto the Wonder Dog.     

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