Consulo Indicium - 11/5/18

Information for your Consideration…

Factoid – By 2020, the total volume of medical information will double every 73 days. So, the question becomes – how do we teach our young physicians, nurses and other health care providers to stay abreast of the latest and best approaches in care delivery?  It’s not just automating information.  It’s not just “augmented intelligence”.  The issue demands our immediate attention…

Factoid 02 – Medical researchers are actively studying the retina as an early-warning system for onset of not only diabetes – which is well known – but, also dementia, multiple sclerosis, Parkinson’s disease, Alzheimer’s, schizophrenia and more. I think I’ll invent a mirror that can be used for this purpose.  Darn.  I bet someone is already working on it… 

Exercise: An Old Idea Giving Shape to Better Outcomes – As we all know, falling is the bane of growing older.  Balance and proprioception become more difficult as we age.  In one of my JAMA articles that was lying on the floor waiting for me to read it – when I picked it up – I learned that an old form of aerobic training has become the new model.  In the September 10, 2018 issue of JAMA Internal Medicine, tai chi was found to be more effective than balance and strengthening exercises in preventing falls among adults.  The study came from Oregon with a randomized selection of older adults (primarily white women, average age = 78) who engaged in a twice weekly program of tai chi for 60 minutes.  After 6 months of training, the tai chi group was found to have significantly fewer falls than the traditional exercise and the control groups.  The end result: move slow, keep focused and do tai chi!!  Now, about that yoga exercise for cleansing the mind…

On The Upside-01: Healthcare Groups Oppose Rule Penalizing Use of Public Benefits by Immigrants – The Trump Administration via the Department of Homeland Security proposed a rule last month that would penalize legal immigrants for using government benefits like Medicaid.  It’s a rule that rang the alarm bells among a wide range of healthcare and public health organizations. Stepping up to the plate in opposition to the rule were the American Hospital Association, America's Essential Hospitals, the American Academy of Family Physicians and the American Academy of Pediatrics. Beyond the medical groups, there was a broad coalition of advocacy groups seeking to block the rule. According to experts in the field, literally hundreds of thousands of children and other members of low-income legal immigrant families would be forced out of participating in public programs that provide nutrition, housing and healthcare services. The opposing medical groups cited the ensuing public health dangers as a major consideration in why the rule was ill-advised.  Kudos to the health care leaders and advocates for drawing the line!!!

…And, for those who think I’m not a middle-of-the-roader…

On The Upside-02: CMS Proposes Telehealth Expansion for Medicare Advantage Plans – The Trump Administration via the Centers for Medicare and Medicaid Services made a 362-page proposal to eliminate geographical restrictions on telehealth access in Medicare Advantage (MA) plans by 2020. The change would enable those plans located in urban areas to use connected health technology services as a core component of their approach. Furthermore, the proposal would allow members access to telecare services in the home as well as through medical service locations.  The proposal was posted by CMS last week and will be available for comments through December 31st.  The proposal emanates from language in the Bipartisan Budget Act of 2018 signed into law by President Donald Trump earlier this year, which included provisions to increase the use of telehealth and telemedicine by MA plans. In issuing the proposal, CMS stated that it believes the change “…will increase access to patient-centered care by giving enrollees more control to determine when, where, and how they access benefits.” One of the benefits will be cost savings in care delivery to the tune of about $4.5 billion dollars over the next decade once implementation begins.  In other news, the Department of Agriculture announced over $39M in learning grants related to telehealth and telemedicine.  Kudos to the Trump Administration leaders at CMS!!

Rural Hospital Closures Spike – The General Accounting Office (GAO) noted recently in a late September report that a total of 64 rural hospitals closed between 2013 and 2017 which is more than twice as many closures as the previous five-year period.  The number did not include the eight that closed and then reopened.  Emily Rappleye, the Managing Editor of Becker’s Hospital Review, wrote a very concise list of “10 things” to remember about these closures.  Rather than synthesize her thoughts, I’m quoting her in the following excerpt from her article in early October.  Here are the “10 things”:

  1. “This has happened before.Between 1985 and 1988, 140 rural hospitals closed, accounting for about 5 percent of the rural hospitals in existence in 1985. These closures are credited to the then-new financial pressures of the Medicare Inpatient Prospective Payment System created in 1983.
  2. “Comparatively fewer urban hospitals closed. Forty-nine urban hospitals closed between 2013 and 2017, accounting for about 2 percent of all urban hospitals in 2013. The 64 rural closures accounted for 3 percent of rural hospitals in 2013.
  3. “Most closures – 77 percent – occurred in the South. Texas accounted for 22 percent of the closures between 2013 and 2017, more than the entire Midwest (11 percent) combined.
  4. “The hospitals that closed were predominantly for-profit. Thirty-six percent of the hospitals that closed between 2013-17 were for-profit, though for-profit hospitals accounted for just 11 percent of rural hospitals in 2013.
  5. “The hospitals that closed were also predominately designated Medicare Dependent. Of the 64 hospitals that closed between 2013-17, 25 percent were designated Medicare Dependent hospitals, though just 9 percent of rural hospitals were Medicare Dependent in 2013.
  6. “Financial issues were the root cause of most closures. The GAO notes rural hospital closures typically occurred when hospitals had negative margins and were unable to cover fixed costs.
  7. “Declining levels of inpatient care often aggravated the hospitals' financial standing. These declines stemmed from increased competition from federally qualified health systems and other larger health systems, as well as a declining rural population overall. The report notes 2010-16 was the first period of rural population decline in American history.
  8. “Medicare payment reductions were also a major factor in the closures. The GAO notes the average rural hospital in 2016 counted on Medicare for 46 percent of gross patient revenue. Medicare payment reductions across the board contribute to negative margins for rural hospitals, while reductions in Medicare bad debt payments also add financial pressure.
  9. “Medicaid payments are a boon to rural hospitals. Supporting past research, the GAO found rural hospitals in Medicaid expansion states were far less likely to close than those in states that had not expanded Medicaid as of April 2018.
  10. “More than half of the closed hospitals converted into another type of healthcare facility,such as urgent care, primary care or emergency services. Forty-seven percent ceased all services.” 

Hmmm – Social Media Use by Physicians – When I was going to medical school, we didn’t have to worry about things like social media.  Facebook, Instagram, Twitter, Snapchat and all the rest didn’t exist because there was no access to the Internet.  It’s didn’t exist, yet!  So, if you haven’t read the AMA Code of Medical Ethics  you may want to consider a closer read in lieu of yet another endless evening of “working the web”.  The Code recognizes that there is real value in the use of social media and – at the same time – a special need for caution among the physician community in how it is used. It’s becoming more and more of an issue.  The AMA is also now offering a credit-eligible CME course, Boundaries for Physicians: The Code of Medical Ethics, which provides guidance to physicians for identifying and understanding how to maintain proper boundaries with their patients and to articulate and understand the underlying importance of those boundaries to the practice of medicine. The module is not only available for CME credit but is also free to members or $20 for non-members.  It’s worth it.

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