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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