Consulo Indicium - 3/28/22

Information for your Consideration…

Before We Focus On Healthcare – I just wanted to share our son’s first two cuts from his new album – “Shores of Mercy” – that will be released in July 2022. He’s got a wonderful voice, a great style and a heart of gold. Please meet Michael Kiel Cash, sit back, listen and Enjoy… BTW, you should also check out his sister, Cookie Harrist, the most incredible improvisational dancer…

Nearly 100 Medical Societies Advocate Medicare Reform – In a letter dated February 24, 2022, almost 100 professional healthcare societies signed onto a request of Congress advocating reform of the Medicare physician payment system. In their letter, they stated:

"We respectfully request that your committees collaborate with the provider community to immediately initiate formal proceedings (hearing, roundtables, expert panels, etc.) to discuss potential reforms to the Medicare physician payment system to ensure continued beneficiary access to care…"

The letter focused on the scheduled cuts to the Medicare Physician Fee Schedule (MPFS). The challenges cited include:

• the Medicare Access and CHIP Reauthorization Act’s (MACRA) Quality Payment Program (QPP), which have prevented most clinicians from meaningfully participating in the program; and,
• the lack of non-physician clinician integration in the Merit-Based Incentive Payment System (MIPS)due to technical ineligibility for reporting various measures related to MIPS scoring.

The continuing problems with these issues brought together this very broad advocacy by the health care community and resulted in the societies calling for a focus on expansion of the Alternative Payment Models program including extending the current incentives for participating in Advanced APMS. With the strength of nearly 100 health care organizations representing the bulk of providers and care delivery organizations across the entire country, let’s hope that Congress listens and engages in some bipartisan and bicameral support for changes. In the years since Medicare was formed, the program has become a foundation for care delivery in the nation.

Forgiving Debt – It’s no surprise that the issue of “forgiving student debt” has become a perennial topic among our political leaders. Why? In large measure because the level of student debt has continued to grow from a level of $1.4 Trillion several years ago to about $1.9 Trillion at the last report. Furthermore, Bard College recently released a study noting that by forgiving student loan debt the USA would experience a net positive contribution to the economy. Anecdotally, I’m amazed at the level of debt students are experiencing. In fact, over the last ten years, the average cost of tuition has increased significantly – from $17,045 in 2008 – 2009 to $24,623 in 2018 – 2019 or, a 44.5% increase over the course of the decade. And, importantly, this does not include the cost of living expenses associated with attending college. I obviously grew up in a different era. I was able to obtain low cost loans throughout my entire educational training period and ended up with over $50,000 in debt – which at the time was a “huge” amount of debt but at low interest rates. In fact, the amount of debt was similar to the debt one of my friends had when he bought a house for about that cost as I entered practice. My interpretation was that my education was equivalent to small starter house in a nice neighborhood. The debt of students in today’s world; however, outstrips those thoughts by a very large margin. Something needs to be done… 

The Bust Before The Shortage – As reported by CNBC.com, there were 17.5 million undergraduates that were enrolled in US colleges for the fall semester in 2021. The enrollment represents a decline of 6.5% from 2019 or, the largest enrollment drop in 50 years. Furthermore, it was reported that community college enrollment was also down by 14.1% over the same two year period. We should anticipate that this drop in enrollment will portend a workforce shortage down the road only to be exacerbated by the retirement of the Boomers (starting several years ago) which is already causing workforce shortages. What’s a nation to do? Hmmm…in addition to student loan relief and re-engaging Boomers – what about our immigration policies?

And, Now – The Evolving Shortage – In a survey of over 20,000 respondents from 124 institutions across the USA, 20% of physicians or, 1 in 5 MDs indicated that they intend to exit practice within the next two years! The study was funded by the American Medical Association and reported in Mayo Clinic Proceedings: Innovation, Quality & Outcomes, “COVID-Related Stress and Work Intentions in a Sample of U.S. Health Care Workers.” Overall, researchers found that burnout, workload, fear of infection, anxiety and/or depression due to COVID-19 and the number of years in practice were associated with intent to reduce work hours or leave. And, despite the title of the article, the other important finding was that COVID-19 load by county was not associated with the intent to reduce work hours or leave current practice. The lead author – Christine Sinsky, MD who serves as the AMA’s Vice President of Professional Satisfaction – made the following important observation about the results of the survey:

“Our study demonstrates that the U.S. health care workforce is in peril. If even one-third to one-half of nurses and physicians carry out their expressed intensions to cut back or leave, we won’t have enough staff to meet the needs of patients.”

The double whammy of the Boomer physicians nearing retirement and the stresses of Covid-19 care delivery have amplified the evolving shortage of health care providers. And, it’s not just the physicians. The study also found that medical and nursing assistant positions are also experiencing a difficult time in filling positions for essentially the same reasons. As a result, staffing for clinics is becoming a major problem across the nation.

Telemedicine Demand Continues Strong – In late February, Doximity issued a new report noting that nearly three fourths (73%) of patients noted that they intend to use telemedicine services in the coming (I’m hopeful 😊) post-pandemic era. That level of support compares to a level of 58% intending to use telemedicine in 2020 or, a very significant increase in use patterns – most likely due to experience (my interpretation). As part of their 2021 State of Telemedicine Report, Doximity included 1,000 adults with chronic illnesses and 1,000 who were generally healthy.

Additional findings included:

• The percent of patients who actually participated in a telemedicine visit during the past year grew from 42% in 2020 to 67% in 2021.
• Patients using telemedicine indicated that the quality of care was the same or better compared to in-patient visits and, increased from 40% (2020) to 55% (2021).
  • For patients without chronic illness, the increase went from 28% (2020) to 47% (2021); and,
  • For patients with chronic illnesses, it increased from 53% (2020) to 63% (2021).
• Physicians were also surveyed with more than 67% noting that access to telemedicine helped enhance the trust factor with their patients, especially from historically marginalized communities.
• The preferred method for interacting with providers was 59% favoring mobile devices and 38% preferring the use of computers. In fact, 19% of patients with household incomes less than $25,000 used their smartphones as the method for interaction…

These data points resulted in the following conclusion from the report:

“Given that patients from lower income backgrounds and patients from historically marginalized groups are more reliant on smartphones for telemedicine access at home, healthcare systems can promote health equity by investing in mobile-first solutions that optimize for potentially slower, variable internet speeds.”

Pandemic Update – Conversations about the new “BA.2 subvariant” are dominating the pandemic chatterboxes this week. The virus first appeared in the USA on January 22, 2022 and has grown as a percent of total cases over the ensuing weeks. This past week, BA.2 subvariant represented 34.9% of all cases – a growth of 11+% over the course of just one week. So, to state the obvious – it appears to be highly contagious. HOWEVER, based on limited research data, it seems to only be problematic for those who are unvaccinated (hmmm…there is a consistent message here that percolates up with virtually each variant 😊). A recent Danish study found the following:

• The BA.2 subvariant spreads more easily across all groups regardless of sex, age, household size and vaccination status,
• The unvaccinated exhibited a higher transmissibility of BA.2 compared to the BA.1 Omicron strain and had a higher viral load which could account for the higher infectivity; and,
• The probability of spread within a household was 39% for BA.2 compared to 29% for BA.1.

The most important point for everyone to remember is that the SARS-CoV-2 virus (= the cause of COVID-19) is changing constantly.  With change comes further mutations of the genetic code over time. This is what viruses do AND, it is why they survive! As a result, we should expect that new variants of SARS-CoV-2 will continue to emerge – with some succeeding at spread and others “falling to the floor” so to speak. Stay tuned…I’m trying to stay on top of the ongoing pandemic. 

And, Now – For The Disheartening News – In a new report published in Nature, researchers have found that COVID-19 infections potentially cause a greater loss of gray matter due to tissue damage in the brain. Yikes!! This finding strikes home!! Despite my best efforts at sequestration and double vaccination+booster, I was infected with Covid-19 in the early days of the Omicron surge. I say “infected” but my symptoms only lasted a couple of days so, it was a “light infection” 😊 – but, an infection nonetheless. Of interest, the new report noted that any type of infection can cause greater loss of gray matter and tissue damage in the brain than naturally occurs in people who have not been infected with the virus. I take note of these studies as a maturing proffer of wisdom. I’m also sensitive about brain loss since my Mom experienced Alzheimer’s disease during the last decade of her life. I definitely do not want that experience.

The study in Nature was limited with only 785 people residing in Britain, aged 51 to 81, constituting the study group. Researchers were able to obtain before-and-after brain images of these individuals from the U.K. Biobank. Individuals infected with COVID-19 exhibited a greater reduction in their brain volumes overall and performed worse on cognitive tests than those who had not been infected. Of particular note, the study found that brain changes occurred among people “who had much milder disease.” (i.e. that’s me). Stay tuned. As I noted, this is an area of personal interest that I will no doubt be following in the coming months, years and decades (I have High Hopes!!) Perhaps we’ll solve this problem over the course of my remaining lifetime 😊. If you don’t believe me, check out the “High Hopes” hyperlink!!!

Since We’re On Aging, How About The Rest Of Me? While there is a massive amount of money being placed on the table to support research and treatment for a slew of specific diseases that seem to arise much more frequently in the aged population, Leonid Peshkin thinks we may be off track. He is a lecturer and machine learning/artificial intelligence biology expert at Harvard’s Blavatnik Institute and, leader among those researchers who increasingly view specific diseases (e.g. diabetes, heart disease, Alzheimer’s) as merely symptoms of a much bigger, more universal process: aging itself or, getting older! In fact, he is leading ongoing research on the use of adeno-associated virus (AAV) gene therapies for intervening in the aging process to mitigate the onset of these problems. Peshkin, in an online interview shared the following thoughts:

“I’ve always felt like aging is a disease that is no different than any other disease, and just because we are so used to it, we shouldn’t take it for granted…I want to look at the root cause of aging and understand it fundamentally. What is the cause and what is the effect? What is high up in this cascade? And most importantly: How can we fix aging?”

He and his co-researchers have developed a new research model using the Daphnia (a “flea”) as the study species (Hmmm…substituting fleas for humans 😊). They selected the species because it has a one month life span and is a relatively complex organism with cells that are similar to human neuron and muscle cells. It is also transparent so that researchers can observe a beating two-chambered heart, eyes, brain – sort of like a “mini-Me” = my characterization). And, most importantly, the Daphnia has been used in drug research for many years. If you are interested in the “nits and nats” of this new, innovative approach to aging research, check out the details in a recent issue of Aging Cell. I was obviously intrigued.