Consulo Indicium - 10/17/22

Information for your Consideration…

By A Whisker – On Saturday mornings, CNN has a broadcast by Michael Smerconish – a commentator out of Philadelphia. It always has interesting twists and perspectives on the “news”. One part of the show is where he queries his viewers on a current topic. This past Saturday (2022-1008) he tried a new twist by asking the question: “Would you trust in your physician if you knew they struggled with undergraduate organic chemistry?” It obviously got my attention right away since I did “OK” in pre-med organic chemistry but, I was not the best in the class either. There were over 20+ thousand respondents to his in-the-moment poll with 60% indicating that it would not alter their trust and 40% responding that it would. Whew! Organic chemistry is most often viewed as the washout course for undergrad pre-medical students. And, I would argue that the organic chemistry professors relish their role. If you do well, you’ll be considered for medical school. If not, you’re likely washed out. I made it by a whisker 😊. When I was admitted, the Dean for Students – Dr. Wally Nelson – pulled me aside and said with a wink and a nod, “Sometimes, we admit students because we think they’ll make a difference in medicine.” Hmmm…I hope I met the expectations!

An Increased Uptake Of COVID-19 Boosters = Potential Decrease By Almost 90K Deaths. The Commonwealth Fund did an analysis of data on the immunization rates and results of subsequent COVID-19 infections. The results? “…if 80% of eligible people receive their booster dose” nearly 950,000 hospitalizations and 90,000 deaths would be prevented. On top of that over $50B in costs would be saved. The analysis is not only compelling – it’s distressing given the mis-information that’s been spread about the vaccinations. We need to get the word out in the various forums in which we are working…

TRACKING COVID IN THE U.S.

The Malicious Virus Surges Again – Are we ever going to get ahead of it? Is the end of COVID on the horizon? Yes! And, No! I have faith in the ongoing research being conducted around the world that eventually we will get a handle on the effort by COVID to cause disease among the human species. At the same time, it’s evident that the fight is not over!! In fact, you can check out the state of the COVID infectivity and hospitalization rate at the site above. You’ll note that there is actually a bit of a gentle plateau or even a slight decline in the number of cases in the USA at the present time. However, the FDA issued yet another warning that while Omicron Subvariant BA.5 seems to be causing most of the new COVID-19 cases in the USA, it is the evolving number cases related to Omicron Subvariant BA4.6 that is causing concern. Why? It’s because the BA4.6 is not as responsive to the vaccine as the other variants. Regardless, it is VERY CLEAR that everyone should not only be getting their vaccination but also lining up for their boosters on a regular basis. As of this writing (2022-10 09), only about 8 million out of 200 million USA citizens who are eligible for the booster have received the repeat immunization. As the winter months come upon us, we’re going to be spending more time inside – with one another – which will increase the likelihood of viral spread. So, vaccination is the first preventive measure and, masking will come along again if we see an upsurge. Already, researchers are beginning to notice that wastewater Omicron viral levels are up in certain part of the country especially in the Northeast.  So, stay tuned!! This could be the canary in the coal mine for yet another surge in the coming couple of months. The European findings are a harbinger of a potential surge in the USA… 

Health Equity Accreditation: The Next Step – The National Committee for Quality Assurance (NCQA) recently announced the healthcare entities that have earned accreditation from the new Health Equity Accreditation Plus evaluation program. The new program was announced last fall. The recipients include two health systems and seven insurance plans around the country. It was the first time that health systems had been included in the evaluation process as part of the NCQA program. The message? Integration of health care systems and insurance plans continues at a slow pace but, integration nonetheless. The essential components of the evaluation process include the following elements:

• Building cultures that link to external health equity initiatives,
• Collecting race, ethnicity, and language (REaL) data to support individuals' cultural and linguistic needs; and,
• Identifying health equity and related care needs such as: 1) data that assesses social risk and need, 2) in-depth patient and consumer engagement, 3) strong partnerships with community-based organizations; and, 4) social need referral systems and partners.

Guns, Again? – The use of firearms as the cause for homicides and suicides continues its ongoing growth across the USA. In 2021 compared to 2020 there was an increase in gun-related homicides (= 21,000 people or 57+ people/day) from 79% to 81% and for suicides (= 26,000 people or 71 people/day) from 53% to 55%. In fact, 2021 is now the highwater mark for gun-related deaths over the last 30 years. Gun purchases through 2021 were made by 18% of American households with about 5% purchasing a gun for the first time. Researchers who were involved in the data analysis noted that the findings “underscore the urgent need for prevention efforts…” such as more effective outreach, hospital-based interventions, and reducing access to firearms among people at risk of harming themselves or someone else. Hmmm? How about sensible gun control? When I talk with the gun owners I know, it seems that we could develop “sensible” gun control measures but, then again, the NRA would not find that acceptable.

The Path Toward Value-Based Care Delivery – In an online study published in the Annals of Family Medicine the use of “facilitators” (i.e. trained professionals in health care counseling) was shown to be effective with better outcomes for selected cardiovascular-related problems. The types of facilitated conversations included aspirin use, smoking cessation, blood pressure control and other preventive care-focused areas. The review included the assessment of 162 facilitators employed at 1,630 small- to medium-sized primary care practices. The study shows the way for possible (? probable) improvement in other clinical areas such as CHF, kidney disease, diabetes, and other clinical problems with “high value” returns through the reduction of ongoing healthcare costs. This finding totally resonates with my personal experience as a clinician. When I was in active practice – oh, so many years ago – I found that the combination of my nurse practitioner, pharmacist and social worker working in collaboration as a team with me was MUCH more effective than me working alone. However, the changes in the reimbursement system over all of those years destroyed the incentives. We need to – no, we must – move toward value-based care delivery models if we’re going to be successful in simultaneously enhancing outcomes and reducing costs. 

Extending The Obvious – The Pew Charitable Trusts recently released a report regarding the Medicare Care Choices Model (MCCM) program which extended hospice services to those individuals who were suffering from other long-term illnesses aside from a terminal disease such as dementia, respiratory diseases, and other common problems. Originally, the Medicare hospice program was set up in 1982 to provide extended home care for those with cancer. Back then – as a newly minted physician – cancer was a grim diagnosis. We’ve come so very far in our treatments in today’s world. The study included 4500+ participants who received hospice support services over the period 2016 – 2020. The results are significant. Medicare expenditures for the MCCM participants were 17% lower than non-participants (i.e. $45,976 versus $53,229) over the course of the evaluation. Why did that occur? It was due to the 26% fewer inpatient hospital admissions, 38% fewer ICU stays; and, 30% fewer days in other inpatient hospital units. The study will be a big boost to making palliative care more available and helps in the shift toward “value-based care delivery” (See note immediately above). 

More On Medicare – I’m following the Medicare data points a lot more closely this year than last. Want to know why? It’s because I’m now part of the problem due to my total reliance upon Medicare as a source of coverage for health insurance 😊.  So, I was pleased to learn of the Biden Administration announcement that Part A and B premiums will drop in 2023 Medicare premium rates will drop in 2023. The changes will also apply to the 2023 Medicare Part D income-related monthly adjustment amounts. The reason the rates are going down (a “tish” – but, an important “tish” for those on limited incomes) relates to the lower-than-expected expenditures held in the contingency for the addition of the new dementia drug, ducanumab (= Aduhelm) as well as lower-than-expected costs for Part B services. But I would caution that this does not solve the longer term problem of potential Medicare insolvency! We need to deal with the whole structure and payment methods of the program to get a grip on that one. More on this later… 

Shifting The Problem – There was a recent report in The Washington Post noting that “more than 2.5 million adolescents were current e-cigarette users in 2022, with the majority choosing flavored, disposable products”. The report comes from a federal study conducted by the Centers for Disease Control (CDC) in collaboration with the Food and Drug Administration (FDA) as part of the National Youth Tobacco Survey. Current users were grouped according to the total number among all such youth with middle school users representing 3+% and high school users at 14% of the total populace. In the latter group, a full ¼ of them were daily users!! “Use” was defined as the use of e-cigarettes at least one day in the prior month. What is most disconcerting is that the study showed that 85% of the users favored vapes in fruit, dessert, or candy flavors. Aren’t we simply shifting the problem from smokers to vapers? What are the long-term implications of vaping? I bet (no data on my side at this point) that the data will show – very clearly – that vaping causes some time of long-term health problems… We are simply shifting the problem from cigarettes to another source. For the policy makers – how stupid is that?

Telehealth Continues To Climb – FAIR Health is “…an independent nonprofit that collects data for and manages the nation’s largest database of privately billed health insurance claims and is entrusted with Medicare Parts A, B and D claims data for 2013 to the present.” The organization conducts a Monthly Telehealth Regional tracking report on telehealth. The latest report reveals a continuing increase in utilization for three of the four US census regions. FAIR Health monitors claim lines, procedure codes, and diagnostic categories derived from the billing information on care delivery. Beyond the general increase, certain specialties are the leaders in use. For example, social workers are the highest users in all of the regions. Among the medical specialties, the psychiatrists take the lead and their use increased by 8.1%. The highest users in the Midwest were primary care non-physicians and psychologists which I surmise relates to the remoteness of care delivery in the rural areas – many of which can be better served through the application of telehealth services. As for diagnosis, the most frequent problems were acute respiratory disease with COVID-19 coming in #2. However, in the Northeast, acute respiratory diseases and infections fell out of the most frequent list of diagnosis.