Consulo Indicium - 4/15/24

Information for your Consideration…

Voices For Value-Based Care – Check out the quote above from Zameer Rizi who opined in a Medical Economics article that we need to take a serious look at moving toward “value-based care” (VBC) payment models as the foundation for American health care. As my long-time readers know, I’ve been a proponent of VBC for many years. By emphasizing “value” rather than simply “doing things”, the healthcare system will realize – based on the existing VBC pilot programs - not only improved productivity and enhanced outcomes – but, also service delivery at lower cost. It’s definitely where the USA needs to go from my perspective!   

Compounding the need for serious consideration of a national approach to VBC is the increasing consolidation of care delivery providers through the expansion of private equity control. For example, a report emanating from researchers at the University of California Berkeley clearly shows the consolidation pattern. They reviewed more than 300 metropolitan areas and the growth of private equity since 2012. In about 18% of the metro markets a single firm was shown to control more than half of the specialty service sites in that market. Such control while possibly creating some efficiencies also creates marketplaces that are unable to function without those services. The end result is that the system becomes beholden to them as a source of care delivery. The other concerning fact is that much consolidation has occurred in the “ology” fields – in particular, for urology, gastroenterology, obstetrics-gynecology, radiology, orthopedics, and oncology – all of which have seen a near doubling of private equity control in recent years. Not to be left out, there has even been a jump in consolidation related to the primary care fields as well.

As noted in the Zameer Rizi Medical Economics article cited above: “Although acquisition by a [private equity] firm can alleviate financial strain by providing capital and technology to the practice, it may also bring a focus on increasing short-term profits and a high debt burden…a focus on short-term profits may lead to overuse or misuse of lucrative treatments and services, an increase in prices, and substitution of lower-cost healthcare providers for physicians—all of which can compromise healthcare quality."

But, more importantly, the issues are not solely about the economics of private equity involvement in health care. The other major considerations relate to the burgeoning explosion of elders (I’m one of them) moving into the Medicare system and our need as a society to provide equitable health care for ALL Americans – not just those who have resources and employment status by allowing them to have insurance coverage. These two factors stress the resources of local, state, and federal resources. As a result, an emphasis on “value” via effective qualitative, quantitative, and evaluation methodologies with appropriate incentives is clearly in the best interest of society at large.

Advocacy most often precedes action. So, my suggestion is that we – as leaders in the healthcare community – need to step up to the plate and “advocate” a move toward value-based care delivery. The data seems clear that a move toward VBC will create better and more value for health care, the public, and the economy. Without it, I believe society and the greater needs of that society will suffer. Your thoughts are appreciated 

So, Is Concierge Primary Care Better? – First, a bit of explanation. “Concierge care” is the type of service accorded to those individuals who pay somewhere between $2500 - $5,000 (depending on your geographic region) to gain access to a primary care provider 24x7. Those who are concerned about access and cost express the notion that this type of model ultimately harms the healthcare system through increased costs and disparities (NOTE: I am among those arguing that perspective). In fact, researchers have found that overall costs of healthcare increase by 30 – 50% in total for those who are enrolled in concierge medicine practices. However, the proponents argue that the practice allows for those physicians who would otherwise retire to continue in the practice of medicine on a “scaled back” model so that the approach helps to resolve the workforce shortage issue. For a review of the topic, consider reading the full assessment of the practice in Concierge medicine is an important phenomenon since it is growing among not-for-profit and academic medical centers as a way of “upstreaming” patients with resources into those institutions.


These questions of economic drivers for access to health care are part of the dark side of health care – from my perspective – and, something that misses the mark. I believe that equitable health care should be available to all. Gamesmanship seen in health care delivery – while it has always been there – seems to be on the upswing. Something needs to be done… Then, again – as noted above: advocacy most often precedes action. So, where are the advocates?

Where Have All The Babies Gone? Back in the day, when the Boomettes or GenX were beginning their focus on having families, the USA broke the 1957 record for baby production by having 4,317,000 babies. That was in 2007. And, it was anticipated that the Millennials would even break that record when they came of age because of their size. But, then everything changed. Most analysts would argue that the onset of the Great Recession of 2008/9 clearly played a role in the early stages of a decline in baby production across the USA when over 10% of the workforce lost their jobs. It also affected other nations like China, Europe, and others, as well. By 2013, the Dow Jones Industrial Average was on an incredible growth pattern that continues to this date. But, the baby production did not return. It’s been difficult for analysts to identify any other specific factors that could account for the decline in baby-making not only here in the USA but worldwide. Although the data is unclear, there are some levers that seem to be at play, including: a growing concern among Millennials about the ecology of “too many people” inhabiting Mother Earth, the much higher uptake of highly effective contraception, and the economy – more generally – in recent years has been a force due to the costs associated with raising children. Many analysts point to the enhanced occupational opportunities for women and the ability to engage in such employment through more virtual means by both sexes. And, the high level of student debt has become an albatross for many young adults. But, the available research does not lend much support to these ideas as fundamental explanations for the decline in the overall birth rate. It’s an open question that does not seem to have a clear answer. Regardless, the Baby Bust is going to have major repercussions across society as we have seen with the closure of high schools now moving to colleges leading to a decline in trained workforce and the like. As a side note, Maine (where I reside) has the distinction of now being the “oldest” state in the USA – something discussed in the quiet corners of living rooms throughout the state. What to do? My personal perspective is that the issue is a societal and generational phenomenon that has not yet been adequately defined. There are lots of opinions but so far, not a lot of answers. BTW, those medical students considering Ob-Gyn should really think about moving into Family Practice 😊 – see the next item…

Regardless, Rural Maternity Care Is In Trouble – I got my start in healthcare (as distinct from “medical care”) when I took on the role of serving as the start-up Director for the Center for Rural Health at the University of North Dakota. During those formative years, we held on to the concept that “studying” rural health was not sufficient. We needed to “actively support and develop” rural health by working with rural communities across the Upper Midwest on the issues they faced in healthcare. One issue that falls into that bailiwick is maternity care.

It is within this context that a new study by the Center for Healthcare Quality and Payment Reform (CHQPR) in Pittsburgh caught my interest. The report – released in January 2024 –highlights the “crisis in rural maternity care.” The report goes on to note that it is insufficient to simply train more providers of any type. It is also essential to train “…medical and nursing students need to be recruited and trained specifically to deliver team-based care in rural areas.” I couldn’t agree more. And, again the problem comes down to people power and money – two consistent themes for healthcare, in general. Here are some of the data points highlighted from the study:

  • Roughly 20% of the USA populace resides in rural America – yet it is a populace that is often ignored or dismissed.
  • 55% of the rural hospitals across the USA do not currently offer labor and delivery services. And, in 10 states, the data is even worse where more than two-thirds do not offer this critical service. In fact, since the mid-1990s, more than 200 USA rural hospitals have stopped delivering babies.
  • Why? Because the vast majority were losing money on maternal care delivery services due to “all payor” forms of cost constraints as well as with liability increasing.

What makes these statistics particularly alarming is the fact that the USA has the highest infant and maternal rate of mortality rate among the G-20 economies throughout the world. That’s a sad statement for a nation that concurrently holds the position as one of the very richest in the world. The CHQPR study points out that pregnant women are 3X more likely to die in the USA compared to Australia, Britain, Canada, France, Germany, and other developed countries. And, to increase the urgency of the issue, the gap is getting wider!!

The CHQPR concluded its report with the following statement: “It is not an exaggeration to say that rural maternity care is in a state of crisis, and a crisis demands immediate action. Every day that steps are not taken to implement the changes in workforce recruitment and payments described above increases the likelihood that more women and babies will die unnecessarily.”

And, Then, There Are the Comparisons of Medicare Advantage vs. Traditional Medicare – In a recent study conducted by policy researchers at the American Enterprise Institute and Harvard Medical School, findings revealed that not only does Medicare Advantage cover a disproportionate share of the disadvantaged senior populace compared to traditional fee-for-service Medicare – it also outperforms on several key metrics. In particular, Advantage beneficiaries evidence experienced a 70% lower hospital readmission rate compared to their fee-for-service counterparts. Advantage members also had 35% lower rates of inappropriate medication use and comparable rates of medication adherence as well as fewer preventable inpatient admissions. One of the partners in the study was Inovalon, a healthcare cloud supplier to the healthcare industry. A copy of the full report is available at the Inovalon website. The conclusion of the study noted that it “…underscores the role that care management and coordination can play in promoting quality within the Medicare program. Furthermore, the study indicates that the lack of care management in Medicare’s fee-for-service program has negative ramifications for beneficiaries and that recent reforms to [fee-for-service Medicare]—such as the introduction of accountable care organizations and value-based initiatives—have clearly not brought sufficient care management to the fee-for-service program.” 

Oh Oh! Time To Make Some Dietary Adjustments – A recent research article in the British Medical Journal provided the results from a new “meta-analysis” study of over 45 studies covering about 10 million people. The results? The study found “convincing evidence that higher ultra-processed food intake was associated with about a 50% increased risk of cardiovascular disease-related death, a 48 to 53% higher risk of anxiety and common mental disorders, and a 12% greater risk of Type 2 diabetes.” The report also noted that there was “…highly suggestive evidence...indicated that diets high in ultra-processed foods were associated with a 21% greater risk of death from any cause.” This report comes on top of the daily admonishments that my wife is providing me on the value of fruits and vegetables as dietary staples that should be at the top of the list – rather than the bottom of my personal food pyramid. I guess I should be relieved that she would like to keep me alive 😊. 

The Transition of Mankind Into Some Form of Plastic! – Many of you may have read the disturbing news that microplastics are becoming ubiquitous abscesses across the entire earth extending from the personal “me” to the ocean across the entire earth. Yikes!!! They’re even found in soils and sediments that extend back to the early 1700s before microplastics were a production problem for humankind. Why? Because they are so small that they seep everywhere!! The results come from a study published in the journal Science Advances by European researchers who studied the sediment of three lakes in Latvia. It’s all part of the Anthropocene Epoch which is defined as the study of human impact on the environment since the 1950s.  and meant to delineate when humans started having a large impact on our environment. The more disturbing part of the study was the ubiquitous nature of microplastics which as so small that they are even found in human cells. Just imagine what will happen to Jupiter in another couple hundred years after humans form their colonies and such in the outlying planets😊.

Overdose Deaths From Smoking Accelerating – The US Centers for Disease Control (CDC) recently released a new report on the perils of drug overdose deaths. The report noted that the percentage of deaths from smoking drugs has overtaken the injection of drugs as the leading cause of death.  It increased by a whopping 74% from 13.3% to 23.1% over the two years of 2020-22. Meanwhile, the percentage of overdose deaths from injections fell from 22.7% to 16.1% over the same period. In essence, while drug users may be increasingly aware of the perils of injecting drugs, the message hasn’t caught on for snorting and such.

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