Consulo Indicium 2/15/18

Information for your Consideration...
How About An #Alt-Wall Movement? - In the last year, we've heard about the Alt-Right which has been defined as the "alternative right" or, a loosely-connected and somewhat ill-defined grouping of white supremacists, neo-Nazis, neo-fascists, and other far-right fringe hate groups.  And, yes - full disclosure - I loath the Alt-Right! Now, I've come to learn that there are Alt-Dating, Alt-Clothing, Alt-Comedy, Alt-pretty much anything sites that have emerged in the last year. It seems that all things "Alt" are in seemingly high fashion. So, I'm proposing that we consider establishing the #Alt-Wall Movement. Our colors for the movement will be redwhite and blue!
The notion of the #Alt-Wall Movement came to me the other day when I was reading about a couple of issues near and dear to my heart: public health, cybersecurity and the opioid crisis. I mean, if we can have an Alt-Clothing Movement why not simply call for an #Alt-Wall Movement. Let's start with a definition which I propose unilaterally as a loosely-connected and somewhat ill-defined grouping of committed American citizens, neo-moderate, multi-racial people who all originated from some other country and, even some fringy neo-ChristoMusliBuddhaHindu types who believe all religions have merit but, most importantly, uniformly feel that decisions inclusive of the vast majority of us generally stand the test of time. Wow, that's a mouth full of a definition. And, yes - full disclosure - I love the Alt-Wall idea!
Let me digress for a moment to explain the idea further. On the public health side, we've seen in recent weeks an effort by the Trump Administration to decimate the investment we've been making in recent years to halt the spread of infectious disease epidemics such as Ebola and Zika. In the last couple of weeks, the US Centers for Disease Control and Prevention (CDC) announced a massive downsizing of epidemic control projects in 39 out of 49 countries. Why? Because the funds to support these programs are running out! The only problem with the Wall of support for epidemiology programs is that they cannot be touched. They are not "big and beautiful". They don't gleam and glisten in the sunshine. Rather, they are the hard work of people educating and treating people to prevent the spread of disease. And, it is through those efforts that we stopped the Ebola virus from spreading across our borders and infecting our people. We caught those little viruses in the nick of time. And, it was because of the virtual Epidemiological Wall we created through the largess and ongoing support of the American taxpayer. So, now we issue proclamations and statements, but the Administration is not following through with funds.
The same could be said for the Cybersecurity WallCybersecurity is a hidden, little understood problem that reaches across all industries in the USA. It's become abundantly clear in the last couple of months that our voter systems were hijacked. And, if those can be hijacked - what about all the other vulnerable systems that exist in our great nation. What about the electrical grid? What about the transportation infrastructure? What about the very cars we seemingly control when we are driving down the highway?
And, then there's the Opioid Wall - yet another wall that gets rhetorical support when the fire in the kitchen gets too hot. The opioid problem is a pernicious, unrelenting and growing problem that gets worse by the day. It is infecting families across the nation. But, when things die down a bit, funding disappears.
So, my take is that we have an "Alt-Wall" problem!! There is an evolving Epidemiological Wall problem by decimating funding for CDC work both domestically and internationally. There is a Cybersecurity Wall problem which we've only begun to scratch the surface on. And, there's the Opioid Wall problem that So, the #Alt-Wall Movement needs funding. And, I have an idea for that as well... How about taking all the funding proposed for some of the other "walls" - like the one proposed on the Southern US-Northern Mexico border - and use it for the #Alt-Wall Movement. If the movement gains momentum, I predict there will be far more support for it than any of the other "wall" projects proposed by the Trump Administration to date.
So, my request to all of you out there within listening range is write a letter to your Congressional representative, your Senator, your Governor and demand that funding be earmarked for the #Alt-Wall Movement. Note in your letter that the trifecta of Epidemiology, Cybersecurity and Opioids should get the bulk of the funding. You should also note that funding for these three areas combined will be less that those other walls. Now - that should get some support...
A Quick Diversion - If you've been following the Olympics, you may have noticed that one of the stars of the Women's USA Hockey team is Monique Lamoureux.   She is from Grand Forks, North Dakota - where I Iived for a decade and, where I watched her brothers play hockey for the UND Men's Hockey team. Monique and her twin sister, Jocelyne, have been crucial in helping the Women's USA team attain silver medals in prior Olympics. The Lamoureux's are infamous in North Dakota!! Their father, Pierre, was a goalie on the UND team a bunch of years ago and Monique's four older brothers all played as well. They got their start by playing outdoors - as all good hockey players do when they start out!! - on the English Coulee in Grand Forks. Just wanted you to know since hockey is the main sport for those of us who grew up in North Dakota although I was never any good. But, I am a good fan...
A Trump Tax Bill Analysis - The Trump Administration released the proposed FY19 $4.4 trillion budget - which while it was declared "dead on arrival" like most Presidential budgets also contains some changes in how health care dollars would be expended. The emphasis of the Efficient, Effective, Accountable: An American Budget is on bolstering our defense spending while promoting austerity in nondefense programs. It will be very interesting to see what the Republican legislators do with this budget because of the nearly $1 trillion in additions to the deficit for FY19 and upwards of $7 trillion plus over the next decade. The Freedom Caucus and the Tea Party members must be going nuts at this point. This is, in large measure, why the budget is "dead on arrival" - from both sides of the aisle.
While there are lots of places to provide commentary, the health care portion of the budget deserves some attention because of what it portends from a directional standpoint by the Trump Administration. Some of the notable health care changes include the following:

1. Reductions in federal obligations projected as part of a rescission of the Accountable Care Act (ACA) including $675 billion in projected savings by 2028 from the "repeal and replace" initiative - What the Administration could not get through Congress, it is attempting to do through the budget process in a maneuver that is similar to the Graham-Cassidy bill. It would also repeal the Medicaid expansion program as it exists and instead promote a state block grant program. Also, those who are on Medicaid, a per-capita cap program is proposed which is intended to create an incentive on the part of states to keep costs below a certain ceiling level. The states with higher reimbursement rates will be the ones most adversely affected by this particular policy proposal. But, this is just the beginning, it appears. Long story short - there will no doubt be another battle on the health care side of equation. Other elements include:

  • Deny benefits to people who cannot prove their immigration status (= $2.2 billion in cuts over 10 years),
  • Increase beneficiaries' copayments for improper use of the emergency room ($1.3 billion in cuts over 10 years); and,
  • Allow asset testing, which adds up all the value of a person's property and belongings, in addition to income as a test of Medicaid eligibility ($2 billion in cuts over 10 years). 

2. HHS will receive a huge decrease in discretionary spending - these efforts would focus on decreasing or diminishing considerably several federal programs, including:

  • Responsibilities of the Agency for Healthcare Research and Quality (AHRQ) which has been under attack for a number of years would be reallocated to other agencies such as the National Institutes of Health (~$68 million net savings after merging programs between AHRQ and NIH),
  • The Community Services Block Grant program which provides more than $700 million in annual grants for health care, food, and workforce programs is deemed duplicative of other existing programs - although which ones it is not clear; and,
  • The health care workforce programs for supporting the training of medical and other health sciences students in the form of programs to offset the cost of their education would be decreased (~ $451 million in savings). The White House contends that these programs do little to improve the workforce supply around the nation. 

3. Funding to combat the opioid epidemic is a major focus of the budget. President Trump allots $5 billion in new resources for HHS over the next five years starting with $1 billion in 2019 to address opioid abuse, treatment and prevention. The funds will focus on a media campaign, improved access to opioid overdose reversal drugs, surveillance and prevention efforts, drug courts, services for pregnant women addicted to opioids, and supplemental funds for Native Americans and Alaska Natives, among a series of other initiatives. But, long story short, this pales in comparison to what is needed. It is estimated that the opioid crisis is now costing the USA north of $80 billion per year. As Everett Dirksen (R-IL) the senior statesman from Illinois once said, "A billion here, a billion there and pretty soon you're talking real money." In this case, we have a long ways to go. For example, the proposed budget only allocates $123 million for the Substance Abuse and Mental Health Services Administration and $126 million for the Centers for Disease Control and Prevention. All paltry at best.

4. Some notable exceptions to the health care cuts are proposed in the form of an additional $70.7 billion for the Veterans Health Administration or, a 9.6% increase from 2017 - The additional VA funds include $11.9 billion for a newly consolidated veteran community care program, $381 million to address the opioid epidemic; and, $8.6 billion for veteran-focused mental health services. The budget also calls for Congress to set aside $75.6 billion in advance appropriations for VA care in 2020.

And, these changes are just for starters. There does not appear to be a coherent "plan" as part of an overarching strategy. Rather, the focus seems to be on cutting programs. There is further analysis on the proposed impact related to Medicare and we'll be following that in the coming week. Stay tuned...
Waitin' For Azar's Moves - A lot of us are waiting to see in which direction the new US Secretary of Health and Human Services - Alex M. Azar, II- moves after moving into his digs at the Hubert Humphrey Building in Washington, DC. As it relates to Obamacare, the question being asked is, will he "let it fail" as announced by his Boss (i.e. Mr. Trump) earlier last year or use his significant authority to "make it better"? One of the issues I keep raising is that the "problems" with Obamacare will be addressed by coming to the middle from a policy perspective rather than at either end of the extremes or, in other words, the far right or far left. When you consider Medicare and Medicaid, as an example, it was not perfect when it was first passed. It was only after the tweaking that occurred over the following decade that the policy finally began to settle in as a worthwhile piece of legislation that truly met the needs of the American public. The same will no doubt apply to Obamacare - assuming it continues to weather the policy storm.
If you review the hyperlink on votes taken by the US House of Representatives over the period 1949 - 2011 in the attached graphic, you can see how the legislative body has become increasingly polarized. This makes solving the Obamacare problems - let alone the rest of the nation's problems - increasingly difficult. So, how does this happen? Gerrymandering is the answer. Over the last two decades the number of "safe districts" has expanded considerably to the point where there are virtually no contested elections in certain districts. The end result is that we as "the people" are getting the results we have allowed to occur.   The Democrats for their part have not exactly been at the forefront of proposals for improving the Obamacare legislation. In fact, the changes they would enact - if given the chance - are relatively unclear. But, lawmakers on both sides have floated a range of options extending from the need to control prescription drug costs, to shoring up the Obamacare exchange program, to revival of the perennial "public option" idea to compete with private carriers on the notion that such an approach would drive down prices. Regardless, many of us hope that Mr. Azar is open to some suggestions on "changes" that would improve Obamacare rather than simply disrupting it in an effort to destroy it. We shall see...
Accountable Care Organizations (ACOs) Growth Continues - The adoption of the ACOmodel for reimbursement of health care services has more than doubled since 2013 going from 34% to 71% according to a recent report by the Healthcare Intelligence Network. In addition, over the same period, the use of shared savings models for provider reimbursement increased from 22% to 33%. The other major finding of the report was the shift from managerial leadership derived from Physician-Hospital Organizations (PHOs) to Integrated Delivery Networks (IDNs) which now represent more than one quarter of all ACO initiatives.
At the same time, another survey was released by Leavitt Partners showing that physicians are not nearly so excited about the use of value-based payment models for either controlling costs or improving health outcomes. In each case, about one-fifth to one-third of the physicians felt that bundled payments or ACO initiatives would manage costs more effectively. So, it seems that there is a disconnect between the frontline physicians and the health system executives. It seems; however, that the attitude of the physicians is primarily related to a lack of information or experience with the new, evolving payment methodologies. Clearly, more work needs to be done. According to the Leavitt Partners report, the fact that frontline physicians are uninformed on the effects of payment methodologies relates directly to the investment level of the organizations the physicians work within. It seems to be a simple dictum: Little investment in educating physicians results in little understanding of the evolving change.
Where Do We Spend Our Time? If you haven't signed up for the blog of Peter Ubel, MDyou should check him out at Peter Ubel or, on Twitter @PeterUbel. He recently had a rant on the use of the electronic health record (EHR) and the amount of time it takes from physicians interacting with patients. He noted one study from The Annals of Internal Medicinewhere the research teams directly observed the activities of physicians in outpatient clinics. They reviewed four specialties: family medicine, internal medicine, cardiology, and orthopedics. The study revealed that the physicians spent about one-half their work time on interacting with the EHR. One-half!!! In another study from Health Affairs the work of primary care physicians on inputting information into their EHRs was studies. The results were similar. These results confirm my own personal "at home" results where my 88-year-old father-in-law complained to me several months ago that traveling for more than an hour to get to the doctor's office then, waiting in the waiting room for at least another hour, having some tests done by technicians and then, "only talking with the doctor for 10 minutes or less" made no sense to him. I couldn't agree with him more. Not all systems are bad. But, just like we need to not become captive to our iPhones - so, we must not become captive to the EHRs we use to support our care delivery.
Healthcare Consultants

    ...Inspiring creative change to benefit the human condition