Consulo Indicium - 5/1/18

Information for your Consideration…

 Ominous Clouds On The Horizon – As I grew up on the Great Plains, one of the lessons I learned is that when you see a really dark storm on the horizon – it’s important to pay attention.  So, we have one of those metaphorical storms brewing on the American horizon in my estimation.  So, what is it?  In 2020, according to the Congressional Budget Office, the federal deficit will exceed $1 trillion (yes, that’s “T” as in terrible).  The new tax law advanced the increase by a couple of years and over the years 2021 to 2028, the rate of increase in the annual deficit will be 4.9% of GDP or, higher than at any point since World War II.  Even more troubling, the total national debt will reach $33 trillion or 96% of GDP over the next decade.  What are we doing?  What kind of legacy are we leaving our children? Congress and our elected officials (all of them) are simply kicking the can down the road.  In my experience, ominous clouds on the horizon generally cause major – in some cases disastrous – damage and destruction.  Are we headed in that direction?  I think so…

Statistics Worth Noting And, Checking – In 2016, the USA witnessed the highest share of homicides attributable to guns in the last century at 74.5%.  In fact, we’ve seen more gun-related deaths since 1968 (1.58 million) than all of the USA wars combined (1.48 million) according to the according to data compiled from various sources by Snopes – the Fact Checker. Furthermore, the rate of homicide by guns is higher than we have seen at any time since the 1920s at the height of Prohibition – the next highest time period.  It was a time when mobsters were carrying around machine guns and other automatic weapons.  It’s also a time when the National Rifle Association (NRA) became an advocate for stricter gun control.  Hmmmm!! 

Alright, Alright – Let’s Exercise – For many of us, getting our bodies moving with exercise is a challenging daily task or, should I say “chore”.  Well, get the lead out.  There’s a new study that ties your marbles to your muscles.  In a long-term study started in 1968, investigators found that high levels of cardiovascular exercise resulted in a dramatic reduction in dementia for middle-aged women at a level of 88% LESS than those participants who did not exercise regularly!!  The dementia examinations occurred in six separate evaluations over time.  In fact, the study showed that the highly fit women who did develop dementia did so an average of 11 years later than the moderately fit women.  So, while the researchers follow-up with further studies, I recommend that everyone continue to exercise – and, we’ll start with me…

And, in a related consideration, researchers have for many years questioned why our cognitive abilities decline over time.  The consensus has been that part of the reason is that the brain did not create new cells as older cells died off.  Such a model would ultimately result in the loss of nerve connections leading to memory and reasoning loss along with declines in language skills.  But, the researchers at Columbia University have reported that the brain, in fact, makes new nerve cells, especially in the parts of the brain involved in memory.  Specifically, the researchers found that cellular replacement occurred in older and younger people.  However, in the aged brain, the reduction in blood flow for nourishing the new cells was far less than among the younger subjects. This takes us back full circle to the other study mentioned immediately above. So, the mantra (coming from multiple studies) is exercise, exercise, exercise

Congressional Opioid Inaction – There seems to be a lot of inaction, action among the four US House and Senate committees that are considering legislation to address the ongoing opioid epidemic.  The good part is that what some are describing as “the most sweeping proposal” is a draft bipartisan bill winding through the US Senate Education, Labor, and Pensions Committee.  It includes provisions such as accelerating the development of non-addictive alternatives, enhancing existing enforcement efforts of current opioid controls; and, increasing the grant programs to the states that have been hit the hardest by the opioid epidemic.  But, some of these provisions will take time.  For example, Francis Collins, MD, the Director of the National Institutes of Health (NIH) has noted that it will likely take at least five years for a non-addictive for pain medication to become available. 

On the research front, a new study was recently reported in JAMA Psychiatry that treating people in jails and prisons for opioid addiction show some promising results for reducing the incidence of deaths after discharge.  Specifically, the report discussed a program instituted by the Rhode Island Department of Corrections in 2016 and resulted in a 61% decrease in post-incarceration deaths.   In discussing the results of the study, one of the researchers from the Boston Medical Center Grayken Center for Addition and an Adjunct Associate Professor at Brown University – Traci Green, MD offered the following assessment: “This program reaches an extremely vulnerable population at an extremely vulnerable time with the best treatment available for opioid use disorder…Here we have a program that’s shown to work, and it’s absolutely replicable in other places. Not only do we see that a statewide program treating people using medications for addiction treatment is possible and reduces deaths, but also this approach intervenes on the opioid epidemic at its most lethal and socially disrupting point — incarceration — to give hope and heal communities.”  So, onward with the replication

 Obscurity Vs. Transparency – If you have ever tried to traverse the pathways of health insurance or pharmacy benefits managers (PBMs), you know that it is a treacherous course.  The out-of-pocket costs seem (to me, at least) to shift every year.  One of the little known requirements imposed by those health insurance providers and PBMs is that pharmacists are often restricted from informing patients that a certain drug is cheaper if paid for out-of-pocket rather than paying for the drug through their insurance program.  Senators Susan Collins (R-ME) and Claire McCaskill (D-MO) introduced S. 2554 or, the Patient Right to Know Drug Prices Act which removes the “gag clause” imposed by the insurers and PBMs. The increase in transparency is CRITICAL as we move forward towards value-based care delivery.  Without it, consumers will not be empowered and the whole notion of fostering “value” will be crippled.  Kudos to the Senators for taking the lead.  Let’s get behind them and support the legislation. 

 Let’s Get On Board! – Two of my colleagues – John Halamka, M.D., CIO at Beth Israel Deaconess Medical Center (the “other doc who wears all black”) and David Bates, M.D., Senior Vice President for Innovation at Brigham and Women’s Hospital – along with some other colleagues from the British National Health Service and Scotland have called on Congress to allow for the creation of a uniform health identifier.  The ability to move in this direction was banned by Congress due to privacy concerns.  However, as the advocates noted, the ban has fostered an environment that has allowed misidentification and medical errors which could be easily correctable to continue.  We need to get ahead of the curve here (finally) and move in this direction.  The article from the NEJM Catalyst made the following point:  “When accurate information is attached to the right patient, data access is timelier for clinical, administrative, quality improvement and research purposes; inappropriate care, redundant tests and medical errors are reduced; and health information exchange becomes easier—within organizations as well as between.  Identifiers are also beneficial for patient mobility, allowing information to be linked to patients and following them as they move.”  Let’s get behind them. There is growing and strong support in the medical community for moving in this direction.  Write your Congressional delegation!

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