Future Health - 10/16/20

Delivering care in the new virtual world… 

Predictions and Findings – I clipped an article in mid-June 2020 in the pre-chaos stage of the Covid-19 pandemic from StatNews (9 Ways COVID-19 May Forever Upend the U.S. Health Care Industry”). You may remember this period. It was when we were hovering around 100,000 lives and 30 million jobs lost. It seems like so very long ago. As part of the article, StatNews interviewed both prominent Democrat and Republican health care leaders to come up with a set of “findings” occurring as a result of the pandemic. Sometimes it is good to look back – even for only a couple of months – to secure lessons for the future. Those findings included the following:

  1. The pandemic has accelerated telemedicine by a decade.
  2. The pandemic is driving us yet another step away from traditional employer-based health insurance.
  3. Home health aides are the new, new thing as we move away from institutional care.
  4. Racial disparities will not only become evident but exacerbated through the pandemic.
  5. Drug affordability will move to the forefront – and, it has – with the opportunity for the drug industry to rehab its reputation.
  6. There will be a push – if not a shove – to have American drugs made in America!
  7. The government’s role in “health preparedness” will receive increased scrutiny – and support.
  8. Increasing the role of nurses, nurse practitioners and physician assistants on the primary care front will move front and center.
  9. The economic underbelly of the “fee-for-service” system of “doing” will be exposed.

These are thoughts from four months ago (mid-June) that resonate even more strongly here in mid-October and will, no doubt, become the major themes for debates in the coming year. Mark my word…

Future Health - 9/29/20

Delivering care in the new virtual world… 

National Quality Forum (NQF) High Impact Opportunities –  The NQF recently released a set of ten recommendations that would help the health care community provide consistently high-quality care for every person in the U.S. by 2030 – if they were adopted. The recommendations evolved from a convened group of about 100 leaders and stakeholders. The outcomes of those discussions can be more fully defined in the hyperlink. The report emphasizes the need for high-quality care, citing medical errors as the third leading cause of death in the U.S. (about 250,000 deaths each year). The quick version; however, is as follows:

  1. Implement a single-person identifier to match people to health records across all care settings.
  2. Standardize quality data to enable improvement and outcomes analysis.
  3. Adopt population health-based payment as the primary payment model.
  4. Standardize data and interventions to reduce disparities and achieve health equity.
  5. Create actionable intelligence to better educate and engage healthcare consumers.
  6. Ensure advanced technologies improve safe and appropriate outcomes.
  7. Integrate virtual and innovative care models into the delivery system.
  8. Improve access to optimal care by recognizing clinical licenses across the U.S.
  9. Accelerate adoption of leading practices.
  10. Cultivate workforce competencies in safe, appropriate, person-centered care.

Telehealth Task Force Releases Policy Recommendations – A task force established by the American Telemedicine Association, Alliance for Connected Care and National Committee for Quality Assurance released a report in mid-September. The report comes at a time when the Centers for Medicare and Medicaid as well as the private insurers are weighing how and when to expand telehealth coverage once the emergency phase ends. The task force noted that many of the pre-existing limitations were set when the use of telehealth coverage was largely unproven and there were concerns about overuse, cost, and quality of service. But the pandemic has put many of those questions to rest. Specific recommendations include:

  • “Removal of strict limits on sites where telehealth visits may originate, conditions clinicians may treat, and which clinicians and providers may use telehealth,
  • Accept that telehealth visits can be used to “establish clinician/patient relationships” rather than serve as a follow-on to existing relationships,
  • Allow audio-only telehealth visits where evidence demonstrates such practices to be effective, safe, and appropriate, or where care would likely be hampered without access to such services,
  • Allow the use of asynchronous telehealth (e.g., remote patient monitoring) while concurrently generating more data and information on best practices to ensure quality, safety, and program integrity,
  • Adopt policies related to use of all telehealth modalities based on evidence related to the effectiveness, safety, and ability to increase access to care,
  • Allow insurers to provide telehealth technology (e.g. tablets, smartphones, and other devices) as supplemental benefits; and,
  • Importantly, allow telehealth services across state lines by expediting licensure reciprocity between states while simultaneously maintaining patient protections and disciplinary actions.

Future Health - 9/3/20

Delivering care in the new virtual world… 

The Future is Here! – Over the last century, health care has been professionalized to the point where there are stipulations, requirements, conditions and other similar requirements related to the delivery of health care services. These requirements apply to providers such as physicians, nurses, pharmacists and other clinicians as well as to institutions such as hospitals, emergent care centers, surgicenters, long-term care facilities and the like. We are at the formative stages on the consumerization of health care and it is accelerating. To make the point, I offer up this email I received from the Autoderm.com website. 

Dear Friends, A quick update on our end. We have integrated our artificial intelligence (AI) API, named Autoderm into the messaging app Telegram as a skin search bot. From just a photo our AI can screen for 43 skin diseases. It will then give you an instant answer on what your skin ailment is likely to be. No signup required, just download Autoderm bot and snap your skin. We have also launched our bot on Product Hunt, check it out and ask us anything. 

Seems clear enough…

Driving Quality for the Future – The National Quality Forum released an important but under-reported set of recommendations designed to foster and support high-quality care for every person in the U.S. by 2030. The actionable steps were identified through the work of about 100 leaders from across the industry and represent important next steps for “making health care better”. The ten steps include:

  1. Implement a single-person identifier to match people to health records across all care settings.
  2. Standardize quality data to enable improvement and outcomes analysis.
  3. Adopt population health-based payment as the primary payment model.
  4. Standardize data and interventions to reduce disparities and achieve health equity.
  5. Create actionable intelligence to better educate and engage healthcare consumers.
  6. Ensure advanced technologies improve safe and appropriate outcomes.
  7. Integrate virtual and innovative care models into the delivery system.
  8. Improve access to optimal care by recognizing clinical licenses across the U.S.
  9. Accelerate adoption of leading practices.
  10. Cultivate workforce competencies in safe, appropriate, person-centered care.

Other Invitation – In my last blog I indicated that the President should invite a number of key leaders to The White House to convene an expert panel for solving the pandemic – and, I asked the question: Besides Bill Gates and Anthony Fauci, MD – who should be invited? There were a lot of responses. Here is a listing of the suggested invitees as part of a starter kit:

  • Governor Larry Hogan (R-MD) – Chair, National Governors Association
  • Andrew Cuomo (D-NY) – Vice Chair, National Governors Association
  • Tim Storey, Executive Director – National Conference of State Legislatures
  • Delos Gosgrove, MD – Former President/CEO, The Cleveland Clinic Foundation
  • Ron Williams, Former Chairman/CEO, Aetna
  • Mary Wakefield, RN, Ph.D. – Past Deputy Secretary, US-DHHS
  • Senator Bill Frist, MD (R-TN) – Physician and Former Senator, the State of Tennessee
  • Richard Besser, MD – President/CEO, Robert Wood Johnson Foundation
  • Karen Daley, RN, Ph.D. – Past President, American Nurses Association
  • Ernest Grant, RN, Ph.D. - Current President, American Nurses Association
  • David Shulkin, MD – Former Secretary, Veterans Administration
  • Derrick Johnson, President, NAACP
  • Catalina Experanza Garcia, MD – Physician and Founder, Dallas Women’s Foundation
  • Leanna Wen, MD – Health Commissioner, City of Baltimore
  • Maura Healy (R-MA) – Attorney General, State of Massachusetts
  • Kevin Vigilante, MD – Executive Vice President, Booz Allen Hamilton
  • Sally Super, RN – Front Line Health Care Worker, San Diego 

BUT, THESE ARE JUST SOME INITIAL THOUGHTS.  I’m absolutely positive there are others that should be added to the list AND, I’m confident that these leaders would be responsive to a call for “help”. After all – it would be the President of the United States calling :-) . Who would not want to receive such a call – from any President…regardless of your political perspective! It’s our duty as American citizens.  And, finally – don’t be offended if you’re not on the above list. More later…as always!

Approaches To Alternative Care Delivery

Ideas and thoughts on how care delivery can be transformed… 

Now, About Health Care Reform – While the news seems to be all about the pandemic, there are underlying consequences that those of us in health care should be seriously considering.  One of THE major issues in the next six months leading up to the November Presidential elections is “health insurance”. A recent article in Lancet caught my attention on the savings that could potentially accrue from a Medicare-for-All Act.  What is especially important to be considering is that over the last year public debt has grown by – at last count – by over $2 trillion. To be specific, U.S. public debt was about 23.7 trillion or, more than 1.65 trillion more than a year earlier. But, that was BEFORE all of the legislation passed by Congress to deal with the pandemic.  Now, I’m not arguing against the moves by Congress to help businesses and those in need.  That’s what government is for…that’s why we are the “United” States of America. However, the growth of public debt on top of an exploding debt load creates a morass and – health care will be target #1 for managing the debt. Those of us in the health care field know that the cost of health care in the US compared to other nations is exceedingly high. There are compounding factors, however, that make this issue even more important as the pandemic recedes (or, doesn’t – argh). First, we have a decline in the number of primary care providers due to age and loss of interest among younger physicians. Second, the boomers are coming of an age where the use of health care services will skyrocket. I’ve been arguing for some time that the age wave tsunami will be the major force that will precipitate health care reform. Third, an unanticipated (by some) pandemic occurred that is creating crushing additions to our national debt. But, there are solutions – which gets into my long diatribe on what we need to be doing to solve the problem. For the moment, let’s stay with the national debt problem which not only is causing political turmoil between Democrats and Republicans but is now spilling over into a public demanding access to care.

Last year, the Congressional Budget Office (CBO) released its Long-Term Budget Outlook report which repeated prior warnings on the federal budget’s unsustainable long-term trajectory. The CBO’s report articulated the following (a cut and paste from their “publicly available” report):

  • Debt is Rising Unsustainably.Under current law, CBO projects federal debt held by the public will rise from 78% of GDP this year to 144% by 2049 – more than a third higher than the historic record of 106% set just after World War II.
  • Spending is Growing Faster than Revenue.CBO projects spending will grow rapidly, from less than 21% of GDP in 2019 to over 28% by 2049. Revenue will grow more slowly, from 16.5% of GDP this year to 19.5% by 2049. As a result, annual deficits are expected to more than double from 4.2% of GDP in 2019 to 8.7% by 2049. But, note – these findings were pre-COVID-19!!
  • Major Trust Funds Are Headed Toward Insolvency.CBO projects the Highway, Pension Benefit Guaranty Corporation Multi-Employer, Medicare Hospital Insurance, Social Security Disability Insurance, and Social Security Old-Age and Survivors Insurance trust funds will all be exhausted in the next 13 years without action to stabilize their finances. Now, if we want to create a Boomer revolt in this country – we will ignore these specific CBO findings!!
  • High and Rising Debt Will Have Adverse and Potentially Dangerous Consequences.CBO estimates that income per person would be almost $9,000 higher in 2049 if we fix the debt compared to continuing current policy as in CBO’s alternative scenario. …Rising debt will slow income growth, increase interest payments, place upward pressure on interest rates, weaken the ability to respond to the next recession or emergency, place an undue burden on future generations, and heighten the risk of a fiscal crisis. So, if as an alternative to the Boomer revolution, we want to create a Millennial revolt – we will ignore these specific CBO findings!!
  • Fixing the Debt Will Get Harder the Longer Policymakers Wait. Delaying necessary deficit reduction means larger spending cuts and tax increases concentrated on fewer people. CBO estimates the size of the adjustment would grow by 50% if policymakers wait ten years to take action. In other words – if the current leaders don’t solve the problem soon, the future leaders will be left with a huge problem. Perhaps we should get the future leaders on board sooner…

Long story short, my prediction is that Medicare, Medicaid and Social Security will be front of mind in the coming election cycle and, regardless of outcome, will be target #1 in the next Congressional debate.

Now, back to the Lancet article.  In essence, the article argues that the ongoing efforts to “repeal and replace” the Affordable Care Act (or, undermine it in various fashions) is exacerbating health-care inequities. The authors argue that “a universal system, such as that proposed in the Medicare for All Act, has the potential to transform the availability and efficiency of American health-care services.” Specifically, they calculate that a single-payer, universal health-care system would most likely lead to a 13% savings in national health-care expenditure or, about $450 billion on an annual basis. With the debt piling up the way it is as a result of the pandemic, every penny, dime or nickel will be scrutinized in the coming decades.  Again, health care will be front and center.  Mark my word. 

Future Health - 1/30/20

Delivering care in the new virtual world…

The New World of Learning – It seems that knowledge is no longer held in places of higher learning.  In fact, in “Tweets” (you know – the magical place where all knowledge now resides), it seems that physicians are watching YouTube videos as part of their preparation for conducting surgical procedures.  It makes “see one, do one, teach one” seem quaint. The only problem is that many of the videos are showing unsafe and even sub-optical approaches to surgical interventions.  Hmmm…  Perhaps there is a better way?

Use Of Virology In Treatment Protocols – In the recent issue of Gene Therapy based on research completed in Brazil at the Sao Paulo State Cancer Institute, the researchers used a manipulated virus which was injected into mice, and was described as a way of treating mouse prostate cancer. Who knew that mice have prostate cancer?  More importantly, prostate cancer is among one of the top two most frequent cancers in men right up there after the incidence of lung cancer.  There were two results in the study.  First, many of the cancer cells were destroyed as a result of the injections.  Second, the cancer cells were also deemed to be more susceptible to chemotherapeutic drugs.  These findings while new – point toward a new direction in the treatment of cancers – and, as likely – other disease states as well.  Keep your eyes out for these new directions in cancer treatment.  No doubt, there will be more to come.

Artificial Intelligence and Medical Diagnosis – There is increasing evidence that the use of artificial intelligence and machine learning will be serving as critical adjuncts to the care delivery process.  In fact, I have described these capabilities as “clinical augmented intelligence”.  Business Insider Intelligence recently put together a comprehensive analysis on the impact of artificial intelligence in clinical care.  If you’re leading efforts to determine which directions in the use of AI/ML will be the most productive, it would be worth obtaining a copy of the report. Some of the key findings of the report include two important points.  First, the use of AI in diagnostic imaging, clinical decision support, and precision medicine offers the greatest cost savings and efficiency opportunities across hospitals. And, second, it is important for US hospitals to begin the process of developing and implementing effective AI strategies. Those health care systems which are moving forward with effective AI strategies will be reaping the rewards on AI use that supports improved outcomes, efficiencies, and/or reduced costs.  The report is worthy of your consideration and there are no benefits that accrue to The Fickenscher Files!

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