Future Health - 11/15/22

Delivering care in the new virtual world… 

But, Amazon Pulls Back From Telehealth For the Time Being – In the November 10th issue of The Wall Street Journal, the CEO of Amazon, Andy Jassy, announced the scaling back of several unprofitable businesses. And, the Amazon Care telehealth solution was one of the cuts!! According to the report, Amazon lost ($3B) in 2022 after posting $33B positive in 2021 and $21B positive in 2020. However, that does not mean Amazon is “out” of the health care business. In fact, Amazon continues to hold a $3.9B One Medical acquisition on the table. One Medical offers virtual as well as in-person primary care services. Keep an eye out on Amazon as I anticipate we have not seen the last of their efforts in the health care arena… 

A Longer-Term Consideration – One of the side effects of the COVID-19 Pandemic has been the impact on the next generation. Specifically, the National Assessment of Educational Progress report – often referred to as the “Nation’s Report Card” was recently released and provides some ominous forewarnings on the education front. In virtually all of the states – and, I suspect worldwide as well – math and reading scores are down significantly. For 8th graders, only 26% of students showed proficiency which was down from 34% in 2019. The reading scores were equally ominous with only a third of students meeting proficiency standards in over half the states. There seems to be lots of finger pointing between Republicans and Democrats on the reasons for the decline. Rather than finger pointing; however, we should identify the core problem and create bipartisan, remedial solutions!! 

Approaches To Alternative Care Delivery

Ideas and thoughts on how care delivery can be transformed…

 The Ongoing Assessment of Telehealth and Telecare – Research on the effectiveness and efficiency of telehealth and telecare is clearly accelerating. In a new study published in the Journal of the American Medical Association (JAMA) the use of telehealth was found to be superior to in-person care for 11 of 16 quality performance measures related to primary care services. The American Academy of Family Physician’s Robert Graham Center in conjunction with Wellspan Health – a Pennsylvania-based health care system – collaborated in a study that included more than 500,000 patients who received primary care services across the Wellspan system over an 18 month period.  The HEDIS (Healthcare Effectiveness Data and Information Set) measures were used as a point of reference for evaluating results in care delivery. In comparing the two approaches, in-person care was found to achieve better results in medication-based measures versus telehealth which scored higher in testing support services and counseling measures related to such care issues as vaccinations, chronic disease testing, cancer screening evaluations and depression screenings. Long story short – the data clearly showed the need for “integration” of the in-person and telehealth components of primary care delivery something I’ve been advocating for too long… The ongoing research will clearly help all of us as we move forward with telehealth and telecare initiatives in response to the ongoing march (however slight it may be seem to be) toward value-based care delivery models.

Future Health - 3/7/22

Delivering care in the new virtual world… 

On Guns and Gun Violence – First, the topic of guns and gun violence is fraught with political peril – and, I realize it! Second, I grew up in North Dakota where owning a gun was a way of life. Third, the focus of our “way of life” was on hunting birds, deer, and such – not, on hunting humans. Fourth, I did my residency in The Bronx where the opposite was the way of life and hunting humans were far more common. So, as you can see from the outset, I’ve been conditioned with certain experiences that serve as a backdrop to my observations.

Also, as a person who was trained to use science, I’ve turned to the “what works?” with “good results?” approach to problem-solving. So, I thought it might be useful to look at some of the data points we should consider in any discussion related to guns and gun violence. I turned to two reputable organizations for their data on the topic. The American Public Health Association provides regular updates on the state of gun violence in the USA. This data was augmented by my review of the annual Pew Research Center updates on attitudes toward gun policy options.  In addition to the Pew research, here are some data points to consider:

  • Four-in-ten U.S. adults say they live in a household with a gun, including 30% who say they personally own one,according to a Pew Research Center survey conducted in June 2021.
  • Based on the political affiliations of the respondents, there are clear differences in gun ownership rates with 44% of Republicans and Republican-leaning independents indicating they own a gun compared to 20% of Democrats and Democratic leaners. But, it’s not just political party affiliation. To be clear, gender, geography, and other factors are also at play related to gun ownership.
  • Among the nearly two dozen countries we are often compared to including such places as Australia, France, Italy, Spain, and the United Kingdom, 82% of the deaths overall among adults and 91% of all children deaths (ages 0-14) were located in the USA.
  • Each year, more than 39,000 people in the USA die from gun violence, and tens of thousands more suffer non-fatal gun injuries. By comparison, in 2021 there were just over 38,000 deaths from automobile accidents, but, we do insist on everyone wearing seat belts otherwise it would be much higher…
  • Guns are the leading method of suicide in the USA, accounting for half of all suicide deaths. Furthermore, the use of firearms in suicide results in death 85% of the time, compared to just 3% for other methods such as drug overdose. Why is this important? Because almost 90% of people who attempt suicide once do not attempt suicide a second time.
  • Finally, a recent poll revealed that 84% of gun owners and 74% of NRA members, AND 90% of non-gun owners support a requirement for universal background-check system for all gun sales. Hmmm – that means that bipartisan support for effective gun legislation should be very feasible. So, why is it not happening? Oh, that’s right – the NRA is opposed!

Future Health - 1/27/22

Delivering care in the new virtual world… 

Vaccination Effectiveness and Lessons Learned – In recent weeks as the pandemic has continued to wax and wane, one of the arguments against the need for vaccination has been that vaccinations do not work. In fact, vaccination does not always prevent infection – especially from the more recent Omicron variant. BUT, that doesn’t mean one should not be vaccinated!! I’m a case in point. I’m fully vaccinated and boosted according the schedules put forward by the CDC and Moderna (my vaccination of choice – actually, availability at the time). My story? As prep for a minor surgical procedure, I sequestered myself for two weeks prior to the surgery in an effort to assure that I would not become infected prior to the procedure. I was successful – except for one small error. Thinking ahead (😊), I went to our local grocery store for an errand to pick up some food at 7:00 AM in the morning when it opens. There were three of us in the store + staff – all masked. Whew! I made it. Then, I decided to go to the Post Office because I had received a notice of a package in my POB. When I arrived, there was a young man standing at the common table going through his mail with a cough. 

Argh! I decided to wait until he left. I did. When he left I immediately went to my POB. Then, I picked up my mail but made the mistake of going to the same common table and went through my mail. All of this was done wearing a N-95 mask, so I was protected.

vaxstatus

The next morning I got up to an every so slight irritation in the back of my throat but it was gone by mid-morning. I then went to the clinic as directed for my COVID-19 PSR test. All went well. I went home and came back two days later no worse for the wear but with the sore throat a bit worse. When I approached the desk to check in, the clerk simply held up a note that said: “Covid Positive”. I couldn’t believe it. Mr. Cautious. Dr. Knows-the-Road with a positive COVID test!

So, what’s the moral of the story? First, if you do have the vaccination and booster shots, your likelihood of death is 0.1% compared to a 9.74% chance if you’re not vaccinated (SEE above). That’s the ultimate bad outcome but less bad outcomes are more common. Second, you can get infected from COVID-19 – especially with Omicron – even with the prior vaccination and booster shots. It is not uncommon but it is also most commonly less serious. In essence, there is a meaningful but less problematic chance of infection!! BTW – I infected my wife (and Associate Editor) and she had a few more problems and sequelae than me even though she was equally vaccinated and boosted.

dailyhosp      weeklyhosp

The above two charts show VERY CLEARLY that the rate of hospitalization among the vaccinated crowd in minimal compared to those who forego the jab!![1] Also, note that the official data includes patients who have been admitted for heart problems, accidents and other issues so it likely overstates the level of hospitalization among the vaccinated. A recent study at the University of California revealed that about one-third of the admissions are in this latter category. In New York, it’s even higher at 43% of the hospitalizations were individuals who had COVID-19 but were admitted for other reasons. So, if you know anyone who has not been vaccinated – share the data. The graphs above should open their eyes to the realities of the current environment. If their eyes are not opened, they run the risk of closing them forever...

The other lesson here is that while wearing an N-95 mask is important, walking into a haze or cloud of leftover coughing is not a smart idea. It’s better to let the cloud dissipate or just move on and come back to the task at hand another day 😊.

[1] Sources: New York City Department of Health, Washington Department of Health

 

 

 

 

 

 

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.
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