Information for your Consideration… 

Ficky Errors – I got a message that some of my hyperlinks did not work in the last edition of The Fickenscher Files. I apologize for the inconvenience and hope it did not present a problem with the readers. BTW – feedback is always appreciated… BTW, The Fickenscher Files are prepared by me not ChatGPT although I do use Grammarly for checking the grammar in my blog. However, the content is determined by me – so you can hold me accountable there…

On The Medicare Roller Coaster – The Medicare program has become over the years an “essential” asset for those who are Medicare eligible and those with disabilities. As a consumer of the program, I take note of any changes. Most people may not be aware but President Biden recently signed bipartisan legislation that passed both the Senate and House for implementing the Inflation Reduction Act. The new legislation will affect access and make financial relief available for the 49 million older adults and those with disabilities who rely upon Medicare for drug services. For the very first time, there will be an annual limit on what Medicare beneficiaries pay out-of-pocket for their prescription medications!! That’s big news. There are six elements to the Act which affect Medicare:

• Starting in 2023: 1) Vaccines can be obtained without copays; and, 2) Insulin co-pays are limited to a max of $35/month;
• Starting in 2024: 1) More people will become eligible for the “Extra Help” program which offsets out-to-pocket costs for those who fall under certain income limits; and, 2) the 5% co-insurance requirement for catastrophic coverage is eliminated; and,
• Starting in 2025: 1) the annual cap on prescription medications costs will be $2000; and, 2) recipients can opt for monthly payments to “smooth” out the yearly out-of-pocket costs for their prescription medications, if desired.

The only problem with the new system is that the payments for advisors who went through all of the options to provide recommendations for Medicare recipients are going away! So, it will be more difficult to obtain unbiased advice on which of the Medicare Advantage or regular Medicare programs to select. Those of us who are Medicare-eligible will have to do a lot more homework to prepare for the October 15 – 30 sign-up period. The problem I foresee is for those individuals who have disabilities and/or medical problems (e.g. Alzheimer’s) that prevent them from making good decisions on the fly. Whoever created the rules on this front seemed to miss the mark in my estimation. While I can make good decisions on which direction to take I have some colleagues and friends that will be baffled if they have to figure out the options on their own. If anyone thinks I’m overstating it – let me know. So, it is a bit of a roller coaster… 

Paul Keckley’s Thoughts And Considerations – If you don’t get the “Keckley Report”, it is definitely one to read regularly. Paul (a good friend) regularly offers up his thoughts on all things health care. I was struck by his recent post on: “ Are Employers Ready to Move from the Back Bench in U.S. Healthcare?” from August 26, 2024. Here are a few highlights that he noted that are important for all of us in the healthcare industry to consider as we look to the future:

• For 2024, the USA population was 342 million citizens. Of that population, 92.3% (= 316M) have health insurance of which just over half of this group (51.9%) are through employment-based coverage, 17.8% (61M) hold Medicare coverage; and, 23.1% (79M) have Medicaid/CHIP coverage and 164 million through employment-based coverage.
• The Congressional Budget Office (CBO) is predicting that Medicare coverage will increase by an estimated 18% through 2032 with Medicaid/CHIP remaining about the same and employer-based coverage increasing by about 3.0% Needless to say, this puts the focus on the federal level on the state of Medicare – something America’s seniors care a lot about!! It’s an area that is ripe for further evolution and change.
• The cost of health care has risen more than 50% since 2017. Such unmitigated cost increases are clearly a front-burner issue for government, employers, self-pay individuals, or anyone taking a hard look at the healthcare world over the next several years.

Staying abreast of all these changes within the industry as well as policy analysis is a part of The Keckley Report, a period analysis on all things healthcare. If you don’t already subscribe, I highly, HIGHLY recommend it as a resource for staying abreast of policy and developments within the healthcare arena. Paul is methodical in his assessments and a trusted advisor. You will not go wrong in signing up for his regular reports. The level of increases across the board is the biggest reason that I believe we are headed toward a “value-based” financing approach to healthcare in the not-too-distant future. Too many people are affected for change not to occur!!

Private Equity Takes a Hit – The California legislature recently passed Assembly Bill (AB) 3129 on August 31, 2024. Governor Newsom (D-CA) has until September 30^th to decide on whether or not to sign it into law or to veto the legislation. In essence, effective January 1, 2024, the new law will require healthcare investors – of any type – to notify and obtain written consent from the California Attorney General before finalizing the investment in certain healthcare facilities or with healthcare providers. The bill essentially raises the bar on the corporate practice of medicine by creating a protective oversight responsibility in the AG’s office to guard against commercial exploitation of the industry by private equity groups or hedge funds. While a majority of states ban corporations from practicing medicine, there are loopholes in many of those state bans. The private equity groups have become quite good at taking advantage of those loopholes by manipulating the financial levers to create mechanisms for controlling physician behavior and services.

So, why is there an evolving outrage in the healthcare community toward private equity? It’s because the only focus of these investments is on profitability – not outcomes. Most analysts within the industry – including me – have concluded that an outright ban on private equity ownership of doctors’ practices is the only way to mitigate the risks of a focus on profitability over outcomes and value. This, in essence, is the reason the California bill received such strong support in the legislature. But, the California bill goes one step further. It also includes hospitals and nursing homes in the mix. Why? Because – if you follow the money – the American taxpayer ends up with the brunt of the cost shift as these equity expenditures are folded into pricing increases by private insurance, Medicare, and Medicaid reimbursement. We – the taxpayers – end up paying the piper!!

And, to add fuel to the fire, a new report was recently released by the industry watchdog group Private Equity Stakeholder Project (PESP) on the continuing trend of bankruptcies among private equity-owned healthcare companies. In fact, private equity bankruptcies represent nearly a fourth of all bankruptcies in the healthcare space for 2024. In some respects, such levels are not surprising since many of these investments are made in high-risk ventures at the start. Eileen O’Grady, the Director of Programs at PESP observed in a statement of Health Exec on the topics: “Private equity’s aggressive financial strategies increase the risk of bankruptcy and threaten the delivery of critical healthcare services. The use of excessive debt by these firms can have significant ripple effects on the broader healthcare industry. This year might see a grim scenario of more healthcare bankruptcies if current trends persist.” In further analysis by PESP, the increase in private equity bankruptcies over the last five years has escalated by 112% with these firms holding responsibility for 1/5 of all healthcare bankruptcies. 

CDC Recommends Watercress – A recent announcement by the Centers for Disease Control and Prevention (CDC) caught my attention. It was an analysis of the “nutrient density” of various foods or, in lay terms – the “healthiest” foods which were all vegetables in the top tier. And, the winner? Watercress which came in with a density score of 100 out of 100!! The runners-up included: Chinese cabbage (91.99 points), Swiss chard (89.27 points), Beetroot (87.08 points); and, Spinach (86.43 points). I thanked my lucky stars that Spinach was on the list. It’s become one of my favs among the vegetables – more so than Watercress. Which is a cruciferous vegetable that is part of the same family as kale, broccoli, Chinese cabbage, arugula, and Brussels sprouts (the underlined veggies are my other go-to's). So, the CDC findings were in line with my wife’s (almost) daily admonition that I need to eat “6 cups of fruits or vegetables” per day; and, she also reminds me that “Burger King does not serve them!” Take note and enjoy the Watercress or, Spinach – if you’re like me…but, Broccoli and Brussels Sprouts are also scrumdiliumptious! 

Incidence Of Male Cancer Expected To Increase By 2050 – In a new report coming out of Australia in the journal, Cancer. the incident of “…cancer cases and deaths among men are expected to surge by 2050.” The investigators analyzed cancer cases and deaths for 30 different types of cancer across 185 territories and countries in 2022. The increase in cancer cases goes from 10.3M to 19M over the 28 years or, an 84% increase! And, more importantly, the death rate also increases from 5.4M to 10.5M or, a 117% increase. Now, this applies to men over the age of 65 years. The question is “Why?” Most likely, it’s because the number of men moving into the age cohort will also be increasing AND, globally, cancer care/treatment on an international level is not equivalent to US standards. The result is a global increase in male cancer incidence and death rates.

Information for your Consideration…

Concerns Of “We The People” – The Kaiser Family Foundation completed a health tracking poll last February 2024 to ascertain the public’s perspective on the state of the Accountable Care Act (ACA) and health care costs. To put it mildly – health care is a BIG CONCERN! The surveyed about 1,300 adult voters across the political spectrum. And, across that spectrum, several key points of pain were identified:

• 74% were “somewhat” or “very” worried about their ability to afford unplanned medical bills (NOTE: Count me in as well!!)
• 73% were “somewhat” or “very” concerned about the overall cost of healthcare services.
• Of those with health insurance, 48% were concerned about the cost of their monthly premiums.
• And, of those who are lacking insurance – 25% have delayed or postponed accessing healthcare services but 61% of the uninsured simply skip needed medical care.
• Where the two sides differed was on the issues related to the ACA with 59% of Democrats noting a favorable view of the plan; and, 23% of Republicans wanting to limit the plan and 39% being favorable toward outright repeal.
• And, not to be forgotten, 36% of Republicans versus 71% of Democrats viewed the future of ACA as “very important”

Shuffling The Chairs At DHHS  - There seems to be a fair amount of movement in the US Department of Health and Human Services (DHHS) of late with the recent announcement on the creation of an Assistant Secretary for Technology Policy – which in reality represents an expansion of the Office of the National Coordinator. But, it’s a noteworthy advancement because it not only includes an upper level oversight appointment but also the creation of a Chief Technology Officer, Chief Data Officer and a Chief AI Officer. Yowser!! Or, perhaps I should say – Finally!! In making the announcement, Andrea Palm, DHHS Deputy Secretary said: “These organizational changes will ensure that HHS is best suited to serve the American people during this incredibly dynamic time in the technology space.” All of this recent activity and response stems from the 2023 Biden Executive Order on AI that charged DHHS with responsibility for implementing a plan to deal with the evolving avalanche of all things AI/ML affecting health care. So, we are likely to see even more down the road…for example, like the following…

But, There’s More: Kudos To ONC – For those of us who follow the information technology space, the Office of the National Coordinator (ONC) recently issued a new proposed rule for all healthcare providers and health plans receiving Health and Human Service funding of any type. It would require use of “certified” health information tech tools and adherence to ONC standards by all health care providers and plans. The implications are significant. Why? Because the new requirements related to the acquisition, implementation, and upgrading of all health information and the systems used for sharing the information. In essence, it moves the idea of “interoperability” objectives previously described in the Health Information Technology for Economic and Clinical Health Act (HITECH Act) into reality.

In essence, the new rule is designed to ensure that all health IT systems procured by HHS or that connect to the agency in any form such as healthcare providers, health plans, or insurance issuers who contract for payments be fully compliant with the standards and implementation specifications set by regulation. The penalties are not inconsequential. For example, there are penalties for those vendors that prevent the “unreasonable” access, exchange or sharing of electronic health information (EHI) of up to $1 million. And, furthermore, “unreasonableness” is not just a technical connectivity issue. It also applies to the fees charged by IT vendors for providing the connectivity. It’s a good measure. The feds through Medicare, Medicaid, FQHCs, the VA and other funding operations are the biggest game in town when it comes to health care finance. It creates quite a strong incentive by the vendors and payors to move forward on something that should have been accomplished (my perspective) several decades ago!! In sum, the good news is that all of the major Health Info Tech (HIT) organizations have been working on the interoperability issues and while there will no doubt be some hiccups, the industry is finally moving forward in this most important area for enhancing care delivery across the board. If you have any comments on the proposed rule, they must be submitted by October 8, 2024. Shortly after that point, the rule will be finalized.’’

The Summer COVID-19 Surge Is Upon Us – Throughout early August and as we move into the Fall, the US Centers for Disease Control and Prevention is issuing warnings that COVID-19 is once again running rampant. The coastal areas of the USA seem to be the hardest hit. Furthermore, through my information “friends survey,” it seems that travelers coming from Europe and the Far East are bringing the virus home 😊. So, taking some precautions by those travelers coming home after wonderful trips abroad should definitely be considered. The Family Physician Newsletter does a good job of tracking the pandemic and includes information on “long COVID”, treatment options, testing and testing options. Check it out for good, reliable, and readable information.

And, Don’t Forget The Other Virus – In addition to the covert COVID-19 virus that passes human-to-human, it’s now summertime. The West Nile Virus is still out there and increasingly being identified by health departments across the USA. The rate of infections is far, far less than but can be just as problematic. And, like COVID-19, the spread is a function of community. So, lather up with mosquito repellent and keep those mosquito growth areas (e.g. stagnant water pools) cleaned up.

More Dementia News – Some might wonder why I’m reporting more information on dementia these days. It’s for two reasons. First, I’ve reached an inflection point where I’m now beyond the 70 year mark when dementia seems to reach an accelerating velocity among friends and neighbors. And, second, the research on preventive and treatment options for managing the problem area is also accelerating. For example, there’s a new study recently published in JAMA Network Open on the dietary patterns of dementia patients. The report noted that eating an anti-inflammatory diet of whole grains, fruits and vegetables instead of an inflammatory diet consisting primarily of red or processed meats and ultra-processed foods (e.g. sodas, sugar-coated cereals, fries and ice cream) resulted in lowering of the risk of dementia risk by 31%! Furthermore, the researchers noted that the benefits were also present for those patients with a history of stroke, heart disease and type-2 diabetes. This speaks to my wife’s daily mantra of: “Six cups of fruits and vegetables per day”. BTW, I do miss the mark but not as frequently as I once did AND, I do like ice cream 😊.

Now – About The Caffeine – As my long-time readers will know, I’m obsessed with ongoing studies, trials and reports on caffeine consumption. Why? Because for many years now, I’m one of the top consumers (my suggestion) of caffeine – in the form of strong coffee. I love it. I rarely get the signs and symptoms of too much consumption (e.g. headaches, jitteriness, etc.) and find the flavors of the various grinds to be wonderful. But, yet another report has come out reporting that individuals who drink more than 400 milligrams of caffeine a day appear more likely to develop heart disease. In fact, the investigators discovered that individuals consuming the highest amounts of caffeine (e.g. 600 milligrams/day or more) had significantly elevated heart rate and blood pressure even after five minutes of rest following a three-minute step test. Whew!! I’ll just be safe 😊. My BP runs in the “just over the 100s over 60s” and my pulse is a solid 82 (there’s nothing like reliable pacemakers). So, perhaps I’m an outlier. Actually, several people have mentioned that but I don’t think it related to caffeine…

Information for your Consideration… 

Access To Care In Rural Areas – One of the multi-decade issues faced in the USA – but, also in rural areas throughout the world – is access to health care services. As a long-time rural health proponent, I’ve followed many different initiatives for solving the problem – which often comes down to a lack of people resources for delivering appropriate care. It’s been 35+ years since I served as President of the National Rural Health Association, and I’ve continued to be a proponent of solutions and trials for solving the ongoing rural health care delivery problems. More recently, several Members of the Rural Health Caucus in the U.S. House of Representatives introduced a bill to allow for the ownership and operation of new hospitals in rural areas.

The bipartisan Physician Led and Rural Access to Quality Care Act (NOTE: a full text is here) would amend Title XVIII of the Social Security Act, which specifically bans the opening of new physician-owned hospitals. The ban intends to prevent a conflict of interest by the provision of unnecessary care by physician owners of rural hospitals. Specifically, the SSA amendments would allow “certain exemptions to rules for physician-owned hospitals in rural areas and remove a ban that prevents existing physician-owned hospitals from expanding.” The bill even includes specific parameters for determining eligibility such as a “new” hospital must be at least 35 miles or more away, or 15 miles if the new hospital is only accessible through secondary roads (e.g. in mountainous areas).

To be honest, I’m not sure this addresses the rural health problem. I can think of other initiatives that might be more successful at enhancing access to care in rural areas such as:

• Establishing ubiquitous internet access across the entire nation,
• Increasing training programs across the board for all the healthcare professions in rural areas,
• Enhancing EMS services,
• Funding public health programs,
• Addressing the many social determinants of health that prevent adequate access to follow-up care by patients,
• Re-investment in the National Health Service Corps; and,
• Any number of other initiatives that might provide equivalent or even better care delivery for rural areas.

While the intent is good, training the next generation on the use of technologies, enhancing their ability to provide quality care, refocusing – once again – on the need for adequate “primary care” training and other considerations will more likely yield better long-term results than more institutions. I’m not opposed to the idea but, think the investment should be weighed against all of the other options that are clearly on the table. The Congressional delegation has already received support from the American Medical Association, the American Association of Orthopedic Surgeons, Physician-Led Healthcare For America, and a few others. Notably absent in the press release was the support of the National Rural Health Association.

Finally, the other looming issue is the notion of private equity in longitudinal problems like access to care in rural areas. In recent years, I’ve become increasingly skeptical about the use of the private equity model as a resource for all types of health care. First and foremost, private equity at the end of the day is about enhancing financial return. It is not necessarily about “equity”. In fact, while the above rural coalition of Congressional representatives introduced their efforts to expand “private equity” by allowing physicians to own and operate rural hospitals, another group of bipartisan Congressional representatives advocated and passed the bipartisan Lower Costs, More Transparency Act. 

While there are several provisions in the legislation, it essentially attempts to enhance private equity ownership transparency in the area of vertical integration by insurers. It did not address the other elements of private equity. But, the issue is getting attention. In the US Senate, Senators Grassley (R-IA) and Whitehouse )D-RI) introduced legislation related to private equity backing among hospitals; and, Senator Peters (D-MI) introduced measures to obtain information on private equity backing of emergency departments. In a more sweeping legislative effort, Senator Markey (D-MA) released a draft legislative proposal as the “Health over Wealth Act” that would establish oversight programs to improve transparency related to hospital ownership by private-equity or corporate-owned institutions, physician practices, hospices, behavioral health providers, and other similar provider services outside of rural health. So, the issue is getting attention. 

Then, just as I had finished the final draft of The Fickenscher Files, I received a report from an industry watchdog group, the Private Equity Stakeholder Project (PESP). They follow the private equity marketplace and among healthcare companies and reported that 23% of all bankruptcies (so far) in 2024 for the healthcare market were for private equity owned organizations. In large measure, it’s because of the amount of debt incurred by the PE firms in purchasing these entities. Furthermore, the latest report expands upon a prior PESP report in April which noted that PE bankruptcies have increased 112% over the last five years in healthcare. Your thoughts? 

USA Screening For Five Cancers Costs $43B – A recent article in the Annals of Internal Medicine reported on an analysis of healthcare expenditures in 2021 on the costs of preventive cancer screening programs for five different cancers in the USA. The five cancers of focus were lung, colorectal, breast, cervical, and prostate cancers. While $43B seems like a lot – and, it is – in the scope of investments it represents only about 2.53% of USA national expenditures for health care (based on an estimated $1.7T overall investment). The investigators also determined that 88% of the expenditures were paid by private insurance with the remainder covered by government programs (i.e. Medicare, Medicaid, etc.). I may be wrong on this front – but, given the number of patients on government programs versus private insurance, the investment in screening by these government programs seems low…

A Stark Statistic – Have you heard any discussions among the politicos on the future of Social Security? Most likely, the answer would be “Nada!” It’s an issue that affects about 68 million Americans who have been paying into “the system” for all these decades and are now entering their retirement years. It’s an issue that requires debate and discernment on how to manage – AND, the solution (from my perspective) will be a “bipartisan” solution. It will not be solved through name-calling. It will not be solved by placing Senatorial and Congressional heads in the sand. It will only be resolved by all our leaders working together to address an issue that affects every American citizen, eventually. Why is it so important? In large measure, because the vast majority of citizens underestimate the cost to society. In preparing this short “call to action” I asked three colleagues who are with me what they thought the cost of Social Security is on an annual basis. The guesses were: “$500M”, “$250M”; and, “$100M”. All were off by a significant measure. The actual cost in 2024 will be about $1.5T (= “trillion”) from a fund that has been tapped for “loans” by the federal government. So, where will the money come from? Hmmm? Now, that’s a policy issue I’d like to hear discussed rather than the size of crowds, the “weirdness” of one side or the other or, other such machinations. 

Don’t Swat The Honeybees – First, if you’ve ever hung around the garden and taken notice of the honeybees, you’ll know that they are fairly innocuous. They glide around the flowers sniffing out the honey they gather for the honeycombs back home. But, there’s something science has only recently figured out about the innocent honeybee. According to research conducted at Michigan State University, neural engineers have determined that honeybees are excellent spotters of lung cancer victims by virtue of very sensitive sensors in their antennae. How did they figure this out? Well, that’s the interesting part. They hooked up the honeybees to electrodes, then they passed various scents under their antennae. By monitoring the honeybee’s recorded brain activity, the researchers were able to discern when various scents were recognized. A researcher from the French National Research Institute noted that for honeybees, recognizing “scents” is their lingua franca. In fact, the use of various animals – and, now insects – for recognizing scents in humans has been recognized for some time. I just wonder how they got those little helmets on the honeybees for capturing the neural notes (sic).

The Exploding Incident Of Syphilis – I’ve just returned from Norway where we visited the Leprosarium where Hansen’s Disease was first described. Upon my return when I was catching up on my readings, I learned that the incidence of syphilis in the USA has gone from less than 32,000 cases back in 2000 to more than 207,000 in 2022 according to the U.S. Centers for Disease Control and Prevention. It translates to 62 cases per 100,000 people and has particularly become a problem among pregnant women and babies. The problem is that in many cases syphilis is asymptomatic coupled with the overall decrease in funding for standard public health programs funding has been frequently pulled from the “low incident” disease prevention programs – syphilis being one of them! There are many social determinant issues at play as well that need to be managed more effectively. In too many cases, the tests are done but the conversations do not occur related to prevention and sources of infection.

The Ignored Pandemic – The US Centers for Disease Control and Prevention recently announced that for the 12 months ending in November 2023, the number of USA overdose deaths approached 110,000 or – to put it in context – a 54.2% increase over the 12 months ending in November 2019. Furthermore, almost 70% of the deaths were related to fentanyl and other synthetic opioids. In addition, the overdose death rate was highest among the 35 – 64 year-old age group with Black and Native American men holding the highest level of deaths with 60 per 100,000. Among teens (years 14 – 18), opioid deaths were the third leading cause of death behind firearm deaths and vehicle collisions. Again, it’s fentanyl!! AND, furthermore, the problem is far worse in the rural areas of the country. Plus, the above data does not include the associated secondary effects of the drug pandemic related to crime. Not only does our nation need “preventive” intervention, but it also needs effective “treatment” and “outreach” programs to solve the problem.

 

The Era Of Loneliness – Last year, the US Surgeon General declared that the nation was suffering from a loneliness health epidemic. According to a recent poll by Cigna, the number of US adults who described call themselves as lonely increased from 46% (2017) to 58% (2018). So, why is this happening? It appears to be related to the recent changes we’ve had in work environments since the global pandemic started in 2020. For example, more than 40% of fully remote workers polled by Bright Horizons indicated that they often go days without leaving the house. Furthermore, for those working in in-office environments, the workers indicated they spend only 8% of their time in face-to-face meetings. For example, Axios reported that in 2023, the share of workers who stayed muted for the entirety of a virtual meeting was 7.2%, up from 4.8% in 2022. In fact, I frequently tell people that I’ve become a “Zoomaholic” – which when I’m home is absolutely true!! In another survey by Cushman & Wakefield (a consulting firm), virtual work time has tripled since 2020. We have all become a nation of isolated workers in cubicles across virtually all industries – and, it seems to be associated with burnout, isolation, and loneliness.

It’s also evident in environments that customarily in the past were ablaze with energy. Think of subways where interactions were more common, lobbies where people often interacted, cafeterias where workers congregated and caught up with one another, and, a host of other examples. Now, those options for human interaction most often do not exist. Instead, we all (including me) pull our “devices” to check emails, news (argh ☹), and other sources of information or, even to simply play games. Wordle or such. So, what to do about it?

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 HealthExec.com. 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.