Consulo Indicium - 5/1/19

Information for your Consideration…

When The Future Is Too Close – It was rather disturbing to receive a notice in the media this past week that if Congress does not take action soon [to quote from the report]: “…tens of millions of Americans will only receive about three-quarters of their Social Security benefits when they retire.” Hmmm.  Now, if you were only three, four or five decades into life that wouldn’t be totally alarming.  But, if the future were much nearer than the past, it could you make more than pause – which is why I paused when I read the notice.  The annual report for the Medicare and Social Security Trust funds noted that Social Security will be tapped out 2035 and Medicare by 2026.  Yikes!  That’s seven years away.  Hmmm – another pause and big deep breath.  The recent media reports media reports are noting that the major problem steps from lower-than-anticipated tax revenue (income) and higher-than-anticipated (outflow) payments to the medical system.  In fact, Medicare’s costs “…are expected to continue rising sharply over the next several decades, from about 3.7% of the total U.S. economy to 5.9%, putting a strain on the federal budget that lawmakers must act to avoid.” So, it seems that Congress – that divided group of politicians who keep pointing fingers across the aisle – is not acting to solve the problem. A whole series of policy options have been outlined to close or reduce the long-term financing problem for both Social Security and Medicare.  Furthermore, earlier action by Congress would make the problem easier to solve that delayed action.  Is it any wonder that the American public is increasingly disenchanted with the ill-will and dysfunctional state of American politics? 

The entire Medicare and Social Security funding issue is a major issue.  Together, these two federal responsibilities accounted for 45% of Federal program expenditures – excluding net interest on the debt – in FY18. The unified budget reflects current trust fund operations. The impact of drawdowns on the balances for Medicare and Society Security as well as any transfers from the general fund impact directly on the overall budget of the US government. It’s time for leadership on both sides of the aisle to shut down their Twitter accounts and put aside the name calling so that they can listen to one another and solve problems.  Now is a far better time than later.  As I have said repeatedly, if we don’t solve these two problems – my generation will bankrupt the nation or, you’re going to see a lot of very old, angry folks out on the streets making lots of noise.  Perhaps you already are seeing that happen?

The other disturbing aspect of the report is the projection that the annual cost of Social Security benefits expressed as a share of workers’ taxable earnings is growing from 13.8% (2018) to about 16.6% (2040).  In other words, Social Security will be taking away dollars from our regular earnings in an era when the economy of the US is expected to continue experiencing pressure from our international friends and foes.  But, the Medicare side of the equation is where those of us in the health care community can have an impact by advocating for changes that will increase the solvency of the program.  The most worrisome portion of the report was the projected insolvency of the Hospital Insurance (HI) Trust Fund which pays for inpatient hospital services, skilled nursing facility and home health services following hospital stays, and hospice care. With depletion just around the corner in 2026 (yes, 7 years away!), it means that we (= the health care community) need to do our part toward increasing efficiency and effectiveness of the services we provide. The report does note: “It is possible that U.S. health care practices are becoming more efficient as new payment models develop and providers anticipate less rapid growth of reimbursement rates in both the public and private sectors than has occurred during the past several decades.” From my perspective, it’s time to accelerate our efforts. My generation will thank all of you who step forward but, even more importantly, the generations that follow the Boomers will thank you even more for lifting a large anchor off of their economic shoulders. If you only want an overview, the short version is available.  If you’re so inclined, I suggest the full report. 

Sustaining Primary Care – As a primary care Family Physician, I have felt for some time that the entire specialty has been throttled for the last couple of decades.  From low reimbursements to a de-emphasis on team models of care delivery, the specialty has not been able to adequately contribute to the efficiency and effectiveness equation.  And, yet, even the most recent studies are showing the critical importance of primary care as a foundational element of care delivery.  With the move toward value-based care delivery, the need for a strong primary care component will be even more important.  To that end, HHS Secretary Alex Azar – to his credit – announced an aggressive strategy for shifting primary care from fee-for-service payments to a global fee model.  Two approaches were outlined.  First, one of the approaches will be focused on small primary-care practices with bonuses and penalties tied to their ability to keep their patients "healthy and at home." Larger practices and health systems will be given even more lucrative upside models that also pose steeper risks. The various options range from 50% of risk/reward to 100%.  There’s also a "geographic option" whereby health systems or insurance plans could assume the primary care risk for a swath of communities within a particular region.  The launch date for these initiatives is January 2020. Over the next several weeks and months, these new initiatives will no doubt receive greater scrutiny. 

In a related discussion on the future of virtual primary care, mHealth Intelligence reports that the  program must be “…more nuanced, identifying specific patient populations and offering specific services, and they’re looking beyond early numbers and revenues to focus on cost savings, downstream revenue opportunities and patient engagement and satisfaction.” Key factors to note in the primary care telehealth space include the facts that telehealth adoption is increasing, there are challenges in simply measuring success by utilization and revenues; and, the focus of such programs needs to be focused on what patients want and expect. As efforts continue to develop the virtual primary care capabilities within health care organizations, it is increasingly clear that a focus on value-based care delivery models will carry the concept forward.  I look forward to following this important movement which will dramatically alter our notion of care delivery over the coming months. 

What About Telemedicine Full Time? – A recent study published in Health Affairs surveyed physicians from the 2016 American Medical Association database and identified 15.4% of the physicians reporting the use of telemedicine in their practices.  But, the trend is growing according to recent reports in Bloomberg. The report noted that a growing number of physicians are practicing telemedicine because they “…prefer to treat patients remotely, from the comfort of their own homes.” My prediction?  By 2025, more than 50% of practices will incorporate some element of virtual care into their practice settings.  Not to be outdone by private practice, the Veteran’s Administration recently submitted requests to Congress for $1 billion in additional funding for telehealth initiatives.  

And, Then, There’s The Workforce Challenge – Anyone who is on the front lines of health care knows about the gap that is becoming increasingly evident in the adequacy of professional skills among the workforce which is making it hard for the U.S. healthcare industry to fill jobs.  A recent report outlined the major factors contributing to the problem.  They include:

• The skills gap in the healthcare sector is larger than for any other part of the overall economy. It is in large measure due to the lengthy training and licensing required to become a healthcare professional.
• A disparity in demand is also evident. Some healthcare roles have far more job seekers than job postings.  This includes home health aides, nursing/medical assistants, direct caregivers, and dental assistants. On the other hand, those positions that require lengthy training (e.g. RNs, PTs, speech language pathologists, NPs/PAs) are in short supply.

The report goes on to note that "…healthcare faces a greater hiring challenge than do other sectors". The authors suggested that health care organizations need to invest more in training due to the “…unique role [health care plays] in society, one that will only become more critical as the population ages." 

In Case You Missed It - Did you know that 25 states are now part of the Interstate Medical Licensure Compact? And, what does that mean?  The compact provides physicians with an expedited means of applying for a license to practice telehealth in member states.  As Humayun Chaudhry, DO, President and CEO of the Federation of State Medical Boards (FSMB) noted: “The expansion of the Compact to half of all U.S. states is an incredible achievement and testament to state medical boards’ efforts to innovate and improve license portability.”  To date, the states included in the Compact include: Alabama, Arizona, Tennessee, Colorado, Idaho, Illinois, Iowa, Kansas, Maine, Maryland, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, Oklahoma, Pennsylvania, South Dakota, Michigan, Utah, Vermont, Washington, West Virginia, Wisconsin, Wyoming, the District of Columbia and Guam. The Compact is one of those changes that brightens the future of telehealth and telecare.

 The Continuing March Of Technology – A new report in the journal Depression and Anxiety confirms work that was previously developed and supported at MITRE Corporation on behalf of the Veterans Administration.  The new study describes the use of an algorithm that identified 18 indicators from a list of 40,500 speech characteristics that were key markers for diagnosing post-traumatic stress disorder (PTSD).  The algorithm reported in the study revealed a 89% concurrence with expert diagnostic assessment.  The study marks the future direction where I’m projecting that clinicians will wear earpieces that “whisper” in their ear, “PTSD”.  But, it’s far more than PTSD.  It’s depression.  It’s Parkinson’s disease.  It’s attention deficit hyperactivity disorders (ADHD).  It’s any number of problems that present clinically with auditory cues.