Consulo Indicium - 4/28/20

Information for your Consideration…

 Telehealth Explodes – I was recently as a meeting where I was informed that one of the dictums of Silicon Valley is that “change happens” when the elements of changes in the LENS appear.  LENS is the acronym for Laws, Economics and National Security. I pass it along because the LENS has not appeared, but it happened at hyper-speed. Over the months of March and April, the number of virtual health-care interactions were on pace to top 1 billion by year’s end, according to analysts at Forrester Research. That would represent a massive expansion from telemedicine usage before the coronavirus pandemic. Then, to compound the LENS argument, an announcement was made by the Centers for Medicare and Medicaid Services (CMS) to suspend “…several regulations to enable hospitals, clinics and other providers to boost their front-line medical staff during the coronavirus pandemic” – the telehealth movement exploded. The reasons for the proposed CMS changes was to “reduce certification requirements for clinicians, with the aim of expanding workforce flexibilities and enabling practitioners to be hired quickly and ‘perform work to the fullest extent of their licenses.’” I have been arguing for years that once CMS made a move on telehealth, the rest of the payors would likely follow suit.  In fact, that is the case. In fact, multiple analysts are predicting general medical care visits to top 200 million this year, up sharply from their original expectation of 36 million visits for all of 2020. Frost and Sullivan came to essentially the same conclusion noting that March telehealth visits surged 50% amid the coronavirus pandemic. Telemedicine providers like Teladoc were reporting video visits of more than 15,000 per day. So, finally, the revolution has started.

But, wait: “Houston – we have a problem!” One of the concerns I’ve been highlighting for those who will listen is the resulting “disintermediation” of primary care.  Dismembering, taking apart, disintermediation – whatever you want to call it – is an unanticipated tragedy in American health care.  Why?  It’s because primary care has traditionally served as the “coordinator” and “manager” of all the basic health care problems that exist across a populace. By removing the 70% of primary care that can be accomplished using tele-technologies, we are removing the financial base for most primary care practices. And, it’s important because primary care has been shown repeatedly over the decades to be the main contributor to reducing overall costs in health care.  Now, I realize that I’m a Family Physician and I’ve drunk the Kool-Aid but the data supports my argument. Rather than removing the telecare portion, we should be integrating it with the primary care providers which is most often an afterthought.  As a result, patients see Tele-Whoever and come into the office noting that they were given “such and such” medicine but they “don’t seem to be much better” – and, the face-to-face primary care provider has no information for managing the problem effectively.  Disintermediation is a tragedy and, it’s happening. 

Now, as a final note – I’m clearly bullish on telehealth and telecare. But, telemedicine is just one component of the overall picture.  We should take advantage of the pandemic and the CMS decisions to move forward as quickly as possible with the entire spectrum of telecare. There will be lots of mistakes; however, we must consider the long game while we move to solve the short game.  

Mythology, Mistakes and Misery – Having grown up in the heartland, the mythology is that “it’ll never get here”.  The mistake is not ordering prudent and proven approaches toward managing wide scale public health emergencies. And, the misery is the disease burden that could be reduced through the appropriate application of those proven approaches. So, when the bump in the number of cases from the rural areas was announced last week, it wasn’t a surprise.  The largest increase in coronavirus cases was clearly among those states that ignored the CDC and proceeded to manage the crisis without stay at home orders. South Dakota was the winner with a massive 205% increase in cases. It was followed by Iowa with 82%, Nebraska at 74%, Arkansas at 60%; and, Oklahoma with a 53% increase in cases over the prior week, The data was compiled by Johns Hopkins University. My home state of North Dakota along with Utah and Wyoming experienced a slight increase even though they also had not issued “stay-at-home” orders. I guess I could try to forgive North Dakota – after all, with roughly a population of 762,062 spread over 70,762 square miles or 10 people per square mile – it’s easy to get to the six feet apart rule (Governor Burgum, I’m giving you a break J and, a friendly nudge).  And, for Wyoming, I’ll forgive ‘cause it’s a family consideration. But, Utah – no excuses. Perhaps we should look at Salt Lake City alone? So, we’ll keep a watchful eye on the Plains States.  They are likely to succumb as well and if it happens it won’t be pretty.  The resources in the rural areas are weaker when it comes to the management of the coronavirus symptoms and disease.  Then, came the announcement that the Nebraska Crossing Mall was going to open in Nebraska as “a test”. My crimminy (that’s a rural term for, “Are you kidding” ☹).

Managing The Spread of Coronavirus – Many of you probably saw the graphic on CNN. However, the CDC recently released a study that originated in China showing how a single patron infected nine others at an air-conditioned restaurant in China. The infected patron did not show any symptoms until after the luncheon at a Guangzhou restaurant.  All of the infections occurred in among the guests at her table (4 patrons) or in the adjacent tables (5 patrons). If that doesn’t make you anxious about the transmission of the virus – nothing will.  In fact, the data is clearly pointing in the direction that not only open coughing but also simple breathing can disperse the virus from an infected person.  Hmmm – the ability to do massive, public-wide testing might be a good idea. 

Visualization of the COVID-19 Spread in America – Sometimes a visual can convey a problem more effectively than all the words you can must.  Check out this graphic which depicts the growth of the COVID-19 spread in the USA over the last 6 weeks.  Then, consider the implications…  Enough said!!

Now, Despite the Visualization – Perhaps the most disturbing part of the “realization” that society has been consumed by a pandemic is the fact in a Pew study nearly a third of Americans believe in a conspiracy theory about the origins of the coronavirus with a full 30% of Americans believing scientists were involved in the spread of COVID-19 and 23% that it was created by them. That isn’t what happened. 43% concurred with that opinion noting that the virus “came about naturally.” Even more baffling, 1% said the virus didn’t actually exist.

The Probable Unanticipated Surge – A new study from Australia revealed a massive 67% increase in online gambling in the weeks following the shutdown of all non-essential services in that country due to COVID-19 across the nation. The online social poker site – Global Poker – showed a similar increase of 43% for online poker. The data also revealed a 255% increase in first-time poker players. According to their data, about 40 million Americans, or 6.8% of the adult populace use online poker either alone or with friends on a regular basis.

Family violence is yet another potential disruptive problem that may rear its head in the current pandemic.  Andrew Campbell published a paper in Forensic Science International Reports in early April highlight the possible increase in family violence around the globe due to the pandemic. I would cite his article as a cautionary “warning” on the “potential” for family violence erupting as the pandemic continues its course. Why? He points to considerations like the need for social-distancing, sheltering in-place, restricted travel, and the closure of key community resources supporting the victims of family violence as potential risk factors. He also noted that alcohol abuse is a frequent concurrent problem in the household and that “with bars and restaurants being limited to take-out service only in many communities, family violence perpetrators who abuse alcohol may be even more likely to do so in the home, likely increasing risk for the entire household.”

On top of that problem is the fact that there are now reports of increasing gun and ammunition sales in the U.S. This availability of guns and ammunition in the home – which is a concern for the vast majority of health care professionals – has been shown to be clearly linked fatal domestic violence incidents [²]. Where the guns and ammunition are managed properly, the problems are infrequent. However, most households don’t engage in such precautionary measures.  While there are not yet any reports in the academic literature, it would be unlikely that we get through the current pandemic without an increase in family violence given the results of past disruptive events (e.g. hurricanes, regional fires, etc.). So, we will need to keep an eye out for this potential problem. An additional – undocumented – consideration is the likelihood that in addition to increased problem with alcohol abuse, we will also see an increase in drug overdose deaths. The risks are high and, I predict, the rural areas will be hardest hit with this problem. EMS services are more likely to be volunteer in nature (that’s how I got started in life BTW) but “timely” access to services can be compromised.  We will see.