Consulo Indicium - 8/14/24
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?
