Finding a New Normal with Coronavirus

We have been self-distancing through the COVID-19 pandemic for a few months now. What a wild ride it has been! Despite the number infected – over 1.25 million – and more than 75,000 deaths, many still question the legitimacy of the extraordinary measures that shut down our economy. Uninformed proclamations comparing COVID-19 to the seasonal flu are an affront to anyone who has been sickened or died from this disease. The average length of stay of those hospitalized (especially those requiring ICU care and ventilator support), not to mention the number of deaths, is far greater than with the flu.

Still, should we have shut down the economy? Professors at the Kellogg School of Management at Northwestern University called it a “brutal trade-off: inducing massive economic suffering in order to save human lives.”  Their research concludes that not closing the economy ultimately would be much costlier to society, potentially tens of trillions of dollars in addition to major loss of life. Consider it a “damned if you do; damned if you don’t” choice. I am grateful we chose to flatten the curve and save lives.

How do we recover from this mess? Many states are starting to loosen restrictive measures to reopen our economy. Trillions of dollars have been designated for businesses and individual taxpayers. That will help ease some of the financial suffering. But, we have paid a collective price psychologically as well.

The unpredictable factor in this recovery is going to be people. What are we willing to do when we emerge from isolation? Some never really changed their behavior to begin with. For those who did take the pandemic seriously – and still do – it is not as easy as flipping a switch and going back to a pre-coronavirus routine. Predictions for a rapid economic boom assume we will all be hitting the malls and restaurants as if nothing ever happened.

Me? I think I have PCSD – Post Coronavirus Stress Disorder. My habits have changed. My sense of personal space and need for barriers is heightened. I avoid people. It will take me months or longer before I go back into a store and don’t wonder whose germy fingers have been on everything. Interacting with strangers – or even friends I haven’t seen in a while – has a more dangerous feel to it. Consciously or not, we are figuring out what our personal risk tolerance is. Are there too many people in that store? Are the employees at that restaurant being careful enough? We decide with our feet and our pocketbooks.

Some will emerge sooner and more confidently than others. Peggy Noonan, columnist for the Wall Street Journal, called for patience and grace when other people are moving faster or slower in the recovery process than perhaps we think they should. “What will hurt us is secretly rooting for disaster for those who don’t share our priors.”  In the church, we refer in jest to some theological differences as “non-salvation issues” over which we can agree to disagree. As we emerge from our coronavirus self-isolation, we should respect that not everyone will be either as cautious or as cavalier as we may be. Extend grace.

The ideal conditions for me personally to feel truly comfortable again would be a) I have been infected (and recovered), and am proven immune, or b) I have been vaccinated. Only then will I regain my more nonchalant attitude toward life. Either of these conditions is imperfect assurance; only time and testing – and good science – will provide clarity on the true COVID-19 status of any of us.

In the meantime, I will continue my new habits (obsessions, really): self-distancing and cleanliness. I will avoid crowds for the foreseeable future. When I attend church services – at least in the beginning – I am at a minimum going to mask myself on entering and exiting, if not the entire service. The last thing I want is to be an undiagnosed carrier who infects an elderly or at-risk fellow church member. In public, I carry disinfectant wipes for use in the grocery store, at the gas pump, etc. Finally, I wash my hands. No, I really scrub them. Lots of bubbles all around. Often. (Admittedly, I still have trouble not touching my face.)

One more thing. Once we have a vaccine, we cannot let the anti-vaxxers and conspiracy theorists have their way. Legislators must remove conscientious and religious exemptions from vaccination requirements.

Eventually – hopefully next year sometime – enough of us will have recovered or been immunized and life truly can return to the pre-coronavirus routine… at least until the next pandemic comes along. Please, can we wait another century for that?

DETCOG, Broadband and Health

Can you hear me now? That phrase, made popular by Verizon Wireless in the early 2000s, epitomizes the frustration of rural America over lack of reliable cell phone coverage. To this day – despite what cell phone carriers like AT&T, Sprint, and Verizon advertise – coverage in many areas (including at my house inside the Lufkin, Texas city limits) is suboptimal. AT&T’s answer? Just use WiFi calling! That may work for me; I have adequate internet access. But what about the majority of deep East Texans? More than just being an inconvenience, poor cell phone coverage and inadequate broadband access are harming our health.

Broadband is the infrastructure and information technology network that delivers high speed connectivity to the internet. Think of broadband as a pipeline of information. As with any pipeline, the rate of flow (water, gas, data, etc.) can depend on the number of users, time of day, and reliability of service. But you have to be able to connect to the pipeline.

In the early days, the internet was accessed through slow, often expensive dial-up connections. Today, high speed or broadband internet access is via DSL (or Digital Subscriber Line), fiber-optic, wireless, cable, and satellite services, often bundled with phone and TV subscriptions.

Broadband access is about more than faster access to Facebook and Instagram. Increasingly, reliable and high-speed internet access is important for community health. The Federal Communications Commission (FCC), which is responsible for regulating the radio, television and phone industries, established a Connect2HealthFCC Task Force to raise consumer awareness about the value of broadband in the health and care sectors. You may know about heart-healthy diet and recipe apps and wearable fitness trackers, but did you know that we now have medical devices like pacemakers, defibrillators, glucose monitors, insulin pumps, and neuro-monitoring systems that can utilize wireless technology to control or program a medical device remotely and monitor and transmit patient data from the medical device to the healthcare team? Those without internet access can get delayed and inadequate care.

Maps showing lack of broadband coverage look just like maps of poor, rural America where healthcare is also lacking. In Kentucky, for example, the same areas where higher rates of lung cancer are seen are those with limited broadband access. These county-by-county maps are similar to what we see in deep East Texas with cancer deaths and health outcomes. This does not mean that lack of broadband access causes lung cancer, obviously! But the social determinants of health (such as education level and income) that are associated with smoking, lung cancer, heart disease, obesity, and overall health outcomes, are more pronounced in areas with limited broadband access.

So how could access to broadband increase the health of a community? The FCC believes that “broadband-enabled technology solutions can help us meet the health and care challenges of today and tomorrow by connection people to the people, services and information they need to get well and stay healthy.” Possible solutions that are especially important in deep East Texas include telehealth and telemedicine for improved access to physicians and specialists (including mental health services), health information technology and access, fall detectors, pharmacy connectivity, personal health data upload capability, and connectivity to hospitals and emergency rooms. With a growing and aging population compounded by a shortage of primary care physicians nationwide estimated in the tens of thousands –especially pronounced in rural areas – remote connectivity options for healthcare become even more important.

The Deep East Texas Council of Governments (DETCOG), under the leadership of Executive Director Lonnie Hunt, recently received a report titled Deep East Texas Broadband Growth Strategy, which detailed the potential economic growth (10,300 new jobs and $1.4 billion in GDP growth over 10 years) and growth in median household income associated with near complete broadband access, a loft goal. In IT, education, and telehealth alone, investments have the potential to impact the region with 2,500 jobs and $300 million in GDP over the next ten years.

DETCOG’s goal is to support development of a regional fiber optic-based broadband network throughout its twelve-county region. They hope to do this through creation of a non-profit or other entity that would manage the project, bring the necessary partners together to accomplish the goals, and oversee planning, financing, and implementation of the regional broadband network. Full implementation realistically will cost hundreds of millions of dollars. But it doesn’t have to all come at once.

In February, with support from the TLL Temple Foundation, DETCOG started the process to contract with a major law firm with offices in Washington, DC, to create an entity to manage broadband in East Texas. Funding such an entity and project will not be easy. Other COGs have tapped into grants like the FCC’s Rural Health Care Program, which provides funding to eligible health care providers for telecommunications and broadband services necessary for the provision of health care. Electric and telephone cooperatives, public utilities, internet providers, local, state, and federal entities, and foundations can and should play a role.

Do you hear me now? We must support DETCOG’s vision for a fiber optic network for all of deep East Texas. This will be a long term project requiring many players, both public and private, to accomplish. We need – we must have – high-speed broadband access in our entire region for jobs, for the economy, and for our health.

Money, Insurance, and Health: An Unfair Relationship

Money doesn't buy happiness, or so they say. But money can buy better health. Add one more difference between the haves and the have nots.

There are many determinants of health. Some behaviors are more under our individual control than others. The Big Three, as I like to call them – smoking, diet, and exercise – would, at first glance, seem to be entirely personal choices. That would be untrue.

Social and economic factors are a major determinant of health. These factors include education level, employment, income, family and social support, and community safety. Each of these factors is correlated with financial well-being. In fact, these social and economic factors as a whole are more important even than individual health behaviors, such as tobacco use, diet and exercise, alcohol and drug use, and sexual activity, since health behaviors also correlate strongly with educational level, employment, income, etc. In other words, we cannot address health behaviors in isolation; we must simultaneously address education, jobs, social services, and community safety if we are to improve health.

Another significant determinant of health – the one that gets the most national attention – is access to and quality of healthcare. In the United States, that access is governed primarily by insurance coverage. Every country rations healthcare; in the United States, we just happen to ration it by separating the insured from the uninsured, and that is very much along economic lines. A privileged few are wealthy enough to be able to pay out of pocket for whatever care they need, but they rarely need to. They have insurance. Good insurance. They can afford to pay their deductible, however high it may be. The working poor, however, have some income but little or no savings and often no health insurance coverage at all. They are the ones who get hit with the entire, undiscounted bill for their care. Bankruptcy is an all-too-common result.

Our healthcare system does make some patchwork provision for the truly indigent, but no one should kid themselves that charity care is in any way equivalent – either in breadth of coverage or ease of use – to what we want for ourselves. Even those with insurance are burdened with astronomical deductibles and copays that most simply can’t afford. These persistent financial burdens can force patients to choose less expensive procedures or to go without care altogether.

And then there is Obamacare.

Implementation of the Affordable Care Act, aka Obamacare, started in 2010, when 16% of the US population – more than 40 million people – were uninsured. Healthcare provided since the advent of Obamacare is, as promised, both more affordable and more available. The percentage of people without health insurance has been cut in half.

The dirty little secret is that many healthcare providers don’t take Obamacare plans, funneling patients into inadequate primary care networks and forcing them to drive long distances for more specialized care. In other words, even under Obamacare we continue to ration care with money-related barriers. No question, Obamacare is far from perfect, but it is still better than nothing.

Ray Perryman, considered by many to be the Texas economist par excellence, issued a report in April 2019 titled Economic Benefits of Expanding Health Insurance Coverage in Texas. In this report, Dr. Perryman states, "Health care needs do not simply go away because individuals do not have insurance coverage. Instead, medical issues tend to escalate and lead to higher costs and worse outcomes. Texas would gain over $110 billion in new Federal health spending during the first 10 years." For the callous who are only interested in the economic benefit accrued to the state’s coffers, this report delivers that in spades.

Guess what, though? According to the Perryman Group report, expanding health insurance coverage in Texas also would result in enhanced “health and wellbeing of individuals directly affected by receiving coverage” as well as “reductions in the numbers of uninsured, fewer emergency room visits, improved health outcomes, enhanced employment and productivity, and other desirable developments.” That is a win-win, my friends.

There has been little political appetite to expanding coverage in Texas for fear of “socialized medicine” and an ever-more-intrusive Federal Government. I get it. We can have differences of opinion about whether and how much healthcare is a “right”, how much “responsibility” is required along the way, and the role of government in healthcare. But, leveraging $9.00 in federal resources for every $1.00 in state funding that results in improved health and return on investment is a bet I would make any day of the week.

Our individual and community health depends on many things. Money – or lack thereof – is the most insidious factor. Improving the health of an entire county, as measured by the Robert Wood Johnson County Health Rankings, will require a concerted effort on both the public and private sector fronts and with both large and small scale efforts. Expanding health insurance coverage in Texas via the Affordable Care Act would be an impactful place to start.

The Financial Burden of Cancer Care

As a board-certified radiation oncologist, I’m trained to know all about cancer and its physical effects on people. Similarly, as a board-certified hospice and palliative care physician, I am well-versed about the psychosocial and spiritual trials patients go through, especially at the end of life. But a recent study I read stopped me in my tracks with a disturbing finding: Cancer is bankrupting an astounding number of patients.

Adrienne Gilligan, PhD, publishing her research in the American Journal of Medicine, found that 42% of cancer patients deplete their life savings within 2 years of diagnosis. This “financial toxicity” –  arguably every bit as serious as the emotional and physical toxicity associated with cancer treatment – risks forcing far too many cancer patients to make an agonizing choice between almost certain death and overwhelming debt.

The Advisory Board Company, a Washington, DC-based organization that researches best practices in healthcare and other industries, highlighted from Gilligan’s article that “the direct medical costs from cancer exceed $80 billion in the United States. [The authors] cited previous research finding that up to 85% of cancer patients leave the workforce during their initial treatment, and more than 50% of cancer patients at some point experience bankruptcy, house repossession, loss of independence, and breakdowns in their relationships.”

One observation from this research that should be even more concerning for those of us in deep East Texas is that in more vulnerable populations with lower socioeconomic status and clinical factors such as smoking and poorer health – this describes Angelina County and surrounding counties – the risk of asset depletion is even greater. Even for those with health insurance, the researchers wrote, deductibles and copayments for treatment, supportive care, and nonmedical or indirect costs (for example, travel, caregiver time, and lost productivity) may be financially devastating.

I see this financial burden all the time. Monthly, I get a report from my billing office on the bills that patients are not paying despite multiple contacts. Most of the time, these are deductibles and copays that patients – who live paycheck to paycheck and who have no savings to start with – never are going to be able to pay. Sometimes it is the entire bill, in the case of uninsured and indigent patients. As a physician, I really only have two options: send them to a collection agency to harass them and try to get whatever proverbial blood out of the turnip they can, or write them off. That my patients should suffer not only with a cancer diagnosis and treatment side effects but also possible bankruptcy is absurd. I am rightfully appalled and angered that our federal healthcare reimbursement system and the private insurance complex have achieved “cost savings” by placing more and more of the financial burden onto patients, who simply are unable to pay. The bankruptcy monster is always at the door.

Doctors are familiar with the Latin phrase primum non nocere – first, do no harm. The idea is really that we should balance the risks of treatment with the benefits. I imagine when that phrase was coined the author did not have financial harm in mind. Today, it has become one of the most important “risks” when weighed against the hoped for gains of treatment. Unfortunately, the provision of healthcare has become a commodity and providers are reduced to revenue-producing cogs on the wheel in a system that has replaced the patients’ needs with productivity metrics. The profession of medicine is less and less in charge of the provision of medicine.

In spite of this new reality, healthcare providers – doctors, hospitals, etc. – must recognize that the mission of any healthcare organization is first and foremost health, not profit. When profit alone drives healthcare decisions, the cart is before the horse. And forcing patients into bankruptcy with draconian billing and collection policies profits no one (except maybe collection agencies). Accounts that have little chance of being paid need to be written off quickly and completely.

In hospital systems, some critical services – for example, social work, patient navigation, discharge planning – may have no direct link to the bottom line in terms of a reimbursable, codable procedure or office visit, but nonetheless have a profound impact on preventing financial losses by impacting readmission rates and avoidable costs associated with inability to comply with prescribed courses of treatment. In addition, finding sources of payment for patients can bring dollars in that otherwise would not be seen. These services must not only continue, but be expanded.

Ultimately, legislators need to change the way healthcare services are valued and reimbursed so that the increasingly unmanageable financial burden that falls on everyone – even the insured, hardworking folk – doesn’t bankrupt us all. This isn’t about patient responsibility; it is about preventing personal financial catastrophe. And now it’s January with high deductibles and never-ending copays to meet. I’m afraid we are in for a bumpy ride. Happy New Year!

The Crockett Hospital’s Painful Demise

June 30, 2017 was a sad day for Crockett, Texas, our neighbor just 47 miles to the west. Little River Healthcare ended its management affiliation with the Houston County Hospital District that Friday, effectively shuttering the Crockett hospital. Nearly 200 employees are affected by the closure.

The simple sign taped on the front door said, “HOSPITAL CLOSED” and directed people to either call 911 in an emergency or to go to Palestine Regional Medical Center, the closest hospital 39 miles away.*

Though this seemed like a sudden event, in many ways it was a slow death over many years. The 49-bed Crockett hospital – most recently known as Timberlands Healthcare, under the management of Little River Healthcare since April 18, 2016 – had danced with several management partners over the last several years. Little River Healthcare didn’t even last 15 months. 

Prior to Little River Healthcare, CHC (Community Hospital Corporation) was brought in June 1, 2015 to run the Crockett hospital for an interim period after the hospital’s messy divorce from East Texas Medical Center (ETMC) in Tyler. ETMC ran the hospital for 10 years. ETMC claimed to have invested $27 million in facility and technology upgrades in Crockett, but for a hospital in the 21st century, that was a paltry amount when spread out over 10 years. 

So why didn’t Little River Healthcare succeed?

According to published news reports, Little River Healthcare blamed Blue Cross and Blue Shield for not paying $32 million it was owed; BCBS would not comment. Little River stated that when it took over the Crockett hospital, the hospital had been “cash flow negative for a long time,” but that they thought they could turn it around.

It was a helluva lot to turn around. Payroll alone was $1.5 million per month. To keep the hospital running in its current state would have cost $2.7 million per month. The Houston County Hospital District board had already increased property taxes to the max amount and even borrowed money in an attempt to keep the hospital afloat. 

LRH Co-Owner Ryan Downton was quoted as saying, “We came to the conclusion the patient volume just isn’t there in the town anymore.” The problem was not volume; it was reimbursement. You can double or triple the number of patients you see, but if you don’t get paid adequately, you are just digging a deeper hole.

Crockett is a dying town. According to the Census Bureau, its population is around 6,500 and shrinking. 39% of the population is living in poverty. Only half of those 16 years of age and older are employed. A mere 17.2% of the population 25 years and older has a bachelor’s degree or higher (and 22.4% don’t even have a high school diploma). 27.4% of the population under the age of 65 has no health insurance. In today’s medical climate, no hospital can survive with this demographic. No hospital district can squeeze enough taxes and reimbursement out of an uneducated, poverty-stricken, unemployed, and under- or un-insured demographic to keep a hospital afloat.

What happened in Crockett is, unfortunately, not unusual. At least 15 rural hospitals have closed across Texas over the last several years. Dozens of counties in Texas have just a single physician – or none at all.

I grieve for Crockett. My brother and his wife live there. I have had the privilege of treating many dear patients from Crockett over the years. We share a compassionate state representative, Trent Ashby, whose rural upbringing cannot be far from his mind in a situation like this. Trent has said he is “committed to working with all of the involved stakeholders to mitigate the loss of existing jobs and help move forward with a plan to increase access to healthcare in our area of the state.” I don’t doubt it one bit. But to be honest, there’s not much he can do. CHI St. Luke’s Health Memorial Lufkin leadership was over in Crockett even before the closing to assist some with employment, but even they can’t come close to softening the impact of nearly 200 jobs lost.

Ultimately, this falls far too heavily on the shoulders of the local Houston County Hospital District board to find a solution. They can’t pull money out of thin air or tax property any higher. And they certainly can’t get paid for healthcare when no insurance coverage or safety net exists. I hope the hospital district board can reassess and reallocate resources to focus on providing comprehensive primary care and prevention services to the citizens of Houston County, at a minimum. They also need to strengthen relationships with surrounding regional hospitals to provide higher level of care services where needed. 

Those of us outside Houston County need to open our eyes. Without a much deeper, systemic and national change in how we allocate and pay for healthcare in this country, what just happened in Crockett is going to be replicated in more and more communities around the country. Let’s help Crockett, but don’t think it can’t happen to us.

*Will Johnson, Senior Reporter for the Messenger News in Grapeland, and Caleb Beames with KTRE-TV have done an excellent job reporting on the hospital closure, and I am indebted to them for some of the details and quotes in this column.

What I Would Like to See in Healthcare Reform (Part 2)

Last month, I wrote about the bloated, incredibly inefficient federal bureaucracy that eats up hundreds of billions of dollars annually in administrative costs. I mentioned that Obamacare was not, in my opinion, true healthcare reform and did not address these inefficiencies; rather, it simply added people to the rolls of a broken system.

In this column, I am not intending to argue for or against Obamacare or whether we “repeal and replace” or go with “Obamacare Lite”, whatever that might be. I am simply pointing out areas where I see daily a burden for both patients and providers. My dream would be for simplification of much of the process of valuing, coding, and billing for healthcare services. Whether any of these thoughts are achievable or affordable, I don’t know.

Let’s start with that dreaded hospital bill. Medical billing is indecipherable. Even patients with advanced degrees can spend hours trying to interpret the bill they receive for a hospital stay. And that bill is obscenely higher than what either the hospital or the providers are going to get paid. What’s ironic is that bill often has no correlation with the actual cost of the care received or the value that the federal government (or the insurance company) places on that care. We must simplify how we charge for medical care and how hospitals and providers get paid. Unfortunately, the only patients who get stuck with the full, inflated bill are those without insurance – the ones who can least afford to pay it. That is unethical.

The overall cost of care (and your bill) is determined by coding every aspect of care, from the Kleenex and bedpan to the heart valve. For every cancer patient I treat, there are dozens of separate codes submitted for reimbursement covering all different aspects of planning, designing, QA’ing, and delivering treatment. I have no doubt that much of that could be combined into, say, a fixed reimbursement for treating prostate cancer. The problem is, when the government wants to bundle procedures together, they do it to cut overall reimbursement immensely. We still do the work; we deserve to get paid. Why can’t we work out a way to simplify, cut administrative costs, and make it a win-win both for the providers and the payors?

Along the same lines, consider a simple office visit to the doctor. The complexity required to determine whether I get paid a level 2 or level 3 office visit – which reimburse only $25 and $50 – is outrageous. These so-called Evaluation and Management (E&M) codes – and there are many of them – are based on four different possible levels of complexity of three aspects of the patient encounter: history, examination, and medical decision-making. Take history, for example. The proper level of complexity is determined by the presence or absence of documentation for four sub-elements: chief complaint, history of present illness, review of systems, and past, family, and/or social history. Do you see where I am going with this? Documentation of these encounters (consultations, follow up office visits) often takes longer than the encounter itself! And, any "error" in billing is considered fraud and abuse. It is common to hear patients complain that their doctor never looked at them, but was always looking at the computer screen. We need to simplify coding and put physicians back face-to-face with their patients.

Then there is the ever-increasing burden of deductibles and co-pays. We have such a mishmash of healthcare plans, each with their own deductibles and co-pays, that it is virtually impossible to keep it all straight. At the beginning of every year, doctors’ offices and hospitals cringe. Did a patient change insurance plans, or did their insurance lapse? What about the deductible for the new year? What about co-pays? More than half of Americans have less than $1,000 in savings. Deductibles for individuals enrolled in the lowest-priced Obamacare health plans will average more than $6,000 in 2017. Can the majority of Americans afford that? Certainly not! This is an unfair burden both on patients and on providers, who end up providing that care for free. Why? Most of it gets written off, but only after we spend a lot of personnel time and effort proving we try to bill for what we can’t collect in order to avoid the appearance of fraud and abuse. Those patients who are forced to pay may rack up credit card debt, get sent to a collection agency, and/or go bankrupt. Some go without the care they need rather than add to their debt. I truly believe co-pays and deductibles are a vestige of a bygone era. I would like to see the dollars saved by decreasing the administrative burden of healthcare go to actually paying hospitals and providers what they deserve and earn, and do away with co-pays and deductibles. There should be one price for a procedure or encounter, and that cost should be paid 100% by insurance.

What about insurance companies? In the best of circumstances, they pay fairly and quickly. But too often they can and do delay patient care and prevent patients from getting the care they need in a timely manner, if at all. They do this through a process called precertification or prior authorization (read: denial). And sometimes when they do give prior authorization, they still deny payment. This ought to be illegal. But it happens without recourse because the state insurance regulations are written in favor of the insurance companies. We need to loosen the precertification grip on the practice of medicine, and we need to be able to hold insurance companies accountable to their agreements. A preauthorization is a contract to pay.

The two hospitals in Lufkin (Woodland Heights Medical Center and CHI St. Luke’s Health Memorial) have spent tens of millions of dollars on electronic health records, not to mention what individual and group physician practices have spent, all mandated by the federal government. To what end? This was supposed to be about “quality”, but that emperor had no clothes. There is precious little improvement in communication between providers and hospitals than before electronic health records. The various doctor’s offices use a number of different vendors, and each hospital uses their own separate vendor. None of them share information with each other. I dream of a truly universal electronic health record language with seamless interconnectivity between offices and hospitals, but I sure don’t want to live through the incredible expense, time and effort it would take to get there. But I do dream.

Finally, let’s talk about rights. I have never felt that free or universal healthcare was a “right”. Hear me out. No one has a "right" to healthcare without some responsibility. That responsibility may be in purchasing insurance, but that is not the only way to contribute. The most glaring, but not the only, example is smoking. Half of long-term smokers will die of a smoking-related illness. If you smoke, the rest of us are burdened with some (or all) of your healthcare costs. On average, a pack of cigarettes in the US costs a smoker $5.51, while the combined medical costs and productivity losses attributable to each pack are approximately $18.05, according to researchers. This is where consumption taxes are attractive, but only if the tax truly goes to help offset the cost of healthcare. How we balance rights and responsibilities in healthcare is a good subject for a doctoral dissertation.

As well all hear about and read about proposed healthcare changes over the next year or two, look for what they are really trying to change, and ask yourself, are they really improving the system, or are they just trying to squeeze more people under a broken umbrella? Can they do both? Let’s hope they try.

Support Raising the Smoking Age to 21

The 85th Texas Legislative Session is in full swing. On Wednesday, February 15, a bill was filed in the House by Representative (and physician) John Zerwas (R) to raise the smoking age in Texas to 21 (so-called Tobacco 21, or T21 for short). A companion bill has been filed in the Senate. This is truly a bipartisan effort and is a great idea. For decades now, the legal drinking age has been 21. Tobacco kills far more people than alcohol, and almost all long-term smokers start smoking before they reach the age of 21.

Deep East Texas contains the lowest ranked counties in Texas for health outcomes, and part of that is due to our higher smoking rates. Nearly 90 percent of adults who smoke started smoking before the age of 18 and nearly 100 percent started by age 26. 18- and 19-year-old smokers are a major supplier of cigarettes for younger kids, who rely on friends and classmates to buy them. Raising the smoking age to 21 can help decrease our smoking rates as well as save tax dollars on future healthcare spending related to tobacco use.

Speaking of tax dollars, annual Texas health care expenditures directly caused by tobacco use amount to a whopping $8.85 billion, and we taxpayers bear part of that cost. The State Medicaid program’s total health spend as a result of tobacco use is $1.96 billion. No, we can’t save all of that, unfortunately, unless no one smokes. However, Jeffrey Fellows, PhD, in a Center for Health research report wrote, “Increasing the smoking age to 21 [in Texas] would result in 30,500 fewer smokers after three years, and lead to $185 million in reduced healthcare expenditures and productivity costs over five years. Lower cigarette excise tax revenue of $3.4 million would reduce the 5-year net savings; however the state would still generate a net financial savings of just under $182 million.”

It isn’t just about dollars; it’s about lives, too.

The Institute of Medicine predicts that smoking prevalence would decline by 12 percent if the national minimum age of sale was raised to 21. One of their models also predicted that raising the national minimum age of sale to 21 would result in approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for those individuals born between 2000 and 2019. Smoking kills.

In case you wonder if the tobacco companies think this will work, here’s a quote from a 1986 Philip Morris report (one of the largest suppliers of tobacco products worldwide): “Raising the legal minimum age for cigarette purchaser to 21 could gut our key young adult market (17-20) where we sell about 25 billion cigarettes and enjoy a 70 percent market share.” To the tobacco industry, it is always and only about market share and profit.

Raising the smoking age to 21 isn’t the only answer to our smoking and poor health epidemic. Many cities and even entire states have gone smoke-free. Texas needs to. Dietary and exercise components of good health also need to be emphasized. But if we can lessen the number of the next generation who start to smoke simply by increasing the smoking age of to 21, why wouldn’t we? That’s right… there is no good answer. For a healthier Texas and Angelina County, support Tobacco 21.

What I Would Like to See in Healthcare Reform (Part 1)

I often tell people that if all I had to do was take care of patients, life would be grand. It is the countless hours of dealing with the administrative aspects of healthcare that have practically ruined the practice of medicine for many physicians. You should care; it takes away from our time with you.

TheHill.com, noted that physicians and their staff spent over 15 hours per week complying with quality reporting requirements and that for every hour a physician spends with patients, an additional two hours are consumed completing administrative tasks related to the visit. This meaningless (to physicians, anyway) work has costs in both time and money, leads to burnout, and is increasingly mentioned as the reason for early retirement. I, for one, found myself daydreaming in a committee meeting the other day and I calculated that it was 3361 days until my 65th birthday. That's 9 years, 2 months, and 15 days. No, am not planning to retire early, but sometimes I sure wish I could. Healthcare needs reform.

The average person thought Obamacare WAS healthcare reform. In reality, Obamacare did nothing to actually improve the healthcare system; it simply added more people to the rolls. Don't get me wrong. Having more people insured is not a bad thing. But we need more than just additional enrollees in a broken system.

After Trump was elected, there was an initial, overly optimistic assumption that Obamacare was on its last leg. Recent infighting among policy makers suggests Obamacare may be more like the proverbial cat with nine lives. I only hope true reform is part of whatever "replacement" or "repair" Congress and the President come up with.

In particular, let's hope some of that reform will significantly scale back a bloated, paranoid bureaucracy that sucks hundreds of billions of dollars out of healthcare that could go to those who actually care for patients. And, perhaps, some could go back into the taxpayers' pockets.

Back in 2012, Berkshire Hathaway CEO Warren Buffett called healthcare "the tapeworm of the American economy". To be more accurate, the federal government is healthcare's tapeworm. In an online article in Medical Economics last year, Ryan Gamlin, who studies what drives inefficiency, waste, and harm in U.S. healthcare, found that "as countries spend a larger percentage of their healthcare dollars on administration (as opposed to public health, or providing patient care, for example), things get worse for patients and healthcare providers. High administrative expenditures seem to be associated with negative experiences of providing and receiving healthcare." That is a nice way of saying there's a ton of money wasted going to paper pushers.

Helen Adamopoulos, writing in Becker's Hospital Review in 2014, noted that US hospital administrative costs account for more than 25% of hospital spending, more than double that of Canada, for example, where hospitals receive global, lump-sum budgets. In contrast, US hospitals must bill per patient or DRG (diagnosis-related group), requiring additional clerical and management workers and specialized IT systems. They also have to negotiate payment rates with multiple payers with differing billing procedures and documentation requirements, driving up administrative spending. Not to mention all the personnel, time, and IT required to satisfy CMS’s (the Centers for Medicare & Medicaid Services) monstrous appetite for "quality" and "safety" data, with the ever-present threat of fraud and abuse hanging over every unintentional misstep.

What should be a simple process of billing for services provided is a minefield. And anyone who has ever tried to understand a hospital bill knows it is an impossible task. Aliya Jiwani, writing in BMC Health Services Research, notes that billing and insurance-related (BIR) administrative costs in 2012 were estimated to be $471 billion and that fully 80% of this spending, which provides little to no added value to the healthcare system, could be saved with a simplified financing system. Jiwani predicted that greater use of deductibles under Obamacare will likely further increase administrative costs, stating, "Empirical evidence from similar reform in Massachusetts is not encouraging: exchanges added 4% to health plan costs, and the reform sharply increased administrative staffing compared with other states."

A CNBC report of a Health Affairs study tagged the extra administrative costs of Obamacare at more than a quarter of a trillion dollars, an average of $1,375 per newly insured person, per year, from 2012 through 2022. The Health Affairs blog authors reported, " The overhead cost equals a whopping 22.5 percent of the total estimated $2.76 trillion in all federal government spending for the Affordable Care Act programs during that time."

What do I wish we could be different in our healthcare system? In March, I will discuss some specific changes that would reduce the administrative burden on healthcare providers and, in many ways, return us to a simpler, more direct, and frankly better transaction of healthcare.

Resolve to Improve the Health of our Region

January is a time of resolution, and often our New Year resolutions focus on diet and exercise. My friends, we need a city, county, and region resolution to lose weight!

In July, 2016, Sabrina Perry wrote an article for HealthGrove.com – a health data analysis and visualization site – titled, The County with the Highest Obesity Rate in Every State. She repeated the American Medical Association’s contention that obesity is a disease and noted that the World Health Organization considers obesity a global epidemic. I perused the article with interest, looking for the county in Texas that got the dubious honor of being the fattest. Unfortunately, it was our very own Angelina County.

Look around and it is evident. Angelina County has the highest obesity rate in Texas, coming in at 37.5%. That means nearly 4 out of 10 of us aren’t just overweight; we are downright fat. To achieve the dubious distinction of being fat, you have to get to a body mass index (BMI) of over 30. To give you an idea what it takes to qualify as obese, consider a 5’11” male such as myself. My appropriate weight is less than 180 pounds (and probably more like 160 pounds). Any more than that and I am considered overweight. But to be considered obese – which is what 37.5% of Angelina County residents are – I would need to weigh 215 pounds or more. For me, that would be at least 35 pounds overweight, if not more. I routinely see patients with a BMI of 40 or more, which is considered extreme (or morbid) obesity. That would be a whopping 100 pounds overweight for me.

What can we do?

Dan Buettner, author and founder of bluezones.com, has been writing for years about particular geographic pockets around the world where people live longer. According to the website, “Residents of the Blue Zones live in very different parts of the world. Yet they have nine commonalities that lead to longer, healthier, happier lives.” So much of this is what has been preached to us for decades: don’t smoke, eat your vegetables and legumes, exercise, don’t overeat, and drink wine in moderation. On top of this are stress-related factors, having strong family and friend relationships, and spirituality.

It’s not just that we are obese. Our overall health is terrible. The Robert Wood Johnson Foundation ranks population health by county. In Texas, many of the lowest ranked counties are in deep East Texas. Wouldn’t it be great if Lufkin could be known not just for pump jacks and forests, but also for the health of our citizens? This can only work for communities if each of us individually works at it. We have family, friends, and lots of churches. Strengthen those relationships. And, let’s stop smoking, exercise, and eat right!

I recently participated in a set of strategic planning sessions hosted by the Texas Forest Country Partnership called Stronger Economies Together, or SET. The purpose was to set goals for growth across a broad spectrum of our regional economy, from forestry and tourism to manufacturing and healthcare. Our SET healthcare workgroup noted that we have significant work to do if we are going to impact the poor healthcare factors and outcomes the Robert Wood Johnson Foundation identified in the deep East Texas region. We set an ambitious goal simply to raise our overall health ranking from the lowest 20% to the next lowest; in other words, from poor to still below average. But we have to start somewhere.

This will require a multi-year effort working with all aspects of the healthcare and social service community to start to move the dial toward a healthier region. We can do it, but we all need to make – and keep – that that resolution for better health!

Feeding the Hungry this Holiday Season

Our series of articles titled Business is Everyone’s Business has focused so far on various employers, both large and small, and their economic or employment impact in the region. In this season of Thanksgiving and Christmas, we must also remember that our local non-profits are everyone’s business as well.

The Thanksgiving holidays saw a great outpouring of giving through the Community Food Drive, originally started by our own “saint” Rev. Bettie Kennedy and now ably overseen by Bruce Love. On November 21, 2015, two thousand boxes of food were quickly packed and distributed throughout the community. Hundreds of volunteers, young and old, black and white, rich and poor came together for a common purpose and in one accord. That singular, annual event has great impact. Do you ever wonder how that need is met throughout the year?

The Christian Information & Service Center is an amazing organization that provides food for our hungry day in and day out. CISC, a 501 (c)(3) organization led by the indomitable Yulonda Richard, has a mission to be a Christian witness and minister to those in need specifically by feeding the hungry within Angelina County. It is a volunteer-supported organization that exists because of donations given in love by individuals and local churches. These donations allow CISC to operate locally in Lufkin to provide food out of the East Texas Food Bank in Tyler.

The need is significant. One in seven Americans will visit a food bank this year. 465,000 East Texans are at risk of hunger. Every year, CISC hands out over 2M pounds of food to around 200,000 people on a budget of $347,000. Though the primary assistance to the community is free food for low-income residents within Angelina County, CISC also offers various programs throughout the year, such as the "BackPack Buddies" after-school feeding program, the "Senior Food Box" senior citizen program which feeds over 2,600 seniors per year, and the "21-Day Meal Program," which aims at feeding children who are on summer vacation. There is also an avenue for assistance with gas vouchers, sleeping bags, bus tickets or utility assistance.

According to Yulonda Richard, the recent layoffs in Angelina County have led to an increase in the number of clients seeking help at CISC. Previous statistics showed that forty-nine percent of the households served have at least one employed adult, and the rest are mostly children and seniors on fixed incomes. It is, to a large extent, the working poor who really need a helping hand.

If you have ever driven by CISC in the morning, you know there are people there at 6:30 AM waiting, even though the doors don’t open until 9:30 AM. Fresh fruits, vegetables, meats, dairy, bread, everything you find in the grocery store CISC delivers. The majority of the donations come from right here in Angelina County: money, food, church support.

How can you help? Come to the Believe in Christmas! musical this Sunday, December 6, 2015 at 6 PM at Lufkin’s First Baptist Church. First Baptist and New Beginnings Baptist are uniting for the second year to celebrate unity, worship together, and support CISC. Admission is free, but bring canned goods or even a monetary donation for CISC when you come. As Yulonda Richard says, “It doesn’t matter what we give, God always expands it. As long as you are giving from the heart, God will increase it.”

CISC may not be the most glamorous non-profit in town, but they just might be the most impactful. As we move through this holiday season, remember that supporting local non-profits like CISC is everyone’s business.

PineCrest has Far-reaching Economic Impact

Mayor Bob Brown, City Manager Keith Wright, Chamber CEO Jim Johnson and other local government and business leaders recently launched a series titled Business is Everyone’s Business. The purpose of this initiative is to highlight local businesses and remind us not only of their economic impact but also the importance of our community support.

I recently asked the Texas Comptroller of Public Accounts office to provide me with updated statistics on the contribution of the healthcare sector to our local economy, and I was startled at the findings. Employment in the healthcare industry in Angelina County grew from 7,091 FTEs in 2005 to 8,411 in 2014. In 2014, 23 percent of all jobs in Angelina County were in the healthcare industry (up from 20 percent in 2013). In 2013, the healthcare industry accounted for $401,447,145 or 13 percent of the gross regional product in Angelina County. Angelina County truly is the healthcare hub of our deep East Texas region.

Within the healthcare industry, there are the major employers we all know about, like CHI St. Luke’s Health Memorial (1200 employees), Woodland Heights Medical Center (580 employees) and the Burke Center (400 employees throughout East Texas). There are myriad small businesses providing pharmacy, home health, hospice, and various diagnostic and therapeutic services to our region. We also have a number of nursing, rehabilitation and long term care facilities, one of which I want to feature today.

PineCrest, part of Methodist Retirement Communities, is a not-for-profit continuing care retirement community offering independent living, assisted living, memory support, skilled nursing and home health. Open since 1992 and located on 55 acres, PineCrest employs 220 people with an annual payroll of $6 million (mostly to Angelina County residents) and an additional spend of $3 million going to physical plant operations, utilities, contractors, and others.

Much more than a nursing home, PineCrest has 82 residential apartments, 36 patio homes, 21 assisted living apartments, 40 memory care units, and 51 skilled nursing units with 19 of those dedicated to transitional rehab. PineCrest also has on-site banking, full-service dining, a bistro, grocery store, library, chapel, beauty salons, a wellness center, and even a large auditorium to hold banquets, seminars, or private parties.

According to Amy Thomas, Executive Director at PineCrest, they currently serve around 237 residents, which include those with spouses. PineCrest is constantly reinvesting in our local community with ongoing renovations. PineCrest residents also contribute to the local economy as any of our county residents would, whether dining out, going to the grocery store, shopping, buying gas, attending Angelina Arts Alliance and Pines Theater shows, as well as with expected healthcare-related visits (hospitals, doctors, pharmacies, etc.).

PineCrest supports our broader economy in other, unexpected ways. For example, they partner with SFA as an intern site for social workers and as a clinical site for nursing students in SFA’s Bachelors nursing program. In addition, PineCrest is an intern site for SFA’s hospitality program. PineCrest also partners with Angelina College with AC’s LVN, RN, and CNA programs. These affiliations have led to numerous full time healthcare positions not only at PineCrest but at other facilities in our community.

PineCrest residents serve as volunteers at CHI St. Luke’s Health Memorial and at AC’s Adult Learning Center. And local high school students are working with PineCrest residents in a program called Wisdom for Youth with Senior Expertise (WYSE), which promotes inter-generational learning through shared experiences. An Alzheimer’s support group is also facilitated at PineCrest. Though these programs may not have a direct economic impact, their quality of life impact is significant.

PineCrest is a true community within our community, and one that is far from insular or isolated. I’m grateful for PineCrest’s economic impact as well as their influence far beyond simple employment statistics. PineCrest demonstrates that Business is Everyone’s Business!

Shop Local, Get Well Local

I have the privilege this year of serving as Chairman of the Board for the Lufkin/Angelina County Chamber of Commerce. The Chamber, along with the City of Lufkin and the Economic Development Partnership, commissioned a retail study that will help us in recruiting even more business to the area. Do you support our local economy by shopping local?

Even more important to our economy, where do you go for your healthcare?

As a physician community leader, I have a unique perspective on the healthcare sector. Across the state level and nationally, healthcare accounts for 11%-12% of a local economy. In the Lufkin area, it is nearly double that at 20%. Over the last 11 years, all other sectors of the economy combined have shown miniscule growth (0.5%). The healthcare sector grew by 36.3% during that same period. 7,424 Lufkin area jobs are directly linked to the healthcare sector, with a direct tie-in of $193.26 million in annual disposable income. It is not an understatement to say that the healthcare sector is a strong driver of Lufkin’s economic growth.

Of course, everyone is a bit nervous about the recent changes at Lufkin Industries and Temple-Inland. In my role with the Chamber, I am grateful for the recent outreach from new leadership from both GE/Lufkin Industries and Georgia Pacific. I urge both companies to continue the legacy left to them of strong involvement with the Chamber, the United Way, and the many other organizations that contribute to our quality of life. But, each of us has a responsibility to our community. Now – more than ever – how we act as individuals will drive our local economy.

We love to tout how much we love Lufkin, then we turn around and head to Houston for healthcare… when our local facilities and personnel are top notch. Those of us who are blessed with jobs and insurance have a responsibility to our community to direct our healthcare dollars locally as much as possible.

Why? Your community non-profit hospital, Memorial Health System of East Texas, has a mission to care for all – even those who do not have insurance or means to pay. For example, the Arthur Temple Sr. Regional Cancer Center has never turned a patient away due to inability to pay. Those Houston hospitals aren’t going to care for our indigent or uninsured, but they are more than happy to take our insurance. MD Anderson, for example, has a history of not even giving appointments without proof of payment up front. When you leave for healthcare services that can be delivered locally, you are diverting resources away that can not only help support local care for all, but improve our local economy. In these times of ever-increasing bureaucracy and ever-tightening reimbursement, we need to consciously support what we have here… or it may go away.

Ah, but then the argument turns to perceived quality of care. A couple of years ago, I looked at our cancer patient population to determine the #1 cause of delay in starting treatment. It was not income level or lack of insurance. It was seeking a second opinion out of town. Ironic, isn’t it, that thinking you need to go somewhere else for treatment might actually hurt you in the long run! Your local healthcare providers are perfectly capable of making the decision of what needs to be treated in the big city, and it is far less than what most people think.

To tweak an expression: “What stays in Lufkin is good for Lufkin.” Shop local? You bet. Stay local for healthcare? Absolutely.