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Healthcare Costs: Low-Hanging Fruit

A simple and low-tech change to U.S. healthcare holds great promise and offers a fast pay-back. It’s re-investment in primary care coupled with giving primary care providers the right role in the healthcare system and incentives.

The logic is easy to follow. It’s built on three principles:

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1. Primary care providers can help people avoid illness and identify problems earlier, particularly if they can truly get to know their patients and build a relationship of trust. All that is required is making the provider accessible, spending more time with the patient, and providing resources to ensure that patients are following through on behaviors, meds, and treatments. Providers will tell you that it is difficult/impossible to build trust, get patients to be honest, and change behavior during a ten-minute visit (e.g.).

2. Primary care providers can treat at least 80% of medical conditions in a venue that is fundamentally lower-cost and less stressful for patients than advanced-care venues. Today’s primary care business model loads each provider with about 2,500 patients which means visits last 10-12 minutes. The provider is forced to refer anything complex to a specialist doctor, resulting in a second appointment that costs more. If primary care doctors had more time for more complex problems, they could solve many of them, saving both money and suffering. This link provides a poignant example.

3. Primary care doctors can help patients manage the rest of the medical system: decide what treatment they need, choose the best providers, avoid overpaying, and recover after acute care. This works best if they are financially independent from advanced care providers [which is the opposite of the current trend towards hospital systems owning primary care practices].

Several start-up companies and many primary care practices are pushing in this direction. The movement is called “Direct Primary Care (DPC).” These providers employ a different business model, which enables a much better care model:

•  DPC providers receive a fixed monthly fee paid by the patient and/or thehealth plan; many DPC practices do not bill insurance at all. This is not expensive: about $60 per month for most patients (and $100 for the least healthy) enables the provider to earn a competitive salary. Eliminating the overhead created by insurance billing and high patient volume, which typically eats up 30%-40% of revenue, helps greatly.

•  Reducing the panel size from about 2,500 to around 1,200 results in twice as much time per patient. Hence, DPC providers can understand patients better and manage more complex problems.

•  DPC practices make themselves much more accessible to patients. They typically offer Saturday hours, 24×7 phone access, and appointments within 24 hours. Easy access is a powerful tool to surface health problems early and head-off ER visits, many of which occur only because the primary care provider is not available.

•  Because DPC providers are paid for care, not for procedures, they can use phone consults, email, video, and other technology much more extensively. This enables more contacts with patients and faster response. Today many providers resist phone and email consults with patients partly because insurance reimbursement for these encounters is much less than for an office visit, and often $0.

It just makes sense that more intensive primary care will improve health, reduce downstream healthcare costs, and improve patient experience. Data coming forth from diverse sources shows that it works. WeCare Clinics, Iora Health, Qliance Medical Management*, MDVIP, and OneMedical have all reported reductions in total healthcare costs for their patients of 15% or more versus population norms**. Most of these programs are only a few years old; there is reason to expect that results will improve as their providers have a chance to deepen patient relationships and see the cumulative benefit of preventive work that they have done in the past.

There are a couple of knocks on direct primary care. Some equate it to “concierge medicine”, which is a high-priced service for the affluent. The idea did start with affluent customers, as many new products do, but it has become thoroughly mainstream: leading DPC providers now serve unions and Medicaid patients as well as large corporations with a broad spectrum of employees. The health and cost benefits tend to be greatest with down-scale patient groups because many of these people are chronically ill and have never had a real primary care relationship.

The other knock comes from a policy perspective: how can you reduce panel sizes when there is a shortage of primary care doctors and it takes ten years to train new doctors? DPC practices are increasing primary care capacity by hiring nurse-practitioners and physician assistants to work along MDs and by using technology to leverage provider time: e.g., a five-minute call or email can often substitute for a 20 minute office visit. Today there are about 280,000 MDs in the U.S. and about 80,000 NPs and PAs working in primary care; moving that ratio to 1:1 is a dramatic expansion of primary care capacity**.

Moreover, a major cause of the primary care doctor shortage is the low pay and status that primary care MDs have been afforded by the U.S. medical establishment. They earn about half what the average MD earns and often burn out from the 25-patients-per-day treadmill; it’s no surprise that the percent of medical school graduates choosing primary care has dropped from ~50% in the 1990s to less than 20% recently. Letting this happen was a huge policy error. Improving pay, status, and working conditions for primary care MDs is fundamental to a long term solution to the supply/demand problem.

Sometime the best answer is the simplest: go back to the basics, in this case primary care, and do it right.

Review and update of a controversial 20-year-old theory of consciousness published in Physics of Life Reviews claims that consciousness derives from deeper level, finer scale activities inside brain neurons. The recent discovery of quantum vibrations in “microtubules” inside brain neurons corroborates this theory, according to review authors Stuart Hameroff and Sir Roger Penrose. They suggest that EEG rhythms (brain waves) also derive from deeper level microtubule vibrations, and that from a practical standpoint, treating brain microtubule vibrations could benefit a host of mental, neurological, and cognitive conditions.

The theory, called “orchestrated objective reduction” (‘Orch OR’), was first put forward in the mid-1990s by eminent mathematical physicist Sir Roger Penrose, FRS, Mathematical Institute and Wadham College, University of Oxford, and prominent anesthesiologist Stuart Hameroff, MD, Anesthesiology, Psychology and Center for Consciousness Studies, The University of Arizona, Tucson. They suggested that quantum vibrational computations in microtubules were “orchestrated” (“Orch”) by synaptic inputs and memory stored in microtubules, and terminated by Penrose “objective reduction” (‘OR’), hence “Orch OR.” Microtubules are major components of the cell structural skeleton.

Orch OR was harshly criticized from its inception, as the brain was considered too “warm, wet, and noisy” for seemingly delicate quantum processes.. However, evidence has now shown warm quantum coherence in plant photosynthesis, bird brain navigation, our sense of smell, and brain microtubules. The recent discovery of warm temperature quantum vibrations in microtubules inside brain neurons by the research group led by Anirban Bandyopadhyay, PhD, at the National Institute of Material Sciences in Tsukuba, Japan (and now at MIT), corroborates the pair’s theory and suggests that EEG rhythms also derive from deeper level microtubule vibrations. In addition, work from the laboratory of Roderick G. Eckenhoff, MD, at the University of Pennsylvania, suggests that anesthesia, which selectively erases consciousness while sparing non-conscious brain activities, acts via microtubules in brain neurons.

"The origin of consciousness reflects our place in the universe, the nature of our existence. Did consciousness evolve from complex computations among brain neurons, as most scientists assert? Or has consciousness, in some sense, been here all along, as spiritual approaches maintain?" ask Hameroff and Penrose in the current review. "This opens a potential Pandora’s Box, but our theory accommodates both these views, suggesting consciousness derives from quantum vibrations in microtubules, protein polymers inside brain neurons, which both govern neuronal and synaptic function, and connect brain processes to self-organizing processes in the fine scale, ‘proto-conscious’ quantum structure of reality."

After 20 years of skeptical criticism, “the evidence now clearly supports Orch OR,” continue Hameroff and Penrose. “Our new paper updates the evidence, clarifies Orch OR quantum bits, or “qubits,” as helical pathways in microtubule lattices, rebuts critics, and reviews 20 testable predictions of Orch OR published in 1998 — of these, six are confirmed and none refuted.”

An important new facet of the theory is introduced. Microtubule quantum vibrations (e.g. in megahertz) appear to interfere and produce much slower EEG “beat frequencies.” Despite a century of clinical use, the underlying origins of EEG rhythms have remained a mystery. Clinical trials of brief brain stimulation aimed at microtubule resonances with megahertz mechanical vibrations using transcranial ultrasound have shown reported improvements in mood, and may prove useful against Alzheimer’s disease and brain injury in the future.

Lead author Stuart Hameroff concludes, “Orch OR is the most rigorous, comprehensive and successfully-tested theory of consciousness ever put forth. From a practical standpoint, treating brain microtubule vibrations could benefit a host of mental, neurological, and cognitive conditions.”

The review is accompanied by eight commentaries from outside authorities, including an Australian group of Orch OR arch-skeptics. To all, Hameroff and Penrose respond robustly.

Penrose, Hameroff and Bandyopadhyay will explore their theories during a session on “Microtubules and the Big Consciousness Debate” at the Brainstorm Sessions, a public three-day event at the Brakke Grond in Amsterdam, the Netherlands, January 16-18, 2014. They will engage skeptics in a debate on the nature of consciousness, and Bandyopadhyay and his team will couple microtubule vibrations from active neurons to play Indian musical instruments. “Consciousness depends on anharmonic vibrations of microtubules inside neurons, similar to certain kinds of Indian music, but unlike Western music which is harmonic,” Hameroff explains.

Story Source:

The above story is based on materials provided by ElsevierNote: Materials may be edited for content and length.

Journal References:

  1. Stuart Hameroff and Roger Penrose. Consciousness in the universe: A review of the ‘Orch OR’ theoryPhysics of Life Reviews, 2013 DOI:10.1016/j.plrev.2013.08.002
  2. Stuart Hameroff, MD, and Roger Penrose. Reply to criticism of the ‘Orch OR qubit’–‘Orchestrated objective reduction’ is scientifically justifiedPhysics of Life Reviews, 2013 DOI: 10.1016/j.plrev.2013.11.00
  3. Stuart Hameroff, Roger Penrose. Consciousness in the universePhysics of Life Reviews, 2013; DOI: 10.1016/j.plrev.2013.08.002
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