PROVIDENCE – Deep into the story in The Wall Street Journal account last week of the $70 billion acquisition by CVS of Aetna was what reporters and editors call the nut graph, in effect burying the lede.

In building its new platform to reduce health costs and improve consumer experience around the delivery of health care, CVS said it would be honing in on five chronic diseases. “The company has said a major focus will be on better managing five chronic conditions: diabetes, cardiovascular disease, high blood pressure, asthma and behavioral health,” the reporters wrote.

If there was ever a full-throated endorsement by a huge national health industry player of the innovative work being done in Rhode Island with the development of nine current health equity zones to create community-based solutions to the issues around health, social and economic disparities, this was it, even if it was unintended.

The problem, of course, is that neither the reporters from The Wall Street Journal nor the new reincarnation of CVS necessarily realized the import of what was being said.

The concept around health equity zones is based upon the evidence-based reality that health care outcomes are 10 percent genetics, 10 percent what happens in a doctor’s or nurse’s office, and 80 percent of what happens in the community where you live.

Translated, all the money in the world spent on reimbursing consolidated health systems and large corporate box stores for the delivery of health care will not move the meter on health outcomes, despite the ever-increasing rise in medical costs and the belief in the power of Big Data analytics.

The question is: Will the new CVS takeover of Aetna translate into better health outcomes, or will it only shift the flow of dollars to a different corporate kettle of wealth, monetizing customer convenience?

Better management vs. prevention
When it comes to making investments to change health outcomes, understanding the difference between “better management” and “prevention” is a key part of the health equity equation.

• Take asthma, for instance, one of the five chronic conditions being targeted by the CVS. What triggers asthma attacks? In most cases, its poor environmental conditions in the home, such as mold, mildew, dust mites, rodent droppings, cockroach remains and droppings, pet dander, and second-hand cigarette smoke. That is what the Centers for Disease Control and Prevention says. In the outside world, the triggers include outdoor air pollution, from cars, tiny particulates from industrial smokestacks and emissions, as well as extreme weather conditions and pollen; once again, those are the triggers, according to the CDC.

While managing and “treating” asthma at CVS may provide a way to avoid “unnecessary” visits to the emergency room, it does nothing to alleviate or prevent the sources of the asthma triggers. It may also not change the outcomes when it comes to “chronic absenteeism” that plagues school systems.

What is the best medicine to change the outcomes for asthma? Research has shown that it is healthy, safe, affordable housing, particularly in core urban areas of Rhode Island and the nation. Whatever the clinical advances in treating asthma, the best prevention methods in lowering the incidence of asthma may be to think upstream: to invest in improving the housing in the community, rehabbing abandoned properties, rebuilding neighborhoods. Also, to invest in reducing the amount of toxic air pollution in already overburdened areas of country, particularly low-income neighborhoods nearest to highways and downwind from smokestack industries.

• Next on the list of chronic diseases that CVS hopes to manage is cardiovascular disease – heart disease, still the number-one killer in the U.S. for men and women, often blamed on smoking and lifestyle choices.

The problem is that low-level lead poisoning may be phunking with the nation’s heart health, causing as many as 412,000 deaths a year in the U.S. from heart disease, according to the a study published in The Lancet in March of 2018. [See link below to the study.]

As ConvergenceRI reported: “No one disputes that heart disease is still the number-one killer of men and women, the underlying cause of death for some 800,000 Americans each year, accounting for a third of all deaths in the U.S., according to the American Heart Association. [See link below to ConvergenceRI story, “The Pb funk.”]

The story continued: “In turn, the health insurance industry and the health care delivery system spend hundreds of billions a year in treatment for coronary heart disease, stroke, and high blood pressure. The annual cost of treating heart disease in the U.S. is estimated to be approximately $300 billion a year. Heart attacks [$11.5 billion] and coronary heart disease [$10.4 billion] were two of the 10 most expensive hospital discharge diagnoses a year, according to American Heart Association statistics, using 2013 data.

“The usual suspects in the risk factors attributed to the high incidence of heart disease are: smoking, physical inactivity, nutrition, obesity, cholesterol, high blood pressure, and diabetes, with clinical treatments targeting care interventions around reducing these risk factors.

“But a startling new study published on March 12 by The Lancet, “Low level lead exposure and mortality in U.S. adults: a population based cohort study,” found that approximately 412,000 deaths a year in the U.S. from heart disease could be attributable to low level lead exposure.

The principal author of the study, Dr. Bruce Lanphear, professor of Health Science at Simon Fraser University in British Columbia, believes that low-level lead exposure is an important but largely overlooked key risk factor for heart disease mortality for adults in the U.S.

Translated, adults – not just when they first exposed to lead as children – are life-long victims of low levels of lead poisoning, leading to their death from heart disease.

How dangerous is lead? The Harvard Gazette reported on the recent summit on lead and public health held at Harvard University on Nov. 15, 2018, quoting Lanphear, one of the presenters.

“For too long we’ve blamed people for their lifestyle choices and failed to regulate the industries,” said Lanphear. Although the passage in 1970 of the Clean Air Act somewhat mitigated the problem of atmospheric lead, Lanphear estimates that lead exposure still leads to about 400,000 premature deaths each year in the U.S., including 185,000 heart attacks.

Translated, lead exposure may be a major contributor to a variety of life-threatening diseases, according to Lanphear’s research. Its role in coronary heart disease, for example, may be right up there with smoking diabetes, and excess weight, all factors that received much more attention, according to The Harvard Gazette.

The solution to reducing cardiovascular heart disease, it turns out, may be linked to reducing lead exposure in children, because of the way it persists for a lifetime: invest in safe, healthy, affordable lead-free housing, similar to the solution to asthma.

The question is: Will CVS, as part of its new business model, be willing to make that investment in safe, healthy affordable housing in places such as Woonsocket, R.I. where the corporate behemoth has its corporate headquarters?

• Another really big chronic disease that CVS has put on its target list is behavioral health. Exactly how CVS plans to monetize better management of behavioral health is unclear: it could be a combination of better medication adherence, better prescription monitoring practices, and better access and referrals to counseling.

Rhode Island is in the midst of its own major pilot program, BH Link, a 24/7 crisis, triage and outreach center, which seeks to connect potential behavioral and mental health clients with treatment options. Before launching a new behavioral health approach, CVS may want to study the actual results of the pilot program known as BH Link.

Reading the tea leaves from the research being conducted by big-time health consultants, such as Chilmark Research, the focus may probably be on what is known as telehealth: connecting CVS customers/patients by remote access to provide clinical support beyond the hospital.

A new research report by Chilmark “considers the role of emerging stakeholders – a list that includes retail health, urgent care, employer-sponsored clinics, digital therapeutics solutions, and the “smart home” enabled by voice-activated virtual assistants.”

Of course, the renewed focus targeting behavioral health as a chronic disease appears to be very much tied to the ongoing epidemic in opioid OD deaths that is ravaging the nation.

The decline in life expectancy in 2017, as measured by the Centers for Disease Control and Prevention, has been attributed to two factors: the number of deaths of accidental drug overdoses, and the increase in the number of suicides, two thirds of what sociologist Shannon Monnat has called the diseases of despair, looking at deaths from drugs, alcohol and suicide, often tied to a bleak sense of an economic future for young people between the ages of 25-34.

What would be interesting was if CVS, building upon the de-identified datasets that Aetna has access to, would publish and share a transparent, integrated data report for the mortality from alcohol, suicide and drugs for different regions of the country.

Also, CVS might want to take into account the work being done a local health equity zone in South County, which is working a collaborative fashion with schools, hospitals and community groups, to forge a collaborative approach to suicide prevention. [See link below to ConvergenceRI story, “New bridge over troubled waters.”]

What makes the Zero Suicide initiative relevant, funded by a $2 million, five-year federal grant, is that it is a collaboration, involving two hospitals, Westerly and South County, the Thundermist, Wood River and Rhode University health centers, in partnership with Health Bodies, Healthy Minds, one of nine operating Health Equity Zones in Rhode Island. It also includes the Narragansett Indian tribe as a collaborator.

“What is different about our approach,” Orban explained, “is that Zero Suicide is typically implemented within one organization – one hospital system or one health center takes it on.” Instead, Orban continued, “We are taking a population health approach and implementing [the program] in multiple health care settings in an effort to bring down our countywide suicide rate,” which is the highest in Rhode Island.

About 65 percent of the grant money will be spent on patients who don’t have insurance that covers their mental health or behavioral health treatments, or they are under-insured, so that their insurance will not pay for it, according to Dr. Robert Harrison, the Zero Suicide project director.

Orban also said that a large part of the effort will be focused on identifying folks that may be suffering from depression or have suicide ideation.

“A big part of what we will be doing is training people and implementing standard protocols for screening, identification and follow up,” she said.

The question is: how much is CVS willing to play as a collaborator in such efforts when it comes to behavioral health?

• Finally, there is the chronic disease of diabetes on the target list prepared by CVS. For all the money spent managing diabetes as a chronic disease, particularly as it ravages the older population in America and in Rhode Island, new research keeps emerging that challenges a lot of the assumptions around diabetes as being related to medication adherence, nutrition, and exercise, behaviors that can reduce the symptoms of the disease.

There is the ongoing research, for instance, being conducted by Joseph Braun, an associate professor in the Department of Epidemiology at the School of Public Health at Brown University, which has examined early life environmental chemical exposures before conception and in pregnant women, infants, and children, with a special interest in obesity and the impact of endocrine-disrupting chemicals during gestation, infancy and childhood.

The research suggests that there is a relationship between early-life exposure to bisphenol A (BPA), phthalates, triclosan and perfluoroalkyl substances (PFAS) with childhood neurobehavioral disorders and obesity [excess adiposity].

While diabetes clearly has a genetic component, and is also clearly influenced by behavioral choices around nutrition [think sugar-laden products such as candy and soda in those store aisles], in terms of prevention, the best kind of investment might be to limit exposure to certain kinds of toxic substances.

The question is: what kinds of educational material would CVS be willing to provide to its customers/patients related to preventing or minimizing early life exposure to environmental chemical exposures as a pathway to managing/preventing diabetes?