Unbiased Analysis of Today's Healthcare Issues

Measles kills more kids that AIDS

Written By: Jason Shafrin - Mar• 01•15

Globally, measles is a significant killer of kids and the threat is growing in the US as vaccination rates decrease.  Citing a Global Burden of Disease study published in the Lancet, Wonk Blog reports that in 2013 measles killed over 82,000 children under age 5.  This puts measles as #7 on the list of the top causes of child death.




Friday Links

Written By: Jason Shafrin - Feb• 26•15

HWR is up

Written By: Jason Shafrin - Feb• 26•15

David Williams has posted Health Wonk Review: Happy 10th anniversary edition at Health Business Blog. It’s Health Business Blog’s 10 year anniversary so be sure to stop by to read David’s post and wish him well – 10 years Internet time is a veritable eon!


The end of wearables?

Written By: Jason Shafrin - Feb• 24•15

Wearable technology is all the rage.  There was even a recent paper in JAMA about wearable technology.  However, will wearables soon to be old news?  What is the future?  Joe Kvedar gives his thoughts on the topic:

Thus, we have plentiful pedometer apps…We’ve also solved how to run these apps in the background without disrupting the phone tasks or draining the battery. So, is it time to ask, “do we really need fitness wearables anymore?

I’d frame the question a different way. Is the future of patient-generated data migrating to the mobile phone (the proverbial digital Swiss Army Knife of life) or will it be migrating to the realm of micro-sized wearable seeds, ingestibles, injectables, bandaids and the like?  I was a fellow panelist with tech guru and futurist Nicholas Negroponte, and in an off-handed comment, he said that wearables are just a temporary fad and that the future is in ingestibles.

What is does an ingestible sensor look like? Take a look.

Narrow Networks

Written By: Jason Shafrin - Feb• 23•15

One of the ways health plans in the health insurance exchanges have been able to keep premiums down is through offering beneficiaries very narrow networks. By steering patients towards “efficient” doctors, premiums stay low. However, patients may worry that these “low cost” doctors are lower quality than those outside of the network. The tradeoff between cost and quality is one health policy wonks have wrestled with for many years.

In an attempt to ensure quality and access to care is adequate, CMS has instituted a number of checks on network adequacy. Tim Jost writes in the Health Affairs blog that qualified health plans (QHP) must:

…must meet network adequacy standards assessed, as in 2015, on a “reasonable access” standard. Insurers must submit detailed network provider data, including information on physicians, facilities, and pharmacies…A QHP insurer must publish a current, accurate, and complete provider directory including information regarding providers accepting new patients, the provider’s location, contact information, specialty, medical group, and any institutional affiliations.

In addition to ensuring that patients have up-to-date information on which providers are covered by their network, CMS is also mandating that QHPs cover some of the key providers in an area.

For 2016 as for 2015, QHP insurers must contract with at least 30 percent of available essential community providers (ECPs) in their service area, offer contracts in good faith to all available Indian health providers, and offer a contract in good faith to at least one ECP in each ECP category.

CMS will also monitor whether plans are attempting to restrict access to prescription drugs.

Drug formularies will also be monitored more closely for 2016. CMS will review formularies to identify outlier plans with unusually large numbers of drugs subject to prior authorization or step therapy. It will also review formularies to ensure access to clinically appropriate drugs for treatment of bipolar disorder, diabetes, rheumatoid arthritis, and schizophrenia. Other conditions, including HIV, may be considered for future reviews.

It is unclear whether the CMS initiatives will increase quality of care and access to care for patients; it is equally unclear whether these initiatives will drive up plan premiums. We’ll have to wait and see what happens.

Do Weight Loss Wellness Programs work?

Written By: Jason Shafrin - Feb• 22•15

In short, ‘no’.  At least that is the conclusion reached by a recent AJMC paper that looks at the evidence available for employer-sponsored wellness programs.  The authors write:

American corporations continue to expand wellness programs, which now reach an estimated 90% of workers in large organizations, yet no study has demonstrated that the main focus of these programs—weight control—has any positive effect. There is no published evidence that large-scale corporate attempts to control employee body weight through financial incentives and penalties have generated savings from long-term weight loss, or a reduction in inpatient admissions associated with obesity or even long-term weight loss itself. Other evidence contradicts the hypothesis that population obesity rates meaningfully retard economic growth or manufacturing productivity. Quite the contrary, overscreening and crash dieting can impact employee morale and even harm employee health. Therefore, the authors believe that corporations should disband or significantly reconfigure weight-oriented wellness programs, and that the Affordable Care Act should be amended to require such programs to conform to accepted guidelines for harm avoidance.

HT: Incidental Economist.

Friday Links

Written By: Jason Shafrin - Feb• 20•15

Coordinating Federal Efforts for Patients with Serious Mental Illness

Written By: Jason Shafrin - Feb• 18•15

Following up a December 2014 Government Accountability Office (GAO) report, testimony last week Linda T. Kohn, Director of Health Care at the GAO describes how fragmented the federal government provides very fragmented support services care for individuals with serious mental illness.  Coordinate across agencies is lacking and few agencies have conducted evaluations of their programs.

Agencies identified 112 federal programs that generally supported individuals with serious mental illness in fiscal year 2013. The majority of these programs addressed broad issues, such as individuals suffering from homelessness, which can include individuals with serious mental illness. The programs were spread across eight federal agencies: DOD, DOJ, DOL, Education, HHS, HUD, SSA, and VA….
Interagency coordination for programs supporting individuals with serious mental illness is lacking. HHS [the Department of Health and Human Services] is charged with leading the federal government’s public health efforts related to mental health, and SAMHSA [Substance Abuse and Mental Health Services Administration]  is required to promote coordination of programs relating to mental illness throughout the federal government…
Agencies completed few evaluations of the programs specifically targeting individuals with serious mental illness. As of September 2014, of the 30 programs specifically targeting individuals with serious mental illness, 9 programs had a completed program evaluation—7 by SAMHSA and 2 by DOD.

Ms. Kohn concludes with the following.

In conclusion, individuals with serious mental illness can face significant challenges getting the services they need. The public health, social, and economic impact of serious mental illness, coupled with the constrained fiscal environment of recent years, highlights the need to ensure that federal programs efficiently and effectively use their resources to support
the complex needs of individuals with serious mental illness

Below you can see a the types of SMI programs by agency.

Regional Growth in Medicare Spending, 1992–2010

Written By: Jason Shafrin - Feb• 17•15

Below is an abstract from a paper I co-wrote with Camille Chicklis, Thomas MaCurdy, Jay Bhattacharya, and Dan Rodgers.  The title of the paper is Regional Growth in Medicare Spending, 1992–2010.
Objective: To determine if regions with high Medicare expenditures in a given setting remain high cost over time.

Data Sources/Study Setting: One hundred percent of national Medicare Parts A and B fee-for-service beneficiary claims data and enrollment for 1992–2010.

Study Design: Patients are classified into regions. Claims are price-standardized. Risk adjustment is performed at the beneficiary level using the CMS Hierarchical Condition Categories model. Correlation analyses are conducted.

Data Collection/Extraction Methods: The data were obtained through a contract with CMS for a study performed for the Institute of Medicine.

Principal Findings: High-cost regions in 1992 are likely to remain high cost in 2010. Stability in regional spending is highest in the home health, inpatient hospital, and outpatient hospital settings over this time period. Despite the persistence of a region’s relative spending over time, a region’s spending levels in all settings except home health tend to regress toward the mean.

ConclusionsRelatively high-cost regions tend to remain so over long periods of time, even after controlling for patient health status and geographic price variation, suggesting that the observed effect reflects real differences in practice patterns.


The Republican Response to Obamacare

Written By: Jason Shafrin - Feb• 17•15

For years, Republicans have campaigned to repeal Obamacare. The biggest question in their campaign is what to replace it with. One year ago, Republicans unveiled the Patient Choice, Affordability, Responsibility, and Empowerment Act (Patient CARE).  Now, the Republicans have a new plan.   What’s in the new plan?  The Healthcare Economist reviews the highlights.

  • No lifetime limits. “…insurance companies would be prohibited from imposing lifetime limits on a consumer”
  • Less restrictive community rating. “Under Obamacare, insurance companies are banned from charging older Americans more than three times what they charge younger individuals…Our proposal would repeal this costly mandate and…adopt an age rating ratio that limits the amount an older individual will pay to no more than five times what a younger individual pays in premium dollars (5 to 1) as a federal baseline…after the adoption of our proposal, any state could adopt age and family rating rules that are more or less restrictive than the federal standard.”
  • Dependent coverage to 26.  Like Obamacare, the Republican plan would allow adult dependents to stay on their parents insurance until age 26, but it would also allow states to opt out of this provisions if they should so choose.
  • Guaranteed renewability.  Insurance companies will not be allowed to cancel insurance coverage except in the case of fraud.
  • End of the individual mandate.  The individual mandate would be repealed, but…
  • “Continuous Coverage” protections. “Under this new protection, individuals moving from one health plan to another—regardless of whether it was in the individual, small group, or large employer markets—could not be medically unwritten and denied a plan based on a preexisting condition if they were continuously enrolled in a health plan.”  Although the individual mandate would be repealed, individuals would have an incentive to retain coverage because only by being continuously enrolled in health insurance could a person ensure they are not disqualified from the continuous coverage provision. “Insurers would be required to offer coverage at standard rates based on age and residence to individuals who have stayed continuously insured with at least catastrophic coverage for a period of at least 18 months, without a significant break in coverage, similar to the HIPAA protections that exist under some circumstances today. So long as an individual, or family in the case of a family policy, has stayed continuously covered, they could not be forced to pay a higher premium solely because of a costly health condition when switching plans.”
  • Subsidies based on age and income.  Individuals would receive a subsidy to purchase health insurance.  This subsidy would depend on the individual’s age, household composition (e.g., single vs. family) and income.
  • High-risk pools.  The goal would be to use some federal funding to help states cover the highest risk patients.  This will drive down premiums for the general consumer, but states’ budgets will certainly take a hit unless federal funding is generous.
  • Medicaid reform.  Obamacare expanded access to Medicaid; this plan aims to reduce the number of Medicaid beneficiaries.  The proposal states that “individuals eligible for Medicaid would also be eligible for and have the choice to use the health tax credit to help purchase health coverage.For example, if a state chose to auto-enroll an eligible individual into Medicaid, that individual could retain the right to opt-out of Medicaid and use the health tax credit to purchase health coverage.”  The federal funding for this program would grow at inflation + 1%.  The proposal would also allow states to experiment with health opportunity accounts (HOA) that Medicaid beneficiaries could use to fund health care expenditures out of pocket.
  • Malpractice caps. The Republican proposal would place caps on non-economic damages and limitations on attorney’s fees.
  • Tax deductability of health insurance.  The Republican proposal “…caps the tax exclusion for employee’s health coverage at $12,000 for an individual and $30,000 for a family.”  This is similar to Obamacare’s “Cadillac tax”, except the thresholds are even higher.