Archive for the ‘health care’ Category

It’s The Zip Code, Stupid!

Monday, February 26th, 2018

“Sixty-percent of life expectancy, which has gone down two years in a row, is determined by where you live, 30% by your genetic code and 10% by the clinical care you get. Zip code matters more than genetic code.”

That was the sobering message delivered by AETNA CEO Mark Bertolini during an interview on CBS this morning. And he’s right. A May 2017 study from JAMA Internal Medicine concluded that geography is the biggest X-Factor in today’s American Hellzapoppin version of health care. The study analyzed every US county using data from deidentified death records from the National Center for Health Statistics (NCHS), and population counts from the US Census Bureau, NCHS, and the Human Mortality Databas and found striking differences in life expectancy. The gap between counties from lowest to highest life expectancy at birth was 20.1 years.

And, surpirse, surprise, it turns out if you live in a wealthy county with excellent access to high level health care, like Summit County, Colorado (life expectancy: 86.83), you’re likely to live about 15 years longer than if you live, say, in Humphries County, Mississippi, where life expectancy at birth is 71.9 years.  So, yes, Zip Code matters. According to the study:

In this population-based analysis, inequalities in life expectancy among counties are large and growing, and much of the variation in life expectancy can be explained by differences in socioeconomic and race/ethnicity factors, behavioral and metabolic risk factors, and health care factors.

On the whole, though, US life expectancy at birth increased by 5.3 years for both men and women — from 73.8 years to 79.1 years — between 1980 and 2014. But the county-by-county magnitude of the increase was determined by where one lives. That is, wealthy counties showed significantly greater increases in life expectancy than poor counties.

What is even more alarming is that some counties have experienced declines in life expectancy since 1980.

The JAMA study is another view from a different angle of inequality in America. According to Bertolini, CVS’s pending acquisition of AETNA, the third largest health insurer in the nation, will be a positive step in leveling the health care field when fully rolled out. He believes CVS’s 10,000 stores will evolve into much more than the Minute Clinics a lot of them are now. Time will tell, but CVS may be on to something here. In an op-ed in today’s New York Times, Ezekiel Emanuel pointed out that since 1981:

The population has increased by 40 percent, but hospitalizations have decreased by more than 10 percent. There is now a lower rate of hospitalizations than in 1946. As a result, the number of hospitals has declined to 5,534 this year from 6,933 in 1981.

People are apparently trying their mightiest to get health care anywhere except a hospital. According to Ezekiel, hospitals now seem less therapeutic; more life-threatening. Also, and this is where CVS is heading, complex care can now be provided somewhere else.

Another red flag from Mark Bertolini’s CBS interview was his reference to life expectancy dropping two years in a row. He’s right about that, too. In 2015 and 2016, life expectancy declined by a statistically significant 0.2 and 0.1 years, respectively.¹ Until now, life expectancy in America hadn’t declined since 1993.

All this is happening while our modern-day Tower of Babel – the US government – remains unwilling, unable, or both, to do anything constructive to improve the situation. Our more than 30-year health care train wreck needs serious attention, not partisan bloviation. To paraphrase Winston Churchill, ” That is a situation up with which we must no longer put.”

The men and women of Humphries County deserve nothing less.

 

¹ 2015’s drop was originally put at 0.1 year by the CDC, but was revised to 0.2 years after Medicare data were re-evaluated.

Going for the gold: An Olympic edition of Health Wonk Review

Friday, February 16th, 2018

Steve Anderson has posted the Health Wonk Review for February 15, 2018: Going for the Gold Edition at HealthInsurance.org blog. It’s an entertaining and wide-ranging smorgasbord of health policy topics of the day.

Here are a few of the topics d’jour:

  • Amazon/Bershire Hathaway/PMorgan’s foray into healthcare
  • Unexpected ER bills
  • CMS attack on freedom of the press
  • Predictions about Alex Azar, newly appointed HHS Secretary
  • The ACA
  • Peruvian healthcare
  • A different kind of hospital coverage
  • A recap of Health Action 2018, Families USA’s annual meet for healthcare activists.

If you aren’t familiar with healthinsurance.org, you should be. Check out the impressive roster of contributing authors and the excellent state health guides.

And just a heads up: In 2018, Health Wonks are on a once-per month schedule so catch this issue – you won’t have a chance for more wonkery until March.

Who’d A Thunk It? Something Good Out Of DC!

Monday, February 12th, 2018

Watching our legislators doing their thing in the nation’s capital, one can be forgiven for thinking Vlad the Impaler could learn a thing or two from these folks. But last Friday, in a rare Washington Kumbaya moment, peace broke out and the Bipartisan Budget Act zipped into law with the speed of an Olympic skater, Rand Paul notwithstanding.

The newly minted budget act has pork for everyone, but the pork I like is one little section that won’t get much press coverage, because it benefits poor people who are aging and sick: America’s Dual Eligibles. Duals are those among us who, by virtue of their age, health status and poverty are eligible for both Medicare and Medicaid benefits. The new budget act permanently re-authorizes Special Needs Plans aimed at caring for Duals.

Under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) [Pub. L. 108-173), Congress created a new type of Medicare Advantage coordinated care plan focused on individuals with special needs. “Special needs individuals” were identified by Congress as: 1) institutionalized beneficiaries; 2) dually eligible; and/or 3) beneficiaries with severe or disabling chronic conditions. The MMA allowed for the creation of “Special Needs Plans” for these populations. For example, to accommodate the new legislation, my state, Massachusetts, created the Senior Care Option health plan, which “covers all of the services normally paid for through Medicare and MassHealth (Medicaid).”

Medicare, because of the aging of the Baby Boomers, and Medicaid, because of increasing poverty and state expansion through the Affordable Care Act, have grown significantly since 2010, making Special Needs Plans more and more important. Trouble was, Congress had to re-authorize the plans every few years. That concern is now in the past. The Bipartisan Budget Act, with its permanent re-authorization of Special Needs plans makes sure the safety net created by the plans is solid, secure and long-lasting.

The new budget act also re-authorizes the Children’s Health Insurance Plan (CHIP) for another ten years, something that has long had bipartisan support.

Finally, this Congress has done something that will benefit our most vulnerable citizens. Let’s hope it’s not a one-off.

Happy holiday Health Wonk Review

Thursday, December 14th, 2017

Santa reading Health Wonk Review

First, let us go on record for saying that there is no sly political motive to our use of the term “holiday” in the title of this post. Admittedly, we have a bit of a liberal slant, but we have no aversion to using the phrase “Merry Christmas.” But ho, ho, ho, we do have an inordinate fondness for alliteration. Of course, we might have called it the Happy Hanukkah Health Wonk Review instead, but we wanted to encompass Hanukkah, Christmas, Kwanza, New Year’s, and even the dubious Festivus. Whatever your flavor or inclination, we wish you a merry, happy, joyful one. Pentatonix says it better than we ever could, so a bit of a seasonal interlude before we get to this week’s entries.

The Happy Holiday Health Wonk Review

*** First up, at Managed Care Matters, Joe Paduda is never one to shy away from calling it as he sees it and this week his submission takes on the GOP tax bill, which he describes as “a mess, riddled with math errors, contradictory language, and un-implementable directives.” Congressional leaders say they have reached some agreement and will vote before the end of the year, so Joe’s post will give context.

*** Roy Poses proves once again that the devil is in the details and he consistently makes it his blogging business to dig through the details to hold feet to the fire. At Heath Care Renewal, he tracks down more about a barely-reported Pfizer settlement for “alleged” anti-competitive behavior that nearly slipped through the radar. He says that the lack of negative consequences suggests that the impunity of top health care leaders is is worsening. Check out his post One Barely Noticed Settlement by Pfizer Suggests the Futility of Polite Protests about Health Policy.

*** How will the CVS purchase of Aetna affect the healthcare landscape? Jason Shafrin aka The Healthcare Economist weighs in with his informed observations.  And another of our regular wonks weighs in on the merger. David Williams of Health Business Blog posts CVS + Aetna. Are we sure this adds up? Despite talksthat this combo will lead to a revolution in care delivery, he remains a skeptic and talks about why.

*** Acknowledging that the individual market for health insurance has become unaffordable for many of the unsubsidized — particularly older would-be enrollees — Andrew Sprung outlines various ways to keep Modified Adjusted Gross Income (MAGI) below the subsidy line. Check out his post Steering clear of the subsidy cliff in the ACA marketplace at xpostfactoid.

***  Vincent Grippi of CareCentrix submitted a fun #CareTalk video podcast, featuring HWR regular David Williams teaming with John Driscoll of CareCentrix. In a point-counterpoint format, they spar about the implications of 2017 elections on healthcare (think Maine), move on to value-based healthcare and they close the 10 minute segment with a lightning round.

*** Brad Flansbaum of The Hospital Leader has an interesting post about Locums vs F/T Hospitalists, posing the question, do temps stack up? He reports on a JAMA study, adding his perspective. Now I must confess that the term “locums” was a new to me, but Brad gives it good context. But if you are curious to the origins, as I was, Wikipedia is your friend.

*** In his post The Positive Side of Sharing, InsureBlog’s Henry Stern has the latest on a reader’s experience with a Health Care Sharing Ministry. (He offers this spoiler alert: it’s actually been pretty good).

*** Shopping for individual health insurance or know someone who is? If your state uses HealthCare.gov, you have until December 15 to enroll, but in other states, you may be able to enroll as late as January 31. Victims of Hurricanes Irma and Harvey may also have extensions. Louise Norris has all the details in her  guide to buying individual health insurance at healthinsurance.org. For more, see Timothy Jost’s post on Health Affairs Blog: Open Enrollment Ends Friday—Except For Those Qualifying For Special Enrollment Periods.

*** For our post, we’re delving into our archives for an expose of a mysterious employer. Many have nothing but good to say about him, but others think he is not a good employer. Judge for yourself:

Santa’s workshop: “OSHA problems galore” say whistleblowers
The risks of being Santa
Is Santa Claus a bad employer?

 

Health Wonk Review’s “Pink Edition”

Thursday, October 12th, 2017

InsureBlog’s Hank Stern has posted the latest edition, the “Pink Edition,” of Health Wonk Review.

Why the “Pink Edition?” Because October is National Breast Cancer Awareness Month, and Hank and his team, Love, Hope and Faith, are doing their best to raise money to help eradicate this terrible disease. They’re participating in a walk to do just that on October 21, and Hank would love some help from the HWR community. Something to think about.

So, after making a donation to Hank’s worthwhile cause, we hope you’ll grab a cup of whatever suits you best, put your feet up and once again revel in all things health wonkery.

This Cat Is Dead. Let It Stay That Way.

Friday, September 22nd, 2017

“Seriously. This is BANANAS” – Senator Chris Murphy, (D-CT), on Graham-Cassidy.

When I was in college I was part of a pretty successful folk group. We played all over, cut a few LPs. It was a great time. On college campuses we would sing a simple, little, nearly childish song that somehow actually became a bit of a hit. It was called The Cat Came Back.

Oh, the cat came back.
She didn’t want to stay.
She was sittin’ on the back porch
The very next day.

Well, there’s a new cat sittin’ on the porch, and it’s called Graham-Cassidy.

Every time we stick a fork in it and call it dead, a new zombie repeal and replace Obamacare horrendoma springs to life.

The selling point of this one, at least according to Senators Graham and Cassidy (and Vice President Pence yesterday morning on CBS), seems to be centered on the idea that passage of this bill will finally allow the states to plot their own health care futures.

That was also the position argued yesterday in a New York Times Op-Ed by Philip Klein, the Managing Editor of the Washington Examiner (Is this a coordinated effort?). In Graham Cassidy has One Great Idea Klein claims the different states have different healthcare needs and, consequently, should be able to address those needs through their own creativity rather than arbitrary requirements of  Washington.

A more flexible system would give states latitude to pursue healthcare programs that are a better fit for their populations’ ideological sensibilities. And there are practical reasons to think of healthcare as a state-based issue: Every one has its own demographics, health challenges and other unique characteristics.

“Ideological sensibilities?” Excuse me? Oh, well.

One thing that strikes me square in the jaw about the states rights argument is this: For the last 26 years, states have been able, with federal waiver approval, to craft their own Medicaid programs as long as the results are revenue neutral and comply with minimum requirements.

By way of explanation, Medicaid has been with us since 30 July 1965 when President Johnson signed it and Medicare into law. Medicaid has been a lifeline for the poor who, prior to the Affordable Care Act, were mostly uninsured for health care. The ER was their primary care physician. The Act had a number of goals, one of which was to lower the number of uninsured and underinsured Americans. Since these people were nearly all of the lower income variety, the Act provided federal funding for states to expand Medicaid. Thirty-one states plus the District of Columbia did that. And the numbers of uninsured dropped significantly in those states.

In 1991, the Social Security Act was amended to create federal waiver programs. States were given the authority, through what are known as Section 1115 waivers, to tailor their own Medicaid programs to their own population needs. As of September 2017, there are 33 states with 41 approved waivers and 18 states with 21 pending waivers. A subset of state waivers are aimed at healthcare delivery system reforms. They are known by the catchy title Delivery System Reform Incentive Payment waiversDSRIP waivers allow states to create innovative programs that reform how care is delivered and paid for. These are demonstration projects and come with federal funding. Lots of it. For example, one of Texas’s two DSRIP waivers, just concluded, provided $11.5 billion over five years. The Texas Health and Human Services Commission has applied for an extension and in May, 2017, submitted to the CMS its positive evaluation of the program’s results (Despite this deep drink at the federal trough, you might remember Texas’s very public, Alamo-like  rejection of federal money to expand Medicaid).

Personally, I think there are many reasons to bury the Graham-Cassidy cat so deep it never sees the sun again. Others have written and catalogued them (see America’s newest health care expert Jimmy Kimmel). But not much has been said to refute this ridiculous let-the-states-have-a-chance claim. The states already have, and have had for 26 years, autonomy to innovate and create programs, with the help of federal funding, that zero in on the needs of their particular populations within sensible federal limits. Graham-Cassidy would do away with those limits, significantly lower funding, force millions of our fellow citizens to become uninsured (again), drop the states down a deep well of chaos and put us all back in the wild west of health care.

Yesterday, in a highly unusual move, the Board of Directors of the National Association of Medicaid Directors (NAMD) issued a statement highly critical of Graham-Cassidy, saying it would place a massive burden on the states.

“Taken together, the per-capita caps and the envisioned block grants would constitute the largest intergovernmental transfer of financial risk from the federal government to the states in our country’s history.”

And last night, after learning of NAMD’s statement, Senator Chris Murphy (D-CT) tweeted, “You can’t get ALL 50 state Medicaid Directors to agree on anything else in health care. Seriously. This is BANANAS.”

America’s health care system is complicated (“Nobody knew healthcare could be so complicated!”) and full of inside baseball stuff. But it does allow states to chart their own destinies. So, here’s a question for Lindsay, Bill and Mike: What’s the real reason you’re trying so hard to resurrect this dead cat?

 

 

Reactions To “Pharma’s Nine Words”

Monday, May 15th, 2017

We received a lot of thoughtful feedback to last week’s post on drug company Direct To Consumer (DTC) television advertising. I thought I’d share a couple that are representative of the whole.

This from a doctor in Florida:

You have acutely illustrated the challenge that allopathic physicians now battle with every day. In short, big Pharma has found a way to circumnavigate the drug salesperson and physician and go directly to the end consumer
Every physician feels significant pressure to satisfy their patients even when the request for certain pharmaceuticals is unreasonable; if the patient walks out of your office empty-handed chances are they won’t come back, so at the very least most patients have some prescription in hand upon their exit.

And this from a C-Suite Chief of Marketing:

I must confess upfront that I was one of those “DTC advertisers” in the early 2000s, having worked with Eli Lilly, Boehringer Ingelheim and Pfizer to name a few former clients.

Over the years I’ve read conflicting studies on DTC’s effectiveness and impact.  This said, there is typically a relationship between the largest category spender and market share.

You may also be interested in a dated survey from the FDA on the subject.  While there are definitely some “pro’s” associated with these efforts, including but not limited to patient empowerment (more prepared for doctor’s appointment, asking thoughtful questions, generally being more involved in one’s health, and better conversations about one’s condition and possible treatments). But there are also some “con’s,” including but not limited to:  overpromises/over statements of a drug’s potential benefits (and a corresponding downplay of possible side effects); pressure on physician’s part to prescribe a patient-requested drug, among others.  (But let’s not forget that there were physicians who were also in pharma’s pockets long before DTC, prescribing certain drugs based on lucrative relationships with companies.  Certainly not all of them… but unfortunately there were – and likely still are – some “bad apples.”)

It will be interesting to see how this debate evolves as baby boomers age.  Let’s hope that the patient is the ultimate winner here!

We can all agree with that last bit about hoping the “patient is the ultimate winner.”

We welcome responsible, thoughtful comments from our readers.

 

 

Pharma’s Nine Words

Thursday, May 11th, 2017

Any idea what the nine most frequently spoken words on US television are? How about:

My doctor said…

Tell your doctor…

Ask your doctor…

These words come at the beginning, “My doctor said,” the middle, “Tell your doctor,” and the end, “Ask your doctor,” of Direct To Consumer (DTC) television advertising with which Big Pharma bombards Americans every day. This is especially true during the morning network shows between 7:00 and 9:00 AM, the evening news hours and the occasionally funny prime time sitcoms that follow. The ads also feature a swell story with great looking actors and sweet music that plays as someone doing a voiceover tells us all about the 25, or so, ways the drug being pushed can kill us.

DTC ads come in many forms, but in 2015  69% of them were television ads with about a third of those coming from Pfizer. These ads have been allowed since the mid-1980s, but gained momentum in 1997 when the FDA relaxed the rules regarding television. Since then, it’s been Katy bar the door.

According to Pharmacy and Therapeutics (P&T), a peer reviewed journal for managed care and hospital formulary management:

The average American television viewer watches as many as nine drug ads a day, totaling 16 hours per year, which far exceeds the amount of time the average individual spends with a primary care physician.5,23,27

Since beginning the recovery from the Great Recession, television DTC has seen staggering growth:

 

 

According to Kantar Media, 72% of the commercial breaks in the CBS Evening News now have at least one pharmaceutical ad in them. These ads have a specific demographic target: Baby Boomers. Until 2012, they were mainly aimed at conditions such as dry eyes, erectile dysfunction, smoking cessation, chronic pain, constipation, heartburn, allergies and cholesterol. But in the last five years, they’ve made a deep dive into cancer, rheumatoid arthritis, and other illnesses to seniors. And, a reflection of our time, Opioid Induced Constipation hit the field during the 2015 Super Bowl. I can still hear the collective national gasp from that one.

Kantar Media reports Pharma spent $6.4 billion on DTC in 2016, with television garnering more than two-thirds of the spend. Since 2012, television spending is up 62%. During that time, the number of drug companies annually spending more than $50 million and the number spending more than $100 million has doubled. For example, last year, makers of Viagra and Cialis spent a combined $306 million convincing older (and increasingly younger) men that without those magic little pills their once prodigious sexual prowess, rapidly approaching Wooly Mammoth-like extinction, will never rise again, literally (but watch out for that 4-hour thing).

And when a new drug hits the market, first year spending can be breathtaking. Consider Opdivo, which debuted in 2015. The drug treats a certain kind of end-stage lung cancer (non-small cell lung cancer), which has a US patient population of less than 200,000. Yet Bristol-Myers Squibb, Opdivo’s maker, spent $93 million marketing it in its first year.

All this money begs an obvious question: Does it work? Well, even Pharma’s not sure, saying ROI is only one measure of a brand’s marketing success. Who is sure? The American Medical Association, which, in 2015, saying it was a colossal waste of money, called for an “outright ban” on Direct To Consumer advertising. The AMA also said doctors felt pressured by vulnerable patients who were looking for relief from one thing or another and that older drugs often work just as well, or even better, than the newer high-priced brands. Of course, it is preposterous to think we’ll ever return to to good old days of the 1980s before DTC advertising became more than a gleam in a marketer’s eye. The drug lobby is nearly omnipotent and there is the  little matter of commercial free speech. Moreover, drug makers claim they are providing valuable information with which consumers can make informed choices. Yet, according to the World Health Organization, “DTC is used to drive choice, not to inform it.”

America is one of only two countries in the world that allow Direct To Consumer drug advertising, the other being New Zealand, a country with a population of less than 4 million. The medical community doesn’t like it there, either.

Pharma has long had a wish to bring DTC to the European Union. That’s not going to be happening, however, as last year 22 of the 27 members rejected the idea.

The P&T white paper, mentioned above is presents an excellent analysis of DTC advertising, and ProCon.org has a nifty for-and-against page regarding DTC advertising. They’re both worth a look.

Who Knew? Medical Marijuana Works (at least for chronic pain)

Thursday, March 2nd, 2017

Dean Hashimoto, MD, JD, is a highly-respected researcher and teacher, practicing at Massachusetts’s Partners Health Care (think Harvard and Massachusetts General Hospital) and teaching at Boston College Law School. Today, at WCRI’s Annual Conference, his topic was Medical Marijuana and Workers’ Compensation: Recent Scientific, Legal and Policy Developments.

He led off with the results of a January,2017, scientific report from the National Academies of Sciences, Engineering and Medicine (NAS). The NAS report is a comprehensive, in-depth review of existing evidence regarding the health effects and potentially therapeutic uses of Medical Marijuana (cannabis). The report arrived at nearly 100 research conclusions categorized by the weight of evidence (conclusive, substantial, moderate, limited, no or insufficient).

One of the report’s conclusions that had “conclusive and substantial support” was this: Medical Marijuana is proven to improve chronic pain in adults. There is “moderate” support for the conclusion that Medical Marijuana improves short-term sleep outcomes for both fibromyalgia and chronic pain.

Of course, there are downsides. The report also concludes (DUH!) that Medical Marijuana carries with it an increased risk of motor vehicle crashes. Also, however, there was conclusive, substantial support that taking Medical Marijuana can lead to the development of schizophrenia and other psychoses. Yikes!

The NAS report also investigated whether there was an association between cannabis and occupational injury. The conclusion? There was no conclusion, because the available studies do not permit one to be made with any degree of certainty.

The bottom line? Medical Marijuana presents a potentially therapeutic benefit in the treatment of chronic pain.

Well, that’s not really the bottom line. No, because the larger issue is this: Medical Marijuana is being used in a number of states. Today, along with Dr. Hashimoto, we also heard compelling stories from Paul Sighinolfi, of Maine’s Workers’ Compensation Board, and Paul Tauiello, of the Colorado Division of Workers’ Compensation, describing the successful medical use of cannabis which is generating momentum in both states toward the therapeutic use of cannabis. The trouble is the usage of Marijuana in any form is federally illegal in every state. Seems there is a collision coming, and it may not be pretty.

WCRI – Day One, Session One

Thursday, March 2nd, 2017

Here we are in Boston again for yet another year of swimming the Australian Crawl through the mother of all data dumps from the Workers’ Compensation Research Institute’s annual conference.

WCRI’s first year President, John Ruser, led off the day with a sneak peak at the Institute’s new website, which seems clean and easy to navigate.

Then the fun began. Former Oklahoma Senator Tom Coburn, who happens to be a medical doctor and a Republican, and former Representative Henry Waxman, a California Democrat, looked into their crystal balls to discuss the future, of lack of it, of the Affordable Care Act.

Not surprisingly, the two former legislators had differing opinions, and I’ll bet you can bet what they were.

Coburn opined that we no longer have three equal branches of government, because the congress has ceded its authority to the Executive branch. Waxman bemoaned the lack of bi-partisanship.

John Ruser asked each about “repeal and replace,” opening a ballroom size can of worms. If you’ve been watching Sunday morning television, you know how that went. Predictably, Waxman, the Democrat, and Coburn, the Republican, argued from opposite ends of the spectrum. Each of these intelligent and seemingly reasonable people sincerely believe their position is the right one.

One thing they did agree about was whether the federal government would do anything about workers’ compensation. The answer: No.  That discussion morphed into social security disability, with Senator Coburn saying 27 million people are now on the rolls. This is not true. According to the Social Security Administration, less than 16 million people now receive social security disability benefits.

Coburn and Waxman, two rational people, are not going to agree on what to do about the Affordable Care Act. Not even close, and that is a shame.

Colleague Joe Paduda has an excellent summary of this session here.