Tag Archives: Health Policy

The State of Emergency: What the data tell us about emergency department use in California

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The State of Emergency

hospital emergency department entrance sign

The California Health Care Foundation recently published the latest edition in its wide-ranging Almanac series, California Emergency Departments: Use Grows as Coverage Expands. This timely publication is loaded with data that paint a detailed picture of broad trends in hospital emergency department (ED) care across the state. Recently, I talked about the Almanac’s findings with Kristof Stremikis, who directs CHCF’s Market Analysis and Insight team. Senior program officer Robbin Gaines produced the report as part of the team’s mission to promote greater transparency and accountability in California’s health care system. 

Q: California’s 334 hospital emergency departments provide a vital service to every part of the state. How are they faring?

A: The biggest takeaway from our Almanac is that California EDs are serving significantly more patients than they were just 10 years ago. When we control for population growth, the rate of ED use has grown 33% over the last decade, from 280 to 371 visits per 1,000 residents per year. Visits are up regardless of the type of insurance a patient has. Now, there’s a lot to unpack and understand about these figures, but when we think about the future, it’s important to realize that we are likely to continue to see increased demand for emergency services as the population ages. From a policy standpoint, we need to double down on efforts to ensure patients have access to the care they need in the most appropriate setting, be that an emergency department or somewhere else.

Q: What’s behind the increase in emergency department visits?

A: We don’t exactly know why more people are showing up in California emergency departments, but we do know ED use has been on the rise for at least 30 years. Across the nation, emergency departments have long been a major source of care across all categories of patients. We also know that regardless of source of coverage, California’s public and private payers are covering more visits per enrollee than they were a decade ago.

Sometimes ED use cannot be avoided. A few data points in our most recent Almanac suggest that a significant proportion of the rise in ED visits is due to clinically necessary visits. When we look at the acuity of ED visits, moderate and severe symptoms — including life-threatening ones — constituted all of the increase over the past decade. The number of visits with low or minor acuity fell. That is a big deal. This happened as the number of Californians with Medicare and Medi-Cal increased substantially during this period, and these programs cover a lot of older and sicker Californians who are more likely to need emergency care.

We also know that some of this rise is attributable to visits that could have been avoided. Precisely identifying what portion of visits are avoidable is difficult, and we do not include an estimate in our Almanac. But we know they are there — public and private payers in California have been working hard for years to identify and prevent unnecessary ED use.

Q: How big a problem are avoidable visits? And why would someone go to the ED if they don’t need to?

A: Available research does not point to a precise percentage of ED visits that could be avoided. The most conservative definition classifies as avoidable things like visits for low-acuity mental health and dental issues. Using that methodology, perhaps 3% of ED visits in California did not need to happen. But other estimates are much higher, sometimes exceeding 70% in the commercial market. What is clearer are the reasons why patients go to the ED over other options. Some people can’t take off work when doctors’ offices are normally open. Others have limited or negative perceptions of alternatives. Researchers have found that there is also an increasing number of patients who are referred to the ED by their physician.

Q: The number of ED departments has stayed flat during this period of growth. How are hospitals handling the additional visits?

A: The number of dedicated ED spaces for individual patients, or “treatment stations,” has increased almost 30% over the last decade. In 2016, the average treatment station handled 1,846 patients, or approximately five visits per day, up from 1,656 patient visits in 2006. Despite a 44% increase in total ED visits between 2006 and 2016, the number of visits by patients who left without being seen fell by almost 15%. That is remarkable.

Q: The data show a lot of regional variation in ED use. Are some regions or health plans better than others at addressing ED challenges?

A: ED use does vary widely, from a low of 311 visits per 1,000 residents in Orange County to a high of 516 in the Northern and Sierra region. Patient characteristics (such as age, race, and income), lack of alternatives, and physician referral patterns may all play a role in the relatively high rates of ED use in certain parts of the state. Among the promising strategies that can be deployed regionally are increasing access to primary care services in rural areas through telehealth, providing outreach and case management to frequent users, and addressing the needs of patients with behavioral health and substance use disorders.

Q: The Almanac shows an increase in the percentage of ED visits that are for Medi-Cal beneficiaries, due in large part to the expansion of eligibility for the program. What else would explain why the percentage from Medi-Cal went up?

A: Medi-Cal paid for a larger proportion of California’s ED visits in 2016 than in 2006 because it now covers many more Californians. When we control for the number of beneficiaries covered by various programs, a Medi-Cal member is less likely to end up in an emergency room than someone covered by Medicare, though more likely than someone with private insurance. Regardless of insurance type, the number of visits per enrollee is increasing.

Though we did not include the data in our Almanac, the state closely tracks ED use among Medi-Cal beneficiaries on its monthly managed care performance dashboards. Elderly and seriously disabled beneficiaries remain the most likely to visit the ED, at almost twice the rate of the next highest group, which is the Medi-Cal expansion population. Fortunately, the rate among the expansion population has decreased over the last several years, from about 70 visits per 1,000 member months in January 2014 to around 50 in June 2017. This may reflect managed care plan efforts to connect new patients with primary care “medical homes.”

When we look at the acuity of ED visits, moderate and severe symptoms — including life-threatening ones — constituted all of the increase over the past decade. The number of visits with low or minor acuity fell. That is a big deal.

Q: Critics of the Affordable Care Act (ACA) cite increasing ED visits, especially from people in the expansion population, as evidence that the law isn’t working in California. Is that a fair criticism?

A: Both critics and proponents of the ACA probably agree that the law is complicated — and complicated reforms need to be carefully unpacked and evaluated over long periods of time. One of the law’s major goals was to expand access to insurance coverage, and on this measure the law has made tremendous progress. As of 2016, only 7% of California residents lacked health insurance. Expanding Medi-Cal was the cornerstone of that success.

The relationship between ED use and health insurance coverage is complex, with studies showing both increases and decreases in use when people gain or lose coverage. What is much more clear is that the ACA did not create the problem of ED use — though it has led to decreases in bad debt and charity care reported by our state’s hospitals. What is needed now is further research into just how many of our state’s ED visits are avoidable and how to scale the best approaches to reducing avoidable ED use throughout California’s market.

Q: What’s being done to address avoidable ED use at a local level?

A: On the public side, the ongoing Whole Person Care pilot program in Medi-Cal is one example of where innovation is taking place on this issue — 17 of the 25 counties participating in the program have made it an explicit goal to reduce avoidable ED use. Just last week, 17 health systems, including several in California, announced a major initiative to reduce avoidable ED use among Medicaid beneficiaries. This is likely to include some combination of enhanced access to primary care, behavioral health care, and social services. On the private side, the issue of avoidable ED use has attracted the attention of California payers like Anthem, Blue Shield, and Kaiser Permanente for several years. These groups have also worked to increase access to primary care using medical homes that offer after-hours and weekend care.

Another approach involves targeting those patients who are frequent ED users. In California, one recent study suggested frequent users were less than 10% of the population but accounted for nearly one-third of the visits. Intensive case management, health coaching, and community support for high users are all promising interventions. Finally, specific case management programs for substance use disorder and mental health problems are being considered.

Q: A report like this Almanac is obviously limited by the data that is currently available. What additional data points would you like to have for future issues?

A: I think the most important metric to focus on is potentially avoidable use of the emergency departments rather than the overall number of visits. While the California data we report here certainly do capture the universe that includes avoidable use, it does not allow us to parse out the differences among the subsets. It is always helpful to have additional research to help identify this type of visit, the reasons why a patient decided to go to the ED, and the strategies that would be most effective at helping patients get their care in more appropriate settings.

 

 

Behind Rising Health-Care Bills: Secret Hospital Deals

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https://www.realclearhealth.com/2018/09/20/behind_rising_health-care_bills_secret_hospital_deals_278180.html?utm_source=morning-scan&utm_medium=email&utm_campaign=mailchimp-newsletter&utm_source=RC+Health+Morning+Scan&utm_campaign=82a1cdfd43-MAILCHIMP_RSS_EMAIL_CAMPAIGN&utm_medium=email&utm_term=0_b4baf6b587-82a1cdfd43-84752421

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Last year, Cigna Corp. and the New York hospital system Northwell Health discussed developing an insurance plan that would offer low-cost coverage by excluding some other health-care providers, according to people with knowledge of the matter. It never happened.

The problem was a separate contract between Cigna and New York-Presbyterian, the powerful hospital operator that is a Northwell rival. Cigna couldn’t find a way to work around restrictive language that blocked it from selling any plans that didn’t include New York-Presbyterian.

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Consolidation in California’s Health System Leads to Higher Prices and Premiums

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https://www.commonwealthfund.org/publications/journal-article/2018/sep/consolidation-california-health-system-higher-prices

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The Issue

Integration and consolidation among health care providers and health plans has the potential to improve the coordination and quality of patient care. However, when markets become highly concentrated — served by a single or a few large health care organizations — competition is curtailed and health care prices and insurance premiums tend to rise.

In a Commonwealth Fund–supported study in Health Affairs, researchers explored the effect of market consolidation across California between 2010 and 2016 on outpatient visit prices and premiums for individual coverage on the Covered California marketplace. The study focused on two measures of consolidation: the percentage of physicians in practices owned by hospitals and the total market share controlled by hospitals, health plans, and physician practices in a particular area.

What the Study Found

  • The number of physicians in hospital-owned practices increased from 25 percent to 40 percent across select California counties between 2010 and 2016.
  • Hospital employment increased more steeply among specialists than primary care physicians. Among the specialties studied (i.e., cardiology, hematology/oncology, orthopedics, and radiology), employment rose to 54 percent from 20 percent. In comparison, primary care physician employment increased to 38 percent from 26 percent.
  • Premiums for individual coverage rose the most, by 12 percent, in areas with both high consolidation among hospitals and a high percentage of hospital-owned physician practices.
  • Prices of specialty outpatient visits were 9 percent higher in areas with 100 percent hospital-physician employment compared to areas with average levels. Prices of primary care visits were 5 percent higher in areas with high versus average hospital-physician employment.
  • Seven counties were identified as “hot spots,” or markets with concerning levels of health care mergers and consolidation that could be limiting competition.

The Big Picture

The significant price increases in California markets with high hospital-physician employment and hospital consolidation point to the need for careful scrutiny of health care mergers and acquisitions. Additional research is needed to determine if the price increases are tied to improvements in patient care. For instance, if care is more expensive because it is more comprehensive, then overall utilization and spending should decrease. At the same time, regulatory laws and actions may be needed to prevent some health care organizations from attaining unfair market advantages that shut out rivals and raise prices.

The Bottom Line

In California, hospital acquisition of physician practices, particularly in markets with limited hospital competition, is associated with higher prices for outpatient visits and higher insurance premiums on the individual marketplace.

 

 

Congress Is Making Quiet Progress on Drug Costs

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https://www.commonwealthfund.org/blog/2018/congress-making-quiet-progress-drug-costs?omnicid=EALERT1477719&mid=henrykotula@yahoo.com

Progress on drug costs

While the Trump administration has taken small steps to implement its blueprint to lower prescription drug prices, Congress has recently made quiet progress on some policies that could help lower drug costs for patients.

First, both the Senate and House advanced legislation to ban “gag clauses” that prevent pharmacists from telling patients that they can save money on medications by paying for them out of pocket. Certain prescription benefit managers (PBMs) have used gag clauses as part of their formulary design. While this is not a widespread industry practice, a 2016 survey of community pharmacists found that nearly 60 percent had encountered a gag clause in the previous 10 months. Two bills (S. 2553 and H.R. 6733) would prohibit private Medicare plans from instituting gag clauses. A third, related bill (S. 2554) — passed by the Senate on Monday with overwhelming support — prohibits private health insurance plans from using them. While they enable pharmacists to advise patients on how to spend less at the pharmacy counter, these bans won’t necessarily lower the prices of drugs.

Second, a lesser-known provision of S. 2554, added by the Senate Committee on Health, Education, Labor and Pensions (HELP), could help lower drug prices by shedding light on patent-settlement agreements between drug manufacturers. Brand-name manufacturers sometimes use these agreements to extend their monopolies and keep drug prices higher by directly and indirectly compensating generic manufacturers for voluntarily delaying generics from coming to market. The Congressional Budget Office has found that setting a standard to rein in these types of settlements would produce $2.4 billion in savings over 10 years.

The HELP committee provision would require manufacturers of biologics (large-molecule drugs) and biosimilars (nearly identical copies of original biologics) to report patent-settlement agreements to the Federal Trade Commission (FTC) — an important step in understanding and preventing abuse of what is sometimes referred to as “pay for delay.”

Pay-for-Delay Stalls Drug Competition, Costing Patients Billions

In 2003, Congress required patent-settlement agreements between brand-name and generic small-molecule drug manufacturers to be filed with the FTC for review after they are made. (Currently most drugs sold are small-molecule drugs, but the biologics market is growing rapidly.) Such agreements effectively delay the sale of lower-cost generic drugs by nearly 17 months longer than agreements without payments, according to a 2010 report by the FTC. These anticompetitive agreements cost taxpayers approximately $3.5 billion each year.

In 2012, the U.S. Supreme Court decided in FTC v. Actavis that a brand-name drug manufacturer’s payment to a generic competitor to settle patent litigation can violate antitrust law. After the Court’s decision, the number of pay-for-delay agreements declined two years in a row. With drug companies now required to report these settlements to the FTC, the agency has been able to act to protect patients from anticompetitive deals that delay cheaper, generic drug products from coming to market. The FTC reviews reported settlements and, if it determines an agreement violates antitrust law, the agency challenges the agreement in the courts.

For example, in 2008 the FTC sued Cephalon, Inc., for paying four generic companies $300 million to delay marketing of their generic versions of Cephalon’s sleep-disorder drug, Provigil, until 2012. In 2015, the FTC reached a settlement with Cephalon’s owner, Teva Pharmaceutical Industries, Ltd., which agreed to ending pay-for-delay agreements for all their U.S. operations. The company also paid $1.2 billion in compensation for Cephalon’s anticompetitive behavior.

FTC Reporting Requirement Does Not Apply to Biologic and Biosimilar Manufacturers

The FTC reporting requirement applies only to small-molecule drugs, however, and not to far more expensive biologics and biosimilars. The potential savings of having biosimilars available for sale are significant: even one biosimilar competing against a brand-name biologic can result in a 35 percent lower price for patients and payers. Without delays in competition with brand-name biologics, biosimilars could save $54 billion to $250 billion over 10 years.

But there are concerns that manufacturers are entering into pay-for-delay agreements to keep prices for these drugs artificially high. Since 2015, when the biosimilar pathway was implemented, the FDA has approved 12 biosimilars, yet only three are currently available to patients — likely because of patent litigation and pay-for-delay agreements.

FTC Review Is Part of the Solution

In his remarks upon releasing the U.S. Food and Drug Administration’s Biosimilars Action Plan in July, FDA commissioner Scott Gottlieb noted the FTC’s key role in monitoring U.S. markets to protect consumers from anticompetitive behaviors, including those of prescription drug manufacturers. He also pointed out the patent litigation tactics manufacturers use to delay biosimilar competition.

As it does for the small-molecule drug market, the FTC can play a proactive role in monitoring what is happening in the biologic and biosimilar markets. At a workshop on drug pricing held last year, acting FTC chair Maureen Ohlhausen said that while her agency has been making progress in eliminating pay-for-delay agreements, it has not seen the last of them. She said they will remain a target. But to move forward, the FTC needs clearer authority to review patent settlements between biologic and biosimilar manufacturers.

With Senate passage of S. 2554 and its FTC reporting provision, Congress has taken an important step in encouraging a robust biosimilar market. (While the House has not passed a similar measure, the Senate bill could be added to a reconciliation of the House and Senate gag clause bills.) Engaging all the relevant market regulators — including the FTC, the U.S. Patent and Trademark Office, the Centers for Medicare and Medicaid Services, and the FDA — will inject needed competition into this nascent market and help lower drug prices for U.S. consumers.

 

How hospitals protect high prices

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https://www.axios.com/newsletters/axios-vitals-5af4f54b-8427-48c2-b638-933a1ae4883a.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Large hospital systems don’t command high prices just because patients like them, or just because they have strong market share. There’s also another big reason: their contracts with insurance companies actively prohibit the sort of competitive pressures a free market is supposed to support.

“The free market has been distorted in an unhealthy way,” health care consultant Stuart Piltch told the Wall Street Journal’s Anna Wilde Mathews for this deep dive into hospitals’ pricing practices.

How it works: Hospital systems are consolidating rapidly and buying up physicians’ practices (which charge higher prices once they’re part of a hospital).

On top of that, per WSJ: Hospitals’ deals with insurance companies “use an array of secret contract terms to protect their turf and block efforts to curb health-care costs.”

  • Some hospitals do not allow their prices to be posted on the comparison-shopping sites insurers provide to their customers.
  • They often require insurers to cover every facility or doctor the hospital owns, and prohibit insurers from offering incentives — like lower copays — for patients to use less expensive competitors.
  • When Walmart, the country’s biggest private employer, wanted to exclude the lowest-quality 5% of providers from its network, its insurers couldn’t do so because of their hospital contracts.

The other side: Hospital executives told the Journal that mergers don’t drive higher prices, and reiterated their position that hospitals have to collect higher payments from private insurance to make up for the lower rates they get from Medicare and Medicaid.

My thought bubble: High-deductible health plans are increasingly popular, in part, because of the idea that patients will use their purchasing power to drive a more efficient system overall.

  • But if Walmart doesn’t have enough market power to actually penalize low-quality providers, you and I definitely don’t, either — especially if we can’t find out what the prices are, and especially if we only have one hospital to choose from in the first place.

Go deeper: Think drug costs are bad? Try hospital prices

 

 

Can Paying for a Health Problem as a Whole, Not Piece by Piece, Save Medicare Money?

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Can Paying for a Health Problem as a Whole, Not Piece by Piece, Save Medicare Money?

Among the standard complaints about the American health care system is that care is expensive and wasteful. These two problems are related, and to address them, Medicare has new ways to pay for care.

Until recently, Medicare paid for each health care service and reimbursed each health care organization separately. It didn’t matter if tests were duplicated or if a more efficient way of delivering care was available — as long as doctors and organizations were paid for what they did, they just kept providing care the way they always had.

But ordinary people do not think this way. We focus on solving our health problem, not which — or how many — discrete health care services might address it. New Medicare programs are devised to more closely align how care is paid for with what we want that care to achieve.

One of these programs is known as bundled payments. Instead of paying separately for every health care service associated with a medical event, you pay (or Medicare pays, in this case) one price for the entire episode. If health care providers can address the problem for less, they keep the difference, or some of it. If they spend more, they lose money. Bundled payment programs vary, but some also include penalties for poor quality or bonuses for good quality.

Medicare has several bundled payment programs for hip and knee replacements — the most common type of Medicare procedures — and associated care that takes place within 90 days. This includes the operation itself, as well as follow-up rehabilitation (also known as post-acute care). In theory, if doctors and hospitals get one payment encompassing all this, they will better coordinate their efforts to limit waste and keep costs down.

Do bundled payments work? They certainly appear promising, at least for some treatments. But it’s important to conduct rigorous evaluations.

Previous studies for Medicare by the Lewin Group and other researchers suggest that Medicare’s Bundled Payments for Care Improvement program has reduced the amount Medicare pays for each hip and knee replacement.

But that doesn’t mean the program saved money over all.

One possible issue would be if, despite saving money per procedure, health care providers wastefully increased the number of procedures — replacing hips and knees that they might not otherwise. A related concern is if hospitals try to increase profits by nudging services toward patients who may not need a procedure as much as patients with more severe and more expensive conditions. An average joint replacement costs $26,000, split almost equally between the initial procedure and post-acute care. But more expensive cases can be $75,000 to $125,000 — a costly proposition for hospitals.

A recent study published in JAMA examined whether the volume of Medicare-financed hip and knee replacements changed in the markets served by hospitals that volunteered for a bundled payments program, relative to markets with no hospitals joining the program. It found no evidence that the bundled payment program increased hip and knee replacement volume, and it found almost no evidence that hospitals skewed their services toward patients whose procedures cost less.

“These results suggest bundled payments are a win-win,” said Ezekiel Emanuel, a co-author of the study. “They save payers like Medicare money and encourage hospitals and physicians to be more efficient in the delivery of care.”

But Robert Berenson, a fellow at the Urban Institute, urges some caution. “Studying one kind of procedure doesn’t tell you much about the rest of health care,” he said. “A lot of health care is not like knee and hip replacements.”

Michael Chernew, a Harvard health economist, agreed. “Bundles can certainly be a helpful tool in fostering greater efficiency in our health care system,” he said. “But the findings for hip and knee replacements may not generalize to other types of care.”

Christine Yee, a health economist with the Partnered Evidence-Based Policy Resource Center at the Boston Veterans Affairs Healthcare System, has studied Medicare’s previous efforts and summarized studies about them. (I and several others were also involved in compiling that summary.) “Medicare has tried bundled payments in one form or another for more than three decades,” Ms. Yee said. “They tend to save money, and when post-acute care is included in the bundle, use of those kinds of services often goes down.”

One limitation shared by all of these studies is that they are voluntary: No hospital is required to participate. Nor are they randomized into the new payment system (treatment) or business as usual (control). Therefore we can’t be certain that apparent savings are real. Maybe hospitals that joined the bundled payment programs are more efficient (or can more easily become so) than the ones that didn’t.

Another new study in JAMA examines a mandatory, randomized trial of bundled payments. On April 1, 2016, Medicare randomly assigned 75 markets to be subject to bundled payments for knee and hip replacements and 121 markets to business as usual. This policy experiment, known as the Comprehensive Care for Joint Replacement program, will continue for five years. The JAMA study analyzed just the first year of data.

“In this first look at the data, we examined post-acute care because it is an area where there is concern about overuse,” said Amy Finkelstein, an M.I.T. health economist and an author of the study. “In addition, prior work suggested that it’s a type of care that hospitals can often avoid.”

The study found that bundled payments reduced the use of post-acute care by about 3 percent, which is less than what prior studies found. “Those prior studies weren’t randomized trials, so some of the savings they estimate may really be due to which hospitals chose to participate in bundled payment programs,” Ms. Finkelstein said. Despite reduced post-acute care use, the study did not find savings to Medicare once the costs of paying out bonuses were factored in. The study also found no evidence of harm to health care quality, no increase in the volume of hip and knee replacements, and no change in the types of patients treated.

“Savings could emerge in later years because it may take time for hospitals to fully change their behavior, “ Ms. Finkelstein said. In addition, the program’s financial incentives will increase over time; bonuses for saving money and penalties for failing to do so will rise.

On the other hand, Dr. Berenson said, health care providers could figure out how to work the system: “In three to five years, we may see volume go up in a way that offsets savings through reduced payments for a procedure. We’ll wait and see.”

Medicare put its best foot forward by using a randomized design. Not only were the markets selected in a randomized fashion, but providers in those markets were also required to participate. Though common in medical studies, randomization is rare in health care policy, as is mandatory participation. Nearly 80 percent of medical studies are randomized trials, but less than 20 percent of studies testing health system change are. Organizations that would be subject to the experiments often strongly resist randomizing health system changes and forcing providers to participate.

Unfortunately, the randomization of the Comprehensive Care for Joint Replacement program will be partly compromised in coming years. The Centers for Medicare and Medicaid Services announced last year that hospitals in only half of markets under the program would have to stay in it. Participation is voluntary in the other half, and only one-quarter of hospitals opted in.

Going to a partly voluntary program will make it harder to learn about longer-term effects, Ms. Finkelstein said, and to get at the answers we’re seeking.

It’s Hard for Doctors to Unlearn Things. That’s Costly for All of Us.

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It’s Hard for Doctors to Unlearn Things. That’s Costly for All of Us.

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We know it can be hard to persuade physicians to do some things that have proven benefits, such as monitor blood pressure or keep patients on anticoagulants. But it might be even harder to get them to stop doing things.

In May, a systematic review in JAMA Pediatrics looked at the medical literature related to overuse in pediatric care published in 2016. The articles were ranked by the quality of methods; the magnitude of potential harm to patients from overuse; and the potential number of children that might be harmed.

In 2016 alone, studies were published that showed that we still recommend that children consume commercial rehydration drinks (like Pedialyte), which cost more, when their drink of choice would do. We give antidepressants to children too often. We induce deliveries too early, instead of waiting for labor to kick in naturally, which is associated with developmental issues in children born that way. We get X-rays of ankles looking for injuries we almost never find. And although there’s almost no evidence that hydrolyzed formulas do anything to prevent allergic or autoimmune disease, they’re still recommended in many guidelines.

Those researchers had reviewed the literature on overuse in children before, looking at all the studies from a year earlier. They modeled the work on a set of papers in JAMA Internal Medicine that looked at overuse in adults through a review of the literature published in 2015, 2014 and 2013.

Overuse is rampant. And it can harm patients.

By the end of the 20th century, for example, research seemed to indicate that we wanted to keep patients in the intensive care unit in a tight range of blood glucose levels. The evidence base for these recommendations came from observational studies that showed that patients with such tight control seemed less likely to develop adverse outcomes like infections or hyperglycemia, and they seemed more likely to survive.

Researchers tested this recommendation prospectively in a randomized controlled trial in a surgical intensive care unit. The results, published in 2001, appeared to confirm the prior findings, that tight glycemic control saved lives.

The study wasn’t perfect. It wasn’t blinded, for instance, and there were downsides to the recommendations. About 5 percent of those who received the intensive therapy had severe hypoglycemia at least once. The mortality in the control group was higher than what might be expected. Finally, this was a study of mostly post-cardiac surgery patients, and it wasn’t clear how widely the findings could be generalized.

Nevertheless, this was a huge benefit, and given the severity of the population being treated (intensive care patients are usually very, very ill), many experts called for changes in treatment while further research was done.

That larger work was published in 2009. The study randomly assigned more than 6,000 patients admitted to an intensive care unit for more than three days — to either tight or traditional glucose control. This time, there was a significantly higher rate of death in the tight control group (27.5 percent vs. 24.9 percent), as well as a much higher rate of severe hypoglycemia (6.8 percent vs. 0.5 percent). These findings applied to patients over all and to subgroups (like surgical versus medical patients).

In light of this, guidelines changed again. Physicians were asked to stop the widespread tight glycemic control.

In 2015, some enterprising researchers set out to look at how this knowledge changed physician behavior. Beginning in 2001, they looked at how physicians adopted the recommendations to use tight glycemic control in patients admitted to intensive care units. Starting in 2009, they looked at how physicians absorbed new information telling them to stop.

From 2001 through 2012, they analyzed data on more than 377,000 admissions to 113 intensive care units in 56 hospitals. Before the first trial was published, in 2001, 17 percent of admissions used tight glycemic control. Beginning in that year, however, there was a slow but steady increase in its use. About 1.7 percent more patients were being treated with recommended practice each quarter.

It’s hard to change behavior, but over time, physicians did. By 2009, the use of tight glycemic control had increased to about 23 percent. Many might have hoped for more, but at least there was progress.

Starting in 2009, however, the reverse was recommended. Doctors were asked to stop. Tight glycemic control was associated not only with higher mortality, but also with more adverse events.

That didn’t happen. From 2009 through 2012, there was no decrease in tight glycemic control. The authors argued that “there is an urgent need to understand and promote the de-adoption of ineffective clinical practices.”

That is, of course, an understatement.

Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation, is entirely focused on the identification of care that physicians routinely recommend but shouldn’t. Almost 600 different tests, procedures or treatments, collected over the last six years, are currently listed on their website. Almost all the recommendations basically say “don’t do” them.

This overuse doesn’t provide a benefit. It can lead to harms. It can also cost a lot of money.

The public shares some culpability. Americans often seem to prefer more care than less. But a lot of it still comes from physicians, and from our inability to stop when the evidence tells us to. Professional organizations and others that issue such guidelines also seem better at telling physicians about new practices than about abandoning old ones.

I asked Daniel Niven, the lead author of the 2015 study, why it’s so hard to persuade doctors to discontinue certain practices. He said physicians have a hard time unlearning what they have learned, even when there’s newer and better science available. He said, “Even if the new contradictory science is accepted, providers often struggle applying this information in their daily clinical practice, not because they don’t want to, but rather, because they work within a system that doesn’t adapt well to changing evidence.”

He also said doctors might need to be more thoughtful about prevention: “We need to take a more cautious approach to technology adoption, and learn from mistakes of early adoption of health care technologies based on little or low-quality clinical evidence. This way we can prevent the need to ‘break up’ with the practice when the high-quality evidence shows that it is ineffective.”

Overuse represents a significant problem. As policymakers look for ways to save money without harming quality in the health care system, reducing overuse seems as if it should be a top option.

 

Medicaid rolls set to be slashed under Trump-approved work rules

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Medicaid rolls set to be slashed under Trump-approved work rules

Image result for medicaid work requirements

The thousands of people who lost Medicaid coverage this month in Arkansas for not following newly implemented work requirements may be a sign of what’s to come in other GOP-led states.

Indiana and New Hampshire are slated to implement their Medicaid work requirements next year, and a slew of other states are awaiting approval from the Trump administration.

Arkansas has served as a test case of sorts since it was the first state to implement work requirements, and this month it became the first state to kick off beneficiaries for not following them.

The state removed more than 4,000 people from the Medicaid rolls, with some estimates saying that number could climb to 50,000 when the requirements are fully implemented in 2019.

“I think other states should be thinking seriously about the warnings that Arkansas’ experience has for their states,” said Erin Brantley, a senior research associate at George Washington University’s Milken Institute of Public Health.

While many people in Arkansas’ program are exempt from reporting their activities to the state because they’re already working, others are not, meaning they need to file monthly reports through an online portal to show they are meeting the requirements.

Of those who lost coverage this month, about 95 percent didn’t file the necessary documents with the state. That led to their removal from Medicaid, though some may have been working working the required 80 hours a month.

It’s unclear why those participants didn’t file reports, especially if they were working, though some say it could be due to confusion, an inability to access a computer or general unawareness about the new requirements.

The state said it conducted “extensive” outreach that included sending more than 136,000 letters and emails and making more than 150,000 phone calls from April through August.

“It seems that [the state] is doing some outreach, but a lot of individuals still don’t know about the new requirements and are not setting up their accounts,” said Robin Rudowitz, associate director of the Kaiser Family Foundation’s program for Medicaid and the uninsured.

“There are many lessons to be learned about online reporting, and communication, and having individuals understand what the requirements are,” Rudowitz said. “The changes to these programs are difficult to communicate.”

In a report published in the journal Health Affairs this month, the author conducted interviews with 18 Medicaid recipients in northeast Arkansas and found that a dozen had not heard about the state’s new requirements.

Seema Verma, head of the U.S. Center for Medicare and Medicaid Services, which is responsible for reviewing state requests for work requirements, characterized Arkansas’ recent removal of Medicaid recipients as a positive step.

“I’m excited by the partnerships that Arkansas has fostered to connect Medicaid beneficiaries to work and educational opportunities, and I look forward to our continued collaboration as we thoroughly evaluate the results of their innovative reforms,” Verma said in a tweet the same day that 4,000 recipients lost coverage.

The work requirements have prompted lawsuits in Kentucky and Arkansas by advocates who say they are harmful to those in need. The judge that blocked a similar program in Kentucky earlier this year will also preside over the Arkansas case.

The Trump administration says “able-bodied” adults on Medicaid should work if they’re able to. In all three states, the work requirements apply only to those who gained coverage through ObamaCare’s Medicaid expansion, which allowed for covering more low-income adults.

It’s unclear how the work requirements will impact beneficiaries in Indiana and New Hampshire when they are rolled out next year, but both states are planning to rescind coverage for those who don’t meet the new work rules.

Beneficiaries in Indiana will have to work at least eight months each year, and an 80-hour-a-month requirement will be gradually phased in over an 18-month period. Compliance with the requirements will be checked annually instead of monthly, like in Arkansas.

New Hampshire beneficiaries subject to the new requirements must work 100 hours a month beginning in January. Enrollees who don’t meet the threshold for one month will have their coverage suspended.

Some argue that the true purpose of Medicaid work requirements is to cut spending for the federal program, a priority of conservatives for years.

“This policy is clearly not designed to help people find work. It’s designed to take them off Medicaid,” said Joan Alker, executive director of the Center for Children and Families at the Georgetown University School of Public Policy, referring to the Arkansas policy.

“It’s nothing to do with promoting work, supporting work — it’s about creating red tape for folks who are not able to jump over these bureaucratic hurdles for one reason or another — no internet access, they may not know, may be homeless, may not get the letter,” she said. “Those are the ones that will lose coverage.”

 

 

The Health 202: The rate of people without health insurance is creeping upward

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https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/09/13/the-health-202-the-rate-of-people-without-health-insurance-is-creeping-upward/5b99569b1b326b47ec95958c/?utm_term=.ae9e8af79dd2

 

THE PROGNOSIS

New Census Bureau data on the number of uninsured Americans is either a testament to the resiliency of the Affordable Care Act or a sign that President Trump’s anti-ACA rhetoric and policies are starting to work.

As our colleague Jeff Stein reported Wednesday, there was a slight uptick in the number of Americans without health insurance in 2017 compared to 2016, even though that number essentially remained statistically flat. Still, the fact that uninsured rate went up at all, by about 400,000 people, marks the first time since the ACA’s implementation that the uninsured rate didn’t drop. 

Supporters of the ACA worry the news marks the beginning of a trend, especially when some of Trump administration policies intended to circumvent the ACA go into effect next year.

Ahead of open enrollment last year, the Trump administration dramatically decreased funding for any Obamacare outreach or advertising, limited resources for “navigators” who help people find an insurance plan, and shortened the window for people to sign up for insurance from three months to six weeks in states that use a federally run marketplace.

“Even with all of that, health coverage stayed steady. But at the same time, we’d like to see further progress in the rate of the uninsured,” said Judith Solomon of the Center on Budget and Policy Priorities.

It’s part of a pattern to weaken the 2010 health-care law known as Obamacare. After the GOP Congress failed to repeal and replace the ACA last summer, the Trump administration moved to dilute the law in other ways: including signing off on a plan to eliminate the individual mandate penalty next year; allowing individuals to buy skimpier, short-term health plans without certain coverage requirements under Obamacare; and seeking to allow states to put conditions on Medicaid coverage.

Some of the most prominent health care organizations in the country came together this morning to voice their disapproval of those short-term plans — including the American Cancer Society Cancer Action Network, the American Heart Association, Planned Parenthood Federation of America, the National Women’s Law Center, the , American Academy of Family Physicians, the American Academy of Pediatrics and Families USA.

“The Administration’s decision to expand short-term health plans will leave cancer patients and survivors with higher premiums and fewer insurance options,” said Dr. Gwen Nichols, chief medical officer of the Leukemia & Lymphoma Society.

The groups’ statements, compiled and released by Sen. Tammy Baldwin (D-Wis.), are in support of the senator’s effort to have Congress rescind the White House regulation. Nearly every Democratic senator has signed a resolution of disapproval to overturn it.

The census data reflects trends that started last year, when the administration’s policies had yet to be implemented. Fourteen states saw their uninsured populations rise in 2017. The only three states that didn’t see a spike in that number were New York, California and Louisiana. The first two aren’t surprising given those states’ robust efforts to enroll their own residents, while Louisiana expanded Medicaid in June 2016 so its decrease represents those low-income individuals who now have government coverage.

Medicaid expansion in most of the 33 states and D.C. that have done so under the ACA has predictably decreased the number of people without coverage. The uninsured rate last year in states with an expanded Medicaid program was 6.6 percent compared to 12.2 percent in non-expansion states — a gap that has only continued to grow since 2013.

To be fair, as Larry Levitt, senior vice president at the Kaiser Family Foundation, pointed out on Twitter: the uninsured rate started leveling off before the Trump administration started its work. But Levitt suggested the uninsured rate may really rise in 2019 when elimination of the individual mandate penalty takes effect. Moreover, states are increasingly taking the White House up on its suggestion to add work requirements to their Medicaid programs — in just the first three months of it being implemented in Arkansas, more than 4,000 people were jettisoned from the rolls for failure to comply.

Matthew Fiedler, a health-policy expert at the Brookings Institution, agreed with Levitt’s assessment, noting that the bulk of the people who were uninsured pre-ACA have already been enrolled  in the program. He contended that if policy had remained static, there would likely have been a modest decline instead of similar increase in the uninsured rate — though not a dramatic one. The real effects, he said, of the Trump administration’s efforts to chip away at the ACA are still to come. 

“I don’t think the right takeaway is that none of the policy changes will have a negative effect. I think they will going forward, we just haven’t seen that yet,” he said. “I think if your goal is to evaluate the ACA, I think the right takeaway is that there was a lot of progress, but more policy progress to be made.”

Of course, Democrats and Republicans have disparate views on how to get there. Democrats are now pushing for a public option or a universal health care system in which the government would foot the bill for many health-care costs. A lot of them feel  the ACA “got us roughly 40 percent there and established a framework for lawmakers to make that progress going forward,” Fiedler said. That’s why we’re now seeing so many Democratic candidates and lawmakers embracing some iteration of a “Medicare for all” program.  

Republicans still criticize the ACA as vast government overreach and are vowing they will take another stab at repealing it should they maintain the congressional majorities after the November midterms.

“We made an effort to fully repeal and replace ObamaCare and we’ll continue,” Vice President Pence said while campaigning for Baldwin’s opponent, Leah Vukmir, if the GOP performs well in the midterms.

One additional interesting data point from the census is ages at which there was the greatest increases or decreases in the uninsured rate. As highlighted in the chart above, rates of those without insurance rose at ages 18 and 19 — when children are no longer eligible for the Children’s Health Insurance Program; and for those between ages 25 and 26 — when children no longer qualify for their parents’ insurance. The uninsured rate dropped, however, for those aged 64 and 65 — when adults are eligible for Medicare.

The greatest spike in those without insurance was documented for 26 year olds. That’s likely because young adults are typically healthier and feel less urgency to pay for insurance when they lose coverage under their family’s plan.

As noted by the New York Times’ Margot Sanger Katz on Twitter, these stats show just how crucial government programs and laws have been in providing health coverage to Americans:

Envisioning new roles for the health system

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It’s obvious that if we’re going to make healthcare a sustainable proposition for the nation, we have to address the elephant in the room—inefficient, high-cost hospital systems that are built and incentivized to maximize reimbursement, not outcomes. One of our core beliefs is that we’re not going to fix that problem without engaging health systems in the work. The notion that we’re going to “disrupt” hospitals and make them “obsolete” is the worst kind of wishful thinking, a David-and-Goliath fantasy that doesn’t us any closer to a real solution. What’s needed are re-envisioned health systems that transform the way they organize and deliver care in a way that drives real value for consumers. Over the next several weeks in this space, we’re going to share one of our core frameworks for working with health systems to advance that goal. We’ll lay it out piece by piece, and then discuss some of the major implications for health system leaders.
 
We start with a conceptual depiction of the status quo. We describe today’s health system as “Event Health” because most providers are in the business of single-serve interactions with patients, paid on a fee-for-service basis. And indeed, many of the healthcare needs that consumers have present as “events”—acute episodes of illness that can be addressed with a one-time service interaction. For instance, I may have a sinus infection and need treatment, and a single visit to urgent care solves the problem. But across the stages of their lives, consumers have other kinds of health needs as well: some are episodic, with multiple events taking place over a defined time period (think pregnancy and childbirth, joint replacement, heart surgery). And some are just conditions that need to be managed over an extended period (diabetes, depression, cancer). But our health system is a hammer looking for nails—addressing health needs of every type with an event-driven model. Next week, we’ll begin to discuss alternative organizing principles for the health system that moves beyond this “Event Health” approach.