February 27th, 2014
For decades, it’s been no secret that some physicians have financial relationships with health care manufacturing companies. For example, a pharmaceutical firm might fund a cardiologist at an academic medical center to research an experimental medication for lowering cholesterol. Or, an orthopedic surgeon might receive a consulting fee from a medical device manufacturer for counsel about an artificial hip.
These widespread collaborations can involve gifts, meals, speaking fees, travel support, or payment for research activities. The good news is that these joint efforts have led to the discovery, design, and development of landmark drugs and life-saving devices, as well as numerous other major therapeutic inventions and innovations.
However, these commonplace transactions between physicians and the makers of drugs, devices, biological and medical supplies, or group purchasing organizations (GPOs) also cause considerable controversy. That’s because such payments from manufacturers to providers sometimes introduce conflicts of interest. Improper influence over research, education, and clinical decision-making can be exerted. Clinical integrity and patient care can be compromised. More explicitly, a physician may tout one drug over another during a continuing education session, primarily because he happens to be receiving a grant from its manufacturer.
Among consumers’ most serious concerns is that such financial relationships have always occurred privately, known only to the parties directly involved while the public remained in the dark. Read the rest of this entry »
February 25th, 2014
Health care providers across the country are diagnosing, prescribing, and bandaging, but for many patients, that may not be enough to improve health.
Health care providers have a unique opportunity to improve patient health outcomes by practicing empathy for their patients and complex life circumstances. Empathy is defined as, “the ability to understand and share the feelings of another,” and studies have shown that empathy is an important skill for health care providers and is significantly associated with improved clinical outcomes.
Social Determinants of Health
Social and environmental factors (also known as social determinants of health) have a larger impact on health than medical intervention. Social determinants of health such as income, education, food and housing access, and racial and ethnic inequality affect the health of a person from birth to death, and can be difficult to understand and control for within a health care visit. Due to a lack of social resources, patients are unable to fully comply with treatment plans, follow provider instructions, return for a follow-up visit, and ultimately, experience good health outcomes. A few specific examples include: problems accessing care without insurance, finding funds to cover needed services or prescriptions, securing transportation to get to and from appointments on time, or speaking the same language as a health care provider. Read the rest of this entry »
February 24th, 2014
As noted in a previous Health Affairs Blog post by Katy Kozhimannil and Ezra Golberstein, there is significant variability in cesarean delivery rates across the United States, but this is also true worldwide. Worldwide cesarean delivery rates have come under scrutiny and criticism since the World Health Organization (WHO) suggested in 1985 that the optimal rate should not exceed 10 to 15 percent.
Although currently there is no expert agreement on a single optimal level, a general consensus has emerged that extremely low rates (less than 5 percent) suggest underuse and higher rates (greater than 10-15 percent) suggest overuse. Globally, the average rate sits slightly above that recommended level at 16 percent. However, the mean value masks the underlying variability that exists across countries and the different issues inherent in the variation. Of countries which report at least some cesarean deliveries, the range of use runs from 1 percent (Niger) to 52 percent (Brazil) of live child births.
Middle and High-Income Countries
Cesarean rates in middle and high-income countries have continued to increase over the last decade (most are significantly over 15 percent). The average rate among the Organisation for Economic Co-operation and Development (OECD)-member countries is 26.9 per 100 live births (range: 14.7 to 49.0). Comparatively, the United States has a very high rate of cesarean delivery (31.4 per 100 live births). In Switzerland, for example, cesarean section rates varied in 2010 from less than 20 percent to over 40 percent in a region. Within a region, the rates also varied by hospital. A study in France found more cesarean sections were performed in for-profit hospitals than in public hospitals, which treat more complicated pregnancies, suggesting that financial incentives may also play a role in explaining excess cesarean deliveries. Read the rest of this entry »
February 24th, 2014
On February 23, 2014, the Centers on Medicare and Medicaid Services released a State Medicaid Directors Letter analyzing the application of Medicaid liens, estate recoveries, transfer-of-asset rules, and post-eligibility income rules to individuals who become eligible for Medicaid because of their modified-adjusted gross income (MAGI).
Contrary to the flat-earth concept of Medicaid espoused by Chief Justice Roberts in National Federation of Independent Business v. Sebelius, Medicaid has never been a single program but rather a cluster of programs with quite different purposes and rules. One of its more controversial and problematic roles has been to serve as our nation’s default program for financing long-term care services. Nursing home care, and even community-based long term care, is very costly, and long-term care can easily overwhelm the income and resources of people who are otherwise comfortably middle income. From its inception, Medicaid has been available to pay for long-term care for people who are unable to afford it after they have effectively become impoverished by “spending down” their own assets and income.
From very early in the Medicaid program’s history, however, there has been a concern that people who could otherwise afford to pay for at least some long-term care services would voluntarily impoverish themselves, transferring assets to their children or to others to make themselves eligible for Medicaid. Congress and the states have therefore adopted laws and regulations to limit asset transfers by Medicaid recipients. These prohibitions were initially evaded through the use of trusts and other financial devices, resulting in the enactment of additional laws to bar these evasions. Read the rest of this entry »
February 22nd, 2014
On February 20, 2014, the Departments of Labor, Treasury, and Health and Human Services released a joint final rule to implement an Affordable Care Act provision prohibiting self-insured and insured group health plans from requiring employees to wait more than 90 days before health insurance becomes effective. The final regulation also contains amendments to pre-existing Health Insurance Affordability and Accountability Act regulations to bring them into ACA compliance.
The three agencies also released on February 20 a proposed rule addressing the relationship between orientation programs and the 90-day waiting period.
The Joint Final Rule On Waiting Periods
Waiting periods before health insurance becomes effective are quite common in employer-sponsored insurance. The agencies estimate based on information from the Kaiser Family Foundation/Health Research and Education Trust 2013 employee benefits report that nine percent of new employees, or about 459,000 in 2013, were subject to waiting periods of 4 months or more and may thus be affected by this rule; however, as discussed below, the rule does not necessarily mean that all employees hired will get coverage within 90 days. Read the rest of this entry »
February 21st, 2014
On Christmas Eve 2011, protesters from a local church marched to the entrance of our hospital, Rush University Medical Center in Chicago. They demanded we provide organ transplants for sick members of their congregation. We invited them in and listened to their gut wrenching stories. George, twenty-two, was brought to the United States as a six-month-old. He developed renal failure at age sixteen while covered under the Children’s Health Insurance Program. Now he was uninsured, on dialysis and refused a transplant evaluation at the same institution that treated him as a child. Another undocumented immigrant, Martin, was twenty-six. He too was uninsured and on dialysis.
Chicago has six adult transplant centers. Initially none would evaluate George or Martin for transplantation because they were uninsured. In the Narrative Matters essay, “Undocumented Immigrants And Kidney Transplant: Costs And Controversy,” published in the February issue of Health Affairs, Vanessa Grubbs tells a similarly heartfelt story of a patient in need of a transplant: Mr. Rojas. George, Martin and Mr. Rojas are not US citizens, but it was their lack of health insurance that kept transplantation out of reach. Foreign-born immigrants always have access to a transplant evaluation (the prerequisite for organ transplant) if they have insurance or the cash to pay.
In theory, the organ allocation system in the United States is based on justice and equity. The National Organ Transplant Act (NOTA) was passed in 1984 to create a fair system of organ transplantation in the United States. A federal task force, created by the act, was charged to design an organ allocation system “based on medical criteria that are publicly stated and fairly applied.” The task force emphasized that organs should be distributed to those eligible “regardless of their ability to pay.” Both NOTA and the bylaws of the United Network for Organ Sharing, the nonprofit organization that manages the national transplant network, require that need, not financial or citizenship status, guide transplant allocation decisions. Undeniably, the system of altruistic donation is only viable if a donating individual believes organs are allocated fairly. Read the rest of this entry »
February 20th, 2014
On February 18, 2014, Judge James Spencer of the United States District Court for the Eastern District of Virginia became the second federal judge to reject the legal theory that was supposed to “drive a stake through the heart of Obamacare.” Several lawsuits have been brought by Affordable Care Act opponents claiming that the federal exchange, which now exists in 34 states, lacks legal authority to issue premium tax credits and that an Internal Revenue Service rule authorizing the federal exchange to do so is illegal.
In January, Judge Paul Friedman of the District Court for the District of Columbia threw out a lawsuit, Halbig v. Sebelius, arguing this theory. Judge Spencer, in dismissing King v. Sebelius, followed Judge Friedman’s lead, but found additional reasons for rejecting the challenger’s arguments.
The challenge is based on the wording of two phrases in a section of the ACA that addresses the calculation of the amount of premium tax credits. The section refers to calculating the amount of the tax credit taking into consideration the premium of a qualified health plan in which an individual is enrolled “through an Exchange established by the State under [section] 1311 of the” ACA. The plaintiffs in these cases claim that this means that premium tax credits are only available through state, and not federal, exchanges. Plaintiffs claim that Congress included this provision because it had a strong preference for state exchanges and wanted to force states to establish exchanges by denying premium tax credits to the residents of states that failed to do so. Read the rest of this entry »
February 20th, 2014
Something unexpected is happening in Washington. As most eyes track partisan battles over immigration and the Affordable Care Act, key Congressional committees have been quietly advancing truly bipartisan legislation to strengthen Medicare.
Since 2002, an outdated Medicare cost control called the Sustainable Growth Rate (SGR) has repeatedly threatened drastic Medicare provider cuts. After a decade of temporary fixes, SGR repeal appears within reach. A bipartisan, bicameral agreement by key Congressional leaders announced on February 6, 2014 goes a step further by pairing repeal with bipartisan reforms that pay physicians for the quality and value of care they deliver, not the number of tests and procedures they order.
When one of every three health care dollars is wasted on care that does not improve patients’ health, transitioning away from volume-based reimbursement would be momentous. Few policy changes are more fundamental to containing health care costs and protecting the solvency of Medicare.
The challenge in Congress has shifted from getting a bipartisan agreement on new cost controls to paying for the repeal of the old one. The Congressional Budget Office (CBO) estimates the cost of the Senate version of the bipartisan repeal bill at $149 billion over 10 years. Read the rest of this entry »
February 19th, 2014
Editor’s Note: This post is the fourth in a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on an upcoming volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.
As we enter the world of accountable care, palliative care programs bring tremendous assets to our health care system. Accountable care organizations (ACOs) seek to improve quality and reduce costs for a defined population of patients, and palliative care offers value on both the quality and cost sides of the equation.
Palliative Care Improves Quality
Patients facing a serious illness value survival, quality of life, and minimization of suffering for themselves and their families. For patients with far-advanced disease, hospice care is the “gold standard” of care in meeting these goals. Palliative care achieves these goals for patients who are living with a serious illness but may not be at the end of life. Many studies demonstrate a panoply of improved outcomes for patients receiving palliative care: improved quality of life, reduced symptoms, enhanced emotional support, improved communication with physicians, earlier and more frequent use of hospice, reductions in family distress, improved survival, and greater satisfaction with care. Read the rest of this entry »
February 18th, 2014
Evidence continues to build that hunger should be approached in some measure as a public health issue, and Hilary Seligman of the University of California, San Francisco and co-authors contribute to this trove of research in the January Health Affairs journal article “Exhaustion of Food Budgets at Month’s End and Hospital Admissions for Hypoglycemia.” Hunger-relief organizations across the country can attest to the long-observed pattern of a rise in demand for food distribution at the end of the month. In fact, meal providers and food pantries tailor their decisions about purchasing, staffing, and program design around the uptick in client need as the month comes to a close. Seligman et al correlate this surge in demand with an increase in hospitalization among low-income individuals the fourth week of the month (a 27 percent increase in hospitalization among low-income individuals for hypoglycemia, according to their study). These findings suggest the profound need to devise food policies and programs with public health in mind.
However, to effectively address hunger as a public health issue in particular, hunger-relief organizations, community health organizations, universities, government, and others must take a collective impact approach. This cross-sector approach to complex, systemic social issues fosters coordination among such groups so they can have a greater positive impact than if they were to operate independent of one another; it is being turned to with increasing frequency to create large-scale social change. Policy can encourage a collective impact approach; it is already happening in the case of hospitals, which under Section 3025 of the Affordable Care Act, are penalized a portion of their Medicare reimbursement if they have a higher than expected rate of acute care readmissions within 30 days of discharge. (See 42 CFR part 412P.)
New community and regional partnerships are beginning to develop in part because of this incentive. The Atlanta Community Food Bank, for example, which distributed 21.8 percent more food and grocery items this past fiscal year than the last, is in early discussions with the Atlanta Regional Commission, the city health department, regional hospitals, and universities. Together they aim to confront the need for better health education and sustained access to nutritious food among low-income individuals discharged from hospitals for chronic, diet-related disease like diabetes, congestive heart failure, and associated complications. This is precisely the type of alliance that could help address the issues laid out in “Exhaustion of Food Budgets…” Policymakers need to build on this kind of ingenuity taking place in the field – especially if those in the field are expected to do more with less. That will certainly be the case, as the recently enacted Farm Bill imposes $8.6 billion in cuts to SNAP over the next 10 years, increasing demand on hunger-relief organizations even further. Read the rest of this entry »