Pandemic Bonds

The World Bank is trying to insure against one of the worst crises in the world: a pandemic.  The Economist reports that the World Bank:

…has issued $425m in pandemic bonds to support its new Pandemic Emergency Financing Facility (PEF), which is intended to channel funding to countries facing a deadly disease.  The bonds cover six viruses likely to spark outbreaks: new influenza viruses, coronaviruses (like SARS and MERS), filoviruses (like Ebola), Lassa fever, Rift Valley fever and Crimean Congo fever. Investors forgo their principal when a virus reaches a predetermined contagion level, based on rate of growth, number of deaths and whether it crosses international borders. The facility covers 77 of the world’s poorest countries.

The World Bank FAQ are here.  These FAQ’s provide some interesting precedents in the world of catastrophe bonds.

One example is the Caribbean Catastrophe Risk Insurance Facility (CCRIF), designed to provide participating countries with access to affordable and effective coverage against natural disasters. Another example is the Pacific Catastrophic Risk Facility (PCRAFI), a risk insurance pool of five small Pacific islands that was also incubated by the Bank. A third example is the Turkish Catastrophe Insurance Pool (TCIP), a mandatory scheme for homeowners’ earthquake insurance, which was backed by WBG financing at inception.

This is a interesting proposal to help developing countries secure funding in the case a pandemic occurs.  However, if the World Bank invests these funds, one may wonder whether financial markets would crash in the case of a large scale pandemic resulting in an insolvent fund.  Let’s hope that does not happen, but I am curious what precautions were taken to avoid this scenarios.

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The dark days of dentistry

Student loan-repayment options for dental residents

Health Equity Lessons from July 23, 1967, Detroit

On July 23, 1967, I was a girl attending my cousin’s wedding at a swanky hotel in mid-town Detroit. Driving home with my parents and sisters after the wedding, the radio news channel warned us of the blazing fires that were burning in a part of the city not far from where we were on a highway leading out to the suburbs.

Fifty years and five days later, I am addressing the subject of health equity at a speech over breakfast at the American Hospital Association 25th Annual Health Leadership Summit today.

In my talk, I’ll connect the dots between me-as-a-child in ’67 Detroit to evolving as a health economist to work with clients on solutions underpinned by social determinants of health, to drive individual, population, and public health across America.

Picture me in the back seat of Daddy’s Mercury Monterey, him behind the wheel of the car driving us into the heart of what looked like war-torn streets to me sometime after the area calmed down….the looted stores, the smoky air, the neighbors cleaning up their neighborhoods…what I didn’t know is that 43 people would die as a result of the uprising and police response.

A few years later I was in junior high, reading a syllabus of books that included The Autobiography of Malcolm X, Why We Can’t Wait by Martin Luther King, and Black Boy by Richard Wright, among other works that continued to shape my maturing world-view.

Later in college, I took a course in Urban Economics from a professor whose teachings, ethos and spirit would shape me forever: Bill Neenan, PhD, was also known as William B. Neenan, SJ. “SJ?” some of you might ask. “Society of the Jesuits,” I would answer. Bill was that rare priest who did a PhD in economics and taught in the secular world of The University of Michigan’s department of economics just as I was considering a major in the subject. His book on urban economics is one of the main textbooks on the topic. His teaching, sense of humor, and outlook for good and hope profoundly informed my own approach to the subject, and ultimately, my professional path in health economics.

Fast-forward past twenty-plus years working with hospitals, health plans, clinicians, technology developers, consumer goods and electronics companies, financial services and non-profit organizations. Listening to and working with all these stakeholders in health over two+ decades has offered me another kind of education. Today, I share my most important learning with delegates to the AHA meeting: that social factors, and not so much healthcare, are the most important contributors to our community’s health and wellbeing.

Those social determinants (SDOHs) are the aspects of daily living that impact us in our homes and communities where we live, work, play, pray and learn: living conditions, friendly neighbors and social connections, good and healthy food, clean water, safe neighborhoods, and, yes indeed, health care access (THINK: primary care, medicines, and early diagnosis among these inputs).

I like this illustration conceived by Becky Hurst of Adelaide, South Australia, where she works on community engagement strategies. Note that Becky includes “affordable internet access” in her SDOHs, along with climate change resilience and thriving and diverse economies.

The streets around 12th and Claremont in Detroit erupted in July 1967 as a result of economic and social strife: job creation in the auto companies had slowed, and highways were built which enabled “white flight” out of the city into the suburbs and exurbs (including my own). The city of Detroit was plagued by a cocktail of negative social determinants which contributed to this event that would forever change my hometown.

Health Populi’s Hot Points:  I will point to this cartoon in my talk at the AHA meeting, noting we’re in The Best of Times and The Worst of Times. In healthcare, it feels like the worst of times as in the U.S., we are so challenged by the opioid crisis, costs spiraling, clinician burnout, and consumers health-financially insecure.

It can also be the Best of Times for health — if we recognize, together, the role of social determinants to address root causes of healthcare woes and disparities. Health insurance is surely an on-ramp to health care access: it is necessary, but not sufficient, to deal with our health care challenges and public health inequities. I point to an article in JAMA (the Journal of the American Medical Association) published July 26, 2017, from Rita Rubin, looking at the “Half-century After ‘Summer of Love,'” where free clinics still play a vital role in American health care since evolving from 1967 when the Haight-Asbury Free Clinic was founded in San Francisco — 50 years ago.

Health can and must be baked into all policies, from food and transportation to housing and education. We can make health if we work collaboratively across the health/care ecosystem, and on Capitol Hill as well.

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Links

• Does anyone look at physician quality data?
• Healthcare CEO pay.
• The skinny on skinny repeal.
• NHS: Smokers and obese must wait for surgery
• 35 best health and science summer books

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Ready for Vacation? Pack Your Dentist’s Phone Number

When you’re packing for vacation, you wouldn’t think of leaving your sunscreen or bathing suit behind. However, it may not have occurred to you to bring your dentist’s phone number with you. Yet your home dental office can be a big help if you have tooth troubles while away.

For one thing, your dentist can help determine if you have a problem that needs to be taken care of immediately or if it can wait until you come back. In addition, your dentist may offer helpful tips for dealing with the situation in the short-term.

Also, your dentist may be able to help you find a local dentist who speaks your language and has suitable training. That way, you won’t have the added worry of communication problems or that the approach to dental care will be vastly different.

If you can’t reach your dentist and need to find dental care while on vacation, the hotel concierge may be a good resource. However, if you are in a foreign country, you might first want to contact your home country’s embassy or consulate for an unbiased recommendation.

So before you leave, don’t forget to bring your toothbrush, your floss…and your dentist’s phone number.

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Fix the ACA, Most Americans Say

 

61% of Americans hold negative views of repealing-and-replacing the Affordable Care Act, according to the July 2017 Health Tracking Poll from the Kaiser Family Foundation. This month’s survey focused on Americans’ views on Republican legislative efforts to repeal and replace the Affordable Care Act (ACA). As of the writing of this post, the majority of the Senate rejected the full repeal of the ACA, but the situation is very fluid.

Note that this poll was conducted by phone between July 5-10, 2017, among 1,183 U.S. adults ages 18 and older.

The column chart here illustrates that the proportion of people who feel unfavorable about the ACA replacement plan grew 6 percentage points, form 55% to 61%, over one month from June to July 2017.

Another sign that the majority of Americans do not seek the wholesale rejection of the ACA is that two-thirds of the public opposes major reductions in Federal funding for Medicaid.

The vast majority of Americans, 71%, would prefer that Republicans in Congress collaborate with Democrats to improve the ACA and not repeal it: this statistic includes 91% of Democrats who seek cross-the-aisle work on the law, 72% of Independents, and 41% of Republicans.

There’s an important “partisan intensity gap” KFF found when it comes to the proportion of people favorable to keeping the Affordable Care Act (50%) versus the percent of people favoring repeal-and-replace of the ACA (28%).

 

 

 

 

 

 

 

 

 

 

The second chart gauges Americans’ views on whether health care is going “in the right direction” in the U.S. or gotten off on the “wrong track.” By July 2017, 70% of people said health care is on the wrong track, up 8 percentage points since February. During that period, see that fewer people believe health care is going in the right direction (down from 31% to 24% in the two months from April to July).

Health Populi’s Hot Points:  There’s an informative study in the June 2017 issue of Health Affairs, devoted to health equity, on Americans’ perceptions of healthcare quality compared with health citizens living in other countries. [I covered that research in-depth here in Health Populi last month].

 

 

 

 

 

 

 

 

In the health care debate in Congress, such as it is, there’s one crucial outcome that’s not been given much airtime by anyone on Capitol Hill on either side of the aisle. That’s the fact that the Affordable Care Act significantly reduced socioeconomic disparities in health care access. The evidence for this ROI on the ACA was published this week in a web-first article in Health Affairs by a team from Boston University. The line graph illustrates that poorer people (with income categories shown on the x-axis) benefited from the ACA between 2013 and 2015 via greater insurance coverage, access to primary care providers, and less self-rationing of health care due to cost.

These three metrics are part of the argument and ROI on the ACA “working.” The KFF July 2017 poll finds that most Americans want to see Congress make improvements on this law, from which millions of fellow health citizens have benefited.

 

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Amazon to dive into health care?

The answer is yes according to CNBC.

Amazon has started a secret skunkworks lab dedicated to opportunities in health care, including new areas such as electronic medical records and telemedicine. Amazon has dubbed this stealth team 1492…

Amazon has become increasingly interested in exploring new business in healthcare. For example, Amazon has another unit exploring selling pharmaceuticals, CNBC reported in May.The new team is currently looking at opportunities that involve pushing and pulling data from legacy electronic medical record systems. If successful, Amazon could make that information available to consumers and their doctors. It is also hoping to build a platform for telemedicine, which in turn could make it easier for people to have virtual consultations with doctors, one of the people said.

The group is also exploring health applications for existing Amazon hardware, including Echo and Dash Wand. Hospitals and doctor’s offices have already dabbled in developing skills for Amazon’s voice assistant Alexa, which presents a big opportunity for the e-commerce company.

Unsurprisingly, Amazon is also considering healthcare applications for their Echo product as well as their Alex voice assistant. Many may not know, but Amazon is already in the healthcare business, as a leading seller of medical supplies.

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ACE Panel needs volunteers to share opinions

Appropriate Use Criteria, or how I learned to love CMS telling doctors what to do

As part of Section 218(b) of the Protecting Access to Medicare Act, CMS instituted the appropriate use criteria (AUC) for the use of advanced diagnostic imaging.  In order to be reimbursed for these diagnostic imaging services, physicians must consult with and document that they used AUC software before recommending advanced diagnostic imaging.  Failing to document use of clinical decision support (CDS) with AUC criteria would lead to the claim being rejected (i.e., not paid).

At first glance, this seems like a great idea. AUCs are evidence based guidelines that can ostensibly help physicians use diagnostic imaging appropriately.  However, are top-down mandates helpful for improving care?  Aren’t there already clinical guidelines in place to assist practitioners?

Although AUC are evidence-based, my guess is that they will be ineffective in practice and physicians will see them as an administrative burden.

Even Atul Gawande–one of the strongest advocates of checklists–recognized that purely top-down approaches typically do not work. He strongly advocates for the clinical team taking the lead in adopting checklists.  However, that does not always happen:

…the most extreme example, they turned [our 19-item checklist] into an 81-item checklist. It was impossible to use. We’d specifically designed it to be something you could run through in 60 seconds or less at each pause point, so you weren’t distracted from the main operation. And you could see that the administration in the hospital had got hold of it, and they were using it to try to impose their ideas. And essentially, the clinical team was not the team that were designing and controlling the checklist. Invariably, you look at that and you know that everybody is completely ignoring it, and it has become just a tick box effort instead of an enabler of greater capability.

This is a key concern with AUC.  Will it actually be a tool to improve care or will doctors not take it seriously and just consider it another paperwork task that takes them away from patient care?

Although initially the AUC provisions were going to go into effect on January 1, 2018, the implementation of AUC for diagnostic imaging is being delayed until January 1, 2019.  This will give providers more time to implement the necessary software, but I am skeptical that CMS dictates on practicing medicine will be taken to heart by real-world providers.

 

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Electric Toothbrush VS Manual Toothbrush

Over the era of man, we’ve had a lot of ideas for oral upkeep. From consuming certain plants to scrub molars, to using seashells as dental implants, it’s no surprise we have such a variety of toothbrushes after millennia of tooth brushing. But with all the technologies available to us today, we’re left with a new-age dilemma: should we be using an electric or manual toothbrush?

 

Though the basic design of the toothbrush hasn’t changed much over the past century (using a handle with clustered bristles), the invention of the electric toothbrush back in 1950s represented a huge milestone in our capacities and technologies. Originally, the purpose of the electric brush was to assist people with disabilities to keep up with their oral hygiene without help. But over the last 20 years, these instruments have become a staple in every supermarket. There’s been a real debate in our lifetime about the electric versus traditional toothbrush.

 

Of course, the manual and electric toothbrushes each have their advantages and disadvantages. We’ll lay out all the objective data for you, but your preference will almost always be the deciding factor.

Advantages of a manual toothbrush:

 

• Proven by generations of use to be efficient.
• Manual toothbrushes are cheaper, which also enables users to invest more of their dental budget in sensitivity-specific toothpastes or tooth whitening packs, or other dental products.
• Most manual toothbrushes have added features like tongue scrapers and gum massagers. The tongue scraper comes in handy, as only a tiny portion of the population invests in an individual tongue scraper.
• More portable in size and doesn’t risk losing charge or needing batteries.

 

Disadvantages of a manual toothbrush:

 

• Contrary to the electric toothbrush, manuals don’t have an installed timer—so, it’s easier to do a quick brush that ultimately won’t be sufficient.
• Without the electric action motion, the brushing is all up to you. You probably won’t move as fast as an electric brush can, and can also get tired if you try to brush more aggressively.

 

Advantages of an electric toothbrush

 

• Bigger handles—some people like having a more substantial handle to hold onto.
• The installed timer in many models is beneficial for those who are prone to quick or lazy brushing.
• For most of us, the massaging vibration motion is pleasant across the teeth and gums.
• Smaller brush heads mean electric brushes can be better for getting hard-to-reach places.
• Helpful for people suffering from arthritis or joint pain.

 

Disadvantages of an electric toothbrush:

 

• Electric toothbrushes can be very expensive, not to mention purchasing brush heads or replacement chargers and batteries.
• The science is indecisive whether these brushes are actually better, and therefore worth the investment.
• Electric brushes require charging or battery replacement, and you risk being left without the brush working on a trip.
• Electric toothbrushes are overall less portable than manual ones.

 

When it comes down to it, the best toothbrush is the one that you’re really going to use. Keep in mind that you should be buying a new toothbrush every three-to-four months, which gives you plenty of opportunity to try different options. Keep on trying different bristle patterns or styles until you find the toothbrush you like best.

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Weaving Accenture’s Five Digital Health Technology Trends for 2017

Technology should serve people, and Accenture has identified five major key trends that, together, could forge a person-centered, -friendly, -empowering healthcare system. This is Accenture’s Digital Health Technology Vision for 2017.

“Should” and “could” are the important adverbs here, because if tech doesn’t deliver, driving efficiency and effectiveness, personalizing medical treatments, and inspiring people to become more health literate and health-engaging, then tech is just a Field of Dreams being built and available, with no people taking advantage of the potential benefits.

The five new-new tech trends are:

• AI is the new UI, where healthcare experience is everything
• Ecosystem power plays, going beyond platforms
• The workforce market place, a more liquid, accessible, effective health care labor pool
• Design for humans, to inspire positive health behaviors
• The uncharted, redefining standards and organizations in healthcare.

“Its no longer about what technology can do for people,” Accenture suggests. “It’s about what people can do with technology.”

In health and healthcare, “what people can do with technology” impacts real-time workflows, diagnostics, treatments, research, tools, organizational design, business models, and consumer behaviors — from initial appointment scheduling through to self-care for conditions previously only treatable in tertiary (high-tech) hospital settings.

Today the home, the doctor’s, office, and a growing array of lower-cost sites can adopt any or all of these five technology trends to reinvent care at the front-end, bolster patients’ health outcomes, and reimagine and improve every touchpoint in-between. That’s a tall order and what I’m at Accenture HQ to help trend-weave.

Here in Chicago today, I’m midwifing a live webcast on these trends with Mike Redding, Managing Director of Accenture Ventures; Lisa Suennen, Managing Director at GE Ventures, blogger at Venture Valkyrie, and co-host of the Health TechTonics podcast; and, Dr. Kaveh Safavi, Senior Managing Director for Accenture’s global healthcare business who works with Accenture’s broad portfolio of healthcare clients.

Stay tuned for the webcast on the day, 25th July 2017, at 930 am Eastern, or tune into a video-on-demand replay after that date. The four of us will participate in a live conversation about these trends through the healthcare lens, informed by Mike’s work outside of the health/care segment, and Lisa’s and Kaveh’s up-close-and-personal work with ecosystem stakeholders. I’ll be keeping us firmly focused on the person at the center of healthcare — patients, providers, consumers and caregivers — and the opportunity for these technologies to help make healthcare better.

 

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Innovation in small markets

The introduction of new treatment technologies typically occurs where there is a large market.  A lot of innovations are developed to treat disease that affect a large number of people in the developed world because the financial returns are large.  It is less likely to observe innovation in the treatment of rare diseases or diseases that affect individuals in developing countries.  This issue is particularly relevant as the technology to produce new precision medicines comes online.

One of the most widely known regulations to incentivize the development of treatments for rare diseases is the United States Orphan Drug Act (ODA) of 1983.  Other countries, however, have also enacted legislation to incentivize investment in rare diseases. For instance, a paper by Iizuka and Uchida (2017) looks at legislation enacted in Japan.  Japan provides research grants for rare and intractable diseases.  However, Japan also incentivizes innovation through patient demand incentives.

In 1973, the [Japanese] government started implementing a policy that reduces patient cost sharing for a subset of intractable diseases.  Japan implements universal health coverage, and patients below age 70 pay coinsurance of 30% for any medical treatment covered by public health insurance. The demand-side policy reduces patients’ out-of-pocket spending by setting a stop-loss, a maximum amount of monthly out-of-pocket expenditure, for the treatment of qualified intractable diseases, which ranges between 0 to 23,100 JPY per month based on their family income.

Japan also has an ODA-type policy that promotes R&D for conditions that affect <50,000 Japanese patients and are serious diseases with high medical needs.

The authors of the study use a difference-in-difference methodology because in 2009, Japan added 17 intractable diseases to the list of conditions eligible for reduced cost sharing.

Using clinical trials data taken from public registries, we identified the effect of the policy using the DID approach, exploiting the institutional detail that the diseases covered by the policy increased in an arbitrary fashion during our data period. We found that the demand-side policy increased firms’ incentive to innovate. Specifically, firm-sponsored new clinical trials increased as much as 181% when covered by the policy.

Source:

• Iizuka, Toshiaki, and Gyo Uchida. “Promoting Innovation in Small Markets: Evidence from the market for rare and intractable diseases.” Journal of Health Economics 54 (2017): 56-65.

 

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HWR is up

Steve Anderson has posted  Health Wonk Review: Are We There Yet? Edition at medicareresources.org. Check it out.

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Note to Mooch: The ER is Not Universal Health Care

I quote directly from the Twitter feed of Anthony Scaramucci, @scaramucci:

“@dhank2525 agree. We already have Univ Health Care, we made decision long ago to treat everyone that enters an emergency room.”

Mr. Scaramucci is President Trump’s Communications Chief, replacing Sean Spicer. Mr. Scaramucci is neither veteran journalist nor healthcare policy wonk. He’s a successful businessman, which I respect for his savvy and ability to build a fund, attract investors, and create a media persona which he has telegenically broadcast on CNBC and elsewhere over the past decade. He’s got a engaging public personality, and goes by the moniker, “Mooch.”

But as brilliant a businessman as Mooch is, and he is, Mooch’s pronouncement that an ER is equivalent to universal healthcare is so not true, it’s an un-fact. It’s just wrong, and wrong on many levels. And from his businessman’s point-of-view, I want Mooch to know there’s a real return-on-investment (ROI, a concept he’ll appreciate) for funding preventive care and, especially, boosting funding for the social determinants of health which bolster individual, population (say, for a group of people diagnosed with Type 2 diabetes or heart failure), and public health (at the community level).

In sum: ERs are expensive, too expensive for delivering primary care, and too late in health citizens’ lives for supporting prevention and early diagnosis. Let’s review some solid evidence on the ROI of spending more on primary care and the social determinants of health (SDOH).

1. Save by spending more on primary care. The rest of the developed world, those OECD nations (to any one of which Mr. Scaramucci, reportedly, would have liked an ambassadorship), all allocate much more spending per capita to primary care than the U.S. does. A strong primary care backbone is the on-ramp to health care and self-care literacy and competency, and costs the system (and taxpayers) less “earlier” than spending “later” when medical conditions and diseases emerge. Here’s some recent research from the successful business people at PwC on primary care in the New Health Economy. Here’s another view on the importance of primary care in developed economies from The Commonwealth Fund which provides additional insights into the ROI of primary care in countries that have mindfully made the investment in that national primary care backbone.
2. Save by spending more on social care. Those wealthy nations also spend more on social care per capita, like education and housing. Early childhood education is a building block to literacy, health literacy, good jobs, and a civil society. Safe and clean housing also boosts health: that could be a sound argument for the appointment of Dr. Ben Carson as Secretary of Housing and Urban Development (HUD). Here’s a meta-analysis on the direct correlation between social spending and health outcomes published in the policy journal Health Affairs. For further learning on this key issue, here’s a link to work from The Robert Wood Johnson Foundation on how spending on social care has an ROI for peoples’ health outcomes. Here’s the money quote you will surely appreciate: when comparing state-to-state spending, a 20% change in median social-to-health spending was associated with 85,000 fewer adults with obesity and 950,000 fewer adults with mental illness. Allocating more funding to housing and nutrition were found to be particularly impactful.

I’ll be speaking in San Diego at 7 am this Friday morning, 28th July 2017, at the Equity of Health breakfast, part of the American Hospital Association Leadership Summit. I’d love to welcome you to the talk, during which I’ll discuss my work marrying health economics to health care disparities. This work was first inspired and informed with visceral and vivid memories of being a child in suburban Detroit on July 23, 1967 — this week, marking the 50th anniversary of the Detroit riots.

Health Populi’s Hot Points: If you remember one thing from this post, Mooch, consider this: our ZIP code is more important than our genetic code when it comes to health status. Some of us were born to families with good jobs that came with health insurance (perhaps like your family on Long Island or mine in suburban Detroit); our parents sent us kids on to excellent higher education (like you to Wharton and Harvard, and me to the University of Michigan). How lucky are/were we?

Other peoples’ ZIP codes haven’t afforded them access to these social determinants of health that, together, help ensure (with an “e,” not an “i”) and set the table for good health and literacy for a good life. That’s the kind of life that shapes our ability to pursue Life, Liberty, and Happiness. You and I both want that for the health citizens of the United States of America.

My job at THINK-Health is to inspire thinking across and among the broad health and healthcare ecosystem stakeholders, from care providers and health insurance plans to pharma and technology, food, consumer goods and electronics, and financial services. I write this to inspire Mooch in considering the opportunities for investing in health, to prevent more unneccessary and ineffective healthcare spending (in the ER) too late to get the ROI on healthy American lives.

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Study clubs from a business perspective

It’s Okay to Be a Coward about Cancer

That is the title of an interesting Time article from cancer surviver Josh Friedman. Friedman is a well-known screenwriter whose work includes credits for such franchises as Terminator, Avatar and War of the Worlds. The article was prompted in part by John McCain’s recent brain cancer diagnosis (glioblastoma to be specific).

One excerpt is especially poignant.

As a storyteller I think hard about the tales we tell. Toughness and courage are staples of our cultural business. But these are not how we survive cancer. We survive cancer through luck, science, early detection and real health insurance. If we survived through courage, I probably wouldn’t have.

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Pharmacies Morph Into Primary Care Health Destinations

The business and mission of pharmacies are being re-shaped by several major market forces, most impactful being uncertain health reform prospects at the Federal level — especially for Medicaid, which is a major payor for prescription drugs. Medicaid covered 14% of retail prescriptions dispensed in 2016, according to QuintilesIMS; Medicare accounted for 27% of retail prescriptions.

“But if affordability, accessibility, quality, innovation, responsiveness and choices are among the standards that will be applied to any future changes, pharmacy has strong legs to stand on,” Steve Anderson, president and CEO of the National Association of Chain Drug Stores, said in the PoweRx Top 50 report from Drug Store News (DSN).

The pharmacy has always been a healthcare destination by the nature of what happens in the proverbial “back-of-the-store:” dispensing prescription drugs, typically written by physicians. 50% of people in America take at least one prescription drug. 1 in two people in America have taken at least one prescription drug in the past 30 days, and 4.4 billion prescriptions were written in the U.S. in 2016.

The table organizes DSN’s roster of the leading pharmacy retailers by 2016 Rx sales.

The opportunities in the so-called “front of the store” (including the aisles in the fast-growing number of pharmacies situated in grocery stores) hold promise for boosting health consumers’ overall health and wellness.

Consider these example from DSN’s report, which fit into Health Populi’s mantra that Health/care is Everywhere:

CVS, #1, quitting tobacco in 2014, is moving onto healthier food offerings, removing products that contain partially hydrogenated oils from its private-label products. The chain is also baking health into its beauty offerings, which is a trend we can see happening in the all-beauty chains, Sephora and Ulta, as well. CVS gets learnings from a Digital Innovation Lab located in South Boston to test new ideas, including the newly-rolled out CVS Curbside and CVS Pay services that boost the store brand’s customer service and convenience.

Walgreens, #2, is part of the Boots Alliance, based in Europe. In the U.S., Walgreens partners with UnitedHealthcare for a Medicare Advantage and Part D prescription plan, and serves 4.8 million seniors through its Medicare plans. Walgreens works in specialty care on cancer, designating several dozen locations as “Community, a Walgreens Pharmacy,” to deliver oncology meds closer to where patients live, and to help with medication therapy management. Walgreens has also been a leader in digital health app development, as well.

Walmart, #4, is already a primary care destination for many of its millions of daily customers, providing pharmacy services along with urgent care, primary care clinics, and huge allocation to over-the-counter floor space. In addition, Walmart is changing messaging around healthier foods, and adding wearable health devices to its electronics department. Walmart also performs medical screenings at its event, “America’s Biggest Health Fair,” for blood pressure, glucose, and vision.

Kroger, #7, is investing in health and wellness for a long-term strategy, acquiring the ModernHEALTH specialty pharmacy in 2016. Specialty pharmacy is fast-growing as Health Populi has discussed, and Kroger sees this add to its health-wellness portfolio as a growth driver for the grocery chain. Kroger also operates The Little Clinic brand of retail clinics. “Health and wellness can be food; it could be mind, body and spirit,” Philecia Avery, Kroger’s VP of Pharmacy, told DSN. One of her missions is to ensure Kroger engages in collaborations that support health and wellness.

Hy-Vee, #18, has grown immunization and in-store clinics through its 8-state Midwestern footprint, and collaborates with local healthcare providers. The chain has invested in expanding nutritionists to bolster nutrition, weight loss, and disease management (e.g., diabetes) in the stores. To make healthy food purchasing easier, the chain operates 179 HealthMarket departments with organic, natural, gluten-free, and allergy-friendly foods, and publishes an in-store magazine called Hy-Vee Balance. Hy-Vee has an exclusive deal with Mark Wahlberg to market his sports nutrition line, Performance Inspired.

Raley’s, #34, opened in 1971 as the first “food-and-drug combo” superstore, DSN reports. The chain operates 121 supermarkets in Northern California and Nevada. Their program, “Let’s Begin,” leads shoppers through steps for leading healthy lifestyles based on personal goals, preferences, and budgets. There are “Better for You” checkout lanes that have replaced artificially sweetened sodas from fridges and added protein bars to the snack selections. “We want to make it easier for our customers to make better choices for their life,” said Raley’s Director of Pharmacy Operations, Dave Fluitt.

The PoweRx 50 report highlights many other examples of pharmacies and grocers building out health-and-wellness strategies, which include growing primary care services beyond immunizations.

Health Populi’s Hot Points:  The pharmacy that dispenses prescription drugs is complemented by goods in front of the counter: over-the-counter products that drive 2.9 billion trips annually to purchase OTCs, according to the Consumer Healthcare Products Association (CHPA).

CHPA found that without the availability of OTCs in the U.S., 60 million Americans would not seek treatment for their conditions. 81% of people in the U.S. Use OTC medicines as a first response to medical ailments. Picture worried parents in the middle of the night: nearly 7 in 10 parents have given their child an OTC medicine late at night to treat a sudden medical symptom.

While OTCs are very useful for children, they’re also convenient and inexpensive for mainstream adults who can access a growing range of OTCs for various conditions shown in the graphic: from sleep to smoking cessation, allergies to yeast infections, OTCs are a tool of health consumer self-care when used appropriately.

Facing growing out-of-pocket costs and first-dollar spending for high deductibles, retail health at the pharmacy for self-care and primary care is a huge opportunity on both the supply side (of pharmacies and grocers with pharmacies) and on the demand side for fiscally-mindful health consumers.

Lowering out-of-pocket costs were top-of-mind for Americans as the new year 2017 began, the Kaiser Family Foundation Health Tracking Poll results found.

Couple that with accessible and attractive spaces and parking, value-based pricing, and healthcare services that people need and demand in their local communities, and pharmacies and grocers can fill the need for greater primary care where people live, work, play, learn, and shop.

 

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Universal Basic Income

Universal basic income is the idea that all individuals in a society should be guaranteed a minimum income.  The logic behind this approach is one of equity.  Many members of society feel that all individuals are entitled to some basic level of financial well-being regardless of their skills, ability or willingness to work.

Current government approaches often aim to subsidize certain groups based on their family situation (e.g., single mothers), health (e.g., disabled) or current income (e.g., earned income tax credit).  Administering these programs can be costly.  Universal basic income is simple to administer, provides the maximum fairness, and may have fewer work disincentives than current programs.  For instance, an individual may wish to take a job with higher pay but if doing so means they would lose their Medicaid benefit, they may decide not to do so.  In effect, their marginal income tax rate would be very high, even potentially more than 100% once one incorporates the value of non-cash benefits.

Universal basic income does suffer from at least two problems.  The first is that it may be more succeptible to corruption.  Whereas current government programs may require (onorous) paperwork to verify program elibility, part of universal basic income’s cost savings could come from a lower administrative need, which could result in additional corruption.  For instance, people may stop informing the government that their elderly loved ones have died because they may want to continue getting their loved ones basic income check.  Also, raising a community’s basic income could reduce the number of people interested in participating in the labor market.

One particular study by Calnitsky and Latner (2017) looks at exactly this question based on data from the Mincome initiative, where the province of Manitoba instituted a basic income program for a certain town. They authors found:

Would people work less if their basic needs were guaranteed outside the market? Never before or since the Dauphin experiment has a rich country tested a guaranteed annual income at the level of an entire town. A community-level experiment accounts for the fact that people make decisions in a social context, not in isolation. Using hitherto unanalyzed data we find an 11.3 percentage point reduction in labor market participation, and nearly 30 percent of that fall can be attributed to “community context” effects. Additionally, we show that withdrawals were driven disproportionately by young and single-headed households. Participants who provide qualitative explanations for work withdrawals typically cite care work, disability and illness, uneven employment opportunities, or educational investment.

 

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Atul Gawande on AI

Tyler Cowen has one of his “Conversations” with Atul Gawande.  The interview is interesting throughout.  Below is an excerpt from their discussion on artificial intelligence.

TYLER COWEN: …How far are we from having an AI that is capable of actually doing diagnosis to people? That is, they might speak into a Skype connection, something like Watson would hear what they say, and they would then diagnose the person well enough that this would be a usable form of healthcare? Is that far, close?

ATUL GAWANDE: Massively far. I think it’s one of the hardest things. You want me to tell why?

COWEN: Tell us why, yes.

GAWANDE: OK, the diagnosis process—people imagine what it is, is that people come to you with a crisply defined problem. “I have symptom one, two, three. I have data to add to it, and now give me the answer.”

The reality is, first of all, people come to you often unable to explain what their problem is. “I have pain.” “Where?” “Hmmm. Well, it’s sort of here.” And they’ll point with a hand. “Well, do you mean there under your rib cage, or you mean in your chest, or . . .”

So you have this probing process that is part of it and how they tell the story. Then there’s also how their story had evolved over time, and they often have to put it in their words. It’s more of a narrative than it is a straight set of data. That’s problem one.

IBM Watson put their AI on this problem, and it would never be the problem I would have put them on. The second part of it is that it changes over time, and you’re adding data along the way. You’re integrating it with a little bit about your view of the understanding of the person and their likelihood to even say that something is a major symptom or not.

There is no question that you can augment the human capability. But the idea that you pull out your phone and it would give you the diagnosis—it is still one of the hardest problems in reducing error in medicine, is the fact that we still have a high rate of error, and the sources of the error have to do with the human being rather than the calculation.

COWEN: But say you only get 15 minutes with your doctor, which is pretty common, and as you know, those conversations don’t always run so well. People are intimidated, they forget the right question to ask. You could have three hours talking to something like Watson. Maybe 80 percent of the dialogue is nonsense, but at the end, you apply machine learning.

And keep in mind, the alternative now is that people use Google, which is in a sense the world’s number one doctor. So AI only needs to be better than Google, which is already a form of AI. In that sense, isn’t it just around the corner that it would be a marginal improvement on what we have today?

GAWANDE: Yeah, one is the replacement question. Can I simply have something that will make the diagnosis? And lots of reasons why that’s difficult. But to augment the human capability, absolutely. There already are programs. One example is called Isabel, where the clinician, having elicited all of this information, can simply put the observations into a list. It will allow them to recognize, “OK, fine. You think that what they have is diagnosis one, but here are eight others in rank order of consideration compared to the one that you think.”

There have been plenty of studies, and it’s been around for more than a decade without the need for AI. This is just crunching some basic data to begin with that can add real value. I think the puzzle of it is that you need that capability to integrate information coming from the person interpreted and be able to get it into these kinds of systems. And in many cases, people may be able to do some of that over time for themselves.

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Strengthening Chronic Care Is Both Personal and Financial for the Patient

 

6 in 10 people diagnosed with a chronic condition do not feel they’re doing everything they can to manage their condition. At the same time, 67% of healthcare providers believe patients aren’t certain about their target health metrics. Three-quarters of physicians are only somewhat confident their patients are truly informed about their present state of health.

Most people and their doctors are on the same page recognizing that patients lack confidence in managing their condition, but how to remedy this recognized challenge? The survey and report, Strengthening Chronic Care, offers some practical advice.

This research was conducted by West Corporation, which Health Populi readers might know by their previous corporate name, Televox, involved in patient communications.

As Peter Drucker is reputed to have coined, “you can’t manage what you don’t measure.” Not knowing one’s quantified target health goals compromises health literacy and effective patient engagement, leading to sub-optimal health outcomes. In a value-based and population health management world, that’s a lose-lose-lose for payors, providers, and patients. And as patients face more direct out-of-pocket costs via high-deductibles and HSAs, this is personal x 2: both clinically and financially.

Being diagnosed with a chronic condition weighs heavily on patients, West found: anxiety, frustration, stress and depression are common co-morbidities and responses among people who get new-news about a chronic condition such as diabetes, obesity, congestive heart failure, or COPD. Over one in five of these patients has difficulty sleeping, and one-fourth feel exhausted.

An obesity diagnosis is particularly hard-hitting: 52% of patients feel depressed after receiving this diagnosis, 48% feel anxious and stressed, and 24% of these folks feel isolated and on their own, West learned.

What do patients want? 70% of people with a chronic condition would like more resources on how to manage their disease, and 91% say they need help in managing their disease….not in the doctor’s office, but at home, between appointments.

Patients would like a range of support for self-care: 88% of people with a chronic condition who want assistance managing their disease believe help with the treatment would make a difference in their overall health:

• 35% want to better understand how to change unhealthy behaviors
• 33% of people want more individualized treatment plans, and
• 31% want tips and tools to better manage their condition
• Intermittent provider check-ins are important: 54% of patients see a weekly or twice-weekly check-in would be valuable.

Most patients with a chronic condition would welcome a remote health monitoring technology to collect, report, and communicate data between themselves from home and their providers. Only 6% of patients did not think this would be useful.

West Corporation surveyed, via Kelton Research, 502 patients with at least one chronic condition and a hospital admission related to that condition; and 417 healthcare providers, to gauge the physician side of the chronic care equation.

Health Populi’s Hot Points:  These findings complement those I discussed earlier this week in Health Populi on patients’ lack of engagement with their EHRs and personal health information.

This research into patients with chronic conditions reveals a ready-to-engage population, currently frustrated by the status quo of episodic visits to doctors with a lack of continuity of care and support for self-management of diseases at home. It’s important to realize that people with chronic conditions tend to be older; so, the fact the vast majority of these patients would welcome a remote health monitoring technology at home to manage conditions, along with more information and tools for self-care, demonstrates that patients are indeed embracing technology in daily living for DIY life. Today, patients are ready for DIY healthcare at home. This is the new home care Holy Grail, and most patients will welcome it.

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Greater St. Louis Dental Society finds key to engaging new dentists: Fun

Teeth and Summer Sports

As much as summer sports are excellent for your physical and mental health, injuries do happen. It’s all fun and games until someone gets hurt. If you didn’t break your arm while playing outdoors as a kid, surely you know someone who did.

But, what are the most common injuries to the face? If you said black eyes, try again—tooth trauma (including losing teeth) is actually the most common summer injury above the neck. Other common injuries include cuts to the lip and bloody noses.

Is there such a thing as a risk-free sport?

Unsurprisingly, some sports come with a higher risk of teeth injuries. Among the most hazardous summer sports for teeth are tennis, soccer, beach volleyball, outdoor basketball and football—in other words, the sports with flying balls. Just one simple mishap can lead to losing a tooth or breaking your jaw.

 

No matter how fun it is to get lost in the game, know what to do in the case of injury. Most accidents won’t be your fault, and so playing carefully isn’t enough. The only real way to avoid injuries to your teeth this summer is to not play summer sports at all, which no dentist would ever want to recommend.
So, what should you do in case of injury?

Some people win matches, others lose teeth. In the case of trauma to your teeth, see your dentist as soon as possible—especially if a whole tooth has come out. Store any whole teeth in water or milk until you make it to the dentist so they can be safely (and successfully) placed back in their spots. Knocked-out teeth should be replaced within a couple of hours, and usually will take few weeks for to stabilize. On the other hand, if your tooth broke, your dentist will have to design dental cups or non-metal crowns.
Should I always wear mouth guards? Even in non-contact spots?

The Academy for Sports Dentistry was formed in 1983 with the aim to protect sport players and to promote communication between dentists, doctors and coaches. Along with their injury prevention goals, the Academy recommends the consistent use of mouth guards. You can find standard mouth guards over-the-counter, which should be just fine for most summer outdoor sports. However, if you are a professional or competitive player, consider a personally-designed mouth guard crafted by your dentist. As compared with the generic guards, a personalized guard fits your teeth perfectly and doesn’t move when you experience a fall or hit. This makes them not only more comfortable, but safer and more effective.

Non-contact sports like tennis are less risky than contact sports—but that doesn’t mean injuries don’t happen. Whenever there’s a chance to take a ball to the face, or fall to the ground, mouth guards are the simplest and smartest way to protect your teeth. Just remember—playing safely only goes so far, because accidents can always happen. Just have your plan in place, and do what you can to keep your teeth where they belong!

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Economic Burden of ACPA+ patients with Rheumatoid Arthritis

That is the topic of my most recent article in the Journal of Managed Care & Specialty Pharmacy along with co-authors Mahlet Gizaw Tebeka, Kwanza Price, Chad Patel, and Kaleb Michaud.  The abstract of the article–titled “The Economic Burden of ACPA-Positive Status Among Patients with Rheumatoid Arthritis“–is below.

BACKGROUND: Anticitrullinated protein antibodies (ACPAs) are serological biomarkers associated with early, rapidly progressing rheumatoid arthritis (RA), including more severe disease and joint damage. ACPA testing has become a routine tool for RA diagnosis and prognosis. Furthermore, treatment efficacy has been shown to vary by ACPA-positive status. However, it is not clear if the economic burden of patients with RA varies by ACPA status.

OBJECTIVE: To determine if the economic burden of RA varies by patient ACPA status.

METHODS: IMS PharMetrics Plus health insurance claims and electronic medical record (EMR) data from 2010-2015 were used to identify patients with incident RA. Patients were aged ≥ 18 years, had ≥ 1 inpatient or ≥ 2 outpatient claims reporting an RA diagnosis code (ICD-9-CM code 714.0), and had an anticyclic citrullinated peptide (anti-CCP; a surrogate of ACPA) antibody test within 6 months of diagnosis. Incident patients were defined as those who had no claims with an RA diagnosis code in the 6 months before the first observed RA diagnosis. The primary outcome of interest was RA-related medical expenditures, defined as the sum of payer- and patient-paid amounts for all claims with an RA diagnosis code. Secondary outcomes included health care utilization metrics such as treatment with a disease-modifying antirheumatic drug (DMARD) and physician visits. Generalized linear regression models were used for each outcome, controlling for ACPA-positive status (defined as anti-CCP ≥ 20 AU/mL), age, sex, and Charlson Comorbidity Index score as explanatory variables.

RESULTS: Of 647,171 patients diagnosed with RA, 89,296 were incident cases, and 47% (n = 42,285) had an anti-CCP test. After restricting this sample to patients with a linked EMR and reported anti-CCP test result, 859 remained, with 24.7% (n = 212) being ACPA-positive. Compared with ACPA-negative patients, adjusted results showed that ACPA-positive patients were more likely to use either conventional (71.2% vs. 49.6%; P < 0.001) or biologic (20.3% vs. 11.8%; P < 0.001) DMARDs during the first year after diagnosis and had more physician visits (5.58 vs. 3.91 times per year; P < 0.001). Annual RA-associated total expenditures were $7,941 for ACPA-positive and $5,243 for ACPA-negative patients (Δ = $2,698; P = 0.002). RA-associated medical expenditures were $4,380 for ACPA-positive and $3,427 for ACPA-negative patients (Δ = $954; P = 0.168), whereas DMARD expenditures were $3,560 and $1,817, respectively (Δ = $1,743; P = 0.001).

CONCLUSIONS: RA-related economic burden is higher for patients who are ACPA-positive compared with those who are ACPA-negative. Providers may wish to inform patients diagnosed with ACPA-positive RA about the likely future disease and economic burden in hopes that both stakeholders can be more proactive in addressing them.

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Patients and “Their” Medical Records: Crossing the Chasm

Most physician practices and hospitals in the U.S. have installed electronic health records (EHRs). But in a classic Field of Dreams scenario, we have made patients’ medical records digital, but people aren’t asking for them or accessing them en masse.

“How do we make it easier for patients to request and manage their own data?” asks a report from the Office of the National Coordinator of Health IT (ONC), Improving the Health Records Request Process for Patients – Highlights from User Experience Research.

The ONC has been responsible for implementing the HITECH Act’s provisions, ensuring that health care providers have met Meaningful Use criteria for implementing EHRs, and then receiving the financial incentives embedded in the Act for meeting those provisions.

Now that the majority of health care providers in the U.S. have indeed purchased and implemented EHRs, it remains for patients, health consumers, and caregivers to take advantage of them. In my post on the EHR Field of Dreams effect, I highlighted research from the U.S. General Accountability Office that explored the question of how the Department of Health and Human Services should assess the effectiveness of efforts to enhance patient access to EHRs.

The ONC team conducted in-depth interviews with 17 patients to understand their health IT personae and personal workflows for accessing their personal medical records. The research also considered medical record release forms and information for 50 large U.S. health systems and hospitals, and interviewed “insiders” –health care stakeholders inside and outside of ONC — to assess how patients request access to medical records data and look for solutions to improve that process.

Why is it so important for people to access their medical records? By doing so, patients and caregivers can better manage and control their health and well-being, ONC notes, by preventing repeat tests, managing clinical numbers (like blood pressure for heart or glucose for diabetes), and sharing decision making with doctors and other clinicians — together, the process of patient and health engagement which boosts health outcomes for individuals and populations.

The general process of a patient requesting their health data works like this, illustrated by the patient journey of Melissa and Ava Crawford, a mother and toddler daughter portrayed in the ONC report:

• A patient/consumer makes an initial inquiry
• The consumer requests the records, which can be done via a paper authorization form (that is then completed and either mailed or faxed to a provider) or online via portal. Sometimes a consumer must write a letter request to the provider and mail or fax that paper ask.
• The consumer waits for a response, which ONC calls “a bit of a black hole for consumers.” This can be as long as 30 days under the HIPAA law.
• The health system receives and verifies the request, then verifies the patient’s identify and address.
• Health systems then fulfill the records request, often a printed copy of the medical record that can be faxed or mailed, PDF files, or a computer disk (CD).

ONC conducted research into the consumer journey along this process to identify opportunities to improve the patient experience of requesting and receiving personal health information.

Health Populi’s Hot Points: Most Americans see their doctors entering medical information electronically, and most people say accessing all kinds of medical information is important, the Kaiser Family Foundation learned in a health tracking poll conducted in August 2016. However, there are big gaps in the information available to U.S. patients online, such as prescription drug histories and lab results: two very popularly demanded information categories. And through the consumer-patient demand lens, 1 in 2 U.S. adults said they had no need to access their health information online, as the chart from the KFF poll attests.

How to bridge the chasm between self-health IT, providers and patients? The most effective patient engagement technologies are biometric measurement devices like WiFi scales and glucometers, apps, texting and wearables — with portals ranking last — according to physicians and clinical leaders polled in a New England Journal of Medicine (NEJM) survey published earlier this month.

The top benefit of engaging patients with these technologies is to support people in their efforts to be healthy, and to provide input to providers on how patients are doing when not in the clinic, this research found.

My friend and collaborator Michael Millenson wrote in the BMJ this month about patient-centred care no longer being “enough.” In this era of technology-enabled healthcare, and rising consumerism among patients, three core principles must underpin the relationship between patient and provider:

• Shared information
• Shared engagement
• Shared accountability.

Michael quotes Jay Katz from his book, The Silent World of Doctor and Patient, who talked 35 years ago about the concept of “caring custody.” Jay explained this as, “the idea of physicians’ Aesculapian authority over patients'” being replaced with “mutual trust.”

It is not enough to build and offer a technology “meant” for patients and people to use for their health and healthcare. Trust underpins all health engagement, and must be designed and “baked” into the offering. Today, that trust is built as much on consumer retail experience (the last-best experience someone has had in their daily life, exemplified at this moment by Amazon) as in a new social health contract between providers and patients.

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Why Medicaid patient access to physicians is limited.

In short, the reason is that Medicaid reimbursement rates for providers is too low.  Saurabh Jha, however, explains the point a bit more artistically in his Health Care Blog piece.

Medicaid pays a cardiologist, with years of training, $25-40 for a consultation to manage a complex patient with multiple comorbidities, on polypharmacy, where the cardiologist must indulge in shared decision making and also ensure the patient adheres to statins.  For comparison, my personal trainer charges me $80. There’s no shared decision making – he tells me to do “burpees” and I must abide or face his wrath.

Note that although Medicaid patients do face challenges to timely access to physicians, particularly in certain regions or for certain specialties, a majority of physicians do accept Medicaid.  The Kaiser Family Foundation found that:

About 70% of office-based physicians accept new Medicaid patients, compared to about 85% who accept new patients with private insurance or Medicare.

This finding does vary across specialty.  For instance, psychiatrists are especially likely to not accept Medicaid patients.

 

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Q&A: Dr. Bruce Terry, full-time dentist, part-time mountaineer

Is VBID gaining a foothold?

The answer is maybe.  Value-based insurance design ties patient cost sharing to the notion of a treatment’s value.  Higher value treatments have lower cost sharing; lower value treatments have higher cost sharing.  The Incidental Economist writes:

In his own practice, Dr. Fendrick feels as if standard insurance is working against him and his patients. “They are deeply concerned about the amount they have to pay out of their own pockets for the things I beg them to do,” he said. “It makes no sense that they pay the same co-payment for a lifesaving drug to treat diabetes or cancer, as for a drug that makes toenail fungus go away.”

This may be changing. The Affordable Care Act includes a V-BID provision, eliminating cost-sharing for more than 100 preventive services, such as vaccinations and cancer screenings. It’s endorsed by four committees of medical experts.

Many large employers and state governments are going further, reducing cost-sharing for high-value care and medications to treat chronic illnesses, like depression and heart disease. This year, the Centers for Medicare and Medicaid Services began a five-year test of value-based design that permits Medicare Advantage plans in seven states to reduce cost-sharing and enhance benefits for enrollees with designated chronic conditions. Bipartisan legislation has been introduced in the House and Senate to expand the program nationwide.

Some treatments are clear blockbusters.  Others are a complete waste of money.  Most treatments, however, are in the middle where higher cost may lead to more patient benefits.  Thus, a key question to be able to implement VBID is to be able to measure value.  That is one thing I am working on through research at the Innovation and Value Initiative.

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Self-Pay Healthcare Up, Hospital Revenues Down

For every 4.2% increase in a hospital’s self-pay patient population, the institution’s revenues would fall by 2.8% in Medicaid expansion states. This is based on the combination of a repeal of the Affordable Care Act and more consumers moving to high-deductible health plans.

That sober metric was calculated by Crowe Horwath, published in its benchmarking report published today with a title warning that, Self-Pay Becomes Ground Zero for Hospital Margins.

The “ground zero” for the average U.S. hospital is the convergence of a potential repeal of the Affordable Care Act (ACA), which could increase the number of uninsured Americans by 22 million in the latest CBO scoring of the Senate’s health reform bill; and, the growth of high-deductible health plans, which transfer greater medical financial risk burden (which translates into self-payment) onto patients.

The simple math, Crowe Horwath calculates, is that for every 2% increase in self-pay in a hospital payer mix due to an erosion in Medicaid, hospitals’ net revenues would decline by 1%.

For its benchmarking methodology, Crowe Horwath analyzed data from over 850 individual hospitals serving acute, critical-access, rehabilitation, psychiatric and cardiovascular care markets in the U.S.

Health Populi’s Hot Points:  This week, Gallup-Sharecare published their Well-Being Index, finding that the percent of uninsured Americans rose to 11.7%, a 7 % increase over the past 12 months (from Q2 2016 to Q2 2017).

Even without an ACA repeal, the shaky health insurance market facing American health citizens, whether un- or under-insured, or more fully insured at the workplace, has led to uncertainty among people facing greater out-of-pocket costs. Healthcare remains the top household financial pocketbook issue for Americans.

I must point out some good news on the financial wellness front as it’s been a rare message here on Health Populi in recent postings. The good news, starting September 15, 2017, is that three of the largest credit agencies (Equifax, Experian, and TransUnion) will address medical spending separately from the overall consumer credit report for a six-month period. Furthermore, medical debt will be removed from a consumer’s credit report once it is paid by a health insurer. More on this can be read here in Kaiser Health News.

Forty-three million Americans have medical debt in collections that has adversely impacted their credit ratings, according to the federal Consumer Financial Protection Bureau. CFPB’s study learned that for 15 million consumers, that medical debt was the only problem with their credit report.

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Links

• Patient-centered medical homes SLR.
• CBO expects US fiscal deficit to grow
• Eigenvectors and eigenvalues explained.
• The opioid crisis and the U.S. job market.
• Your right to your healthcare data.

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Sister follows brother’s footsteps into dentistry

Political Will Is Part of the Prescription for Healthcare Access

The Netherlands, France and Germany are the best places to be a patient, based on the Global Access to Healthcare Index, developed by the Economist Intelligence Unit (EIU).

Throughout the world, nations wrestle with how to provide healthcare to health citizens, in the context of stretched government budgets and demand for innovative and accessible services. The Global Access to Healthcare Index gauges countries’ healthcare systems in light of peoples’ ability to access services, detailed in Global Access to Healthcare: Building Sustainable Health Systems.

The United States comes up 10th in line (tied with Spain) in this analysis.

Countries that score the highest in this index share political and financial commitment to improving access to care and a “strong civil society,” as the EIU describes these nations’ social compacts. Strong national leadership, transparency and accountability are the hallmarks in these high-performing countries.

Public investment is allocated in these top-performing nations that explicitly commit to ensuring the health of their populations. While universal coverage doesn’t guarantee universal access to healthcare services, coverage does play a central role in improving healthcare access — think of it as an on-ramp to care.

Finally, good primary care is key for good access, and ensures a sustainable healthcare system. “Experts are increasingly viewing primary care as one of the best investments governments can make at a time of strained public finances,” EIU asserts. Rafael Bengoa, who co-directs the Institute for Health & Strategy in Bilbao, Spain, and contributed to the report, notes, “you cannot meet the ‘Triple Aim’ without a good primary care set up.”

As the chart illustrates, the Index is built from two domains: accessibility and healthcare systems. Accessibility has to do with prevention and treatment services across disease areas such as child and maternal health, infectious diseases (e.g., HIV/AIDS, malaria, TV and hepatitis), and non-communicable diseases (heart, cancer, diabetes, mental health), long with access to medicines and health equity.

The healthcare system domain covers health policy, infrastructure, and institutions. Note that “political will” is explicitly called out in this methodology.

 

What is particularly surprising in this study is where the U.S. falls on access to medicines — below the top 10, and yet the U.S. pays higher prices for prescription drugs, overall, than any other country the world over. The top ten performing countries for access to medicines are the Netherlands, France, Germany, Australia, Italy, UK, Brazil, Romania, Israel and Thailand.

For efficiency and innovation, the U.S. also ranks lower than the first nine above us — led by Germany, France, the Netherlands, and the UK. Turkey ranks ninth, and the U.S., tenth. This category is driven by expenditures on research and development as a percentage of GDP, the existence of health technology assessment, mechanisms for identifying interventions for de-adoption (that is, suspending use of low-value technologies, drugs and services), and performance-based payment models in hospital reimbursement and primary care.

Health Populi’s Hot Points:  You’re reading Health Populi and I’m a health economist, so I’ll bring this study back to healthcare spending as a percentage of GDP, shown in the map. Dark blue covering the U.S. represents over 13% of GDP, which is actually 18% today — nearly $1 in every $5 of the national economy. That nearly-20% is also the household budget cost of care for the average American family.

The critic of this Index and methodology may argue with its construction and mix of variables, but the general results of the study are informative and not necessarily new-news. But the call-out of political will is timely and worth spotlighting in this moment of national U.S. healthcare reform controversy and stasis.

Simply put: do Americans believe that every individual in the nation should have access to health care services, or not? In an op-ed by emergency  room physician, Dr. Farzon Nahvi, observing via his white coat and life-saving daily work, knows that a free market for healthcare cannot exist.

He is faced with saving lives, day after day, of people who arrive via ambulance, often waking up without realizing they were transported to the ER. “As an emergency medicine physician in a busy urban hospital, I have patients brought to me unconscious several times a day….More than once, however, such patients have regained consciousness furious. It wasn’t that they didn’t want to live — they were all simply upset at the costs their hospitalization incurred,” Dr. Nahvi explains.

He continues: “Most dismaying for me as a physician is that after all of my attempts to apply my compassion and training to save their lives…patients told me some variant of: “Thanks for what you’re doing, but I would rather that you hadn’t.” [A] man with [a] brain bleed, who certainly would have died without our immediate intervention, expressed dismay. In the neurology intensive care unit, with a bolt through his skull to measure the pressure around his brain, he told me that while he did not have health insurance, he did have life insurance. He said he would rather have died and his family gotten that money than have lived and burdened them with the several-hundred-thousand-dollar bill, and likely bankruptcy, he was now stuck with.”

House Speaker Paul Ryan said, “We’re going to have a free market, and you buy what you want to buy,” and if people don’t want it, “then they won’t buy it.” This doesn’t quite work in an emergency room when a provider has taken the Hippocratic Oath.

Do a sufficient number of members of the U.S. Senate have the political will to lay the foundation for a civil, healthy society? Might we Americans have the sort of health system where we can choose life and the pursuit of happiness instead of opting to will a life insurance policy to our loved ones, as Dr. Nahvi’s story so starkly explains?

Imagine a U.S. healthcare system that bolsters primary care for all, provides a basic medicines list, and boosts spending on social care and underlying determinants of health to promote wellness and prevent illness and non-communicable diseases. These are the building blocks of a civil society and a sustainable healthcare system.

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Did P4P work among VA Minorities with Hypertension?

Background

Do pay-for-performance (P4P) programs work?  P4P programs pay paying providers (or health plans) more if they have better outcomes or follow specific best practices. Whether or not they lead to better outcomes has been much debated.  However, many P4P programs implemented in the real world have been evaluated using a pre-post design which could create endogeneity if the date of the P4P implementation is not random.

Study methodology

In contrast, a recent paper by Petersen et al. (2017) uses a cluster randomized controlled trial design to see whether or not a program to incentivize providers based on the quality of care given to patients with hypertension leads to better outcomes.   This particular study looks at the effect of the hypertension P4P program specifically among black hypertensive patients.  Providers were provided training about the JNC 7 hypertension guidelines.

In the study, the trial:

…randomized 12 VA hospital-based primary care clinics to one of four study groups, differentiated by the type of incentive rewarded: (1) physician-level (individual) incentives; (2) practice-level incentives; (3) physician- and practice-level (combined) incentives; and (4) no incentives (control)…To ensure that facilities of the same type would not be concentrated in one arm, randomization was constrained on hospital teaching status, geographic location, participation in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

Physicians who had better outcomes (in the treatment arms) received higher payments.  These outcomes included:

• proportion of sampled black hypertensive patients receiving guideline-recommended antihypertensive medications,
• proportion with controlled blood pressure,
• proportion with uncontrolled blood pressure who received an appropriate clinical response to an uncontrolled blood pressure (e.g., lifestyle recommendation for stage 1 hypertension or guideline-recommended medication adjustment)

On average, the total additional payment per physician during the study was $2,744.

P4P programs can also lead to gaming.  Providers who want to maximize their bonus payments may focus on treating patients that are more likely to be adherent to treatment recommendations or who are relatively more healthy.  To test this, the authors look at “whether a patient switched providers, panel turnover among physician participants, and visit frequency.”

Results

Using this approach, the authors found that:

The proportion of black patients who achieved blood pressure control or received an appropriate response to uncontrolled blood pressure in the final performance period was 6.3 percent (95 percent confidence interval [CI] 0.8– 11.7 percent; p = .03) greater for physicians in the intervention group than for physicians in the control arm…However, after correcting for multiple comparisons (five study outcomes), the significance threshold did not meet the new adjusted significance level of 0.02.

There was no difference between the arms in patient switching rates and it appears that providers did not decrease visit rates for black patients.

In short there is some suggestive that the P4P improved hypertension outcomes.  Of the five outcome measures considered, all improved more in the intervention arm, but only two of these five results had a p-value of 0.05 or lower.

Healthcare Economist’s Discussion

Even if hypertension outcomes improved, however, it is not clear that P4P is optimal.  For instance, providers may increase their effort to treatment hypertension and improve intermediate hypertension outcomes, but may do this at the cost of focusing on a patient’s other diseases.  In particular, consider the case of a patient who has hypertension as well as a rare but more severe disease.  If the patient is requesting care for their rare disease, providers could treat the patient’s top priority at the risk of decreasing their quality score or they could focus on hypertension care but upset patients by not focusing on the patient’s most severe issues of the day.  This multitasking problem is well known in the field of economics, including work by the 2016 Economics Nobel Prize winner Bengt Holmström.

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Are Dental Implants the Best Solution for Tooth Replacement?

Whether you already lost your tooth or will have one removed soon, teeth should be replaced as soon as possible. The loss of even one tooth has more implications than the obvious aesthetic—it affects your overall oral health, too.

 

Immediately after your tooth is pulled out, the jawbone around the tooth begins to retract. This process, known as resorption, is most dramatic in the first three months. Additionally, your surrounding teeth will start moving toward the vacant space, creating tiny gaps between one another. The migration of teeth makes oral hygiene more difficult, and can change the shape of your face.

 

Causes of tooth loss

 

There are many reasons why you might lose a tooth. In most cases, it’s the result of an accident. You could lose a tooth in a traffic accident or in a sport activity, or any other time you take an accidental blow to the face.

10 reasons why dental implants are the best solution

 

Research has consistently shown that dental implants are the best solution to replace the loss of a tooth. Here are nine reasons why:

 

1. A dental implant functions as an equivalent substitute for your tooth, both in appearance and function. You will feel, speak and eat just as though you had a natural tooth.
2. Longevity. With appropriate care, your implant can last forever, as compared with the dental bridge with an average lifespan of seven years.
3. Dental implants prevent the loss of bone in your jaw (resorption). In comparison to dental prosthesis or a dental bridge, implants are the only solution that keeps the bone intact, and has even shown to encourage jawbone growth.
4. Chewing is undisrupted with dental implants, as opposed to prosthesis. Your new dental implant is often even steadier than natural teeth.
5. Dental implants are not susceptible to cavities. But remember, it’s still important maintain regular oral hygiene—it’s not just for your teeth, but for your gum health, too.
6. You spare neighboring teeth from damage that happens during the construction of a dental bridge. Dental implants are also the most secure option to prevent other teeth around your mouth from shifting.
7. Dental implants in their current form are the result of decades of research, and all the newest technologies. Titanium-based implants have only been around for 30 years—this is your state-of-the-art option for tooth replacement.
8. You don’t need to add new products or tools to your oral hygiene. Brushing your teeth is the same as always.
9. You’ll keep your smile and your self-confidence intact. And with dental implants, depending on the cause of tooth loss, many patients report how their confidence and quality of life even improved after their implant.
10. In the long run, dental implants can be more cost-efficient than any alternative, because they don’t have to be replaced.

 

There are many other reasons why dental implants are the most beneficial, long-lasting and functional tooth replacement solution. And with advancing technology, there are now options to have implants placed with one surgical procedure instead of two. Each of these options starts with a consultation with your dentist.

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