Let’s Increase Life Expectancy in America in 2018 – A New Year for Opioids, Social Determinants, and Financial Health

For this end-of-year post leading into 2018, I choose to address the big topic of how long we live in America, and what underpins the sobering fact that life expectancy is falling.

Life expectancy in the United States declined to 78.6 years in 2016, placing America at number 37 on the list of 137 countries the World Economic Forum (WEF) has ranked in their annual Global Competitiveness Report 2017-2018.

The first chart shows the declining years for Americans compared with health citizens of Australia, France, Canada, Finland, and the UK. While Australians’ and Britons’ life expectancies declined from 2015-16, their outcomes are still several years greater, at 82.5 for the Aussies (#10) and 81.6 for the Brits (#20).

The U.S. falls between #36, Qatar, and #38, Poland, in this analysis, below lower-income nations like South Korea (#12), Malta (#16), Chile (#18), and Slovenia (#29).

The WEF report talks about countries’ abilities to do business and mashes up dozens of data points, well beyond life expectancy. The Global Competitive Index is made up of factors covering institutions, infrastructure, macroeconomics, health and primary education, higher education and training, goods market efficiency, labor market efficiency, financial market development, technological readiness, market size, and innovation.

There are three sub-indexes that make up the big GCI: basic requirements, efficiency enhancers, and innovation and sophistication factors. Overall, the U.S. scores very high, #2, on the macro Global Competitive Index, just after Switzerland and before Singapore; good news, indeed, for business.

But you have to dive deep into the 393 page document, to page 326, to see the low performance of the U.S. in one specific sub-index which is what underlies America’s declining life expectancy and risk factors to living well: on the “basic requirements sub-index,” the U.S. garners the 25th spot on the list of 137.

What comprises “basic requirements?” we’re begged to ask. These pillars are shown in the second diagram on the left third of the chart: they are institutions, infrastructure, macroeconomics, and health and primary education.

Most of the datapoints underneath these pillars are social determinants of health: beyond health and primary education, macroeconomics set the context for health citizens’ financial wellness, job and income security. Infrastructure can bolster or diminish public health through clean (or dirty) water, clean (or dirty) air, safe and healthy physical built environments, and accessible and active transportation networks.

The U.S. performance on basic requirements improved at the margin in 2016, with the macroeconomic environment at a low of 83 out of the 137 world nations.

Health Populi’s Hot Points:  Thinking about the WEF “fine print” on basic requirements can help us understand what underlies declining life expectancy in the United States of America.

Most of the coverage of this statistic has been focused on the impact of the opioid epidemic in the U.S. A few others, rightly, point to obesity and the risk factors for non-communicable disease.

The U.S. is hardly “united” in this statistic: for people who live longer, it helps to be born and raised in a wealthier zip code, have access to better education and healthy food sources. A Lancet article published earlier this year, Inequality and the health-care system in the USA, noted that “widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes.”

Overlay these new data from the U.S. Bureau of Economic Analysis (BEA) on personal consumption, credit card use, and declining savings rates among Americans. These stats were published on 22nd December 2017, so are current as of end-of-year 2017.

Americans’ personal income grew 3.8%, up from 1.5% a year ago. That sounds like good news; however, this was driven in major part by inflation, which increased in 2017 (blame that primarily on energy prices). Adjusted, people’s disposable personal income growth was only 0.88% after taxes and inflation.

Couple this with consumer spending, which may be topping out. Why? Because the personal savings rate in the U.S. hit a new low, falling to 2.9%, shown in the diagram. Based on this new low savings rate, consumers are turning more to credit to pay for consumption.

So credit card use is rising while personal saving is falling.

“The consumer is maxed out,” notes Eric Basmajian who so wisely parsed the BEA data. See this chart for which Eric arrayed the tax rates for OECD nations, from highest to lowest. Check out the U.S., second from the bottom, just above South Africa.

While income disparities continue to widen in the U.S., the Tax Cuts and Jobs Act signed by President Trump on 22nd December does not have as an explicit objective of redistribution of wealth from the very wealthy to the lowest-earning 20% of Americans.

Thus, the dramatic disparity between rich and not-so-rich, at the root-of-the-root of declining health in America, will persist into 2018.

Filter this personal economic data through a health care lens. Most Americans live paycheck to paycheck to make ends meet, a CareerBuilder survey learned earlier this year. Over one-half of Americans could not pay for a $400 emergency without borrowing money from someone or taking it out of their 401(k) retirement fund.

Gallup’s November 2017 poll on health care costs found that about one-third of Americans put off medical treatment due to costs, and more women (37%) than men (22%) do. This may be due to the fact that women’s healthcare costs are typically higher than men’s. What’s most somber about this statistic is that nearly two-thirds of people who forego care due to cost say they have a serious condition. Self-rationing of care due to cost can lead to earlier, avoidable, disability and death.

Let 2018 be a year when we value health, health care providers, and truth-telling so we can join together to help make America’s healthcare great again.

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Nurses Rate Highest for Ethics in American Professions Once Again in Gallup Poll

Nurses working in the U.S. are number one when it comes to ethics and honesty, the Gallup Poll found for the sixteenth year in a row. After nurses, military officers, grade school teachers, medical doctors and pharmacists rank second through fifth in ethical-line behind top-rated nursing.

It’s important to note that consumers have ranked pharmacists and doctors in second and third place in this annual survey for many years. This year, both professions fall below the military and teachers. Nurses have been #1 in this study every year since Gallup launched the survey in 1999, except for 2001 when firefighters topped the list after 9/11.

At the bottom end of honesty and ethics we find lobbyists, auto sellers, and members of Congress ranking lowest in this year’s Gallup Poll, with Members of Congress as a profession garnering the greatest majority of Americans ranked “low” or “very low.” To that point, Gallup notes, “In a rare show of unity, roughly six in 10 Republicans, independents and Democrats alike rate the honesty of members of Congress lower than all other professions tested.”

The survey question is: “Please tell me how you would rate the honesty and ethical standards of people in these different fields — very high, high, average, low, or very low?” The Poll was fielded among 1,049 U.S. adults between 4th – 11th December 2017.

You can review some of my previous looks into this important study at the following links:

2016 – Nursing Seen As the Most Ethical Profession in America 

2013 – Nurses Are the Most Trusted Professionals in America

2012 – Nurses, Pharmacists and Doctors Rank Top in Honest Says the Gallup Poll 

2009 – Health Workers Are the Most Trusted Profession

Health Populi’s Hot Points:  The precipitous honesty/ethics ratings drop in consumers’ trust in pharmacists is stunning in 2017: see Gallup’s line chart to realize that 3 in 4 health consumers ranked pharmacists with very high or high ethics and honesty just two years ago, falling 13 percentage points in just two years. Gallup calls out the opioid crisis as a key contributor to this decline.

I agree, and I would also add patients’ growing exposure to high prescription drug prices via both the pricing of medicines coupled with enrollment in high-deductible health plans where patients, now consumers, are financially responsible for paying first-dollar for specialty drugs and health care. Because consumers pay for medicines at the point-of-purchase in pharmacies, they may be under the impression that drugstores set prices for drugs. Many consumers do not understand the job PBMs play in developing formularies (approved drug lists) and price tiers for co-pays and coinsurance. Consider this a prescription drug pricing literacy gap. Companies like GoodRx, Blink Health and Oration are playing important roles bridging this gap.

The third chart is the one I created from last year’s Gallup Poll, illustrating that nurses, pharmacists, and doctors ranked first, second and third in line (tied with engineers).

What held from last year’s Poll is the lowest ranks of Congress people, car salespeople, and ad practitioners.

What has also held — for nearly all of sixteen years — is that nurses are the most trusted form of human capital in America. Imagine how health care can be made better if nurses were supported to the highest level of their license to deliver patient care? Imagine if nurses provided input into service and UX design for healthcare? What if more nurses were deployed in pharmacies and grocery stories to help people bolster health and wellness?

Wouldn’t it be nice if those Members of Congress could design health care legislation that boosted, through funding and licensing, nurses’ starring and valued role in health and health care in America? Might this effort even help the political profession rebuild some long-lost ethical capital?

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What happens to CHIP?

The Children’s Health Insurance Program (CHIP) is a federal program that provides matching funds to states in order for them to provide health insurance to children.  The program was designed to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid.

Currently, however, the program is in jeopardy.  In fact, federal funding for CHIP expired September 30.  Some states, such as Colorado, have supplied emergency funding to keep CHIP afloat in their states.  On December 21, the federal government did pass $2.85 billion of emergency funding.  As funding was backdated to October 1, the 6 months of funding will only cover expenses through the end of March, 2018.

There are arguments on both sides of the aisle about the merits of CHIP.  Provide health insurance to kids has clear value to these children and their families.  Also, CHIP makes the U.S. society more equitable.  Those opposed to CHIP may prefer other ways to help kids get insurance, such as vouchers to purchase private insurance, or may even prefer to end CHIP and spend the tax money on other federal programs (e.g., education, defense), or tax cuts or may fear that CHIP may decrease the labor supply of parents who otherwise would work to get coverage for their kids.

Regardless of where you stand on the political spectrum, this uncertainty is clearly bad for all involved.  States have a hard time planning their budgets if they are unsure whether federal funds will materialized.  The federal government’s need to dip into emergency funding leads to a lack of fiscal discipline.  These expenses should be planned for.  Most importantly, parents and their children need to be able to plan for the future.  If CHIP is available, clearly many parents will want this coverage for their children.  If the program is not available, however, then perhaps some would return to work at suboptimal jobs rather than continue a job hunt in order to get health insurance for their family.  Large purchases (e.g., house, car, durable goods) clearly depend on the amount disposable income families have and this amount would decreases significantly if they had to buy insurance rather than be covered through CHIP.

Clear planning, transparency, and predictability are the hallmarks of good government.  This debate over CHIP funding–similar to the debates over the “doc fix” over physician reimbursement–shows that these emergency funding approaches are not only bad for the budget, but they hurt the people they are supposed to help by increasing the amount of uncertainty in their lives.

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What Kind of an Example Do You Set?

Monkey see, monkey do is a common expression when explaining the sometimes age-inappropriate actions taken by small children. As parents we know little ones are watching our every move. While most of the time we take this to mean they are watching our bad behavior, the truth is they are also watching our mundane, every day behavior. 

 

This realization can be somewhat terrifying. 

 

Imagine having your life filmed and then having the opportunity to watch it back. How many things would you cringe at or wish you could change? While there is no way we can ensure prefect behavior (in us or our kids) it is important to remember that their brains and eyes are always engaged and soaking everything in. 

 

Experts believe that by 15 months, children have both the fine motor skills and mental capacity to imitate many adult behaviors. It is important to use this impressionable age to teach your children life skills, such as good oral health with includes diligent brushing and regular flossing. Promote successful smiles in your house by being the good example. The experts in Dr. Ku’s office have given you a few examples below to get started with! 

 

Brush and floss daily 

 

Let’s start out with an easy one: Let your children watch you brush your teeth every morning and night. Even if it means it elongates the process—and a little extra brushing never hurts – let them be part of the routine. For the younger set let them brush a few of your teeth or turn the water on in the sink. For older kids consider brushing your teeth together. This added accountability will ensure the two minutes twice a day happens no matter what. 

 

Since flossing can still be difficult for many children, let them try to floss their teeth while you do yours. Then help them out to ensure all the space between the teeth is cleaned out. Who knew tooth brushing could be a form of bonding? 

 

Take them with you to the dentist  

 

We understand that no one really looks forward to going to the dentist, but it is important to not let that anxiety rub off on your children. At your next annual appointment bring your children along to show how easy and painless the appointments really are. Just like with adults, the anxiety and fear of the unknown is many times worse than the actual appointment for the child. Here at Dr. Ku’s we can help talk the child through your appointment so they know what will happen when they visit. Who knows, we may inspire a career or two along the way! 

 

Have an open dialogue  

 

Discussing normal bodily changes can be both awkward for the parent and the child so many shy away from the discussion until it is too late. Thankfully, discussing oral health is easier than many topics, so consider it your training ground for the teenage years. Begin at an early age talking about the benefits of good oral health and how to determine when there is a problem. This will lay the foundation for your child to come to you in the future if they sense something in their mouth is off or they are experiencing pain.  

 

Heap on the praise  

 

Don’t forget to praise your child for regular flossing and brushing. From potty training to showering to everything in between, parents are accustomed to praising most things that occur in the bathroom. The establishment of a good oral health routine should be no different. Positive reinforcement can do wonders when creating a good routine.   

 

While dentists are great at providing pointers and tips parents are the at-home example that ensures all the pieces fall into place. This holiday season give the gift of setting a good example of excellent oral health. Committing to a being a good example is also a great New Year’s Resolution. Do you have any unique ways that you incorporate your child into your routine to set the best example? Let us know by leaving us a comment!

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Friday Links

• An open-source approach to value assessment
• Economic freedom in North America.
• Cyberbullying and suicide.
• Why are we moving away from academic medical centers to academic health systems?
• Reform within state employee health plans

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Clever Gifts—At Every Price

Choosing gifts for a variety of people at just as many price points can be stressful. The secret Santa or a long-distance friend can be even more difficult to buy for when you don’t spend time with them regularly on top of it. 

 

Gift cards seem impersonal, but when it comes time to make a decision, it can be difficult to find something that balances unique interests while staying on a budget. So, we’ve made gift shopping easy, affordable, and quick for you this holiday season! 

 

Gifts under $10 

 

Skip the coffee cup or coffee shop gift card to get something more memorable. Don’t assume cheap has to mean it’s a waste. 

 

Funny socks: This option is great for the office secret Santa! It’s useful without crossing any work boundaries or creating an awkward situation, and stretchy fabric can allow you to just eyeball rough shoe sizes. 

 

Funky pencils: Forget the orange, number two pencil you remember from your school days. Pencils that feature tops of woodland creatures or interesting patters can be stuffed in any stocking, and can actually be put to good use. 

 

Small succulents: For the wanna-be gardener who hasn’t quite cultivated their green thumb, succulents require little work and are small enough to be placed on a desk or windowsill.  

 

Gifts under $25 

 

This price point is perfect for distant family or friends you don’t see often. Gifts under $25 are also great to stock in a closet in case someone drops by unexpectedly with a gift, and you feel the need to reciprocate on the spot (you know that’s happened to you at some point). 

 

Digital wine bottle thermometer: Giving the gift of wine is always appreciated, but it lacks creativity. However, for the wine lover, this unique gadget is perfect to ensure their pinot is always chilled to the right temperature. 

 

Wood coasters: For the nature lover, bring the outdoors in with wood coasters. In addition to being visually pleasing, your furniture will thank you for protecting it against drinking glass rings.  

 

Tea towels: Pick holiday-specific dish towels that can be displayed in the kitchen. These towels are easy to store, and can be packed away as a last-minute gift. 

 

Gifts under $50  

 

These gifts are most likely for close friends and family. Therefore, it’s expected that you put some thought and effort into their procurement…and this expectation only adds to the pressure.  

 

Water-resistant Bluetooth speaker: If you have a niece or nephew who is music lover, a water-resistant Bluetooth speaker is great for summers spent at the pool. They won’t have to worry about ruining a speaker with splashing, and can keep their music source safely away from the pool. 

 

Three–month box subscription: Give the gift that keeps giving. Many subscription services will allow short-term signups: from chocolate to make-up, you can tailor any gift for those who are hardest to shop for. 

 

Portable iPhone photography kit: The current cameras in smart phones today are better than many DSLR cameras on the market. Give additional lenses and a tripod suited specifically for phones to allow the recipient to take professional-quality photos with their cell! 

 

Gifts under $100 

 

For those that are closest, you want to be able to give them something that they will love, and that shows that you take notice of the small things they like.  

 

Neon sign for a table: We all have that friend that has impeccable style, and is nearly impossible to shop for. Tabletop neon signs featuring inspiring words or phrases light up any space, and are edgy with a hint of nostalgia.  

 

Instax Mini 90: Move over, old-school polaroid camera that’s both bulky and heavy! This camera is perfect for creating instant images, and has a hip, streamlined exterior that everyone will love. 

 

Monogrammed cheese board: This is great for people who love to cook, and those who love to eat! The personalization could take a week or more, so get to ordering! 

 

This gift guide is only the beginning. If you see any great gifts exchanged this year, let us know by commenting below and we will update our gift giving guide!

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Why fighting disease is hard

Without a doubt, medicine has made tremendous gains over the last decades and even more progress when viewed across centuries.  Often to treat diseases, physicians and researchers identify a single or primary pathway that is causing the disease.  Maybe there is a gene mutation which causes an abnormality.  Maybe there is a bacteria or virus that is invading the body.  Typically, we look for a single disease cause and identify treatments to that can address this root cause.

Things get much more complicated, however, when disease a disease is caused by numerous factors.  Consider the following example from the book I Contain Multitudes: The Microbes within us and a gander View of Life, examining the case study of researcher Herbert Virgin and his analyses of mice with genetic mutations for Crohn’s disease.

These rodents developed inflated guts, but only if they were infected by a virus that knocked out part of their immune system, and were exposed to an inflammatory toxin and had a normal set of gut bacteria.  If any of these triggers was missing, the mice stayed healthy.  It was the combination of genetic susceptibility, viral infection, immune probles, environmental toxin, and their microbiome that gave them IBD [Irritable Bowel Disease].

Identifying multiple root causes is complex.  In this case, by addressing one of these causes, IBD could be cured.  In practice, however, sometime there many be cases that without addressing all causes, the individual may not recover normal health.

This complexity certainly makes for interesting research for scientist, but also highlights that perhaps medicine has only begun to address the low hanging fruits.  While there is much potential to further cure human diseases, doing so will likely become increasing complex.

As a side note, I do recommend the by I Contain Multitudes book by Ed Yong.  The book describes how bacteria act symbiotically in both positive and negative ways with humans, other animals, and other organisms as well.  The book highlights some recent research, while presenting the content in a non-technical manner.  I found it an enjoyable read to introduce non-biologists to the importance of the microbiome.

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What Healthcare Can Learn from Volkswagen: A Scenario of a Post-Healthcare World

As I am finalizing my schedule for meet-ups at CES in Las Vegas for early January 2018, I’m thinking about digital devices and wearable tech, connected cars, smart homes, and the Internet of Things through my all-health, all-the-time lens.

My friends at TrendWatching write today about the automaker, Volkswagen, which has a division called MOIA started in 2016. VW, like most car manufacturers, is working on strategies to avoid being disrupted and made irrelevant as tectonic forces like autonomous cars and shared rides innovate and re-define the nature of personal transportation.

MOIA is a brand and a self-described “social movement.” The organization’s objective is, “to develop and offer an extensive portfolio of on-demand mobility services that make the lives of people living in urban areas better, cleaner and safer.”

Ole Harris, the brand’s CEO, said that ultimately, MOIA’s goal will be to, “take one million vehicles off the road by 2025.”

Here’s an automaker stating the intention to remove autos from the road.

As TrendWatching puts it: “What would it look like if we launched a start-up whose aim was to reduce sales by one million units?”

Health Populi’s Hot Points: For the legacy healthcare system, some analogous questions would be:

• What is a pharmaceutical company without pills?
• What is a hospital without beds?
• What is a doctor without bricks-and-mortar exam rooms?
• What is a health plan beyond a health insurance marketer?
• What is an electronic health record where data are owned and controlled by patients?

Today, carmakers are challenged by Tesla, Lyft, Uber, Zipcar and shared bicycle services, along with emerging autonomous car developments, some of which are sponsored by the auto companies themselves.

Healthcare providers, plans, and suppliers are challenged by their own equivalents of Teslas and Ubers. Some of the disruptors are obvious — Amazon, of course, along with Health 2.0 companies delivering transparency, new business models for healthcare delivery, medical banking programs, and IoT devices that melt and blur into peoples’ daily lives through enchanting design and useful services.

But there are more subtle forces at work to disarm and disrupt healthcare as we know it: among them, the demographic force that are Millennial consumers and younger, and at the older age spectrum, Boomers. Younger and older patients alike will challenge healthcare providers and suppliers to provide and supply services and products that serve and (co)produce health.

Note that MOIA seeks to, “make make the lives of people….better, cleaner and safer.”

Sounds a lot like health, doesn’t it? That’s no surprise to me: in the Edelman Health Engagement Barometer, we learned that consumers in fact look to auto companies as partners in health.

I’ll be thinking about the implications and lessons of MOIA in and beyond 2018 through my health/care lens with my clients and colleagues. I advise that you do, too.

Please stay connected to the Health Populi blog and my Huffington Post columns during CES week, 7-12 January 2018, for more on new-new digital health things. 

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How is Washington State using evidence-based medicine?

A paper by Rothman et al. (2017) explains what goes on at the Washington Health Technology Assessment Program’s (WHTAP), the first state-administered health technology assessment (HTA) program in the U.S.:

Over the past 9 years, Washington State has been pursuing an innovative and generally effective program to use evidence-based medicine to determine state health care coverage decisions. Its Health Technology Assessment Program committee evaluates diagnostic and therapeutic technologies—except pharmaceuticals, the responsibility of a different group—by the criteria of safety, efficacy, and cost-effectiveness.

How are new diagnostic and therapeutics to be evaluated?  The answer is purely based on cost. As one state official said:

We will be looking for emerging or fast-growing technologies that could have the biggest impact on the state’s budget.

Once treatments are selected, WHTAP determines whether to cover a technology, cover it with conditions, or simply deny coverage.  These decisions affect coverage decisions for state employees, Medicaid, state worker’s compensation programs and correctional health.  Between 2007 and 2013, 67% of technologies of the 39 technologies that were reviewed were covered with conditions, 26% denied, but only 8% covered with no conditions. The key factors affecting this decision were lack of efficacy and lack of safety; a lack of cost-effectiveness only because relevant for technologies with significant capital outlays (e.g., robotic surgery purchases). The factor with the smallest influence was cost-effectiveness.

While using treatments supported by evidence is clearly a good thing, the effect of WHTAP’s decisions on state finances or clinical outcomes is not well known as data are limited.  Further, practicing top-down medicine to identify treatments that are high-value for the average patient may be problematic if there exists significant clinical heterogeneity that physicians, nurses or other health professionals can observe on the ground, but that WHTAP committee members may not be able to see.  Identifying evidence-based treatments is useful; however, we need to keep medical decision-making in the hand of the physician-patient relationship informed by–rather than mandated by–evidence based medicine.

Source:

• Rothman, David J., Kristy L. Blackwood, Whitney Adair, and Sheila M. Rothman. “Evidence‐Based Medicine and State Health Care Coverage: The Washington Health Technology Assessment Program.” Health services research (2017).

 

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Travel Hacks for Winter Getaways

Traveling can be hard, much though we’re excited to do it. With kids’ stuff and the right clothing for the right location, combined with ensuring all things taken through the TSA checkpoint at the airport comply with regulations, it’s no surprise that most Americans choose to stay at their house for the holiday season. However, if you’ve chosen to travel in the coming weeks, those of us here at Dr. Ku’s office want to make it easy and enjoyable. 

 

Plus, gritting your teeth in frustration isn’t great for your jaw or pearly whites. Consider this your go-to travel guide on the “dos” and “don’ts” of packing and hitting the airport! Now, if only little elves would show up and help you finish everything on your to-do list… 

 

DO: Lay out everything you are taking before it goes in the suitcase 

 

Prior to jamming in all the presents and Christmas sweaters, lay out everything you think you want to take. Your bed should be ample space to eyeball it. Then, start consolidating. A week away doesn’t require seven pairs of pants. If you are going to your family’s house, consider doing laundry while you’re there to limit the amount of clothing you’re forced to take. If laundry isn’t an option, layer your clothes. You can wear your outer layers multiple times. Whatever you think you need, you can probably get away with at least 20% less. 

 

DON’T: Bring the full–size toiletries—instead, opt for travel sized varieties 

 

First, if you plan to carry on your bag, remember the 3-1-1 rule that prohibits you from taking more than 3 ounces of liquid in a carry-on through the airport. Use this opportunity to experiment with new products from the travel size aisle at the store. If you hate the new shampoo, good news, it was only a small sampling. If you are checking a bag, still opt for the travel-sized options. First, it weighs less and takes up less space in your bag. And second, if it does leak, there is less to ooze all over the contents of your bag. 

 

DO: Lock your bag and add something to the handle for easy identification 

 

While we never like to think theft will happen, it is always a possibility, especially around the holidays when suitcases are stuffed with gifts. Purchase a TSA-approved lock to ensure your belongs are safe while they are out of your sight. Also, if you have a suitcase that looks like everyone else’s, add a bright ribbon or luggage tag to the handle. This will help you pick it out quickly when it comes off the plane and will prevent others from accidentally taking your luggage. 

 

DON’T: Forget a travel kit for toiletries 

 

Consider carrying on your travel kit of toiletries with all needed medications, your tooth brush and toothpaste, and any other essential items should your bags not make it to your final destination. Traveling up north at this time of year can result in delays due to snow and ice, or cancellations that leave you stranded at the airport. Having these items with you can make your first days on vacation a little less miserable if your bags don’t make it. 

 

DO: Bring patience and a good attitude 

 

The lines are long and we’re all exhausted, schlepping all of our belongings through the airport. While rolling your eyes at the people who forget to take off their shoes in security, or making comments at those moving slowly, try to have a little patience this holiday season. We all want to get to our final destination, and doing it without any drama is the best way—hands down. 

 

Those of us at Dr. Ku’s office hope you and your family have safe travels and a very happy holiday season. Leave us a comment if you have any other tips or tricks for travel!

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The Big Five

UnitedHealthcare, Anthem, Aetna, Cigna and Humana are the five largest health insurers in America. To learn more about them, check out a recent paper by Schoen and Collins (2017) in Health Affairs.

The five largest US commercial health insurance companies together enroll 125 million members, or 43 percent of the country’s insured population…In 2016 Medicare and Medicaid accounted for nearly 60 percent of the companies’ health care revenues and 20 percent of their comprehensive plan membership. Although headlines have focused on losses in the state Marketplaces created by the Affordable Care Act (ACA), the Marketplaces represent only a small fraction of insurers’ members.

With CVS and Aetna merging, it will be interesting to see if Aetna’s market share grows or shrinks based on this merger.

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Health Consumers Face the New Year Concerned About Costs, Security and Caring – Health Populi’s 2018 Forecast

As 2018 approaches, consumers will gather healthy New Year’s Resolutions together. Entering the New Year, most Americans are also dealing with concerns about healthcare costs, cybersecurity, and caring – for physical health, mental stress, and the nation.

Healthcare costs continue to be top-of-mind for consumer pocketbook issues. Entrenched frugality is the new consumer ethos. While the economy might be statistically improving, American consumers’ haven’t regained confidence.

In 2018, frugality will impact how people look at healthcare costs. 88% of US consumers are likely to consider cost when selecting a healthcare provider, a Conduent survey found. Physicians know this: 81% of providers say patients have talked with them about health care costs.

Consumers confront chaos in U.S. healthcare reform, with the over-arching GOP health reform efforts scuttled by a slim margin of “nay votes,” but the just-passed tax bill repealing the individual mandate. “Repeal and replace is now coopt and confuse,” Dr. Ann Hwang, a primary care physician, wrote in Modern Healthcare this week.

Millions of people in the U.S. won’t have health insurance in 2018, and so will face a truly retail experience with health care providers and suppliers in their communities. Cost is the barrier to coverage. Having health insurance makes a difference in whether people get medical care they need, and impacts how healthy people are. Health insurance is a social determinant of health.

“All health sectors have started to try their hand at social interventions,” PwC’s 2018 top industry issues report notes.

One healthcare industry that will get increased consumer and legislative scrutiny in 2018 will be prescription drugs. Across Democrats, Independents and Republicans all, most consumers would like the U.S. Federal government to take more action on lowering the cost of medicines. The Conduent poll also found that 60% of U.S. consumers believe making Rx drugs more affordable should be the nation’s top healthcare priority. Americans are quite aware of their role as payors of the highest prices of prescription drugs in the world. Scott Gottlieb, the current FDA Commissioner, has talked about this policy priority for 2018.

Because consumers have a retail relationship with prescription drugs through pharmacies, the issue gets peoples’ attention due to greater price transparency – at least in the form of co-pay, coinsurance, or first-dollar payment under a high-deductible health plan. Pharmacies understand their role as accessible retail health on-ramps for medications and counsel, and growing role as health care providers. In 2017, CVS launched a drive-up service for consumers to collect their prescriptions at the curbside. Then the company announced intentions to deliver Rx to patients’ homes. Finally, CVS announced its intention to acquire Aetna, the health insurance company.

This vertical integration will be just the start of new business models developing to bring healthcare more conveniently and, potentially, cost-effectively to the consumer in 2018. Perhaps Walmart will buy Humana, Ana Gupta of Leerink Partners recently discussed on CNBC’s Squawk Box.

Expect more retail-facing health delivery programs in the New Year, such as the relationship recently struck between Walgreens and New York Presbyterian’s On-Demand suite of consumer digital health services. Walgreens has been an important influencers in promoting consumers’ use of wearable technology to track health, through the company’s Balance Rewards loyalty program. The company started the Center for Health and Wellbeing Research to expand research into consumer health and self-care. This is but one more sign of the evolving retail health landscape that’s positioned to meet consumer demand for greater access to cost-effective, empowering care channels in the community.

Promoting the use of wearable tech has been part of Walgreens’ consumer health strategy for several years. There’s a growing “retail of physical wellness” Field Agent’s research talks about. 96% of U.S. adults expect to exercise, work out, or play a sport in 2018. People will endeavor to do more physical activity in the New Year, along with nutrition and diet, weight management, and better managing stress and anxiety levels. 57% of Americans own at least one wearable technology to enhance fitness and sports participation, Field Agent found, from activity trackers to apps.

Consumers’ interest in virtual and telehealth will grow in 2018: Accenture’s Voting for Virtual Health poll found that 3 in 4 consumers are interested in using digital technologies to track health status like blood pressure, to follow up appointments after seeing a doctor, to follow-up hospital stays, and to receive reminders for healthy living.

Don’t think it’s only Millennials who demand virtual health services. PwC’s consumer survey found an older age cohort 65 and over willing to use digital devices at home and engage in telehealth visits, too. What underpins older consumers’ willingness-to-try digital health tools is their increased adoption of smartphones: two-thirds of people aged 55-75 had smartphones in 2017, up from 53% in 2015, Deloitte’s Mobile Consumer survey learned.

The FDA’s newly-issued guidance defining what constitutes a medical device clarifies what software and digital health tools constitutes a “medical device.” These reg’s should enable more products to come to market in 2018 for consumers’ use at home and on-the-go for self-care. Consumers’ purchases of digital assistants, like Amazon ECHO and Google Home, will also expand peoples’ digital health adoption through voice-first technology in 2018. With CES 2018 happening in January 2018, I’ll be curating innovations for consumers’ healthcare, so do stay tuned to Health Populi for new-news on the topic of consumer-facing wearable and digital health.

Notwithstanding the FDA’s greater clarity on the supply side development of digital health tools, consumers remained very concerned about the security of their personal health information. The Equifax breach of 2017 made the majority of Americans quite aware of the value of personal data. Most doctors’ information systems have been breached, research from the American Medical Association and Accenture reported. “Physicians, overwhelmingly, are finding themselves the target of cyberattacks that disrupt their practices and put patient safety at risk,” the report observed. “More support from the government, technology and medical sectors would help physicians with a proactive cybersecurity defense to better ensure the availability, confidentially and integrity of health care data,” AMA and Accenture recommend.

But people have a trust paradox when it comes to their digital connections, based on a new poll from Cisco. The paradox is that consumers’ perceived value of the Internet of Things may be high, but trust is low. Despite this chasm, peoples’ connectivity is integrated into daily lives, so much so that many people are unwilling to disconnect. While security breaches erode consumer trust, we may be at a “point of no return,” in Cisco’s words, when it comes to people unwilling to disconnect due to their values for convenience, efficiency, and cost-savings generated through connected cars, smart homes, and wearable technologies.

It may give health consumers some solace to know that hospital leadership looks to increase funding for cybersecurity in 2018, based on UPMC’s Center for Connected Medicine joint survey with The Academy.

And so stay connected people will, some voicing, “Alexa, remind me to eat cleaner today.” Two-thirds of Americans are determined to eat healthier in the New Year, Field Agent’s research found. More people vow to eat less fried food, fast food, and sugar. And, more consumers look to eat more fruit, vegetables and salads, per the CDC’s recommendations based on the Center’s recent report finding that too few Americans consume enough fresh produce in daily diets. Food prescriptions, whether self-imposed or recommended by physicians or health coaches, will be more common in 2018. Emerging food trends will include neuro-nutrition for “mood food” and brain health. Examples of this are Honeybrains, a café with a menu developed by a neurologist, and the subscription meal vendor Euphebe (an abbreviation for their mantra, “You’ll Feel Better”).

Why growing attention to self-care among U.S. healthcare consumers? It’s to feel better and manage healthcare costs, for sure, but there’s another factor: other people. 53% of Americans are engaging in better self-care to be better for others, Field Agent’s poll found.

I conclude this tea-leaf reading on consumers and healthcare for 2018 with another form of connectivity: social. Loneliness takes a toll on our health: “We can’t discount the risks of being socially isolated even if people don’t feel lonely,” Julianne Holt-Lunstad of Brigham Young University said. Despite growing digital connectivity, socially isolated individuals are “a growing epidemic,” according to Dr. Dhruv Khullar at Weill Cornell Medicine NYC.

The APA Stress in America Survey – The State of Our Nation poll found that 59% of Americans say we’re at the lowest point in our nation’s history that people can remember. The biggest sources of stress among Americans are worry about the future of the country, health care, money, work, political climate, and violence and crime.

Let 2018 be a year of greater social connectivity, in real-life, in real-time.

Wishing you a healthy, loving holiday season and New Year of community and personal peace.

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Friday Links

• The cost-effectiveness of CAR-T.
• Cancer gene testing breakthrough.
• Uninsured vs. Insured: ER use.
• Doulas for death.
• What’s the problem with digital DNA?

Plus, please check out the Happy Holiday Health Wonk Review at Workers’ Comp Insider.

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Net Neutrality is Dead: What Happens to Connectivity as a Social Determinant of Health?

Today’s FCC’s repeal of the net neutrality rules for internet service providers will have an impact on healthcare — in particular, the channeling of telehealth services.

“The Federal Communication Commission overturned a two-year-old set of rules passed during the Obama administration to protect consumers against bad behavior from their Internet service providers, overriding protests from consumer groups and Internet companies,” USA Today wrote just after the ruling.

The concern from advocates to keep net neutrality is that the large ISPs — AT&T, Comcast, and Verizon, among them — could be so-called “bad actors” in favoring fast-lane communications for certain content versus other information that consumers, under net neutrality, could access equally. Ultimately, “could ISPs become content-controllers, or charge additional ‘tolls?” those who wish to preserve net neutrality have asked.

The adoption of telehealth, telemedicine, and any healthcare services delivered to consumers via the Internet could face barriers or slow due to the impact of net neutrality, according to several opinions published in the healthcare trade press and academic journals.

“Telecommunication policies may have unintended healthcare consequences,” the Health Affairs blog explained. High-speeds are crucial for connecting healthcare providers to patients for remote health monitoring, and overall connectivity is still needed in rural America.”

To that point, Mei Kwong, policy adviser for the Center for Connected Health Policy, warned, “The last thing you want is for the interaction to suddenly freeze or the audio to go out or for the picture to be pixelated,” in Modern Healthcare today.

Children’s health may be negatively impacted. The American Academy of Pediatrics wrote, “The general public, including parents and caregivers of children, use web-based platforms to access children’s medical records, make appointments and find health information. Having slower access to these tools could potentially result in delays in care and seeking information, and place an undue burden on ready access to quality healthcare and health information,” AAP wrote in testimony to the FCC back in 2014.

Health Populi’s Hot Points:  Broadband access is a social determinant of health, I have argued for some time, such as here in the Huffington Post in July 2016.

Interestingly enough, consumers ‘get’ that ISPs haven’t delivered on customer service, we know from Temkin’s consumer experience survey, shown in the second chart. Note that peoples’ ratings of user experience with Internet service are lowest, ranked with health insurance plans.

In 2018, Internet connectivity should be seen as a basic human right and necessity for health and wellness, such as clean water, clean air, healthy food, and access to basic healthcare services. As America continues to debate the shape of healthcare reform, net neutrality diminishes an important building block to public and individual health for Americans, telehealth and virtual health services. These new modes of healthcare delivery can help the nation lower costs, expand access, and enhance patients’ and healthcare providers’ experience.

 

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Does the value-modifier improve quality and reduce health disparities?

In short, no.  That is the answer Roberts, Zaslavsky and McWilliams reach in their 2017 paper in Annals.

Some background on the value modifier program.  In 2013, practices with 100 or more eligible clinicians were rewarded just from reporting quality measures. By 2014, however:

Practices with 100 or more clinicians were subject to upward, downward, or neutral performance-based payment adjustments, those with 10 to 99 were subject to upward or neutral—but not downward—adjustments, and those with fewer than 10 were unaffected. In 2015, all practices with 10 or more clinicians were exposed to full VM incentives (both penalties and bonuses). Base payment adjustments ranged from 2% to 2% on the basis of 2014 performance and from 4% to 4% on the basis of 2015 performance, but high-performing practices have received much higher bonuses (for example, rate increases of 16% to 32% in 2016), because the VM’s budget neutrality provision stipulated that penalties for failing to meet reporting requirements be redistributed as bonuses.

Because of the eligibility cut-offs at 10 and 100 clinicians and the staggered role-out of the design, the authors use a regression discontinuity approach based on practices around the 10 and 100 clinician threshold.  They use 2014-15 Medicare claims data to examine three outcomes: (i) inpatient admissions for ambulatory care–sensitive conditions, (ii) Medicare spending per beneficiary, and (iii) all-cause readmissions within 30 days of hospital discharge.  Using this approach, they find that:

…differences in hospitalization for ACSCs, readmissions, Medicare spending, and mortality between practices above the size thresholds and those below (the adjusted discontinuities) were small in 2014 and not statistically significant…size. Analyses of the threshold of 100 or more clinicians that used 2015 data revealed no statistically significant discontinuities associated with a second year of full exposure to the VM.

In short, no effect was found. In addition, they found that risk adjustment was inadequate.  Adding addition risk adjustment factors narrowed differences in performance between high and low performing groups in particular among practices that served a disproportionately disadvantaged population.  While the value modifier is built from good intentions–pay more for high quality, low cost care–in practice, the results are not overwhelming.

 

Source:

• Roberts, Eric T., Alan M. Zaslavsky, and J. Michael McWilliams. “The Value-Based Payment Modifier: Program Outcomes and Implications for Disparities.” Annals of Internal Medicine (2017).

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Support for the Affordable Care Act the Highest Since Passage

Americans’ approval of the Affordable Care Act reached its apex in December 2017, the Pew Research Center found. The proportion of people approving the ACA has been growing since the middle of 2016, now at 56% of the public.

The timing of this survey, conducted at the end of November and first few days of December 2017, coincides with Congress’s arm-wrestling a tax bill that would eliminate the individual mandate for health insurance which is an ACA building block for universal coverage in the United States.

Most people in the U.S. also believe that the ACA has had a positive impact on the nation, at a margin of 44% positive versus 35% negative impact.

Looking at the demographics of who feels positive about the law, shown in the second chart, reveals that more women than men approve of the ACA (61% versus 50%); more people of color versus whites, who are split 47/47; and, younger people under 50 versus older folks.

There continues to be a huge chasm between Democrats and Republicans on how members of each party view the law. More Democrats have come to appreciate Obamacare more today, now at 85% of Democrats approving of the ACA. However, the proportion of Republicans approving the ACA remains flat at 14%.

Health Populi’s Hot Points:  Will yesterday’s election of Doug Jones to represent the State of Alabama as a Democrat in the U.S. Senate change the dynamic for the GOP’s tax bill to pass or fail? Vox presents the argument this morning for a tax bill #fail.

Dropping the individual mandate for health insurance would leave 13 million fewer Americans out of health insurance, the CBO calculated, with even more health plan premium increases on Americans seeking coverage.

There are additional health care access challenges that Congress has yet to resolve, namely the re-authorization funding CHIP for children’s health, and funding Federal Qualified Health Centers that cover safety net populations who do not have health insurance.

More Americans are aware of these cracks in U.S. health citizens’ coverage, thus building up more support for the ACA that Pew’s research learned.

At 2017, Americans find a nation facing a new year of health policy chaos and under-funding. With dreams of cancer moonshots, precision medicine, and the promise of AI for improving healthcare, we must ensure the basic human needs of health coverage, access to primary care, nutritious food, and a basic list of drugs. These are what I wish for every American’s Christmas stocking to hold.

For now, the only certainty is the equivalent of a health care lump of coal.

 

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How one project will change the way value is measured in healthcare

That is the title of a recent article in Managed Healthcare Executive on the Innovation and Value Initiative’s new Open-Source Value Project.  The magazine interviewed Mark Linthicum, IVI’s Director of Scientific Communication.  An excerpt is below:

Linthicum: Many healthcare stakeholders are now being asked to make decisions based on value, but few are also given the tools to make those decisions in an evidence-based manner. IVI seeks to solve that problem. The OSVP allows unmatched input by giving diverse stakeholders a seat at the table, especially patients. Future changes to the model and supporting research to advance the underlying methods will all be based on the feedback received from these stakeholders. This process—as well as the open-source nature of the models themselves—incentivizes stakeholders to offer their feedback to ensure that their unique viewpoint is captured in the tool and can be built upon in further iterations.

Do read the whole interview.

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Will Getting Bigger Make Hospitals Get Better?

This month, two hospital mega-mergers were announced between Ascension and Providence, two of the nation’s largest hospital groups; and, between CHI and Dignity Health.

In terms of size, the CHI and Dignity combination would create a larger company than McDonald’s or Macy’s in terms of projected $28 bn of revenue. (Use the chart of America’s top systems to do the math).

For context, other hospital stories this week discuss layoffs at Virtua Health System in southern New Jersey. And this week, the New Jersey Hospital Association annual report called the hospital industry the “$23.4 billion economic bedrock” of the state.

Add a third important item to paint the state-of-the-U.S. hospital-industry picture: Moody’s negative ratings outlook for non-profit hospital finances for 2018.

So will getting bigger through merger and consolidation make the hospital business better?

In the wake of the CVS-Aetna plan to join together, the rationale to go big seems rational. Scale matters when it comes to contracting with health insurance plans at the front-end of pricing and financial planning for the CFO’s office, and to managing population health by controlling more of provider elements of care from several lenses: influencing physician care; crafting inpatient hospital care; doing smarter, cheaper supply purchasing; and leaning out overhead budgets for things like marketing and general management.

But the Wall Street Journal warned today the “serious condition” of U.S. hospitals, despite these big system mergers.

Health Populi’s Hot Points:  In the past two years, I’ve had the amazing opportunity of speaking about new consumers and patients growing into healthcare payors with leadership from hospitals in over 20 states, some more rural, some more urban, and all in some level of financial crisis mode.

After describing the state of this consumer in health and healthcare, and how she/he got here, I have challenged hospital leadership to think more like marketers with a fierce lens on consumer experience and values. That equal proportions of U.S. consumers trust large retail and digital companies to help them manage their health is a jarring statistic to these hospital executives. The tie-up between CVS and Aetna marries the retail health/healthcare segments and responds to this consumer trust issue.

But then, I remind them that nurses, pharmacists, and doctors are the three most-trusted professions in America.

These three professional clinicians are the human capital that comprise the heart of a hospital in a community.

Hospitals should be mindful that trust is necessary for patient/health engagement. And the trust is with hospitals if the organization chooses to leverage that goodwill for a value-exchange. Hospitals are economic engines in their local communities — often, the largest employer in town. “Everyone” in most communities knows someone who works in a hospital.

And hospital employees spend money in communities, bolstering local employment and tax bases.

Partnering with patients means empathizing with them as both clinical subjects and consumers. For the latter, refer to the sage column from JAMA which recommends that Value-Based Healthcare Means Valuing What Matters to Patients. This means thinking about the value-chain of the patient journey, from keeping people well in their communities through to managing sticker-shock in the financial office. The financial toxicity of healthcare is one risk factor threatening the hospital-patient relationship with the patient-as-payor.

As Mufasa told Simba in The Lion King, “You are more than what you have become. Remember who you are.”

Dignity Health remembered who they were based on core values of human kindness in their rebranding, from Catholic Healthcare West to the Dignity Health brand, #HelloHumankindness. Here’s more on that good business case here in Health Populi. 

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U.S. Healthcare Spending

The CMS Office of the Actuary released their 2016 estimates for U.S. health care spending.  We’re getting close to health care taking up 18% of the economy.

Total nominal US health care spending increased 4.3 percent and reached $3.3 trillion in 2016. Per capita spending on health care increased by $354, reaching $10,348. The share of gross domestic product devoted to health care spending was 17.9 percent in 2016, up from 17.7 percent in 2015….Enrollment trends drove the slowdown in Medicaid and private health insurance spending growth in 2016, while slower per enrollee spending growth influenced Medicare spending. Furthermore, spending for retail prescription drugs slowed, partly as a result of lower spending for drugs used to treat hepatitis C, while slower use and intensity of services drove the slowdown in hospital care and physician and clinical services.

As baby boomers continue to age, expect health care to continue to rise as a share of GDP, at least in the short- to medium-run.

 

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Holiday Success: Clever Recipes for All Ages

Throughout the holiday season, dinner tables are comprised of families and friends that span generations. And as one generation grows old and another cycles round the table, times change, and does the food on the table. 

 

While baby boomers might have grown up with a Jello mold as the centerpiece, many millennials might scoff at the jiggly treat. In additional to satisfying a range of palates, most meals also have to include kid-friendly dishes and something for even the pickiest (or most allergy-ridden) of eaters. 

 

Viewing a table full of food for a large, multi-generational group is like a time capsule. In order to please everyone in the family, we at Dr. Ku’s office have compiled a list of the best dishes that remind grandma of her childhood while providing a modern twist to please the foodies.  

 

Wartime veggie turnovers 

 

For those who had grandparents or parents who lived through World War II, they remember the popular dishes that came about from wartime food rationing. Since meat was not as readily available, those in the kitchen had to get creative with using the food they had. 

 

A common meal was the wartime vegetable turnover that was comprised of cooked vegetables in a pastry crust. To modernize this meal, consider putting fresh vegetables, cheeses and meats inside of a flaky bread (somewhat like a calzone). This is a great snack option for between meals, and offers the tooth-healthy nutritional benefits of vegetables and added calcium from the cheese. Consider adding fibrous vegetables such as celery for an added oral health benefit for this grandparent-friendly food! Everyone’s bellies will thank you for it in the end after a good-sized holiday binge. 

 

Fondue 

 

Fondue at the table was a staple of holiday meals in the 70s, and has been memorialized by pop culture and restaurants today. The best part of fondue is that the dipping possibilities are literally endless. From veggies to bread and meat to marshmallows, this dish is something that will be adored by the whole family. 

 

Start with healthier options such as vegetables and lean meats before moving on to the sweet stuff. The protein in both the meat and cheese is a component of good oral health and builds stronger teeth. Just remember, after you’re done dipping the marshmallows in chocolate, go brush your teeth! 

 

Green bean casserole  

 

Creamy soup, canned green beans and fried onions seem to make an odd combination, but this recipe created by Campbell’s more than 60 years ago is a long-standing holiday favorite. While delicious, this dish is also filled with lots of sodium and fat. 

 

This year, opt for fresh green beans at your table. Chewing fibrous foods like green beans help to naturally clean your mouth and dislodge any harmful bacteria lodged at the gum line. 

 

Macaroni and cheese 

 

There isn’t a more kid-friendly food than macaroni and cheese. All generations love this ooey, gooey pasta dish. While no one would classify mac and cheese as a healthy dish, make it at home (instead of opting for a box) to pack in some extra nutritional benefit. Most recipes call for both milk and cheese, which are packed full of calcium and can help strengthen your teeth. Just remember to eat a sensible sized portion and brush your teeth 30-60 minutes after due to the starches in the pasta. 

 

 

Planning a dinner for guests of ages that span seventy or more years can seem daunting. Don’t feel pressured to provide everyone’s favorite meal. One of the best parts of the holidays is experimenting with new foods and giving old favorites a modern twist. Surprise the older generations in your family this year by incorporating modern twists on their childhood favorites. If you’re lucky, it may even prompt them to tell some stories and reign the new year in with full-bellied nostalgia! 

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Will MIPS work?

CMS in the past was on a value-based binge. They aimed to reward physicians based on quality of care (PQRS), based on cost (a component in the value modifier), based on use of EHR (meaningful use bonuses).  However, this imposed a large reporting bonus on physicians, pulling them away from patient care.  To solve the problem, CMS implemented Merit-based Incentive Payment System (MIPS) to consolidate all these value-based reimbursement schemes into one.

Will this new system work?  After reviewing the program, MedPAC was skeptical of MIPS:

MIPS, as designed, is unlikely to clearly identify highvalue or low-value clinicians and hence may be of limited utility for beneficiaries (in selecting high-value clinicians), for clinicians themselves (in understanding their performance and what to do to improve), or for the Medicare program (in adjusting payments based on value)

Specifically, they cite the low reliability of measures due to small patient counts for most measures for any individual physician; the fact that since physicians can select their own measures, comparing across physicians is difficult; budget neutrality rules mean that some physicians could get very high or very low bonus payments in the future.

One paper by Joynt Maddox (2017) looks at participation in MIPS based on previous data found that:

5.0 percent of the 899 practices would have received a performance-based bonus and 7.7 percent a performance-based penalty

Thus, the vast majority of practices would receive no bonus or penalty in practice.

Measuring quality of care is a good thing.  Imposing significant reporting requirements on physicians is not.  Thus, identifying a way to measure and pay for quality is valuable but the data collection burden and overall reliability must be increased to be able to do this.  Another approach–balance billing–would allow high-quality physicians to charge more to Medicare patients, where quality would be defined not by bureaucrats, but by the consumers and patients actually receiving this care.  Letting the market work, just might work.

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Webinars for IVI’s Open-Source Value Project

On November 8^th, the Innovation and Value Initiative (IVI) launched a new effort to help redefine the way we measure value in health care: the Open-Source Value Project (OSVP). A first-of-its-kind effort that engages all health care stakeholders in an open process to advance the way we measure value in health care treatments and services, the OSVP is creating flexible, transparent, iterative, and consensus-based modeling platforms for specific diseases. The first model released as part of the OSVP focused on rheumatoid arthritis, and additional models targeting other diseases are planned. For a quick overview of the OSVP, take a look at this a brief whiteboard video.

IVI is actively seeking input from everyone across the health care system ahead of the January 2018 deadline for public feedback. To facilitate widespread participation, IVI is hosting two public webinars next week to provide information and answer questions:

 WEBINAR 1: Measuring the Value of Health Care Treatments: Time for a New Approach

• Traditional value assessments are often “black boxes” that only account for a single perspective or a single population. The OSVP is designed to better measure value through an iterative and transparent process driven by input from all health care stakeholders. To better understand how the OSVP process works, learn about our first model in rheumatoid arthritis, and find out how to get involved, join us for our upcoming webinar on December 12, 2017 at 4pm EST/1pm PST. Register here.

 WEBINAR 2: Creating Open-Source Models for Value Assessment: A Detailed Discussion of the IVI Rheumatoid Arthritis Model

• OSVP models are built to be entirely open-source, allowing anyone to customize the tool depending on their own assumptions and understanding of value. Learn more about how the IVI model generates customized information on rheumatoid arthritis treatments and how to apply the information in assessing value in health care on December 14, 2017 at 4pm EST/1pm PST. Register here.

 The first webinar is designed to be an overview of the OSVP and our IVI-RA model for a general audience, whereas the second is intended for a more technical audience and will dive into the details of the model and our modeling approach. Both webinars are free and open to the public.

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Patients Continue to Grow Healthcare Consumer Muscles, Alegeus’s 2017 Index Finds

Patients’ health consumer muscles continue to get a work out as more people enroll in high-deductible health plans and face sticker shock for health insurance premiums, prescription drug costs, and that thousand-dollar threshold. The 2017 Alegeus Healthcare Consumerism Index finds growth in patients’, now consumers’, interest and competence in becoming disciplined about planning, saving, and spending for healthcare.

Overall, the healthcare spending index hit 60.1 in 2017, up from 54.4 in 2016. This is a macro benchmark that represents most consumers exhibiting greater healthcare spending engagement with eyes on cost as well as adopting purchasing behaviors for healthcare.

Underneath that 60.1 number are several metrics that measure consumerism: for example, the percentage of consumers seeking prices before receiving medical services increased to 55%, by 15 percentage points over the 2016 Index. This means that a majority of consumers are now looking for price information prior to getting healthcare.

A double-digit increase also occurred with consumers researching physician and facility quality ratings, growing 11 percentage points to 60%.

Two-thirds of consumers tried to understand their cost obligations on their health plan, up 9 percentage points over last year.

While the healthcare consumerism index rose from 2015, people still spend a lot more time shopping for other consumer purchases such as TVs, cars, cell phone providers, and travel, Alegeus found. By comparison, the healthcare index reached 60.1 in 2017; the TV spending index was 78.9 and the car metric, 77.6.

With high deductibles reaching into the thousands of dollars for some consumers, saving for healthcare is an important objective. How do consumers’ healthcare savings stack up versus other savings goals? They rank much lower than saving for emergencies or retirement, and come close to putting money away for college funds.

But it’s important to note that the healthcare saving index rose by 18% in one year, a significant growth. This, in the context of only 50% of consumers making contributions to retirement each month.

For this research, Alegeus surveyed over 1,400 U.S. healthcare consumers in September 2017.

Health Populi’s Hot Points:  The U.S. spent $3.3 trillion on healthcare in 2016, we learned yesterday from the actuaries who work at the Centers for Medicare and Medicaid Services (CMS). Consumers are now the top-payor coupled with the Federal government, each of which covered 28% of that $3.3 trillion spend. Employers assumed 20% of 2016 healthcare spending. Increasingly, companies that cover health insurance are nudging workers into high-deductible health plans.

So peoples’ ability to take on the role of healthcare consumer is critical to their personal financial wellness. This week, as I was digesting the new national health expenditure numbers, I came across another news item that fit into this jigsaw puzzle that is consumer health finance: “Lively and Parasail Join Forces to Help People Afford Health Care.”  This partnership enables consumers enrolled in high-deductible plans to create a Lively HSA and then get a no-interest payment plan from Parasail to cover medical bills over time in “affordable monthly payments” over 36 months with no additional interest. Providers receive immediate payment, which means the patient’s FICO score is preserved. This is an area that’s gotten some attention through the Consumer Financial Protection Board (CFPB), which has closely scrutinize the issue of medical debt. Consumer credit rating agencies recently agreed to treat medical expenses differently than other household financial line items.

Peoples’ patient experience is increasingly getting bundled into their financial experience. Watch for more programs like Lively and Parasail’s to help consumers in their healthcare consumerism journeys to help manage financial health. This, while patients are managing (expensive) treatments to deal with cancers and other conditions whose cost of treatments can exceed the average American family’s income of $57,817.

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Health insurance expansion and physician supply

When new bills pass in Congress or state legislatures that expand health insurance coverage, most researcher look at the demand side effect.  How does the insurance expansion affect the number uninsured?  How does it affect access to care?  How does it affect out of pocket cost?

What is less frequently studied is the supply side effects.  Namely, does expanding insurance coverage increase the number of doctors, nurses, medical assistants and other stuff in the U.S?  This is the question that Chen et al. (2017) examine.  In particular, they look at the re-authorization and expansion of the Children’s Health Insurance Program (CHIP) in 2009 and they test whether the number of pediatricians increase after the CHIP expansion.  They find:

…newly trained pediatricians are 8 percentage points more likely to subspecialize and as much as 17 percentage points more likely to enter private practice after the law passed. There is also suggestive evidence of greater private practice growth in more rural locations. The sharp supply-side changes that we observe indicate that expanding public insurance can have important spillover effects on provider training and practice choices.

Very interesting study.

Source:

• Chen A, Lo Sasso AT, Richards MR. Supply-side effects from public insurance expansions: Evidence from physician labor markets. Health Economics. 2017;1–19. http://ift.tt/2jm63zC

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The Patient as Payor – Consumers and the Government Bear the Largest Share of Healthcare Spending in America

The biggest healthcare spenders in the United States are households and the Federal government, each responsible for paying 28% of the $3.3 trillion spent in 2016.

Private business — that is, employers covering healthcare insurance — paid for 20% of healthcare costs in 2016, based on calculations from the CMS Office of the Actuary’s report on 2016 National Health Expenditures.

The positive spin on this report is that overall national health spending grew at a slower rate in 2016, at 4.3% after 5.8% growth in 2015. This was due to a decline in the growth rates for the use of hospitals, physicians, clinical services, and retail prescription drugs.

Healthcare consumed 17.7% of the GDP in 2016, up 0.5% points from 17.2% in 2015.

Underneath this positive top-line are some less sanguine trends, most notably on the growth of consumers’ healthcare spending. Consumers’ out-of-pocket spending grew faster in 2016 than in 2015, at a rate of 3.9% compared with 2.8% in 2015. This was the fastest rate of growth of OOP costs since 2007. The greater consumer cost burden is attributable primarily to the growth of more consumers enrolled in high-deductible health plans. Out-of-pocket costs include all direct consumer payments: copayments, deductibles, coinsurance, and spending for non-covered services by insurance plans.

Thus, consumers’ role as healthcare payor is “tied” with the Federal government’s, with each bearing 28% of national health spending.

Health Populi’s Hot Points:  Dr. David Blumenthal wrote about the erosion of employer-sponsored benefits in a Commonwealth Fund brief yesterday, asserting that, “job-based health coverage provides far less protection to U.S. workers and their dependents than it once did.” The CMS 2016 NHE statistics notes the expansion of high-deductible health plans adopted by employers for covering workers.

The bar chart illustrates that while the use of healthcare services declined between 2015 and 2016, prices were responsible as a growing factor in per capita health expenditure growth. It’s ironic that today, I attended a webinar sponsored by the USC Annenberg Center for Health Journalism titled, “It’s the Prices Stupid – how sky-high prices are crippling our health care system,” discussing healthcare costs in America that are priced much higher than anywhere in the world. It’s a phrase first coined by the late, great health economist Uwe Reinhardt and colleagues in their seminal essay published in Health Affairs in 2003, It’s the Prices Stupid: Why the United States is So Different from Other Countries.

High prices and consumers’ healthcare cost exposure can nudge people (patients) to postpone or avoid care; this isn’t a new phenomenon, but in the era of high-deductibles and de facto self-insurance up to the deductible, it’s a concerning trend. Avoiding necessary care can result in greater downstream costs to the patient and the health plan, and potential worse conditions (say, a cancer moving from Stage 1 to Stage 4).

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