Wednesday, February 25, 2015

What's at stake with Affordable Care Act challenge in the Supreme Court?

The Supreme Court has already ruled on the Affordable Care Act based on an early constitutional challenge.  But the law is back at the Court based on a challenge that hinges on just four words in the 2012 law.

CNN provides an easy to understand primer on what's at stake this time around.  Find the article, "The latest Obamacare challenge: What you need to know" here.

The article explains that the law establishes the creation of exchanges "through which individuals can purchase competitively priced health insurance".  Sixteen states and the District of Columbia have set up their own exchanges. Folks living in the other 34 states must use the exchange run by the federal government.  And the law provides federal tax credits to income eligible individuals "to help offset the cost of the policies". 

Most of us remember all of this.  States set up their exchanges where you shop for your healthcare coverage.  Lots of governors or state legislatures chose not to create their own exchanges, so their citizens go to the exchange run by the federal government.  And because everyone is supposed to sign up if they don't have coverage elsewhere, the Affordable Care Act provided federal tax credits to help lower income individuals and families buy coverage. 

Simple enough.  Except, those bringing the case that is now before the Supreme Court say the law did not authorize those tax credits for those having to use the federal run exchange.  That's where the four words in the law passed by Congress comes in. 

A synopsis from the CNN article:

The health care law provides for the establishment of "exchanges" through which individuals can purchase competitively priced health insurance. It also authorizes federal tax credits to low- and middle-income Americans to help offset the cost of the policies. Currently 16 states plus the District of Columbia have set up their own exchanges; the remaining 34 states rely on exchanges run by the federal government. Those bringing the case say that the words "established by the State" in a subsection of the law make clear that subsidies are only available to those living in the 16 states that set up their own exchanges. If the court says the IRS rule is invalid, absent some kind of action by the states or Congress, more than 5 million individuals will no longer be eligible for the subsidies, shaking up the individual market.
So this time around the law in its entirety is not at stake.  But apparently the help through tax credits for 5 million individuals is at stake.  (CNN reports that in 2014, more than 5.3 million individuals selected an insurance plan through the federal exchange.)  We'll find out if Congress goofed or not.
Here is how CNN explains it:
Those challenging the law this time say: Congress limited the subsidies in order to encourage the states to set up their own exchanges. But when only a few states acted, the IRS tried to "fix" the law and wrote a rule allowing subsidies for those living in states with state-run exchanges as well as states with federally run exchanges.
The government, defending the law, says: the language at issue is a "term of art" and that Congress always intended the subsidies to be available to everyone. ... it was clear that some states would not establish their own exchanges.
There is a little technicality that is also interesting.  Challenges must have standing - that is to say that have to show that they are being harmed by the law.  The challengers in this case are residents of Virginia, one of the 34 states that did not create their own exchange.  So these Virginia residents don't get the tax credits.  Without the tax credits they can't afford health care coverage offered through the federal exchange.  So sounds like they want the tax credit.  Apparently not.  Remember the "individual mandate" part of the Affordable Care Act - if you don't get coverage, you get a penalty? 
As CNN explains:
The crux of their argument is that if it were not for the tax credits for premiums, they could not afford health insurance and thus would be exempt from the individual mandate to purchase health insurance.

Open Notes and Patient Portals?

Who manages patient access to their health records?  What technology are you employing?  Let us know. 

This article from Reuters made us want to hear from you.

The article posted Tuesday, February 24, "Patients, doctors see benefits of sharing medical records" may be found here.

It introduces the story of a patient who began using OpenNotes when her multiple sclerosis created increasing challenges for her to remember what happened at her last appointment and what follow-ups she was responsible for.

The article cites a new paper online in the British Medical Journal which demonstrates that patient access to their records, including physician notes, can lead to more collaboration between doctor and patient and more educated, engage healthcare consumers as patients.

One metric discovered: "After one year, 99% of patients wanted to continue accessing notes. Despite initial concerns among physicians about additional work, none decided to discontinue use."  And the age of the patient was not a factor in patients using portals to access their information.

Find more information on the study here.

What experiences have you had with managing patient access to their EHR information and the use of patient portals?

Let us here from you!

Thursday, February 19, 2015

What are you seeing or reading about measles?

One article, "Measles May Be in U.S. to Stay, 15 Years After It Left" one of our members found here: By Anna Edney and Michelle Fay Cortez January 26, 2015 -

Here is a summary: 

Measles could once again become native in the U.S., as an outbreak in California linked to Disneyland has put a spotlight on a growing failure to vaccinate that’s helping the disease to spread.

While 94 percent of California kindergarteners were fully inoculated against the virus last school year, in some pockets of California, as much as a quarter of children are undervaccinated
This puts these children at risk of both contracting the disease and becoming a nexus of future spread.

Some facts cited in the article:

In 1990, 3 of every 1,000 children who got measles died from it.  

The virus is one of the most contagious pathogens known to man, and causes more serious complications in about three of 10 patients, according to the CDC.
It was declared eliminated in the U.S. in 2000
Outbreaks are instead started by people visiting from outside the U.S. or who return and bring it back.

The virus is highly contagious, spread through the air by coughing and sneezing. It is also insidious, with patients become infectious four days before the telltale rash appears.

The first vaccine became available in 1963, with the current combination shot approved in 1971. A single injection is 93 percent effective, rising to 97 percent for those who get both doses.

While the poor have long had lower rates of vaccination because of the cost, the number of unvaccinated children in other communities who don’t get their shots is growing because of worries vaccines are linked to autism. Doctors have debunked any such link.

Health experts fear "Re-establishing transmission": 

Re-establishing transmission would mean there is sustained chain of infection among U.S. citizens and the disease can no longer be considered eliminated. The CDC warned in 2012 that without high vaccination rates, measles could return.

Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, said measles re-establishing itself is less likely than the U.S. developing more frequent outbreaks from imported cases.

“You have parents who don’t allow their children to be vaccinated, and they’re clustered in certain areas,” Fauci said in an interview. The parents reinforce their philosophy of not wanting to get the kids vaccinated. So you have a cadre of kids who aren’t vaccinated and someone comes in from a foreign country that does have endemic measles, and you get outbreaks.’’

While there have been a few hundred cases at most documented in the U.S. each year since 2000, 2014 saw a sharp increase to 644 cases representing 23 outbreaks, the CDC said.

The largest outbreak last year occurred among non-vaccinated Amish communities in Ohio where 382 people caught measles. California took the runner-up title with 60 residents falling sick in just the first five months of the year.


Article on Medicare Alternative Payment Models

Medicare Unveils Alternative Payment Models

Find the source article here: Christopher Cheney, for HealthLeaders Media , January 27, 2015 -

Here is the summary:
HHS officials highlight a three-year payment reform timeline, which calls for boosting fee-for-service Medicare reimbursements and increasing reimbursements linked to quality and value.

Federal officials have announced an accelerated effort to use payment reform as a mechanism to shift Medicare and the broader healthcare industry away from the fee-for-service model.

3-Year Timeline

A three-year payment reform timeline is expected to 1) boost the percentage of fee-for-service Medicare reimbursements based on alternative payment models (APM) and 2) to increase the percentage of all reimbursements linked to quality and value.

In the early phase of the payment reform initiative's implementation, APMs will be limited to three pathways: Medicare's existing accountable care organization efforts, the Pioneer ACO program and the Medicare Shared Savings Program; bundled payments; and payment models tied to patient-centered medical homes.

More ambitious value-based payment models are in the works, including episode-of-care payment for chronic illnesses and oncology care that will require providers to shoulder a significant level of cost risk.

The metrics are reported as follows -
The reform initiative calls for Medicare fee-for-service payments through APMs to rise from the current 20% level to 30% by the end of 2016. The percentage is slated to rise to 50% by the end of 2018.

It additionally calls for the percentage of Medicare payments that are linked to quality and value to reach 85% by 2016 and 90% by 2018. Existing Medicare quality and value linked payment programs include the Hospital Value-Based Purchasing (VBP) program and the Hospital Readmission Reduction Program (HRRP).

Marrying Value-Based Care Delivery With Value-Based Payment

HHS officials started foreshadowing the Medicare payment reform initiative in the fall.

In November, the Centers for Medicare & Medicaid Services released details about developing and optimizing APMs, linking fee-for-service payments to quality and value, Medicare ACO and bundled payment projects, and PCMH models.
A primary goal of the Medicare payment reform initiative is to develop and enhance the alignment between value-based healthcare delivery and value-based healthcare payment models.

Thursday, January 29, 2015

Medicare Spending on Children Results is Good for Income, New York Times Reports

Recently, Margot Sanger-Katz wrote the following article outlining a study that showed providing government health care to children correllated with a boost in future earnings that may result in the government recouping some of the funds used to provide the medical care with income taxes.

The article follows:

"When advocates talk about the advantages of government health care, they often talk about a moral obligation to ensure equal access. Or they describe the immediate health and economic rewards of giving people a way to pay for their care.

Now a novel study presents another argument for the medical safety net, at least for children: Giving them health coverage may boost their future earnings for decades. And the taxes they pay on those higher incomes may help pay the government back for some of its investment.

The study used newly available tax records measured over decades to examine the effects of providing Medicaid insurance to children. Instead of looking at the program’s immediate impact on those children and their families, it followed them once they became adults and began paying federal taxes.

People who had been eligible for Medicaid as children, as a group, earned higher wages and paid higher federal taxes than their peers who were not eligible for the federal-state health insurance program. And the more years they were eligible for the program, the larger the difference in earnings.

“If we examine kids that were eligible for different amounts of Medicaid over the course of their childhood, we see that the ones that were eligible for more Medicaid ended up paying more taxes through income and payroll taxes later in life,” said Amanda Kowalski, an assistant professor of economics at Yale and one of the study’s authors.

The results mean that the government’s investment in the children’s health care may not have cost as much as budget analysts expected. The study, by a team that included economists from the Treasury Department, was able to calculate a return on investment in the form of tax revenue.

The return wasn’t high enough to pay the government back for its investment in health insurance by the time the children reached age 28, when the researchers stopped tracking the subjects. By that age, the Treasury had earned back about 14 cents for every dollar that the federal and state governments had spent on insurance. But it did suggest that, if the subjects’ wages continued to follow typical trajectories as they aged, the federal government would earn back about what it spent on its half of the program by the time the children reached 60 — about 56 cents on the dollar, calculated using a formula that took into account the time value of money.

The split in spending between the federal and state governments for Medicaid varies by state, but, on average, federal taxpayers pay 57 cents of each dollar. There may also be some return on investment for states that collect income taxes, but the researchers didn’t measure that.

Here’s what that means in real numbers: The average person in the study with no Medicaid earned a total of $149,000 by age 28. For each year a person was eligible for Medicaid, that income went up by $250, and the taxes the person paid went up accordingly.

“What’s exciting about this is how good the outcome variables that they can look at,” said Janet Currie, a professor of economics and public affairs at Princeton. A few studies have tracked the health outcomes of children who were eligible for Medicaid over time, including one Ms. Currie wrote, but the study’s measures of economic outcomes are new.

The new paper was made possible by a series of policy changes throughout the 1980s and 1990s that slowly expanded Medicaid to cover more and more American children. The changes essentially happened in two phases: First, the federal government allowed the program to include older children, and then individual states approved expansion to those groups. The slow, state-by-state spread of the policy enabled the researchers to compare children who were eligible for Medicaid with a control group of similar children of the same age and family income level who were not eligible for the program. The study looked at children who were eligible for Medicaid, even though not every eligible child actually signed up.

Ms. Currie said that earlier studies of children’s health outcomes also suggest that children with serious illnesses often go on to be sick as adults as well — meaning they are more likely to miss work or have limited career options. Medicaid supports and funds a lot of important preventive health care for very young children. She said the lesson could be that “an ounce of prevention is worth a pound of cure.”

Now that the earlier expansions have had a chance to spread, nearly every low-income child in the country is eligible for Medicaid, and more than a third of all American children are currently enrolled in either Medicaid or a closely related federal-state program, called the Children’s Health Insurance Program.

“If this is right, then we’re going to be seeing a lot more impact for the kids that are born now and in the future,” said Judy Solomon, a vice president for health policy at the left-leaning Center on Budget and Policy Priorities."

Wednesday, January 21, 2015

New York Times Discusses Decline in New Ebola Cases Impact on Vaccine Development

A recent New York Times article examined the complications that arise when there are too few cases of a disease to test the vaccine. A recent meeting of public health and viral disease experts discussed the plans for testing Ebola vaccines in Liberia, Guinea, and Sierra Leone. To date the Ebola epidemic has infected nearly 21,000 individuals and killed more than 8,000 people. 

The New York Times reports: “For this reason, it’s very urgent that we get into the field very quickly to do these clinical trials, because if there are very, very, very few cases of Ebola, as I’m sure you understand, it’s going to be difficult to test whether the vaccines work or not,” Dr. Helen Rees, an adviser to the World Health Organization, said during a news conference on Friday at the organization’s headquarters in Geneva.

Dr. Marie-Paule Kieny, an assistant director general of the W.H.O., said two vaccines had been found safe enough in early testing in countries outside the outbreak zone to justify wider testing in the affected countries. But she said it would take two to four weeks more to determine the proper doses.

She said a clinical trial in Liberia could begin as soon as the end of this month, with studies in Sierra Leone and Guinea starting in February.

Dr. Kieny said it could take up to six months to determine if the vaccines are effective. Production has already begun, so if any of the vaccines proves safe and effective, millions of doses could be quickly made available.

Vaccine effectiveness is determined by how many vaccinated people come down with a disease compared with those who are not vaccinated, or vaccinated later. If few new cases of the disease are occurring, it would be harder to see any difference. Dr. Kieny said plans were being made to increase the size of the trial in Liberia if needed.

In Liberia, there were eight confirmed new cases and 40 probable new cases recorded in the five days ending Jan. 2, down from a peak of 300 confirmed new cases a week in August and September, according to the W.H.O. The number of new cases has been falling in Sierra Leone, but it remains the most heavily affected country. In Guinea, it is not clear if case numbers are falling, the health organization said.

If the epidemic continues to ebb, it may be too late for the vaccines to make a difference in this outbreak. Dr. Rees said that a working group had been formed to discuss how to deploy the vaccines, should they prove safe and effective, but that the situation was changing too rapidly to make such a decision now.

“Hopefully, we will have broken the back of this epidemic by the time we finish these trials,” she said.

Even if that is the case, she and Dr. Kieny said, sporadic cases would most likely occur, and vaccinations might be given to people nearby to protect them and help prevent further spread of the disease — a strategy known as ring vaccination. And it might be wise to vaccinate health workers for long-term protection, they said.

The two vaccines that are most advanced in testing are being developed by GlaxoSmithKline and Merck. The Glaxo vaccine is being developed with theNational Institutes of Health; Merck’s was originally developed by the Public Health Agency of Canada and licensed to a small Iowa company, NewLinkGenetics, which in turn enlisted Merck.

Testing of the Merck vaccine at a hospital in Switzerland was suspended in December after a number of patients developed pain in the joints of their fingers and toes. Testing resumed this week using a lower dose. Dr. Kieny said the pain was generally transient and mild and “not of sufficient concern to stop the development of this vaccine.”

A third vaccine, being developed by Johnson & Johnson, began early safety testing in volunteers this month. That company is also planning tests in West Africa.

There has been debate over how to conduct the studies. Some experts say testing the vaccines against a placebo would be the surest way to determine whether they work. Others counter that it would be unethical to administer a placebo during a deadly epidemic.

The trials will cover all the approaches, with different designs in each country. In Liberia, the Merck and Glaxo vaccines will be tested against each other and against a control, with about 9,000 people in each of the three arms of the study.

In Sierra Leone, vaccine doses will be given to health care workers and others directly involved in responding to the disease. There will be no placebo, and effectiveness will be determined by looking at whether there are fewer cases of Ebola among workers who are vaccinated earlier compared with those who are vaccinated later. Which vaccine is used will depend on which one appears to be the best after data on immune responses is analyzed, Dr. Kieny said.

Guinea will test using the ring vaccination strategy, vaccinating communities when a case of Ebola occurs. Some communities will be given vaccine right away, and others will receive it later, based on random assignment."

Friday, January 16, 2015

Advance Life Support Measures Show No Benefit Over Basic Life Support Measures

Aaron E. Carroll discusses the negative health and economic impacts of using advanced life support measures in the following article, "Doing More for Patients Often Does No Good," featured in the New York Times.  Please share your thoughts as professionals on the impacts of these studies on medical billing and care provided. 

"Given the remarkable advances that have been made in the last 50 or so years in pharmaceuticals, medical devices and surgical procedures, it’s not a surprise that people want more, and more invasive, care than they have had in the past. Just as it’s hard to do nothing when you’re ill, it’s sometimes hard to do less than the maximum when there are different treatments to choose from.

Unfortunately, doing more often does no good. Sometimes, it even leads to harm.

In the United States, when it appears that someone might be in trouble, emergency medical services are dispatched. Many patients die from an out-of-hospital cardiac arrest, but steps taken out in the field can make a difference. Basic life support, the kind you might be taught in a CPR class — involving the use of bag valve masks, cardiopulmonary resuscitation and automated external defibrillators— can absolutely save a life.

Advanced life support, usually requiring a trained paramedic, involves much more. Trained providers may put in endotracheal breathing tubes; start intravenous lines; deliver sophisticated cardiac drugs; and defibrillate patients manually.

We’ve assumed, for the most part, that advanced life support is better than basic life support — so much so that in most areas where both options are available, advanced life support is almost always used. But a recent study in JAMA Internal Medicine brings this assumption into question. Researchers examined Medicare patients who were billed for either advanced life support or basic life support before admission to the hospital from 2009 through most of 2011. They looked at how often patients survived to hospital discharge, and then months later.

What they found was that about 13 percent of patients who received basic life support survived and were discharged versus 9 percent of patients who received advanced life support. More patients who received basic life support lived for 90 days after discharge, too (8 percent versus 5 percent). Basic life support patients also had better neurological outcomes.

Now, of course, this is not a randomized controlled trial. It’s possible that sicker patients received advanced life support and that people who didn’t appear as sick received basic life support. But the authors called all of the state agencies, and they reported that this can’t really happen. After all, a 911 dispatcher can’t tell if it’s a “mild” or “severe” heart attack from a third party on the phone with no medical training. Dispatchers send out advanced life support if it’s available, and basic life support if it’s not.

It’s also possible that there could be differences in bystander CPR administration until help arrives. But the authors attempted to control for that, too. They conducted a number of sensitivity analyses, and in none of them did advanced life support outperform basic life support.

It would also be easier to dismiss this finding if it weren’t corroborated in many other studies. In 2004, results from the Ontario Prehospital Advanced Life Support Study were published in the New England Journal of Medicine. This was a multicenter controlled trial in 17 cities in Canada comparing advanced life support with basic life support. They found that if an instance of cardiac arrest were witnessed by a bystander, the chance of survival significantly improved. They also found that CPR administered by bystanders improved survival, and so did rapid defibrillation. These are all components of basic life support. The addition of advanced life support, however, made no difference in survival.

A 2007 study conducted in Taipei also found that advanced life support did not improve survival to discharge. Even the main components of advanced life support have failed to show results in studies. A 2008 systematic review showed no efficacy for emergency intubation. A 2010 cohort study found advanced airway methods — basically, putting in an airway tube rather than using a bag mask — to be associated with decreased survival compared with basic life support methods, as did a 2013 study in Japan.

A 2012 JAMA study found that the use of epinephrine was associated with worse outcomes, and a 2008 New England Journal of Medicine study found that adding vasopressin (another drug that, likeepinephrine, constricts blood vessels to raise blood pressure) didn’t improve things. A randomized controlled trial of these drugs, published in 2009 in JAMA, found that their use didn’t improve survival either.

The evidence is compelling. Advanced life support does not seem to provide any benefits in the randomized controlled trials, and it’s often associated with worse outcomes in the cohort studies. How can this be so? Some theorize that the things that work have already been incorporated into basic life support. All that the advanced life support may be doing is slowing things down in the field, distracting people from the useful basic life support measures, and delaying the time until a patient can get to the hospital.

It’s hard not to do more if we can, though. We see this in all sorts of areas of care. A few months ago, a study was published in JAMA that examined the outcomes of women with stage 0-III unilateral breast cancer who underwent breast conserving surgery with radiation compared with those who had a unilateral mastectomy and those who had a bilateral prophylactic mastectomy. The 10-year survival differences between the groups were negligible. Breast conservation therapy is more tolerable, is much less invasive and costs less.Continue reading the main story

In fact, breast conservation therapy has become a “standard of excellence” in breast cancer care. But a study published even more recently showed that from 1998 through 2011, the odds of a woman eligible for breast conservation therapy receiving a mastectomy increased. Rates of bilateral mastectomy went up over this time period as well, from 2 percent in 1998 to 11 percent in 2011.

And based on the data from many randomized controlled trials, we know that women who have radiation therapy for early breast cancer do well with less of it. The use of “hypofractionated” whole breast irradiation, which consists of fewer treatments with higher levels of radiation, has been shown to be equally effective for women without any excess side effects. It’s cheaper, easier and just as good. Hypofractionated whole breast radiation has been endorsed by the American Society for Radiation Oncology for women who satisfy certain criteria since 2011.

But a study published a month ago that looked at the use of radiationin women with early stage breast cancer found that in 2013, only about a third of women who qualified for hypofractionated radiation therapy were getting it. The rest got more, but not better, care.

The reasons for this are varied. With respect to the radiation therapy, it’s hard not to lay some of the blame on economics. After all, in a fee-for-service system, more visits and more treatments mean more money. Research shows that twice as many women want hypofractionated radiation therapy as want conventional therapy, but only half of radiation oncologists offer it.

But it’s not all money. It’s also probably fear. Many radiation oncologists are concerned that doing fewer treatments will lead to worse outcomes. That’s most likely the concern of women who choose much more invasive surgery than necessary as well.

It’s certainly the rationale for why advanced life support is so prevalent. The Ontario Prehospital Advanced Life Support Trial was supposed to be a randomized controlled trial, but the paramedicsevidently refused to do it because they felt that holding back advanced life support was unethical. This was in spite of the lack of evidence that it was effective.

More is expensive. More sometimes does no good. Sometimes, more is even harmful. When our policies and care ignore these facts, we all suffer."