How will the Supreme Court rule in King v. Burwell?
Any day now, the Supreme Court will hand down its decision. How will the court rule?
Blame Hollywood. Or, at least, partly blame Hollywood. (We’ll take what we can get.)
Women ages 30 to 55 too often ignore the warning signs of an acute myocardial infarction (AMI), according to a study in Circulation: Cardiovascular Quality and Outcomes. They either don’t recognize more nuanced symptoms (dizziness, aching muscles, indigestion, fatigue), or they fear that their interpretation may be wrong. They often believe that a heart attack must always include an episode of intense chest pain, and while more than 80% of men and women in that age range with AMI do have chest pain, younger women are more likely to not have it
“Women described having symptoms that differed significantly from their expectations of AMI as portrayed by the media, noting theirs was not a Hollywood heart attack,” the study states. As one interviewee puts it, “I didn’t have any of the typical heart attack symptoms that you always hear about on TV and the ER hospital shows.”
Nonetheless, what they experience is all too real, because women in this demographic are twice as likely to die during hospitalization for AMI than men of the same age; and about 55,000 younger women die each year from the disease, making it the leading cause of death among young women. Yale researchers pinpoint five reasons they ignore symptoms or don’t get the help they need in time:
Researchers used a qualitative approach, conducting in-depth interviews with 30 women between October 2006 and May 2007. They stopped the interviewing process at the “saturation” point; when the last few interviews after number 30 provided no new information.
Researchers note a strong “it can’t happen to me” effect, even in women with a history of AMI in their families. Such patients just think they’re too young to worry about it. The study suggests targeted educational campaigns for this cohort.
The patients aren’t the only ones who need to be educated, though. Providers too often discount the possibility that a relatively young woman experiences a heart attack. One interviewee says that her doctor told her that the symptoms for acid reflux often mimics AMI symptoms. “And then throughout, until this last time, anytime that it happened, [I] thought, OK, acid reflux.”
Researchers cite previous negative experiences, such as a poor doctor-patient relationship, being rebuffed or treated disrespectfully, and basically denied care.
“Our participants described delays that occurred for both the typical and the atypical symptoms, as well as delays within the physician’s office and the emergency department,” the study states.
Many women also worry about looking like a hypochondriac. “I know I had too much to do to be wimpy about being sick,” says one interviewee. “…I have worked through the flu. Just feeling like I’ve got to get the job done. You’d think I was the President of the United States.”
Our April 2015 cover story was about the growing clout of PBMs. Reason number one for the power surge is simply that the companies are getting bigger, and size means added leverage with manufacturers and insurers.
Bigger fish are buying smaller fish and then getting acquired by fish bigger than themselves.
Catamaran bought Restat in 2013 and then in March of this year was acquired by UnitedHealth for $12.7 billion.
Rite Aid bought EnvisionRx a month earlier.
Now CVS is buying Omnicare, the largest provider of drugs to nursing homes in the country.
According to the New York Times’s Dealbook, the three giant PBMs—CVS, Express Scripts, and UnitedHealth—control somewhere between two-thirds and three-quarters of the market, depending on how you do the counting.
This morning’s Wall Street Journal coverage of the CVS-Omnicare deal says it puts CVS in the position of taking advantage of two major factors that are sculpting the shape of American health care and its cost: The demographic bolus of baby boomers making its way through old age and the stratospherically expensive specialty drugs for relatively rare diseases.
A PBM world dominated by superpowers just might rein in the cost of the specialty drugs. The large PBM is a force to be reckoned with. Witness Express Scripts pushing back on Gilead and Sovaldi last year.
But there’s also reason to worry about these middlemen, which have been criticized for their lack of transparency and unilateral say-so over formularies and tiers.
New regulations for managed Medicaid promise to shake up an industry that, apparently, needs very much to be shaken up. The implications of last week’s Kaiser Family Foundation (KFF) report (http://files.kff.org/attachment/issue-brief-reading-the-stars-nursing-home-quality-star-ratings-nationally-and-by-state) on the state of nursing homes (hint: not so good) builds even more anticipation about CMS’ plan to unveil the regulations any day now.
The regulations were last updated in 2002, when the issue of the quality of long-term care did not loom over society like the Death Star. To paraphrase Lincoln, we cannot escape history, or demographics (http://www.cbo.gov/sites/default/files/44363-LTC.pdf). CMS, for the first time, wants to regulate long-term care delivered by managed Medicaid.
Source: Congressional Budget Office tabulations based on population projections reported in The 2012 Long-Term Budget Outlook (June 2012), www.cbo.gov/publication/43288.
Members of the baby-boom generation (people born between 1946 and 1964) started turning 65 in 2011 and will turn 85 beginning in 2031.
But not just that. It’s difficult to underestimate the scope of what CMS wants to do: A March KFF report shows just how huge of an overhaul is coming (http://files.kff.org/attachment/issue-brief-awaiting-new-medicaid-manage...).
The part of the proposed regulations that addresses long-term care alone “could be the size of a regular reg,” says Jeff Myers, president and CEO of the Medicaid Health Plans of America (MHPA). MHPA represents 124 commercial and not-for-profit Medicaid plans that serve over 20 million lives in 33 states (http://www.mhpa.org/Membership/Member_Roster/Health_Plans/).
In 2002, managed care was not the presence in Medicaid that it is today. Now, according to KFF, “over half of all Medicaid beneficiaries—primarily children and parents—are enrolled in these plans (http://kff.org/health-reform/issue-brief/medicaid-moving-forward/).” The ACA has also encouraged an influx of single adults onto the Medicaid rolls, most of whom have choosen a managed care plan.
Myers tells Managed Care that nursing homes and other post-acute care still live in FFS territory. He should know: Before joining MHPA, Myers served as the senior vice president of policy and government relations at the American Health Care Association, the lobbying group for post-acute care facilities.
The KFF nursing home study notes that more than a third of those facilities, representing nearly 40% of all nursing home residents, received only one or two stars on the CMS’ Five-Star Quality Rating System for nursing homes this year. That’s the yin. The yang is that 45% of nursing homes, representing 41% of all nursing home residents, got four or five stars.
“There are 11 states where 40% of the nursing homes are frankly failing,” says Myers. “I understand how hard their job is. But I also understand that states and CMS would like to see significant quality. Care coordination, like the kinds of things our plans will do, are a way to drive quality that clearly has not happened in the last five years in the post-acute care space.”
Health plans are used to dealing with hospitals “where theoretically the hospitals share some risk in the outcomes for the patient,” says Myers. “In the post-acute care setting, particularly in the SNFs [skilled nursing facilities], there’s very little risk sharing that drives quality improvement. It would not surprise me if CMS is looking at the kind of managed effort a large plan can provide in this space to start driving quality.”
Aetna is mighty bullish these days, at least according to Investors.com. Aetna wants to buy either Humana or Cigna. The great man theory of history might be in play here, although only history can judge who’s great and who’s not.
Aetna CEO Mark T. Bertolini seems to want to do great things, with his talk—and action—about social justice getting play in high-brow publications.
He gave his lowest salaried employees a substantial raise and told the New Yorker in February that “companies are not just money-making machines. For the good of the social order, these are the kinds of investments we should be willing to make.”
Barron’s reports that Bertolini in so many words told analysts at an investors meeting on May 11 that “government business is the focus for inorganic growth, while compatible cultures for post-merger synergies were viewed as the driver in all transactions.”
Add the sauce of cheap debt, and an Aetna-Humana and Aetna-Cigna deal may become a reality.
Medicare is booming, apparently, and Aetna wants a piece of the action. Barron’s mentions other reasons, perhaps the most interesting one being that Aetna (read Bertolini) is not living in fear of King v. Burwell going against the ACA but is instead betting that a negative ruling won’t completely undo the law but only force lawmakers to fine tune it.
Is that foolish? Or is that leadership?
Well, one of us was wrong and it wasn’t you. That is if you were a bit skeptical about our October 2013 article unveiling a golden age of registries. There’s the headline: “Registries Retooled for Better Data Mining.” There’s the deck: “Simple to create and to extract data from, registries are becoming essential to effective patient and population management.”
Fast-forward to now: According to researchers at Johns Hopkins University School of Medicine, most clinical registries do not measure up to the challenges of modern medicine, lacking both data geared to specialty care and a way for the public to access those data easily.
Managed Care hopes people can learn from our mistakes. (Actually, we hope people forget about our mistakes, but since we’ve already begun….)
To offer a meager defense, our 2013 article reflected the desire that registries can truly affect care in a positive way. Why, just months later, in January 2014, David B. Nash, MD, MBA, the founding dean of the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia, told us: “I hope I live to see the day when I can come in in the morning, have my panel of patients on my office laptop, call up my registry function and there will be Dr. Nash’s performance on a population basis comparing me to my local peers, regional, and even a national peer group.”
But, as either Spinoza or Springsteen noted, “But if dreams came true, oh, wouldn’t that be nice….” Dr. Nash is savvy enough to know the difference between hoping to “live to see the day” and “registries are becoming essential.”
Johns Hopkins researchers looked at 73 health services registries, 66 disease registries, and 14 combined registries—and did not like what they saw.
“With a few notable exceptions, most registries are underdeveloped, underfunded and often not based on sound scientific methodology,” senior investigator Marty Makary, MD, said in a statement. Researchers conducted their search between July 1, 2012 to Nov. 1, 2012.
News made even more disappointing in light of the fact that the Affordable Care Act encourages registries, as Don Liss, MD, the senior medical director at Independence Blue Cross, pointed out in our October 2013 article. “One of the requirements of the patient-centered medical home (PCMH) is to maintain registries. They can be fairly simple or they can be complex and require EHRs. It’s a fundamental change in practice for physicians.”
Johns Hopkins researchers found that 98 of the 117 recognized medical specialties “do not have a national clinical registry affiliation, representing a substantial opportunity for scientific advancement and quality improvement in health care.”
Registries work better when the data are risk adjusted and audited. “We found that less than a quarter of registries in our study risk adjusted or audited their data, suggesting the need for better handling of data in reporting outcomes.”
One of the paradoxes of human nature is that people who have little money are often the most generous. My old Uncle Joe (dead for over 30 years) had half his stomach blown away in the Battle of the Bulge and suffered the rest of his life from what we today would call post-traumatic stress syndrome and what they referred to then as battle fatigue.
That Uncle Joe carried this burden only occurred to me years after his death because those among the Greatest Generation who most experienced the horrors of war tended not to talk about it.
Uncle Joe gave a portion of what little he had to charity. And the charities would ask for more. To one, he wrote: “I would love to help, but I only have enough money for the staples: beer, whiskey, and cigarettes.”
I thought of Uncle Joe yesterday when I read this excellent story by Phil Galewitz on the Kaiser Health News wire. We here at Managed Care have long covered the expansion of Medicaid under the ACA and the historically unique challenges that will bring. We’ve covered wellness from when many considered it the possible savior of health care, to these days, when it faces withering criticism. Not only does wellness not save money, some argue, it doesn’t really improve outcomes.
As Galewitz reports, one place policymakers think wellness will work is Medicaid, where a little bit of prevention could really impact millions of people who interact with the health care system sporadically, often by going to the emergency department.
These well-intentioned programs flounder for the same reason that caring for Medicaid patients is always a struggle: providers deal with a population in which lack of transportation, illiteracy, substance abuse, sedentariness, and poor eating habits come with the territory.
Then there’s this: Most of us—rich, middling, or poor—want to make our own choices. Uncle Joe knew cigarettes would kill him, a fact of which my aunts never tired of reminding him. Didn’t matter. He chain-smoked unfiltered Camels right to the end, each one to the nub.
Wellness that educates does some good although, again, the effectiveness is anyone’s guess. It’s when government, or employers, or insurance companies (with employers’ blessings and encouragement) reach into our lives and tell us that you will eat more healthily, and you will stop smoking, and you will exercise. Or you will be penalized.
So, as the firestorm of debate kindled by New York City’s decision to ban supersized sodas illustrates, wellness doesn’t just camp out in a little corner of the health care industry. It cuts to what kind of society we want to live in. If I am hungry and someone places two plates on opposite sides of the table, one with French fries and the other with carrots, I know which direction I’ll head in. And if they outlaw beer, I am moving Ireland. I don’t smoke so, of course, jail all the smokers. (Sarcasm.)
Which is not to dismiss wellness outright. I understand, and half agree with, the argument that others shouldn’t have to pay for my poor decisions. But there needs to be balance. Unless I’ve missed a major medical development, the mortality rate for all of us remains 100%. And the desire among us to live a long and healthy life probably approaches that number. But at what cost?
Congress could save over 30,000 lives each year with a single piece of legislation that would set the national speed limit at five miles per hour. That’s the definition of a society going nowhere slow.
A sweeping proposal for improving veterans’ health care would use the Kaiser Permanente model of separating the insurance and payer arms of the Veterans Health Administration (VHA), making the provider an accountable care organization (ACO) and allowing vets to purchase insurance from consumer plans. Concerned Veterans for America, a bipartisan policy taskforce that is pushing the Veterans Independence Act, includes some heavy hitters such as former Republican Senator Bill Frist, and former Democratic Congressman Jim Marshall.
They agree that the health care infrastructure was sparse in 1921, when Congress created the VA’s precursor, the Veterans Bureau. Not anymore, and veterans should have the opportunity to seek care almost anywhere, not just in VHA facilities which are too often far from their homes or inadequately staffed.
The ineptitude and, on too many occasions, downright maleficence of the VHA is a result of the iron triangle of Congress, special interest groups, and government bureaucracies refusing to let an enterprise evolve and change, says the taskforce.
“Despite a $91 billion cumulative increase in the VA’s budget since 2006, and a 101,000-person increase in the VA’s staff, the timeliness of health care delivery for a shrinking veteran population has not improved,” says the report.
In 2009, there were 24 million veterans. That’s expected to shrink to 16 million in 2029 (barring future wars). The VHA is a hospital-centered health system, but technology has led to fewer hospitalizations and more visits to doctors’ offices.
The taskforce says that the way to accomplish these goals is to change the VHA into an independent, government-chartered not-for-profit corporation. This, theoretically, would create a firewall between the VHA and political considerations.
“As an independent entity—answering to its customers and balance sheet—it would be liberated to make the decisions necessary to ensure veterans who continue to choose VHA receive quality and timely care,” the report states. “In addition, we believe that separating the VHA into two functional entities—one, the provider of health care services and the other, the payer of health insurance premiums and claims—will give veterans more options.”
The insurance arm would be called the Veterans Health Insurance Program; the provider arm would be called the Veterans Accountable Care Organization.
In addition, an independent entity would have to keep better records, something the current VHA doesn’t do. In fact, the taskforce said that trying to get information from the VHA “was the most time-consuming aspect of our work and will involve the greatest challenge for policymakers.”
This information gap has been cited before, most recently by a CBO report last December, which noted that, “comparing health care costs in the VHA system and the private sector is difficult partly because the Department of Veterans Affairs … has provided limited data to Congress and the public about its costs and operational performance.”
Current veterans can be grandfathered in to the present system if they so choose. They would also have the option of taking their health care funds to the civilian health care system. “Because private health care is somewhat costlier than VHA-based care, most veterans who choose this option will be expected to share in some of the costs of such care, through co-pays and deductibles,” the report states.
Care would also be tiered: Veterans with service-connected disabilities will be top priority because “when it comes to health care obligations, not every veteran is created equal.”
The report concludes that if reforming the VHA was easy, it would have been done long ago. However, a bipartisan effort can break the iron triangle because veterans deserve the best.
Well-crafted articles sit in mental medicine cabinets; handy for when the next time the malady they address surfaces. This story yesterday (http://tinyurl.com/AP-gene) made me think immediately of this gem that ran in Managed Care back in 2000 (http://tinyurl.com/Bee-Moz). No one’s yet pinpointed the expiration date for spoiler alerts: Does Ilsa Lund run off with the crafty/noble Rick Blaine or the noble/crafty Victor Laszio? Watch the movie.
So, you’ve been alerted.
This is how the 2000 column ends: “We’ve decided to offer the position to Mozart. He’s just 34 years old, with a sparkling genetic pedigree and doubtless a long, illustrious career ahead of him. Unfortunately, Herr Beethoven, you are simply not destined for a life of music.”
That’s an argument against genetic profiling à la O. Henry: Beethoven produced his greatest works when he was deaf, and Mozart died young.
Caveat: Genetic testing and genetic profiling are different things, but you can’t profile without the test and perhaps that’s the biggest challenge to Aetna’s program, well-intentioned as it may be. Even with all the confidentiality safeguards in place, how much information do employees want their employers to have? Enough to save lives?
Aetna and the wellness vendor Newtopia certainly hope that genetic testing will save lives in the long run not only for employees found to be predisposed to disease but, as the Associated Press story shows anecdotally, for those who aren’t. If you’re physically unsound but genetically predisposed to be sound, then you may have no one to blame but yourself if, for instance, your eating habits make you vulnerable to diabetes.
Aetna’s breaking new ground here, as it is the only major health plan to offer genetic testing as part of wellness. There are skeptics, however.
Al Lewis, the founder of the Disease Management Purchasing Consortium, wages war against wellness programs, arguing that they are neither clinically nor financially effective. Creating intrusive wellness programs has become an unfortunate pattern for Aetna, he adds.
“It’s almost as though UnitedHealthcare is feeding them these ideas,” Lewis says. “The fact is that there are going to be tons of false-positives and tons of false-negatives just like with every other test. The difference is that genetic testing costs a fortune and you’re just going to annoy these poor employees.”
The AP story focuses on how the Aetna/Newtopia program fares in the Jackson Laboratory. Not so well, Lewis argues. Of Jackson’s 130 employees, 28 started the program and 19 still participate. “The one place that they’re doing something like this is, by any stretch, a failure,” Lewis says. What makes it more troubling is that Jackson does genetic research.
Lewis is more than able to fend for himself (http://tinyurl.com/Lewis-v-Aetna).
So are Aetna officials.
Greg Steinberg, head of clinical innovation at Aetna, takes issue with much of Lewis’s criticism. He stresses that the program is voluntary and that Aetna’s wellness programs in general have been successful clinically and financially (http://tinyurl.com/Aetna-data).
Aetna used the genetic testing program on its own employees, he points out. “The results were dramatic—participants lost weight (an average of 10 pounds) and reduced their waist sizes, helping bring down the risk for bad health outcomes,” says Steinberg. “Participants also reported high levels of engagement in the program. Based on this success, Aetna is now offering the Newtopia program to its largest customers and their employees.”
Steinberg also stresses that 470 Aetna employees volunteered to participate and that the year-long pilot was extended another six months “to allow for continuation of successful outcomes.”
Meanwhile, frozen in time, Ilsa Lund must make a choice: Rick or Victor? Maybe genetic testing makes the decision easier. Of course, Rick and Victor would have to consent first.
Maybe it’s because cars are fun and we’re young when we start driving that we slide easily into the habit of paying automobile insurance. Or maybe it’s because cars are dangerous and our parents and/or the state wouldn’t let us drive without it. The metaphor of allowing beneficiaries to buy health insurance as they do car insurance (just this side of hoary when we used it back in 1998: http://tinyurl.com/98-story) left reality in the dust ages ago. It sounds so nice, but it’s still not happening, according to a Kaiser Family Tracking Poll released in April 2015 (http://tinyurl.com/KFF-poll).
This, despite all the talk of transparency and the overabundance of evidence that two providers can charge very different prices for the same procedure in the same town and get the same outcomes. This, despite the continuing shift in costs to beneficiaries. In the poll, 2 out of 3 people say that finding out how much doctors or hospitals charge is too difficult. Only 6% of people use quality rankings to make a decision about an insurer, doctor, or hospital.
Many health care economists have pointed out that we don’t know prices in health care, as we do in almost everything else we purchase. That’s one problem. But the search for the educated consumer has been going on for a long time (http://tinyurl.com/issue-consumer). Perhaps the bigger issue is that many of us don’t want to know. It’s frustrating, but ask yourself this: When was the last time you compared health care prices?
In the land of Oz, you can take a pill that makes you lose weight. In the land of Oz, endive, red onion, and sea bass decrease the likelihood of ovarian cancer by 75%. In the land of Oz, acupuncture can help patients stop smoking, lose weight, and even avoid colds.
Mehmet Oz, MD, a national talk show host started his career as one of the best heart transplant surgeons in the world, practicing at Columbia and New York-Presbyterian Hospital.
Now, he’s under fire for allegedly peddling quackery. Ten physicians wrote to Columbia on Wednesday demanding that the school cut ties with the celebrity doctor who, they wrote, “has manifested an egregious lack of integrity by promoting quack treatments and cures in the interest of personal financial gain.”
Oz’s long relationship with Columbia includes launching the Cardiovascular Institute and Integrative Medicine Program, and serving as vice-chairman of the surgery department. It is a deep bond that the hospital intends to maintain, as it made clear in is response to the physicians, saying that, “Columbia is committed to the principle of academic freedom and to upholding faculty members’ freedom of expression for statements they make in public discussion (http://tinyurl.com/letter-OZ).”
Oz has been a brand for years now. He’s immensely photogenic and articulate. Oprah Winfrey fell in love with him. Soon, so did the rest of America. He has his own syndicated TV show. But that’s where the problems begin.
A New Yorker profile a couple years ago (http://tinyurl.com/surrender-Oz) reported that, “Much of the advice Oz offers is sensible, and is rooted solidly in scientific literature. That is why the rest of what he does is so hard to understand.”
A study in the BMJ last December (http://tinyurl.com/BMJ-quack) seemed to understand, making headlines that half of what Oz recommends on his show is baseless and/or wrong. “For recommendations in The Dr Oz Show, evidence supported 46%, contradicted 15%, and was not found for 39%.... Approximately half of the recommendations have either no evidence or are contradicted by the best available evidence. Potential conflicts of interest are rarely addressed. The public should be skeptical about recommendations made on medical talk shows.”
Perhaps so should Columbia.
How will the Supreme Court rule in King v. Burwell?
Any day now, the Supreme Court will hand down its decision. How will the court rule?