Aaron E. Carroll's Blog, page 138

AcademyHealth: Medicare Advantage risk selection

One of the concerns about Medicare Advantage (MA) is that it doesn’t serve sick beneficiaries well, motivating some of them to switch to traditional Medicare (TM). My final blog post for AcademyHealth explores this topic.

@afrakt

 

Oglala Lakota County, SD

Here is a map of male life expectancy at birth by US county. Your eye is drawn to the striking red patch on the border of South Dakota and Nebraska. It has a history.

Life expectancy at birth by country, Institute of Health Metrics and Evaluation, University of Washington.

That’s Oglala Lakota County, which falls entirely within the Pine Ridge Reservation of the Oglala Lakota nation. This is the poorest county in America, with $8,768 per capita income. Male infants there have a life expectancy of 65.2 years, compared to 76.5 for the US as a whole. This is less than the (male and female) life expectancy in Laos and Yemen. Oglala Lakota County experienced 1945 deaths per 100,000 population in 2013 (compared to 927 / 100,000 for the US as a whole).

The people of Oglala Lakota County are, clearly, exposed to severely adverse social determinants of health. But this epidemiological language is too impersonal: the social determinants include a history of oppression and murder. The Wounded Knee Massacre of Lakotas by the US 7th Cavalry occurred here in 1890.

Frozen bodies in a mass grave at Wounded Knee. Photograph from 1891.

Many communities have terrible histories. Oglala Lakota County is only the second worst country in the US for male life expectancy. The worst (3142 out of 3142) is McDowell County, West Virginia, where male infants are expected to live only 63.9 years. This is slightly worse than the life expectancy at birth in the Sudan. McDowell County was once a leading coal-producing county, but the industry has since collapsed. In 2015, the county had the highest rate of opioid deaths in the US (141 deaths per 100,000 people, roughly 10 times the rate for the US as a whole).

In light of the 2016 election, there have been many scholarly and popular accounts of the health crises of rural US whites. These concerns are entirely appropriate. But we need to register the health needs of all communities, not just the ones that swing elections.

@Bill_Gardner

Readers ask: Is there brain training for hearing loss?

Since publication of my Upshot post about training your brain to improve eyesight for reading, several readers have asked if there are similar approaches to brain training to improve hearing.

I put that question to some experts, but have not received any responses that suggest there is such a thing. In some cases, experts simply did not respond to my email, so maybe those experts know something but aren’t saying!

Point being, right now I’m not aware of how to improve your hearing through brain training. If someone knows otherwise, I’m all ears.

@afrakt

Healthcare Triage: Orphan Drug Costs

Last week, we argued that the benefits of the Orphan Drug Act are more elusive than commonly assumed. But what are its costs? That’s the topic of this week’s Healthcare Triage.

Sources can be found in the posts Nick has written on the subject! Special thanks to him!

@aaronecarroll

Healthcare Triage News: Measuring Safety Might Actually Improve It…At Least Temporarily

Measuring safety might actually improve it. Unfortunately, those improvements fade away when the measurement is over. This is Healthcare Triage News.

This episode was adapted from a post I wrote for the AcademyHealth blog. Links to further reading and sources can be found there.

@aaronecarroll

Uncertainty (Still) Has Consequences – and Trump Knows It

This post was co-authored with Rachel Sachs, a law professor at Washington University School of Law. It has been cross-posted at Take Care, a blog concerned with President Trump’s constitutional duty to take care to faithfully execute the law.

Yesterday, in an interview with the Wall Street Journal, President Trump admitted that he’s toying with the idea of blowing up the ACA in order to extract concessions from Democrats. He’s now threatening to withhold payments to health insurers on the exchanges – crashing the Affordable Care Act’s individual markets and potentially kicking almost 10 million people off of their insurance, overnight.

Let’s take a step back for a moment. As we explained two weeks ago, the single most destructive thing the administration could do would be to end cost-sharing payments to insurers. The relevant question is the fate of House v. Price, a lawsuit brought by the House of Representatives against President Obama’s HHS Secretary (Sylvia Burwell) in 2014:

The House argued that the administration was acting illegally in making cost-sharing payments to insurers because Congress had not specifically appropriated those funds.  A judge on the District Court for the District of Columbia ruled both that the House had standing to sue (wrong) and that the administration’s spending violated the Appropriations Clause (right).

The Obama administration appealed the case to the DC Circuit, but, of course, on November 7, 2016, there was an intervening event: the election of President Trump.  The GOP-led House then asked the court to stay the litigation to see what the future might hold for health reform. The case is being held in abeyance, with the next status report due at the end of May, just days before insurers must file their insurance plans for 2018.

Here’s why the case is such a big deal for the individual markets:  The ACA instructs insurers to limit the out-of-pocket expenses for enrollees who make less than 250% of the federal poverty level.  This cost-sharing cap thus plays a key role in keeping insurance affordable for the low-income population.  The federal government is then supposed to reimburse insurers for cutting those low-income customers a break.

Without an appropriation, however, the federal government can’t keep making those payments. Insurers would remain bound by the statutory requirement that they reduce cost-sharing for their customers, but they wouldn’t get reimbursed.  Without those funds, most insurers will not only refuse to enter the market next year, but may exit the market immediately—cancelling plans and leaving patients uncovered.

(For more on the case, read Nick’s Vox explainer here.)

Don’t just take our word for it. Yesterday, eight large trade organizations representing physicians, hospital systems, insurers, and businesses wrote to the President to emphasize that “[t]he most critical action to help stabilize the individual market for 2017 and 2018 is to remove uncertainty about continued funding for cost sharing reductions (CSRs).” It’s a big deal to send this letter so publicly—especially when some of its signatories are organizations that have staunchly resisted the ACA (including the Chamber of Commerce).

In his interview with the Wall Street Journal, President Trump acknowledged that this arcane appropriations dispute represents an existential threat to the viability of the individual markets: “Obamacare is dead next month if it doesn’t get that money.” But instead of saying whether he would continue making the payments, he’s deliberately perpetuating uncertainty in order to force Democrats to play ball. For Trump, uncertainty is leverage—why would you surrender a negotiating advantage?

But he’s overplaying his hand. Democrats aren’t about to walk away from their most significant legislative achievement of the past fifty years just because of a fight over cost-sharing reductions. They know that Trump will be blamed if the insurance markets burn—we’ve even got polling data on that. Congressional Republicans are likely to be scrambling for a solution, not the other way around. It’s as if Trump is holding a gun to his own head and threatening to fire: maybe he’s crazy enough to do it, but Democrats won’t save him from himself.

Until yesterday, it was possible to believe that the administration’s waffling on cost-sharing reductions was the product of disorganization and Trump’s own weak grasp of policy. But now we know: it’s a deliberate tactic. Trump is holding the coverage of millions of people hostage in a Hail Mary attempt to force some yet-to-be-specified legislative compromise. Worse still, his comments will complicate congressional efforts over the coming weeks to appropriate the money for the cost-sharing reductions.

President Trump may not like the ACA, but he’ll be held responsible if it falls apart. Even before this interview, lingering uncertainty about health reform was undermining the viability of the 2018 insurance markets. Trump’s latest comments will only deepen that uncertainty.

@RESachs and @nicholas_bagley

Making Sense of Invisible Risk Sharing

Mark Hall and I have a piece at Brookings and the Health Affairs Blog that takes a hard look at the “invisible risk sharing program,” the newest Republican amendment to the American Health Care Act. Here’s a taste:

Despite its novel title, the program embodies an idea that has circulated in obscure health policy circles for a quarter century: a behind-the-scenes reinsurance program for higher-risk subscribers whom insurers identify at the point of enrollment. This new (old) approach works differently from the “retrospective” reinsurance that the Affordable Care Act (ACA) used for its first three years. Under the ACA, insurers were reimbursed for enrollees who turned out to be especially expensive (initially, more than $45,000 in a year). Invisible risk sharing, in contrast, requires insurers to identify in advance which people they believe will incur large claims, and “cede” them (and their premiums) to a high risk pool, funded by both insurers and the government. The pool then pays all the medical costs for these ceded “lives” (people) beyond a somewhat lower threshold (e.g., $10,000).

Either form of reinsurance—AHCA’s prospective or the ACA’s retrospective—is “invisible” in the sense that high-cost subscribers are unaware of its existence. And both types of reinsurance use public funds to lower insurers’ costs and thus reduce premiums. Where the two programs differ is that AHCA’s invisible risk sharing pays nothing for people who unpredictably incur large claims.

Neither approach is inherently superior at reducing premiums. Premium reduction depends entirely on how much funding the program receives in relation to the risks being insured. Rep. Palmer’s amendment leaves all the critical details of the new, invisible program unspecified, making it hard to generate precise estimates. But, its $1.7 billion per year funding is no more than 2 percent of total premiums in the market. Whether these funds are injected at the front end, the back end, or in the middle, there is no alchemistic wizardry that can magically make more risk than this simply melt away.

Do read the whole thing!

@nicholas_bagley

AcademyHealth: Checking up on hospitals makes them perform better

The Joint Commission conducts unannounced on-site inspections through surveys at hospitals every 18 to 36 months. The inspections take a week, and the surveyors collect data on patient safety, infection control, medication management, or more. These surveys are a big deal, because they are how the Joint Commission makes decisions on accreditation. Should a hospital lose accreditation, it can affect its reputation, or even result in censure or closure. When a hospital is being surveyed, its employees know, and hospitals now often make it a point to train staff in “survey readiness”.

A new paper in JAMA Internal Medicine looked at how hospital behavior changes when these surveys are being conducted. They didn’t just look at process measures, though; they looked at how patient outcomes changed. Specifically, they looked at how outcomes differed on survey weeks versus non-survey weeks.

Go read more about it in my latest post over at the AcademyHealth blog.

@aaronecarroll

Prescription drugs can be effective. Taking too many can be a problem.

The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

The point of prescription drugs is to help us get or feel well. Yet so many Americans take multiple medications that doctors are being encouraged to pause before prescribing and think about “deprescribing” as well.

The idea of dropping unnecessary medications started cropping up in the medical literature a decade ago. In recent years, evidence has mounted about the dangers of taking multiple, perhaps unnecessary, medications.

Deprescribing will work only if patients also get involved in the process. Only they can report adverse effects that they sense but that are not apparent to clinicians. And they need to be comfortable weaning from or dropping drugs that they are accustomed to and believe to be helpful.

Yet an increasing number of Americans — typically older ones with multiple chronic conditions — are taking drugs and supplements they don’t need, or so many of them that those substances are interacting with one another in harmful ways. Studies show that some patients can improve their health with fewer drugs.

Though many prescription drugs are highly valuable, taking them can also be dangerous, particularly taking a lot of them at once. The vast majority of higher-quality studies summarized in a systematic review on polypharmacy — the taking of multiple medications — found an association with a bad health event, like a fall, hospitalization or death.

About one-third of adverse events in hospitalizations include a drug-related harm, leading to longer hospital stays and greater expense. The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.

Not every adverse drug event means a patient has been prescribed an unnecessary and harmful drug. But older patients are at greater risk because they tend to have more chronic conditions and take a multiplicity of medications for them. Two-thirds of Medicare beneficiaries have two or more chronic conditions, and almost half take five or more medications. Over a year, almost 20 percent take 10 or more drugs or supplements.

Some are unnecessary. At least one in five older patients are on an inappropriate medication — one that they can do without or that can be switched to a different, safer drug. One study found that 44 percent of frail, older patients were prescribed at least one drug unnecessarily. A study of over 200,000 older veterans with diabetes found that over half were candidates for dropping a blood pressure or blood sugar control medication. Some studies cite even higher numbers — 60 percent of older Americans may be on a drug they don’t need.

Though studies have found a correlation between the number of drugs a patient takes and the risk of an adverse event, the problem may not be the number of drugs, but the wrong ones. Some medications have been identified as more likely to contribute to adverse events, particularly for older patients.

For example, if you’re taking psychotropic agents, such as benzodiazepines or sleep-aid drugs, you may be at increased risk of falling and cognitive impairment. Diuretics and antihypertensives have also been identified as potentially problematic. (The Agency for Healthcare Research and Quality has published a longer list of drugs that are potentially inappropriate for older patients. Note that, even if they are problematic for some patients, they are appropriate for many.)

Relative to the mountain of evidence on the effects of taking prescription drugs, there are very few clinical trials on the effects of not taking them.

Among them is one randomized trial that found that careful evaluation and weekly management of medications taken by older patients reduced unnecessary or inappropriate drug use. Adverse drug reactions fell by 35 percent. Medication use was reduced, along with the risk of falls among a group of older, community-dwelling patients through a program that included a review of medications.

Several other studies also found that withdrawal of psychotropic medications reduced falls. A comprehensive review of deprescribing studies found that some approaches to it can reduce the risk of death. Another recent randomized trial found that frail and older people could drop an average of two drugs from a 10-drug regimen with no adverse effects.

So why isn’t deprescribing more widely considered? According to a systematic review of research on the question, some physicians are not aware that they’re prescribing inappropriately. Other doctors may have difficulty identifying which drugs are inappropriate, in part because of lack of evidence. In other cases, doctors believe that adverse effects of drug interactions are outweighed by benefits.

Physicians also report that some patients resist changing medications, fearing that alternatives — including lifestyle changes — will not be as effective. Other studies found that many doctors are concerned about liability if something should go wrong or worry they’ll fail to meet performance benchmarks — like the proportion of diabetic patients with adequate blood sugar control.

To reduce the chances of problems with medications, experts advocate that physicians more routinely review the medication regimens of their patients, particularly those with many prescriptions. At hospital discharge — when patients leave the hospital, often on more medications than when they entered it — is a particularly important time for such a review. Including nurses and pharmacists in the process can reduce the burden on physicians and the risks to patients.

Patients can play an important role as well. Walid Gellad, a physician in the Veterans Health Administration and at the University of Pittsburgh School of Medicine, advises that at every visit with a doctor, “patients should ask, ‘Are there any medications that I am on that I don’t need anymore, or that I could try going without?’ ”

Patients, of course, should not try weaning themselves off medication without consulting their doctors — but deprescribing is an idea for all parties to keep in mind.

@afrakt

Healthcare Triage: Orphan Drugs: An Introduction

We at Healthcare Triage couldn’t be more excited about this month. We’re doing a whole month on orphan drugs, with the help of Nick Bagley. He wrote a lot about them, and we begged him to let us adapt his work into a series. This is the Introduction. Over the next few weeks, there will be three more. Enjoy!

Sources can be found in the posts Nick has written on the subject!

@aaronecarroll