Short Takes On News & Events

Study Puts A Price Tag On Autism

Autism exacts a heavy toll on families across the country, but what is the financial cost of the disorder?

Image by Leo Reynolds via Flickr

Now we have an actual price tag:  the lifetime cost of supporting a person with autism ranges from $1.4 million to $2.4 million in the United States, depending on whether the person also has an intellectual disability.

That’s according to a report published by JAMA Pediatrics, based on a literature review of studies on individuals with autism and their families.

Those numbers add up to a total cost of about $66 billion a year for children and  $175 billion a year for adults. About 3.5 million people have autism in the U.S.  For kids, the biggest costs were for early education services and loss of income for their parents. For adults, residential care or living accommodations and loss of individual income were the biggest factors.

David Mandell, an associate professor at the University of Pennsylvania Perelman School of Medicine and senior author of the paper, says the costs were much higher than he expected when he began the investigation.

“The only two health conditions I’ve seen with a higher cost estimate are coronary heart disease and cancer,” he said.

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June 9th, 2014, 4:42 PM by Jenny Gold

Short Takes On News & Events

What’s A Surgeon’s Role In An ACO? Not Much So Far, Survey Says

Accountable Care Organizations have given little attention to surgery in the early years of the Medicare program, choosing to focus instead on managing chronic conditions and reducing hospital readmissions.

That’s according to a case study and survey published this week in the journal Health Affairs. The authors conducted case studies at four ACOs in 2012 and sent a survey to all 59 Medicare ACOs in the first year of the program, with 30 responding.

“I’m a surgeon, so I was really curious as this model probably continues to gain steam, what’s this going to mean for me?” said lead author James M. Dupree, a urologist at Baylor College of Medicine. “We found that thus far, very little of the strategic attention seemed to be devoted to surgical care and the integration of surgeons into the ACO.”

That may be a missed opportunity. Surgery represents 50 percent of hospital expenditures, and “thus, even if ACOs are able to achieve their goals in chronic disease management, overlooking the role and cost of surgical care may negate those savings,” the authors write.

They found that surgery was not part of the strategic plan for the first year at any of case study ACOs, and 86 percent of survey respondents rated the priority of reducing unnecessary surgery as “medium,” “low” or “very low.”

This is not surprising given that none of the ACO quality metrics focus on surgery.  But ACOs will likely shift their focus to surgery as the program matures, experts said.

“Any thoughtful leader has a laundry list of things a mile long that they’d like to work on, and working with the surgeons and the specialists just isn’t at the top of the list. It’s something they’d like to do later on,” said David Muhlestein of the consulting firm Leavitt Partners.

It’s not just surgeons, he adds. “Dermatologists, endocrinologists, all the different specialties want to know how they fit in, but generally ACOs are not prioritizing the specialties. They’re focusing on the lowest hanging fruit, and generally the specialties aren’t the lowest hanging fruit.” It’s easier to focus first on things like reducing expensive hospital admissions by managing the care of patients with chronic illnesses, including diabetes.

Another reason, he says, is that it’s hard for an ACO to figure out how to share savings with specialists like surgeons. With a primary care physician, it’s relatively easy to figure out their share of the ACO’s savings by factoring in the number of patients they see. “It’s harder with specialists who may only see a handful of patients a week,” he said

Reducing unnecessary surgeries might be better achieved by helping primary care physicians change their referral patterns rather than targeting the surgeons themselves, said Muhlestein, who had no role in the survey or case study. Many patients may not need to be referred to a surgeon at all when there’s a medical treatment. And for those that do, he says, “you want to refer to a surgeon who is thoughtful and conservative about the decision to operate.”

The authors of the Health Affairs article also found that the amount of any possible shared savings for surgeons would be smaller than the potential revenues they could generate from additional surgeries. Therefore, changing referral patterns to those surgeons might actually be a more effective way to manage the cost and quality of the care they provide.

“A surgeon who was left out of an ACO, or asked to leave an ACO because of poor performance, would risk losing a referral stream from primary care physicians who participated in the organization,” they wrote.

And ACOs may simply not be the best model for managing surgical quality and cost, said Rob Lazerow of The Advisory Board Company: “The ACO model is only one part of the payment transformation going on right now, and it’s probably more effective at rewarding providers for reducing avoidable care than for making unavoidable care more efficient.”

In other words, ACOs are good at reducing the number of surgeries, but not at making the surgeries that have to happen more efficient.  He says the bundled payment model, in which providers get a set amount of money to handle an episode of care, “is a much more direct way to reward surgeons” who are practicing efficiently.

June 5th, 2014, 1:11 PM by Jenny Gold

Short Takes On News & Events

PCORI, NIH Announce Plans For $30 Million Study On Falls

The nation’s largest and most intensive study of how to best prevent seniors’ injuries from falling will begin next year under a $30 million grant announced Wednesday by the Patient-Centered Outcomes Research Institute and the National Institutes of Health.

A diverse group of 6,000 adults over age 75 or their caregivers will be recruited around the country to participate in the study.

More than 18,000 seniors died as the result of falls in 2010, and thousands more are injured every year, according to the  federal Centers for Disease Control and Prevention.

“A serious fall that leads to a bone fracture or hospitalization has been demonstrated to be one of the most devastating events in the life of an older person, comparable to a serious stroke,” said Dr. Thomas Gill, a geriatrician and professor at Yale School of Medicine and one of the study’s three principal investigators.

While previous studies have identified those older adults most at risk for serious falls and how to prevent them in an experimental setting, Dr. Richard Hodes, director of the National Institute on Aging, said this new research goes several steps further.

“We think this study will be unique and play a very critical role in taking the research that has existed to date and translating it to a real advantage to the public,” he said.

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June 5th, 2014, 8:40 AM by Susan Jaffe

Short Takes On News & Events

Medicaid Enrollment Surges By More Than 1 Million In April

Medicaid enrollment surged by more than 1 million people in April, bringing the total growth in the state-federal health insurance program for the poor since September to about 6 million, the Obama administration said Wednesday.

The increase is significant because it shows Medicaid enrollment continued to grow even after the new state and federal online insurance exchanges closed their open enrollment period for private insurance at the end of March. Advocates say the increase also shows states are making headway reducing the backlog of Medicaid applications that built up because of communications problems between and states and other state technological issues.

Overall, Medicaid enrollment in 47 states and the District of Columbia topped 65 million in April, compared to 59 million in September for those same states, according to the report from the Centers for Medicare & Medicaid Services. Connecticut, Maine and North Dakota did not report their Medicaid enrollments.

States that expanded eligibility under the Affordable Care Act to cover residents with incomes up to 138 percent of federal poverty level (about $16,100 for an individual) saw Medicaid enrollments grow by an average of 15.3 percent. States that did not expand reported a 3.3 percent increase.

“This is good news,” said Rachel Klein, director of organizational strategy & enrollment at Families USA, a consumer advocacy group. “This increase reflects the ongoing outreach effort in states … and that states are still processing applications they received earlier.”

Twenty-six states have expanded Medicaid, although New Hampshire is not scheduled to implement it until July. Michigan’s expansion began April 1 — and it has added more than 270,000 people to the program since then, according to state figures.

Medicaid rolls in West Virginia, Oregon and Nevada, all of which expanded eligibility, increased at the fastest pace — all had more than 40 percent growth since September, the CMS report said

Even some states that did not expand saw a surge of enrollees as thousands of people who were previously eligible but not enrolled signed up.  Enrollment in South Carolina grew by more than 14 percent as the state made concerted effort to find those who were previously eligible. Florida, Georgia and Kansas — whose Republican leaders have been hostile to the health law — saw Medicaid grow by about 7 percent since September.

Medicaid enrollment dropped in four states since September — Alabama, Missouri, Nebraska and Wyoming. None expanded eligibility.

While the open enrollment period has ended for buying private insurance through the federal or state marketplaces, consumers may apply for Medicaid and CHIP coverage year round.

June 4th, 2014, 2:28 PM by Phil Galewitz

Short Takes On News & Events

Medicare Could Save Billions By Scrapping Random Drug Plan Assignment

A new study finds that Medicare is spending billions of dollars more than it needs to on prescription drugs for low-income seniors and disabled beneficiaries.

In 2013, an estimated 10 million people who participate in the Medicare prescription drug program, known as Part D, received government subsidies to help pay for that coverage. They account for an estimated three-quarters of the program’s cost. Most of those low-income enrollees are randomly placed in a plan that costs less than the average for the region where the person lives.

But even though these are lower-cost plans, they often end up costing the government and the beneficiary more. If Medicare instead assigned those people to a drug plan based on the actual drugs they took, it could save those patients hassle and money, and potentially save the government billions of dollars, according to the study by researchers from the University of Pittsburgh.  The study appears in the June issue of the policy journal Health Affairs.

Using a 5 percent sample of Medicare drug claims data from 2008 and 2009, the researchers calculated that if Medicare had matched beneficiaries to drug plans using “intelligent reassignment,” rather than random chance,  the government would have saved $5 billion in 2009. That’s because the government is responsible for picking up the copayments for many low-income beneficiaries.

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June 2nd, 2014, 4:00 PM by Julie Rovner

Reporter's Notebook

Pre-Existing Condition Bans – Are They Really Gone?

“Welcome to Cigna,” said the letter, dated May 16, on behalf of my new employer, the Kaiser Family Foundation. They were placing me on a one-year waiting period for any pre-existing conditions.

Seriously? Wasn’t the health law was supposed to end that?

“We have reviewed the evidence of prior creditable coverage provided by you and/or your prior carrier and have determined that you have 0 days of creditable coverage,” the letter said.

Which was really odd, since it came the same day as another letter, also dated May 16, also from Cigna, but on behalf of my now former employer, NPR.  It was a “Certificate of Group Health Plan Coverage,” noting that I had been covered continuously for at least the past 18 months. (It’s more like 10 years, but who’s counting.)

“This letter will serve as your certification of prior coverage with CIGNA HealthCare,” the letter said. “If you have just changed coverage to another CIGNA HealthCare product, you may disregard this certificate.”

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June 2nd, 2014, 2:50 PM by Julie Rovner

Short Takes On News & Events

Most Americans Say The Health Law Has Not Affected Their Families: Poll

More than four years after enactment of the health law, six in 10 Americans say neither they nor their families have been affected by the sweeping measure, according to a poll released Friday.

Among those who say the law has impacted them, Republicans are much more likely to say their families have been hurt by the law (37 percent) than helped (5 percent), while Democrats are more likely to say their families have been helped (26 percent) than hurt (8 percent), according to The Kaiser Family Foundation’s monthly tracking poll. (Kaiser Health News is an editorially independent program of the foundation).

The relationship between partisanship and reported impact of the law holds when controlling for other factors such as income, race/ethnicity and insurance status, the poll found.

Among those who say the law has helped them, the most common response is it allowed someone in their family to get or keep coverage. Among those who say the law has hurt them, the most common response is that their health care costs have increased.

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May 30th, 2014, 6:48 AM by Mary Agnes Carey

Short Takes On News & Events

‘National Dialogue’ Urged On Cost Of New Hepatitis C Drug

The outcry continues over the $1,000-a-pill hepatitis C drug made by California-based Gilead Sciences.

While the drug is a significant advance over older treatments for the viral liver disease, the price set by the company “represents an abuse of market power,” said John Rother, president and CEO of the National Coalition on Health Care, which includes businesses, unions, insurers, consumers and some drugmakers, including the Generic Pharmaceutical Association.

On Wednesday, the group urged a “national dialogue” on the cost, saying Sovaldi’s price tag threatens the budgets of government run-health programs as well as the premiums for everyone who has private insurance.

With more such “specialty drugs” in the pipeline for other conditions that affect millions of people, the group says the drug industry must find “a more sustainable approach” on prices for new products – although it stopped short of giving examples of how that might be done.

The U.S. currently spends more than $300 billion on pharmaceuticals each year.  Simply covering the cost of Sovaldi for the more than 3 million Americans who are estimated to have hepatitis C could double that.

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May 28th, 2014, 3:31 PM by Julie Appleby

Short Takes On News & Events

Can Employers Dump Workers To Health Exchanges? Yes, For A Price

How to expand Americans’ health insurance choices under the Affordable Care Act without sabotaging employer coverage? The Obama administration is still working to get the balance right.

The latest tweak from the Internal Revenue Service essentially prohibits employers from giving workers tax-free dollars to buy policies in the online public marketplaces created by the health law. The New York Times first reported the rule. But the Times’s headline, “I.R.S. Bars Employers From Dumping Workers Into Health Exchanges,” overstates the case.

Nothing stops employers from canceling company plans and leaving workers to buy individual policies sold through the exchanges — as long as they pay the relevant taxes and penalties, said Christopher Condeluci, a Venable lawyer specializing in benefits and taxes. Those will vary according to a company’s size and circumstances.

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May 28th, 2014, 5:00 AM by Jay Hancock

Short Takes On News & Events

Minnesota, Not Florida, Not Hawaii, Is Healthiest State For Seniors

“Minnesota Nice” might be the key to good health for seniors.

Photo by Sharyn Morrow via Flickr

America’s Health Rankings Senior Report rated Minnesota the healthiest state in the nation for adults aged 65 and over — beating out Hawaii. And that retiree and snowbird haven, Florida? It came in 28th.

What could put Minnesota, which just weathered arguably the harshest winter in the country, ahead of those sunny climes? Volunteering is one factor. Minnesotans do more of it and it plays a major role in senior vitality, according to Dr. Reed Tuckson, senior medical adviser to the UnitedHealth foundation, which funds the annual rankings.

“There’s a much better chance to be active, to be engaged, to be alive, to feel excited, to be inspired,” said Tuckson, “and therefore to have a good mental attitude.”

The report grades states on 34 individual measures ranging from the amount of physical activity to prescription drug coverage to flu vaccinations. New Hampshire, Vermont and Massachusetts round out the top 5 states.

Tuckson said Minnesota stands out in a number of key indicators beyond volunteering. Seniors in the state have the lowest prevalence of cognitive problems, and they visit the dentist often.

Seth Boffeli, spokesman for AARP Minnesota said the report underscores that decades of proactive efforts have paid off.  He says Minnesota was ahead of the curve in moving towards community-based living for seniors and away from institutionalized nursing home care, when possible.

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May 22nd, 2014, 5:00 AM by Elizabeth Stawicki, Minnesota Public Radio