The Incidental Economist

This is a guest post by Adm. Brett Giroir, Jessica White, Teresa Manocchio, Sean Klein, Zeid El-Kilani. Adm. Brett Giroir is the 16th Assistant Secretary for Health (@HHS_ASH) at the U.S. Department of Health and Human Services; Jessica White, Teresa Manocchio, Sean Klein, and Zeid El-Kilani work for the Assistant Secretary for Planning and Evaluation (@HHS_ASPE) at the U.S. Department of Health and Human Services. 

As we recognize International Overdose Awareness Day, HHS is calling attention to the co-prescription of naloxone, the Food and Drug Administration (FDA)-approved medication that can save a person’s life when administered during an opioid overdose. Naloxone is available in three formulations – nasal spray, injectable, and auto-injector – and at least one form of naloxone is covered by most health insurance plans, including Medicaid and Medicare.

Since July 2016, prescriptions for naloxone in the U.S. have increased 773%. Expanding the availability and distribution of overdose-reversing drugs is one of the five pillars of HHS’s comprehensive, science-based strategy for combatting the opioid overdose epidemic. These efforts include co-prescribing naloxone in conjunction with an opioid prescription, or prescribing naloxone to at-risk individuals.

As of July 2020, the FDA announced it is requiring changes to the prescribing information for opioids and medications to treat opioid use disorder (OUD). These changes include recommending that as a routine part of prescribing these medications, health care professionals should discuss the availability of naloxone with patients and caregivers, both when beginning and renewing treatment. Additionally, they should consider prescribing naloxone based on a patient’s risk factors for overdose. Previously, in December 2018, HHS released guidance for health care providers and patients detailing how naloxone should be prescribed to all patients at risk for opioid complications, including overdose. Naloxone co-prescribing is also recommended in the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.

Over the past several years, a growing number of states have implemented laws and regulations requiring health care providers to co-prescribe naloxone with opioid prescriptions to patients considered at risk of an overdose. As HHS regularly tracks the number of naloxone prescriptions dispensed in the US within mail order and retail pharmacies, we are greatly encouraged by continued increases in naloxone prescriptions, particularly within states that have recently implemented naloxone co-prescribing legislation.

For example, a California law effective January 1, 2019, requires that prescribers offer a prescription for naloxone when certain conditions are met, including high daily doses of opioids, concurrent opioid and benzodiazepine prescriptions, and increased risk of an opioid overdose (e.g. a patient with a history of OUD or previous overdose). Prior to the effective date of the law, naloxone prescriptions averaged approximately 1,800 monthly. In the first month following the effective date of the law, naloxone prescriptions jumped 282% (Figure 1) and have averaged approximately 13,800 monthly since.

Recent mail order and retail pharmacy data from New Jersey reflect similar trends. An administrative order issued on May 21, 2020 directs practitioners to prescribe naloxone for any individual receiving high daily doses of opioids or concurrent opioid and benzodiazepine prescriptions. Even during a pandemic, naloxone co-prescribing laws lead to increased naloxone prescriptions. Data from June 2020 show an increase in naloxone prescriptions in New Jersey of 1,058% over May (Figure 2).

Although the number of naloxone prescriptions is not necessarily representative of naloxone use or decreasing opioid overdose deaths, naloxone continues to play an important role as one pillar of our comprehensive strategy to address the opioid crisis.

Share this...

Twitter

Facebook

email

Tweetable

There’s been a lot of discussion about differences in susceptibility and symptom severity among people with different blood types. Does your blood type determine how likely you are to contract COVID-19 and/or the severity of your case? We’re looking at some initial data to see how this idea holds up.

@DrTiff_PhD

Share this...

Twitter

Facebook

email

Tweetable

The following originally appeared on The Upshot (copyright 2020, The New York Times Company). 

American opponents of proposed government-run health systems have long used the word “choice” as a weapon.

One reason “Medicare for all” met its end this year has been the decades-long priming of the public that a health system should preserve choice — of plans and doctors and hospitals. To have choice is to be free, according to many.

So how many Americans actually have choices, and what type of freedom do choices provide?

Making mistakes with Medicare

Current Medicare enrollees have more choices than any other Americans — to some, in fact, an overwhelmingly large number of them.

In 2019, 90 percent of Medicare enrollees had access to at least 10 Medicare Advantage plans, which are government-subsidized, private-plan alternatives to the traditional public program.

But this is just the beginning. If Medicare beneficiaries who elect to enroll in the traditional public program want drug coverage, they must choose from large numbers of private prescription drug plans. In 2014, beneficiaries could choose from an average of 28 drug plans. They can also select private plans that wrap around traditional Medicare, filling in some of its gaps, and this doesn’t even count plan options that may be available through former employers as retiree benefits.

Choosing among all these options would be a challenge for anyone, or, as a Kaiser Family Foundation report put it, “a daunting task.”

“Medicare beneficiaries are so confused, overwhelmed and frustrated with the number of choices and the process of choosing among them, they end up taking shortcuts,” said Gretchen Jacobson, now with the Commonwealth Fund and an author of the report. “Those shortcuts can lead them to select plans that aren’t as beneficial to them as other options.”

In other words, freedom to choose is also freedom to make mistakes.

For instance, in the first year that drug plans were available to Medicare beneficiaries, economists have shown that 88 percent of them chose a more costly plan than they could have. This cost them 30 percent more, on average, and the tendency to select needlessly costly plans persisted in subsequent years. This is the kind of error, as other studies have found, that is easy to make when inundated by choices.

More generally, without some assistance, many people don’t understand the health insurance choices and features. Even common terms can be confusing. In one study, all the subjects said they understood what a “co-pay” was, but 28 percent could not answer a question testing their knowledge of the term; 41 percent couldn’t define what “maximum out-of-pocket” meant.

Of course, just because people make mistakes when faced with choices doesn’t imply that a single plan for all would be a better fit for more people. It all depends on the details.

Medicaid also offers the vast majority of enrollees private-plan choices. States, on average, offered seven plans for enrollees to choose from in 2017. Some types of enrollees — particularly those with more complex health problems — are not able to choose plans and are put into one that specializes in their needs.

According to a systematic review by Michael Sparer, a professor at Columbia University’s Mailman School of Public Health, studies do not find much cost savings to Medicaid programs stemming from all this choice. But some studies indicate that private Medicaid plans do provide better access to some types of care, including primary care.

A caution, however: “Since Medicaid is a state-based program, broad averages don’t tell you much about what is happening in specific states,” he said. “Some states have been able to save money through the managed care options enrollees can select, and some have not.”

It’s much less clear how many choices people with employer-sponsored plans have, because that data isn’t public. Generally speaking, employers serve as a filter, selecting or working with insurers to devise a small number of plans offered to employees.

What we do know is that three in four employers offer just a single plan. These are mostly small businesses, so only a minority of workers are employed by them. Most workers (64 percent) are employed by firms that offer some choice among plans. But most of these workers are at firms that offer just two options. Does this imply workers at these firms have less freedom?

About 4 percent of firms with more than 50 employees offer coverage in private exchanges, akin to what the Affordable Care Act established for individuals. “Private exchanges generated a lot of hype five years ago,” said Paul Fronstin, director of health research at the Employee Benefit Research Institute. “For some reason, they just never became popular.”

He gets his coverage from an exchange that offers a whopping 60 plans. “Choosing among them is no small task, particularly because information about them is so confusing,” he said.

One employer that stands out in offering choices is the federal government. Federal employees can typically choose from about two dozen plans (the number and details vary by state). There are 28 plans in Washington and 21 in Rhode Island, for example.

This year, all A.C.A. marketplace enrollees have choices among plans, on average about 19 of them. Some have over 100.

All told, a rough calculation suggests that about 80 percent of insured Americans have a choice of health plan.

What is ‘freedom’ in health care?

It’s worth considering what accompanies health insurance choice for some Americans. If you work at a company, you could lose access to affordable coverage if you lose your job or if the company decides to stop offering it.

Other people choose coverage plans that can be too skimpy to pay for a major treatment.

Yet others may have options, but they may not be affordable. None of this is necessarily a condemnation of choice per se, just the nature of health insurance choice in America today.

Medicare for all was supposed to address problems like these. As the Finnish author Anu Partanen wrote of a single-payer system: “The point of having the government manage this complicated service is not to take freedom away from the individual. The point is the opposite: to give people more freedom.”

The Medicare for All Act would have offered no choice, enrolling everyone in the same, comprehensive plan with no out-of-pocket cost. Proponents of this approach trust the government to devise a program suitable for all. Detractors of it favor choices precisely because they have less faith that government will do a better job than plans that are in competition. For them, freedom to choose is freedom from tyranny. But too much choice without enough guidance can be overwhelming.

@afrakt

Share this...

Twitter

Facebook

email

Tweetable

Paul Shafer is an assistant professor of health law, policy, and management at the Boston University School of Public Health. Nicole Huberfeld is a professor of law and health law, policy, and management at the Boston University Schools of Law and Public Health. Follow them on Twitter at @shaferpr and @nhuberfeld1.

The Trump administration has had its hands full responding to the coronavirus pandemic, but that hasn’t stopped it from taking steps to reverse much of the gains in health insurance coverage since the Affordable Care Act was passed in 2010. In an article today on The Conversation, we discuss two major actions by the Trump administration that may would typically have made huge headlines but may have gotten lost in the COVID shuffle – 1) attempting to block grant Medicaid and 2) supporting a Supreme Court case that could take down the ACA.

Despite shaky legal footing, the administration has moved ahead with its Healthy Adult Opportunity guidance, issued to state Medicaid directors in January, that allows for states to opt-in to a per capita cap or program-level block grant for Medicaid. Oklahoma was going to be the first to implement this until a ballot initiative to expand Medicaid passed in July.

Block granting Medicaid has been a goal of Republicans for years, including during the ACA repeal efforts in Congress, but has never been able to be passed into law. This end run around federal law has been loudly challenged by legal scholars but is only one plank of the administration’s plans.

Texas v. California will be heard in November, a case in which 17 Republican-led states are trying to take down the ACA through again dubious legal arguments about severability of the individual mandate from the rest of the law. The administration has abdicated its role to defend the law and is arguing in favor of striking it down, trying to accomplish through the courts what it has failed to do through Congress.

As we wrote,

If the ACA is struck down, that means the loss of coverage for preexisting conditions, the return of annual or lifetime caps, or policies being revoked for cancer patients. Those who don’t earn much money still deserve good health care. Nearly everyone will feel it if the Trump administration and Texas are successful, regardless of whether your health insurance is through your work, HealthCare.gov, Medicaid or Medicare.

This fall, the Supreme Court and the voters will have a lot to say about how access and affordability of health insurance coverage look in 2021 and beyond.

Read the whole piece here.

Research for this piece was supported by the Laura and John Arnold Foundation.

Share this...

Twitter

Facebook

email

Tweetable

This is part 4 in our series on the opioid crisis, presented with support from the NIHCM Foundation. We’ve talked about the state of the opioid crisis, deaths of despair, and the disappointing evidence about marijuana as a treatment for opioid dependence. But the outlook doesn’t have to be entirely bleak. In this final episode, we zero in on where we’re still failing and what the data are telling us to do.

@DrTiff_PhD

Share this...

Twitter

Facebook

email

Tweetable

Part 3 of our opioid series, supported by the NIHCM Foundation, examines the potential of marijuana to improve outcomes in opioid addiction therapy. Some studies have suggested that marijuana can ease the path to shaking opioid dependence, but more recent data might be telling us a different story.

@DrTiff_PhD

Share this...

Twitter

Facebook

email

Tweetable

The following originally appeared on the Drivers of Health blog.

Earlier this month, I participated in a plenary panel on confronting structural racism in health services research at the AcademyHealth Annual Research Meeting. I believe most of what I said generalizes outside of this field of research. My opening comments are below, and I was joined on the panel by Don Taylor and Sherilynn Black (Professor and Associate Vice Provost for Faculty Advancement, respectively, at Duke University), Linda Blount (President and CEO of the Black Women’s Health Imperative), and Steven Brown (a Research Associate at the Urban Institute).

As a discipline, health services research is in its sixth decade. That means it grew up in the context of racist laws, practices, and policies. It is not possible for HSR’s institutions and scholarship to have avoided racism’s influence. Let us at least accept this fundamental truth.

Structural racism is all around us, even if we are blind to it. It used to be popular to say one is color blind. But, at least for me, that equated to a lack of attention to racism. I didn’t see it because I didn’t look for it. For a long time I was satisfied with that. But it’s not satisfactory.

There is an unsatisfactory complacency that emerges from believing not being racist is adequate. It’s not adequate. In truth, it’s a passivity that tacitly supports structural racism everywhere, including in HSR. That I was not racist was merely a story I told myself. It didn’t have any impact on my community or the institutions where I work.

This reflects the unjustified and unjustifiable privilege of whiteness. As a white person, I have a privilege to be able to walk away from racism, to not think about it, to not have it contribute to my daily life — in a way that my Black colleagues cannot.

Change for myself, for HSR, and other areas, will require rejecting this privilege. I and my white colleagues have to find ways to challenge ourselves daily in the project of anti-racism. There’s a reason we’re doing this now — we’ve been shocked by videos of Black people being murdered by police. But we must remain motivated without another Black person being killed by racism. We must find a way to make anti-racism critical to our own humanity.

One, of several, ways I’m approaching this is through public writing, including at the New York Times. Each time I write about racism it’s a big effort. I have to face my fears about miscommunicating or being misunderstood. It’s important to push through those fears. With each piece I’ve received feedback — solicited and not — about how I can make improvements. This is challenging to hear when you’ve tried so hard! But this is also part of the necessary work — to listen, to hear, to accept the challenge, and, most importantly, to not walk away.

@afrakt

Share this...

Twitter

Facebook

email

Tweetable

In recent years, life expectancy in the US has dropped, and deaths of despair have been a significant contributor. Drug overdoses and suicides have increased in tandem with the opioid crisis, and the outcome is shorter lives. In this second of four episodes on the current state of the crisis, we’ll talk about these tragic deaths and what we might do about them.

This updated series on the opioid crisis is supported by the National Institute of Healthcare Management.

@DrTiff_PhD

Share this...

Twitter

Facebook

email

Tweetable

Elsa Pearson is a senior policy analyst with Boston University School of Public Health. Follow her on Twitter: @epearsonbusph. Research for this piece was supported by the Laura and John Arnold Foundation.

The first post of this series defined upcoding – billing and coding for more intensive and expensive diagnoses and treatments than what was provided or medically necessary – and presented research on its prevalence. If upcoding is fraudulent or, at the very least, not ideal, and as common as the literature suggests, what can be done about it?

Matthew Fiedler of the Brookings Institution put it aptly when he told me via email that “the right policy response depends some on how you conceive of the problem.” Experts have an array of ideas on how to mitigate upcoding and none will defeat it singlehandedly.

A policy brief written for the American Medical Association’s Journal of Ethics suggested two strategies: medical education and front end analytics. The authors argued that medical education and training is the time to familiarize future physicians with upcoding and other fraudulent billing practices. (I would argue this concept should also apply to training for non-physician providers and administrative staff.) Their review of the literature showed that only one third of medical schools currently have any curriculum time dedicated to fraud and abuse. Without teaching physicians how to code and bill properly, it’s hard to expect them to learn these habits on their own.

Front end analytics seeks to catch fraudulent upcoding algorithmically. Medicare’s Fraud Prevention System already employs this approach. In 2014, the Fraud Prevention System saved Medicare over $210 million from inappropriate billing. It’s clear that front end analytics can work. However, it’s also clear that the current system isn’t doing enough. Medicare should expand its use of front end analytics and private insurers should adopt a similar approach.

Another proposal focuses not on auditing but on Medicare Advantage’s (MA)’s “coding intensity adjustment.” This benchmark of sorts allows the Medicare program to financially adjust (i.e., reduce payment) for common coding differences between traditional Medicare and MA. These coding differences are related to patient complexity-based payments: MA pays more than traditional Medicare for more complex patients, incentivizing MA providers to upcode.

Richard Kronick of the University of California San Diego argued in Health Affairs that the current coding intensity adjustment is smaller than what it could and should be and will lead to $200 billion in overpayments in the next decade. As it stands, the coding intensity adjustment is set annually by political appointees at the Centers for Medicare and Medicaid Services (CMS). Kronick contends it should instead be both mandated by law and methodologically determined so as not to be influenced by ever changing political agendas.

Lastly, Paul Van der Water of the Center on Budget and Policy Priorities suggested MA should not include diagnoses collected in health risk assessments in risk score calculations. Because MA bills based on patient complexity, the incentive is to attach more diagnoses to each patient. Health risk assessments, though intended to inform care, often influence the patient’s documented complexity by added new diagnoses. By omitting those diagnoses from risk score calculations, MA would paint a more accurate representation of its enrollees and reduce upcoding associated with patient complexity.

Van der Water notes that the Medicare Payment Advisory Commission (MedPAC) recommended this to CMS in 2016 but CMS has yet to act. MedPAC also recommended CMS use two years of diagnostic data in risk score calculations to ensure a more accurate representation of patient complexity.

While most of the above solutions are presented in the context of traditional Medicare and MA, many of the concepts are applicable to private providers and insurers as well. Moving the needle on upcoding will require a multifaceted approach, dependent on both regulatory oversight and buy-in from payers and providers.

Share this...

Twitter

Facebook

email

Tweetable

In a previous post, I walked you through my decision to have radiation therapy only, without chemotherapy. Now I’ve started therapy. This post is about what it’s like. I hope it will help you make an informed decision about radiation if, God forbid, you get throat cancer. Or it can give you insight into the experience of someone in your life who is going through this.

Radiation therapy means that a machine projects a beam of particles at your tumour. The particles damage the DNA in the cells of the tumour, making them less able to reproduce, and killing them. But to hit the tumour, they need to pass through healthy tissue, and they can also hit the healthy tissue on the margins of the tumour. Radiation damages healthy tissue, but not as much as tumour cells. The particles are photons, so if you think this sounds like getting a severe sunburn, that’s not far off. If all goes well, my tumour will be destroyed, and the throat tissue surrounding it will just be badly burned.

There are other side effects. Bones exposed to radiation are weakened. Radiating the throat damages your salivary glands, giving you a dry mouth. This is unpleasant, but what’s worse is that saliva is essential to tooth decay prevention. A dentist who specializes in radiotherapy patients delivered a come-to-Jesus talk. I have to give my teeth a special fluoride treatment every day, or I will need horrifying dental surgery. Yes, Lord! I haven’t missed a treatment yet.

A proton beam therapy machine. It looks like a $200M capital investment to me.

Proton beam therapy is also used in the US. There are data indicating that proton beams are just as effective as photons in terms of throat cancer survival, but protons produce less severe side effects. However, proton beam therapy is not available in Canada for my cancer. This is because

Proton therapy costs range from about $30,000 to $120,000 [US dollars]. In contrast,… IMRT (intensity-modulated radiation therapy [which is what I am getting]) costs about $15,000. A radiation treatment center with stereotactic capabilities costs about $7 million to build, versus roughly $200 million for a proton therapy center.

This price difference is one reason why Canada spends $4800 and the US $9900 per capita on health care (2016 spending). This difference allows Canada to spend substantially more on other social benefits, including universal parental leaves, child care, and subsidized university tuition. My view is that this is a better set of investments in public health and well-being, even though I am the loser in this case.

Before I started treatment, I got a computerized tomography (CT) scan of my throat to locate my tumour precisely. They began by injecting a radioactive dye that would be preferentially absorbed by the tumour. This made the tumour stand out in the CT image. The purpose of getting a precise image is to allow the radiation team to accurately target the beam at the tumour and minimize the exposure of healthy tissue to radiation.

The radiation mask of my head.

At the CT session, the radiation team made a mask of my face, head, and neck. They took a big sheet of some kind of plastic mesh and warmed it until it softened. Next, I had to lie on my back on a table with my head on a moulded plastic cushion that positioned my head to look at the ceiling. This is the position that they want my head to be in during the radiation. Then they placed the softened plastic sheet over my head and pressed it down so that it conformed to my head and neck. It’s a mesh, so I could breathe through it. In a couple of minutes, the plastic cooled and became rigid. They lifted it off — it wasn’t sticky — and there was my mask.

Why in the world would they do this? I wear the mask during each radiation session. It keeps my head in exactly the same position throughout each session. If I moved my head, the precise targeting of the radiation beam would be for nought. I’d have less radiation exposure to my tumour and more exposure to healthy tissue.

I will be getting 35 radiation sessions, on a Monday through Friday schedule. The idea is to limit the radiation dose at any given session while letting the tumour killing exposure accumulate slowly. Of course, this means that the side effects accumulate too. So far, I have had ten sessions.

Me on the radiation machine table. My mask is above my head.

Here’s what happens in a session. I lie down on the table of what looks like a CT or MRI scanner. There’s a bit of work to get me correctly positioned with respect to the laser lines you can see in the photo. Then they place the mask over my face and clamp it down to the table. This holds my head in position. Then the table, which is motorized, slides me so that my masked head enters the machine. There’s a lot of noise which must be connected somehow to the generation of the beam. After five minutes or so, the table slides me back out. There’s more noise, which I gather is the machine reconfiguring the beam in some way. Then the table slides me back into the machine for another few minutes of radiation. Then I’m slid out, they unclamp the mask, and I’m done.

What is it like to be in the machine? I can feel the warmth of the radiation. It’s not painful — at least, not yet — but there’s an increasingly urgent message from my flesh: “You do realize that this is burning me?” This is clearly going to get worse as treatment progresses.

The mask is now clamped to the table, locking my head into position. The table is about to slide me into the machine.

At first, the mask was a challenge. I can breathe through it, but my breathing is somewhat restricted. The lower edge of the mask presses a bit against my throat. There’s no real danger. But we humans are extraordinarily sensitive to anything that constricts our airways. During my first radiation session, I couldn’t help but think, “what would happen if I started to have trouble breathing?” “What would happen if this thing pressing on my throat got a little tighter?” Having those very thoughts made my heart beat faster, and that made me breathe a little more quickly. But trying to breathe more quickly just increased the feeling that I didn’t have free access to air. That raised my anxiety, which made my heart beat yet faster, and… you can see where this was going.

Deo gratias, I am not an anxious person. And I have participated in sports — long-distance open-water swimming and scuba diving — that teach you to remain calm under stress through careful control of your breathing. I’ve also logged 10 gazillion hours of Buddhist meditation, watching my breath and experiencing how simply breathing shapes your experience of your body and the world. So I knew exactly how to manage being masked: long, slow, steady breaths.

Breathing in, I calm my body and mind.

Breathing out, I smile.

Dwelling in the present moment, I know this is the only moment.

– Thich Nhat Hanh, Buddhist monk

As you can imagine, the mask makes radiation therapy exceptionally difficult for anyone with claustrophobia, anxiety disorders, or panic disorder. Some folks need to be anesthetized. Hypnosis and cognitive behaviour therapy have also been used to train people to tolerate it. If it hasn’t been tried already, may I suggest that a brief course on meditating on the breath might be a great help to radiotherapy patients.

To read my Cancer Posts from the start, please begin here. The next cancer post is here.

@Bill_Gardner

Share this...

Twitter

Facebook

email

Tweetable