Cancer Drugs-Cost Versus Benefit the New Paradigm

Recently, both the New York Times and the Los Angeles Times have published articles about oncologists' new consumer tool to gauge the effectiveness of cancer drugs. This effort was spurred after harsh rebukes of the pharmaceutical industry from clinicians at the Mayo Clinic and Harvard Medical School.  Both of the "Times" articles cite information from the Journal of the American Medical Association (JAMA) article, which ranked cancer fighting drugs from 2009 through 2013 for effectiveness and cost. (1) Oncologists have embraced this new consumer decision aide as it provides health care purchasers and their families with another basis for decision making. And, as it often turns out, the most expensive medication is not necessarily the most effective. Using a scale of 0 to 130 rating system, the cancer drug treatments are ranked for efficacy. Here are the most expensive oncology medications, based on the analysis of experts at JAMA in this study, costs are expressed annually and their effectiveness ranking is listed below:
       RX Ranking by cost-

1. Omacetaxine for chronic myeloid lukemia-$168,366
2. Ibrutinib for mantle cell lymphoma-$157,440
3. Crizotinib for non-small cell lung cancer-$156,544
4. Pomalydomide for multiple myeloma-$150,408
5. Sorafenib for papillary thyroid cancer-$141,984
6. Regorafenib for colorectal cancer-$141,372
7. Ponatinib for chronic myeloid lukemia-$137,592
8. Trametinib for malignant melanoma-$125,280
9. Lenalidomide for mantle cell lymphoma-$124,870
10. Cabozantinib for medulliary thyroid cancer-$118,800

      Same RX showing effectiveness and extended life expectancy due to drug observed response
     Note that some of the drugs lack a proportional effectiveness ranking, this is not an omission.
     Observed effects are quoted from the JAMA article findings.

1. Omacetaxine for chronic myeloid lukemia-14.3% effectiveness, 12.5 months median observed effect
2. Ibrutinib for mantle cell lymphoma-66% effectiveness, 17.5 months median observed effect
3. Crizotinib for non-small cell lung cancer-7.7 months median observed effect versus 3 months on other treatment
4. Pomalydomide for multiple myeloma-29% effectiveness,7.4 months median observed drug effect
5. Sorafenib for papillary thyroid cancer-10.8 months median observed effect versus 5.8
6. Regorafenib for colorectal cancer-2 months median observed drug effect versus 1.7 for other
7. Ponatinib for chronic myeloid lukemia-54% effectiveness, 3.2 to 9.5 months median observed drug effect
8. Trametinib for malignant melanoma-4.8 months versus 1.5 median observed effect
9. Lenalidomide for mantle cell lymphoma-26% effectiveness, median observed effect 16.6 months
10. Cabozantinib for medulliary thyroid cancer-11.2 months median observed effect versus 4 months

As you can see, a high price tag does not assure a fantastic response rate, especially when compared to plain old chemotherapy. Or for example, the non-small cell lung cancer drug, Erlotinib (Tarceva) scored a 44% effectiveness rate and costs $4,600 per month versus the outrageously priced Crizotinib at more than twice that price. Also in comparison, the widely marketed Avastin drug for lung cancers scored only a 16% effectiveness ranking, and it costs $12,000 a month. (2)

Oncologists have banded together to create a Value Framework (3) from which patients and their families can assess the total efficacy of a cancer drug, including cost, response to drug, and a comparison to other treatments. This welcome tool is called a decision aide and it is the latest trend in getting health care quality and purchasing information to the individual patients.

Concern for the efficacy of health care treatments is being expressed by governments as well, with multiple states passing laws requiring drug companies to share their development cost data and not just the drug price. California, Massachusetts, North Carolina, Oregon, and Pennsylvania all have bills pending for pharmaceutical transparency and disclosure. (4) This is all part of the increased effort for greater transparency in health care, driven to the consumer, who actually has to pay for the insurance, the treatments, or the taxes for all of the above.  Although the pharmaceutical pricing model is price-to-whatever-the-U.S.-market-will-bear, this is increasingly becoming a free fall for the consumer who can't afford the treatment and for publicly funded health care programs which are balking at the price gouging.

In 2013, in my book, http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972 I wrote about discerning quality in health care services and this is one more step in empowering patients and their families to make better decisions for their health treatments. To increase your health purchasing IQ continue to read what the healthpolicymaven has to say.  Other articles which may be of interest include:
http://healthpolicymaven.blogspot.com/search/label/cost%20of%20health%20care
http://healthpolicymaven.blogspot.com/2010/11/state-by-state-analysis-of-patient.html

And this is the healthpolicymaven signing off. This article does not offer medical advice and may be shared virally, with appropriate attribution to the writer of course. The healthpolicymaven is a graduate of the University of Washington School of Public Health and Community Medicine and the Daniel Evans School of Public Affairs.

(1) Sham Mailankody, MB BS¹; Vinay Prasad, MD, MPH,  Five Years of Cancer Drug Approvals, Innovation, Efficiency, and Costs, JAMA, July 2015, Volume 1 No. 4
http://oncology.jamanetwork.com/article.aspx?articleid=2212206&utm_source=google_plus_page&utm_medium=sohttp://oncology.jamanetwork.com/article.aspx?articleid=2212206&utm_source=google_plus_page&utm_medium=so

(2) Melissa Healy, Cancer Drugs get a new consumer's guide, Science Now, The Los Angeles Times, June 22, 2015
http://www.latimes.com/science/sciencenow/la-sci-sn-cancer-drugs-consumers-guide-20150622-story.html#page=1

(3)   Lowell E. Schnipper, Nancy E. Davidson, Dana S. Wollins, et, al. American Society of Clinical Oncology Statement: A Conceptual Framework to Assess the Value of Cancer Treatment Options,
American Society of Clinical Oncology, August 2015
http://jco.ascopubs.org/content/early/2015/07/08/JCO.2015.61.6706http://jco.ascopubs.org/content/early/2015/07/08/JCO.2015.61.6706

 (4) Andrew Pollack, Drug Prices Soar, Prompting Calls for Justification, The New York Times, July 23, 2015
http://www.nytimes.com/2015/07/23/business/drug-companies-pushed-from-far-and-wide-to-explain-high-prices.html?_r=0

Cutting Clinician Compensation for Primary Care Is Not the Answer-A Closer Look at Federal Programs

Centers for Medicare and Medicaid Physician Pay Cuts
Cutting Medicare and Medicaid payments to doctors will not engender more support for primary care, which is the weakest link in the chain in U.S. health care. This article examines federal programs established to create an improved healthcare system which have unintended consequences. Under the Budget Control Act of 2007, the Centers for Medicare and Medicaid (CMS) have been required to assess certain health care quality factors and integrate that data into clinician compensation. Initially, doctors were given incentives to show the quality of their care, but now the penalty phase has started. Also, please note, this law has nothing to do with the Affordable Care Act, so those of you with that myopathy, don't get your shorts in a bunch. Based on the Physician Quality Reporting System (PQRS) (1.) results from CMS, 470,000 doctors will get a 1.5% haircut, which is in addition to the overall budget reduction of 2% due to sequestration. (2.) So, in plain English, even the doctors whom managed to qualify for the PQRS quality bonuses, will not see that money, because the federal budget reduction exceeds that value.
Impact on Access to Care
Compensation is an important aspect of the U.S, healthcare system and the levels of reimbursement drive patient care and services. About half the doctors in the United States will not treat Medicaid patients because they cannot afford to do it. (3.) The expansion of Medicaid under the Affordable Care Act in 2010, is a lynch pin in the expansion of health insurance coverage and responsible for increasing access to basic health services for low-income people.
The idea of giving some programs budget restrictions while others are spending according to the  marketplace (private sector insurance plans) won't work. Healthcare budgets only work if everyone in the system is subject to the same constraints, incentives, and rules. In the U.S., our healthcare system is a series of separate systems tethered only by some government regulations and CMS reimbursements. Health care providers cannot afford to overlook Medicare patients, because that group represents 16% of the national population. (4.)  Of that figure, 20% of all health care services are for Medicare recipients and another 15% for Medicaid. However, health care providers do decline to accept new Medicare patients if they lack private Medicare supplement insurance. And of course many providers will not accept Medicaid patients at all.
How Can We Spend So Much and Still Have Poor Access?
 In 2013, the U.S. spent $9,255 per person, still vastly in first place for over spending on dubious health care results. In 2012, the Commonwealth Fund Mirror Mirror On the Wall Health Systems Comparison, shows the U.S. spent $8,508 per capita on health care.

The next largest per capita health care spend was in Norway at $5,669, still one third less than the U.S.A. (5.)  For those readers who may not be math wizards, the per capita measure is the great equalizer, as a country with a smaller population can be compared to a larger one based on this criteria. Some of my readers have complained that it isn't fair to compare smaller countries to the U.S. for health care, so here is a larger country comparison, France spent $4,118 per person in the same time period and it has a population of 68 million. Germany spent $4,495 and it has a population of 80 million. The U.S. population in 2013 was 316 million. However, just for giggles, I took most of the population of Europe and it's health care spend and compared that to the United States.  The combined annual per capita heath services spend was $4,407, after adjusting for proportion of population and national health care spend in this group of European nations comprising 339,789,381 people. (6.) This information was drawn from 10 large European countries with current 2013 health care spending information, expressed in U.S. dollars. So, even when you size up the included European country populations to an aggregate comparable to the USA, Europe still spends about half of what the U.S. does on health care for it's citizens. Europeans spend much less than the U.S. on health care because they have national health care systems, which have been shown to be highly effective in reducing waste, delivering sound primary health care, and serving everyone. They also use a fraction of what the U.S. does to administer their health care programs.
Current State of Affairs
CMS reports that hospital spending has decreased for all health care sectors, public and private. However, this means inpatient treatment, not necessarily stand alone or ambulatory facilities owned by hospitals has been reduced. Many procedures for orthopedic surgery, cardiac care, and chemo therapy are done on an outpatient basis now, so this accounts for some of the reduction of inpatient services. As in basic rules of economics, pressure or restriction in one economic sector will cause a corresponding change elsewhere in the system. In the case of Medicare we are seeing increased cost sharing on the part of Medicare enrollees, increased prescription drug costs, and an antiquated benefit design for basic Medicare coverage.
Suggestions for Improvement
Rather than punishing individual doctors for their onerous work loads and efforts to serve low-income patients, why not look at ways to make it easier for them to do so? Here are some ideas worth considering:

• For clinicians who demonstrate they have met the PQRS standard for 2 out of the preceding 3 years, why not give them a reporting waiver, and only audit them every other year?
• Look at ways to reduce the burden of paperwork within CMS and other regulatory agencies which would certainly provide relief to clinicians, and allow them more time to spend with patients.
• Rather than demanding an insurance wellness plan, why not allow firms to come up with creative approaches? For example, massage has been shown to have health benefits and could be provided to people before they experience restriction in movements and are in need of physical therapy. In our increasingly sedentary society we need to look at ways that inspire low-risk movement. Maybe a roving masseuse who gives chair massages in the office will prevent injuries, so why can't this be covered under preventive services?
• Annual physicals are considered the holy grail of wellness, but they can add to unnecessary medical tests which increase patient anxiety and have not been shown to extend life. I am thinking in particular of the numerous scans and imaging tests. Of course a high resolution MRI can find something wrong with you, but the question is, will it change your life expectancy?
• Automatic treatment protocols, such as the use of statins for lowering cholesterol have not been proven to prevent heart failure, but have been shown to be harmful to the kidneys and liver. The government needs to tread lightly on rewarding protocols as opposed to patient results, such as reduced emergency room admissions, or hospital re-admissions.And at the end of the day, the clinician does not have complete control over the patient's health.

The bi-partisan effort of Congress to scrap the current physician payment formula and find a more equitable and effective method to reward clinician work is a recognition of these problems.(7.) Can you believe it, House Speaker, John Boehner and Democratic Leader, Nancy Pelosi actually worked together on something!

Sources and Citations
(1.) Centers for Medicare and Medicaid
 http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013MLNSE13__AvoidingPQRSPaymentAdjustment_083013.pdf
(2.)  Medscape.com
http://www.medscape.com/viewarticle/843815?src=wnl_edit_medn_wir&spon=34
(3.) Bloomberg News.com
http://www.bloomberg.com/bw/articles/2014-12-18/more-medicaid-patients-less-money-for-doctors
(4.) Kaiser Family Foundation.org
http://kff.org/medicare/state-indicator/medicare-beneficiaries-as-of-total-pop/
(5.) Commonwealth Fund Publications
.http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror
(6.) Office of Economic Development
OECD (2014), "Total expenditure on health per capita", Health: Key Tables from OECD, No. 2.
DOI: http://dx.doi.org/10.1787/hlthxp-cap-table-2014-1-en

(7.) Kaiser Health News.org

 http://kaiserhealthnews.org/news/faq-could-congress-be-ready-to-fix-medicare-pay-for-doctors-2/

Healthpolicymaven is a trademark of Roberta E. Winter and has been used continuously since 2007. This article reflects her views and if you find them compelling, feel free to share it virally, with appropriate attribution of course.

Health Information Data Security in the Private Sector-Things You Need to Know

In February 2015 (1) and in March 2015 (2), there were two huge security breaches at privately run insurance companies, Anthem Health and Premera Blue Cross of Washington. The former was so significant there has been a legislative review. However, what is missing is the public outcry over the "open window" on your most personal information, because that is essentially what a data breach is; a burglar entering a private company and stealing valuable property. This property belongs to you and only under specific circumstances should you authorize anyone else to have access to this information.

 On February 5, 2015, 78.8 million health care records were hacked at Anthem, a Blue Cross Blue Shield affiliate, formerly known as Wellpoint. This means that the social security number, medical history, names, income information and addresses were all compromised. What makes this breach so egregious is unlike getting a new credit card number, changing ones health history is not doable. Additionally, Anthem says between 9 and 20 million people whom were NOT their customers also had medical records compromised. Anthem's fix for the problem was giving hacking victims a subscription for a credit-watch service.

Fast forward to March 17th and Washington State's Premera Blue Cross found itself with it's cyber pants-down as well, posting a data breech for 11 million members. In Premera's security lapse the thieves got away with clinical, social security, birth date, and bank account information. Premera acted quickly to notify customers, but again, it's only fix was to offer a two-year grattice subscription  to a credit watch agency. After which, you will of course be hounded by a credit agency to subscribe.

In both of these cases the insurance companies had their customers and people whom were not their customers' data hacked. For a ring side view, my son, who is not a Premera customer and hasn't been one in a decade, received notification of the security problem. In addition, I, who was a Premera customer last year, did not receive a notification, until Premera sent about six notices to everyone whom has ever lived at my residence in the last 15 years. Of course I contacted the insurance company to question this error and was assured they knew what they were doing. But this begs a question, how long can an insurance company legally hold your personal information and what do they do with it? And, are former customers treated with less data hygiene, hence the confusion on who was to receive the notices, addresses, and whose information was tampered. Premera is being sued by at least one person because of this compromise.

Neither of these scenarios are isolated and in fact security experts think many insurance companies may have been breached and they are simply not yet aware of it. Cyber thieves find the medical information so compelling because medical fraud can amount to millions without the contract limits of other insurance contracts.

Since the Affordable Care Act has codified the use of private sector insurance in publicly funded insurance exchanges, the insurance exchange administrators, state health care departments, and state Medicaid Offices are also in various degrees of partnerships with private insurers. Last year, Community Health Plan had a significant data breach. Some states, with grant incentives from provisions of the Affordable Care Act, have undertaken ambitious programs to identify health risks and theoretically improve health for residents through private companies. My son has been called numerous times by United Healthcare, requesting very personal information, both from a live person and from a robot. I have spoken to United Healthcare representatives numerous times and declined to give the information, but to no avail. In fact, even when I requested I be added to the do-not-call list and pointed out the Anthem data breach, I was told by the company representative that she did not think that would stop the calls.

Which brings me to number two-you do not have to provide personal health information to your insurance company, unless it is for use in ajudicating or paying a claim. Generic information to be used for their own surveillance or marketing efforts does not have to be proffered. As a former insurance broker I can assure you that insurance companies collect information for their own purposes and not necessarily to benefit you. In fact, if it wasn't for legal recourse insurance companies would still be discriminating on the basis of race and sexual orientation. The only person you should share your personal medical information with is your doctor or clinician, who has agreed to the hippocratic oath of confidentiality or at the very least, your attorney, whom almost must keep client information confidential. All of the rest of the data requests should be approached with extreme caution. I for one, only share my health information with my doctor, unless there is a question on a claim. I suggest you do the same, because insurance companies pay claims, they don't take care of your health, leave that to your doctor.

 And this is the healthpolicymaven signing off encouraging prudence when it comes to sharing your medical information, with private sector, as well as quasi-government entities.

This article was written by Roberta E. Winter, an independent freelance journalist and author of http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972. Feel free to share it virally and to make proper attribution when citing material from this article. Speaking of viruses, a study of 95,000 medical records finds NO LINK between Autism and the measles,  mumps, and rubella vaccine. (3) Thanks for vaccinating parents.

(1) http://www.reuters.com/article/2015/02/24/us-anthem-cybersecurity-idUSKBN0LS2CS20150224

(2) http://www.nytimes.com/2015/03/18/business/premera-blue-cross-says-data-breach-exposed-medical-data.html?_r=0

(3)  http://www.iflscience.com/health-and-medicine/study-95000-children-found-no-link-between-autism-and-measles-vaccine

Based on the Evidence-Cardiac and Orthopedic Procedures To Avoid

Here are the latest conclusions from the 2015 Road to Rightcare by the doctor-driven Lown Institute, which aims to prevent unnecessary and ineffective procedures and enhance patient health. To quote one of the conference speakers, America Bracho, M.D., "Health is more than the absence of disease." Become a more powerful practitioner and patient by signing-up for the Rightcare newsletter and to learn more about the practices this multi-disciplinary group is promoting.

 Cardiac Care
Percutaneous Coronary Intervention or Angioplasty
As incredible as it may seem there are thousands of unnecessary and non-beneficial cardiac procedures performed each year in the U.S. Here are the summary notes from the Lown Conference Cardiac Care presentation by Dr. William Boden, FACC, FAHA, Professor of Medicine, Albany Medical College and Chief of Medicine at Stratton VA Medical Center. For patients with chronic and stable angina, the benefits of percutaneous coronary intervention, which involves working a balloon up through the femoral artery to unblock the clogs in the heart, are unclear. In the past, PCI was done for patients who had high risk of death due to a heart attack. Because angioplasty is less invasive than coronary artery bypass  graft or CABG, it has become more popular.  A randomized trial of 1,018 patients comparing PCI or angioplasty to treatment with medication, was conducted in the United Kingdom and Ireland. Of the 504 patients whom underwent PCI, 11 died, compared to the 7 of the 514 randomized patients, whom were treated with medication. Additionally, 21 of the PCI patients had heart attacks compared to 10 of those on medication. These results are quite astounding, because the benefits of not having the surgery are almost twice (1.92 in relative risk variance) what the surgical intervention produced. https://www.dropbox.com/s/nxkqfsnlmjx5zse/Lown%20PCI%20in%20SIHD%20Workshop_Boden_021615.ppt?dl=0
Orthopedic Surgery
There are 800,000 joint replacements done in the U.S. every year by the 20,000 orthopedic surgeons, who are the highest income earners of all clinicians, averaging $413,000 annually, as cited by Dr. Boniface, Clinical Professor and Chairman of Orthopedic Surgery at Northeastern Ohio Medical University. Here is the alphabetized list of commonly performed unnecessary and often ineffective orthopedic procedures as identified by James Rickert, M.D. President of The Society for Patient-Centered Orthopedics, Thomas J. Grogan, M.D. Orthopedic Surgeon, Thomas Boniface, M.D., NEOMED, and Rob Rutherford, M.D. Clinical Instructor, University of Washington:
Adolescent Clavicle Fractures and Surgical Repair
Traditionally family practitioners, which would be pediatricians for adolescents, treated clavicle fractures by deploying a sling to prevent stress on the bone while it healed. Why is surgery being done on so many clavicles which heal on their own?
Anterior Cruciate Ligament or ACL Tear Surgery
Most of us have heard of the "ACL injury" as it is the de rigueur for weekend warriors. However, clinically, many more people are having this surgery than for whom it was intended to treat. In 2008, there were 100,000 ACL surgical repairs and now there are 200,000. In Unraveling U.S. Healthcare-A Personal Guide, I devote a chapter to surgical tips for consumers and why I chose non-surgical treatment for my ACL tear. In fact, a 2013 article published in the American Journal of Sports Medicine demonstrates that patients who opted for a nonsurgical treatment had the same rate of return to sports activities. The Scandinavian  Journal of Medicine and Science in Sports published a study in 2009, which found that 51% of the patients which did not have the ACL repair operation performed better on two of the four, single-legged hop tests. And for those of you who need more evidence, the British Journal of Medicine also published a study in 2013, which showed that ACL reconstruction and rehabilitation did not produce better results than initial rehabilitation and postponement of surgery, after five years of observation.
http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972#
Partial Meniscectomy for Arthritic Knees
Meniscectomy was studied in a randomized controlled trial of 351 patients,  where physical therapy was compared to the surgical repair technique of the meniscectomy and found equal results for pain relief and functional status were achieved with physical therapy. The randomized controlled trial means that patients were chosen at random and followed for the same period of time, using the same measures to assess the effectiveness of the treatment. Conclusion-if you have arthritis this procedure won't help you.
Rotator Cuff Tears and Surgical Intervention
Rotator cuff tears are often asymptomatic, which means the patient is not aware there is a problem and is not experiencing any restrictions. A 2010 article in the Journal of Shoulder and Elbow Surgery found that 20.7% of the general population had rotator cuff tears and asymtomatic tears were twice as common as those in patients with symptoms. This condition, which is an aspect of normal aging is found via the ubiquitous MRI. Despite this evidence, there are 600,000 of these surgeries in the U.S. each year. To put it bluntly, medical evidence shows that physical therapy can be just as effective to treat this problem, and should only be provided to patients who actually have symptoms.Risks of a surgical repair to the rotator cuff include; bleeding, infection, stiffness, re-rupture of the tear, neurovascular injury, and unrelieved pain. For patients whom are 60+ years, a non invasive treatment is preferential to a surgical repair. As the gold-standard randomized controlled trial showed, the results are the same with our without surgery.
Vertebroplasty-A Spinal Treatment
Vertebroplasty is a heavily marketed orthopedic procedure which involves injecting cement into the center of a fractured vertebra. It is used for compression fractures of the spine. The British Medical Journal did a large randomized controlled trial and found there was no evidence this procedure provided any medical benefit. One fourth of women over age 50 have one or more fractures. The rate of vertebroplasty has increased from 45 to 87 cases per 100,000 patients in the Medicare population. Though this treatment is marketed as providing quick pain relief, scientific studies show there is a risk of increased compression fracture, dural tears, infections, cement migration, and the need for additional surgery due to radiculopathy. In a 2009 study published in the New England Journal of Medicine, pain cessation for patients treated with vertebroplasty were similar to those in the control group who did not have the surgery. No commercial entity paid for any of the materials in this study and the costs of the surgery were billed to insurance companies. In the industry funded studies, the cementing procedures is typically compared to sham procedures and not to nonsurgical interventions.Conclusion-This is yet another back surgery which has elusive results-Medicare needs to review this. https://www.dropbox.com/s/pb7arzvpl5garkf/LownBibliography1-1.docx?dl=0
How Changes in Health Policy at the Centers for Medicare and Medicaid Can Improve Care
In the three days I spent at the Lown Care Conference it was obvious the physicians all had ideas on how changes in our national health care policy could drive health care practices and result in better patient care and a reduction in ineffective treatments. Here are their observations on ways to improve health care quality in the nation:

1. United States healthcare is being pushed toward a "risk-based" model which means identifying the most efficacious treatments and creating cost savings is critical. One way to achieve this is through bundling payments or reimbursements for clinicians and health care facilities. This would create less of a financial impetus to perform the highest reimbursement surgery as opposed to the treatment most appropriate for the patient. 
2. CMS needs to make coding changes for cardiac procedures which would not punish the doctor for doing the cost-effective treatment. For example, a doctor's fee should not be linked to the cost of the cardiac catheter.
3. We build over capacity at the medical school level by encouraging more specialists and increasing the supply of highly trained surgeons, which also means we have to generate  demand for services through scope creep, marketing directly to patients, and the ever expansion of facilities to be filled with patients who have the money to pay for the procedures.
4. Consumer or patient-driven health care is not the same as market driven medicine because patients are not commodities, hospitals are not factories, and money should not be the driving force of health care decisions. Education of patients is the key to providing the right care for each patient, with a much stronger emphasis on prevention. We need to collaborate more effectively so that patients can make informed decisions. Health outcomes need to be patient based, not based on Relative Value Units. We need to figure out the health treatments with the most impact and CMS needs to reward those. Patients need to be informed and accountable.
5. Nonoperative treatment needs to be valued more by CMS and insurance companies, because the Journal of Patient Safety cites 440,000 patients are still harmed in U.S. hospitals annually. If doctors are paid for providing preventive care they will do more of it. But as it stands right now, primary care clinicians make the least amount of money in the medical field.  More procedures does not necessarily mean more health. 

State Initiatives
 Rhode Island has sparked a unique health effort to meet community needs in under-served areas by creating community centers which incorporate fitness centers, achieve critical mass in community enrollment through representation of community members, provide urgent care services at the center, offer home health visits, and deploy school-based health programs. They plan to fund it through taxation of health services. University of Minnesota professor, Bill Doherty has co-authored the Citizen Health Care Initiative, which  aims to engage communities, families, and individual patients to participate and generate health improvements. This community model attempts to instill healthier perspectives and behaviors instead of waiting for major medical interventions at the hospital. Washington State has Healthier Washington, a grant funded project, which is exploring everything from reimbursement and design changes to the state Medicaid plan, to community assessment, and resourcing of health care needs.The real question is whether any of these ambitious programs will be able to improve health. My money is on the Rhode Island community center model.

Have I met all of my health goals since I returned from the conference-no, but I am making progress and just remember Winston Churchill's quote, "You can always count on Americans to do the right thing, after they have tried everything else." And this is the healthpolicymaven signing off encouraging you to think about your health and ask questions before you pursue health treatments.

This article was written by Roberta E. Winter, MHA, MPA, an independent health care analyst and writer and may be shared with others. It is not meant to give medical advice, but to highlight what the experts and the medical evidence show for common surgical procedures which are over utilized in the United States. The article is not a comprehensive review of unnecessary surgeries, especially in cardiac care, because it was written for the layperson.

Measles Outbreak-What It Means When Your Neighbors Don't Vaccinate

Outbreak in Preventable Childhood Diseases On the Rise in the United States
The measles outbreak in the nation has been on the rise for the past two years, but is nearly at epidemic proportions now. http://www.cdc.gov/measles/cases-outbreaks.html  There are 141 cases of measles in 17 states so far in 2015. This chart from the CDC shows the states which have the most outbreaks of measles.

 Measles, is a preventable childhood disease for which an immunization (a shot) is usually given to a child when the child reaches nineteen to thirty-five months of age. Measles causes red spots, fever, and in some cases can result in death. This article reviews changes in childhood immunization patterns, which were reported for all fifty states in Unraveling U.S. Healthcare-A Personal Guide, published in 2013.  Information is drawn from the U.S. Centers for Disease Control and Prevention and is inclusive of 2013 calendar year data. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6334a1.htm?s_cid=mm6334a1_e#Tab1

In 2011, the national immunization rate for children between the ages of nineteen and thirty-five months was 83.34% for all recommended childhood vaccinations. In 2013, the immunization rates for the same age-group of children and the same vaccines had dropped to 83.07%.
 Here are the states with the lowest rate of immunization for these diseases as of  the end of the reporting year for 2013, as compared to the national average. As you can see, the western states do poorly for immunization compliance, as reported in my 2013 health scorecards. The one bright spot is Utah, which matches the national average for the top three vaccines. The outlier in the group is Vermont, which has achieved the dubious designation as the state with the lowest rate of childhood immunizations. And though much of the country seems to ignore the District of Columbia, seat of our nation's capitol, it has a better vaccination rate than the national average, at 86.7% penetration versus 83.07%. Here is information from the table, showing the worst states for immunizing their children:

Children's Health Scorecard-2013	National Average		Oregon	Montana	Wyoming	New Mexico	California	Colorado	Alaska	Vermont
Ranking			44	45	46	47	48	49	50	51
DTaP	83.10		83.80	79.00	80.90	79.80	83.10	81.20	75.50	85.80
Hep B	74.20		66.80	73.90	67.00	67.50	70.30	60.20	59.40	44.80
MMR	91.90		89.40	87.30	89.00	89.10	80.70	86.00	90.50	91.20
Average Rate	83.07		80.00	80.07	78.97	78.80	78.03	75.80	75.13	73.93
Variance			-3.07	-3.00	-4.10	-4.27	-5.03	-7.27	-7.93	-9.13
Notes: Negative number means performance is worse than the national average.
Immunization rate is for Heb B only.
Immunization rates are from the Centers for Disease Control for 2013 year In short, this is the reason there are large outbreaks of childhood diseases now. An immunization is a preventive dose to activate the body's immune system to the disease vector. In order to have adequate protection for a population, which means a community, a school, a state, the majority of the population has to become immunized. In the United States, especially on the west coast, we are in danger of losing our herd immunity, which is a scientific term that means the actions of a significant minority can imperil the entire population. The standards for public health in the United States and all developed nations are based on scientific data, using gold-standard studies and analysis, not spurious opinions of the uniformed in social media. The recommended immunizations for children in the above age-group are as follows: Diptheria, Pertussis, and Polio- Pertussis is known as whooping cough and there has been an increase in preventable childhood deaths from this recently as well. Polio of course, causes paralysis and shortened life expectancy and was thought to have been eradicated in the U.S., but thanks to the actions of a minority, this may no longer be the case. Diptheria is a respiratory disease. Measles, Mumps, & Rubella-Measles is an infectious disease causing fever and rash. Mumps is a disease of the salivary glands, causing swelling, fever, and muscle aches. Rubella, also known as German Measles can cause incurable illness for pregnant women, and significantly increases the chance of miscarriage. Influenza-This is a respiratory disease which can and does cause deaths in infants and others whom have immune deficiencies. Hepatitis B-This is a  blood disease which can damage the liver; is transmitted through bodily fluids, and can  be passed from mother to child. Varicella or chicken pox-This is a blister-like rash, fever, and can result in death for those with compromised immune systems. In The Russell Guide for Diabetics, I share information about the science and the reality of childhood diseases. A 2003 Italian study,  found that early childhood exposure to two diseases damaged the immune system and was significantly linked to causation of Type 1 or juvenile diabetes. Here is an excerpt from my book explaining the findings: In 2003, a population-based case-control study in Italy, published results which found that childhood exposure to two infections significantly increased the likelihood of a child contracting Type I Diabetes. Infections which were reviewed in the study included; pertussis (whooping cough), varicella (chicken pox), rubella, parotitis, and morbilli.[1] Here are the findings of the study: 1.      The statistically significant finding with no confounding variables,  showed that children in the Abruzzo region of Italy who were exposed to two of the childhood viruses listed, had a higher incidence of Type I Diabetes compared to the population who had been exposed to a single childhood infection. 2.      Children who had been exposed to only one of the listed childhood infections did not show an increased incidence of contracting Type I Diabetes. 3.      Childhood immunizations were also analyzed as risk factors for contracting Type I Diabetes and there was no statistical increase shown in the incidence of juvenile diabetes for the immunized children. 4.      However, for children who had received the pertussis (whooping cough) and MMR (measles, mumps, and rubella) vaccinations, a significant decrease was found in the contraction of childhood Diabetes.  My brother, Russell was diagnosed with Type 1  Diabetes when he was three years old, three months after his exposure to chicken pox. He had also been exposed to mumps within the year, by his school-age siblings (including moi). Unfortunately, this event was due to the fact immunizations were typically provided through the school at the time of enrollment, so children younger than school age were at risk. Russell died at 42 years of age, following multiple organ transplants, and amputations all related to Type 1 Diabetes. To all parents who think they are "boosting their child's immune system" by avoiding immunizations, do take the long term view and consider all adverse consequences. This article of course, is written for those whom do base their decisions on scientific evidence. Considering the low-level of science readiness in our national population, as compared to other countries, perhaps this issue will ultimately be decided through tort action in the courts. The CDC clearly states these immunizations prevent 722,000 deaths over a lifetime, so the parents whom are abdicating these preventive measures must be assuming some other child or relative will be in that statistic and not their own. Truly it is just a question of time before the actions of one parent bring irreparable illness to the lives of others, which is similar to driving a vehicle without auto insurance. Considering that many of those eschewing immunizations are patrons of  the well heeled in private schools, this population is an easy target for social responsibility through the courts. And this is the healthpolicymaven signing off, encouraging all to share this article virally, just as childhood diseases are spreading through our population. Roberta Winter is the author of http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972# Roberta E. Winter is a graduate of the University of Washington School of Public Health and Community Medicine and the Evans School of Public Affairs. She has spent the past 12 years advocating for consumer issues in health care.

  

Insurance Mandate Tax Tips and Report Card on Performance

One Year Out From the Inaugural Insurance Exchange Launch
Now that the nation has passed its second enrollment in the Affordable Care Act (ACA) Insurance Exchanges, it is time to do a bit of a scorecard and though the second enrollment went well, let's look as the predictions versus the actual participation.
Original Whitehouse Projections Versus Actual Enrollment

Number expected to gain insurance coverage because of either the employer or individual insurance mandates under the ACA-32,000,000
Since the employer mandate is just starting this year and the phase-in penalty for firms without compliant medical plans only applies to firms with 100 or more eligible employees, it is not possible to discern the total reduction in the uninsured yet. But here is the rate of the uninsured as a proportion of the national population.
Uninsured rate prior to ACA- 18% After ACA-12.9%
Number Health & Human Services projected for the 2015 Insurance Exchange Enrollment-9,100,000


Number of the uninsured who obtained coverage through Medicaid or an Exchange product-9,500,000, which exceeded their projection by 4%. This information  may be found at: http://obamacarefacts.com/sign-ups/obamacare-enrollment-numbers/

Number enrolled in the federal insurance exchange-7,100,000
Number enrolled in private insurance exchanges-2,400,000

Percentage of  Actual Enrollment compared to the Eligible Enrollees
I reviewed the Kaiser Family Foundation's report on the insurance exchange enrollment by state and it was no surprise there was a lot of variation, with a low enrollment in the states with robust economies, such as North Dakota (13%) and Massachusetts (8%). Whereas, 87% of the population deemed eligible to enroll in the insurance exchange in Vermont actually did. For more information go to the Kaiser Foundation web site at: http://kff.org/interactive/mapping-marketplace-enrollment/

Income Tax Tips for Insurance Exchange Participants
For my followers, I have been tweeting tax tips regarding the reconciliation of the government tax credits for those who purchased insurance through the exchanges. To assist those who are filing income taxes, here is a step-by-step guide to the insurance mandate and tax credit posting:

1. If you purchased medical insurance through an insurance exchange, either federal or state, you may have received an advance from the federal government, to pay for part of your insurance premiums. If you enrolled in Medicaid through an exchange you did not have to pay any premiums and this does not apply to you..
2. The government advance, which went directly to the insurance company, was an estimate of your tax credit eligibility based on the income and family information you provided at enrollment in the previous year. If your status changed, there may be a difference in the amount the government advanced and what you should have received. 
3. Your insurance exchange should have distributed form 1095-A by January 31st, assuming they have your current contact information. You will need this form to complete your income tax.
4. Form 1095-A has a monthly break-down of your insurance premiums for the 2014 year, both the amount you paid, the amount of the tax credits, which is what the government contributed to the cost of the insurance (thank you Uncle Sam), and the total premium.
5. If you are using an electronic tax preparation tool, which I highly recommend, it will have an insurance page or folder, which will walk you through the form. But just in case you are still old school and use paper returns, the federal tax credits which were used to pay for your insurance will be entered into the Premium Tax Credit form 8962 of your 1040 Personal Income Tax Return. 
6. Enter your total premiums paid, total premiums credited from the government and wait until you complete your return. After you have entered all of the other information to complete your income tax return you will you have a final result in terms of what your tax credits should have been and what they actually were. If the government estimated too high, then you might owe some money. If the government estimated too low, then you will have a refund coming.
7. For example-Total insurance premiums were $7,032 for a single individual (yikes) and you paid $348, with the government contributing the rest. The government paid $4,716, but it turns out you were only eligible for $4,368 in credits. This means you owe the difference between the two or roughly $348. This government advance will be deducted from your tax refund or theoretically, you will get a statement saying you owe income taxes.
8. Bottom line, the federal tax credits were an estimate of what you were eligible for, based on information you provided, and not a guarantee, so expect some variation in the actual result. If the government gave you $4,716 and you only had to give back $600, that is still awesome.

Hopefully this helps some of you with your income tax filing for the 2014 year. This information is not meant to give tax or legal advice (CYA-disclaimer) but is a journalist's view on publicly available information. Feel free to share this with everyone, with appropriate attribution of course.
And this is the healthpolicymaven signing off. Viva Le France!

healthpolicymaven is a trademark which has been in continuous use sine 2007 and is the property of Roberta E. Winter, MHA, MPA, President of Praevalere Inc.

 

Liberty, Equality, and Fraternity As Demonstrated by the French This Week

Since the second largest demographic for healthpolicymaven readers hail from the beautiful country of France, this column acknowledges their January 8th loss, due to the terrorist acts of a few deranged Muslims. Radical Muslims persist in trying unsuccessfully to unravel democratic nations. United States citizens have marveled at the French demonstrations drawing 10,000 people against this senseless violence. The fact so many French people were willing to risk their lives for the sake of a free press underscores one of the fundamental principles of liberty, which is our right to gather and demonstrate, and the right to a free press. It is the latter of these principles which our forefathers held so dear which seems so fragile in these turbulent times. Though in the United States the loss of freedom in our press is due to corporate tyranny and public apathy as opposed to violence. Please understand the United States was appalled at the terrorism in Paris, but we are a country numbed by school shootings every year. The U.S. Justice Department indicates there are 45 violent deaths at schools in the United States each year. http://nces.ed.gov/pubs2014/2014042.pdf  Though a vigorous American population is trying to change this metric, we are making pithy progress. 

For the Americans reading this column, here is some information about our French countrymen, one of our strongest allies,  and their direct impact on the United States:

1. According to the U.S. Census Bureau's 2013 Population Survey the third most common language in the United States is French, after English and Spanish, with 1,755,433 using French as their predominant language. http://www.census.gov/prod/2013pubs/acs-22.pdf
2. Washington State alone has 7,000 French households
3. France is one of the largest investors in U.S. businesses and has been since the 1980's. http://www.econlib.org/library/Enc1/ForeignInvestmentintheUnitedStates.html
4. There are nearly 5,000 French-owned companies doing business in the United States and they employ over 650,000 people.http://www.ambafrance-us.org/spip.php?article2538
5. France is the world's 5th largest economy with a gross national product of 2.8 trillion. http://www.export.gov/france/doingbusinessinfrance/index.asp
6. According to the U.S. State Department there were 1.5 million French visitors in 2013. http://travel.trade.gov/view/f-2000-99-001/forecast/Forecast-COUNTRIES.pdf
7. France is one of the oldest democracies in the world, overthrowing the king in 1789 and Bastille Day is celebrated on July 14th each year.
8. The colors of the French flag are the same as ours and the Statue of Liberty was a gift from France.
9. The French health system is widely considered to be one of the best health care systems in the world, providing care for all, and with electronic medical smart cards for residents since 1997 (something the U.S. still hasn't mastered).
10. The United States spent $8,508 per capita on health care in 2011, while France spent $4,118, and they generated better health results. http://nces.ed.gov/pubs2014/2014042.pdf 

 To all French residents, visitors, and citizens I say "Vive la France! Where would we be without French influence in the troix F's; Food, Fashion, and Film. Merci Beaucoup.

If you are interested in learning more about French culture, here are some organizations in the United States which may be of interest:

Federation of Alliances Francaise U.S.A.
http://www.afusa.org/

French Embassy in the United States
http://www.ambafrance-us.org/

 French Culture.org
http://frenchculture.org/about/cooperation-with-civil-society-organizations

French American Foundation of the United States
http://www.frenchamerican.org/

Feel free to share this liberally throughout the globe. And this is the healthpolicymaven signing off  "au revoir."