The war over the Affordable Care Act may be over, but one battle shows no signs of waning.
The fight over Section 2713 of the Public Health Services Act under ACA’s Section 101 — better known as the health law’s regulation on preventive services — centers on contraception.
The benefit essentially calls for health plans to cover birth control and other services with no additional cost-sharing for enrollees.
But critics quickly seized on the administration’s initial proposal in 2011, which carved out an exception for “religious employers” — such as churches — but not for “religiously affiliated” employers — such as Catholic hospitals. As a result, HHS delayed implementation for religiously affiliated employers by a year but still required them to comply with the mandate.
In February, the White House released another accommodation for religiously affiliated employers. Yet rather than lay the issue to rest, the administration’s proposed amendments drew more than 400,000 comments — the most comments on any government regulation tracked by the Sunlight Foundation.
It’s just the latest salvo in an ongoing controversy. Opponents have filed more than 60 legal challenges against the benefit. Some have called it a “war on religion.”
While the sheer volume is astounding, there’s little mystery behind the root cause.
The contraception benefit touches on a half-dozen pressure points: Politics. Religion. Sex. Federal mandates. Federal entitlements.
“Our health care system is the dumping ground for all of our worst, unresolved arguments as a society,” J.D. Kleinke writes at The Health Care Blog. And the changes at the heart of Obamacare “spark every remaining culture war,” he adds.
And a mandate related to birth control is especially fraught.
Infectious disease is the most hyperbolic of all medical fields, at least when the media gets ahold of such.
Right now we are to fear a new avian influenza virus. Previously there was another avian influenza strain whose outbreak threatened the world and of course SARS and, more distantly, the ebola virus and the threat of bioterrorism. And on the periphery, as these acute threats come and go, is the persistent threat of super bugs; bacteria resistant to multiple antibiotics. Sometimes all antibiotics.
I remember my pharmacology professor in medical school claiming that within our practice lives we would reach the useful end of antibiotics. A claim, literally, that physicians would no longer have any use for antibiotics by the time I reached the end of my career.
Scary stuff but evidence that such outrageousness sells pharmacology in a classroom as much as it does magazines on a news stand. Time magazine a post called “The End of Antibiotics?” referencing a Guardian article along the same lines. This followed a similar 2009 scare article in Time.
The exponential growth in wellness programs indicates that Corporate America believes that medicalizing the workplace, through paying employees to participate in health risk assessments (“HRAs”) and biometric screens, will reduce healthcare spending.
It won’t. As shown in my book Why Nobody Believes the Numbers and subsequent analyses, the publicly reported outcomes data of these programs are made up—often to a laughable degree, starting with the fictional Safeway wellness success story that inspired the original Affordable Care Act wellness emphasis. None of this should be a surprise: in addition to HRAs and blood draws, wellness programs urge employees to go to the doctor, even though most preventive care costs more than it saves. So workplace medicalization saves no money – indeed, it probably increases direct costs with these extra doctor visits – but all this medicalization at least should make a company’s workforce healthier.
Except when it doesn’t — and harms employees instead, which happens altogether too often.
Yes, you read that right. While some health risk assessments just nag/remind employees to do the obvious — quit smoking, exercise more, avoid junk food and buckle their seat belts — many other HRAs and screens, from well-known vendors, provide blatantly incorrect advice that can potentially cause serious harm if followed.
“The Effect of Price Reduction on Salad Bar Purchases at a Corporate Cafeteria.” An excellent peek at the kind of steps that employers ought to take to improve eating habits in their work forces: subsidize the purchase of healthy foods. In this CDC study, reducing the price of salads drove up consumption by 300%. If this was a stock, we would all rush out to buy it.
Influencing behavior through both choice architecture and pricing differentials challenges many employers, however. There is a fear factor in play (“some of my people will be unhappy”), as well as financial issues, because the corporate managers responsible for food services often have their compensation linked to the division’s profitability. You make a lot more money selling soda than you do selling romaine. The same perverse financial conundrum appears when corporate food service companies run cafeterias. The on-site chef and managers typically operate on a tightly managed budget that leaves them little flexibility to seek out and provide healthier options.
A chef employed by one of the largest corporate food service providers in the country told me last year that he could not substitute higher protein Greek yogurt for the sugar-soaked, low-protein yogurt in his breakfast bar. When I asked why, he told me that Greek yogurt was not on his ordering guide, and he was not allowed to buy it from a local club warehouse and bring it in. In this same company, beverage coolers were stuffed to overflowing with sugar-sweetened drinks, all of which were front and center (and cheap), while waters and low-fat milk were shunted to the side coolers. In another scenario, health system leaders I met with last year all raised their hands when I asked if they had wellness programs and kept them up when I asked if they also sold sugar-sweetened beverages in their cafeterias at highly profitable prices. The irony was completely lost on them. They had to be walked through the inconsistency of telling their employees to take (worthless) HRAs and biometrics, but then facilitating access to $0.69 22 oz fountain sodas.
Everyone loves prevention. It may seem strange then, to learn that one of the biggest barriers keeping prevention from reaching its full potential is the current set of performance measures that, ironically, were created to promote them. The reason is that current measures are promoting activities that are inaccurate and inefficient. It is as though explorers who are trying to reach the North Pole have been given a compass that is sending them to Greenland.
This problem is being addressed by a new project conducted by NCQA and funded by the Robert Wood Johnson Foundation. The objective is to evaluate a new type of measure of healthcare quality called GCVR (Global Cardiovascular Risk). The new measure will have an important effect on the prevention of cardiovascular conditions.
To understand how, we need first to understand the limitations of current measures. For reasons that were appropriate when they were initially introduced – about 20 years ago — current performance measures were designed to be simple: simple to implement (e.g. collect the necessary data, do the calculations), and simple to remember and explain. This was accomplished in three main ways. One was to create separate performance measures for different risk factors. Thus there are separate measures for blood pressure control, cholesterol control, glucose control, tobacco use, and so forth.
While a performance measure for any one risk factor might take into account a few other risk factors to some extent, none of them incorporate all the relevant risk factors in a physiologically accurate way. A second simplification is that current measures are based on care processes and treatment goals for biomarkers, rather than on health outcomes. Thus a blood pressure measure asks if a patient with hypertension is controlled to a systolic pressure below 140 mmHG. A third simplification is the use of sharp cut points to determine the need for and success of treatment. For example, patients with hypertension are counted as properly treated if their systolic pressures are below 140 mmHG, otherwise not.
We’re all aware of the past criticisms of “disease management.” According to the critics, these for-profit vendors were in collusion with commercial insurers, relying robo-calls to blanket unsuspecting patients with dubious advice. Their claims of “outcomes” were based on flawed research that was never intended to be science; it was really intended to market their wares.
But suppose this correspondent alerted you to:
1. A company that had developed a patient registry to identify at-risk patients who had not received an evidence-based care recommendation? Software created mailings to those patients that not only informed them of the recommendation but offered them a toll-free number to call if there were questions. Patients who remained non-compliant were then called by coordinators, who made three attempts to contact the patient and assist in any scheduling needs. If necessary, a nurse was available to telephonically engage patients and develop alternative care options.
If you think that sounds like typical vendor-driven telephonic disease management, you’d be right. You’d also be describing an approach to care that was studied by Group Health Cooperative using their electronic record, medical assistants and nurses. When it was applied to colon cancer screening, a randomized study revealed each additional level of support progressively resulted in statistically significant screening rates.
You’d be forgiven if, after reading last month’s Health Affairs, you came to the conclusion that all manner of wellness programs simply will not work; in it, a spate of articles documented myriad failures to make patients healthier, save money, or both.
Which is a shame, because – let’s face it – we need wellness programs to work and, in theory, they should. So I’d rather we figure out how to make wellness work. It seems that a combination of behavioral economics, technology, and networking theory provide a framework for creating, implementing, and sustaining programs to do just that.
Let’s define what we’re talking about. “Wellness program” is an umbrella term for a wide variety of initiatives – from paying for smoking cessation, to smartphone apps to track how much you walk or how well you comply with your plan of care, and everything in between. The term is almost too broad to be useful, but let’s go with it for now.
When we say “Wellness programs don’t work,” the word work does a lot of, well, work. If a wellness program makes people healthier but doesn’t save lives, is it “working”? What if it saves money but doesn’t make people healthier?
Increasingly, the health care community is experimenting to see if managing the health of a defined population – say diabetics – improves their health and also reduces the cost of health care or its rise over time. In other words, the healthcare profession seeks to determine if value can displace volume (our fee-for-service tradition) in delivering medical services. Humana’s first-of-its-kind, two-year pilot health-and-wellness program may provide some welcome answers.
A unique factor of the Team Up 4 Health program reflects its participants – hundreds of residents in Bell County, Kentucky (population: 28,750). Statistics show that its population bears a high incidence of preventable chronic illnesses. One-third of the county’s adults are obese and one-in-eight has Type 2 diabetes.
I find myself, probably like many of you, spending way too much time in front of my computer.
When I do face-to-face meetings, my colleagues and I typically met around some conference table, sometimes at an airport lounge (nothing like getting the most out of a long layover), and quite often at coffee shops (hello Starbucks!). But that means that the most common denominator across all these locations wasn’t the desk, or, the keyboard, or even the coffee. The common denominator in the modern workday is our, um, tush.
As we work, we sit more than we do anything else. We’re averaging 9.3 hours a day, compared to 7.7 hours of sleeping. Sitting is so prevalent and so pervasive that we don’t even question how much we’re doing it. And, everyone else is doing it also, so it doesn’t even occur to us that it’s not okay. In that way, I’ve come to see that sitting is the smoking of our generation.
According to a widely circulated op-ed in the New York Times by Paul Campos, a law professor at the University of Colorado with whom I don’t believe I have ever managed to agree on anything, our “fear” of fat — namely, epidemic obesity — is, in a word, absurd. Prof. Campos is the author of a book entitled The Obesity Myth, and has established something of a cottage industry for some time contending that the fuss we make about epidemic obesity is all some government-manufactured conspiracy theory, or a confabulation serving the interests of the weight-loss-pharmaceutical complex.
In this instance, the op-ed was reacting to a meta-analysis, published last week in JAMA, and itself the subject of extensive media attention, indicating that mortality rates go up as obesity gets severe, but that mild obesity and overweight are actually associated with lower overall mortality than so-called “healthy” weight. This study — debunked for important deficiencies by many leading scientists around the country, and with important limitations acknowledged by its own authors — was treated by Prof. Campos as if a third tablet on the summit of Mount Sinai.
We’ll get into the details of the meta-anlysis shortly, but first I’d like to say: Treating science like a ping-pong ball is what’s absurd, and what scares the hell out of me. Treating any one study as if its findings annihilate the gradual, hard-earned accumulation of evidence over decades is absurd, and scares the hell out of me. Iconoclasts who get lots of attention just by refuting the conventional wisdom, and who are occasionally and importantly right, but far more often wrong — are often rather absurd, and scare the hell out of me.
And so does the obesity epidemic.