Podcast: KHN’s ‘What The Health?’ Ask Us Anything!

This week, KHN’s “What the Health?” panelists answered questions submitted by listeners.

Among the topics covered were why Medicare doesn’t cover most dental care, how to address high drug prices and what federal officials do with all that data they collect from health care providers.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Stephanie Armour of The Wall Street Journal and Paige Winfield Cunningham of The Washington Post.

The panel addressed questions including the following:

  • “Besides your podcast, what resources, including books and journals, do you recommend people read to build basic knowledge about the U.S. payer system?”
  • “What is the likelihood that Congress will pass legislation to include full dental care in Medicare, say in the next 10 years?”
  • “CMS collects an extraordinary amount of data from its various quality reporting programs. … What does the agency do with this data and is there any evidence quality reporting improves patient outcomes or achieves other policy aims?”
  • “Do you have a view on whether Medicare paying less money for prescription drugs would lead to drug companies charging more to private insurers?”
  • “There’s been a lot of back-and-forth lately between the National Institutes of Health, the Department of Health and Human Services and the media regarding fetal tissue research. HHS is currently doing a review, and the Trump administration just posted a ban to the NIH labs to stop procuring any new fetal tissue. This jeopardizes many research studies, especially those studying HIV. What do you think the long-term consequences of this will be?”

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunes, Stitcher or Google Play.

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How The Government Shutdown Affects Health Programs

[This story was updated at 9:38 a.m.]

There seems to be no end in sight for the current partial government shutdown, the third since the beginning of the Trump administration.

For the vast majority of the federal government’s public health efforts, though, it’s business as usual.

That’s because Congress has already passed five of its major appropriations bills, funding about three-fourths of the federal government, including the Department of Health and Human Services and the Department of Veterans Affairs.

But seven bills are outstanding — including those that fund the Interior, Agriculture and Justice departments — and that puts the squeeze on some important health-related initiatives.

The shutdown itself is not about health policies. It’s the result of differences of opinion between the administration and congressional Democrats regarding Trump’s so-called border wall. But it’s far-reaching, nonetheless. Here’s where things stand:

Funding for “big-ticket” health programs is already in place, alleviating much of the shutdown’s immediate potential impact.

Since HHS funding is set through September, the flagship government health care programs — think Obamacare, Medicare and Medicaid — are insulated.

That’s also true of public health surveillance, like tracking the flu virus, a responsibility of the Centers for Disease Control and Prevention. The National Institutes of Health, which oversees major biomedical research, is also fine. It’s a stark contrast to last January’s shutdown, which sent home about half of HHS’ staff.

But some other public health operations are vulnerable because of complicated funding streams.  

Although the Food and Drug Administration falls under the HHS umbrella, it receives significant funding for its food safety operations through the spending bill for the Department of Agriculture, which is entirely caught up in the shutdown.

Last year, that tallied an estimated $2.9 billion to support among other things these FDA oversight efforts, which involve everything from food recalls to routine facility inspections and cosmetics regulation. Not having those dollars now means, according to the FDA contingency plan, that about 40 percent of the agency — thousands of government workers — is furloughed.

The FDA’s responsibilities for drug approval and oversight are funded by user fees and are generally not affected. Regulation of tobacco products is also continuing.

Health services for Native Americans are also on hold.

Because Congress has yet to approve funding for the Indian Health Service, which is run by HHS but gets its money through the Department of the Interior, IHS feels the full weight of the shutdown. The only services that can continue are those that meet “immediate needs of the patients, medical staff, and medical facilities,” according to the shutdown contingency plan.

 

That includes IHS-run clinics, which provide direct health care to tribes around the country. These facilities are open, and many staffers are reporting to work because they are deemed “excepted,” said Jennifer Buschik, an agency spokeswoman. But they will not be paid until Congress and the administration reach a deal.

Other IHS programs are taking a more direct hit. For example, the agency has suspended grants that support tribal health programs, as well as preventive health clinics run by the Office of Urban Indian Health Programs.

Public health efforts by Homeland Security and the EPA face serious constraints.

The Department of Homeland Security’s Office of Health Affairs assesses threats posed by infectious diseases, pandemics and biological and chemical attacks. It is supposed to be scaling back, according to the department’s shutdown contingency plan. This office is just one component of the 204-person Countering Weapons of Mass Destruction Office, which is retaining about 65 employees during the funding gap.

Other DHS health workers are likely to work without pay — for instance, health inspectors at the border, said Peter Boogaard, who was an agency spokesman under the Obama administration. According to DHS’ plan, the vast majority of border patrol employees will continue working through the shutdown.

The Environmental Protection Agency has also run out of funding. According to its contingency plan, it’s keeping on more than 700 employees without pay, including those who work on Superfund sites or other activities where the “threat to life or property is imminent.” (More than 13,000 EPA workers have been furloughed.)

That limits the agency’s capacity for activities including inspecting water that people drink and regulating pesticides.

But it’s not just regulation. The public health stakes are visceral — and sometimes, frankly, pretty gross.

Just look at the National Park Service, which has halted restroom maintenance and trash service for lack of funding. On Sunday, Yosemite National Park in California closed its campgrounds. On Wednesday, Joshua Tree National Park, also in California, did the same.

Why? Per a park service press release: “The park is being forced to take this action for health and safety concerns as vault toilets reach capacity.”

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Woman first to claim infection after surgery at New Jersey facility

NEW YORK (Reuters) – A former patient at a New Jersey surgical facility that state health officials said may have exposed thousands of patients to HIV and other blood-borne pathogens has tested positive for hepatitis B, one of her lawyers said on Thursday.

The unidentified 58-year-old Brooklyn woman, a plaintiff in a lawsuit filed on Monday, is the first of 3,778 former patients at HealthPlus Surgery Center in Saddle Brook, New Jersey, known to claim she or he became infected because of faulty sterilization and medication practices at the facility.

The New Jersey Department of Health last week said patients who had procedures done at HealthPlus between Jan. 1 and Sept. 7 2018 may have been exposed to HIV, hepatitis B and hepatitis C. It urged them to get tested at “out of an abundance of caution.”

The legal action, brought in U.S. district court in Brooklyn, accuses HealthPlus of “recklessly and negligently” failing to follow sterilization and other procedures. The lawsuit, which seeks class action status, asks for unspecified damages.

Attorney Marc Held, whose firm joined with the woman’s firm in filing the lawsuit, said in an email that she received her positive test results earlier this week, after having had shoulder surgery at HealthPlus last year.

HealthPlus attorney Mark Manigan said state health officials still must conduct a “comprehensive analysis” to determine, among other things, if the positive test result reflects a pre-existing condition.

“To our knowledge, no infection has been linked to exposure at HealthPlus and definitive results may be weeks or months away,” Manigan said in an emailed statement.

HealthPlus notified the patients last month that “lapses in infection control in sterilization/cleaning instruments and the injection of medications” may have exposed them to the diseases, and offered to reimburse them for the cost of testing.

Another former patient filed a lawsuit in a New Jersey state court last Friday alleging that HealthPlus engaged in “wanton misconduct — on a continuing basis” by exposing patients to dangerous pathogens.

Reporting by Peter Szekely; Editing by Steve Orlofsky

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Most U.S. patients not using online medical portals

(Reuters Health) – Most people in the U.S. with health insurance don’t use the patient portals that are increasingly provided by doctors for online communication, a new study suggests.

In a nationally representative survey, researchers found that nearly two-thirds of insured participants had not used an online medical portal in the past year.

Disparities among those who said they’d been offered portal use, and among those who chose to use it, suggest this technology can become a source of unequal access to healthcare, the study team writes in Health Affairs.

“Previous research has shown there are real benefits to portal use. Patients become more engaged in their own health and really stick to their treatments,” said senior author Denise Anthony of the University of Michigan in Ann Arbor.

“However, new treatments in health care, and new technologies in general, can end up increasing inequality,” she told Reuters Health by email.

Anthony and her colleagues analyzed data on 2,325 insured patients who participated in the 2017 Health Information National Trends Survey and who had a medical visit during the year before the survey. The researchers wanted to understand the characteristics of portal users and nonusers and the reasons, such as technology issues or security concerns, why many patients don’t use online sites to access their medical records.

Overall, 63 percent of survey participants reported not using a patient portal during the past year, and 60 percent reported not having been offered access to a portal.

Nonusers were more likely to be men, aged 65 or older, to be unemployed, live in a rural location, have public insurance through Medicaid, have a high school diploma or less education and to lack a regular doctor. Similar characteristics, as well as being non-white, were seen among people who said they weren’t offered access to a patient portal.

People who were offered access to a portal and didn’t use it were more likely to have less than a college education, to be insured by Medicaid, to be 65 or older, live in a rural area and to be Hispanic.

Among the reasons participants gave for not using online portals, 25 percent mentioned issues with internet access, 32 percent said they had no online medical record, 70 percent said they preferred to speak directly to the doctor, and 22 percent were concerned about privacy issues.

“We also know from our previous research that privacy concerns can affect patients’ relationships with physicians, including how they communicate and trust their doctors, so these concerns are important beyond portals,” Anthony said.

It’s possible that some participants were not offered portal access because their doctor did not have one, the study team noted. Another limitations is that the survey relied on participants to recall whether they were offered use of a portal.

“The underlying assumption is generally a ‘Build it and they will come’ mentality about technology, but this study gives great perspective about both who is offered/using the portal as well as why certain groups experience barriers,” said Courtney Lyles of the University of California, San Francisco, who wasn’t involved in the study.

“Everyone is generally interested in online tools to make life more convenient, but we can’t separate that from the skills and relationships that surround technology use,” she told Reuters Health by email.

Future studies should consider the role of digital inclusion and digital literacy, Lyles added. Doctors will need to do more to help patients use portals during visits, as well as connecting them to resources for digital support such as local libraries and community groups.

“We have to think broadly about diverse patients and their needs and not be satisfied if this technology is used by the most well-resourced (and potentially healthiest) patients alone,” she said.

SOURCE: bit.ly/2ArMGNP Health Affairs, online December 3, 2018.

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Drug companies greet 2019 with U.S. price hikes

NEW YORK (Reuters) – Drugmakers kicked off 2019 with price increases in the United States on more than 250 prescription drugs, including the world’s top-selling medicine, Humira, although the pace of price hikes was slower than last year.

FILE PHOTO: A person holds pharmaceutical tablets and capsules in this picture illustration taken in Ljubljana September 18, 2013. REUTERS/Srdjan Zivulovic

The industry has been under pressure by the U.S. President Donald Trump to hold their prices level as his administration works on plans aimed at lowering the costs of medications for consumers in the world’s most expensive pharmaceutical market.

During a White House meeting with members of his Cabinet, U.S. President Donald Trump on Wednesday said he expected to see a tremendous decrease in drug prices. Health and Human Services (HHS) Secretary Alex Azar was at the meeting.

The overall number of price increases was down by around a third from last year, when drugmakers raised prices on more than 400 medicines, according to data provided by Rx Savings Solutions, which helps health plans and employers seek lower cost prescription medicines.

Allergan Plc was particularly aggressive. It raised list prices on more than 50 drugs, and more than half of those by 9.5 percent, according to the Rx Savings data

AbbVie Inc increased by 6.2 percent the list price of its blockbuster rheumatoid arthritis treatment Humira, which is on pace to record about $20 billion in sales in 2018.

Allergan said in a statement that its average list price increase across its portfolio is around 3.8 percent this year. It said it does not expect to realize any net benefit from the increases this year because of higher rebates and discounts it expects to make to payers.

AbbVie did not immediately respond to request for comment.

More price increases are expected this month. Reuters reported late last year that nearly 30 drugmakers had notified California agencies they plan to raise list prices of their drugs. Not all of those increases have been announced yet.

The United States, which leaves drug pricing to market competition, has higher prices than in other countries where governments directly or indirectly control the costs, making it the world’s most lucrative market for manufacturers.

HHS has proposed policy changes aimed at lowering drug prices and passing more of the discounts negotiated by health insurers on to patients. Those measures are not expected to provide relief to consumers in the short-term, however, and fall short of giving government health agencies direct authority to negotiate or regulate drug prices.

“It’s business as usual” for drugmakers, said Rx Savings Solutions Chief Executive Michael Rea, who said he believes there has to be meaningful changes to the marketplace, rather than new regulations in order for drug prices to drop.

Reporting by Michael Erman; additional reporting by Jeff Mason in Washington; Editing by Bill Berkrot

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Seniors with heart failure not harmed by moderate alcohol use

(Reuters Health) – Older people with heart failure may be able to continue drinking moderately without harming their health, a new study suggests.

In fact, heart failure patients who consume up to seven drinks a week may actually live longer than those who completely avoid alcohol, researchers report in JAMA Network Open.

“If you’re 65 and above and have had a diagnosis of heart failure and previously consumed mild to moderate amounts of alcohol, you can probably continue to do so without any harm,” said senior study author Dr. David L. Brown, a professor of medicine at Washington University in St. Louis, Missouri. “And it may actually be associated with some benefit in terms of longevity, although there is no way to show cause and effect from this study. We found that those who continued to consume moderate amounts of alcohol after diagnosis lived almost a year longer than those who never consumed alcohol.”

But, Brown cautioned, “if you have never consumed alcohol, don’t start on the basis of this study.”

Brown got the idea for the study when a patient in the hospital with a new diagnosis of heart failure asked if he could continue to have a cocktail every night.

Heart failure is diagnosed when the organ can’t pump enough blood to the body. There are a host of reasons why this can happen, Brown said, including “having a heart attack that results in loss of heart muscle function, longstanding high blood pressure, obesity, diabetes and even drinking excessive amounts of alcohol.”

To determine whether alcohol should be taken off the menu for heart failure patients, Brown and colleagues looked at health records for nearly 6,000 patients aged 65 and older who signed on to the Cardiovascular Health Study between 1989 and 1993 at four sites in the U.S. In that group were 393 individuals with a new diagnosis of heart failure in the first nine years of follow-up.

Participants with heart failure were followed through June 2013 with regular phone calls. Researchers found that 129 of the heart failure patients continued to drink after they were diagnosed, with most of them consuming the equivalent of one to seven drinks per week.

One drink was equal to 12 ounces of beer, a 6-ounce glass of wine or a 1.5-ounce shot of spirits. Just 17 heart failure patients consumed more than seven drinks a week. Of the 168 patients who abstained from alcohol, just over half were former drinkers and the rest had never been drinkers.

After accounting for factors that could influence heart failure progression, including age, sex, income, smoking history, diabetes and history of heart or kidney disease, researchers found that patients who continued to drink after their heart failure diagnosis lived longer.

On average, the non-drinkers lived 2,640 days after their diagnosis, compared with 3,046 days among those who consumed one to seven drinks a week and 2,806 days among those who consumed more than seven drinks a week.

Why would moderate drinking contribute to a longer life among heart failure patients? “That’s the $64,000 question. We don’t have the answer for that,” Brown said.

“And we still don’t know if alcohol is the primary reason people lived longer,” he added. “It may be that people who drink do it as part of a social network and that is the benefit rather than the alcohol.”

The findings will help doctors counsel heart failure patients who want to know if they can continue to drink, said Dr. Erin Michos of the Ciccarone Center for the Prevention of Heart Disease at the Johns Hopkins School of Medicine in Baltimore, Maryland.

But, Michos noted, the study doesn’t apply to all heart failure patients. “Their study was limited to those who had already survived to at least 65 years . . . and the mean age of these heart failure patients was 79 years; thus their findings cannot necessarily be extrapolated to younger individuals who might have longer life expectancies,” she said in an email.

SOURCE: bit.ly/2Tfd6cU JAMA Network Open, online December 28, 2018.

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One-floor living helps seniors ‘age in place’

(Reuters Health) – Older adults are less likely to need to change residences if their homes have certain features, including no stairs, a new study found.

“Most older adults do not want to move to a nursing home, and supporting older adults to age in the community has potential to improve quality of life and costs for care,” said lead study author Marianne Granbom of Johns Hopkins University in Baltimore, Maryland, and Lund University in Sweden.

“But to truly understand how aging in place can be supported, we need to shift focus from merely looking at individual health problems to also include the environments they live in,” she told Reuters Health by email.

Granbom and colleagues analyzed data collected between 2011 and 2105 on 7,197 U.S. adults ages 65 and older. During that period, about eight percent moved within the community and four percent moved to residential care facilities such as nursing homes and assisted living. Overall, those who lived alone, had a lower annual income, and visited the hospital during the past year were more likely to move.

After taking health factors into account, poor indoor accessibility was strongly associated with moving to a new home in the community, but not with moving to a nursing home, the researchers reported in Journals of Gerontology.

Having a one-floor house or having the kitchen, bedroom and bathroom on one floor were the features most strongly associated with aging in place. Dwellings with elevator access, lifts or stair-glides were also helpful. No other home environment factors, such as entrance accessibility or housing conditions, were associated with relocation.

For older adults, moving to more age-friendly home environments could help postpone the need for a nursing home, Granbom said.

The study found that the longer the adults had lived in their current homes, the less likely they were to move at all. Future studies could incorporate the emotional attachment to home to better understand the complexities of relocation decisions, the authors wrote.

Dr. France Legare of Laval University in Quebec, Canada, who wasn’t involved with this study but who has researched housing decisions among older adults, suggests some home-planning ideas to consider.

“During construction, leaving a space for a lift that could be installed later could be helpful, especially in dense cities where dwellings are often two or three stories,” Legare said in a phone interview. “Even if it isn’t built yet, having a potential area for a lift could help people age in place and make housing decisions as they grow older.”

Other features such as improved lighting, a no-step entrance, walk-in showers with grab bars, and railings on both sides of indoor stairs could help, said Jon Pynoos of the University of Southern California is Los Angeles, California, who has researched the future of housing for older adults.

“In a home with two or more stories, stacking closets that could later be replaced with a small elevator might be a good investment,” Pynoos, who wasn’t involved with this study, told Reuters Health by email. “Basically, plan ahead.”

SOURCE: bit.ly/2QhMypg Journals of Gerontology: Social Sciences, online December 5, 2018.

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Cryotherapy malfunction results in burn, blisters

(Reuters Health) – Whole-body cryotherapy – a trendy procedure that exposes the naked body to subzero temperatures – isn’t backed by evidence and can be risky, doctors say.

Spas and gyms advertise cryotherapy as a way to treat sore muscles, back pain, and skin problems. But a report in the Journal of the American Academy of Dermatology highlights a danger.

In the report, a 71-year-old man using whole-body cryotherapy was severely burned when a nozzle malfunctioned and sprayed liquid nitrogen directly on his back for less than a minute. He had stinging, pain and redness, which developed into blisters with a yellow pus.

“With the rise of cryotherapy facilities and the ease that consumers can be treated, it’s important to spread awareness of the harmful side effects,” said coauthor Dr. Jordan Wang of Thomas Jefferson University Hospital, where the patient was treated.

Cryotherapy chambers engulf the body from the neck down in a liquid nitrogen mist at temperatures between minus-150 to minus 220 degrees Fahrenheit (minus-100 to minus-140 Celsius) for several minutes. The head stays above the top of the chamber.

“Most consumers are unaware of the potential side effects and the lack of data behind how useful treatments are,” Wang told Reuters Health by email.

“Cryotherapy is increasing in popularity, but it’s not an FDA-approved treatment, and there’s not good regulation of the safety of these devices,” said Dr. Lisa Chipps, a dermatologist in Beverly Hills, California. Chipps, who wasn’t involved with this case, is president-elect of the American Board of Facial Cosmetic Surgery.

“When patients are undergoing non-FDA-approved treatments, they need to be aware of the potential risks of that device or service,” she told Reuters Health by phone.

Traditionally, dermatologists use cryotherapy to treat skin lesions such as viral warts, some skin cancers, and precancerous sun spots. Applied in very small areas by a trained physician, the liquid nitrogen freezes the skin and lesion.

Whole-body cryotherapy was originally given to patients with multiple sclerosis or rheumatoid arthritis for anti-inflammation effects. In recent years, it’s become popular for a wider audience. Proponents say the extreme cold helps muscle recovery after strenuous activity better than ice packs or cold water immersion.

However, the FDA hasn’t approved any cryotherapy chambers and warns about potential harmful effects including asphyxiation, frostbite, burns and eye injuries. A 2015 Cochrane review of previously published studies found insufficient evidence to support the benefits of muscle recovery for active young men, and no data exist for women or elite athletes.

“If the burn had happened on the patient’s face in this case, that would have been disfiguring,” said Dr. Anthony Rossi, a dermatological surgeon at Memorial Sloan-Kettering Cancer Center in New York City, who wasn’t involved with this case.

“Most of these cryotherapy chambers shield the fingers and toes, but what about his genitals or other areas?” Rossi told Reuters Health by phone. “People are going into this thinking they’ll receive a medical benefit, but it’s a cool trend that lacks evidence.”

SOURCE: bit.ly/2QhjiPF Journal of the American Academy of Dermatology, online December 4, 2018.

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