Affordable Care Act Saves Medicare Recipients Billions On Prescription Drugs

Editor’s Choice
Main Category: Medicare / Medicaid / SCHIP
Also Included In: Seniors / Aging
Article Date: 04 Dec 2012 – 10:00 PST

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Affordable Care Act Saves Medicare Recipients Billions On Prescription Drugs

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As the last week of Medicare Open Enrollment gets closer, Health and Human Services Secretary Kathleen Sebelius declared yesterday that savings on prescription drugs have topped $5 billion thanks to the Affordable Care Act.

Over 5.8 million people using Medicare have benefited from the help the health care law gives with the Medicare prescription drug coverage gap referred to as the “donut hole”.

In the initial 10 months of 2012, close to 2.8 million people have saved an average of $677 on drug prescriptions alone. At the same time, around 23.4 million people with regular medicare had one or more preventive services for free, with 2.5 million of them getting an Annual Wellness Visit.

Secretary Sebelius said:

“The health care law is saving money for people with Medicare. Everyone with Medicare should look at their health and drug plan options for additional value before the Medicare open enrollment period ends this week.”

Medicare coverage stops when prescription costs total $2,930 or higher. Specifically, for 2013 the law gives individuals with medicare who are in the donut hole, higher savings with discounts increasing to 53 percent of the cost of brand name drugs and 21 percent for generic drugs. These discounts will also help seniors who have exhausted their coverage and are forced to pay out-of-pocket for prescription medications. The donut hole will be closed in 2020, until then, savings on Medicare coverage of prescription drugs will slowly grow.

The new law gives Medicare recipients the opportunity to be healthier by eliminating co-pay and deductibles for a number of preventive services. Prior to 2011, individuals with Medicare were charged out-of-pocket for many preventive services. Expenses are now less of a concern for elders who wish to treat problems early and remain healthy. An estimated 32.5 million people with original Medicare or Medicare Advantage acquired one or more free preventive benefits.

An additional benefit is that affordable drugs will encourage more people to take their mediation, resulting in reduced long-term medical costs. If a Medicare patient takes an antibiotic to ward off infection, or regularly uses their hypertension or insulin medications, they are saving the government money by stabilizing their health conditions and therefore preventing expensive emergency hospitalizations.

Open Enrollment Ends December 7

Every year during Medicare’s open enrollment time, those individuals with Medicare should compare expenses, advantages, and drug and health plans to define the best value for the coming year. Medicare users should explore their health care options frequently because a person’s unique health issues combined with their health or prescription drug plan can be altered from year to year.

The Centers for Medicare and Medicaid Services (CMS) recommend that Medicare users enroll in high quality plans and get the greatest value for their money. The ratings of Medicare health and prescription drug plans are important, and searching for a 5 star plan is recommended.

Written by Kelly Fitzgerald
Copyright: Medical News Today
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Terminating Medicare Consults Linked To A Rise In Total Spending

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Main Category: Medicare / Medicaid / SCHIP
Also Included In: Health Insurance / Medical Insurance
Article Date: 27 Nov 2012 – 10:00 PST

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Terminating Medicare Consults Linked To A Rise In Total Spending

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Getting rid of payments for Medicare consultations frequently billed by specialists was seen to be connected with a new increase in spending during visits to specialists as well as primary care doctors, suggests a new study examining medicare data published in Archives of Internal Medicine.

Preceding 2010, Medicare costs for consultations were significantly greater than for office visits that were almost identical in terms of difficulty, and were frequently charged by primary care physicians (PCPs). In January of 2010, Medicare got rid of consultation payments from the Part B Physician Fee Schedule and simultaneously increased costs for office visits.

Regarding the budget, these changes would leave it unaffected since it would reduce payments to specialists but increase payments to PCPs.

A research team led by Zirui Song, Ph.D., of Harvard Medical School, Boston, analyzed the relationship of this policy with spending, capacity and coding for office visits during the initial year of the plan going into effect. Zirui and his colleagues investigated outpatient claims from 2007 to 2010 for over 2.2 million Medicare beneficiaries with Medicare Supplemental coverage via sizable employers.

The authors explained:

“Medicare’s elimination of consultations was associated with a 6.5 percent increase in overall spending for outpatient encounters in 2012. This increased spending was explained by higher fees paid for office visits and by increased intensity of coding. Our results suggest that the policy did not achieve its goal of budget neutrality in the first year. However, it did appear to narrow the gap in Medicare payments for office encounters between PCPs and specialists.”

The researchers found that an average of $10.20 extra was spent per beneficiary per quarter on physician meetings after the policy was enacted, however, the total volume of physician visits was unchanged. The rise in spending was accounted for by higher office-visit fees from the policy and a shift in the direction of higher-difficulty visits to trouble PCPs and specialists.

The authors conclude that their examination of Medicare’s termination of consultations bring about possible lessons for policymakers. Volume effects connected with fee decreases depend on the type of service.

The researchers said:

“Finally, the inherent flexibility and subjectivity of code definitions could lead to potentially undesirable coding behavior in response to fee-based policies, as numerous areas in the physician fee schedule feature a gradient of service intensities captured by a set of closely related codes.”

Written by Kelly Fitzgerald
Copyright: Medical News Today
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“Unintended Consequences of Eliminating Medicare Payments for Consultations”
Zirui Song, PhD; John Z. Ayanian, MD, MPP; Jacob Wallace, BA; Yulei He, PhD, MS; Teresa B. Gibson, PhD; Michael E. Chernew, PhD
Archives of Internal Medicine, November 2012, doi:10.1001/jamainternmed.2013.1125.
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Most Medicare Patients Wait Weeks Before Breast Cancer Surgery

Main Category: Breast Cancer
Also Included In: Medicare / Medicaid / SCHIP
Article Date: 21 Nov 2012 – 1:00 PST

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Although patients may feel anxious waiting weeks from the time of their first doctor visit to evaluate their breast until they have breast cancer surgery, new findings from Fox Chase Cancer Center show that these waits are typical in the United States. Results were published in the Journal of Clinical Oncology. Looking at data collected from more than 72,000 Medicare patients diagnosed with non-metastatic breast cancer, researchers – led by Richard J. Bleicher, M.D., attending surgeon and director of the Breast Fellowship Program at Fox Chase – found that, in 2005, half of the breast cancer patients underwent breast cancer surgery at least 32 days after first consulting their doctor about their breast problem. This is an increase from 1992, when half of the patients waited no more than 21 days.

“For many Medicare patients, it can take a month or more from the time they first see their doctor to evaluate their breast concern, make a diagnosis, and get them to the operating room,” says Bleicher. “So if a woman learns that her surgery date is weeks after her evaluation, where she was found to have a breast cancer, she should know this length of time is typical, and should not be concerned.”

“Although this interval may sound alarming at first, it does not appear to have a detrimental effect on outcomes. We don’t have the outcomes data for this group of patients yet, but we have seen improvements in survival over the past few decades in breast cancer overall.” Bleicher adds.

Before this study, Bleicher explains, it was unclear how long people were actually waiting for surgery and how the surgery type and workup affected that wait. Experts had data from individual institutions, but nothing that captured waiting times nationwide. So when patients got anxious hearing their surgery was weeks away, doctors were unable to tell them whether such wait times were longer than the norm, and thus potentially dangerous.

“It’s not clear why people are waiting longer for surgery,” says Bleicher. Now that patients have access to more information about cancer, they may take longer to make decisions about surgery; alternatively, a larger patient population could be filling operating rooms, making it harder to schedule surgeries. Indeed, patients undergoing more complicated procedures – such as mastectomy with breast reconstruction – waited longer than average.

Longer delays were also seen in patients who received certain types of biopsies and imaging. This suggests that part of the increase in wait time may stem from greater use of a wider variety of current tools to detect and image the tumors before surgery, says Bleicher. This may also explain why patients may be living longer, even though the time from presentation to their doctor until surgery steadily increased from 1992 to 2005.

“Patients should be aware that even though breast cancer feels like an emergency needing to be addressed tomorrow, it doesn’t have to be dealt with in a matter of days,” says Bleicher. “These results should reassure women that, if they are not in the operating room tomorrow, that’s typical.”

He adds that the findings apply only to patients receiving Medicare, and wait times may differ for those with private insurance or no insurance at all.

Even within the Medicare population, there was some variation – wait times were longer for women (29 days, versus 24 days for men), younger patients (29 days), blacks and Hispanics (37 days each), people living in large metropolitan areas and the northeast (32 and 33 days, respectively).

“Although these results suggest that doctors and patients shouldn’t be concerned about small delays in getting to surgery, we need to continue to monitor how long people are waiting,” says Bleicher. “Researchers must ensure that this time interval doesn’t increase dramatically or start to affect outcomes in certain patient groups, particularly those who already wait longer than the average.”

Dr. Bleicher’s co-authors include Karen Ruth, Elin R. Sigurdson, Eric Ross, Yu-Ning Wong, Sameer A. Patel, Marcia Boraas,Neal S. Topham, and Brian L. Egleston from Fox Chase.
Fox Chase Cancer Center
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Medicare Barrier To Hospice Increases Hospitalization

Main Category: Palliative Care / Hospice Care
Also Included In: Medicare / Medicaid / SCHIP;  Alzheimer’s / Dementia
Article Date: 02 Nov 2012 – 1:00 PDT

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A Medicare rule that blocks thousands of nursing home residents from receiving simultaneous reimbursement for hospice and skilled nursing facility (SNF) care at the end of life may result in those residents receiving more aggressive treatment and hospitalization, according a new analysis.

“This study is the first, to the knowledge of the authors, to attempt to understand how treatments and outcomes vary for nursing home residents with advanced dementia who use Medicare SNF care near the end of life and who do or do not enroll in Medicare hospice,” wrote researchers, including lead author Susan Miller, research professor of health services policy and practice at Brown University, in the Journal of the American Geriatrics Society.

Miller said the outcomes are often unwanted treatments.

“Unfortunately, given the high use of Medicare skilled care near the end of life and policy that prevents simultaneous Medicare reimbursement for skilled nursing and hospice care, aggressive treatments that may not be the preference of families or their loved ones are common,” she said.

The federal government will investigate this issue under the Medicare Hospice Concurrent Care demonstration project mandated by the Affordable Care Act.

About half of all nursing home residents dying with advanced dementia have Medicare SNF care in the last 90 days of life, but residents with this care are not allowed to receive simultaneous hospice and SNF Medicare reimbursement for the same terminal illness. The two services have different medical goals.

Because of the rule, previous research has reported, 46 percent of residents with advanced dementia but no SNF use hospice, while only 30 percent of similar residents who do have SNF use hospice (some residents can still end up with both services simultaneously if, for instance, SNF addresses a different condition than their terminal illness).

What Miller and her colleagues found is that whether and when SNF patients have access to hospice makes an important difference in the care they receive at end of life. That matters to many families, because it is not an easy decision, emotionally or financially, to give up SNF in favor of hospice.

“What I’ve heard from physicians is that families may be advised about hospice, but when the family learns that by choosing hospice and thus giving up SNF they’d have to pay for the entire nursing home stay, they will choose SNF over hospice,” she said. “One physician told me a story about a significant other who wanted hospice for their family member. It was cheaper for that person just to quit their job, stay home and care for the person and get hospice rather than to pay for nursing home care because the nursing home cost more than they were making.”

To conduct her analysis, Miller and her co-authors studied the Medicare records of 4,344 nursing home residents with SNF care and advanced dementia who died in 2006. Of the sample, 1,086 received hospice care either concurrent with SNF or afterward. The other 3,528 patients were demographically and medically similar, but did not receive hospice care.

One of team’s key findings was that residents with hospice either during or after SNF care were far less likely to die in the hospital than people without hospice. Those with concurrent SNF and hospice were 87 percent less likely to die in the hospital. Those with hospice after SNF were 98 percent less likely. In the meantime, the data showed the patients with hospice received less aggressive treatments in many other ways. Fewer received feeding tubes, medications (except hypnotic and antianxiety drugs), IV fluids, and occupational or physical therapy than those with no hospice.

The researchers also measured two key outcomes that were more complicated to interpret: persistent difficulty breathing and persistent pain. Residents with hospice after SNF were 37 percent less likely than those without hospice to experience persistent difficulty breathing, or dyspnea, but residents with concurrent hospice and SNF had no significant difference in their experience of this problem. With persistent pain, those with hospice after SNF were not less likely to experience it than residents with no hospice, but those with concurrent SNF and hospice were 65 percent more likely to experience pain.

Miller said that the pain comparison, in particular, is puzzling because of the subjectivity of measuring pain and the likelihood that people who elect hospice care do so in part because of elevated levels of pain.

Overall, Miller said, the results show that the Medicare rule that reduces access to hospice at end of life significantly affects the treatment nursing home residents receive.

Whether it is worth it, from a cost perspective, to change the policy, is not clear, Miller said. The ACA-mandated demonstration will help answer that. But evidence from prior studies suggests that Medicare does tend to save money when nursing home residents do not have long hospice stays. Miller said she plans future studies to look at costs and alternative ways to bring palliative care to nursing home patients with advanced dementia.

In addition to Miller, the paper’s other authors are Julie Lima of Brown and Dr. Susan Mitchell of the Institute for Aging Research at Hebrew Senior Life and Deaconness Medical Center in Boston.
The Alzheimer’s Association (grant 2008-086) and the National Institute on Aging (grants AG027296 and AG033640) funded the study.
Brown University
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Medicare Regional Analysis Masks Substantial Local Variation In Health Care Spending

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Public Health
Article Date: 02 Nov 2012 – 0:00 PDT

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Reforming Medicare payments based on large geographic regions may be too bluntly targeted to promote the best use of health care resources, a new analysis from the University of Pittsburgh Graduate School of Public Health suggests. The analysis will be published in the Nov. 1 issue of the New England Journal of Medicine.

“Much policy attention has been drawn to the large geographic variation in health care spending across regions, and for good reason – because regional variation points to inefficient use of resources,” said lead author Yuting Zhang, Ph.D., associate professor of health economics at Pitt Public Health. “But it is important to effectively target these policies to reduce overutilization while maintaining access to high-quality care.”

Policies that are too widely focused, such as at the larger regional level, could leave many high-spending locales untouched while inadvertently penalizing some low-spending locales. However, policies that are too finely focused, such as at the physician-level, could miss system-level factors that account for high utilization in some areas, Dr. Zhang said.

Previous geographic variation analyses primarily focused on regional areas, such as the hospital referral regions (HRRs) described in the Dartmouth Atlas of Health Care. The United States can be divided into 306 HRRs, which are areas served by large tertiary hospitals where patients are referred for major cardiovascular surgical procedures and for neurosurgery.

The HRRs can be further divided into 3,436 Dartmouth hospital-service areas (HSAs), where residents receive most of their hospital care from the hospitals in the area.

Dr. Zhang and her colleagues used enrollment, pharmacy claims and medical claims data from 2006 through 2009 from the Centers for Medicare and Medicaid Services for a 5 percent random sample of Medicare beneficiaries enrolled in stand-alone Part D plans. The study sample included about 1 million beneficiaries each year.

“We found substantial misalignment of high-spending HSAs and HRRs, after adjusting for population difference across regions,” Dr. Zhang said. “Many low-spending HSAs are located within high-spending HRRs, and many high-spending HSAs are located within low-spending HRRs.”

Only about half of the HSAs located within the highest-spending fifth of HRRs are themselves in the highest spending fifth of HSAs. Conversely, only about half of the highest-spending fifth of HSAs were located within the highest-spending fifth of HRRs.

For example, Manhattan was one of the HRRs with the highest drug spending in the nation, while Albuquerque was one of the lowest, after adjusting for population difference in the regions. However, the lowest-spending HSA in Manhattan had lower spending than about a quarter of the HSAs within Albuquerque.

“If a reform policy targeted the Manhattan HRR for lower Medicare payments, it would penalize low-spending local hospitals while missing the higher-spending local hospitals within the Manhattan HRR,” Dr. Zhang said.

Using their analysis, Dr. Zhang and her colleagues could not determine the “right” level to target policy reforms, but suggest that focusing exclusively on the regional level is too blunt.

The study was funded by the Institute of Medicine grant no. HHSP22320042509X, National Institute of Mental Health grant no. RC1 MH088510 and the Agency for Healthcare Research and Quality grant no. R01 HS018657.
Co-authors include Seo Hyon Baik, Ph.D., of GSPH’s Department of Health Policy and Management; A. Mark Fendrick, M.D., of the University of Michigan School of Medicine; and Katherine Baicker, Ph.D., of the Harvard University School of Public Health.
University of Pittsburgh Schools of the Health Sciences
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Health Costs For Seniors In Canada Rising Slowly: Points Way To Medicare Solvency

Main Category: Seniors / Aging
Also Included In: Medicare / Medicaid / SCHIP;  Primary Care / General Practice
Article Date: 31 Oct 2012 – 0:00 PDT

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Health Costs For Seniors In Canada Rising Slowly: Points Way To Medicare Solvency

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A study published in Archives of Internal Medicine finds that per capita Medicare spending on the elderly has grown nearly three times faster in the United States than in Canada since 1980. (Canada’s program, which covers all Canadians, not just the elderly, is also called Medicare.) Cost grew more slowly in Canada despite a 1984 law banning co-payments and deductibles.

In the first study of its kind, Dr. David U. Himmelstein and Dr. Steffie Woolhandler, professors at the City University of New York’s School of Public Health, analyzed decades of detailed Medicare spending data for persons aged 65 and older in the U.S. and Canada.

After adjusting for inflation, the authors found U.S. Medicare spending per elderly enrollee rose 198.7 percent from 1980 through 2009. In Canada, the comparable figure was 73 percent.

According to the authors, the findings have important implications for the debate on how to save Medicare. “Had U.S. Medicare spending per elderly enrollee increased as slowly as in Canada, the savings from 1980 through 2009 would have totaled $2.156 trillion,” said Himmelstein. “That’s equivalent to more than one-sixth of the U.S. national debt.”

The new findings appear in the Archives of Internal Medicine, a leading medical journal published by the American Medical Association. The article, which takes the form of a research letter, includes supplementary analyses based on less detailed data showing that the U.S. could have reaped even larger savings – nearly $3 trillion – from 1971 to 2009.

The article cites several reasons for Canada’s better record on cost containment: Less paperwork and administrative bloat throughout their health system (administrative costs account for 16.7 percent of total health spending vs. 31 percent in the U.S.); the use of lump-sum budgets for hospitals; stringent controls on spending for new buildings and expensive new equipment; the use of single-buyer purchasing power to rein in drug and device prices; relatively low litigation and malpractice costs; and an emphasis on primary care.

Woolhandler commented: “In a nutshell, including the elderly in a universal, nonprofit, publicly administered single-payer system has been the key to Canada’s cost control. Although U.S. Medicare is often called a single-payer system, that’s not quite accurate. It’s true that traditional Medicare is relatively efficient – only about 2 percent of its budget goes to administration, according the most recent trustees’ report, versus about 14 percent for privately run Medicare managed-care plans – but Medicare is only one of many health care payers in the United States.

“As a result,” Woolhandler said, “doctors’ and hospitals’ administrative costs are inflated by having to deal with a multitude of payers and by having to track eligibility, attribute costs and bill for individual services. This extra paperwork and bureaucracy is a major contributor to rising costs in the U.S., and these costs spill over into the relatively efficient Medicare program.

“In contrast, Canada’s single-payer system is much more streamlined and lean throughout, with big dividends for clinical care.”

The article cites several studies that show clinical outcomes in Canada are as good if not better than in the U.S.

The article notes that some U.S. politicians advocate replacing traditional Medicare with vouchers that seniors could use to buy private coverage. Still others advocate offering incentives for health providers to limit care. Yet none of these proposals have proven themselves to be effective in containing costs, the authors write.

“Canada’s road-tested cost containment methods offer an alternative,” they say.

In addition to their positions at CUNY, Himmelstein and Woolhandler are visiting professors of medicine at Harvard Medical School and co-founders of Physicians for a National Health Program. PNHP played no role in supporting their research.
“Cost control in a parallel universe: Medicare spending in the U.S. and Canada,” David U. Himmelstein, M.D., Steffie Woolhandler, M.D., M.P.H. Archives of Internal Medicine, online publication date Oct. 29, 2012.
Physicians for a National Health Program
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Costs Significantly Less When Outpatient Urological Surgery Performed In Physician Offices & ACCs

Main Category: Urology / Nephrology
Also Included In: Primary Care / General Practice;  Medicare / Medicaid / SCHIP
Article Date: 24 Oct 2012 – 1:00 PDT

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More and more outpatient surgical procedures are being done at nonhospital-based facilities such as freestanding ambulatory surgical centers and physician offices, instead of at hospital-based outpatient departments. A new study comparing the cost to Medicare of 22 urological surgical procedures performed in each setting has found that ambulatory surgery centers and physician offices are less costly than hospitals. The results are published in the December issue of The Journal of Urology.

“Our findings indicate that for comparable procedures, hospitals were associated with significantly higher payments than ambulatory surgical centers and the physician office,” says lead investigator John M. Hollingsworth, MD, Department of Urology, Dow Division of Health Services Research and Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor. “In fact, offloading 50% of the procedures from hospitals to ambulatory surgery centers would save the Medicare program nearly $66 million annually.”

Investigators examined national Medicare claims from 1998 to 2006, identifying elderly patients who underwent one of 22 common outpatient urological procedures. They measured all relevant payments made within 30 days of the procedure to capture any costs that may have resulted from postoperative complications and unexpected hospitalizations. They assessed the extent to which hospital payments, professional services, and facility payments vary by the ambulatory care setting where a procedure is performed.

The authors found that 88% of the procedures examined were performed at an ambulatory surgical center or physician office. Ambulatory surgical centers and physician offices were less costly than hospitals for all but two of the procedures. For instance, average adjusted total payments for urodynamic procedures performed at ambulatory surgical centers were less than a third of those done in hospitals. Compared to hospitals, office based prostate biopsies were nearly 75% less costly. While physician offices tended to be more cost-efficient than ambulatory surgical centers, the difference was not significant. Facility payments tended to be the driver of payment differences.

The average Charlson score, which measures how severely ill a patient is, was lower for patients treated in a nonhospital setting. Dr. Hollingsworth notes that low risk patients may be more likely to be treated in an ambulatory setting, and the results may reflect the lower cost of treating patients who are less seriously ill. While Medicare claims data may not be generalizable to other payers, Dr. Hollingsworth says, “the Medicare program accounts for 19% of total national spending on personal health services, making it the single largest payer in the United States. Therefore, with regard to health care financing, as Medicare goes, so goes the nation.”

Dr. Hollingsworth and his colleagues observe that if the cost differences between nonhospital and hospital settings are unjustified, e.g., due to inefficiencies rather than case mix, service, or content, then Medicare might base payment in the future on costs at the least expensive setting. “Alternatively, Medicare may bundle reimbursements to facilities and physicians involved in care around a single outpatient surgical episode into a single payment. The observed variation in facilities payments suggests opportunities for improvement,” they conclude.

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News From Annals Of Internal Medicine: Oct. 23, 2012

Main Category: Men’s Health
Also Included In: Endocrinology;  Medicare / Medicaid / SCHIP
Article Date: 24 Oct 2012 – 0:00 PDT

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1. Task Force Recommends Against Hormone Replacement Therapy for Postmenopausal Women

The United States Preventive Services Task Force recommends against the use of estrogen and progestin for the prevention of chronic medical conditions in postmenopausal women and the use of estrogen alone for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy. Following a review of 51 articles published since 2002, the Task Force concluded that risks associated with these hormone replacement therapies (HRT) outweigh the chronic disease prevention benefits. The Task Force found that both estrogen alone and estrogen plus progestin reduce the risk for fractures, but increase risk for stroke, thromboembolic events, gallbladder disease, and urinary incontinence. Estrogen alone decreased risk for breast cancer. Estrogen plus progestin increased risk for probable dementia and breast cancer. The risk for breast cancer increased for women with prior oral contraceptive use, prior menopausal estrogen plus progestin therapy, or current smoking. The recommendations apply to average-risk women who have undergone menopause, and are not about the use of hormone therapy to treat symptoms of menopause, such as hot flashes or vaginal atrophy. These recommendations match the Task Force’s 2005 recommendations on HRT.

2. Physician Thought Leaders Weigh In on Upcoming Election: It’s All About Health Care

The authors of three separate editorials discuss the presidential candidates’ positions on healthcare, and how the winner will influence the nation’s care.

David Blumenthal, MD, MPP, Chief Health Information and Innovation Officer at Partners Health System in Boston authored the first editorial. According to Dr. Blumenthal, voters should be focused on health care even more so than the economy, as the next president will profoundly influence the future of the country’s health care system. Dr. Blumenthal calls the 2012 presidential election “the most important health care election in the history of the Republic.” He focuses on the importance of covering currently uninsured Americans.

In the second editorial, Robert Berenson, MD, a senior fellow at the Urban Institute in Washington, D.C. explains how health care could change under a Democratic or Republican president. While the Affordable Care Act will provide currently uninsured patients with regular and continuous care from their selected clinicians, the shortage of primary care physicians may bulk under the weight of increased patient volume. Dr. Berenson also discusses the need to revise the current reimbursement system so that health care providers are paid for “value” and not “volume.”

Gail Wilensky, PhD, an economist and senior fellow at Project Hope in Bethesda, MD, authored the third editorial, focusing on how the election will impact physicians. In addition to reduced Medicare fees, primary care physicians will be faced with a large workload increase as more patients are insured. According to the author, there are important differences between the candidates’ approaches to expanding coverage and slowing spending, but the most important issue is how to fix the Resource-Based Relative Value Scale reimbursement system and how to handle the mandatory cuts to Medicare.

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Big Drop in Colon Cancer Attributed to Colonoscopy

By Rita Rubin
WebMD Health News

doctor holding a colonoscope

Oct. 23, 2012 — Wider use of colonoscopy has led to a more dramatic decline in colorectal cancer rates, a new study suggests.

Colorectal cancer cases and deaths have been falling for decades, with the most recent decline likely due to screening tests that enable doctors to detect and, if necessary, remove precancerous growths, researchers write in the journal Gastroenterology.

Still, the disease kills more Americans than any other cancer except lung cancer, and half of all Americans over 50 aren’t getting any screening for it, according to the American Cancer Society.

Since Medicare and private insurers began covering screening colonoscopy for average-risk people in 2001, colonoscopy has become the main screening tool. But some recent studies have questioned whether it is any better at reducing cancers in the upper part of the colon than sigmoidoscopy, the scientists write.

Colonoscopy involves inserting a flexible lighted tube tipped with a camera through the entire rectum and colon. Sigmoidoscopy involves inserting a flexible camera-tipped tube through the rectum and only into the lower part of the colon.

The new study analyzed hospitalization data from the largest inpatient care database in the U.S., which includes patients covered by Medicare, Medicaid, and all private insurance companies. It was developed by the federal Agency for Health Care Research and Quality.

Researchers compiled the rates of all hospitalizations for colorectal cancer surgery from 1993 to 2009. Most people diagnosed with the disease undergo at least one operation, called a resection, so the number of resections for colorectal cancer closely reflects the number of cases, the scientists say.

‘Dramatic’ Declines

Overall, the colorectal cancer surgery rate, expressed as the number per 100,000 people, dropped from 71.1 in 1993 to 47.3 in 2009. Most of the decline occurred in the latter half of that period, which correlates with the expansion of Medicare and private insurers’ coverage of colonoscopy.

“The curves are very dramatic,” says researcher Uri Ladabaum, MD, associate professor of gastroenterology and hepatology at Stanford University. “Once we got the data and looked at it, we said, ‘Wow, this is really quite a marked change here.’”

The rate of operations in the lower part of the colon fell from 38.7 per 100,000 people in 1993 to 23.2 in 2009. While the resection rate in the upper part of the colon fell from 30 per 100,000 people in 1993 to 22.7 in 2009, it declined significantly only after 2002.

Ladabaum’s team attributes the decline to the wider use of colonoscopy.

“[It] is fairly logical,” says Brenda Edwards, PhD, a senior advisor for cancer surveillance at the National Cancer Institute in Bethesda, Md. She wasn’t involved with the study. Still, “as they point out, this is not a cause-and-effect kind of thing,” Edwards says, because patients weren’t randomly assigned to colonoscopy or another screening test.

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Improving Outpatient Management Could Reduce The High Rate Of Readmission Of Kidney Transplant Patients

Main Category: Transplants / Organ Donations
Also Included In: Urology / Nephrology;  Medicare / Medicaid / SCHIP
Article Date: 18 Oct 2012 – 0:00 PDT

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Three in 10 patients receiving a kidney transplant require readmission to the hospital within 30 days of discharge following surgery, according to a Johns Hopkins analysis of six years of national data.

The findings, published online in the American Journal of Transplantation, suggest more needs to be done to manage patients outside the hospital to keep them from costly and potentially preventable return visits. Readmissions are said to cost the U.S. health care system $25 billion a year. The Centers for Medicare and Medicaid Services has begun the process of decreasing reimbursements to hospitals with high readmission rates, using readmissions as a surrogate measure of hospital quality.

“We need to be aware that kidney transplant recipients have an extremely high risk of returning to the hospital in the first 30 days after discharge, and that readmissions may very well be prevented by putting in place better systems for outpatient management,” says study leader Dorry L. Segev, M.D., Ph.D., an associate professor of surgery at the Johns Hopkins University School of Medicine. “Some patients just need more intense monitoring.”

Segev and his colleagues examined data provided by the Organ Procurement and Transplantation Network, Medicare, and the United States Renal Data System from more than 32,000 patients who received kidney transplants in U.S. hospitals between Jan. 1, 2000 and Dec. 31, 2005. While 31 percent of transplant recipients required readmission within 30 days, the percent of patients returning varied by hospital, from 18 percent to nearly 50 percent, a variation that could not be accounted for by conventional issues of center volume or demographics.

Age, race, body mass index, diabetes, heart disease and several other factors were associated with early hospital readmission. African-Americans had an 11 percent increased risk of readmission, and obese patients had a 15 percent increased risk, while diabetic women were at a 29 percent increased risk. Interestingly, those patients who stayed in the hospital for five or more days at the time of their transplants were more likely to be readmitted within 30 days. Segev says this may be a sign that the more complex cases early on appear to remain complex and more likely to require additional care.

Patients who bounce back to the hospital are not returning only for complications related to their new organs – such as infections or problems related to immunosuppressant drugs they need to keep from rejecting the new organ – but often for problems related to other illnesses they had before they received their transplants. Segev says even though medical teams make sure that the heart disease or diabetes a transplant candidate may have is stable before a transplant takes place, those conditions can still cause complications after surgery. The entire medical team needs to be sure people with co-morbidities are very closely followed, he says.

“Kidney transplant is complex and the management of the first 30 days is complex,” he adds. “We will never get the readmission rate down to zero, but it’s highly likely we can get it down from nearly one-third.”

Segev says he hopes that transplant centers with higher rates of readmission can learn lessons from centers with lower rates. They may find that those centers schedule more frequent outpatient visits, offer more opportunities to communicate with clinicians via email or the telephone, or are better at coordinating services such as blood work that may be needed after discharge so that critical post-transplant medication adjustments can be made quickly before a readmission is required.

Other Johns Hopkins researchers involved in the study include Mara A. McAdams-DeMarco, Ph.D.; Morgan E. Grams, M.D., M.H.S.; Erin Carlyle Hall, M.D., M.P.H.; and Josef Coresh, M.D.
The study was supported by grants from the National Kidney Foundation of Maryland, the American Federation for Aging Research, the National Institutes of Health’s National Institute on Aging (K23AG032885) and NIH’s National Institute of Diabetes and Digestive and Kidney Diseases (R21DK085409).
Johns Hopkins Medicine
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