Category Archives: Hot Topics

Obamacare Lives On, For Now…

This morning, the Supreme Court of the United States ruled that individuals who purchase health insurance through the federal government’s exchange will continue to be eligible for tax subsidies.

This King v. Burwell ruling came after months of political upheaval and planning for the aftermath of the court decision. An estimated 87 percent of individuals who enrolled through healthcare.gov are receiving subsidies. If the plaintiff had won the case, more than 6.4 million people would have lost the subsidies and faced an average premium rate increase of 47 percent, according to the RAND Corporation. The Urban Institute estimated that by using the available subsidy, a typical single person earning below 200 percent of the poverty level spends 4.1 percent of their annual income on insurance. Without the subsidy, it would take 30 percent of that person’s income to keep the insurance.

The case revolved around four words in the Affordable Care Act (ACA): “established by the state.” The plaintiff argued that this means the law prohibits the federal government from providing premium tax credits and cost-sharing reductions to residents who live in states that did not establish their own state health insurance marketplaces. Thirty-four states do not have state-based exchanges.

Today, Justice Roberts wrote in the ruling that “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them” and that the law must be read with its intent in mind.

The White House went on record multiple times that it did not have a contingency plan to restore subsidies if the Supreme Court ruled against the administration.

If subsidies were shut down, analysts predicted a classic “death spiral.” Insurers would suddenly have a risk pool filled with high-need, high-cost people, after having priced their 2015 premiums based on a balanced pool containing both healthy and sick people. Many insurers might leave the market, and remaining plans would be forced to absorb disproportionately high-risk customers from any exiting insurers, as they’re required to do under the individual mandate.

The insurance and hospital industries are hailing the rule for creating a “more stable” future. Share prices soared, with several hospitals hitting all-time highs. Democrats on the Hill announced the ruling as a win for America while many Republicans made it clear they will not give up their efforts to repeal the law. Presidential candidates on both fronts released statements and took to Twitter to share their views.

Rand Paul posted that “this decision turns both the rule of law and common sense on its head,” while Hillary Clinton tweeted, “Yes! SCOTUS affirms what we know is true in our hearts & under the law: Health insurance should be affordable & available to all.

Although there will continue to be hot rhetoric from Republican presidential candidates, this suit has been widely regarded as a “final test” for the ACA. It is highly unlikely that the ACA will have to face another legal challenge of this magnitude in the courts. The other controversial provision, the individual mandate, was upheld by the Supreme Court in 2012.

It appears the ACA is the law of the land – here to say forevermore… unless there is a total Republican sweep of Congress and the White House in 2016. Then the fun begins again.

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Framing the Conversation on Dying in America

As a semi-typical middle schooler cramming for the Spelling Bee, my favorite thing about words was that they had both connotations and denotations. Denotations may be the dictionary definitions the announcer gives out, the ones I begrudgingly memorized, but the connotations were the ones that mattered. As more states look at end-of-life care and more articles crawl up the newsfeeds, I find myself thinking about how the words we use interchangeably are often masquerading as synonyms to further complicate already-complicated issues.

Dying is never easy. The ethics of physician-assisted dying is nuanced on both sides. Proponents argue for a right of self-determination; if we hold to our rights on living the way we want to live and receive healthcare to maintain our living capabilities, it only seems natural to receive help from the medical system to spend our last days in a dignified manner. For some people, this is much too simplified. Patients can feel pressured by families, psychological disorders, pain, financial problems, and the feeling that they are too burdensome on others. There is the possibility of developing into a weapon against the disabled community, or growing into a system of injustice against seniors.

At the same time, who can deny a terminally ill patient the right to remove himself from pain? The right-to-die and slippery slope arguments are complex, balanced on a multitude of factors that range from gender and economic variables to geographic location and religion.

How does this complexity relay itself to a world of click-baiting headlines and 140 characters? Not easily.

When the subject was “Dr. Death,” the enigmatic pathologist Jack Kevorkian who helped over a hundred patients die, the media was not as divided. Dr. Kevorkian often broke his own rules and many reports on both sides of the debate questioned whether his patients were even terminally ill. His “mercy machine” was dubbed the “death van” and his legacy remains exceptionally controversial. But activist and patient Brittany Maynard brought a different light.

“Brittany Maynard, because she’s young, vivacious, attractive, a newlywed, has a dog, and is a very different kind of person from the average middle-aged or older person who has to confront issues about terminal illness, changes the optics of the debate.”

According to bioethicist Arthur Caplan, her story grabbed the attention of a new generation. Her video went viral, blogs on both sides erupted and Twitter was all ears. Her courage and background captured imaginations and emphasized the relevance of the conversation to a broader audience. But it didn’t make it any less complicated.

Take the headlines in themselves- “physician-assisted suicide” is the key phrase that garners the most media hits, but supporters might prefer “physician-assisted death” or “aid in dying.” The “Death with Dignity” movement, discussions on the “End-of-Life Option Act” and organizations like “Compassion and Choices” remove the seemingly problematic connotation of “suicide.” Implicit within the understanding of that word is the notion that it is wrong; the person making this decision needs intervention, even involuntary psychiatric treatment but not drugs for dying. Those who attempt suicide are not generally seen as people making conscious decisions. Thus, their rights of self-determination are overstepped by a moral medical system that saves lives. The “end of life option,” on the other hand, highlights the autonomy each patient has in deciding how to die. The implication is that just as we plan for each stage in our lives, we should make informed choices on death as a natural extension of life.

When asked about allowing doctors to “end the patient’s life by some painless means,” a grand majority (70%) of Americans were in favor of allowing doctors to hasten a terminally ill patient’s death. But when asked about doctors helping a patient “commit suicide,” only 51% were supportive.

A 2013 Gallup poll is the perfect example of how much word choices say. There is no question of reaching an easy consensus on the issue, but framing the debate? That can be an important conversation to reduce noise. Dying vs. Suicide, Murder vs. Mercy, Choose vs Commit – the issue brings to light the myriad ways in which those who spark conversation in society direct the debate.

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Getting to the Point of Precision Medicine

The Twitterverse was aflutter during President Obama’s State of the Union (SOTU) address. According to social media listening tool Sysomos, there were approximately 2.1 million #SOTU- related mentions on Twitter during the one hour speech covering a wide range of economic, social and health care related topics. What’s more interesting, First lady Obama hosted a health data scientist who’d once worked for Google, IBM and now with the U.S. Digital Service. Presumptuously, the health care industry expected an announcement about advancing the role of health IT and interoperability among the provider community. Instead, what we heard was President Obama calling for an increased focus on research and development in “precision medicine” projects – a fledgling, and important, industry sector within the disease and molecular diagnostic community.

Specifically, the President’s agenda aimed at “using digital and genomic data to develop highly targeted disease treatments. The proposal would invest in ‘precision medicine’, an innovative field that provides healthcare professionals with tools, knowledge and treatments to tailor care to a person’s unique characteristics — such as their genetic makeup,” according to The White House blog.

As stated in The White House Release, “recent advances in genomics and digital data have produced powerful new discoveries about health and disease that have made it possible to design highly effective, targeted treatments for cancer and other diseases.” Obama’s proposal “will engage patients and healthcare providers in delivering this new era of medicine.”

Precision medicine has been a movement afoot that re-coined ‘personalized medicine’ to ‘precision medicine’, a new term to give the concept a fresh start by medical academia and health tech industry. Essentially, it is using the same knowledge we have gained by mapping the human DNA to use but with more advanced technologies. Either way you slice it, precision medicine, or personalized medicine 2.0, combats the 20th century ‘one size fits all’ mindset to drug therapy, and applies the data extrapolated  from genome mapping into more effective medicines to help speed up patient recovery, stave off diseases, and advance new drug discovery.

According to Dr. Lakdawalla of the National Pharmaceutical Council, whose organization’s primary mission is to improve quality of care and control costs by driving public and private research in comparative effectiveness, or ‘patient-centered outcomes research’ (PCOR), claims “there are new methods and economic analysis of data that allows researchers to estimate individual effects of drugs. We can look at 100,000 people’s information and compare two different treatments and figure out what each treatment is going to do to the individuals as if they were on each drug at the same time.”

However, even with these advances in mind, the health care community is still having difficulty putting actionable data to use. According to Dr. Lakdawalla, “there are many struggles within the health care community – among medical academia, researchers, providers and insurers – to meet the needs of the entire population and the individual by getting the right therapy to the right person at the right time.“

While the health tech and biogenetic forces continue to evolve their methodologies to support the advancement of patient-centered outcomes, The Myth of Average: Why Individual Patient Differences Matter outlines practical methods that can help identify patient diversity. What it boils down to is that patients today should be having an informed conversation with their health care provider (HCP), but patients are simply not aware of the right questions to ask their HCP in time of need. There should be an informed discussion among the physician and patient to decide on the best treatment based on the patient preferences and their personal response to certain drugs.

In order to advance precision medicine and make a tangible difference in patients’ lives, we must focus on developing a practical approach that begins with educating patients on the right questions to ask their HCPs, and empowering HCPs to factor in their patients’ individual needs when discussing their treatment options.

It is safe to say that in the end, regardless of political affiliation, we all want what President Obama called for in his address, “to cure diseases like cancer and diabetes — and to give all of us access to the personalized information we need to keep ourselves and our families healthier.”

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At Institute of Medicine obesity panel, a coordinated public effort is the doctor’s orders

The obesity epidemic is one of the most pressing problems the health care sector faces. Accounting for $190 billion in health care spending annually, obesity is one of the leading causes of preventable death in the United States.

While the numbers are staggering and the implications of obesity are grave, we are at a potential turning point in the fight.

The Institute of Medicine recently hosted a roundtable panel entitled “The Current State of Obesity Solutions in the United States.” During the discussion, leaders from the private sector, governments and non-profit groups reported on the progress of solutions and the actions being taken to rally against this disease.

Many panel members were optimistic about the state of potential solutions. A heavy emphasis was placed on strengthening patient engagement, expanding a “systems approach” in which obesity registries, data metrics and expanded health teams are used, and bolstering efforts to combat childhood obesity with increased exercise and nutrition standards.

Obesity as a disease needs a joint clinical-community response

The resonating theme from the panel was the need for a strengthened clinical-community relationship in which a larger part of the community participates in promoting a healthy lifestyle. Dr. Howard Koh, assistant secretary for health, spoke about the role society plays as health providers. “Health care goes beyond the doctor’s office; health starts where people live, learn, labor, play and pray.”

Dr. Howard Koh

Instead of stigmatizing obesity as an individual problem, Dr. Koh advocated for the treatment of obesity as a disease, requiring more than a simple diet plan and exercise routine.

The panel concurred that obesity is not just a health problem; it is a social problem that requires a comprehensive social response. Dr. Bill Dietz, chief consultant for the Institute of Medicine, compared the obesity epidemic and potential plateau in obesity rates in children to the rise and fall of tobacco use during the mid-20th century.

Lessons society can learn from anti-smoking campaigns

Smoking was first considered a critical public health issue when the link between smoking and cancer was originally reported in the 1950s. The rate of tobacco use leveled off during that period, but remained high well into the 1990s until rates gradually decreased.

Dr. Dietz explained that this drop off was the result of a very coordinated social campaign to inform the public about the severely negative impacts of smoking, while also providing resources to help users quit. With support from inside and outside the health care community, the campaign brought together doctors, celebrity spokespeople and educators to fundamentally alter perceptions and attitudes about smoking.

While anti-smoking campaigns tend to focus on scare tactics and graphic content to stigmatize smoking, I believe obesity campaigns should focus on providing support structures and promoting the tremendous rewards of living a healthy lifestyle.

Employers role in fighting obesity

One piece of good news is that public policy has recognized the necessity of broadening health care engagement outside of the doctor-patient relationship. A provision within the Affordable Care Act allows employers to charge obese employees an additional thirty to fifty percent in health care contributions to cover the increased cost of being obese, which on average is $1,152 more a year for men and $3,613 more for women.

The goal here is not to punish people for being obese, but rather to encourage individuals and employers alike to recognize the real costs of being obese.

One of those employers is Hy-Vee Inc., a grocery store chain in the Midwest. Speaking at the panel on behalf of Hy-Vee was assistant vice president of health and wellness Helen Eddy. Eddy explained how Hy-Vee uses a comprehensive method to promote the health of its employees; from healthy food choices in the work place, to an exercise-friendly work environment and behavior modification designed to address unhealthy choices.

The results are impressive. The cost of employer health care contributions is $6,400 per employee, nearly half the national average of $10,000 to $12,000 per employee. Hy-Vee has been able to give its employees a one month premium holiday five of the last six years.

There are some exciting things happening in the fight against this disease, but one big obstacle remains. Obesity needs to be recognized as a widespread social crisis, not just an individual problem. Increased social awareness and engagement can change that.

With obesity rates in children decreasing in many states, there is a glimmer of hope. Something is working. The question is will obesity rates plateau for decades to come just as tobacco use has in the past? Is stagnation good enough? What is your opinion?

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Money, mobile devices and courageous communicators critical to the success of digital health

The Consumer Electronics Show(CES 2014) kicks off today and includes an entire track dedicated to Digital Health. In fact, this year’s event will dedicate its largest footprint ever to health and wellness.  Industry expert John Korry recently categorized emerging medical technologies at CES 2014 as follows:

  1. Real time monitoring of chronic diseasemHealth Photo
  2. Aging-in-place
  3. Wearable technology for fitness

Yet, many of these “new” technology solutions have been available for a number of years. I’ve been on the digital health bandwagon since the turn of the century when I first learned about a Veteran’s Administration pilot using what is now the Bosch Healthcare Telehealth Solutions device to coordinate the care of veterans living with chronic disease. Fast forward twelve years, and the partnership has grown to provide care coordination and telehealth services to over 60,000 veterans. Why is this type of technology not more commonplace?

Follow the money. And mobile devices.

The reality is that these technologies have failed to penetrate the market due to lack of reimbursement – both for the start-up investment costs to purchase the devices and for ongoing clinical support.

As an example, I looked into purchasing the Philips Personal Medication Dispenser for my mother who is on Medicare. The machine distributes the exact dose she needs at the exact time she needs it, but costs more than $800 and was not covered by insurance. Additionally, I would need to pay out of pocket for a home health aide to help her fill the machine as she cannot not operate it on her own, adding an additional hefty expense. The machine and service is certainly cheaper than assisted living rent (which would be the next step if she can’t manage her own medications), but it’s still a hard pill to swallow (pun intended) for those who are forced to pay out of pocket.

It’s also cheaper than hospitalization, which might result if she does not take her medication as directed. Thirty to 50 percent of patients don’t adhere to their medication regimens, leading to approximately $100 billion in preventable costs annually (the costs for those hospital stays that insurers do cover could buy 125 million personal medication dispensers, for those of you playing at home).

In the end, I didn’t purchase the personal medication dispenser, but I did opt for a holiday gift of Philips’ Lifeline with AutoAlert. It is still a heavy investment of more than $500 annually, but it is worth the 24-7-365 monitoring service that helps my mother remain at home and gives us the peace of mind that help is always available. Plus, there was no start-up cost and we can pay monthly for the service.

Despite the fact that most of these new solutions are not covered by the largest public insurers in the U.S., digital health services and apps are gaining popularity because of people like me—those of us who are paying out-of-pocket to improve their health and wellness—and by private payers and other accountable-care payment models that are willing to pilot and evaluate new technologies. (PwC’s video and mHealth commissioned reports provide more detailed information about the trends).

Where does that leave the digital health technologies in terms of access to the biggest sectors of the insured: Medicare, Medicaid and subsidized individual coverage? Government pilots like the Medicare Health Support Program did not meet cost-saving expectations—the start-up and program costs were just too high. But now that almost every American is already paying out-of-pocket for their smart phone, which can serve as a highly interactive digital health device, has one of the biggest barriers to digital health adoption—the up-front technology investment—evaporated?  Smart phones may not solve every problem, but they do hold promise to break through the reimbursement barrier.

What can digital health companies do to hasten adoption?

For digital health to truly penetrate, companies need to work together to:

  • market to the end-customer who has growing influence and is choosing more often to use their discretionary income on health-related medical technology;
  • develop a sound strategy for unlocking the private and public insurance systems to support reimbursement for the accompanying clinical services; and
  • educate clinical partners about solutions that improve patient care and provide revenue streams.

The strategies themselves may seem simple yet are terribly difficult to implement. However, a company’s leadership usually can control 99 percent of the difficulty by demanding alignment and coordination among diverse teams such as regulatory affairs, clinical research, managed markets, marketing and communications. Communicators can take the lead in helping facilitate this internal alignment. Here are three specific ways to accomplish these strategies:

  1. Make the economic case: Traditionally, health care innovation is driven by the need to provide clinical studies designed only to prove efficacy and safety. However, the “holy grail” should be clinical studies that show efficacy AND impact on cost. Cost-savings is ideal but cost neutral and cost-containment may also do the trick in our current health care environment. Some companies choose to do economic modeling, but of real value is a study designed specifically to consider cost implications. Both the clinical and economic case should be planned for when considering medical technology or medical intervention. There will continue to be pilot projects that result in lackluster outcomes, but those who understand the current system of health care know this more about the broken systems in which pilots are tested, rather than the technology itself. The role of the communicator is to put the results in the proper context.
  2. Feed patient demand: Even in the face of what some call a “government takeover of health care” we still see a dramatic rise in active consumerism that can help fuel innovation in and the adoption of digital health technologies. Patient voices can help in reimbursement discussions but also influence patient satisfaction scores which are becoming more important when choosing a provider, a hospital or an insurance company. Access to mobile health technologies and the patient’s experience could influence a consumer rating for the provider and service and become a significant differentiator in marketing efforts. Patient demand will certainly grow if companies collect and share engaging patient stories through every available traditional and social media channel. Of course consumers want the same technologies used in finance, travel, energy and almost every other industry to be used in health care. Consumers are sharing opinions online, voting with downloads and backing it up with their checkbooks. And, in a free-market society, consumers usually win.
  3. Work with medical and consumer groups: The power of third-party advocates cannot be overstated. Sustaining good relationships with these groups over time has enormous benefit. A few examples:
    • Anything said by a third party about a service or product is at least 10 times more valuable than if said by a company representative. This goes for product review boards and regulatory bodies as well.
    • Advocates help shape the opinion of policymakers and other influencers, and their opinions are sought by the media. They give speeches in front of large crowds—usually to people that include your target audience. You want them to proactively bring your product up as a positive example.
    • If you have good relationships with key third parties, they can serve as allies on media stories and regulatory issues.
    • Frequent discussions with third parties can broaden your strategic understanding of stakeholder needs, and help you spot trends and foresee potential problems.

Let’s get to work.

It’s 2014 and it’s time for a fresh start. We’re going to see a lot of innovative, promising health technologies this week at CES, and communications professionals can help get them to market successfully. Gather the right people together in your company and answer the following three questions:

  1. What are we doing to make the economic case about the value of our solution?
  2. What are we doing to find and promote our patient stories?
  3. What are we doing to cultivate relationships with clinical and consumer advocacy groups?

We’d love to hear what you come up with. Share your comments here or @hcpolicymatters.

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