June 17, 2014 Once again, U.S. has most expensive, least effective healthcare system in survey A report released Monday by a respected think tank ranks the United States dead last in the quality of its healthcare system when compared with 10 other western, industrialized nations, the same spot it occupied in four previous studies by the same organization. Not only did the U.S. fail to move up between 2004 and 2014 — as other nations did with concerted effort and significant reforms — it also has maintained this dubious distinction while spending far more per capita ($8,508) on healthcare than Norway ($5,669), which has the second most expensive system. “Although the U.S. spends more on healthcare than any other country and has the highest proportion of specialist physicians, survey findings indicate that from the patients’ perspective, and based on outcome indicators, the performance of American healthcare is severely lacking,” the Commonwealth Fund, a New York-based foundation that promotes improved healthcare, concluded in its extensive analysis. The data for the 2014 report was collected before the Affordable Care Act went into full effect, so that reform may eventually boost the U.S. out of last place by providing health insurance to some of the 50 million people who lacked it. But, according to the study, the problems of our healthcare system remain so pervasive that it will take more than better access and equity to resolve them. Karen Davis, a professor in the Bloomberg School of Public Health at Johns Hopkins University and lead author of the study, said overall improvement “is a matter of accountability, having information on your performance relative to your peers and being held accountable to achieving a kind of care that patients should expect to get.” The United Kingdom, which spends just $3,405 per person on healthcare, placed first overall in the comparison of 11 nations that include Australia, New Zealand, Switzerland, Canada, France, Germany and others. (Previous surveys examined smaller numbers of nations.) In 2004, the U.K. ranked third of the five nations studied. “They’re not your grandmother’s national health service any more,” Davis said. The U.K. diagnosed its healthcare system’s problems and addressed them, Davis said. “They really have moved up over time. A lot of it has been systematic attention to increasing resources in the system,” she said. Officials hired more specialists, gave bonuses to family physicians who meet quality targets and adopted health system information systems that allow physicians to easily share information about patients. And everyone has a doctor. The United States, on the other hand, “ranks behind most countries on many measures of health outcomes, quality, and efficiency. U.S. physicians face particular difficulties receiving timely information, coordinating care, and dealing with administrative hassles,” the report concludes. The U.S. is beginning to catch up as it responds to financial incentives to improve health information systems, and Obamacare should strengthen that effort. The U.S. fares well in providing preventive care and patient-centered care, according to the report. But among its many deficiencies, according to Davis and the report, are a relative shortage of primary care physicians; lack of access to primary care, especially for the poor; a large number of low-income residents who skip needed care, do not get a recommended test or do not fill a prescription because of cost; high infant mortality; inordinate levels of mortality from conditions that could have been controlled, such as high blood pressure; and lower healthy life expectancy at age 60. Davis said that while the government can set standards, provide incentives and exact penalties for poor performance, professional organizations that represent various parts of the medical system must get behind the effort to force changes, and many have. Visit the Washington Post for the report. MS initiative helps people make the most of their new health coverage The Centers for Medicare & Medicaid Services (CMS) launched a national initiative “From Coverage to Care” (C2C), which is designed to help answer questions that people may have about their new health coverage, to help them make the most of their new benefits, including taking full advantage of primary care and preventive services. It also seeks to give health care providers the tools they need to promote patient engagement. “Helping to ensure that new healthcare consumers know about the benefits available through their coverage, and how to use it appropriately to obtain primary care and preventive services is essential to improving the health of the nation and reducing health care costs,” said Dr. Cara V. James, director of the CMS Office of Minority Health. Dr. James noted that, “to achieve these goals, we need to make sure that people who are newly covered know that their coverage can help them stay healthy, not just help them get better if they get sick.” C2C will be an ongoing project. As more and more people obtain coverage, there will be a continuous need to ensure that people have answers to questions they might have about their new coverage and are appropriately connected to the health care system to help them live long, healthy lives. Today’s launch also marks the release of the new Roadmap to Better Care and a Healthier You, which includes 8 steps to help consumers and healthcare providers be informed about the diverse benefits available through their coverage and how to use it appropriately to access to primary care and preventive services. Among other things, the “Roadmap” contains information on healthcare coverage terms, the differences between primary care and emergency care, and the cost differences of decisions to seek care in- and out-of-network, where applicable to the consumer’s health plan. Visit CMS for more information. Artificial pancreas offers hope to diabetes patients An artificial pancreas developed by Boston researchers shows considerable promise to dramatically change the treatment of type 1 diabetes, potentially enabling 2 million Americans to eat what they want without counting carbohydrates or calculating insulin injections, researchers announced Sunday. Investigators from Massachusetts General Hospital and Boston University developed the experimental device, which consists of an automated pump that releases the hormones insulin and glucagon and a glucose monitoring system controlled by an iPhone app. In a new study published online in the New England Journal of Medicine, the researchers found that 52 adults and teens who used the mobile system for five days had healthier blood sugar levels compared to when they used standard treatments that required them to check their own blood sugar levels and determine how much insulin to inject via a pump device. “This is not a cure,” said study coauthor Edward Damiano, an associate professor of biomedical engineering at Boston University who holds a patent on the software that makes the automatic dosing decisions. “It’s taking diabetes management to its ultimate potential and unburdens people with type 1 diabetes from thinking about all the things that go into managing diabetes every day of their lives.” Damiano, whose 15-year-old son developed type 1 diabetes during his first year of life, said he wakes up two to three times a night to check his son’s blood sugar to prevent it from falling to a dangerously low level, called hypoglycemia, which can cause seizures, a coma, and sometimes even death. Having an automated device, which is expected to become available by 2017 after more testing and upgrades, would save Damiano and other parents from having to wake up in the middle of the night to avoid medical emergencies, he said. Children with type 1 diabetes are eight times more likely to die from severe hypoglycemia at night — called dead in bed syndrome — than in a car accident. Diabetes experts who were not involved in the study cautioned that automated devices need far more rigorous testing to determine if they’ll be safe enough to become widespread. The rate of type 1 diabetes — in which the body’s immune cells attack and destroy a healthy insulin-producing pancreas — has, for unknown reasons, been surging over the past few decades, with nearly 16,000 children under age 18 now diagnosed with the condition every year. (Type 2 diabetes, by comparison, is a more common condition, and tends to occur well into adulthood and has far more explainable causes, such as genetics, obesity, and a lack of exercise.) In the new study, all of the study participants were closely monitored — adults were accompanied by nurses round-the-clock and the teens were in a summer camp for those with type 1 diabetes — to ensure that their blood sugar levels wouldn’t rise too high or fall too low, which could cause seizures or other complications. The research found that adult patients with type 1 diabetes who used the experimental device had lower blood sugar levels overall than the control group while also spending 67 percent less time in a state of hypoglycemia. Visit the Boston Globe for the article. Whooping cough reaches epidemic level in California For the first time in four years, California is experiencing a statewide epidemic of pertussis, or whooping cough, with infants under the age of 6 months facing the greatest risk of hospitalization or death, according to state health authorities. California counties have reported 3,458 cases of the disease this year, including two infant deaths. While that figure is less than the 9,163 cases reported in 2010 — the last epidemic year — health officials say this year's caseload is on track to meet that level. A disease is considered an epidemic if it exceeds anticipated levels; it is not the same as declaring a public health emergency, said Dr. Gil Chavez, an epidemiologist and deputy director at the California Department of Public Health. On average, state epidemiologists expect to see 80 to 100 cases of whooping cough each month. In the last two weeks, California counties reported more than 800. The earliest age an infant can be vaccinated is six weeks. Because of this, health officials say every pregnant woman should get a Tdap vaccination in the third trimester of pregnancy, as the mother's immunity will transfer to her baby — at least temporarily. Unlike the measles vaccine, pertussis vaccines do not provide lifelong immunity. It's partially for this reason that whooping cough is cyclical: It reaches epidemic levels every three to five years. The disease is caused by the bacterium Bordetella pertussis, which clings to the tiny hairs, or cilia, that line human air passages. The hairs usually work to keep the passageways clean by sweeping them, but B. pertussis produces toxins that paralyze the hairs and inflame surrounding tissues. Visit the Los Angeles Times for the story. Nurses play critical role in responding to global resurgence of pertussis Concerted effort is needed to reverse the ongoing rise in pertussis cases and deaths, especially among children and young people, according to the article by Emily Peake, APRN, MSN, FNP-C, CLC, and Lisa K. McGuire, MSN, MBA-HCM, RN. "This effort begins with nurses and nurse practitioners and other primary care providers who educate patients and the public," they write. "The battle of pertussis is winnable through education, awareness, and vaccination." Caused by infection with Bordetella pertussis bacteria, pertussis has been increasing in recent years. In the United States, average annual pertussis cases increased from less than 3,000 cases per year during the 1980s to 48,000 in 2012, including 20 deaths. Worldwide, there are an estimated 50 million cases of pertussis and 300,000 deaths. Pertussis is a major cause of death in infants worldwide. Why is pertussis on the rise? "Ambivalence toward precautionary childhood vaccinations" is a key reason, along with the lack of well-child visits and appropriate boosters. The arrival of non-vaccinated immigrants may also be linked to new clusters of pertussis outbreaks, according to Peake and McGuire. They write, "Nurses should educate patients and the public that follow-up booster vaccinations at all ages are critical to maintain immunity to pertussis and other vaccine-preventable diseases." Issues including vaccine availability and cost, literacy and language barriers, and lack of information all contribute to the lack of recommended vaccinations. Fear of vaccination and religious objections also play a role. Most states allow exemptions from vaccination based on religious reasons, and there's evidence that even non-religious parents are using these exemptions to avoid vaccinating their children. Nurses should reassure parents that that recommended vaccines are safe. Current diphtheria-tetanus-pertussis vaccines do not contain the mercury-containing preservative thimerosal. Adverse events occur in only a small fraction of vaccinated children, and most of these are mild local reactions. The World Health Organization is working to increase the percentage of infants who receive at least three doses of pertussis vaccine to 90 percent or higher, especially in developing countries. The authors discuss some international efforts to fight pertussis and other vaccinepreventable diseases, such as the United Nations Foundation's [email protected] campaign. Closer to home, partnerships should be formed with service organizations, food banks, churches, hospitals and schools. Nurses can also advocate for policies aimed at making universal vaccinations available for adolescents and adults. Visit Wolters Kluwer for the report. Threat grows from liver illness tied to obesity Despite major gains in fighting hepatitis C and other chronic liver conditions, public health officials are now faced with a growing epidemic of liver disease that is tightly linked to the obesity crisis. In the past two decades, the prevalence of the disease, known as nonalcoholic fatty liver, has more than doubled in teenagers and adolescents, and climbed at a similar rate in adults. Studies based on federal surveys and diagnostic testing have found that it occurs in about 10 percent of children and at least 20 percent of adults in the United States, eclipsing the rate of any other chronic liver condition. There are no drugs approved to treat the disease, and it is quickly becoming a leading cause of liver transplants around the country. Doctors say that the disease, which causes the liver to swell with fat, is particularly striking because it is nearly identical to the liver damage that is seen in heavy drinkers. But in this case the damage is done not by alcohol, but by poor diet and excess weight. Most patients have a less severe form of the disease, with no obvious symptoms. But having nonalcoholic fatty liver is a strong risk factor for developing heart disease and Type 2 diabetes. And in 10 to 20 percent of patients, the fat that infiltrates the liver leads to inflammation and scarring that can slowly shut down the organ, setting the stage for cirrhosis, liver cancer and ultimately liver failure. Studies show that 2 to 3 percent of American adults, or at least five million people, have this more progressive form of the disease, known as nonalcoholic steatohepatitis, or NASH. “This is the face of liver disease in the United States,” said Dr. Shahid M. Malik of the Center for Liver Diseases at the University of Pittsburgh Medical Center. “If you’re at any liver transplant center in the country, there’s no doubt that this is a big problem.” Three decades ago, NASH was so rare that there was no medical name for it. Many doctors assumed that fat that accumulated in the liver was fairly harmless. But today, NASH is a growing strain on liver clinics and the fastest rising cause of liver transplants. A study by the Mayo Clinic found that the percentage of all transplants performed nationwide because of NASH had reached 10 percent by 2009, up from 1 percent in 2001, even as the rates for hepatitis C, alcoholic liver disease and other conditions remained stable. NASH is projected to surpass hepatitis C as the leading cause of liver transplants by 2020, in part because of new drugs that can effectively cure hepatitis C, but also because of the rapid growth of fatty liver disease. Fatty liver strikes people of all races and ethnicities. But it is particularly widespread among Hispanics because they frequently carry a variant of a gene, known as PNPLA3, that drives the liver to aggressively produce and store triglycerides, a type of fat. The variant is at least twice as common in Hispanic Americans compared with African-Americans and non-Hispanic whites. At the University of California, Los Angeles, home to one of the largest liver transplant centers in the world, nearly 25 percent of all liver transplants are performed because of NASH, up from 3 percent in 2002. If the prevalence of NASH continues to increase at its current rate and effective treatments are not found, about 25 million Americans will have the disease by 2025, and five million will need new livers, said Dr. Ronald W. Busuttil, chief of the division of liver transplantation at the David Geffen School of Medicine at U.C.L.A. With NASH rates rising rapidly, drug companies are racing to produce the first drug to treat it. In January, Intercept Pharmaceuticals, a small biotechnology firm, announced that its clinical trial of obeticholic acid showed promise in treating NASH, causing its stock price to soar. The National Institutes of Health, which sponsored the trial, are expected to present results from it later this year. Another company, Galectin Therapeutics, was granted a special fast-track designation by the Food and Drug Administration to speed its development of GR-MD-02, a drug that may help reverse some of the more advanced symptoms of the disease. But it will be several years before any drugs for NASH reach the market, said Dr. Kathleen Corey, the director of the Massachusetts General Hospital Fatty Liver Clinic, which was founded four years ago. Like many hepatologists, Dr. Corey helps her patients manage their high cholesterol, blood sugar and other metabolic problems that coincide with fatty liver. She counsels them to avoid sugar and alcohol, and she offers them high dosages of vitamin E, an antioxidant that studies show can relieve some symptoms of the disease. And she urges them to lose weight, the only proven way to reduce fat in the liver. Some researchers believe that insulin resistance, a hallmark of Type 2 diabetes, may be an underlying cause of fatty liver. But not everyone who has the disease is insulin resistant. Nor is every fatty liver patient overweight. People of Asian descent, for example, develop the disease at a lower body mass index than others, said Dr. Rohit Loomba, a fatty liver specialist at the University of California, San Diego, School of Medicine. Doctors are also trying to figure out why some people with fatty liver progress to NASH and cirrhosis, while others do not. Dr. Loomba said that continual weight gain seems to be one driving force behind the progression. Visit the New York Times for the article. Providers want patients to read medical records, spot errors Healthcare providers are giving patients more access to their medical records so they can help spot and correct errors and omissions. Studies show errors can occur on as many as 95% of the medication lists found in patient medical records. Errors include outdated data and omissions that many patients could readily identify, including prescription drugs that are no longer taken and incorrect data about frequency or dosage. Patients also are being asked to fill in the blanks about pain relievers and other over-the-counter medications, as well as supplements and vitamins, all of which can interact with prescription drugs. Technology is giving the efforts a boost: More than half of doctors use electronic medical records, compared with just 17% in 2008, according to the federal government, which offers financial incentives to providers tied in part to giving patients access to their health information online. Several large medical providers, including Cleveland Clinic, Mayo Clinic, the Veterans Health Administration, Geisinger Health System and Kaiser Permanente, are giving patients direct online access to their doctors' notes. And they are experimenting with different ways to solicit feedback and allow patients to correct or add to their records. "If we don't have accurate data we can't take care of patients appropriately," says Jonathan Darer, chief innovation officer at Geisinger. The aim is to move patients and doctors into a relationship of "shared accountability" and more effective medical care, he says. While studies have shown that immediate harm to a patient because of faulty medical records is rare, such errors can lead doctors to miss important information, such as whether patients aren't taking their drugs as prescribed, which can lead to worsening of a disease or condition. In an emergency, it's critical to know what drugs are in a patient's system, as hospital staff may prescribe new drugs that conflict with them. Outpatient medical records often contain missing or inaccurate data, including: New prescription medicines aren't listed, or medicines are listed that the patient isn't taking anymore. An incorrect or outdated dosage of a prescription medicine. Duplicate prescriptions for brand-name and generic medications. Over-the-counter remedies, such as pain relievers, vitamins or other supplements, aren't listed. -Incomplete or missing information about medication allergies. -Erroneous information about treatment outcome, such as a condition that is noted as resolved but is still a problem. Updated information about lab results is missing. Details about symptoms, as reported by the patient, are missing. Inaccuracies in diagnosis. Even when gaps in the medical record are a result of the patient's failure to provide updated or complete information, providers might still face legal liability in the event of an adverse or allergic reaction or a prescription that doubles something the patient is already taking. The risk is especially high for older patients, who often take several medications for one or more chronic diseases and may not recognize that, say, a brand-name drug and a generic-name drug are the same. Patients with access to their own medical information are more likely to ask questions, identify inaccuracies and give additional information that might affect data in their records, according to research conducted by research organization NORC at the University of Chicago, under contract with the federal Office of the National Coordinator for Health Information Technology. Geisinger is currently adopting the medication feedback initiative more broadly in the health system, which serves northeastern and central Pennsylvania. It also is expanding its use of another initiative, Open Notes, which currently allows some 168,000 patients to view their doctors' notes online through a secure patient portal. Patients can add their own notes, and starting this summer family caregivers will be able to add notes, including asking for corrections about patients who may not be able to comment on their own. Visit the Wall Street Journal for the article. PhRMA, Advocates: Specialty drug costs too high Here’s the next salvo in the back and forth between insurers and the drug industry over drug prices: the Pharmaceutical Research and Manufacturers of America are pushing the Department of Health and Human Services to take action to protect consumers who have gained insurance via the health law’s online marketplaces from high, out-of-pocket costs for specialty drugs. Specialty drugs are most often prescribed for complex, chronic and often costly health conditions like rheumatoid arthritis and hepatitis C that require continuous monitoring by a health care provider. At a June press event, PhRMA, the drug industry’s trade association, and five patient advocacy groups, ranging from the Colon Cancer Alliance to the Immune Deficiency Foundation, pointed to an analysis by the consulting firm Avalere Health — commissioned by PhRMA — as reason for worry regarding these medicines. The Avalere study examined 123 formularies from silver-level exchange plans — the benchmark plan that will generally pay 70 percent of covered medical expenses, leaving the consumer responsible for 30 percent – and found that a fifth of them required cost sharing of 40 percent or more for certain classes of specialty drugs used to treat HIV/AIDS, multiple sclerosis, bipolar disorder, cancer and other illnesses. Avalere also concluded that 60 percent of silver plan formularies placed all medications for multiple sclerosis, Crohn’s disease, cancer and other illnesses in the plan’s highest formulary tier. That means patients who need these medicines would face the highest coinsurance percentage. PhRMA President John Castellani called on HHS to limit insurers’ ability to structure drug coverage in a way that subjects patients with these types of chronic and severe illnesses from these type of high out-of-pocket costs. Insurers are currently submitting exchange premium rates for 2015, and Castellani said HHS could take action before those rates are finalized. Others at the event, including Carl Schmid, deputy executive director at the AIDS Institute, said HHS could redefine essential health benefits to stipulate that plans not include high cost-sharing for specialty prescription drugs. Silver-level plans mostly have an average of $70 for tier 3 drugs, and $270 for tier 4, according to a presentation to a recent meeting of the International Myeloma Foundation, one of the groups at the event. The groups, however, did not address issues related to the drugs’ actual price tags — only coverage costs to patients. But America’s Health Insurance Plans, the trade group for insurers, said in a blog post that PhMRA is trying to distract attention from drug pricing. Meanwhile, these recent comments come amid growing debate on the issue. The National Coalition on Health Care launched in May the Campaign for Sustainable Rx Pricing, which includes more than 80 organizations that represent employers, disease advocacy groups, providers and consumers. John Rother, president and CEO of the NCHC, said though the concern about patients paying large coinsurance percentages is a valid one, it’s not the real problem — instead it is the overall cost of specialty drugs. “Putting a limit on coinsurance probably would require legislative action, whereas reducing price is something companies could do tomorrow,” Rother told Kaiser Health News. “All we’re arguing about here is whether you pay out of one pocket or another. The real problem is the total price they have to pay. It’s not a poor industry — they can make it up on volume particular in the international market.” AARP, which is a member of NCHC, also said if insurers were to eat the cost of specialty drugs without some amount of cost sharing, premiums would rise. (Kaiser Health News) Visit WebMd for the article.