Cancer Drugs-Cost Versus Benefit the New Paradigm

Recently, both the New York Times and the Los Angeles Times have published articles about oncologists' new consumer tool to gauge the effectiveness of cancer drugs. This effort was spurred after harsh rebukes of the pharmaceutical industry from clinicians at the Mayo Clinic and Harvard Medical School.  Both of the "Times" articles cite information from the Journal of the American Medical Association (JAMA) article, which ranked cancer fighting drugs from 2009 through 2013 for effectiveness and cost. (1) Oncologists have embraced this new consumer decision aide as it provides health care purchasers and their families with another basis for decision making. And, as it often turns out, the most expensive medication is not necessarily the most effective. Using a scale of 0 to 130 rating system, the cancer drug treatments are ranked for efficacy. Here are the most expensive oncology medications, based on the analysis of experts at JAMA in this study, costs are expressed annually and their effectiveness ranking is listed below:
       RX Ranking by cost-

1. Omacetaxine for chronic myeloid lukemia-$168,366
2. Ibrutinib for mantle cell lymphoma-$157,440
3. Crizotinib for non-small cell lung cancer-$156,544
4. Pomalydomide for multiple myeloma-$150,408
5. Sorafenib for papillary thyroid cancer-$141,984
6. Regorafenib for colorectal cancer-$141,372
7. Ponatinib for chronic myeloid lukemia-$137,592
8. Trametinib for malignant melanoma-$125,280
9. Lenalidomide for mantle cell lymphoma-$124,870
10. Cabozantinib for medulliary thyroid cancer-$118,800

      Same RX showing effectiveness and extended life expectancy due to drug observed response
     Note that some of the drugs lack a proportional effectiveness ranking, this is not an omission.
     Observed effects are quoted from the JAMA article findings.

1. Omacetaxine for chronic myeloid lukemia-14.3% effectiveness, 12.5 months median observed effect
2. Ibrutinib for mantle cell lymphoma-66% effectiveness, 17.5 months median observed effect
3. Crizotinib for non-small cell lung cancer-7.7 months median observed effect versus 3 months on other treatment
4. Pomalydomide for multiple myeloma-29% effectiveness,7.4 months median observed drug effect
5. Sorafenib for papillary thyroid cancer-10.8 months median observed effect versus 5.8
6. Regorafenib for colorectal cancer-2 months median observed drug effect versus 1.7 for other
7. Ponatinib for chronic myeloid lukemia-54% effectiveness, 3.2 to 9.5 months median observed drug effect
8. Trametinib for malignant melanoma-4.8 months versus 1.5 median observed effect
9. Lenalidomide for mantle cell lymphoma-26% effectiveness, median observed effect 16.6 months
10. Cabozantinib for medulliary thyroid cancer-11.2 months median observed effect versus 4 months

As you can see, a high price tag does not assure a fantastic response rate, especially when compared to plain old chemotherapy. Or for example, the non-small cell lung cancer drug, Erlotinib (Tarceva) scored a 44% effectiveness rate and costs $4,600 per month versus the outrageously priced Crizotinib at more than twice that price. Also in comparison, the widely marketed Avastin drug for lung cancers scored only a 16% effectiveness ranking, and it costs $12,000 a month. (2)

Oncologists have banded together to create a Value Framework (3) from which patients and their families can assess the total efficacy of a cancer drug, including cost, response to drug, and a comparison to other treatments. This welcome tool is called a decision aide and it is the latest trend in getting health care quality and purchasing information to the individual patients.

Concern for the efficacy of health care treatments is being expressed by governments as well, with multiple states passing laws requiring drug companies to share their development cost data and not just the drug price. California, Massachusetts, North Carolina, Oregon, and Pennsylvania all have bills pending for pharmaceutical transparency and disclosure. (4) This is all part of the increased effort for greater transparency in health care, driven to the consumer, who actually has to pay for the insurance, the treatments, or the taxes for all of the above.  Although the pharmaceutical pricing model is price-to-whatever-the-U.S.-market-will-bear, this is increasingly becoming a free fall for the consumer who can't afford the treatment and for publicly funded health care programs which are balking at the price gouging.

In 2013, in my book, http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972 I wrote about discerning quality in health care services and this is one more step in empowering patients and their families to make better decisions for their health treatments. To increase your health purchasing IQ continue to read what the healthpolicymaven has to say.  Other articles which may be of interest include:
http://healthpolicymaven.blogspot.com/search/label/cost%20of%20health%20care
http://healthpolicymaven.blogspot.com/2010/11/state-by-state-analysis-of-patient.html

And this is the healthpolicymaven signing off. This article does not offer medical advice and may be shared virally, with appropriate attribution to the writer of course. The healthpolicymaven is a graduate of the University of Washington School of Public Health and Community Medicine and the Daniel Evans School of Public Affairs.

(1) Sham Mailankody, MB BS¹; Vinay Prasad, MD, MPH,  Five Years of Cancer Drug Approvals, Innovation, Efficiency, and Costs, JAMA, July 2015, Volume 1 No. 4
http://oncology.jamanetwork.com/article.aspx?articleid=2212206&utm_source=google_plus_page&utm_medium=sohttp://oncology.jamanetwork.com/article.aspx?articleid=2212206&utm_source=google_plus_page&utm_medium=so

(2) Melissa Healy, Cancer Drugs get a new consumer's guide, Science Now, The Los Angeles Times, June 22, 2015
http://www.latimes.com/science/sciencenow/la-sci-sn-cancer-drugs-consumers-guide-20150622-story.html#page=1

(3)   Lowell E. Schnipper, Nancy E. Davidson, Dana S. Wollins, et, al. American Society of Clinical Oncology Statement: A Conceptual Framework to Assess the Value of Cancer Treatment Options,
American Society of Clinical Oncology, August 2015
http://jco.ascopubs.org/content/early/2015/07/08/JCO.2015.61.6706http://jco.ascopubs.org/content/early/2015/07/08/JCO.2015.61.6706

 (4) Andrew Pollack, Drug Prices Soar, Prompting Calls for Justification, The New York Times, July 23, 2015
http://www.nytimes.com/2015/07/23/business/drug-companies-pushed-from-far-and-wide-to-explain-high-prices.html?_r=0

Based on the Evidence-Cardiac and Orthopedic Procedures To Avoid

Here are the latest conclusions from the 2015 Road to Rightcare by the doctor-driven Lown Institute, which aims to prevent unnecessary and ineffective procedures and enhance patient health. To quote one of the conference speakers, America Bracho, M.D., "Health is more than the absence of disease." Become a more powerful practitioner and patient by signing-up for the Rightcare newsletter and to learn more about the practices this multi-disciplinary group is promoting.

 Cardiac Care
Percutaneous Coronary Intervention or Angioplasty
As incredible as it may seem there are thousands of unnecessary and non-beneficial cardiac procedures performed each year in the U.S. Here are the summary notes from the Lown Conference Cardiac Care presentation by Dr. William Boden, FACC, FAHA, Professor of Medicine, Albany Medical College and Chief of Medicine at Stratton VA Medical Center. For patients with chronic and stable angina, the benefits of percutaneous coronary intervention, which involves working a balloon up through the femoral artery to unblock the clogs in the heart, are unclear. In the past, PCI was done for patients who had high risk of death due to a heart attack. Because angioplasty is less invasive than coronary artery bypass  graft or CABG, it has become more popular.  A randomized trial of 1,018 patients comparing PCI or angioplasty to treatment with medication, was conducted in the United Kingdom and Ireland. Of the 504 patients whom underwent PCI, 11 died, compared to the 7 of the 514 randomized patients, whom were treated with medication. Additionally, 21 of the PCI patients had heart attacks compared to 10 of those on medication. These results are quite astounding, because the benefits of not having the surgery are almost twice (1.92 in relative risk variance) what the surgical intervention produced. https://www.dropbox.com/s/nxkqfsnlmjx5zse/Lown%20PCI%20in%20SIHD%20Workshop_Boden_021615.ppt?dl=0
Orthopedic Surgery
There are 800,000 joint replacements done in the U.S. every year by the 20,000 orthopedic surgeons, who are the highest income earners of all clinicians, averaging $413,000 annually, as cited by Dr. Boniface, Clinical Professor and Chairman of Orthopedic Surgery at Northeastern Ohio Medical University. Here is the alphabetized list of commonly performed unnecessary and often ineffective orthopedic procedures as identified by James Rickert, M.D. President of The Society for Patient-Centered Orthopedics, Thomas J. Grogan, M.D. Orthopedic Surgeon, Thomas Boniface, M.D., NEOMED, and Rob Rutherford, M.D. Clinical Instructor, University of Washington:
Adolescent Clavicle Fractures and Surgical Repair
Traditionally family practitioners, which would be pediatricians for adolescents, treated clavicle fractures by deploying a sling to prevent stress on the bone while it healed. Why is surgery being done on so many clavicles which heal on their own?
Anterior Cruciate Ligament or ACL Tear Surgery
Most of us have heard of the "ACL injury" as it is the de rigueur for weekend warriors. However, clinically, many more people are having this surgery than for whom it was intended to treat. In 2008, there were 100,000 ACL surgical repairs and now there are 200,000. In Unraveling U.S. Healthcare-A Personal Guide, I devote a chapter to surgical tips for consumers and why I chose non-surgical treatment for my ACL tear. In fact, a 2013 article published in the American Journal of Sports Medicine demonstrates that patients who opted for a nonsurgical treatment had the same rate of return to sports activities. The Scandinavian  Journal of Medicine and Science in Sports published a study in 2009, which found that 51% of the patients which did not have the ACL repair operation performed better on two of the four, single-legged hop tests. And for those of you who need more evidence, the British Journal of Medicine also published a study in 2013, which showed that ACL reconstruction and rehabilitation did not produce better results than initial rehabilitation and postponement of surgery, after five years of observation.
http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972#
Partial Meniscectomy for Arthritic Knees
Meniscectomy was studied in a randomized controlled trial of 351 patients,  where physical therapy was compared to the surgical repair technique of the meniscectomy and found equal results for pain relief and functional status were achieved with physical therapy. The randomized controlled trial means that patients were chosen at random and followed for the same period of time, using the same measures to assess the effectiveness of the treatment. Conclusion-if you have arthritis this procedure won't help you.
Rotator Cuff Tears and Surgical Intervention
Rotator cuff tears are often asymptomatic, which means the patient is not aware there is a problem and is not experiencing any restrictions. A 2010 article in the Journal of Shoulder and Elbow Surgery found that 20.7% of the general population had rotator cuff tears and asymtomatic tears were twice as common as those in patients with symptoms. This condition, which is an aspect of normal aging is found via the ubiquitous MRI. Despite this evidence, there are 600,000 of these surgeries in the U.S. each year. To put it bluntly, medical evidence shows that physical therapy can be just as effective to treat this problem, and should only be provided to patients who actually have symptoms.Risks of a surgical repair to the rotator cuff include; bleeding, infection, stiffness, re-rupture of the tear, neurovascular injury, and unrelieved pain. For patients whom are 60+ years, a non invasive treatment is preferential to a surgical repair. As the gold-standard randomized controlled trial showed, the results are the same with our without surgery.
Vertebroplasty-A Spinal Treatment
Vertebroplasty is a heavily marketed orthopedic procedure which involves injecting cement into the center of a fractured vertebra. It is used for compression fractures of the spine. The British Medical Journal did a large randomized controlled trial and found there was no evidence this procedure provided any medical benefit. One fourth of women over age 50 have one or more fractures. The rate of vertebroplasty has increased from 45 to 87 cases per 100,000 patients in the Medicare population. Though this treatment is marketed as providing quick pain relief, scientific studies show there is a risk of increased compression fracture, dural tears, infections, cement migration, and the need for additional surgery due to radiculopathy. In a 2009 study published in the New England Journal of Medicine, pain cessation for patients treated with vertebroplasty were similar to those in the control group who did not have the surgery. No commercial entity paid for any of the materials in this study and the costs of the surgery were billed to insurance companies. In the industry funded studies, the cementing procedures is typically compared to sham procedures and not to nonsurgical interventions.Conclusion-This is yet another back surgery which has elusive results-Medicare needs to review this. https://www.dropbox.com/s/pb7arzvpl5garkf/LownBibliography1-1.docx?dl=0
How Changes in Health Policy at the Centers for Medicare and Medicaid Can Improve Care
In the three days I spent at the Lown Care Conference it was obvious the physicians all had ideas on how changes in our national health care policy could drive health care practices and result in better patient care and a reduction in ineffective treatments. Here are their observations on ways to improve health care quality in the nation:

1. United States healthcare is being pushed toward a "risk-based" model which means identifying the most efficacious treatments and creating cost savings is critical. One way to achieve this is through bundling payments or reimbursements for clinicians and health care facilities. This would create less of a financial impetus to perform the highest reimbursement surgery as opposed to the treatment most appropriate for the patient. 
2. CMS needs to make coding changes for cardiac procedures which would not punish the doctor for doing the cost-effective treatment. For example, a doctor's fee should not be linked to the cost of the cardiac catheter.
3. We build over capacity at the medical school level by encouraging more specialists and increasing the supply of highly trained surgeons, which also means we have to generate  demand for services through scope creep, marketing directly to patients, and the ever expansion of facilities to be filled with patients who have the money to pay for the procedures.
4. Consumer or patient-driven health care is not the same as market driven medicine because patients are not commodities, hospitals are not factories, and money should not be the driving force of health care decisions. Education of patients is the key to providing the right care for each patient, with a much stronger emphasis on prevention. We need to collaborate more effectively so that patients can make informed decisions. Health outcomes need to be patient based, not based on Relative Value Units. We need to figure out the health treatments with the most impact and CMS needs to reward those. Patients need to be informed and accountable.
5. Nonoperative treatment needs to be valued more by CMS and insurance companies, because the Journal of Patient Safety cites 440,000 patients are still harmed in U.S. hospitals annually. If doctors are paid for providing preventive care they will do more of it. But as it stands right now, primary care clinicians make the least amount of money in the medical field.  More procedures does not necessarily mean more health. 

State Initiatives
 Rhode Island has sparked a unique health effort to meet community needs in under-served areas by creating community centers which incorporate fitness centers, achieve critical mass in community enrollment through representation of community members, provide urgent care services at the center, offer home health visits, and deploy school-based health programs. They plan to fund it through taxation of health services. University of Minnesota professor, Bill Doherty has co-authored the Citizen Health Care Initiative, which  aims to engage communities, families, and individual patients to participate and generate health improvements. This community model attempts to instill healthier perspectives and behaviors instead of waiting for major medical interventions at the hospital. Washington State has Healthier Washington, a grant funded project, which is exploring everything from reimbursement and design changes to the state Medicaid plan, to community assessment, and resourcing of health care needs.The real question is whether any of these ambitious programs will be able to improve health. My money is on the Rhode Island community center model.

Have I met all of my health goals since I returned from the conference-no, but I am making progress and just remember Winston Churchill's quote, "You can always count on Americans to do the right thing, after they have tried everything else." And this is the healthpolicymaven signing off encouraging you to think about your health and ask questions before you pursue health treatments.

This article was written by Roberta E. Winter, MHA, MPA, an independent health care analyst and writer and may be shared with others. It is not meant to give medical advice, but to highlight what the experts and the medical evidence show for common surgical procedures which are over utilized in the United States. The article is not a comprehensive review of unnecessary surgeries, especially in cardiac care, because it was written for the layperson.

Measles Outbreak-What It Means When Your Neighbors Don't Vaccinate

Outbreak in Preventable Childhood Diseases On the Rise in the United States
The measles outbreak in the nation has been on the rise for the past two years, but is nearly at epidemic proportions now. http://www.cdc.gov/measles/cases-outbreaks.html  There are 141 cases of measles in 17 states so far in 2015. This chart from the CDC shows the states which have the most outbreaks of measles.

 Measles, is a preventable childhood disease for which an immunization (a shot) is usually given to a child when the child reaches nineteen to thirty-five months of age. Measles causes red spots, fever, and in some cases can result in death. This article reviews changes in childhood immunization patterns, which were reported for all fifty states in Unraveling U.S. Healthcare-A Personal Guide, published in 2013.  Information is drawn from the U.S. Centers for Disease Control and Prevention and is inclusive of 2013 calendar year data. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6334a1.htm?s_cid=mm6334a1_e#Tab1

In 2011, the national immunization rate for children between the ages of nineteen and thirty-five months was 83.34% for all recommended childhood vaccinations. In 2013, the immunization rates for the same age-group of children and the same vaccines had dropped to 83.07%.
 Here are the states with the lowest rate of immunization for these diseases as of  the end of the reporting year for 2013, as compared to the national average. As you can see, the western states do poorly for immunization compliance, as reported in my 2013 health scorecards. The one bright spot is Utah, which matches the national average for the top three vaccines. The outlier in the group is Vermont, which has achieved the dubious designation as the state with the lowest rate of childhood immunizations. And though much of the country seems to ignore the District of Columbia, seat of our nation's capitol, it has a better vaccination rate than the national average, at 86.7% penetration versus 83.07%. Here is information from the table, showing the worst states for immunizing their children:

Children's Health Scorecard-2013	National Average		Oregon	Montana	Wyoming	New Mexico	California	Colorado	Alaska	Vermont
Ranking			44	45	46	47	48	49	50	51
DTaP	83.10		83.80	79.00	80.90	79.80	83.10	81.20	75.50	85.80
Hep B	74.20		66.80	73.90	67.00	67.50	70.30	60.20	59.40	44.80
MMR	91.90		89.40	87.30	89.00	89.10	80.70	86.00	90.50	91.20
Average Rate	83.07		80.00	80.07	78.97	78.80	78.03	75.80	75.13	73.93
Variance			-3.07	-3.00	-4.10	-4.27	-5.03	-7.27	-7.93	-9.13
Notes: Negative number means performance is worse than the national average.
Immunization rate is for Heb B only.
Immunization rates are from the Centers for Disease Control for 2013 year In short, this is the reason there are large outbreaks of childhood diseases now. An immunization is a preventive dose to activate the body's immune system to the disease vector. In order to have adequate protection for a population, which means a community, a school, a state, the majority of the population has to become immunized. In the United States, especially on the west coast, we are in danger of losing our herd immunity, which is a scientific term that means the actions of a significant minority can imperil the entire population. The standards for public health in the United States and all developed nations are based on scientific data, using gold-standard studies and analysis, not spurious opinions of the uniformed in social media. The recommended immunizations for children in the above age-group are as follows: Diptheria, Pertussis, and Polio- Pertussis is known as whooping cough and there has been an increase in preventable childhood deaths from this recently as well. Polio of course, causes paralysis and shortened life expectancy and was thought to have been eradicated in the U.S., but thanks to the actions of a minority, this may no longer be the case. Diptheria is a respiratory disease. Measles, Mumps, & Rubella-Measles is an infectious disease causing fever and rash. Mumps is a disease of the salivary glands, causing swelling, fever, and muscle aches. Rubella, also known as German Measles can cause incurable illness for pregnant women, and significantly increases the chance of miscarriage. Influenza-This is a respiratory disease which can and does cause deaths in infants and others whom have immune deficiencies. Hepatitis B-This is a  blood disease which can damage the liver; is transmitted through bodily fluids, and can  be passed from mother to child. Varicella or chicken pox-This is a blister-like rash, fever, and can result in death for those with compromised immune systems. In The Russell Guide for Diabetics, I share information about the science and the reality of childhood diseases. A 2003 Italian study,  found that early childhood exposure to two diseases damaged the immune system and was significantly linked to causation of Type 1 or juvenile diabetes. Here is an excerpt from my book explaining the findings: In 2003, a population-based case-control study in Italy, published results which found that childhood exposure to two infections significantly increased the likelihood of a child contracting Type I Diabetes. Infections which were reviewed in the study included; pertussis (whooping cough), varicella (chicken pox), rubella, parotitis, and morbilli.[1]Here are the findings of the study: 1.      The statistically significant finding with no confounding variables,  showed that children in the Abruzzo region of Italy who were exposed to two of the childhood viruses listed, had a higher incidence of Type I Diabetes compared to the population who had been exposed to a single childhood infection. 2.      Children who had been exposed to only one of the listed childhood infections did not show an increased incidence of contracting Type I Diabetes. 3.      Childhood immunizations were also analyzed as risk factors for contracting Type I Diabetes and there was no statistical increase shown in the incidence of juvenile diabetes for the immunized children. 4.      However, for children who had received the pertussis (whooping cough) and MMR (measles, mumps, and rubella) vaccinations, a significant decrease was found in the contraction of childhood Diabetes.  My brother, Russell was diagnosed with Type 1  Diabetes when he was three years old, three months after his exposure to chicken pox. He had also been exposed to mumps within the year, by his school-age siblings (including moi). Unfortunately, this event was due to the fact immunizations were typically provided through the school at the time of enrollment, so children younger than school age were at risk. Russell died at 42 years of age, following multiple organ transplants, and amputations all related to Type 1 Diabetes. To all parents who think they are "boosting their child's immune system" by avoiding immunizations, do take the long term view and consider all adverse consequences. This article of course, is written for those whom do base their decisions on scientific evidence. Considering the low-level of science readiness in our national population, as compared to other countries, perhaps this issue will ultimately be decided through tort action in the courts. The CDC clearly states these immunizations prevent 722,000 deaths over a lifetime, so the parents whom are abdicating these preventive measures must be assuming some other child or relative will be in that statistic and not their own. Truly it is just a question of time before the actions of one parent bring irreparable illness to the lives of others, which is similar to driving a vehicle without auto insurance. Considering that many of those eschewing immunizations are patrons of  the well heeled in private schools, this population is an easy target for social responsibility through the courts. And this is the healthpolicymaven signing off, encouraging all to share this article virally, just as childhood diseases are spreading through our population. Roberta Winter is the author of http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972# Roberta E. Winter is a graduate of the University of Washington School of Public Health and Community Medicine and the Evans School of Public Affairs. She has spent the past 12 years advocating for consumer issues in health care.

  

Medicaid Changes from the Accountable Care Act-Whether or Not Your State Adopted the Revised Eligibility Guidelines

What State Medicaid Expansions May look like in 2014

This article reviews the draft model for one state’s answer to the Medicaid Expansion under the Accountable Care Act. Washington State has posted the preliminary benchmarks and plan design for accommodating this act.[1]Warning to readers-this article may contain acronyms which are mind numbing, but part of the lumbering vernacular, and wherever possible the full name is cited.

Medicaid Eligibility

 To start with there are a dozen categories of “fast track” exemptions for Medicaid applicants and here is that list:

1. Health care for disabled workers
2. Family planning extension (more on this later)
3. Take charge family planning (whoa Nelly)
4. Psychologically indigent inpatient program (example-homeless folks)
5. Involuntary treatment act (hopefully this will apply to some of the nut-jobs who manage to obtain machine guns)
6. Kidney disease program (for those on dialysis)
7. ADATSA(Alcohol Drug Addiction Treatment Support Act)
8. Social Security Income qualifiers based on their low income status
9. Basic Health Plan qualifiers (subsidized medical insurance program for WA state residents with incomes no more than 200% of the Federal Poverty Level)
10. Medical Care Services Program (This is a managed care program run by the WA State Health Care Authority)
11. Medicaid qualifiers by virtue of low-income status
12. Children’s Health Insurance Plan Enrollees (CHIP)

Benchmark Plan Coverage

Next up are the definitions of the benchmark plan for insurance coverage mandates and here are those potential confounders:

1. Essential health benefits,
2. Essential health benefits reference plan
3. Base benchmark plan, benchmark
4. Alternative benefits plans

The benchmark plan must cover the following criteria in the benefit design:

1. BCBS-This refers to the bench mark equivalent coverage based on Blue Cross/Blue Shield plans
2. EPSTD-Early and Periodic Screening, Diagnosis, and Treatment Program which applies to children under 21 who are covered by the state Medicaid program
3. Non emergency transportation-What is this, a taxi to town?
4. Family planning services & supplies-AKA birth control options

People who are Exempt from the Benchmark Criteria and Eligible for Standard Medicaid Benefits include:

1. Pregnant women 
2.  Individuals who qualify for Medicaid based on being blind or disabled
3. Dual eligible enrollees, which is a category of people on both Medicare and Medicaid plans 
4.  Terminally ill hospice patients
5. Inpatients in hospitals, nursing home and ICF (assisted living facilities) who must spend all but a minimal amount of their income for the cost of medical care 
6.  TANF/Section 1931 enrollees, which is for parents and caretakers of incapacitated persons
7. Medically frail individuals, including those with disabilities that impair ability in one or more activities of daily living
8. Children in foster care 
9.  Individuals who qualify for LTC (long term care) services based on their medical condition
10. Individuals who only qualify for emergency care (?) 
11.  Individuals who qualify based on the  “spend down” of their total resources-such as senior citizens needing help with nursing home care.

Essential Health Benefits in 2014

The federal government has created ten essential health benefit plans for the states to adopt. Each state may have more than one benchmark Medicaid plan for eligible adults, which differs from the insurance exchange mandates, which are slated to have only one benchmark plan. Also, under current law, the mental-health-parity benefits for Medicaid only apply to Medicaid Managed Care Plans, and not the general Medicaid plans, but this is changing in 2014. According to federal mandates, essential health benefits must include the following insurance benefits:

1. Ambulatory services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services
6. Prescription drugs
7. Rehabilitative and habilitativeservices and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

With regard to the habilitative services and devices, this sounds like assistance for home living and a new word invented by the government order.

Benchmarking the New Medicaid Plan Design

Criteria which will be considered to establish a state benchmark for the Medicaid expansion plans include any of the following factors: the largest small group plan by enrollment (Blue Shield/Regence), the three largest state employee plans by enrollment, the largest three federal employee plans, and the largest commercial HMO in the state (Group Health Cooperative). The insurance companies will need to determine if their plans comply with the new criteria if they choose to participate in the Medicaid insurance offering, however, since so many of the state’s children are enrolled on the Children’s Health Insurance Plan (CHIP) it is expected that most carriers will. According to the Casey Foundation, 23% of the children in the United States live in poverty and in Washington State this metric was 18% in 2011.[2]In 2009, 57% of Washington’s Medicaid enrollees were children and this is true for other states as well.[3] The state with the most children living in poverty at that time was Mississippi at 32%.

Areas Not Affected by the Accountable Care Rules (ACO)

The ACA rules still allow Medicaid cost sharing in co-payments, deductibles, and contributions for services, which vary depending on the enrollee category. Medicaid does have the demonstration waiver provision under Section 1115, which allows states to petition for plan design changes which may have higher cost sharing provisions. Families with incomes equal to or less than the federal poverty level are allowed to have co-payments or cost sharing up to 5% of their income without any premium payments.  Allowable co-payments for 2012 are $3.80 for most services and $7.60 for none-life threatening-emergency room visits, as well as $3.80 for prescription drugs. There are also enrollees who are exempt from these co-payment requirements and they are as follows:

1. Pregnant women
2. Terminally ill people in hospice care
3. Medicaid enrollees who are already spending most of their income on health care costs during a hospitalization
4. Family Planning Services and supplies
5. Services provided by Indian Health Care entities for American Indians
6. Emergency services
7. All services are limited to one co-payment per service

Section 1115 Waiver Programs under Medicaid

Currently, forty states require some co-payment from parents enrolled on Medicaid and twenty-six states require co-payments for adults enrolled on their Section 1115 waiver programs. According to the Kaiser Commission Survey on Medicaid for the 2011 year, both Illinois and Wisconsin charge co-payments to Medicaid enrollees with incomes in excess of 150% of the federal level.

Bottom line, even for states not adopting the Affordable Care Act Medicaid expansion standards, there will still be an increase in their Medicaid enrollment for the following four reasons:

1. National insurance mandate requires insurance, so those who are of low income will become enrolled on Medicaid
2. Federal Subsidies through the insurance exchanges
3. Ease of enrollment process which integrates Medicaid and the insurance exchange offerings
4. In plain English, there will continue to be growth in Medicaid enrollment as long as there are so many people who are poor in this country

 And this is enough complexity and regulation analysis for a single setting so the healthpolicymaven is signing off.

This article was written by Roberta E. Winter, MHA, MPA and may be freely shared, with proper acknowledgement.

Additional sources for this article include the Center for Medicare and Medicaid- Medicaid Overview dated September 11, 2012 and the Kaiser Family Foundation Commission on Medicaid and the Uninsured report in November 2012.

---

[1] http://www.hca.wa.gov/me/documents/Bnchmrk_Benefit_Cost_Sharing_December_2012.pdf

[2] http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?ind=43

[3] http://www.statehealthfacts.org/profileind.jsp?cat=4&sub=52&rgn=49

Akins Assault on Women's Health & Dignity

Assault on Women’s Health Revisited with Senator Akin, leaving the Republican Party Belly-aching

Though the memory of the 2011 Republican attempts to redefine the rape of an unconscious woman as a noncriminal activity and thus not rape, are still etched in my memory, the party continues to horrify the nation with its Neanderthal postulations. The latest assertion came from Senator Akin from Missouri, who stated that women are unlikely to get pregnant in a true rape situation, because the woman’s Zen warrior vagina is able to battle the offending sperm from penetrating her nubile eggs.  OK, Akin didn’t say that part, but I thought I would add some humor to the situation.  Once again we seem to have a Republican senatorial candidate who still wants to redefine rape, so this ugly issue has not been vanquished.   In the interest of refining the conversation by adding some facts, this article will address actual data on rape, biology, and national data on abortion services for women.

Once and For All Here Are the Definitions and Data on Rape

The New York Times reported that nearly 1 out of 5 women admitted to having been sexually assaulted in the United States. The National Intimate Partner and Sexual Violence Survey, which was funded by the Department of Defense reviewed the records of 16,507 adults and of those, 33% of the women indicated they had been raped, beaten, or stalked, or horrifically, in combination. Rape was defined as a completed forced penetration, forced penetration facilitated by drugs or alcohol, or attempted forced penetration. If you apply this relationship to the U.S. female population about  1.3 million American women are rape victims annually. In the same survey 1 out of 71 men also reported they had been raped. [1]

Biology

The ability of a sperm to penetrate an egg or ovum has little to do with the female vagina’s functioning, but rather with the sperms facileness and speed within the window of opportunity in terms of the female ovulation cycle. The vagina is the entry point for the sperm. Where the individual woman’s work really comes into play is in the ability to carry the fertilized egg through  the development cycle of the pregnancy term. The woman’s “welcoming vagina” does not clinically decide pregnancy, as-in- yea for the good guy and nea for the rapist.

Implications for Women’s Health Care

The assault on women’s health care has been ongoing for years, but the attempts to offer low income women the same health care options that wealthier women have for family planning has increased the temperature of this pot boiler. In my previous articles on statewide positions for reproductive autonomy I have revealed which states restrict oral birth control, even for private sector employees, those that restrict birth control options for any state worker, and of course, those seeking the personhood amendment for an unborn fetus. If these states are so concerned for the unborn child, let’s take a closer look at the welfare of children in Missouri, which spawned the odious Senator Akin.

Missouri  currently has a ban on abortion, which is not enforceable because of federal protection under Roe-V-Wade. Though Missouri has not criminalized abortion (yet), it is one of the more restrictive states for this medical procedure. For example, in the State of Missouri, all private insurance plans are restricted from providing abortion coverage in their health plans. This flies in the face of the national statistic which indicates that 46% of private employer plans offered abortion services in their group medical plans according to a 2003 Kaiser Foundation Survey.  So Missouri already makes it tough for women who are forcibly impregnated.  Missouri also denies access to abortion for Medicaid women.

According to the Kaiser Foundation 2010 National Insurance Survey, 82% of Missourian women had some type of insurance, with nearly 19% on Missouri Medicaid or other state subsidized plan for women living in poverty. Compared to the nation, Missouri is in the middle in terms of how much income a woman is allowed to have in order to qualify for its Medicaid program, at 185% of the federal poverty level.

Akin has created a lot of belly-aching though his views are shared by many in the Republican Party which has recently come out with its formal platform stating it is against abortion even in the event of rape or incest.  Though I pride myself on my objectivity and data-driven approach to policy making and of course my voting process, my ability to consider any Republican candidate as suitable material for elected office is waning when the party spends its time coming up with this type of proclamation during one of the worst economic depressions the United States has seen. To all women in this country, I remind you that we are at least 51% of the country’s population and I encourage you all to vote with your autonomous vaginas in-tact.

For more information on how your state ranks in terms of reproductive autonomy, contact the healthpolicymaven, who conducted a fifty-state survey in 2010 and recently updated it in 2012.

And this is the healthpolicymaven signing off still unpenetrated by the Republican attempts to control my privacy.

This article was written by Roberta E. Winter, MHA, MPA, and may be reprinted with her permission. I do encourage you all to share it virally for this issue deserves attention.

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[1]Naomi Wolf,  Vagina, A New Biography, Published by Harper Collins, September 2012,  Chapter, The Traumatized Vagina, p. 97