In an attempt to reach out to pre-diabetics and improve children's physical activity, BlueChoice HealthPlan of South Carolina is adding two disease management programs in January.
Under its Great Expectations umbrella of services, the Columbia, SC-based independent licensee of the Blue Cross and Blue Shield Association will enroll all members with pre-diabetes conditions into a new program automatically. Those members will receive educational materials about diet, exercise, and risk-factor modification, have free access to nationally recognized diabetes education centers, and may receive free glucose monitors.
The insurer will also provide telephonic outreach to high-risk members and other Web resources. BlueChoice hopes these items will help pre-diabetics manage their pre-diabetes and prevent or delay Type 2 diabetes.
The second Great Expectations program is called "WalkingWorks for South Carolina Schools," which will promote physician activity to reduce childhood obesity, a major risk factor for diabetes. In this program, BlueChoice will collaborate with schools to create a walking program within the school setting. The insurer will provide free initial training and telephonic support for teachers and administrators and will give children educational materials about healthy food choices and offer access to free interactive tools.
Rolanda Aiken, BlueChoice HealthPlan's vice president of health services, said these programs are important because 10% of South Carolinians have diabetes and the state's direct and indirect healthcare costs for diabetes totaled about $2.6 billion in 2007.
"With nearly 55% of South Carolina children inactive after school, our state leads the nation in the percentage who do not participate in extracurricular sports or lessons," said Aiken. "South Carolina ranks sixth nationally in the highest proportion of overweight children, seventh in the highest proportion of children who are obese, and 10th in the highest proportion of children who fail to meet physical activity recommendations."
BlueChoice's other Great Expectations programs focus on asthma, chronic obstructive pulmonary disease, maternity, back care, depression, heart disease, heart failure, men's health, women's health, migraine, weight loss, smoking cessation, and alcohol management. More than 185,000 people in South Carolina are enrolled in Great Expectations programs.
Might the city of Duncan, a community of 22,000 people 80 miles southeast of Oklahoma City, hold the secret to squelching healthcare costs without sacrificing quality?
Offhand, I wouldn't have thought so. But what they've done bears consideration.
Five years ago, the self-insured city's officials realized their health costs were spiraling "out of sight, at about a 20% to 25% increase a year," recalls city manager Clyde Shaw. That was about $2.38 million a year, a lot for just 200 employees and 400 dependents and retirees.
Shaw and the city developed a partnership with MedEncentive, a pay-for-performance healthcare administrator, which claims a unique twist.
Instead of just rewarding physicians for following guidelines in a variation of the pay-for-performance model, MedEncentive incentivizes patients as well. They receive as much as $30 or a refund of their copayments if they fill out an online questionnaire, read material about their conditions that their doctors assign them, and then pass a multi-choice test about their diagnosis.
"It's about doctor-patient mutual accountability," says Jeff Greene, MedEncentive's CEO.
MedEncentive tosses around words like "triangulation," which means connecting the health payer, which in this case would be the city, with the patient and the doctor. Patients read about their conditions in a part of the process called "information therapy," which may also be called "patient literacy."
And doctors sign statements that they will adhere to evidence-based practices, set forth through accepted models established by entities, such as the Intermountain Healthcare System or the Mayo Clinic. And they can deviate from that depending on the patient's needs, and still receive payment rewards. The only caveat is that they are asked to fill out an online form to explain why the patient's course of care needed variation.
Patients and doctors can evaluate each other through the process in terms of whether the doctors are following guidelines, and whether the patient is being compliant.
I wondered if physicians would bridle at a system that might require anything even remotely resembling "cookbook medicine." But William Stewart, MD, a family practitioner in Duncan, says doctors met with MedEncentive officials "many times early on and developed a trust relationship."
"The plan rewards practices which do good medicine, with better outcomes for patients," Stewart says. And, he says, practicing by a so-called cookbook "is typically good medicine. The greater the variance in practice, the greater that practice should be looked over cautiously."
Physicians receive a fee of $10 or $15 for responding to patients' e-mails and patients get most or all of their copay refunded if they read materials and answer the questions.
"The patient education part of the program is probably the most important as chronic illnesses [diabetes, hypertension, and heart disease] eat most of medical dollars," Stewart says.
After five years of the Duncan experiment, the city has some exciting news, Shaw says. Instead of continuing its gradual increase in healthcare costs, employees, retirees, and dependents are costing the city roughly the same amount as they were five years ago, $2.3 million, Shaw says.
Now the nearby hospital, Duncan Regional, is looking at partnering with MedEncentive as well for its 500 employees.
Six other companies, in Oklahoma, Kansas, and Washington, have installed the system as well, expanding the "MedEncentive solution" from Duncan's 600 enrollees to 7,000 nationally.
How did they do it? Hard to tell.
Shaw thinks it's because patients are managing their chronic conditions better, and thus aren't hospitalized as much. "Patients are continuing to go to the doctor, but now, they look at their healthcare and they are asking 'is the test I want to get really necessary?'"
MedEncentive's Green points to a report by the Rand Corp. which found that physicians practice evidence-based guidelines only 55% of the time. That variation must mean that many patients aren't getting care that is known to work most of the time.
"Doctors get stuck in their ways, medicine advances, and they don't keep up. They're in a hurry. Often they don't pay enough attention on what they need to do," Greene says. With the MedEncentive program, there's only been a 1.3% deviation from evidence-based guidelines, he says.
Stewart isn't sure why the program seems to be working, but he agrees that it is. "Major [health] events still occur," Stewart says. "But I think patients do take better care of themselves when they're better educated. It's made patients more aware of the importance of their insurance and medical costs."
And they are less likely to choose more expensive options when they're knowledgeable about what the guidelines recommend, he says.
In its recently-released five-year report of the Duncan experience, MedEncentive noted the system "offers great hope for improving healthcare quality, while at the same time empowering and motivating people to be healthier, all of which will lead to more affordable healthcare."
Hospitalizations and deaths from the H1N1 virus this year are much higher among Native Americans and Alaska Natives than other racial or ethnic groups, according to a report from the Centers for Disease Control and Prevention, in cooperation with a 12-state investigation project.
"During (the period between) April 15 and Nov. 13, American Indian and Alaska Natives in the 12 participating states had an H1N1 mortality rate four times higher," the CDC said in its Morbidity and Mortality Weekly Report (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5848a1.htm) last week.
Reasons for this disparity in death rates are unknown, but CDC suggested it could be because of a higher prevalence of chronic health conditions in those populations, which make them predisposed to influenza complications, as well as poverty and delayed access to care.
CDC suggested increased awareness of these patient populations and their healthcare providers to educate about the "potential severity of influenza and current recommendations regarding the timely use of antiviral medications."
The 12 states highlighted are Alabama, Alaska, Arizona, Michigan, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Utah, Washington, and Wyoming, which are regions of the country where 50% of the U.S. Native American and Alaska Native populations reside.
Specifically, of the 426 H1N1 deaths in those states during that period, 42, or 9.9%, occurred among those populations, although they make up approximately 3% of the population in those states. The incidence was 3.7 per 100,000, compared with .9 per 100,000 for all other racial/ethnic populations combined.
Of those 42 deaths, 81% had high-risk health conditions, compared to 77.6% of persons in all other racial/ethnic populations combined.
Taking a break from the debate on the Senate floor on Tuesday afternoon, the Democratic leaders visited the White House to discuss the current healthcare reform bill efforts. The meeting with the senators was not a "roll call vote," President Obama emphasized in a briefing afterward, but "a broad-based discussion of how we move forward."
"We are on the precipice of an achievement that has eluded Congresses and presidents for decades," Obama said.
No mentions were made of Medicare buy-ins or government alternatives to private insurance, but he did focus on what would happen "if we don't get this done"--citing rising premiums, more employers dropping coverage, and Medicare "blowing a hole" in the budget.
Meanwhile, on the Senate floor later on Tuesday, four amendments were brought up for a vote:
Drug reimportation. After waiting for almost a week for a vote, the amendment introduced by Sen. Byron Dorgan (D-ND) calling for the legalized importation of prescription medicine from Canada and other countries failed to win approval in a 51-48 vote (with 60 votes required for approval). Dorgan, who said the motion would save $100 million over the next 10 years, received support from both sides of the aisle. He has been trying to pass similar legislation for more than 10 years. In earlier floor debate on Tuesday, Dorgan said arguments about the amendment lacking safety controls for reimportation were "unbelievably bogus."
Approval of the amendment could have jeopardized the overall support for the bill from the pharmaceutical industry, which has pledged $80 billion over the next decade toward reform efforts. Food and Drug Administration Commissioner Margaret Hamburg wrote senators last week saying that she thought the proposal could make it easier for counterfeit drugs to enter the county.
Drug reimportation (again). A substitute amendment proposed by Sen. Frank Lautenberg (D NJ) was also turned down 56-43. Lautenberg's bill was similar to Dorgan's, but it added provisions that the secretary of Health and Human Services would first certify that such imports were safe and would decrease costs.
"As much as we want to cut costs for consumers, we cannot afford to cut corners and risk exposing Americans to drugs that are ineffective or unsafe." Lautenberg said.
Remit to Finance Committee. An amendment by Sen. Mike Crapo (R-ID) to send the Senate reform bill back to the Senate Finance Committee failed 45-54. In his floor arguments, Crapo said the Senate bill contained hundreds of billions of dollars in new taxes and fees, and that it failed to reduce costs. Sen. Max Baucus (D-MT) countered that Crapo's motion was "a plan to keep Americans from getting their tax cuts." Five Democrats broke ranks and voted for the bill.
Middle class protection. The Baucus amendment calling for protection of middle-class families and small businesses from possible tax increases passed 97-1. Sen. Feingold (D-WI) cast the dissenting vote.
The H1N1 flu outbreak has exposed serious gaps in the nation's ability to respond to public health emergencies and the economic crisis is straining an already fragile public health system, according to a report released Tuesday by the Trust for America's Health (TFAH) and the Robert Wood Johnson Foundation.
The report, "Ready or Not? Protecting the Public's Health from Diseases, Disasters, and Bioterrorism," found that 20 states scored six or less out of 10 key indicators of public health emergency preparedness, and nearly two thirds of states scored seven or less. Eight states tied for the highest score of nine out of 10: Arkansas, Delaware, New York, North Carolina, North Dakota, Oklahoma, Texas, and Vermont. Montana had the lowest score at three out of 10.
The preparedness indicators were developed in consultation with leading public health experts based on data from publicly available sources or information provided by public officials.
The report showed "that a Band Aid approach to public health is inadequate," said Richard Hamburg, deputy director of TFAH. "As the second wave of H1N1 starts to dissipate, it doesn't mean we can let down our defenses. In fact, it's time to double down and provide a sustained investment in the underlying infrastructure, so we will be prepared for the next emergency and the one after that."
Overall, the report did find that the investments made in pandemic and public health preparedness over the past several years improved U.S. readiness for the H1N1 outbreak. However, it also found that decades of chronic underfunding meant that many core systems were not ready for the effects of the flu.
Some key infrastructure concerns were a lack of real time coordinated disease surveillance and laboratory testing, outdated vaccine production capabilities, limited hospital surge capacity, and a shrinking public health workforce. Also, the report found that half of the states experienced cuts to their public health funding and federal preparedness funds, which puts improvements made since Sept. 11 at risk.
Other key findings from the report include:
Twenty-seven states cut funding for public health from fiscal 2007 08 to 2008 09.
Thirteen states have purchased less than 50% of their share of federally subsidized antiviral drugs to stockpile for use during an influenza pandemic.
Fourteen states do not have the capacity in place to assure the timely pick up and delivery of laboratory samples on a 24/7 basis to the Laboratory Response Network.
Eleven states and Washington , DC, report not having enough laboratory staffing capacity to work five 12 hour days for six to eight weeks in response to an infectious disease outbreak, such as H1N1.
Cases of Methicillin-resistant Staphylococcus aureus infections (MRSA) increased four-fold in California hospitals between 1999 and 2007 to 52,000 cases, according to a new state report, which also suggests the annual number of MRSA deaths are 3.2 times more than estimates for seasonal influenza.
The largest increase in MRSA cases came in young to mid-range adult aged patients, who were admitted from home with infections of the skin.
The report said that by patient group, the biggest increase in resistant strains of the bacteria over that eight-year period was attributed to patients admitted to hospitals from prisons or jails, which saw a greater than 2000% increase. Also contributing to the rise was a 540% increase in newborns with resistant strains and a 120% increase in MRSA admissions from long-term care facilities.
Asked to comment on why these patient groups had higher rates of resistant strains, report author Mary Tran says, "These increasing rates could reflect increasing circulation of MRSA in the community, but we have no specific information to address this question."
While there was little change in patient characteristics for strains of the bacteria that are sensitive to antibiotic treatment, there was a marked shift in those with MRSA.
There was a 1,663% increase in the number of children with MRSA (from 188 to 3,315), a 556% increase in the number of adults between the ages of 18 to 64 (from 3,996 to 26,226), and a 143% increase in the number of seniors (from 9,320 to 22,678).
There was some good news in the report. The percentage of patients with MRSA who died within 30 days of arriving in the hospital decreased from 35% in 1999 to 24% in 2007 and the length of hospital stays for patients with MRSA declined from 21 days to 15 days in this period.
But the percent of patients with infection who resisted treatment with antibiotics increased from 30% to 60%. Nationally, MRSA cases increased from 45% to 60%.
The report noted that over the years, the resistant strain of bacteria has become more virulent and is more often found in healthy people, without pre-existing conditions, people who have not had any contact with a healthcare setting.
They manifest as pimples or boils, but can also cause more serious skin infections or infect surgical wounds, the bloodstream, the lungs or urinary tract.
Jan Emerson, spokeswoman for the California Hospital Association, said the report doesn't provide a lot of detail "other than the total of cases jumped between 1999 and 2007. Also it appears most of the cases came from community-acquired MRSA rather than hospital-acquired MRSA."
Jon Rosenberg, MD, of the California Department of Public Health's Infectious Disease Branch, says the OSHPD report is a reminder for hospital workers and other healthcare providers to be especially on their guard to use precautions when treating patients.
"We know that more and more we're seeing patients with this particularly nasty organism that we don't want spreading through the healthcare system," Rosenberg says. To this point, most of the strains of MRSA are being brought in from the community, not passed around within hospital settings, but that could change if providers aren't vigilant.
"You need to observe he highest levels of infection control," he says. "The thing that's different about this organism is the potential threat to the healthcare worker."
With nearly 500 arrests in four cities, and more than $1 billion in fraudulent claims identified in less than two years, federal officials have announced that the highly successful Medicare Fraud Strike Force will expand to Brooklyn, Tampa, and Baton Rouge.
Tuesday's announcement came on the same day that prosecutors in Miami, Detroit, and Brooklyn unsealed criminal indictments against 30 people—including doctors and nurses—who were charged with alleged schemes to bilk Medicare out of $61 million in false claims.
"Medicare fraud schemes are driven by greed—pure and simple," said Assistant U.S. Attorney General Lanny A. Breuer of the Department of Justice's Criminal Division. "The people who perpetrate these crimes rob Medicare of precious dollars by fraudulently billing for made-up or unnecessary services."
The joint DOJ-HHS Medicare Fraud Strike Force is a multi-agency team of federal, state, and local investigators, who rely on Medicare data analysis and community policing. The expansion of strike force operations into seven cities is a key component of the so-called Health Care Fraud Prevention & Enforcement Action Team, a joint initiative announced in May between DOJ and HHS.
"In Miami, Los Angeles, Detroit, and Houston, the Medicare Fraud Strike Force is making significant progress against these schemes," Breuer said. "Through the strike force's proven data analysis, we are now also identifying the worst offenders in Brooklyn, Tampa, and Baton Rouge, and we will continue to target Medicare fraudsters in these communities."
Charges against the defendants arrested this week include conspiracy to defraud Medicare, conspiracy to launder money, money laundering, criminal false claims, making false statements, and receiving kickbacks. The defendants allegedly participated in schemes to submit claims to Medicare for products and services that were medically unnecessary and often never provided.
In Detroit, defendants allegedly paid kickbacks to patients who received instructions from sham clinic owners and recruiters to feign symptoms to justify expensive testing, including nerve conduction studies. In Brooklyn, two defendants allegedly billed Medicare for durable medical equipment for beneficiaries who often did not need them. In Miami, 15 defendants, including doctors and nurses, allegedly made fraudulent claims to Medicare for home health services. In a separate Miami case, defendants allegedly submitted false claims from a storefront HIV/AIDS clinic for sham injection and infusion treatments.
Collectively, the defendants in the three cities allegedly submitted about $61 million in false claims to Medicare. Since the strike force's inception in March 2007, more than 460 people have been indicted from sham operations that collectively have falsely billed Medicare for more than $1 billion.
As health reform negotiations continued, President Obama urged Senate Democrats to overcome lingering disputes and push a healthcare overhaul through the chamber before Christmas. Sen. Joseph I. Lieberman (I-CT), once a critic of the legislation, appeared to be warming to the $848 billion package after Senate leaders said they were ready to jettison a plan to extend Medicare coverage to uninsured people as young as 55. He said that he expects to support the bill if that provision is dropped, the Washington Post reports.
Four days before the Senate jettisoned the idea of expanding Medicare to younger Americans, a dozen Senate Democrats sent a letter warning that the proposal would make it harder for elderly patients in parts of the country to find care. The letter, sent to Senate Majority Leader Harry M. Reid (D-NV), attests to the effectiveness of a campaign by influential hospital and physician lobbyists to defeat the idea, the Washington Post reports. It also underscores the difficulty of forging policy and political deals in the environment in which Congress is trying to reshape the nation's healthcare system, reports the Post.
President Obama declared himself "cautiously optimistic" after a meeting with the entire Senate Democratic caucus, where he urged senators to put aside their differences and "seize the moment" to pass a measure that would extend health coverage to 30 million uninsured Americans, the New York Times reports. President Obama is confronting an increasingly sharp divide on the Democratic left, with liberals in the Senate and the House split on critical issues, the Times reports.
