Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
The use of bundled payments for treatment of Medicare beneficiaries with end-stage renal disease (ESRD)—using a single payment to pay for dialysis and related services, including inject able drugs—will officially begin Jan. 1, 2011, by the Centers for Medicare and Medicaid Services (CMS). However, moving into this new payment territory will create questions of quality and access that CMS should answer, suggests the Government Accountability Office (GAO).
Under the current fee-for-service system of payment, certain demographic groups showed above average Medicare expenses for injectable ESRD drugs. For example, Medicare spent $782 per month in 2007 on injectable ESRD drugs for each African American beneficiary. This was nearly 13% higher than the average for all beneficiaries on dialysis and also was higher than for other racial groups.
In addition, monthly Medicare spending for beneficiaries with additional coverage through Medicaid was about 6% higher than the average across all beneficiaries on dialysis.
Although GAO did not identify those factors that created these differences, staff did obtain information from 73 nephrology clinicians and researchers on the factors that they thought would result in above average doses of injectable ESRD drugs. This included more than a dozen factors—such as chronic blood loss and low iron stores—as likely to result in above average doses of injectable ESRD drugs.
As required by law, CMS's proposed design for the new payment system for dialysis care includes two payment mechanisms to address differences among beneficiaries in their costs of dialysis care.
With the first payment mechanism—a case mix adjustment—CMS proposes to adjust payments based on characteristics such as age, sex, and certain clinical conditions, which are associated with beneficiaries' costs of dialysis care. The second proposed payment mechanism—an outlier policy—calls for making additional payments to providers when they treat patients whose costs of care are substantially higher than would be expected.
Missing from these preliminary plans, though, is to what extent CMS will monitor the effects on the quality of and access to dialysis care for different groups of beneficiaries. In particular, these areas should focus on above average costs of dialysis care under the new bundled payment system, GAO said.
This monitoring should begin as soon as possible once the new bundled payment system is implemented and should be used to create potential refinements to the payment system, GAO added.
Medicare Advantage plans—faced with funding cuts starting in 2011 under the new healthcare reform law—may be taking a greater interest in providing greater quality care. Starting in 2012, their payments will be tied to the star rating scores that are now posted on the Centers for Medicare and Medicaid Services (CMS) Web site and Plan Finder, a Web tool designed to help beneficiaries select Medicare Advantage plans.
Plans receiving four or more stars will be eligible for quality bonuses of up to 5% of local fee for service costs when phased in. In addition, the higher rated plans will also be able to keep a larger percentage of rebate dollars plans use to reduce beneficiaries' cost sharing, according to a report from Avalere Health, healthcare advisory company in Washington, DC.
In the long run, the incentives could blunt some of the estimated $200 billion in cuts to Medicare Advantage plan payments for the highest quality plans. This may also prompt shifts in enrollment as plan benefit designs become increasingly reliant on their performance, Avalere reports. Currently, about 11 million beneficiaries are enrolled in Medicare Advantage—about a quarter of the Medicare population.
At the current time, nearly half (47%) of Medicare Advantage beneficiaries are enrolled in plans that received only medium quality ratings or less (three or fewer stars). Almost 39% were in plans rated "3.5" and up, and only 0.3% of enrollees were in a 5-star, or top rated, plan. (Another 14.1% are unaccounted for, due to a plan being too new to measure or insufficient data.)
Avalere made the comparisons by using CMS 2010 Part C Report Card, released in November 2009, and enrollment data released in April 2010 to see if the beneficiaries' plan selections correspond with five star quality ratings assigned by the government.
Many plans are likely to be focused on improving their scores as payment becomes increasingly tied to quality, said Bonnie Washington, a vice president at Avalere Health. "In the short term, that may mean more attention on dealing with complaints or their customer service. Long term, we'll likely see more focus in areas such as outcomes, improving beneficiary experience, and disease management, which may ultimately benefit consumers."
An independent panel convened this week by the National Institutes of Health (NIH) concluded that the value of preventive strategies—such as mental stimulation, exercise, or dietary supplements—for delaying the onset or reduction in the severity of decline of Alzheimer's disease has not been demonstrated in rigorous studies.
"Alzheimer's disease is a feared and heart breaking disease," said Martha L. Daviglus, MD, conference panel chair and professor of preventive medicine and medicine at Northwestern University, Chicago. "We wish we could tell people that taking a pill or doing a puzzle every day would prevent this terrible disease, but current evidence doesn't support this."
The panel said that its assessment this week of available evidence revealed that progress to understand how the onset of these conditions might be delayed—or prevented—is limited by inconsistent definitions of what actually constitutes Alzheimer's disease and cognitive decline.
Other factors were related to incomplete understanding of the natural history of the disease or limited understanding of the aging process in general. The panel recommended that the research community and clinicians collaborate to develop, test, and adopt objective measures of baseline cognitive function and changes over time.
Although various risk factors were examined, age was found to be the strongest known risk factor for Alzheimer's disease. Also, a genetic variant of a cholesterol ferrying protein—apolipoprotein E—had strong evidence in association with the risk for developing Alzheimer's disease.
In its review, the panel could determined no evidence that even any modifiable factors—such as use of dietary supplements, use of prescription or non prescription drugs, diet, exercise, or social engagement—was associated with a reduced risk of Alzheimer's disease.
However, they noted that although little evidence exists that these interventions lessen cognitive decline, some are not necessarily harmful and may confer other benefits.
"These associations are examples of the classic chicken or the egg quandary. Are people able to stay mentally sharp over time because they are physically active and socially engaged or are they simply more likely to stay physically active and socially engaged because they are mentally sharp?" Daviglus said.
The panel also found that certain chronic diseases—such as diabetes and depression—and risk factors such as smoking may be associated with increased risk of both Alzheimer's disease and cognitive decline. However, those studies have not yet showed that these medical or lifestyle factors actually cause or prevent Alzheimer's disease or cognitive decline.
To obtain stronger information, the panel called for more research—especially into areas that characterize the natural history and progression of these diseases in the community. They also recommended the establishment of registries for Alzheimer's disease and cognitive decline, modeled on existing registries for cancer.
A federal appeals court on Thursday upheld the legality of Bayer AG to pay a potential generic competitor, Barr Pharmaceuticals, to delay introduction of Cipro, a popular antibiotic. But, in an unusual move, the court said that the issue—better known as "pay to delay"—needs additional court review because of the "exceptional importance" of antitrust implications in the case.
In the case, the U.S. Second Circuit Court of Appeals said that its hands were tied on the issue by a previous ruling on the drug Tamoxifen. However, the court "invited" the plaintiffs in the case (including retail pharmacies CVS and Rite Aid) to petition for a rehearing by the full appeals court.
It was news met with enthusiasm by Federal Trade Commission (FTC), which said in a report earlier this year that "pay for delay" of generic medications had cost American consumers $3.5 billion annually in higher drug prices. "This is further evidence that courts are rethinking their approach to pay for delay settlements," said FTC Chairman Jon Leibowitz in a statement Thursday.
"Hopefully, the courts will put an end to these deals. In the meantime, the FTC will continue to explain, in court and in the halls of Congress, why these sweetheart deals for drug companies are such a bad deal for American consumers and taxpayers," Leibowitz added.
Restrictions on "pay to delay" were included in the House healthcare reform bill and in President Obama's healthcare reform proposal. However, it was not included in the final Senate bill—and subsequent healthcare reform law—passed last month.
During the Bush Administration, the Department of Justice had supported the pay to delay idea—saying these settlements were allowed "within the scope of the patents." However, in a reversal, DOJ said last year in a court filing that similar drug patent settlements should be presumed unlawful.
In Thursday's ruling, the court cited the DOJ brief as a reason for revisiting the antitrust issue. The court also cited as a reason to revisit the issue remarks from Sen. Orrin Hatch (R UT)—co-author of the congressional law addressing drug patents and generics—who called "these types of reverse payments . . . appalling."
The application of electronic medical records (EMRs) for inpatient and outpatient use holds a lot of promise. With taps on a keyboard, data on a patient's allergies, prescription use, previous hospitalizations, or clinical tests are instantly available. But could surrounding oneself with this data build a barrier toward effective real-time, face-to-face communications between patients and providers and between providers?
Researchers with the Center for Studying Health System Change in Washington earlier this month took a closer look at whether EMR use could impact interpersonal communications. Based on interviews with 52 clinicians at 26 physician practices, they noted that reliance on EMRs could sometimes block valuable cues—obtained, for instance, from patient conversations or body language—that may prove valuable in providing quality patient care.
In general, quick access to EMR data can let physicians focus on the patient rather than gathering information from a variety of paper sources during visits. As one physician explained to the researchers, "we do not have to call down the hall for a lab or test result, we spend more quality time [with the patient] in a more context-rich way."
But ironically, this convenience can create pitfalls. The researchers noted, for instance, that EMRs have enabled some providers to lessen the number of times they engage with patients because—relative to paper charts—more information is available before actually ever seeing the patient face-to-face. As one internist who was interviewed by the researchers observed: "My concern now is that we’re listening less because we have more information when we walk in the room—and it’s not all trustworthy."
Another internist, who worked in both outpatient and inpatient settings, also agreed that he was worried that EMRs could diminish real time communication with patients: "A lot of us feel like we’re already seeing it," he said. "One of the hospitalists said [one day]: 'This is great. I used the EMR before I came here. I was able to sit down with my bagel and coffee and do my rounds before I even got in.'"
Some of the physicians interviewed noted that the format of many EMRs—with checkboxes—created a temptation to focus on filling out those boxes, rather than spend more time with open-ended questions with the patient. However, by focusing on the checkboxes in taking a patient history, the risk arises that "subtle or nuanced symptoms might go unidentified," the researchers said.
Also, reliance on EMRs could result in poorer communications with other providers in inpatient or clinical environments. While the use of other communication tools with EMRs—such as e mail and instant messaging—can sometimes help clinicians, they can also hinder care when a time lag occurs between responses.
Some of those interviewed thought that performing tasks such as scheduling or follow-up visits were enhanced by staff using EMRs with e mail or instant messaging. But on the other hand, some said that the use of e-mails with EMRs decreased the likelihood that real time communication would occur when needed most—such as during patient emergencies.
One physician commented to the researchers that individuals will use EMRs and electronic communications—instead of knocking on a practice door or walking across the hall to talk to a partner or colleague. "You might not see your partner all day, whereas in the old days, we would ask what does [that partner or colleague] think?"
But as EMR use grows, providers could take some advice from experienced EMR users in avoiding some of these pitfalls. For instance, several physicians interviewed said that showing patients portions of their records "could facilitate more accurate documentation and joint decision making." This could also help avoid a sense of alienation for patients while the physician or provider looks at the computer screen.
One physician noted that reviewing a problem list and a medication list together "provides a nice triangular interaction between the physician, the computer and the patient.
For communications between providers, many of those interviewed believe nothing could replace the "interactive aspects" of face-to face or phone conversations for complicated patient situations.
No doubt about it, EMRs are likely to provide new and improved dimensions to quality care. But in this era where data can be transferred as fast as the speed of light, maybe it might be worth considering slowing down with a little old-fashioned "face time."
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Two separate studies reveal that consumers' confidence in their ability to access and pay for healthcare is dropping. In one study from Thomson Reuters, consumer confidence appeared to slide from the beginning of the year, while uninsured medical expenses appeared to be a pressing financial concern, according to a survey conducted for the American Institute of Certified Public Accountants (AICPA).
With Thomson Reuters' Consumer Healthcare Sentiment Index, confidence dropped three points from a baseline index of 100 in December 2009 to 97 in March of this year. The index has two parts: a retrospective component that gauges respondents' experiences during the past three months, and a prospective component that gauges their expectations for the coming three months.
In February, when the index dipped to 98, a "statistically significant number" of people reported that they had delayed filling or failed to fill a prescription in the past three months. These individuals said they expected to delay or cancel a diagnostic test in the next three months.
In March, an increasing number of people said they lost or reduced their health insurance coverage in the past three months. At the same time, more people said they expected to delay or cancel an elective surgery, diagnostic test, physician visits, or therapy in the next three months.
"Strikingly, Americans expect the situation to worsen significantly in the next three months," said Gary Pickens, chief research officer at Thomson Reuters.
In the AICPA survey, conducted by Harris Interactive, uninsured medical expenses (at 11%) closely fell behind retirement (12%) among a list of top 15 financial concerns among Americans. The concern about uninsured medical expenses rose from 6% in 2008 and 8% in 2009.
The vast majority of Americans (86%) reported having some form of health insurance, AICPA said. However, 58% of those with coverage have seen their premiums go up in the past year; about half of the insured said their premiums have increased up to 10%, while a quarter said their premiums went up between 11% to 20%. Seventeen percent said their premiums have increased more than 21%.
For the uninsured, the most common reason stated of why someone didn't have health insurance was that it was unaffordable (47%). Much smaller percentages indicate their employer doesn't provide health insurance (17%) or that they are currently unemployed (16%).
Health insurers, feeling pressure from Congress and the Department of Health and Human Services (HHS), said late Wednesday that they will accelerate by almost five months implementation of the provision of the healthcare reform law that stops the practice of rescission.
Karen Ignagni, CEO and president of America's Health Insurance Plans (AHIP), announced in letters to HHS and Congress that its member plans are "committed to implementing the new standard in May 2010 to ensure that individuals and families will have greater peace of mind when purchasing coverage on their own." The initial rescission provision was to go into effect Sept. 23.
"While data from the National Association of Insurance Commissioners show that rescissions are exceptionally rare, we recognize the significant hardship that rescissions of coverage have on individuals and families," Ignagni said.
"A number of health insurance plans already provide this valuable service to their individual market policyholders," she added. "Other plans are in the process of reaching out to state officials and third-party review organizations to explore ways to make independent review available to consumers."
The announcement came after insurance giants WellPoint and UnitedHealthcare announced on Tuesday and Wednesday, respectively, that they would end any use of rescissions effective May 1—except when cases of cases of "fraud or intentional misrepresentation of material fact" were evident.
In a letter sent on Tuesday by the heads of the House Ways and Means, Energy and Commerce, and Education and Labor committees, seven major insurers—WellPoint, Kaiser Permanente, Assurant Health, UnitedHealth Group, Humana, Blue Cross Blue Shield Association, and Aetna—were asked to immediately end their efforts to rescind health insurance coverage.
The rescission issue came up on the congressional and HHS radar screens late last week following a media report that several women with breast cancer had their coverage cancelled by WellPoint. The report received a strong denial in a letter from WellPoint CEO and President Angela Braly to HHS Secretary Kathleen Sebelius, but the issue of rescission appeared to take on a life of its own as public interest increased.
After UnitedHealthcare made its announcement on Wednesday, Sebelius said in a statement that "the days when insurers can drop coverage when patients get sick are coming to an end—but insurers don’t need to wait to do the right thing.”
Sebelius said she had hoped that insurers would follow the precedent they set earlier in the month by implementing policies before the September healthcare reform law target date that would permit parents to keep adult children on their policies if needed through age 26.
House Speaker Nancy Pelosi (D-CA) had more of a political response to the AHIP announcement: "The decision by the insurance companies is another sign that Republicans calling for repeal are out of touch—as the companies that fought reform are now backing away from the shocking practices they once employed," she said.
"Moving forward, Congress will . . . continue to support independent, external, third party reviews to ensure that rescissions only occur in cases of fraud," she added.
Nancy Ann DeParle, director of the White House Office of Health Reform, said in a statement that "it’s heartening to see that the insurance companies who employed these terrible practices—and fought reform—are coming around doing the right thing by instituting the ban right away. We’ll be watching closely and holding them to their word."
As Health and Human Services Secretary Kathleen Sebelius was speaking Tuesday at the American Hospital Association's annual membership forum in Washington, DC, several insurers were being asked to clarify coverage policies—particularly in regard to rescissions—in advance of a federal deadline under the new healthcare reform act.
Sebelius told hospital leaders about media reports that emerged last week on "how the nation's largest insurance company, WellPoint, was specifically targeting women with breast cancer with the goal of canceling their coverage." While the accuracy of the reports has been challenged by WellPoint, an unwanted spotlight was placed on the controversial subject of rescission.
Sebelius said that she was asking insurers to implement a provision—prior to the September deadline stipulated in the new healthcare reform law—"to agree not to rescind the coverage of any premium paying customer except in cases of deliberate fraud."
Her request paralleled a request included in a letter sent Tuesday by the heads of three House committees—Ways and Means, Energy and Commerce, and Education and Labor—to seven insurance companies CEOs "to end any such abusive practices immediately." The companies are WellPoint, Kaiser Permanente, Assurant Health, UnitedHealth Group, Humana, Blue Cross Blue Shield Association, and Aetna.
Indianapolis based WellPoint became the first to announce on Tuesday that starting on May 1, it will implement a provision preventing its insurers from rescinding policies except in cases of fraud.
The action comes on the heels of another HHS request a week ago in which insurers agreed to implement policies—before a September healthcare reform deadline—that would permit parents to keep adult children on their policies through age 26.
"Already, almost all of the country's largest health insurers have agreed to extend parental coverage including WellPoint, Humana, United, Aetna, Kaiser, Coventry, and Blue Cross Blue Shield plans across the country," Sebelius told the AHA audience.
"And I'm pleased to announce that in the last few days, I received letters from Cigna and a group of prominent non profit insurers including Geisinger, Health Partners, and Group Health of Seattle saying that they would do the same," she added.
In addition to communicating with insurers about the new reform legislation, Sebelius said that over the last few weeks, HHS also has "been working closely with states to set up high risk insurance pools for a particularly vulnerable group of Americans: people who are uninsured and have preexisting conditions."
The goal is "to have this program up and running within the next few months," she said. "We've already had many conversations with states about what the best way to provide health security for these people is—whether it's through a state pool that they design or through a larger federal pool that operates across state lines."
Ultimately, the states will choose which option is best for their residents, and "we're going to give them all the support they need to make that choice," she said. "This combination of partnership and being proactive is a model for how we hope to carry out this law."
Sebelius also noted that the federal government has a role in the transformation of the healthcare system—such as helping to measure and reward quality of care, creating incentives to drive changes in payment and delivery systems, and providing targeted resources to help empower consumers.
"But ultimately, this isn't about us. It's about giving Americans and their healthcare providers more choices and more control," she said.
While healthcare reform legislation may be just a month old, attendees of the American Hospital Association's annual membership meeting in Washington, DC, on Monday were told that hospitals are facing major challenges that need to be addressed right now to ensure quality care delivery will continue.
In earlier times, the mantra of healthcare leaders was "do more with less," said AHA President and CEO Rich Umbdenstock. But now there's a new twist: "That's changing to 'do better with less.'" This means that hospitals need to move to the forefront now to improve patient care quality, safety and reliability; construct new integrative models of care; and stop medical mistakes.
"We have to seize this opportunity and ensure hospitals are natural leaders at this time of great challenge and transformation," Umbdenstock said. But to get there, hospitals will require help at the federal level. And, according to two House members, Congress is listening and ready to assist.
One of the major areas of concern has been how hospitals can become "meaningful users" of electronic health records and adopters of health information technology under current federal proposals.
"We share the concerns that have been articulated by [the AHA] that the [Centers for Medicare and Medicaid Services] rule tries to push things too far too fast," said Rep. Chris Van Hollen (D-MD), who is chair of the Democratic Congressional Campaign Committee and who played a visible role in guiding healthcare reform through the House as assistant to House Speaker Nancy Pelosi (D CA).
"I think you have made the case very well that the short timetable will result in a disallocation of resources," Van Hollen told the AHA audience. "There will be many hospitals that [we are] assuming can't make it. Since the idea is to encourage hospitals and other providers to move in this direction, it doesn't make sense to create a target that nobody can meet."
Rep. Michael Burgess, MD (R-TX), a member of the House Energy and Commerce Committee and chair of the Congressional Health Care Caucus, was one of the legislators instrumental in sending out a letter (signed by 249 House members) to the acting CMS chief last month encouraging the agency to modify its definition for hospitals to become meaningful users of EHRs.
He told the hospital leaders that the "all-or-nothing approach that hospitals" adopt 23 separate EHR objectives has only been accomplished so far by a few hospitals. "The rule, in fact, should be altered--recognizing a practical staged approach to EHR adoption and rewarding the efforts already underway in various hospitals."
Burgess noted that the letter urged CMS to changed transition time from 2015 to 2017 for Medicare payment penalties incurred by non-meaningful users of EHRs. He also said the letter encouraged CMS to drop "non-clinical objectives" such as electronic insurance verification and claims submissions that are not related to patient care.
Van Hollen said definitions in the healthcare reform legislation will have to be revisited such as what are "hospital readmissions" for which Medicare will cease to pay. "The key is to figure out a smart way to distinguish between necessary and unnecessary readmissions. This is an area where we're probably going to have to work with you to refine the statute as we move forward," he said.
While the House voted on a temporary fix this month (through May 31) to stop the physician payment sustainable growth rate cut, a long-term fix is needed, Van Hollen said. "This is no way to be conducting a health payment system," he said. If a permanent fix cannot be obtain (which was in the House bill passed last year), "at the very least we hope to enact a five-year fix, which would certainly be better than the month-to-month and year-to-year approach."
The doc fix extension package did have some good news for hospitals, Burgess added. It included changes proposed in some of the provisions in the CMS EHR letter, such as including definitions of hospital-based physicians. Previously under the rule, physicians practicing in outpatient centers and clinics were excluded from being eligible for the EHR incentive payments.
A National Institutes of Health working group has highlighted 11 key categories of diseases and other health consequences that are occurring, or are expected to occur soon, due to climate change.
In a new report, A Human Health Perspective on Climate Change, the group said that environmental consequences of climate change—such as sea level rise, changes in precipitation resulting in flooding and drought, heat waves, more intense hurricanes and storms, and degraded air quality—will affect human health both directly and indirectly and the way their healthcare is provided.
The study "articulates, in a concrete way, that human beings are vulnerable in many ways to the health effects of climate change," said Linda Birnbaum, PhD, director of NIH's National Institute of Environmental Health Sciences (NIEHS) and the National Toxicology Program, whose institute led the interagency effort. "It lays out both what we know and what we need to know about these effects in a way that will allow the health research community to bring its collective knowledge to bear on solving these problems."
The study highlights the state of the science on the human health consequences of climate change on:
Asthma, respiratory allergies. Climate change will affect air quality through several pathways including aeroallergens such as pollen and mold spores and increases in regional ambient concentrations of ozone, fine particles, and dust. Some of these pollutants can directly cause respiratory disease or exacerbate respiratory disease in susceptible individuals.
Mental health and stress related disorders. Many mental health disorders can also lead to other chronic diseases and even death. Stress related disorders derive from abnormal responses to acute or prolonged anxiety, and include diseases such as obsessive compulsive disorder and post traumatic stress disorder.
Cancer. One possible direct impact of climate change on cancer may be through increases in exposure to toxic chemicals that are known or suspected to cause cancer following heavy rainfall. In the case of heavy rainfall or flooding, there may be an increase in leaching of toxic chemicals and heavy metals from storage sites and increased contamination of water with runoff containing persistent chemicals that are already in the environment.
Neurological diseases and disorders. Onset of diseases such as Alzheimer’s and Parkinson Disease are occurring at earlier ages across the population, the study noted. Environmental factors are suspected of playing a large role in both the onset and severity of these conditions—although there is a gap in our understanding of this role.
Cardiovascular disease and stroke. Cardiovascular mortality associated with heat has been declining over time—presumably the result of increased air conditioning use. However, mortality associated with extreme cold has remained constant. Cardiovascular hospital admissions increase with heat.
Waterborne diseases. A recent shift has been seen in waterborne disease outbreaks from gastrointestinal toward respiratory infections such as that caused by Legionella, which lives in cooling ponds and is transmitted through air conditioning systems. In addition to diarrheal disease, waterborne pathogens are implicated in other illnesses with immunologic, neurologic, hematologic, metabolic, pulmonary, ocular, renal and nutritional complications.
Foodborne diseases and nutrition. Drought has been shown to encourage crop pests such as aphids, locusts, and whiteflies, as well as the spread of the mold Aspergillus flavus that produces aflatoxin, a substance that may contribute to the development of liver cancer in people who eat contaminated corn and nuts.
Weather related morbidity and mortality. A changing climate, coupled with changing demographics, is expected to magnify the already significant adverse effects of extreme weather on public health. For example, the intensity and frequency of precipitation events in the United States have increased over the past 100 years in many locations.
Heat related morbidity and mortality. Factors such as age and the burden of other serious illnesses such as heart disease and diabetes that might exacerbate heat related problems are critical. In the U.S., the number of individuals 65 years of age and older—who are more susceptible to heat effects—is expected to increase from 12.4% in 2000 to 20% in 2060.
Vectorborne and zoonotic diseases. This includes diseases, such as malaria, which can be transmitted from animals to humans. A "severe degradation" of rural and urban climate and sanitation conditions could bring malaria, epidemic typhus, plague, and yellow fever "to their former prominence."
Human developmental effects. The environment can be a "potent modifier" of normal development and behavior, according to the report. Environmental effects on development include subtle changes such as small reductions in IQ from exposure to lead, changes in onset of puberty from exposure to endocrine disrupting chemicals, and birth defects such as cleft palate due to dioxin like compounds.
