Today's News and Commentary

About the public’s health

Culpeper Literacy Council helps spread health literacy to seniors: Health illiteracy is major barrier to understanding and obtaining necessary care. This article is about a local program in Culpeper Virginia that is successfully addressing this problem. “The Culpeper Literacy Council partnered with the Culpeper Wellness Foundation to help teach seniors at the Culpeper Senior Center health literacy.” The program also “helps train medical professionals to identify behaviors or language barriers for someone lacking health literacy…”
Read the story

Judge upholds New York City's mandatory measles vaccination order: Brooklyn Judge Lawrence Knipel “ruled against a group of parents who challenged New York City’s recently imposed mandatory measles vaccination order, rejecting their arguments that the city’s public health authority exceeded its authority… The judge rejected the parents’ contention that the vaccination order was excessive or coercive, noting that it does not call for forcibly administering the vaccine to those who refuse it.” Failure to be vaccinated carries a fine.

Read the story

As the scope of corporate well-being programs continues to expand, large employers expected to spend an average of $3.6million in 2019: This research from the 10th annual Health and Well-Being Survey from Fidelity Investments and the National Business Group on Health provides the spending amounts and types of corporate wellness programs. Check Wednesday’s blog for the entry about the lack of their effectiveness.

Read the announcement

Senator McConnell, a Tobacco Ally, Supports Raising Age to Buy Cigarettes: While I usually do not comment on proposed legislation, this one is noteworthy. Senate Majority Leader McConnell has come out in favor of increasing the smoking and vaping age to 21.

Read the article (NY Times but appears to be open access)

Medicine’s racist past makes many African-Americans wary of giving blood — but sickle cell patients have urgent need: African-Americans have good reasons for not trusting the US healthcare system. Most prominent is the Tuskegee study that watched AA men deteriorate and die from treatable syphilis infections so researchers could watch the natural course of the disease (which had been know for centuries). This “human interest” story makes the point that distrust is also affecting AA’s willingness to donate blood at a time when many in their communities need transfusions to treat sickle cell disease.

Read the article

Nanoethics: It’s time for big thinking about nanomedicine: Newer technologies raise ethical issues about their use. The April issue of the AMA Journal of Ethics is devoted to such issues around nanotechnology’s applications in medicine. The link below will take you to some of the articles that appear to have open access.

Connect to the ethics articles

About pharma

Human Gain-of-Function MC4R Variants Show Signaling Bias and Protect against Obesity:
Researchers from the University of Cambridge studied 500,000 people and found 61 variants in the Melanocortin-4 Receptor gene. This gene regulates how satisfied someone feels after eating, called postprandial satiety. In fact, it can also regulate appetite. Some variants cause people to be less satisfied- so they eat more. Other variants are what the authors call “protective,” since less interest in eating leads to lower rates of obesity, Type 2 diabetes and cardiovascular disease. I am sure you see where this research is going. Perhaps we can replace bariatric surgery with genetic modification in the not too distant future.

Read the abstract
Read about the findings in the NY Times


Drug Companies Reaped Billions from New US Tax Law: This Oxfam study was published April 9 but just came to my attention. Like many other US corporations, Johnson & Johnson, Pfizer, Merck and Abbott Laboratories used much of their billions of dollars in tax savings for stock buybacks and dividend payments rather than R&D investments.

Read the report

FDA Sends Warning Letters on Dietary Supplements: The FDA is cracking down on manufacturers of dietary supplements whose products do not meet its guidelines. The agency has a website where such products are listed; the problem is getting people to know about and use this resource.

Read the article (Wall Street Journal but appears to be open access)

About health insurance

Health Insurance Coverage for People Under Age 65: Definitions and Estimates for 2015 to 2018: The Congressional Budget Office issued this study reporting, among other things, that between 2017 and 2018 1.1 million more people were uninsured.

Read the study

Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2020: CMS has issued its final rules for 2020 concerning benefits and payment parameters for ACA health plans. (It is scheduled for publication in the Federal Register on 04/25/2019.)
It is a very long document that included initial recommendations, comments, response to comments and final rules. Among the changes in the final rule:

  1. If a drug has an appropriate, generic equivalent, discount coupons can no longer be applied towards an enrollee's maximum out-of-pocket costs. This measure was directed against pharma companies using this tactic to raise prices for insurers.

  2. Reduces user fees for plans sold on the exchanges by 0.5%. CMS hopes these savings will be passed along to its customers. Presumably, part of these fees were used to promote the plans to the public. Since the Trump administration has cut back on this activity, it is only fair the plans do not have to pay for it.

  3. Refines the adjusters for payments by risk category. The categories used in this adjustment for each plan level (bronze, silver, etc.) include age, sex, diagnosis, enrollment duration and prescription use. The final rule also calls for enforcement of the accuracy of this information. (Diagnosis code accuracy has been particularly problematic.)

  4. CMS expresses support to reduce high silver level premiums (silver loading) that were the result of elimination of cost sharing reductions (CSRs). CMS is open to reinstitution of the CSRs but nothing definitive will be done until, at soonest, 2021.

Read the final rule

About healthcare IT

Trends in Healthcare Payments  Ninth Annual Report: 2018:  Healthcare payments company Instamed issued its 2018 report. The findings are not very encouraging. For example, 90% of providers still ”leverage paper and manual processes for collections” and 53% of payers are still sending checks to providers. In the face of these inefficiencies, “80% of patients reported that ‘convenience factors’ would be enough to make them switch providers.”

Read the report (Free signup to download pdf)

Hospitals’ Use of Electronic Health Records Data, 2015-2017:This report is from the Office of the National Coordinator…dated April 2019. The first problem is much government data is at least a year out of date (I have seen some agencies still using charts from 2016). The overall message here is that statistically significant improvements in many areas of hospital IT use occurred between 2015 and 2016, but improvements stagnated in 2017. A bright spot is that in 2017, 94 percent of hospitals used their EHR data to perform hospital processes that inform clinical practice (the same percentage as in 2016).

.Read the report

Today's News and Commentary

About the public’s health

71-year-old heart study gets $38M grant for another 6 years: The iconic Framingham Heart Study  was refunded for an additional 6 years. This cohort study has provided many valuable insights into heart disease.

Read the announcement

2019’s Best & Worst States for Children’s Health Care: For those interested in rankings, this one from WalletHub rates states on their care of children. The methodology is interesting; for example one of the three major score components is oral health- not often included in these tabulations. Another interesting finding is correlations (or lack thereof) between local features and overall rank. For example, New York ranks 7th overall but is 48th on the number of pediatricians and family physicians per capita.

Read the rankings

About healthcare technology

Restoration of brain circulation and cellular functions hours post-mortem: This research is the top tech story of the day and is in almost all media. Researchers took pigs heads from a slaughterhouse and documented that individual neuronal activity could be preserved for a time with an infused chemical solution and a waste filter.

Read the abstract


In utero gene editing for monogenic lung disease: This paper details the use of gene editing in a mouse fetus who did not produce a chemical (surfactant) that would help keep the lungs expanded after birth. Researchers hope this new technique, which delivered CRISPR gene-editing reagents into the amniotic fluid, can be used some day to correct in utero human problems.

Read the research

Lentiviral Gene Therapy Combined with Low-Dose Busulfan in Infants with SCID-X1: This article was another with widespread coverage in the media. Researchers attached a gene to a virus and then infused it into patients with Severe Combined Immunodeficiency (commonly known from the “bubble boy” who’s genetic mutation impaired his ability to mount an immune response). The treatment was a success.

Read the research


Fundamentally new MRI method developed to measure brain function in milliseconds: “Investigators from Brigham and Women’s Hospital, in collaboration with colleagues at King’s College London and INSERM-Paris, have discovered a fundamentally new way to measure brain function using a technology known as magnetic resonance elastography (MRE), an approach that creates maps of tissue stiffness using an MRI scanner.” Traditional functional MRI machines can take as long as 6 seconds to detect changes in brain activity. This new method can measure the activity in about 0.1 seconds. This device promises to be a real breakthrough for neuroscience research.

Read the story

Does Gender Leave an Epigenetic Imprint on the Brain?: Environmental stimuli can affect genomes by epigenetic modification, usually adding a methyl group. This article explains how these epigenetic changes can occur with gender-specific behavior in the young. “The argument we are making is that boys and girls, and men and women, have different exposures and experiences based on societal expectations or perceived expectations (i.e., gender), and that some of these exposures/experiences are known to cause epigenetic changes in the brain based on carefully controlled animal studies.” This article is a fascinating look into gender and genetics.

Read the article

Best Buy Continues To Bet On Digital Health With New TytoHome Deal: Move over Amazon. Best Buy is now the exclusive seller for the first home telemedicine device.

Read the article

About healthcare quality

CMS lays out post-acute care data requirements in proposed rule: CMS aims to improve the quality of post-acute care. One of the big problems is errors from patient transfers. To address this issue, CMS has added the Transfer of Health Information to the Provider–Post-Acute Care (PAC) Measure to assesses whether or not a current reconciled medication list is given to the subsequent provider when a patient is discharged or transferred from his or her current PAC setting. Another measure is called The Transfer of Health Information to the Patient–Post-Acute Care (PAC), which assesses “whether or not a current reconciled medication list was provided to the patient, family or caregiver when the patient was discharged from a PAC setting to a private home or apartment, a board and care home, assisted living, a group home, transitional living or home under care of an organized home health service organization or a hospice.”

Read the article

About pharma

Biologics Are Natural Monopolies (Part 1): Why Biosimilars Do Not Create Effective Competition: This article is a thought piece about cost and price regulation of biologicals. The authors advocate that instead of looking to biosimilars to reduce cost by increasing competition, there should be price controls after market exclusivity expires. This article is an interesting, thoughtful piece about an important and costly part of our healthcare system.

Read the article

Today's News and Commentary

About health Insurance

“Medicare for all” has had a lot of different meanings depending on the candidate who is asked about it. Senator Sanders appeared at a Fox News-sponsored town hall meeting on Monday and gave his version. You can “cut to the chase” at 25:45. Basically he says: no premiums, no out of pocket expenses and complete freedom to choose providers. He admits taxes will need to be raised to fund the program, but claims the overall costs will be lower than they are now. The Urban Institute evaluated Sander’s original proposal and found expenses over a 10 year period would go up by about $5 Trillion.

In a related article in today’s Wall Street Journal, Harvard Business School Professor Regina Herzlinger and Fraser Institute’s Centre for Health Policy Studies Associate Director Bacchus Barua write about the Canadian system and caution about “single payer” government-sponsored schemes.

At a time when our country is moving more toward government funded care and demonizing the private sector, most other countries are looking to their private sectors to alleviate access problems and often improve quality of care.

Uninsured Adults in States that Did Not Expand Who Would Become Eligible for Medicaid under Expansion: This research by the Kaiser Family Foundation found that if the 14 states which do not currently participate in the ACA’s Medicaid expansion would join the program, 4.4 million more people would be eligible. The study details results by state.

Read the research

Value-Based Care in America: State-by-State: A Change Healthcare study found that a total of 48 “states and territories” (including the District of Columbia and Puerto Rico) implemented government-sponsored, value-based reimbursement (VBR) programs in 2018. That compares with only 6 in 2013. Details vary state by state and the report has those individual differences.

Read the report

Humana Launches Oncology Model of Care Program to Improve the Patient Experience and Health Outcomes in Cancer Care: In its fourth specialty-based value payment model, Humana announced provider partners who will furnish oncology services. Details about the arrangements are sparse.

Read the announcement

Better quality, lower costs when providers and payers share risk: According to the Integrated Healthcare Association: “A capitation payment model results in better value and outcomes than a fee-for-service model.” For example, in California, “60,000 more women would have been screened for breast cancer and hundreds would have been treated for breast cancer earlier if all California providers shared risk with payers.” It’s a rediscovery of HMOs from 30 years ago!

Read the article

About healthcare IT

WHO releases first guideline on digital health interventions: The WHO is recommending a number of digital interventions to improve healthcare. Among the recommendations that have already been successfully implemented are sending reminders to pregnant women to attend antenatal care appointments and having children return for vaccinations. 

Read the announcement

Decision Support and Alerts of Apps for Self-management of Blood Glucose for Type 2 Diabetes: A number of apps are on the market to help diabetics control their blood sugars, many of which are not FDA approved. The question is how well they work. The answer is: not well. This research found that: “The majority of diabetes apps did not provide real-time decision support or situation-specific education on blood glucose self-management. Only 20.7% of apps with explicit alert messages for hypoglycemia and 15.3% for hyperglycemia also prompted an action. Of concern, in most apps, consecutive low or high blood glucose values did not trigger an escalation of alerts that could prevent severe hypoglycemia or hyperglycemia.” This case seems appropriate for FDA intervention.

Read the study

Text Messages May Improve Adherence in Diabetes: On the other hand…simple reminders can help, according to this study,

Read the report

About pharma

Feds oppose white-coat kickbacks suit out of 'animus' against whistleblowers: judge: This is a new one. The Department of Justice recommended withdrawal of a whistleblower suit because of lack of evidence. However, the judge in the case said the government lawyers displayed “animus” against the plaintiff and that was the reason fo their wanting the action to go away. They must proceed.

Read the story

About the public’s health

The fact that the opioid crisis needs a multi-pronged program to succeed is emphasized by two stories of failure in different parts of the healthcare system.
This morning, The Washington Post reported that 60 people ( including 31 doctors, seven pharmacists, eight nurse practitioners and seven other licensed medical professionals) were indicted for their involvement in 350,000 illegal prescriptions that accounted for 32 million pills. The alleged offenders were from Kentucky, Ohio, Tennessee, Alabama and West Virginia.
In the other story, CVS was fined $535K for filling forged Percocet prescriptions.

Effect of a Workplace Wellness Program on Employee Health and Economic OutcomesA Randomized Clinical Trial: Well-meaning employers often adopt programs they think will lower cost by improving employee health. This study found that: “Among employees of a large US warehouse retail company, a workplace wellness program resulted in significantly greater rates of some positive self-reported health behaviors among those exposed compared with employees who were not exposed, but there were no significant differences in clinical measures of health, health care spending and utilization, and employment outcomes after 18 months.” Note the discordance between self-reported health and actual clinical measures.

Read the research

Republicans reject Democratic attempts to tighten vaccine laws: This article documents Republican efforts to block states from mandating vaccinations (or at least severely limiting opt out opportunities). GOP lawmakers claim the laws infringe on personal freedoms. I wonder how they feel about the rights of those who want to protect themselves from preventable infectious diseases.

Read the story

Today's News and Commentary

About technology

3D Printing of Personalized Thick and Perfusable Cardiac Patches and Hearts: This article may be the top story of the month. Israeli scientists have created a small heart by using 3D printing. While only the size of a rabbit heart, it has all the structure of the human organ, including blood vessels.

Read the research article

In African Villages, These Phones Become Ultrasound Scanners: A hand-held ultrasound scanner called the Butterfly iQ can be used to diagnose conditions ranging from broken bones to pneumonia. While it is ideally suited to rural areas without access to imaging, one day it will be an in-office diagnostic capability in first world countries.

Read the story (NY Times but appears to be open access)

About the public’s health

Report: U.S. economic burden of chronic diseases tops $3.8 trillion—and expected to double:
”The U.S. economic burden of chronic diseases such as Alzheimer's, diabetes, heart disease, obesity and cancer has reached about $3.8 trillion in direct and indirect costs—or nearly one-fifth of GDP, according to a new report from Fitch Solutions, which is a unit of Fitch Group.”

Read the article (Open access)

Cost-Effectiveness of the US Food and Drug Administration Added Sugar Labeling Policy for Improving Diet and Health:This research claims that adding sugar contents to labels could prevent hundreds of thousand of cases of such conditions as heart disease, diabetes, etc. Resultant savings would be in the many millions of dollars. The problem is: “no interventional studies on added sugar labels were identified;” meaning these savings would require people to actually read the labels and act on the information. A leap of faith?

Read the just-published article

Americans Are Delaying Health Care Until Tax Refunds Arrive: We know many people who spend down their flexible health accounts at year-end to avoid losing the money. This finding is the exact opposite. People wait for their tax refunds to get healthcare.

Read the story

Disparities in Inpatient Intensity of End-of-Life Care for Complex Chronic Conditions: We are usually concerned about underutilization of services for poor and non-white populations as a measure of health disparities. This study showed the opposite- non-white and poor children received much more care at end of life than did the other groups. The conclusion was: “Sociodemographic disparities in the intensity of end-of-life care… raise concerns about whether all children are receiving high-quality and goal concordant end-of-life care.”

Read the abstract (Subscription required for the full article)

About pharma

Amgen sets $21,900 annual price for new Evenity bone drug: The previously reported bone-restoring medication now has a price.

Read the annnouncement

U.S. Supreme Court rejects Allergan bid to use tribe to shield drug patents: Allergen tried to shield its Restasis drug from competitors by transferring the patent to New York’s Saint Regis Mohawk Tribe.
The theory was that the tribe is a sovereign nation that was sheltered from FDA actions. The high court said, in effect, nice try but no.

Read the announcement 

US Nationwide Disclosure of Industry Payments and Public Trust in Physicians: Concerns about pharma companies influencing physicians through cash and even small give-aways (like pens and mugs) led to enactment of the Physician Payments Sunshine Act (PPSA) at the start of the ACA in 2010. Even legal and ethical gifts (like paying physicians to answer surveys) must be reported. This research found that: “Nationwide public disclosure of industry payments may be associated with decreased trust in physicians and in the medical profession. More judicious presentation of payments information may counteract unintended negative trust and spillover consequences of public disclosure.”

Read the research

About healthcare IT

Assessment of Inpatient Time Allocation Among First-Year Internal Medicine Residents Using Time-Motion Observations: Previous studies have shown that practicing physicians often spend more time on the computer than with patients (even in the exam room). This recent study revealed the same is happening to physicians in training, Seems like we work for computers rather than the opposite.

Read the research

About healthcare insurance

How affordability of health care varies by income among people with employer coverage: This study showed that poorer people spend a higher percentage of their income on healthcare costs- no surprise. However, it points out that employer-sponsored insurance is more expensive for them than insurance from the exchanges because with the former there are no premium subsidies..

Read the research

About healthcare quality and safety

Ensuring Safety and Quality in America’s Nursing Homes: Yesterday CMS Administrator Verma announced a program to enhance quality and safety in nursing homes, reviewing such issues as overmedication and abuse.

Read the announcement

Today's News and Commentary

About pharma

Medicare Spending on 22 Drugs Jumped 500% From 2013-2017: Recent postings have cited proposed Congressional action on increased drug costs for all payers. This article’s title should prompt the question- what took them so long to catch on?

Read the article

Prevalence and Nondisclosure of Complementary and Alternative Medicine [CAM} Use in Patients With Cancer and Cancer Survivors in the United States: Cancer patients often get desperate and use untested medicines. However, these CAMs can harmfully interact with standard care. This study quantified the problem: “In this comprehensive national study, 1023 of 3118 (33.3%) participants with a history of cancer reported CAM use in the past year, 288 (29.3%) of whom did not disclose use of CAM to their physician.”

Read the article (Subscription required, abstract may be available)

Medicare Aims to Expand Coverage of Cancer Care. But Is It Enough?: In the next few weeks, Medicare will announce its decision on coverage for CAR T therapy for cancer treatments. These therapies are individualized for each patient and are thus extremely expensive. The guidelines will be watched closely by the private sector as all payers are struggling with costs for individualized care.

Read the article (NY Times but appears to be open access)

Maryland, Massachusetts statehouses press drug-pricing bills as feds founder: Instead of waiting for federal action, some states are trying to control drug prices on their own. California was mentioned in a previous post. This article reviews what two other states, MD and MA, are doing.

Read the article

AMA teams up with biotech incubator to connect physicians with startups: Very often tech companies come up with solutions to medical problems without clinician input. This project provides a different approach: “The AMA and Sling Health, a student-run biotechnology incubator, launched the clinical problem database on the AMA's Physician Innovation Network, an online forum that connects physicians and health technology companies looking for clinician feedback.”

Read the announcement

About health insurance

Democratic proposals to overhaul health care: A 2020 primer: As the baseball saying goes- you can’t tell the players without a program. This article summarizes which Democrats favor which healthcare proposals.

Read the explanation

Sutter Health agrees to pay $30M to settle accusations of inflated MA 'risk scores': Medicare Advantage contracts have payments that are adjusted by severity of illness of the beneficiary. These adjustments are driven by diagnosis codes. Sutter agreed to settle charges that it incorrectly used codes that paid more.

Read the story

About healthcare IT

Clinical decision support for high-cost imaging: A randomized clinical trial: “There is widespread concern over the health risks and healthcare costs from potentially inappropriate high-cost imaging. As a result, the Centers for Medicare and Medicaid Services (CMS) will soon require high-cost imaging orders to be accompanied by Clinical Decision Support (CDS): software that provides appropriateness information at the time orders are placed via a best practice alert for targeted (i.e. likely inappropriate) imaging orders…We find that CDS reduced targeted imaging orders by a statistically significant 6%, however there was no statistically significant change in the total number of high-cost scans or of low-cost scans. The results suggest that the impending CMS mandate requiring healthcare systems to adopt CDS may modestly increase the appropriateness of high-cost imaging.” This study raises the question of whether there are other measures that would have more impact on the high cost of imaging.

Read the research

12 healthcare areas where AI will result in near-term breakthroughs: This article provides a nice summary of the areas in healthcare where artificial intelligence could be helpful in the near future. Despite technical feasibility, we will need to see how these technologies are regulated to assess their availability.

Read the article

About healthcare quality

Differential Safety Between Top-Ranked Cancer Hospitals and Their Affiliates for Complex Cancer Surgery: Branding is a form of a promise of consistency- hopefully high quality consistency. This research found that when high quality cancer treatment hospitals co-brand their care with affiliates it is not a guarantee of the same level of quality. This finding also raises transparency issues.

Read the research

Today's News and Commentary

About the public’s health

Dietary proteins and protein sources and risk of death: the Kuopio Ischaemic Heart Disease Risk Factor Study: The Finns have been researching the long term epidemiological effects of diet for many years. This latest study found: “Higher ratio of animal to plant protein in diet and higher meat intake were associated with increased mortality risk. Higher total protein intake appeared to be associated with mortality mainly among those with a predisposing disease. “

Read the abstract

Association Between Secondary Prevention Medication Use and Outcomes in Frail Older Adults After Acute Myocardial Infarction: This research highlights the need to individualize patient care taking into account quality of life issues. The researchers concluded: “Use of more guideline-recommended medications after myocardial infarction was associated with decreased mortality in older, predominantly frail adults, but no difference in rehospitalization. Results for functional decline from the main and stability analyses were discordant and did not rule out an increased risk associated with more medication use.”

Read the research

Safety and Effectiveness of Consumer Antiseptic Rubs; Topical Antimicrobial Drug Products for Over-the-Counter Human Use: Most people believe that antiseptic hand rubs are safe and possibly the most sanitary way to clean hands. About that first assumption: In 2016 the FDA declared “28 ineligible active ingredients” in those products. Today, the FDA issued a statement that the three remaining active ingredients that are eligible for review —benzalkonium chloride, ethyl alcohol, and isopropyl alcohol— need to be studied further and cannot be classified as Generally Regarded As Safe (GRAS). As for the best cleaning method? It is still soap and water.

Read the Federal Register statement

About health insurance

Industry Voices—Are healthcare consumers satisfied with health insurers? Millennial data show warning signs: This article is a nice review of millennials’ preferences as they apply to health insurance products and services. It has a number of references to industry research studies.

Read the article

MACPAC calls for Congress to eliminate the drug rebate cap: CMS has been discussing elimination of drug rebates for Medicare Part D. Now the Medicaid and CHIP Payment and Access Commission (MACPAC) is recommending Congress end the cap on drug rebates paid to state Medicaid programs.

Read the story

Today's News and Commentary

About the public’s health

Big soda pours big bucks into California’s Capitol: As California considers a tax on sugared drinks, this article exposes the extent of lobbying against the proposal. “A California Healthline analysis found that 9 in 10 state senators and members of the Assembly, or a member of their staff, accepted a campaign contribution, gift or charitable donation in 2017 and 2018 from the American Beverage Association (or its political action committee), the Coca-Cola Co. or PepsiCo — the three largest givers in the industry.”

Read the story

Global, national, and urban burdens of paediatric asthma incidence attributable to ambient NO2 pollution: estimates from global datasets: Yet another reason (other than global warming) to control air pollution. This study documents the link between nitrogen dioxide pollution and new pediatric asthma cases. The primary source of the pollutant is autos.

Read the research

Can officials require vaccinations against measles? A century-old case may give them a foothold: In the face of the measles epidemic, questions have arisen about the legality of compelling immunization. This article recalls a 1902 Massachusetts case that concerned smallpox and discusses legal issues on this topic.

Read the article

Health care price check: A couple retiring today needs $285,000 as medical expenses in retirement remain relatively steady:This study comes from Fidelity Investments. The good news is that 35-year-old couple can potentially save $285,000 in 30 Years by investing $2,820 annually.

Read the article

FDA warns about risks of using home use test strips that are pre-owned or not authorized for sale in U.S., including those for glucose, warfarin: Test strips are being sold online on eBay, Craigslist, and Amazon, or directly from online sellers. The FDA warns that these strips may not perform to specifications and give erroneous results.

Read the warning

About healthcare IT

Executive Spotlight—Karen DeSalvo on what 'frustrates' her most about healthcare—and why she gives props to the Trump administration: In this interview, former National Coordinator for Health Information Technology Karen DeSalvo opines on current and future healthcare IT issues. One of the topics is patient centered systems. But we still do not have unique patient identifiers as do most other countries.

Read the interview

Electronic Capabilities for Patient Engagement among U.S. Non-Federal Acute Care Hospitals: 2013-2017: This research is from the Office of the National Coordinator. The upshot is we still have a long way to go before electronic capabilities reach their potential. For example, most “hospitals (62 percent) reported that fewer than 25 percent of their patients activated their access to their patient portal.”

Read the report

About health insurance

Republican senators float bill with protections for pre-existing conditions: Republicans are afraid that if the ACA is eliminated they will be blamed for what Americans like most about it: no denials for preexisting conditions and no health-related premium adjustments. So a group of GOP senators led by Sen. Thom Tillis of North Carolina is proposing a bill to address those concerns. However, it allows insurers to exclude any preexisting condition from coverage, even if they issue a policy for all other health care possibilities. The bill does not have widespread support so Republicans will have to go to “Plan B.”

Read the story

July hearing expected in Obama health care law case: Judge Leslie Southwick of the U.S. Court of Appeals for the 5th Circuit in New Orleans has agreed to expedite hearing the appeal of the ruling that invalidated the ACA.

Read the announcement

Oak Street Health and Aetna Team Up to Expand Access to Value-Based Care in Indiana and Michigan: One more example of an insurer partnering with primary care clinic providers.

Read the announcement

Idaho becomes 2nd state to support scaled-back Medicaid expansion: The people of Idaho and Utah voted to participate in Medicaid programs under the ACA. But Republican administrations in those states chose to limit the expansion.

Read the story

New Consumer Testing Shows Limited Consumer Understanding of Short-Term Plans and Need for Continued State and NAIC Action: Republicans are touting short term health plans as an affordable alternative to ACA offerings. But this study from the National Association of Insurance Commissioners shows that people do not know what they are buying. The results are not surprising given other older studies that showed poor understanding of basic health insurance terms.

Read the research

Today's News and Commentary

About pharma

Most Osteoporosis Drugs Don’t Build Bone. This One Does: The FDA has approved Evenity, Amgen’s new drug to treat post menopausal osteoporosis. The drug works by a new mechanism that encourages new bone growth. Once the patient has grown enough new bone (after about a year), she is then placed on maintenance therapy with a bisphosphonate to prevent further loss. The downside is a contraindication if the patient has has a heart attack or stroke in the year before administering the medication. Pricing is still unknown.

Read the article(NY Times but appears to be open access)

CVS, Cigna, Humana blame Big Pharma at Senate hearing for skyrocketing US drug prices: As previously mentioned, yesterday was the day big pharma benefit managers (PBMs) testified before the Senate Finance Committee about their role in high drug costs. Predictably, their fingers pointed to “Big Pharma” and not those who manage the benefits.

Read about the hearing

Hikes on Medicare drug premiums could be delayed until after 2020 elections: In a related article, the Trump administration has proposed giving any drug rebates back to patients. Because insurers count on those rebates, their loss would cause an increase in premiums. 2020 proposals for Part D are due in 8 weeks and the rebate issue is still not settled. CMS directer Verma has told companies to use old criteria for their pricing bids. We will need to wait to see how all theses changes play out.

Read the article (Washington Post but appears to be open access)

Invisible Middlemen Are Slowing Down American Health Care: This in-depth article provides a good working insight into how PBMs work (or often do not work).

Read the article

Walgreens Unveils Latest Primary Care Partner: VillageMD: In the latest pair-up of pharmacies and healthcare providers, Walgreens is partnering with Chicago-based VillageMD to set up primary care clinics next to their stores in the Houston area. This move is seen as a competitive strategy to answer expanded in-store healthcare services CVS is setting up.

Read the story

Sanofi turns to subscriptions to offer patients insulin at $99 per month: Netflix comes to pharma. For a monthly fee of $99, diabetic patients can get all their insulin from Sanofi.

Read the article

About health insurance

UnitedHealthcare to expand bundled payments in its Medicare Advantage plans: Continuing a trend of value-based payments, UnitedHealthcare is expanding its bundled payments to providers caring for members in the insurer’s Medicare Advantage plans. The bundles will cover single and double hip joint replacements, single and double knee join replacements, non-cervical spinal fusion, cardiac valve replacement, coronary bypass, and percutaneous coronary intervention. 

Read the announcement

About healthcare IT

Provider, health IT groups praise proposed bills to change patient privacy regulations: Care of opioid-addicted patients requires knowledge about all their health problems. But the law governing disclosure of patient information about substance abuse (so-called 42 CFR Part 2) is very strict and makes necessary information sharing difficult. Now lawmakers are finally standardizing these privacy requirements to harmonize them with HIPAA.

Read the story

Federal agencies charge 24 in $1.2B Medicare telemedicine fraud scheme: Did you ever get a robocall asking about your backspin and offering a helpful device that Medicare will cover? If so, your intuition was correct- it was most likely part of a huge international fraud scheme. Read this article for the details and check the youtube video link.

Read the story

Today's News and Commentary

About insurance

Blue Cross and Blue Shield of Texas and Sanitas USA to Open Medical Centers in Dallas and Houston: In another cross functional joint venture, these two companies are opening primary care clinics in Dallas and Houston. The difference from many other examples in this category is that they will be open to self-pay and Medicare patients as well as Blue Cross members.

Read the announcement

Here are two articles summarizing the federal governments thoughts about revamping the way it pays for care. The first is about MedPAC’s thoughts regarding Medicare abandoning fee for service. The second reports on Adam Boehler’s (director of the Center for Medicare and Medicaid Innovation) speech yesterday at the American Hospital Association conference. The focus was on post-acute care bundles.

Mulvaney, administration officials emerge from Camp David summit planning health care rollout 'fairly shortly': In the latest update on when the GOP will offer its own healthcare proposal, it will not wait for after the 2020 election as the President most recently announced. Instead, his acting chief of staff said it will come “fairly shortly.”

Read the article

DOJ asks for speedy hearing in case that could kill Obamacare: On the theme of “repeal (or kill) and replace,” the Justice Department has asked for an accelerated appeal of the ruling that could invalidate the ACA.

Read the announcement


About the public’s health

Lost Productivity From Heart Attack, Stroke Are Twice Direct Medical Costs, Study Finds: In addition to paying attention to social determinants of health, this article is a reminder that we should account for non-medical costs of illness in making cost-benefit decisions.

Read the article

The Economic Burden of Elevated Blood Glucose Levels in 2017: Diagnosed and Undiagnosed Diabetes, Gestational Diabetes, and Prediabetes: Speaking of costs, those for diabetes are still growing. “The economic burden associated with diagnosed diabetes (all ages), undiagnosed diabetes and prediabetes (adults), and gestational diabetes (mothers and newborns) reached nearly $404 billion in 2017…” More multifaceted approaches are still needed. More taxes on sugary drinks, for example?

Read the research

In a Poor Kenyan Community, Cheap Antibiotics Fuel Deadly Drug-Resistant Infections: This is a well-written article about antibiotic resistance as a global issue. Because generic antibiotics are cheap and plentiful in developing countries, and because they are available without a prescription, they are being used indiscriminately—causing bacterial resistance to emerge. Mobile populations spread these organisms, causing global public health problems.

Read the article (NY Times but appears to be open access)

New York orders measles vaccinations in Brooklyn amid outbreak, mayor says: The mandate covers all unvaccinated people and carries a $1000 fine for non-compliance. More governmental entities are moving to these mandates as measles continues to be spread.

Read the story (Washington Post but appears to be open access)

Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians: These guidelines come from the academic professional society of internal medicine (adult medicine) specialists and concerns the frequency of mammography for normal risk women. One screen is out- physician exam for breast masses. Self-exam was eliminated as an effective detection strategy for screening normal risk women a number of years ago.

Read the recommendations

Judge rules New York county can’t ban unvaccinated children from schools, parks: Recall the previous story about Rockland County, NY banning unvaccinated children from public places? Nevermind. A “a state judge put the injunction on hold.”

Read the story

Association Among Dietary Supplement Use, Nutrient Intake, and Mortality Among U.S. Adults: A Cohort Study: Many healthy people are still buying dietary/nutritional supplements hoping that it will reduce their mortality risk. This study found that: ‘Use of dietary supplements is not associated with mortality benefits among U.S. adults.”

Read the research abstract

About pharma

The 5 drugs to watch in 2019: In order to accurately recommend premiums and out of pocket costs, healthcare actuaries need to know not only current but future costs of care. Optum (the non-insurance part of United HealthGroup) issued its 2019 list of 5 drugs to watch for their impact on health care costs.

Read about these drugs

ViiV Healthcare's Dovato approved in US as first two-drug single-tablet regimen for patients with treatment-naïve HIV: HIV treatments have become simpler, as medications no longer need to be taken as often, and combinations pills have been introduced. This announcement is about approval of the first two-drug single-tablet for patients with treatment-naïve HIV.

Read the announcement

Two new research studies show promise for treating problems with aging brains. The first study (in mice) found that blocking the gene CD22 enhanced the ability of microglia to clear debris- improving spatial memory and associative memory. The second study used 25 min of electrical “stimulation, frequency-tuned to individual brain network dynamics…The end result was rapid improvement in working-memory performance that outlasted a 50 min post-stimulation period.”

Today's News and Commentary

About pharma

The top 15 pharma companies by 2018 revenue: For those of you into lists, here is one of the top 15 pharma companies by revenue.

Read the article

NIH to undertake first in-human trial of universal influenza vaccine: The National Institute of Allergy and Infectious Diseases announced it is starting human trials of a universal flu vaccine. If successful, it would not need to change each year in anticipation of a prevalent strain. The question remains: who will manufacture, sell and profit from it?

Read the announcement


About the public’s health

Chicago health tech incubator’s products reach 92 million patients: This article is an update on Matter, the Chicago health tech incubator. It has had great success identifying important healthcare problems and nurturing startup companies to solve them. [Disclosure: I have lectured there and advised several of the companies.]

Read the article

National Hospital Ambulatory Medical Care Survey: 2016 Emergency Department Summary Tables: The CDC just released this study (even though it is for 2016). It has a wealth of data including who went to the ED (age, sex, race, geography), when they went (time of day and season), how they got there, how long they waited, what their diagnoses and acuity of illness were, whether they were admitted, and what their insurance was. Overall, the number of visits was significantly increased from the previous year; Medicaid was the most common insurance; blacks had by far the highest utilization; stomach pain was the most common diagnosis, and 70% of patients are seen in an hour or less. Lots to think about with respect to lowering these numbers.

Read the full report

About health insurance

The Implications of “Medicare for All” for US Hospitals: As previously reported, the definition of this proposal varies across its diverse proponents. Nevertheless, expanding Medicare will have serious repercussions on the entire healthcare system.
In order to make up for lower Medicare rates, hospitals rely on their ability to charge higher amounts to private payers (“cost shifting”). This article quantifies how much hospitals will lose if they cannot cost shift: “Given the relative proportion of patients with each type of insurance, the estimated net effect on hospitals would be a 15.9% decline in revenue, equal to a loss of $151 billion nationally incurred by 5262 US community hospitals.”

Read the research

Medicare for All Might Require Student Debt Relief to Work: On the same theme as the above article, this one discusses the implication of Medicare for All on physician payments. Much of the article is about how payments are a lot higher in this country than in all others. It does not address the fact that physician behavior is behind overall higher costs- not just their incomes. Reducing charges alone will not solve our cost problems.

Read the article

CMS Finalizes Expanded Medicare Advantage Telehealth Coverage: Currently, telemedicine services are an add-on option for Medicare Advantage plans. Starting next year, CMS will start paying for them as a core benefit. This action is significant and may give a real boost to this communication sector.

Read the article

Centene and Washington University collaborate to advance personalized medicine research: In a continuing trend of public-private collaborations in population health, insurer Centene has agreed to fund up to $100 million over 10 years for research at Washington University. The studies will focus on personalized medicine approaches to Alzheimer's disease, breast cancer, diabetes and obesity. 

Read the announcement

Medicare Part D wasn’t built for costly specialty drugs. MedPAC wants to change that: Part D is the child of the Medicare Modernization Act of 2003. At that time, specialty pharmaceuticals were not as important to overall costs as they are today. In fact, they account for a large majority of the rising pharma costs. Policy makers thought this problem would be mitigated by the emergence of generic forms of these expensive drugs (so-called biosimilars). But their introduction has not lived up to expectations. MedPAC is therefore considering changing recommendations to update the structure of Part D to address these rapidly rising costs.

Read the article

U.S. judge expecting CVS merger hearing for May: It’s not over until it’s over. Although the CVS-Aetna deal closed in November, Judge Richard Leon of the U.S. District Court for the District of Columbia has taken the unprecedented step of agreeing to hear arguments from those who still oppose the deal, including the American Medical Association. While the justice department cleared the purchase, the judge is unsure of its antitrust implications.

Read the story

Medicaid expansion tied to fewer heart-related deaths, study finds: The title is self-explanatory but has implications if proposals to cut Medicaid go forward.

Read the story

Concerns Regarding the Proposed Rule to Restrict Drug Manufacturer Rebates in Medicare Part D and Medicaid MCOs: This analysis by Matrix Global Advisors reviews the evidence on what would happen if Medicare Part D restricts (or eliminates) drug rebates. There is a nice illustration of the value/cost chain on page 2 and summaries by various authorities/agencies that speak against the proposal as cost increasing. From a patient perspective, the argument is that insurers count on the rebates to subsidize costs; if the rebates are decreased, premiums will go up. This paper is worth reading for the thought process it forces on the careful reader.

Read the analysis

Plan to End Drug Rebates Adds Protections for Insurers: Continuing the above theme, the Trump administration is proposing to “offer a risk-sharing system” for insurers if Part D drug rebate losses would cause the companies to increase their premiums. So who pays the federal government to pay the insurance companies?

Read the story

Medtronic, Blue Cross sign glucose monitor deal linked to patient outcomes: This deal is another example of value-based products. The agreement requires Medtronic to pay rebates to Blue Cross of Minnesota if members with diabetes who use Medtronic's Guardian Connect device fail to keep their blood sugar levels within a targeted range for a specific period of time. Patients who use the device and participate in the Medtronic user-engagement program called the Inner Circle can earn up to $300 a year to offset the cost of the monitor and sensors.

Read the story

Walmart, Other Employers Get Choosier About Workers’ Doctors: Usually insurance companies are the ones imposing narrow provider networks. This interesting article explains how and why employers are now doing the same for their employees.

Read the article

About healthcare IT

CTA Brings Together Tech Giants, Trade Associations to Improve Efficiencies in AI and Health Care: More than 30 organizations, including Google and IBM, have joined the Consumer Technology Association to “examine and advance the impact of AI in health care by providing standards and recommend best practices to enhance the application of the technology.”

Read the announcement

Apple envisions devices that can 'smell' blood sugar, toxic gases: A quick read but fascinating. So much father along than “Star Trek” technology.

Read the article

Telemedicine tied to more antibiotics for kids, study finds: There is something still to be said for having a primary care doctor. Bottom line: “Children received prescriptions for antibiotics more than half the time during telemedicine visits, compared with 42% at urgent care clinics and 31% at doctors’ offices.”

Read the article

Today's News and Commentary

About the public’s health

Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in China: The beneficial and deleterious effects of alcohol consumption have been debated for many years. This large study, published yesterday in The Lancet , concludes that: “Genetic epidemiology shows that the apparently protective effects of moderate alcohol intake against stroke are largely non-causal. Alcohol consumption uniformly increases blood pressure and stroke risk, and appears in this one study to have little net effect on the risk of myocardial infarction.”

Read the research

Association of Racial Disparities With Access to Kidney Transplant After the Implementation of the New Kidney Allocation System: In order to assure fairness, allocation systems for organ transplants have undergone many changes over the years. This article documents that the recent kidney allocation system had reduced racial disparities among transplant recipients but differences still exist. Further modification of this method still needs to be done.

Read the research

Global life expectancy up 5.5 years since 2000; income and access to care play key roles: WHO: Some good news! Global health initiatives (aided by economic improvements) are making a positive difference in life expectancies.

Read the story

Dubstep artist Skrillex could protect against mosquito bites: Serious science but fun music. “According to a recent scientific study, the way to avoid mosquito bites is to listen to electronic music - specifically dubstep, specifically by US artist Skrillex.”

Read the article

How to Minimize Exposures to Hormone Disrupters: The food we buy that is packaged in plastics and other materials can pick up carcinogenic toxins and can also modify hormone activity. This article offers some simple measures to avoid harmful products.

Read the article

About pharma

FDA’s Gottlieb heads back to AEI to tackle drug prices: Today is Dr. Scott Gottlieb’s last day as FDA Commissioner. He will be returning to the American Enterprise Institute where he says he will continue to fight for drug price reform.

Read the Washington Post interview (Appears to be open access)

CVS expands same-day prescription delivery nationwide: CVS is shortening the time from its previous minimum of 1-2 days. The next innovation will be delivery of your medication before you actually need it.

Read the announcement

FDA Clears Avanos Medical’s Drug Infusion Pump: Many patients get their first doses of opioids after an operation when they control the amount of their intravenous medication via a bedside pump. This newly approved device does not use opioids but instead uses “a catheter to continuously release numbing medicine near a patient’s surgical incision.”

Read the announcement

Lundbeck, Alexion and Jazz to pay nearly $123 million to settle US kickback allegations: This story highlights ongoing legal action for what the government euphemistically calls “misconduct.” Pharma companies set up foundations that help fund patients’ out of pocket expenses for costly pharmaceuticals. This process allows those companies to charge payers (including the federal government) much higher prices than they would if individuals had to pay large copays or deductibles. The federal government is now cracking down on such practices.

Read the article

AbbVie's massive Humira discounts are stifling Netherlands biosimilars: report: How can pharma companies fight introduction of less costly biosimilars? It appears that sufficiently lowering the branded drug’s price is a successful strategy- at least in the Netherland’s market. This strategy can also jjhave major implications in other markets and for other drugs.

Read the article

FDA's Assessment of Currently Marketed ARB drug products: In the ongoing story about carcinogenic contaminants in angiotensin receptor blockers, the FDA has supplied a list of safe medications in this class. Some are combination products.

Check the list

About healthcare quality

Study Identifies Potential Fix for Hospital Star Rating Program: Hospitals have often complained about the validity of the CMS-generated star ratings that characterize their quality of care. This research finds reason for this challenge and suggests an alternative method, including redistribution of weights for the measures.

Read the research announcement

About healthcare information systems

MedPAC to Recommend National Coding Guidelines for Emergency Departments: Citing large discrepancies in coding emergency department billing under the Outpatient Prospective Pay System, MedPAC is recommending national coding standards. This standardization could cut into the profits of EDs that routinely “upcode.”

Read the article

‘Alexa, find me a doctor’: Amazon Alexa adds new medical skills: Alexa is now HIPAA compliant, allowing the voice recognition software to provide help with health-related issues. For examples, you can ask Alexa to retrieve your blood sugars or find a doctor for a certain type of problem.

Read the story for more details

Today's News and Commentary

About the public’s health

Are worksite clinics an old-school solution to employers’ current cost problems?: Medical care at the workplace is a very old concept that is making a comeback. This article provides a nice overview of this topic.

Read the article

Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017: The importance of diet to health is not a new concept. This research quantifies this link: “In 2017, 11 million …deaths and 255 million… DALYs [Disability Adjusted Life Years] were attributable to dietary risk factors. High intake of sodium (3 million… deaths and 70 million… DALYs), low intake of whole grains (3 million … deaths and 82 million… –DALYs), and low intake of fruits (2 million… deaths and 65 million… DALYs) were the leading dietary risk factors for deaths and DALYs globally and in many countries.”

Read the research

Avalere: Despite dropouts, BPCI Advanced participation shows providers open to greater risk: The CMS program called Bundled Payments for Care Improvement (BPCI) Advanced requires renewing participants, as of March 1, to assume financial risk as a condition to their participation. While a number of participants have decided to continue, there has been a significant dropout rate. Reports on these numbers are either “glass half empty of half full.” After this year will there be enough risk-bearing programs left to make a significant impact on the cost and quality of healthcare?

Read the article

About pharma

Key House lawmakers reach bipartisan deal to advance long-stalled drug pricing bill: The House Energy and Commerce Committee has achieved bipartisan support in passing measures to ease the process of getting generics to market. One of these measures is the CREATES Act (Creating and Restoring Equal Access to Equivalent Samples), which prevents branded drug manufacturers from withholding their products from generic companies who need reference samples for  testing their products.

Read the story
For more details on the dozen bills passed by the committee read this announcement

Cigna, Express Scripts Capping Insulin Co-Pays at $25 for Participating Commercial Members: To address the ongoing problem of high and rising insulin costs, Cigna and Express Scripts are limiting expenses to a $25 copayment for participating members.

Read the story

About insurance

Shifting Care from Office to Outpatient Settings: Services are Increasingly Performed in Outpatient Settings with Higher Prices: It has long been known that care costs more in the hospitals outpatient departments than when the same services are provided in a doctor’s office. This article has an interactive graphic that helps quantify these differences.

Read the article

Today's News and Commentary

Light news day

About healthcare IT

Proposed Regulatory Framework for Modifications to Artificial Intelligence/Machine Learning (AI/ML)-Based Software as a Medical Device (SaMD) - Discussion Paper and Request for Feedback: The FDA has issued a framework for regulating artificial intelligence/machine learning software and is asking for comments. This paper is very thought provoking and makes one consider the difference between a human-designed algorithm for machine use and the subconscious algorithms of humans themselves.

Read the paper

About insurance

UnitedHealthcare and the AMA Collaborate to Understand and Address Social Barriers Preventing People’s Access to Better Health: The purpose of this deal between these two organizations is to develop data gathering tools to assess Social Determinant of Health (SDOH). The process will start with creation of about two dozen new ICD-10 codes related to SDOH.

Read the announcement

Experts on Capitol Hill: Solution to surprise billing should fall to hospitals, insurers—not patients: This article is a report about yesterday’s Congressional hearing on surprise billing. Despite Congressional attention and testimony by experts on the topic, we will need to wait to see if any meaningful action occurs to fix this problem. My bet is no.

Read the story

Today's News and Commentary

About quality and safety

Healthcare groups renew calls for CMS to remove Hospital Compare ratings until methodology addressed: The title is self explanatory. It is not the first time the methodology has caused headaches for providers. When the first hospital rankings came out (about 30 years ago), they were not risk adjusted- resulting in some interesting results for “best places” to obtain care. Bruce Vladeck, the administrator of what is now CMS, did away with the rankings- but they are back.

Read the article for the latest concerns

About insurance

Trump, in Reversal, Says Replacing Obamacare Can Wait Until After Election: Remember yesterday’s story about a Republican health plan coming under White House direction? Never mind. The President new says the he will wait until after the 2020 election to do something. What will that be? Repeal and replace. Haven’t we been here before?

Read the reversal announcement

NOTE TO: Medicare Advantage Organizations, Prescription Drug Plan Sponsors, and Other Interested Parties: CMS issued its final rules and comments about Medicare advantage rate changes (up 2.53% for the coming plan year) and other guidances, such as allowable extra benefits these plans can offer.

Read the document

Two Republican attorneys general urge court to uphold Obamacare:Republican attorneys general from Ohio and Montana have joined Democratic colleagues in appealing the ruling to invalidate the ACA based on repeal of the penalty (tax) for not having insurance.

Read the story

The U.S. Healthcare Cost Crisis:
This Gallup poll has some interesting findings about American’s attitudes toward healthcare. Among the findings were: “Americans borrowed an estimated $88 billion in the past 12 months to pay for healthcare” and “ 65 million adults had a health issue but did not seek treatment due to costs in the past 12 months.”

Read the survey (Free signup required)

Association Between Insurance Status and Access to Hospital Care in Emergency Department Disposition: There used to be a term for transferring uninsured or poorly insured patients to other hospitals after ER stabilization: Dumping. Does this problem still exist? “After accounting for hospital critical care capability and patient case mix, the study found that uninsured patients and Medicaid beneficiaries with common medical conditions appeared to have higher odds of interhospital transfer.”

Read the research (Abstract is open access, full research requires subscription)

About the public’s health

Healthcare executives rate the industry's top 10 challenges: What keeps healthcare executives “up at night? This article explains the “top 10 challenges.” Most were on the list last year. New on this list are: “External market disruption” from such companies as Amazon, Chase, Apple, Walmart and Google; “Operational effectiveness” achieved by increased efficiency; and “Opioid management.”

Read about the 10 challenges

Today's News and Commentary

About insurance

Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2019: Findings from a 50-State Survey: The Kaiser Family Foundation just released its 17th annual report on Medicaid and the Children’s Health Insurance Program (CHIP) eligibility, enrollment, renewal, and cost sharing policies. It is a great update and worth reading- if only to get overall messages from the graphics.

Read the report

Doughnut Hole Is Gone, But Medicare’s Uncapped Drug Costs Still Bite Into Budgets: This article is a reminder that there is no cap on Medicare Part D expenses- even for those who purchase an insurance policy. At the highest payment levels, beneficiaries are still responsible for 5% of payments.

Read the story

Trent Haywood reflects on the BCBS Institute's first year: One year ago, the Blue Cross/Blue Shield Association set up the BCBS institute to develop partnerships and solutions addressing social determinants of health. This article is an interview with the institute’s president, Dr. Haywood. It is an interesting approach to addressing healthcare through the Association’s members.

Read the interview

White House to send 'principles' for Obamacare replacement plan to Capitol Hill: This article updates the back and forth between the White House and Republican members of Congress about the responsibility for crafting its party’s health care message. The President first claimed that healthcare would be a Republican issue in the next election, but left the details to Congress. Then some members of Congress were said to be gathering to work on it. Saturday, the Washington Post reported “Republicans have no intention of heeding President Trump’s urgent demands for a new health-care plan to replace the Affordable Care Act.” Now, Acting White House chief of staff Mick Mulvaney said the White House would be sending guidance to Congress on how to replace the ACA. Stay tuned for the next installment of this highly coordinated effort.

Read the article

Physicians score overwhelming victory in bid to fix prior authorization: As recently reported, The AMA documented widespread problems with physicians getting timely prior authorization (PA) responses from health plans. In the first instance of a law to correct these issues, Kentucky has passed legislation mandating certain changes to insurance company practices. Under the measure:  

—Physicians will receive responses on PA requests within 24 hours for urgent services and within five days for non-urgent services. 

—Prescriptions for chronic-condition maintenance drugs will be valid for one year, and any change in dosage during this period will be covered.   

—Insurers’ PA procedures will be posted online as well as a complete list of services requiring PA. 

—Insurer PA reviewers will be licensed physicians and, when possible, of the same specialty as the requesting physician.  

—Physicians and other clinicians will be able to electronically request and transmit PAs.

The new law takes effect Jan. 1, 2020.

Read the article

About pharma

FDA Raises Impurity Threshold to Address Losartan Shortage: Many manufacturers of the antihypertensive drug losartan had their product contaminated with the potentially cancer causing substance N-Nitroso-N-methyl-4-aminobutryic acid. Withdrawal from the market of many sources  of this drug has caused a shortage. Now the FDA says it will allow a higher content of this impurity as a way to address the shortage. Losartan is an angiotensin receptor blocking agent (ARB). There are many other drugs in this class that can be substituted. However, manufacturers of two of the substitutes, irbesartan and valsartan, have also had their products recalled. One wonders if it is really necessary to “raise the impurity threshold” or are there other alternatives, like using ACE inhibitors.

Read the announcement

Delivering Better Health and Affordability: Express Scripts issued a report on its value-based system called SafeGuardRx®. The report says the program saved clients more than $2.4billion and slowed drug cost growth. Specific disease category initiatives (like diabetes) are also explained.

Read the report

Biosimilar Groups Seek ‘Structural’ Changes in U.S. Market: According to this article, the US needs to step up its efforts to facilitate development, approval and marketing of biosimilars. “Europeans now make up 90 percent of world biosimilar sales".”

Read the article

First TV drug ad featuring list price debuts today: This article from Friday features the first U.S. direct-to-consumer TV drug ad to disclose price: J&J’s Xarelto.

Read the article

About healthcare quality and safety

2019 Top 10 Patient Safety Concerns: each year ECRI publishes its top 10 patient safety concerns. Here is this year’s list:
1. Diagnostic Stewardship and Test Result Management Using EHRs
2. Antimicrobial Stewardship in Physician Practices and Aging Services
3. Burnout and Its Impact on Patient Safety
4. Patient Safety Concerns Involving Mobile Health
5. Reducing Discomfort with Behavioral Health
6. Detecting Changes in a Patient’s Condition
7. Developing and Maintaining Skills
8. Early Recognition of Sepsis across the Continuum
9. Infections from Peripherally Inserted IV Lines
10. Standardizing Safety Efforts across Large Health Systems

Read the report (May need to register at ECRI.org)

Appellate court case puts peer-review protections in danger: Peer-review documents have been shielded from discovery in malpractice trials. The reason for this confidentiality is to enhance physician compliance with quality-enhancing activities. This process has been put in danger by a recent court case in Michigan which has been appealed.

Read the article

Today's News and Commentary

About insurance

In Blow to Trump, Judge Blocks Health Care Law ‘End Run’: Like yesterday, today’s top story is about a judicial decision concerning insurance. The Trump administration issued a rule allowing formation of “association health plans,” which consist of employers from many types of businesses. The purpose of those plans was to avoid laws that the administration said were too constraining. In his ruling in the case of New York v. United States Department of Labor (filed by New York, 10 other states and D.C), Judge John D. Bates, of the Federal District Court for the District of Columbia said that the rule was: “clearly an end-run around the A.C.A.” Further, it violates ERISA provisions that define what an employer group is.

As an aside, when the ACA was passed, I confirmed with the Department of Labor that the law applies to ERISA plans.

Read the story (NY Times but appears to be open access)

Trump: Group of GOP senators writing 'spectacular' ObamaCare replacement: The President is bragging that healthcare will be a “Republican issue” in the coming election. But he is counting on Republican senators to come up with something to make good on this promise.

Read the article

About pharma

New York accuses six drugmakers including Johnson & Johnson, Purdue of deceptive opioid marketing: After Purdue’s settlement in Oklahoma, this round will have more players and bigger liabilities.

Read the article

National pharmacare to make prescription drugs more accessible and affordable: On the subject of controlling pharma costs, it is instructive to see what Canada is doing. You should understand that, for the most part, Canadians do not have drug coverage unless it is privately purchased- usually through the individual’s employer. The main three aims of the program, called “national pharmacare”, are:

-Creating a Canadian Drug Agency to assess the effectiveness of new prescription drugs and negotiate drug prices on behalf of Canada's drug plans. The goal is to lower costs by up to $3 billion per year in the long term.
-Developing a national formulary – a comprehensive, evidence-based list of prescription drugs – which would help promote coverage that is more consistent across the country.
-Establishing a national strategy for high-cost drugs for rare diseases.

Anything there sound familiar? The difference is they will do it!

Read the article

About the public’s health

“Prescribing” fruits and veggies would save $100 billion in medical costs: An economic study the looked at providing subsides for healthy food found that such a plan could save $100 billion in medical costs. The proposed interventions included a: “(1) 30% subsidy on fruits and vegetables (“F&V incentive”) and (2) 30% subsidy on broader healthful foods including F&V, whole grains, nuts/seeds, seafood, and plant oils (‘healthy food incentive’).” This approach is the opposite of suggestions to raise prices on foods that are unhealthy, like sugary drinks. What if we imposed the latter plan to pay for the former initiative?

Read the story
Read the original research

Disney bans smoking at U.S. theme parks: For a “family-experience” company, what took them so long? By the way, e-cigarettes and vape pens are included in the ban.

Read the story

EPA Science Panel Considering Guidelines That Upend Basic Air Pollution Science: Last year, the EPA disbanded its 20-person subcommittee called the Particulate Matter Review Panel, which recommended targets for air pollution control. Since then, the task has fallen to  the agency’s science panel. At a hearing yesterday, several members of this panel expressed their doubts about “the long-established scientific consensus that air pollution can cause premature death.” One of their arguments echoed the past defense of tobacco use- lack of randomized controlled studies. Obviously there is no ethical or economically feasible way to conduct such trials. More “experts” will be called in before policy changes are made, but this hearing provides another example of the actual or attempted dismantling of environmental safety protections.

Read the article

Today's News and Commentary

About insurance

Federal judge strikes down Medicaid work requirements in Kentucky, Arkansas: This news is today’s top story. The title is self-explanatory. The reason the judge gave for the decision was that the work requirement was not in the best interest of Medicaid’s purpose. However, he did not rule out other methods to save the program money.

Read the story

CMS Should Assess Documentation Necessary to Identify Improper Payments: The GAO reported that in fiscal year 2017, “Medicare FFS [fee for service] had an estimated $23.2 billion in improper payments due to insufficient documentation, while Medicaid FFS had $4.3 billion—accounting for most of the programs’ estimated FFS medical review improper payments.” The Medicare improper payments, while large, have been declining since a peak in 2014.

What if a private insurance company made such an announcement? Imagine what the number would be if we had a single payer system, i.e., the federal government.

“GAO is making four recommendations to CMS, including that CMS assess and ensure the effectiveness of Medicare and Medicaid documentation requirements, and that CMS take steps to ensure Medicaid’s medical reviews effectively address causes of improper payments and result in appropriate corrective actions. CMS concurred with three recommendations, but did not concur with the recommendation on Medicaid medical reviews. GAO maintains that this recommendation is valid as discussed in this report.”

Read the full report

About pharma

Louisiana has picked its 'Netflix' hepatitis C partner: Gilead's new generics unit: Continuing reporting on this story, Louisiana has chosen Gilead to receive fixed, global payments for however many state-funded patients need Hepatitis C medication.

Read the update

Walgreens to sell CBD products in 1,500 stores: Cannabidiol (CBD) is the “non-high” component of marijuana that claims to help anxiety and nausea. In addition to Walgreens, CVS started to offer CBD products in eight states earlier this month.

Read the story

Prevalence and Severity of Rationing During Drug ShortagesA National Survey of Health System Pharmacists: This research quantifies the problem of hospitals’ drug shortages. Some major takeaways: “All respondents [719] reported experiencing drug shortages in the preceding year and 498 respondents (69.2%) reported more than 50 shortages… Most respondents (664 [92.4%]) reported an average of less than 1 month from notification to active shortage…More than one-third of respondents (247 [34.4%]) reported an episode of rationing within the past year. Rationing occurred more frequently at academic hospitals …and academically affiliated hospitals…”

Read the article (Subscription required to full article from JAMA Internal Medicine)

Want to Reduce Opioid Deaths? Get People the Medications They Need: This NY Times editorial explains that while we want to make opioid addiction treatment more prevalent and accessible, the federal government has restricted use of approved medications.

Read the opinion piece

Pharmacy Benefit Managers: Practices, Controversies, and What Lies Ahead:As previously reported, one initiative being considered to lower drug prices is changing the drug rebate system- either eliminating the practice or giving rebates to patients instead of PBMs and payers. This article from the Commonwealth Fund is a great summary of the rebate practices and issues around changing where the rebates will go. Bottom line is it would help if we changed the rebate practices but need to do much more to control high pharma costs.

Read the article

About healthcare IT

CMS offers up to $1.6M in AI challenge for better healthcare prediction tools: In partnership with the American Academy of Family Physicians and the Laura and John Arnold Foundation, CMS announced it will fund projects up to $1.65 million each for its new CMS Artificial Intelligence Health Outcomes Challenge.

Read more about the challenge


Today's News and Commentary

About insurance

Dems unveil plan to build up ObamaCare as Trump steps up attacks: Continuing commentary on yesterday’s top story, Democrats announced their plans to shore up the ACA in the face of the Justice Department’s plan to support legal action to nullify the entire law. The plan focuses on 1) abolishing “skinny plans, ” which offer fewer benefits at lower prices and 2) adding financial support in the forms of tax credits for more people to offset premium costs. (The skinny benefit plans are just another way of excluding people with high cost, pre-existing conditions.) Those two measure could be accomplished within existing laws. Another part of the Democratic proposal is reinstating support for out of pocket expenses. That action is more problematic since it was never part of the ACA and would require Congressional action to allocate funds for that purpose.
All this talk is moot, however, since the Republican Senate is not likely to pass Democratically-sponsored legislation.

Read the article

What Happens if Obamacare Is Struck Down? .Because the ACA touches so many areas, the answer to the title’s question is complex. This article is a great summary of the consequences if the ACA goes away.

Read the article (NY Times but appears to be open access)

Centene and WellCare to Combine to Create a Premier Healthcare Enterprise Focused on Government-Sponsored Healthcare Programs: Just when you thought the insurance market was taking a breather, the consolidation continues.

Read the announcement

Stanford Health Care Joins Sutter Health | Aetna Network: Network expansion is also continuing- even in California.

Read the announcement

Medacta, Geisinger pilot program to cover all future costs for plan members with knee replacement: This venture is a real breakthrough in quality guarantees for payers. Usually these guarantees on healthcare products have covered replacement of the product itself (in cases of devices) and/or costs the patient incurred because of the failure (for medications). This venture will also cover the hospital replacement costs which insurance companies have to pay. The catch is the patient must be part of Geisinger health plan and have services through Geisinger providers.

Read the announcement

How is Value-Based Care Changing Cancer Treatment Decisions?: Value-based payments are in effect or being proposed across the healthcare field. This survey (displayed in nice graphical form) provides oncologists’ opinions about this payment method. The biggest obstacle, no surprise, is pharmaceutical costs. The only way to craft reasonable bundles of care is in an environment of relatively stable prices. With many new treatments and modalities coming to market, such methods are not possible.

Read the survey results


About the public’s health

New York county, declaring emergency over measles, seeks to ban unvaccinated from public places: Unvaccinated children are kept away from school as the method of enforcing public health measures. In the wake of 153 cases of measles in Rockland County, NY, a 30-day state of emergency has been declared that bans unvaccinated children from all enclosed public places, including schools, houses of worship, and shopping malls. Enforcement may be difficult but officials see the action as sending a serious public message about the importance of vaccinations.

Read the article

FDA proposes mammography rule to provide women with breast-density information: Women with dense breast tissue often have problems getting accurately read mammograms. The fault lies with the limits of the technology, which can either miss cancerous tissue or falsely give the impression of an abnormality. The FDA is proposing a rule that would require “mammogram providers to notify women with dense breasts about how the condition could affect the accuracy of their mammograms and recommend they talk with their doctors about whether they should have additional tests to check for cancer.”

Read the article (Washington Post but appears to be open access)

Debate about birth of new neurons in adult brains extends to Alzheimer’s disease: As the population ages, Alzheimer’s disease has become a public health issue- to afflicted individuals as well as the family and caregivers. Treatments have focused on preventing or reversing the accumulation of proteins in nerve cells that are the hallmark of the disease.
This new research provides another possible route of attack. It was formerly thought that new brain cells cease to form at a young age. It has now been found that adults who normally age will continue to produce new cells in the hippocampus (though at declining rates). But new formation is markedly reduced in people who are developing and who have fully developed Alzheimer’s disease. Perhaps focusing on this abnormality will hold greater promise for prevention and cure of this devastating condition.

Read the article (This article is an editorial in Nature and is open access. The original research is by subscription)

About pharma

Purdue agrees to pay $270 million to Oklahoma to resolve OxyContin lawsuit: In the ongoing story about the origins of the opioid epidemic, the manufacturer of OxyContin has agreed to pay the state of Oklahoma to settle a suit over its role in promoting use of these drugs. It will undoubtedly be the first of such payments to governmental entities and individuals.

Read the story

Dignity Health and Shields Health Solutions Bring Affordable Medication and Services to Patients with Complex Chronic Illnesses: Pharma costs and availability have caused hospital coalitions to manufacture their own generic drugs. But high costs are really driven by specialty pharmaceuticals. So Dignity Health is partnering with a specialty drug company to get a handle on costs and continuity of care. The center of these activities will be a hospital-based specialty pharmacy at Dignity Health‘s St. Joseph’s Hospital and Medical Center in Phoenix, which will support all of the system’s locations. [Dignity Health and Catholic Health Initiatives have recently united as one ministry: CommonSpirit Health™.]

Read the announcement

White House, Pelosi in talks on drug pricing legislation: One issue that has bipartisan support is addressing high drug costs.

Read the article

About devices

Device-Safety Experts To FDA: Make Data Public: This article is an update on a previous story in this blog. Many safety device failures have not been made available to the public because of an alternative reporting pathway in the FDA. Read the story for a good refresher on this issue and what is proposed to remedy the problem.

Read the article

Today's News and Commentary

About insurance

ObamaCare enrollment declines slightly to 11.4M sign-ups for 2019: The final numbers are in and show ACA exchange enrollment down by 400,000 from last year. Premiums were up 1.5% on average, but most articles about this news item fail to report the huge price disparities among states. The exact reasons for the drop were not reported. Some blame Trump administration actions to limit enrollment assistance. Others raise the possibility that the fall is good news- more people are employed and are thus on their workplace insurance plans.

Read the announcement

In shift, Trump administration backs judge’s ruling that would kill Obamacare: The healthcare story of the day is that the Trump administration has changed its stance in the appeal of the legality of the ACA. Recall that a US District judge in Texas ruled that because the penalty for not having insurance was repealed, and because the Supreme Court based its constitutionality decision on the presence of the penalty (which the Court ruled was really a tax), the ACA should now be considered void in toto. The justice department originally said the whole law should not be repealed; now it sides with the District Court’s decision and will back it when several states’ attorneys general appeal the case.

Read the story
Read the legal brief of the appeal

Today, House Speaker Pelosi will announce a Democratic outline for a health proposal

You can access the speech here

State-by-State Estimates of the Coverage and Funding Consequences of Full Repeal of the ACA: To provide an understanding of the impact of ACA repeal, read this Urban Institute report published about a week ago.

Read the report

Extended Non-Enforcement of Affordable Care Act-Compliance With Respect to Certain Policies: When the ACA was passed in 2010, certain non-compliant plans were “grandfathered” in for a time. The idea was to give these plans time to come into compliance. CMS has just issued a notice that the grandfathered plans will be allowed for yet another year. This move is another attempt to undermine the ACA.

Read the announcement

About the public’s health

Americans are getting more miserable, and there’s data to prove it: American’s self-reported happiness is the lowest it’s been since at least 1976. Interestingly, Republicans are much happier than Democrats. Health status is also a significant contributor to happiness.

Read the article (From the Washington Post but appears to be open access)

Public Policies to Reduce Sugary Drink Consumption in Children and Adolescents: The American Academy of Pediatrics and American Heart Association have issued a number of recommendations to curb sugary drink use in children and adolescents. Two policies are noteworthy: imposition of increased costs (through such measures as higher taxes) and restrictions on advertising to this group.

Read the policy paper

New guideline recommends low-dose aspirin for many fewer patients: This new guideline has been in the news for the past week. The short article distills it with some other health recommendations from the American Heart Association and American College of Cardiology.

Read the report

Acute Illness Associated With Cannabis Use, by Route of Exposure: An Observational Study: Regardless of your personal feelings about the legality of cannabis availability, a major issue is safety. One problem with promoting safety is that cannabis preparations do not have standardized contents of the active ingredients (THC and CBD). The result is that: “ [Emergency Department, ED] Visits attributable to inhaled cannabis are more frequent than those attributable to edible cannabis, although the latter is associated with more acute psychiatric visits and more ED visits than expected.”

Read the article abstract

About devices

FDA Issues Warning Over Paclitaxel-Coated Balloons, Stents: Paclitaxel is a chemotherapy agent that has been found to slow tissue growth inside blood vessels if it is coated on balloons that expand blockages or stents that hold the vessel open. Based on an updated review of a meta analysis published several months ago, the FDA has issued a warning covering use of such coated devices. The research showed “among the 975 subjects in… 3 trials, there was an approximately 50% increased risk of mortality in subjects treated with paclitaxel-coated devices versus those treated with control devices (20.1% versus 13.4% crude risk of death at 5 years).”

Read the short announcement
Read the FDA letter

About pharma

20 most expensive drugs in the US in 2019: This article is FYI. It excludes drugs that are administered by a healthcare provider. So they are not truly the most expensive. Still, it provides some useful information.

Read the list

Today's News and Commentary

About healthcare IT

Data sharing practices of medicines related apps and the mobile ecosystem: traffic, content, and network analysis: We know that a variety of apps share information with other apps. But to what extent is this practice happening in healthcare? This interesting study used four fake accounts on 24 healthcare sites to track what happens to the data. The bottom line: “19/24 (79%) of sampled apps shared user data.” An additional problem is that none of the sites allowed an opt out on sharing data. Time for more transparency and control of individual data?

Read the study

FDA, DHS Alert to Cybersecurity Flaws Affecting Medtronic Cardiac Devices, Programmers, Monitors: In addition to privacy, security is also an ongoing concern. The title of the article is self-explanatory. As we get more into a medical internet of things, we are increasing the hacking potential.

Read the story

Complying with information blocking rule will be a challenge without standardized APIs: HIMSS: In a related article, as government rules on information blocking are being implemented, lack of standardization among apps will make compliance problematic. Patient desire to not share all data among the apps that do communicate will further complicate compliance evaluation.

Read the article

About pharma

What's it cost to resolve 25,000 Xarelto lawsuits? For Bayer and J&J, $775M: A complication of Xarelto, and other similar anticoagulant medications, is, of course, bleeding. But a number of studies have shown that this complication is less frequent than with the traditionally used medication Coumadin (warfarin). The six cases that have gone to trial thus far have all been decided for the defendants. But the companies want to move forward and avoid the cost of future litigation- so they are willing to come up with $775million to pay plaintiffs. Another victory for our tort system.

Read the article

Drug Prices on TV? They May Be Coming: As previously reported, one federal initiative aimed at lowering pharmaceutical costs is to require pharma-sponsored tv advertising to include price information. Some companies are starting to voluntarily comply by providing on-screen information or listing a website where complicated pricing can be better explained. This article is a nice review of what is happening and who the stakeholders are.

Read the article (NY Times but appears to be open access)

About devices

FDA clears Genetesis’ heart imaging device: This device is a real breakthrough. It can measure a number of cardiac abnormalities by mapping the heart’s electromagnetic fields. The concept has been around for a few years but previous machines required supercooling technology; this version does not- allowing for greater use, including diagnoses in the ER.

Read the announcement
Read about the technology

About insurance

Why hospital associations are dipping their toes into state-based Medicare ACOs: This consolidation has been a long time coming. When hospitals each have their own ACOs, they are responsible for patients who go outside their systems. If hospitals banded together, they could coordinate care and keep “out of network” pricing down. Further, they can also pool resources to get economies of scale and scope. It makes sense that hospital associations would coordinate such activities. Carried to its logical conclusion, you would have state-specific insurance plans that originated from individual hospital plans. What a novel idea! Oh…wait, I forgot about the origin of Blue Cross plans in 1929.

Read the article

Estimated Costs of a Reinsurance Program to Stabilize the Individual Health Insurance Market: National- and State-Level Estimates: One proposal to stabilize the individual health insurance market is to offer federal subsidies for reinsurance to companies who offer this product. This research puts a cost on this plan: “… a reinsurance program with an 80% payment rate and a $40,000 to $250,000 reinsurance corridor would cost $9.5 billion in 2020, or $30.1 billion for 2020-2022 (assuming 5.5% inflation in medical expenditures).”

Read the research

State Innovation Models (SIM) Round 2: RTI prepared this report for CMS to evaluate the second round of the Center for Medicare and Medicaid Innovation's State Innovation Model (SIM). The aim of the project is to get study states to have 80% of payments be value-based (VBP) models (public and private programs). The report found some progress in three areas:

“(1) aligning commercial stakeholder interests toward payment reform,
(2) advancing behavioral health integration and primary care transformation, and
(3) establishing the infrastructure for population health planning and coordination.
The next report, AR4, will explore state experiences related to the impact of specific strategies in each of these three areas.”

However, the report also identified three ongoing obstacles to achieving success: “recruiting small, independent practices to participate in VBP contracting; …. statewide shortages of health care workers essential for delivery transformation; …and lack of federally facilitated models to transform delivery and payment in rural markets, where Medicare is a dominant payer.”

Read the report

The Uncertain Effect of Financial Incentives to Improve Health Behaviors: This opinion piece is a nice summary of the pitfalls of providing financial incentives to change physician behavior.
Many of these programs are just payments for doing something specific- prescribing a stain, for example. But these methods are usually layered on the broken pay-by-volume system, so they have to be substantial in dollars to attract any attention.

Read the research (From JAMA but appears to be open access)