Chief Medical Officer's Top 5 Clinical Stories You May Have Missed in 2015

December 29, 2015

Chief Medical Officer's Top 5 Clinical Stories You May Have Missed in 2015

I am looking back on the challenges and milestones in healthcare that have occurred in the last year. Here are my top highlights from 2015:

1) Impact of government exchanges on population health and healthcare costs:

According to early estimates reported from the National Health Interview Survey (NHIS), conducted by the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS), the number of uninsured people of all ages in the first three months of 2015 was 29 million (9.2%), which is 7 million fewer people than the same period in 2014.  The results show a continued decline in the uninsured since 2013.  This means more people in the U.S. have access to health coverage through the government exchanges, but it’s unclear whether or not the quality and cost of healthcare for these individuals has improved.

From a consumer perspective, it appears that the jury is still out on the impact from the exchanges on quality of care and out-of-pocket costs.  Based on data collected by the Henry J. Kaiser Family Foundation through a survey of adults who had purchased their own coverage, consumers had mixed reviews:

  • 34 percent of enrollees cited lower costs or better access to care, while 29 percent said they were negatively affected, generally as a result of increased costs.
  • 71 percent of those who enrolled in a plan rated their coverage as excellent or good, with 55 percent saying it is an excellent or good value for what they pay; however, 39 percent rated it as an “only fair” or “poor” value.
  • 43 percent said that it is difficult to afford the monthly premiums and nearly half, 46 percent, are not confident they would be able to afford their share of the cost of a major illness or injury.  About one third of those with new plans say they are dissatisfied with their deductibles.

And, there is also the question of impact to the insurance providers.  A number of the large insurance companies are losing money on the exchanges because they’ve found that enrollees were sicker than expected and strong utilizers of services.  Insurers are hoping that new consumers, especially those who are younger and healthier, will sign up to offset the initial surge of sick members.  But many of these healthier individuals have avoided the exchanges due to rising premiums, high deductibles and limited provider networks. 

So, it remains unclear whether the coverage that’s being offered through the health exchanges is providing consumers adequate access to high-quality, affordable healthcare.

2) Healthcare Reimbursement Shifting from Fee-for-Service to Value-Based: 

The shift to value-based reimbursement from the traditional fee-for-service model is forcing providers to change the way they bill for care.  Rather than billing based on the number of visits or tests ordered, payments to providers are now based on the value of care delivered.  This shift is driving improvements to the quality and affordability of the care provided.

In a recent Becker’s Hospital Review article, Ken Cohn, MD, MBA, FACS, discusses his belief that hospitals can start transitioning to a value-based culture “by changing the way physicians interact with patients and each other…”  In the article, Dr. Cohn, discusses five ways hospitals can start moving away from volume towards value-based care.  Two of his points were especially impactful to the care of patients outside of the hospital walls:

Eliminate non-value-added care.  

Based on reports from The Dartmouth Institute for Health Policy and Clinical Practice, it is estimated that 40 percent of the medical care provided in the U.S. may not add value.  Additionally the article cites a study released by the American Academy of Orthopedic Surgeons, in which it was found that 96 percent of orthopedic surgeons practice “defensive medicine”, with 24 percent of tests being ordered without significant benefit to patients.  These findings show that as healthcare transitions more to value-based care, physicians will need to work more closely together to remove unnecessary steps in the delivery of care that are not the in the patient’s best interest.  As an example, in 2012 the ABIM Foundation launched the Choosing Wisely® campaign focused on advancing a national dialogue on avoiding unnecessary medical tests, treatments, and procedures.  To date more than 70 national medical specialty societies have released recommendations to help facilitate decision-making about the most appropriate care based on a patient’s individual situation. 

Encourage patients to make better decisions about their health. 

In a 2002 Health Affairs study, it was found that the contribution of medical care to longevity is only about 10 percent, compared to 40 percent for patient behavioral patterns.  This study speaks to the importance of encouraging patients to adopt a healthy lifestyle.

Value-based care isn’t about seeing more patients, but more about delivering higher quality care ― care that impacts patients overall health and well-being.  The shift to value-based care is a critical step towards transforming our healthcare system.

3) Providers focusing on multi-factors determining individual health: 

Physicians are changing how they are currently using determinants of an individual’s risk for disease, from only looking at one contributing factor e.g. cholesterol as a risk factor for heart disease, to instead focusing on how multiple factors can impact the health of an individual.   According to an article published by the World Health Organization, there are multiple factors that affect the health of individuals:  environment, genetics, socio-economic status, education, and relationships, all of which have significant impact on our health. 

It is the interrelationships among the multiple factors that determine individual and population health. It has been found that interventions that target multiple determinants of health are most likely to be effective.

4) New Drugs Approved by the FDA for Hepatitis C: 

According to the Centers for Disease Control and Prevention (CDC), currently there are approximately 2.7 million Americans infected with Hepatitis C virus (HCV).  Hepatitis C is a liver infection caused by the hepatitis C virus, a blood-borne virus.  In July, the U.S. Food and Drug Administration (FDA) approved two new drugs in the treatment of Hepatitis C, one for genotype 3 and the other for genotype 4, which is the least common form. 

The first drug, NS5A replication complex inhibitor daclatasvir (Daklinza, Bristol-Myers Squibb), was cleared for use with sofosbuvir (Sovaldi, Gilead Sciences) to treat HCV genotype 3 infection.  The FDA indicated in its news release, “Daklinza is the first drug that has demonstrated safety and efficacy to treat genotype 3 HCV infection without the need for co-administration of interferon or ribavirin.”  The second medication approved is a combination of ombitasvir, paritaprevir, and ritonavir (Technivie, AbbVie) in a tablet for use with ribavirin in adult patients with Hepatitis C virus (HCV) genotype 4 infection without scarring and cirrhosis.  Both of these drugs have given providers new options in treating this challenging disease.

These new drugs are in addition to Harvoni, a combination of sofosbuvir (Sovaldi) and ledipasvir, which was FDA approved in October 2014.  The drug has cured more than 90 percent of patients with hepatitis C genotype 1, the most common form in the U.S., after 12 weeks of treatment.  The combination of all three of these medications has been curative for patients with this disease.

5) Free-standing ERs and Urgent Care Venues Changing the Delivery of Care: 

While patient demand for emergency services is increasing, capacity has become more challenging in hospitals.  Over the last ten years there has been a growing demand for other venues that can meet the increasing need for urgent and emergency care.  High-tech, free-standing emergency rooms are popping up to fill the gaps in care, which are increasing the cost of care without increasing value or positively impacting health outcomes.

Free-standing emergency rooms have been expanding rapidly nationwide over the last ten years and now number more than 400 in 45 states.  They are different from urgent care centers in that they are typically open 24 hours and have more high-tech equipment.  They are often located in or around high-end shopping centers and target consumers with private insurance. Although free-standing ERs are offering convenience to patients and helping to ease overcapacity at nearby hospital ERs, they have relatively limited services and are having a significant, and detrimental, impact on overall healthcare spend.

There is mounting concern that free-standing ERs are pulling patients with minor health problems away from lower-cost urgent care centers or doctor’s office, which is increasing costs to insurers and consumers.   Steep prices are being charged at rates similar to hospital ERs, e.g. $1,000 for a single visit, making it costlier than a visit to urgent care and contributing to higher insurance premiums.

Beyond the convenience for consumers, some experts are saying that free-standing ERs may help solve the growing challenge of providing healthcare access as hospitals in rural and underserved areas close.  Primary care physicians, in the Direct Primary Care Medical Home model, can defray the cost of ER utilization by providing coordination of care to their patients and helping them select the most appropriate venue to deliver care.

I am hoping these news stories spur you to think more about these important healthcare topics and how they impact patient care.  If you’d like to discuss any of these topics, follow me on Twitter @jennybajajmd

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