The week in review: June 24-29, 2012
MedWire News: The Supreme Court decision upholding the Patient Protection and Affordable Care Act grabbed most of the attention this week, but other stories of import to US physicians still made news, including the AMA's annual ranking of health insurers, recommendations for screening older men for osteoporosis and everyone for obesity, a call for tight regulation of MD-owned health care facilities, and pilot programs for reducing prescription drug abuse.
High court shocker: Affordable Care Act A-OK
The Supreme Court has ruled that the controversial "individual mandate" provision of the Patient Protection and Affordable Care Act (PPACA) passes constitutional muster as a tax, and that the law itself is constitutional.
The ruling allows the law to be implemented largely intact, and is expected to substantially reduce the number of US citizens without health insurance, currently estimated to be between 45 and 50 million.
Although the Obama administration had argued that the individual mandate provision was enforceable under the interstate commerce clause of the constitution, the five justices in the majority agreed that the law treats failure to buy health insurance as a tax, and that Congress has the power under the constitution to impose taxes.
The court also held that the law's provisions governing the expansion of Medicaid, a federally funded program administered by individual states, is valid, but added that neither Congress nor the President has the power to punish states that do not comply with the law by withholding all Medicaid funding.
The Court did rule, however, that the federal government may withhold new Medicaid funds from states that are not in compliance with the law when it is fully enacted in 2014.
All other provisions of the PPACA are understood to remain intact, including currently enforceable provisions allowing young adults to remain on their parents' health insurance and preventing insurance companies from refusing to insure children with "pre-existing conditions." The pre-existing condition protection will be expanded to adults in 2014.
Medical organizations give decision thumbs up
Hot on the heels of the Affordable Care Act decision, professional medical associations weighed in on the ruling and what it will mean for clinicians, patients, and insurers.
The American Medical Association (AMA), which had staunchly opposed earlier healthcare reform efforts, including Medicare and Medicaid in the 1960s, issued a statement strongly supporting the Supreme Court's rulings.
"The expanded healthcare coverage upheld by the Supreme Court will allow patients to see their doctors earlier rather than waiting for treatment until they are sicker and care is more expensive. The decision upholds funding for important research on the effectiveness of drugs and treatments and protects expanded coverage for prevention and wellness care, which has already benefited about 54 million Americans," said AMA president Jeremy Lazarus in a statement.
Nancy Brown, Chief Executive Officer of the American Heart Association, noted that "by upholding the law, the nation's highest court has sent a clear message that patients should be the first priority in an ever-changing healthcare arena."
"Broad, individual responsibility for healthcare is the foundation for successful implementation of the Affordable Care Act's patient protections," said The American Academy of Family Physicians president Glenn Stream.
In Massachusetts, where a similar law was enacted by then Governor Mitt Romney in 2006, the ruling is seen as vindicating the concept of joint individual and societal responsibility for healthcare.
"Physicians in Massachusetts have been strong supporters of our state health reform movement from the beginning. Universal coverage has been better for our patients, and it's been better for the practice of medicine. When people have insurance, they are more likely to get the care they need, when they need it," said Massachusetts Medical Society President Richard Aghababian.
No bones about it: screen older men for osteoporosis
Men aged 70 years and older, and men in their 50s and 60s with risk factors, should be screened for osteoporosis with central dual-energy X-ray absorptiometry (DXA), say updated guidelines from the Endocrine Society.
The guidelines, published in the Journal of Clinical Endocrinology and Metabolism, include the following recommendations:
- Men 70 years and older and those from the age of 50‑69 years with risk factors for osteoporosis should be tested with DXA.
- Men with vitamin D levels below 30 ng/ml should take vitamin D supplements to achieve at least that level.
- Men 50 years or older who have had hip or spine fractures, those with T scores of -2.5 (the threshold for osteoporosis), and those who are at high risk for fracture due to low bone mineral density and/or clinical risk factors should receive pharmacologic therapies.
- Clinicians should monitor bone mineral density in men who are being treated for osteoporosis with DXA of the spine and hip every 1-2 years.
- Men at risk for osteoporosis should incorporate 1000 to 1200 mg of calcium daily into their diets, preferably through food sources, or calcium supplements as required to ensure adequate intake.
Physician, divest thyself
Physician-owned hospitals should be banned in the USA, because they represent a fundamental conflict of interest between the medical needs of patients and the financial health of the physician owners, says a business ethicist.
The PPACA contains provisions strictly regulating, but not outrightly prohibiting, physician ownership of hospitals, and that is a shame, suggests Joshua Perry, from the University of Indiana (Bloomington) Kelley School of Business.
Perry supports the strict regulation of physician-owned hospitals, noting that the law prevents newly created or expanded doctor-owned hospitals from filing Medicare claims if there is evidence of self-referral ‑ that is, if the referring physician has a financial relationship with the facility.
Currently operating physician-owned facilities are not subject to the new rules, however, and therein lies the rub, Perry says.
"A more prudent, ethically driven course would have been complete closure of existing loopholes that gave rise to physician-owned facilities and the retroactive removal of Medicare certification from those currently operating," Perry said.
Physician-owned specialty hospitals, such as cardiac orthopedic, or specialty surgery centers, treat a less-sick "lower severity" population than do general hospitals, the author found, suggesting that such facilities "either intentionally skim the cream off the top of the patient population or limit treatment to the healthiest and least costly patients."
Doctor-owned hospitals also tend to have low staff-to-patient ratios, more single-patient rooms, and higher employee compensation costs than general hospitals, making them more costly than other centers, Perry notes.
Health insurers earn AMA nod
The largest US health insurers have shown substantial improvement in the accuracy and speed of paying medical claims over the past year, earning praise, if not a gold star, in the American Medical Association (AMA) 5th annual "National Health Insurer Report Card."
Error rates on paid claims were cut in half, from 19.3% in 2011, to 9.5% in 2012, the report card notes.
However, some of the cost savings generated by improved claims accuracy ‑ ranging from 98.3% for UnitedHealthCare to 87.4% for Humana, two of the nation's seven largest commercial insurers ‑ were "partially offset by administrative costs associated with a resurgence of intrusive managed care policies on clinical decisions."
Currently, 4.7% of medical claims are for services for which insurers require pre-authorization, an increase of 23.0% compared with the previous year. The AMA estimates that the requirements will add approximately $ 728 million to the nation's healthcare tab this year.
Insurers have sped up claims handling, improving response times by 17% from 2008 to 2012, and they have become more transparent about the decisions they make to approve, deny, or modify claims, the report card said.
However, medical claim denials, which had been in decline from 2008 through 2011, have been creeping back up, the AMA found, with every private health insurer except Humana increasing its denial rate. Anthem Blue Cross Blue Shield, the most frequent denier, rejected 5.07% of all claims. In contrast, Regence, the most accepting company, had a denial rate of 1.38%.
Midwest states testing ground for Rx abuse programs
Indiana and Ohio will serve as proving grounds for pilot projects aimed at reducing prescription drug abuse, the US Department of Health and Human Services (HHS) has announced.
The agency will monitor whether expanding and improving provider access to prescription-drug monitoring program (PDMP) databases can help to identify prescription drug abuse cases in ambulatory and emergency care settings.
HHS, in cooperation with state, public, and private health agencies, has embarked on two projects testing whether wider dissemination of the information contained in PDMPs can help stem the tide of prescription drug abuse.
PDMPs are computerized databases that collect and analyze electronically transmitted data on the prescribing and dispensing of medications within a state. Currently 49 states have PDMPs that are either active or in development.
The Indiana project will center around emergency department acquisition of data on patient history of prescriptions for controlled substances, using an electronic medical record system developed by the Regenstrief Institute in Indianapolis.
The Ohio demonstration project will focus on the question of how drug-risk indications in electronic medical records affect clinical decision making at the point of care.
Screen for obesity, says USPSTF
The US Preventive Services Task Force (USPSTF) has issued final recommendations on primary care screening and management of obesity in adults, and on behavioral counseling aimed at reducing cardiovascular disease risk.
The obesity recommendation states that adults aged 18 years or older should be screened for obesity, and those with a body mass index of 30 kg/m2 or greater should be referred to "intensive, multicomponent behavioral interventions."
The USPSTF found that the most effective interventions included behavioral management activities such as individual and group counseling sessions, diet and nutritional counseling, physical activity, setting weight loss goals, self-monitoring, and strategies for overcoming barriers to change and for maintaining healthy weight.
The recommendation paper notes that individuals who participated in behavioral interventions lost an average of 4 to 7 kg (8.8 to 15.4 lbs), equivalent to about 6% of baseline weight, compared with little or no weight loss in a no-intervention control group. The Food and Drug Administration considers a 5% weight loss to be clinically important, task force members add.
In addition, among obese patients with elevated plasma glucose, behavioral interventions decreased incident diabetes by approximately 50% over 2-3 years, with a number needed to treat of only seven to prevent one diabetes diagnosis.
By Neil Osterweil