Is the Broker Model Broken?

If you ever squirm through the seeping underbelly of dastardly health insurance tactics like we do here at KBGH, you may have seen this report from The Hill last week outlining some alleged underhanded tactics being used by health insurance brokers.

The tl;dr (too long; didn’t read) version of the story is that the Government Accountability Office (GAO) performed an undercover audit of insurance brokers to determine if companies selling health plans exempt from the Affordable Care Act coverage requirements were being honest about the limitations of those plans. After all, ACA non-compliant plans tend to be cheaper, but they also tend not to cover preexisting conditions.

Out of 31 undercover phone calls to representatives in Alabama, Florida, Kansas, Pennsylvania, and Wyoming, during which GAO agents posed as customers looking for health insurance that covered their preexisting conditions like diabetes or cancer, about a quarter of the time (eight calls) sales representatives engaged in “potentially deceptive marketing practices.” Examples included:

1. Representatives telling the undercover agents that preexisting conditions would be covered, even when the agents claimed conditions that were explicitly excluded by the plan in question.

2. Representatives refusing to provide documentation of coverage prior to enrollment.

3. Representatives implying or asserting that the customer was being enrolled in a comprehensive insurance plan rather than, for example, a health care sharing ministry or membership in an association with a bundle of limited benefit plans.

4. Representatives suggesting that no other coverage was available.

5. Representatives intentionally falsifying the caller’s health status on the application.

 Examples of call recordings are available online.

In spite of its shades of its Dateline NBC-esque qualities, this doesn’t seem to have been a showy, “gotcha” operation. The investigation was requested by Democratic senators Robert P. Casey and Debbie Stabenow as a follow up on an investigative report on misleading online ads for non-ACA plans. But the GAO is a nonpartisan organization. The Hill, which reported the story, is well-known as a centrist or even center-right publication. And as Katie Kieth points out in Health Affairs, this isn’t even the first report of its kind. Many other instances of this kind of behavior have been documented.

What does this mean for you, the employer?

This news alone may not be very relevant to your company’s health coverage. After all, these agents were posing as individuals seeking a non-ACA compliant plan. If you’re in Human Resources this is very unlikely to represent your interactions with a brokerage or the greater health insurance industry. But this isn’t the first time the insurance brokerage industry has been stung recently. In early 2019 a Propublica piece showed that brokers working on commissions–usually three to six percent of the premium–routinely increased the cost of benefits to companies. This isn’t a personality flaw in the broker agents; it’s a feature of a flawed system.

To my knowledge no one has been able to mount a significant defense against these allegations. To the contrary: the 2019 Propublica piece led to senators calling for disclosure of perks and fees paid to brokers, a position enthusiastically supported by Michael Thompson, the president and CEO of the National Alliance of Healthcare Purchaser Coalitions, of which KBGH is a member.

What you can do to protect yourself

KBGH believes that brokers can be a vital part of the health insurance marketplace. Health coverage is confusing, and it is worth good money to make sure your company is getting the best value for its health care dollar. Ideally, we would like to see all brokerages work on a fee basis and take no commission off your premiums, since that commission perversely incentivizes the broker to increase your health coverage costs. To make this easy, Health Rosetta has created a “Benefits Advisor Compensation Disclosure Form” that you can download for free to use with your broker.

But at the very least, we believe in transparency. Your broker should be able to disclose all the ways it is making money off its work with you up front. If your broker refuses to do that, we recommend that you find a new broker.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

Why Six Feet?

“We should all stand six feet apart to prevent the spread of COVID-19.” If you haven’t had that hammered into your head since March, let me be the hammer that takes the last lick at the nail.

Where did that number come from?

Six feet seems arbitrary. Why not five feet? Why not ten feet? In the August 25 issue of the British Medical Journal, “BMJ” for short, a few authors take us on a journey six feet long (or two meters, if you’re in one of the all-but-three countries that has switched from imperial to metric measurement; or two metres if you’re a true pedant).

The two-meter rule has a long history. Scientists in the 19th century, shortly after the very invention of germ theory, placed culture plates around patients who were then asked to cough or sneeze. Then the scientists could culture out whatever bugs landed on the plates. Most of the plates more than 1-2 meters from the test subject failed to grow anything scary. So, two meters became the default distance.

As cameras got better in the 1940s, visual representation of sneezes became possible:

Gross backlit sneeze snapshot brought to you by Wikipedia

One experiment showed that only 10% of droplets traveled as far as 5 ½ feet. So even though 10% of sneezers were able to eject harmful bacteria up to 9 ½ feet away, the two-meter rule was cemented. Unfortunately for hard-core two-meter adherents, recent studies have failed to fully support these original conclusions. Eight out of the ten studies included in a recent systematic review, for example, showed large numbers of respiratory droplets landing beyond 2 meters for particles up to 60 micrometers, a particle size large enough to contain thousands of copies of SARS CoV-2, although not small enough to deposit those viruses into your lungs.

Dragon breath-like eight-meter sneeze plume brought to you by Lydia Bourouiba via Wikipedia

What do we do with this information?

Not to pat my family on the back, but you do the same thing we did this weekend. You pretend that everyone in the world is a smoker, and you protect yourself from the imaginary PM2.5-rich smoke by wearing a mask and keeping your distance. On a shopping trip this past weekend, my wife and I ran into an acquaintance and talked with her, indoors, for several minutes. In our minds, she was actively smoking: we did not shake hands, hug, or get closer than a few feet, and everyone wore a mask.

Two days later, that person tested positive for COVID-19.

I’m going to be careful and self-isolate myself for a couple of weeks just in case; I’m fortunate that my work allows it fairly easily. But for the most part I feel safe because we were all masked, including the infected person, and we stayed relatively physically distant. Because as the authors of this review noted, the risk of transmission, even with prolonged exposure, is relatively low if everyone is masked and the environment is reasonably well-ventilated:

British Medical Journal

As we mentioned in a previous blog post, for example, two Missouri hairstylists who unknowingly exposed hundreds of people to the virus appear to have infected zero clients because of their fastidious facemask use.

So six feet isn’t magical. But it’s still a reasonable number, especially combined with good ventilation and good adherence to masking. The next time you see me, if I keep my distance and don’t shake your hand, it isn’t personal. It’s epidemiology.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

It’s Time For Your Flu Vaccine. Seriously.

With nighttime temperatures forecasted in the 40s next week, it’s no surprise that the time for influenza vaccination is upon us. And since this year’s seasonal flu coincides with an ongoing COVID-19 pandemic that is worse in America than in almost any other developed country, and because influenza vaccination will save lives and reduce symptoms that might be confused with COVID-19, CDC has details on new recommendations for vaccination. Here are the highlights of new information about the flu shot:

• Everyone aged 6 months and above should receive the influenza vaccine.

• Anticipate about two weeks from immunization to protection from the influenza virus.

• The timing of your shot isn’t critical. The duration of immunity from a flu shot is about four months, so the CDC recommends immunization before Halloween if possible in order to provide maximum protection through the heart of the flu season.

• Expect the vaccine to cut your risk of infection by about half, give or take:

• As always, the composition of the seasonal influenza vaccine is an educated guess based on trends in detected circulating viruses. The vaccine historically includes either three (“trivalent”) or four (“quadrivalent”) strains of virus. Each influenza A virus expresses a version of a sugary protein called hemagglutinin, or “H,” and a version of an enzyme called neuraminidase, or “N.” This year, in case you’re interested, trivalent egg-based vaccines contain:

  • Influenza A/Guangdong-Maonan/SWL1536/2019 (H1N1)pdm09 (a version of the virus implicated in the 2009 H1N1 Pandemic)

  • Influenza A/Hong Kong/2671/2019 (H3N2)

  • B/Washington/02/2019 (B/Victoria; a strain that accounted for the vast majority of influenza B infections last year)

• Quadrivalent (four-component) egg-based vaccines contain those three viruses in addition to influenza B/Phuket/3073/2013(Yamagata)

• Non-egg-based vaccines contain:

  • A different H1N1 called influenza A/Hawaii/70/2019(H1N1)pdm09

  • A different H3N2 called A/Hong Kong/45/2019(H3N2)

  • The same B/Washington/02/2019(B/Victoria)

  • The same B/Phuket/3073/2013(Yamagata)

• As you can tell, many versions of the influenza vaccine are available (and two new versions for folks aged 65 and up were recently approved), but the most important choice is not which vaccine to receive, but whether to get vaccinated. If you have questions about which vaccine is best for you, we encourage that you talk to your doctor or other health care professional.

• Common reasons to avoid a flu vaccination are having a fever that day, allergies to certain foods or ingredients like eggs or latex, or a previous serious reaction like swelling or seizure. Feeling a little sore after last year’s injection is not a reason to skip this year’s.

• Because remember: It is impossible to get influenza from the vaccination. The influenza vaccine contains only small amounts of either a protein that stimulates the immune system or an inactivated virus that is not capable of infecting anyone. In randomized, blinded trials (paywall) where some people got flu shots and others got only saline placebo shots, the only differences in symptoms was increased soreness in the arm and redness at the injection site in those people who got a flu shot. There were no differences between the groups in body aches, fever, cough, runny nose, or sore throat.

• In related news, since rates of routine childhood immunization have fallen during the pandemic, new rules from the Department of Health and Human Services now state that pharmacists nationwide will be able to administer routine childhood vaccines–that is, FDA-approved vaccines recommended by the CDC’s Advisory Committee on Immunization Practices for youth ages 3 to 18–during the COVID-19 pandemic. Needless to say, this is controversial.

For other questions about influenza vaccination, contact us or go to www.cdc.gov/flu/. Now go get your shot!

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

What is the value of a mask?

For various reasons the rate of infection in Kansas is back on the way up, and it’s bound to get worse as the weather cools and we all spend more time indoors together.

 As businesspeople, we want to see a return on our investment. But what if the investment we make isn’t in our business or in the stock market, but in our health, and specifically in COVID-19 protection? An analysis from Goldman Sachs recently tried to answer this very question.

How do masks affect usage, case rate, and fatality?

The investigators estimated that the “Effective Lockdown Index, or “ELI,” a statistic of their own that takes into account a combination of official social mobility restrictions and actual social distancing data, took away about 17% from American gross domestic product (GDP) between January and April this year.

Then they looked at data from multiple sources to make a couple big conclusions:

First, mask mandates immediately increase the number of people who mask by about 25%. This seems reasonable and in line with our local experience when the Sedgwick County and City of Wichita emergency orders went into place. (It’s also worth remembering on a national level that Florida and Texas, two of the most-affected states, still don’t have statewide mask mandates).

Second, mask mandates are associated with large reductions in cases and deaths from COVID-19:

Again, this is largely in line with the change seen in Kansas counties with mask mandates versus counties without mask mandates. So using some further reasonable assumptions and fancy statistical methods, the Goldman Sachs folks determined that a national mandate would cause a 15 percent rise in the share of the population that wears masks, which would in turn reduce the daily growth of cases by about one percent.

Gauging the economic impact of wearing a mask

With those numbers in their pockets, the investigators went back to their “ELI” to determine what fraction of the economy would be affected by another March/April-style lockdown:

They determined that another lockdown similar to this past spring’s would cost just short of 5% of total economic activity. As we said last spring, pandemic viruses cause recessions. Then authors writing in The Economist simply divided that share of GDP by the number of people who would start wearing masks under a mandate and came up with a value for mask wearing. They calculated that one American wearing a mask for one day prevents a fall in GDP of $56.14, or about double the initial fine that you would get in Wichita for being a recalcitrant mask non-wearer. As the authors of the Economist piece said, “Not bad for something that you can buy for about 50 cents apiece.” Clearly they’re not taking into account my designer taste in facial covering, but I digress.

 It’s tough to overstate how huge this potential cost savings is. For reference, doubling smoking cessation counseling services, as we covered in a previous blog post, returns about $215 per employee over ten years, the equivalent of about $0.06 per day. I’ll admit that’s not a fair comparison, since we’re comparing the benefit to the employer in the case of smoking cessation versus the benefit to the national economy in mask-wearing. But I think my point is made.

 I’m lucky to live in a mask-mandated city inside a mask-mandated county. But for the rest of us, if we want our businesses to stay open, and if we cannot count on mandates or enforcement at the city, county, state, or federal levels, we need to mandate mask use from our employees ourselves.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

Some telehealth codes are going away. How does this affect you?

In March of this year, you’ll recall that Centers for Medicare and Medicaid Services (CMS) let out the reins on telehealth services, resulting in telemedicine experiencing as much growth in three weeks as it had in the previous several years. Later, services were expanded even further to include things like physical therapy, occupational therapy, and many inpatient services.

The new proposed changes

Earlier this month, CMS released its proposed physician fee schedule for 2021, and they’ve predictably scaled back the services that are covered via telehealth. Gone are 74 codes that CMS finds have “no likelihood of clinical benefit” after the COVID-19 public health emergency ends. Some of the codes that are going away are for certain psychological testing, physical and occupational therapy, and several inpatient management codes.

In their place, though, CMS has approved nine new codes, covered through 2021 at least and ranging from care planning for patients with cognitive impairment to group psychotherapy. The mental health orientation of these new codes is exciting to us at KBGH because of our ongoing work with the Path Forward for Mental Health and Substance Abuse initiative, which includes improved access to tele-behavioral health as one of its five core areas of improvement. COVID-19 has brought an increased focus on the need for tele-behavioral health. Research released from the Wellbeing Trust reports that there could be an increase in “deaths of despair” with 75,000 more deaths due to suicide and drug misuse due to the pandemic. While more people are seeking mental health care, tele-mental health could make access easier, and also help overcome stigma still associated with mental health issues. We want to see telehealth used more extensively in mental health services! If you are interested in working with KBGH on this, please contact us.

But what’s the bottom line for the future of telehealth? It’s pretty positive overall. If your employee population is relatively healthy and unlikely to be hospitalized, and if you are located in a place with plenty of hospital beds staffed with ample physicians, then these new CMS rules aren’t likely to affect you much at all. For sicker patients, or for patients who may only have a hospital readily available that doesn’t have easy access to specialist physicians, these new rules may change their care compared to the last five months. But on the bright side, I hope that the several new telehealth services that are covered on a temporary basis are a signal that CMS has some willingness for experimentation moving forward.

Providing your feedback

If you’re interested in giving CMS feedback on these changes, please consider sending comments on the proposed rule at this link or by mail at:

Centers for Medicare & Medicaid Services, Department of Health and Human Services

Attention: CMS-1734-P

P.O. Box 8016, Baltimore, MD 21244-8016.

Comments on the proposed rule must be received by 5:00 p.m. on October 5, 2020.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

COVID-19 May Be Worse in the Fall. The Time to Protect Yourself is Now.

The rate of new COVID-19 cases is finally headed downward again in Kansas:

Statnews.com

We’re not through this yet.

With fall comes cooler weather and seasonal influenza stacked on top of the COVID-19 pandemic. This looming threat is causing foundational changes in our expectations of the season. Several college conferences have already cancelled sports. Theater releases of movies that cost hundreds of millions of dollars to produce have been delayed indefinitely, and others have gone straight to video on demand. The spookiness of the Halloween season is real, and getting realer every day.

So we and our employees should continue masking. Masking works (as long as the mask isn’t a fleece buff). We should continue socially distancing whenever possible, and we should obviously get vaccinated against seasonal influenza when we can. We should get the COVID-19 vaccine as soon as it is available. But what else can we do?

We can lose weight. Real disaster preparedness isn’t hoarding water or ammunition. It is largely the preparation of your body and your bank account for emergencies. A recent study in the Annals of Internal Medicine found that, especially in people younger than 65, obesity was one of the biggest risk factors for intubation and death with COVID-19. And the bigger patients were, the higher the risk. “Morbidly” obese COVID-19 patients–those with a body mass index, or BMI, of 40 kg/m2 or greater–were 60% more likely to die or require intubation, compared with people of normal weight:

Annals of Internal Medicine

And obesity may even decrease the effectiveness of a future SARS-CoV-2 vaccine.

So if you are one of the roughly 40% of Americans who are obese, then to protect yourself this fall, the time to start reducing risk is now. This isn’t about judgement or shaming. I’ve been very vocal in the past about my disdain for the opinion that obesity is some personal or moral failing. It is not. It is a product of genetics and environment, just like heart disease, cancer risk, and yes, risk for infections.

How can you, as an employer, help your employees reduce risk beyond vaccination?

Traditional worksite wellness programs are disappointing, unfortunately, although as we’ve blogged about in the past, some worksite strategies for weight loss have proven modestly effective around the holidays. And restricting one’s diet to “unprocessed” foods such as those in Group 1 of the NOVA Food Classification System appears to result in weight loss even without intentional dieting. If we take the problem seriously, though, we’re inevitably led to the question of coverage of weight loss programs like the Diabetes Prevention Program, coverage of weight loss medications, and coverage of bariatric surgery. [Disclaimer: KBGH is funded in part by two CDC grants that aim to identify obese or pre-diabetic people and refer them into programs like the Diabetes Prevention Program that help them lose weight and reduce their risk.]

If you’re not already covering these benefits, consider them the next time you update your employee benefits. And, as always, if KBGH can be any help in determining the potential benefits to your employees from these programs or treatments, please contact us!

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

How to be Productive at Work (at home)

I struggle with intense, focused work. I’ve blogged about it at length in the past. COVID-19 has shined a light on my shortcomings in focused work, just like it has exposed so many problems with our healthcare system and our ability to make collective decisions. My ability to think deeply requires even more effort now, in the work-mostly-from-home-era, than it did in the past. I blame my computer, with an assist from my cell phone and my lovable but distracting kids.

How distractions impact our productivity

I’m not alone. Work is changing and, for a fifth of us, the change may be permanent. A paper just posted on the National Bureau of Economic Research website looks at the changes in the work day since the COVID-19 pandemic. The investigators used meeting and email meta-data from over three million subjects and found that, compared to pre-pandemic levels, the number of meetings per person increased by about 13% and that those meetings were attended by about 13% more people. More meetings with more people–yikes. But thankfully, the average length of meetings declined by about 20%, for a net reduction in meeting time per person per day in the “post-lockdown period” of 11.5%. Unsurprisingly, email activity was up. And the length of the average workday went up by about 48 minutes, or 8.2%.

I am 100% in favor of shorter, more frequent meetings as this analysis reveals. (I’m particularly a fan of the Scrum framework for project management, in which all meetings are limited to 15 minutes and–at least in the old, in-person world–are to be held standing up to avoid people settling in for too long a meeting.) But this shift may represent a rearrangement of the chairs at the table, so to speak; even with shorter meetings, all the time we’re currently stuck to computer screens, switching from task to task, has been shown to lead to “attention residue,” a phenomenon by which thinking about your last task interferes with your ability to do your current task. I think this is probably reflected in the additional emails being sent.

Think of it this way: you’re banging away at a spreadsheet or a *ahem* blog post, and a text message dings from your phone. That ding takes you out of the flow of your work, and you have to spend time getting that flow back. How long does it take to get back to your pre-text message work level? Fifteen to twenty minutes! This means that, if you get interrupted by an email, text message every twenty minutes all day long, you’re effectively operating at a permanently reduced level. It’s the equivalent of driving your computer while drunk.

How to work differently to increase productivity

One of the authors who has most affected me in the last few years is Georgetown University computer scientist Cal Newport, writer of Deep Work, among several other productivity-themed books. Newport argues that, as more and more of our routine tasks become automated, the ability to perform tasks which are difficult to automate will be the most valuable skill someone can have. And to learn the skills necessary for those tasks, we need to be able to do focused, uninterrupted work without distractions. His tips on doing deep work and avoiding attention residue, as catalogued by others, are especially prescient for the COVID-19 era:

1. Choose a space that’s distraction free.

If there isn’t such a space in your house or office, use noise cancelling headphones to tell your brain it’s time to focus. Be consistent. If you need to signal to family or co-workers that you’re working, negotiate a signal, like a sign, a hat, or an overturned coffee cup on your desk

2. For each task, figure out how much time you’ll devote in a session.

You don’t necessarily need to finish a task in one setting, so feel free to start small, like 15 minutes, and work your way up from there, building your focus like a muscle.

3. Set an environmental structure that allows you to work deeply.

If you can, silence your phone. Ban yourself from non-focused internet for periods of time. Delete social media apps from your phone, or at least silence notifications. Eliminate email notifications on your desktop. If you use Microsoft’s Outlook email system, customize your settings to create a “personal focus plan.” If you’re writing on Microsoft Word, take advantage of the new “focus” feature that turns the usual screen into full-screen mode so that only text is allowed and all other functions are hidden. Focus mode is in the “View” tab, about ¼ of the way down:

4. Ban yourself from the break room or the kitchen during deep work sessions.

Set goals to measure the success of a session, like words written or powerpoint slides created. Post these rules for yourself where you can see them.

5. Value your free time.

That longer workday the investigators found? I bet that roughly equals the time that people spent commuting prior to the pandemic. Now that many of us aren’t commuting, I say we focus our attention during the day in order to take that time back for ourselves. Make a ritual to end the day and signal to yourself that your work is done.

 A professor of mine in medical school told me that she read non-medical books before bed because, if she didn’t, she would dream about patients all night. I’ve had the same experience with work, and I bet you have, too. Intense experiences during the day can be pretty sticky. Tracking off this, one of the strategies I’ve used for the last few years to engage my brain in focused, undistracted activity is to try to read at least 50 books a year, or about a book a week. I try to read a mix of fiction and non-fiction. I write down all the books I read to keep myself honest. I keep this habit for a few reasons: books, unlike the internet, have a beginning and an end. So I know when I reach the end that I’ve accomplished something, even if my next step is just to pick up the next book and start from page one. Books are cheap if you get most of them from the library.

As with other topics KBGH posts on, we’re here to facilitate discussion, not to be scoldy school marms. So if you’ve found other ways to improve the well-being of employees working from home, please let us know!

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

The COVID-19 vaccine will follow a legacy of remarkably safe vaccines

Trust in vaccines is waning

In addition to social distancing, masking, handwashing, and generally caring about the welfare of our fellow humans, we’re all counting on an effective seasonal vaccine to eventually get us out of the COVID-19 fiasco we’re in now. But survey data shows that a huge chunk of the population is wary of a potential vaccine. This is no surprise; even routine vaccinations are met with skepticism they didn’t receive a couple decades ago, in spite of a scientific literature that overwhelmingly backs up their safety and efficacy.

As you look for data to share with employees to encourage vaccination–not just for COVID-19, but for all vaccine-preventable illnesses–pay attention to work that was just published in the Annals of Internal Medicine (paywall). 

Understanding vaccine labels

Investigators from Sheba Medical Center, Rabin Medical Center, and Tel Aviv Sourasky Medical Center, all in Israel, performed a comprehensive review of “post-marketing surveillance” data over a 20-year period from January 1996 to December 2015. Specifically, they used the FDA’s Vaccine Adverse Event Reporting System (VAERS), a portal through which people can report possible medication adverse events, and then looked at the “labels” of vaccines, to see how the labels of 57 vaccines had changed over that period of time. Labels are those folded package inserts that come wrapped around any medicine bottle. Changes to labels are common after a drug hits the market. Invokana (canagliflozin), a diabetes drug that works extremely well for certain patients, for example, carries a “black box warning” on its label stating that it can increase the risk of foot amputation in certain people.  

But back to our study: for each safety-related modification to a vaccine’s label, researchers noted the date of the label change, the type of safety-related label change (like addition of a boxed warning like Invokana’s, a change in reasons to avoid the vaccine, or a change in other warnings and precautions), any safety issues related to the label change, and the source of the data that led to the label change (like post-marketing surveillance, publications in medical journals, or reassessment of data from old studies). 

Why vaccines labels might get changed

The investigators found that initial approval for 93% of the vaccines was supported by randomized controlled trials, the most reliable form of medical research. The studies were large, with a median 4,161 participants. So the vaccines got off to a good start. After approval, there were 58 label modifications over twenty years associated with 25 vaccines: 49 warnings and precautions, eight new contraindications to using the vaccine, and one safety-related withdrawal.

The most common source of safety data was post-marketing surveillance, which resulted in almost half of label changes. Most of that safety data was identified through the FDA’s VAERS, likely an indication of the quality of the FDA’s post-marketing surveillance of vaccines, even in the eyes of the Israeli docs doing the study. The most common safety issue resulting in a label modification was a change in the population to be vaccinated, such as adding or subtracting pregnant women or patients with abnormal immune systems. These made up about a third of label changes. Newly discovered allergies made up about a fifth of label changes, mostly due to changes in latex-containing packaging. 

We should still be encouraging vaccination

In spite of overwhelming evidence of vaccine safety, the researchers write that “Rates of vaccination uptake have been decreasing in recent years, partly driven by reduced public trust and parental concerns over safety. If vaccines are perceived as unsafe, uptake in the population will decrease further, and the prevalence of infectious diseases and their associated morbidity and mortality will increase.” 

It is our job as health and human resource professionals to have vaccination available, including an eventual COVID-19 vaccine, and to help our patients and employees make good decisions around vaccination. If you have had success in promoting vaccination in the past, to influenza, pneumonia, shingles, or other diseases; or if you have plans to launch a novel vaccination campaign around COVID-19 in the future, please share it with us!

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

You don't pay for smoking cessation. It pays you.

Out of my email inbox’s daily deluge of medical journal push notifications and study updates, an article recently stood out. It outlined a study recently completed by Dr. Tami Gurley-Calvez and Jessica Sand at the University of Kansas School of Medicine to determine the cost-effectiveness of smoking cessation services. The study was commissioned by NAMI, the National Alliance on Mental Illness, with funding from the Kansas Health Foundation.

Increasing coverage for more quit attempts

A single “quit attempt” is defined as four sessions of counseling and 90 days of any single FDA-approved smoking cessation medications like nicotine replacement, varenicline, or bupropion. The investigators compared the costs to payers of continuing to cover two quit attempts per year (eight sessions of counseling and 180 days of medication, as currently mandated by the Affordable Care Act), versus increasing coverage to 4 quit attempts per year, equaling sixteen sessions of counseling and potentially a full year’s coverage of a medication. Costs were the sum of the cost of the counseling sessions and medication costs. Benefits were the projected reduction in medical spending attributed to a reduction in the number of smokers. The investigators assumed a 4.4% relapse rate in people who had quit smoking for more than a year.

For smokers under the age of 65, either model–two quit attempts or four quit attempts–broke even by year four; that is, money paid for counseling and medications was equaled by reduced medical spending. But by year six, the cost-savings of the additional counseling sessions and additional medication coverage really took off:

By year 10, the per-person benefit of covering four quit attempts per year–$215–was almost double that of two quit attempts, at $109. This is to say that your return on investment for paying for additional smoking cessation services appears to roughly double when you double the up-front investment in counseling services and drug coverage.

If you feel a little leery about modeling studies right now, considering the difficulty epidemiologists have had in modeling responses to COVID-19 interventions, know that the conclusions of this study in terms of quit rates are well-established by clinical trials in real people.

We should always be careful about acting on the results of a single study. But there is a strong signal here that, if your company currently covers the ACA-minimum two quit attempts per year, you may benefit financially from increasing coverage to four quit attempts per year. Dr. Gurley-Calvez and Ms. Sand rightly point out that some companies may not expect to keep employees for the five to six years needed to reach net economic benefit. But they also note, as we’ve long pointed out to KBGH members, that if this type of coverage were applied uniformly across a number of diverse companies, we could collectively achieve these economic benefits alongside a healthier employee population, even if the members of that population changed jobs frequently.

If you have strategies your company has used in smoking cessation or substance abuse that you’ve found successful, please share them with us!

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

Diabetes Education is Important. It's So Important That You're Already Covering It

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The burden of diabetes

34.2 million Americans—a little over one in ten—have diabetes mellitus, a group of disorders of glucose metabolism that causes a buildup of sugar in the blood. Diabetes is the leading cause of blindness, kidney dialysis, and non-traumatic foot amputation in the United States. The damage of diabetes isn’t limited to its physical or psychological burden. People with diabetes spend about 2.3 times as much on medical care than people without diabetes: $16,750 in medical expenditures per year, compared with $7,151 for non-diabetic persons.

Empowerment through education

In spite of the incredible disease burden and cost of diabetes, less than seven percent of people diagnosed with diabetes receive Diabetes Self-Management Education and Support (DSMES, or “diabetes education”) within a year of their diagnosis. This is a problem. Diabetes education is one of the most powerful interventions we have for keeping people with diabetes alive. One meta-analysis (a study that combines the data of several separate trials into one dataset) found that attending diabetes education reduced the hemoglobin A1c level, the measure of one’s average blood sugar over a three-month time period, by almost 0.6%, roughly equivalent to taking another daily diabetes medication. Another meta-analysis found that attending diabetes education cut the risk of death by 26%. If true, this is as powerful an effect on death as blood pressure control or treatment of cholesterol.

So the Kansas Business Group on Health is working with the Centers for Disease Control (CDC) to increase awareness of and referral into diabetes education programs. You’re probably covering diabetes education services for your employees already, whether you intend to or not. The Diabetes Coverage Act states:

“Any individual or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization which provides coverage for accident and health services and which is delivered, issued for delivery, amended or renewed on or after January 1, 1999, also, shall provide coverage for equipment, and supplies, limited to hypodermic needles and supplies used exclusively with diabetes management and outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin-using diabetes if prescribed by a health care professional legally authorized to prescribe such services and supplies under the law.”

The benefit is still subject to the usual deductible and co-insurance, and medical necessity requirements.

And we believe employers should be working to get their diabetic employees to attend diabetes education classes. It may prolong the lives of workers, and it may save you, the employer, money (paywall). If you are interested in starting a program through your workplace to get more of your diabetic employees into diabetes education programs, please let us help!

If you’re not ready to go there yet, but you’re interested in finding a diabetes education program in your area, visit here.

How Employers Can Address Social Determinants of Health

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

What makes us healthy?

Modern medicine has something to do with it, and we should work to make sure everyone has access to good care. But visits to the doctor and the hospital probably only account for around 20% of health outcomes. Far more powerful predictors of health come from social and economic factors like family support and income, or from health behaviors like levels of diet, exercise, and smoking. So even countries with universal health coverage see differences in life expectancy between demographic groups, albeit smaller than those in the U.S. We call these predictors of health, the differences in conditions in the places where people live, learn, work and play, “social determinants of health.” They can be diced and divided a number of ways, but respected researcher Michael Marmot lists six categories: 1) conditions of birth and early childhood, like prenatal care and abuse; 2) education; 3) work; 4) the social circumstances of elders; 5) elements of community resilience, like transportation, housing, security, and a sense of community self-efficacy; and, 6) “fairness,” which he defines broadly as sufficient redistribution of wealth to ensure social and economic security and basic equity.

This can seem abstract, so to bring this idea home I encourage you to experiment with the CDC’s Life Expectancy Data Visualization Tool. You’ll see that the life expectancy in Wichita’s census tract 0027.00, centered on Seneca Street and Kellogg Avenue, is 67.1 years, far below the Kansas average life expectancy of 78.6 years. But go east to census tract 0073.02, centered on Rock Road and Douglas Avenue, and you’ll find a life expectancy of 83.8 years. Not coincidentally, the average income for census tract 0027.00 is $29,202, while the average income for census tract 0073.02 is almost three times higher, at $82,679. By my back-of-the-envelope calculations, traveling east from Seneca to Rock Road earns you an average of $8,488.41 additional annual income per mile and an additional 2.65 years of life expectancy per mile.

There are things we can do

That’s depressing. But what’s uplifting about thinking of health in terms of social determinants is that social determinants are modifiable. You can’t change your genetics or your family history of early heart disease. But you can, in theory, move to a safer neighborhood or get a higher-paying job or buy healthier food. And employers can help directly. Round two of what seems to be a revolving door of an infectious pandemic, as we’re experiencing now, may seem like a weird time to talk about this since many businesses are struggling even to keep their doors open and to hang on to essential employees. But I bring it up because COVID-19 has put a magnifying glass on the differences in medical outcomes between groups. Don Berwick has a powerful essay in last week’s Journal of the American Medical Association (paywall) in which he argues that due to political calcification, organizations–like your own company or employer–are possibly the best conduit for addressing social determinants of health, and they don’t have to be social workers to do it.

Help in some cases may be as simple as identifying employees that have been under-valued at your company and making sure they’re paid appropriately. People who make more money simply tend to live longer:

Taking care of employees also makes good business sense

This isn’t intended as a paean to socialism. It’s a strategy that may pay off for employers, too, and I don’t say that as a pointy-headed former academic. I’m simply repeating the case I’ve read in study after study. For example, in a well-known analysis in Harvard Business Review in the mid-aughts, researchers made the case that Costco, by paying its employees a higher wage with more generous benefits, not only had a superior, more stable workforce with less turnover than competitor Sam’s Club, but made almost twice as much money employee-for-employee: in the period of the study Costco made $21,805 in annual profit per hourly employee, compared with $11,615 at Sam’s Club.

Not everything is related to money. We know times are tight. If raises for certain employees aren’t in the cards, you could work within your own Human Relations department or with your employees’ physicians or payors to make sure your employees are screened for risk within social determinants, and it can be done via telemedicine. The University of California-San Francisco has compiled screening tools through its SIREN network. Your employees’ physicians may need some guidance with this. If so, tell them that they can document any positive findings and diagnosis codes from section Z55-Z65 in the ICD-10 catalog for billing and coding. If that seems too big a bite to take right now, organizations like 2-1-1 are ready to assist with local resources, even (or especially) during the current pandemic crisis.

If you decide to take on a project that aims for improvement in one of the social determinants, we are available to help with setting goals, managing progress, and measuring outcomes. Please get in touch with us as you move forward!

How you can help your employees make decisions

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Our work at the Kansas Business Group on Health straddles our employer-oriented pursuits and efforts to advance the goals of two grants from the Centers for Disease Control (CDC). One of the goals of our work with the CDC is to increase the number of people being screened for diabetes. For people who are “pre-diabetic,” meaning their blood sugars are higher than normal but not high enough to qualify for a diagnosis of “full-blown diabetes,” our goal is to get them into the Diabetes Prevention Program (DPP), a one-year behavior change program that, through dietary changes and increased physical activity, reduces the risk of progressing to diabetes by 58%.

This is a challenge. Though the DPP is a covered benefit through Medicare, it is not consistently covered by private insurers. And even with coverage, people’s enthusiasm for paying for and completing a program to treat a disease state that is asymptomatic is generally low. So we work with employers to make the DPP a covered benefit. You may have heard from us about this. If not, please contact us. But we also work with clinics on strategies to increase screening for diabetes and to increase patient use of the DPP.

So we were encouraged to see a paper in the Journal of General Internal Medicine this week (paywall) demonstrating a quick way to substantially increase the likelihood of patients agreeing to enter “intensive lifestyle interventions” like the DPP.

The investigators surveyed patients who qualified for the DPP to measure their intention to participate. 70% of patients at baseline said they would be willing to participate. Then the staff members of the health center presented this decision aid to the subjects by reviewing the icons, reading the written information out loud, and briefly discussing the participants’ needs and next steps:

Northwestern University

The backside of the decision aid, which I’m not showing here, contained open-ended questions assessing needs related to the prevention of type 2 diabetes and defining next steps for management. After seeing the decision aid, the participants in the study willing to participate in the DPP rose to 88%, a statistically significant increase.

This is encouraging for a couple of reasons. First, it didn’t matter who presented the decision aid to the participants. Staff members and medical assistants had similar results.

Second, this is the rare tool that has shown such a positive effect. Simply handing out pamphlets to patients repeatedly fails to change behaviors. When we try to induce behavior change through interaction with patients we have a bad habit of falling back on fear: “Quit smoking or you’ll die young.” “Don’t drink pop or you’ll get diabetes.” The trouble with this strategy is that it has almost no effect on complex, long-term behaviors like diet, physical activity, and smoking. Fear might work to convince someone to take an antibiotic for two weeks to keep from dying from pneumonia, for example. But for longer term decisions, we have to exploit people’s senses of autonomy, mastery, and purpose instead, just like we use in designing meaningful work for employees. (If you’re interested in this topic I recommend Drive by Dan Pink.) But those three components don’t lend themselves easily to a quick intervention. Doctors and nurses are trained in motivational interviewing to accomplish complex behavior change, but it requires a trusting relationship and time to work. This study showed that even a brief intervention, delivered both in writing and in person in a few minutes, can have a powerful effect. What if we could harness this strategy for other behaviors, like encouraging mask-wearing for COVID-19 protection?

The DPP, which is available both as an in-person class and via virtual platforms, has been shown to drastically reduce health care costs for employers of people at high risk of diabetes. If you want to know your own company’s potential savings, go to the American Medical Association’s Cost Saving Calculator. Let us know if we can help make this calculation. And if you’re interested in covering the DPP as a benefit to your employees, contact us!

What Are E-Consults, and Why Aren’t We Using Them More?

This is a re-print of commentary from a past Kansas Business Group on Health newsletter.

In the past, doctors routinely engaged in “curbside” consultation, where one doctor stops another one in the hallway or calls her on the phone to ask a question about patient care that he wasn’t quite sure rose to the level of needing an official in-person consultation. This was great for the system: the enquiring doctor got the information needed, and the patient theoretically benefited, all at zero cost. But the consulting, curbsided physician was not rewarded for her expertise. Enter “e-consults.”

With e-consults the inquiring physician, instead of paging or stopping the other doc, puts the question into a written format, usually through a secure online portal. Then the consulting doc can submit a written answer for a nominal fee. [disclosure: Justin Moore is an endocrine consultant for RubiconMD, an e-consult service]

This monetization of the curbside consultation has benefits: It keeps the care of the patient centered around his relationship with the primary care provider instead of fragmenting his care. It keeps the stakes low; if the primary care doc has chosen the wrong specialist by mistake, or asked a question that has little value, no one tends to be charged for the trouble. In the traditional system of consultation up to 40% of specialist referrals lack either medical necessity, correct specialist choice, or timely transmission of relevant documents. Finally, e-consults can be had immediately, often same-day. In the traditional system our most vulnerable patients, such as those cared for in Federally Qualified Health Centers (FQHCs), only 40% of intended specialist consults are ever scheduled, and there is a 40% no-show rate in those that are successfully scheduled.

This all translates to a $500 annual per-patient savings in one randomized trial of cardiology patients. Medicare even covers asynchronous consults like this now. So if your health plan doesn’t currently cover e-consults, consider a change in your benefits.

What does real disaster preparedness look like?

This is a re-print of commentary from a past Kansas Business Group on Health newsletter.

“Preppers,” those reality-TV characters always gearing up for The End Of The World, have a bad reputation: they’re kooky extremists praying for the government to fail, we think, or they’re the victims of end-of-days preachers stocking their bomb shelters with beans, rice, and ammunition. But the COVID-19 pandemic has given me a different perspective. Modern disasters don’t fit into the mold described by Mad Max movies, paranoiac end-of-days prophecies, or Hank Williams, Jr.’s “A Country Boy Can Survive.” Instead, modern disasters are likely the slow-motion, smoldering problems we’re seeing now: economic decline, a continuously threatening viral illness, and the seeming impending failure of institutions.

How do we prepare ourselves and our employees for this kind of disaster? After a Sunday evening deep-dive into disaster preparation that I’m not completely proud of (but not really ashamed of, either), I’m convinced hoarding dry goods won’t cut it. I see two big items crucial to disaster preparedness that many of us neglect (credit to ThePrepared.com):

First, guard yourself against financial difficulties. As Neal Gabler pointed out in a viral article in The Atlantic a few years ago, roughly half of Americans cannot scrape together $400 in an emergency without using credit cards. So before you or your employees buy emergency potable water containers for your basement, work on building a solid financial foundation. Companies like Tally will help employees get credit card debt under control. Most personal finance sites, like Robinhood, eTrade, and dozens of others now offer commission-free trading now to help put away even small amounts of monthly income for a future rainy day. You can consider making any retirement savings at your company “opt-out” rather than “opt-in,” a strategy that has been shown to radically increase savings rates. Consider a workshop for employees on end-of-life planning. It doesn’t have to be morbid. Make it clear that people with advance directives and wills have less end-of-life anxiety. Financial wellness is inexorably intertwined with physical wellness. As we’ve said before on the KBGH blog: given the high stakes of illness in this country, your doctor may be your real financial planner.

Second, get your physical and mental health to a point where you can handle the physical and emotional demands of an emergency. Ask yourself and your employees, can you walk far enough to get to the grocery store and back in case of a fuel crisis? Can you keep your mind clear under stress? Do you have addictions that will cripple you in case of a catastrophe? If the answer to any of those is “maybe,” now is the best time to start working on them. We should all work to make sure we have the strength to navigate our homes, our work, and our environment without the benefit of motorized transportation, elevators, and automatic doors. Encourage employees to start taking longer and longer walks from home to see if they can get to the grocery store or their kids’ school without a car. Encourage taking the stairs as often as possible (some companies even run the elevators purposely slowly to encourage this). Encourage employees to work to know that, if they fall, they can easily get back up and moving. If someone is not confident in his mind’s ability to handle undue stress, make sure they have the ability to see a mental health professional to learn coping skills for another crisis or to work toward being addiction-free.

It’s fine to indulge yourself in a binge-watch of Doomsday Preppers. But as you watch, pay attention to whether their strategies apply to you. You probably don’t need a gas mask. But you definitely need to be able to carry your grandkids up a flight of stairs and to write a check for $400 on short notice.

Wearing a Mask is an Act of Service

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

From February to October of 2002 father and son John Allen Muhammad and Lee Boyd Malvo killed more than a dozen people and injured several more on a crime spree that started in Tacoma, Washington and ended in an orgy of indiscriminate violence in and around Washington, D.C. The media devoted enormous time and resources to the shootings. Once it was clear the attacks were the work of a serial killer, on-air coverage often lasted for hours after each attack.

The attacks naturally caused a huge amount of public apprehension in the D.C. area. People at gas stations began walking rapidly around their cars in order to make themselves harder targets. Many gas stations hung tarps around fuel pumps to block the view of potential snipers. People attempted to buy gas at the National Naval Medical Center, as they felt safer inside the guarded fence of a military installation. Senate pages got a police escort to and from the United States Capitol every day and were confined to their residence hall except for work activities. Schools cancelled field trips and outdoor sports, and some schools hired additional security officers and changed after-school pick-up procedures in order to minimize the amount of time children spent in the open.

People began wearing bulletproof vests.

Imagine the public reaction if the scale of the D.C. sniper attacks were much, much larger. What if, instead of a dozen or so deaths over nine months, one to two thousand Americans were dying daily in the crosshairs of snipers. Imagine that elders, especially those with medical conditions, were the primary target of the snipers simply because they were easier to kill.

What would be our response to this internal threat? Would we hole up for a month, wait for the death rate from terrorist attacks to plateau, and then largely go about our business? No. I suspect we would devote billions or even trillions of dollars to identifying members of the group, arresting them, and prosecuting them. We would use sophisticated methods to track their movement.

And we would wear bulletproof vests.

You may have figured out where I’m going with this. My analogy is pretty transparent. After the sacrifice of ten weeks of social distancing (which may have prevented 60 million infections and many thousands of deaths), we’re all naturally tired. But a rogue agent known as SARS-CoV-2 is on the move in America and still killing thousands of people per day through not gunshot wounds, but from a disease called COVID-19. We’re not in a second wave of infection; we’re not even out of the first wave yet:

The virus doesn’t kill by gunshot. It kills by airborne transmission and infection of people’s lungs.

Our bulletproof vests are masks. And we should be wearing them.

I know it’s hard to keep up with changing advice. Under the assumption that all masks worn would be medical grade the CDC originally advised against wearing them to avoid shortages. So did I. But the evidence has become very convincing that even cloth masks--our “bulletproof vests”--don’t just protect us. They protect those around us, too. One study showed that if even 60-70 percent of Americans consistently wore masks, and those masks were at least 60-70 percent effective at preventing disease transmission, we would crush the reproductive rate of the virus. The goal of any strategy in infection prevention is to get the number of people infected in turn by each infected person, the “Re,” down to less than 1.0:

Proceedings of the Royal Society A

Watch the rate of infection fall as the rate of mask wearing increases and the rate of effectiveness of the masks increases! The bidirectional effect of masking shines light on a more important point: protecting against coronavirus, whether by being careful with social distancing, by handwashing, or by mask wearing, is an act of service, just like getting vaccinated for other infectious diseases. We can only do so much to protect ourselves; most of our work should be in protecting one another. Two hairstylists in Missouri, who saw hundreds of clients after being unknowingly infected themselves, appear to have infected zero clients because of their faithful facemask use.

So in that regard, COVID-19 is not like a serial killer. COVID-19 is like HIV. Where sex is the dangerous activity (along with shared needles), being indoors with other people is the dangerous activity with COVID-19. Ninety-seven percent of “superspreading events” are indoors. I like Linsey Marr’s analogy about how COVID-19 is like cigarette smoking. Imagine everyone smokes but you. She said, “The denser the smoke, the more likely it is to affect you. It’s the same with this virus: The more of it you inhale, the more likely you are to get sick.” So if everyone around you smoked, you would stay out of crowded spaces that would be quickly filled with smoke. You would try to stand as far from the smokers as you could. If you could open a window to clear some of the smoke, you would. And if you were forced to be in a crowded space you would wear a mask to filter the smoke. 

I’ve had a chance now to see several workplaces’ policies around COVID-19 safety. And they’re pretty good! But we need to encourage our employees to follow those same safety rules outside the office. Ninety percent of Americans report frequently wearing masks. I cannot help but believe that there is a flaw in that data. My recent masked trips to the grocery store in which a small minority of people were wearing them tells me the true number is much smaller than that.

I know it can seem like a performance to wear a mask in public when you may not even know a person who’s been affected by COVID-19. But this shouldn’t be about virtue signaling. Defeating a global disease requires global effort. Protect the people around you. If you’re outdoors alone, you don’t need to mask up. But if you’re in a crowd where you can’t stay six feet from other people, or if you’re indoors with people you don’t live with, for heaven’s sake, wear a mask.

We Need to Support Black Doctors

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The stark differences in health outcomes

We should never reduce any population of people to a set of statistics. Every one of those “statistics” has a story. But here are a few numbers that should get our attention:

African-Americans have a rate of COVID-19 that is three times higher than the infection rate of the population as a whole. Even worse, the risk of death of an African-American person with COVID-19 far exceeds that of other racial groups. While people of white, Latinx, and Asian descent have death rates that all fall between 20 and 23 deaths per 100,000 people, African-Americans have suffered a death rate more than twice as high: 50.3 deaths per 100,000 people. About one out of every 2,000 black people in America have already died of COVID-19. Let me repeat that: one two-thousandth of African Americans are already dead. From one disease. A similar death rate among white people would have resulted in almost 100,000 deaths just in that ethnic group so far. And sadly, Kansas has the highest racial disparity of any of the 41 states reporting such data.

But the damage is not limited to viral illnesses. Americans in general have lives about three years shorter than citizens of peer countries like those in Western Europe.

African-American men have a life expectancy that is, in turn, almost five years shorter than the American average. This means that an African-American man loses the better part of a decade in life expectancy compared to an average western European citizen.

And almost all of this difference is due to heart disease deaths, the risk of which is readily modifiable with solid, basic medical care.

What are the reasons for this disparity?

The basic medical care of black people is neglected for multiple reasons in our country, including a well-deserved historic lack of trust in the medical system by black people. Remember that in the Tuskegee Syphilis Experiment the U.S. Public Health Service intentionally and secretly withheld treatment from a group of black men with syphilis from 1932 to 1972 to study the “natural history” of the disease, jeopardizing the health of the men and any future partners. 1972!

A second problem is a dearth of black physicians, starting in training. African-Americans are tragically underrepresented in medical school. While African-Americans make up 13.4% of the American population, they make up only 7.3% of medical students. This disparity, while slowly shrinking over time, has real consequences. Patients may do better when cared for by someone who looks like they do. A 2018 randomized trial found that black men had far better outcomes when cared for by black doctors: rates of screening for hypertension, diabetes, high cholesterol, and obesity went up markedly in men with black doctors, by more than 25% in some cases. The difference appeared to be due to improved communication. Patients were simply more likely to bring up other health problems when assigned to a black doctor. Interestingly, uptake of “invasive” screenings—tests involving probing or a blood draw–increased only for the group assigned a black doctor. This would seem to reinforce the idea that trust, long missing with the medical establishment, is a vital part of the doctor-patient relationship. And the cultural knowledge imparted by someone from your own community can be priceless, something we have found in our CDC work on community health workers.

The increased rate of screening demonstrated in this study could have huge health implications. The investigators tried to estimate the effect of having more black doctors in the population as a whole and found that even a modest increase could reduce the black-white gap in heart disease mortality by 19%, and the and the overall black-white gap in male life expectancy by 8%.

Efforts are being made to attack this problem from the start. After all, the lack of black trainees isn’t simply the result of fewer black kids wanting to be doctors. Quite the contrary. Locally, the Medical Society of Sedgwick County sends member physicians every year to talk to high school students about the process of applying for and completing medical training. Nationally, the American Medical Association has a program called “Doctors Back to School” to facilitate physicians of color visiting grade schools to encourage minority students to consider careers in medicine. Kids cannot be what they cannot see, as the platitude goes.

But the real impediment to getting more black doctors probably lies in greater systemic reform of the type that is being aggressively advocated for nationwide. We need to see this as a failure of the system, not a failure of individual people. As you watch protests unfold nationally and locally, I hope your view of them changes when you see them through this lens.

Are you a positive deviant?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

How do we know we’re doing a good job? We’ve touched on it in past blog posts. It can be harder to determine than we give it credit for. One strategy we’ve come across in our work on CDC grants is to look for “positive deviance”. We look for microcosms of success within clinics, and then we try to learn from them and diffuse their methods throughout the clinic. With the help of Dr. Bob Badgett from the University of Kansas School of Medicine-Wichita, we have implemented processes in clinics in a few steps:

First, after deciding what outcome we want to measure, we benchmark what others are doing. If we use blood pressure control as an example, we can look at HEDIS data for national benchmarks, which showed that nationally in 2018 61% of commercially-insured patients with hypertension had good control, versus 59% in Medicaid HMOs and 69% in Medicare PPOs.

Next, we look at both individual and team performances in clinics. Let’s pretend that we are interested in the care of patients with high blood pressure at Moore Endocrinology, Inc. We would build a proprietary report to run through Moore Endocrinology Inc’s electronic health record (EHR) that would tell us the blood pressures of every patient seen by every doctor in the clinic and chart them out, like this fictional clinic team:

Most providers cluster around the vertical line that indicates the average rate of control of ~75% (pretty good compared to the national benchmarks). But look at providers 2 and 50. Their rates of control are significantly higher than the others on their team, at 87% and 88%. They are the positive deviants. We don’t just look at providers individually; positive deviants can be broken out into provider teams, and in the case of teaching clinics, even attending physicians (think Dr. Cox and Dr. Kelso on Scrubs). We don’t pay any attention to the negative deviants. All our efforts are put toward finding the people doing unusually well and helping others get to their level.

Next, we look at more granular data within the EHR to get insights into whether or not blood pressure drug regimens were altered appropriately whenever a patient presented with an uncontrolled blood pressure. For example, if a patient’s blood pressure was uncontrolled, did the provider change the dose of a medication, add another medication, or do something to encourage improved medication adherence on the part of the patient, like changing to a cheaper med, offering advice on pill boxes or alarms, or changing to longer-term prescriptions?

Then, with the consent of the providers in the clinic, we meet in small groups and do focused, structured group interviews to determine the practice habits of everyone, without revealing who in the group is the positive deviant, not even to that provider personally. And we find fascinating things. It’s possible that the positive deviant uses a different drug titration strategy than her peers. More likely, she’s encouraging patients to check more blood pressures at home. Maybe she utilizes the medical assistants on her team in an innovative way, such as coaching patients on adherence or proactively reaching out to patients who’ve historically had poor blood pressure control.

Finally, we work with the clinic to determine what clinic-wide changes can be implemented to make everyone else’s practice look more like the positive deviant’s.

The purpose of this blog post isn’t to pat ourselves on the back for a clever strategy in working with clinics. It’s to introduce this idea to you, someone involved with the health and health care insurance coverage of a population of employees.

If your business is a member of the Kansas Business Group on Health you should have received a request to complete a benchmarking survey over the last few weeks. What we’re trying to accomplish with the survey is much like what we’re doing with clinics. We want to find out which of our members is doing certain things particularly well. For example, perhaps Business X has a particularly low rate of spending on drugs; they’re a positive deviant. Without revealing who that business is, we would like to work with that business and other members of the Group to see what Business X is doing to keep costs down. Then we can work with other members of the Group to adopt similar strategies. It’s a team-based approach to take those little microcosms of success and let everyone else learn from them.

So if your business hasn’t had a chance to fill out the survey yet, please go to our website and fill it out (it won’t take more than 10 minutes to complete). Even if you aren’t yet a member of the KBGH, we still encourage you to complete it as it would be helpful to see what you’re doing. The survey will be kept completely anonymous on an organization level, and the data will only be provided in aggregate.

If you have any questions or comments, please contact us!

Which of your employees can return to work – and when?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

In a perspective piece in this week’s New England Journal of Medicine, Dr. Marc Larochelle proposes a three-component strategy for returning to work: 1) a framework for counseling patients about the risks posed by continuing to work, 2) urgent policy changes to ensure financial protections for people who are kept out of work, and 3) a data-driven plan for safe re-entry into the workforce.

Let’s go through his framework for work-related risk first. He summarizes it with this diagram:

New England Journal of Medicine

The occupational risk on the vertical y-axis is defined by OSHA standards. The horizontal x-axis is based on age and the presence of high-risk chronic conditions identified by the CDC, like diabetes and heart disease.

How this could work

Let’s consider a couple hypothetical employees to see how this rubric might work: “Matt” is a 65 year-old man with no chronic medical problems who takes no medications other than an occasional ibuprofen for joint pain. By the CDC risk stratification rubric, then, he is at high-risk based on his age alone. Matt works as a radiology technician with no direct patient contact, but he is within six feet of patients with confirmed or suspected SARS-CoV-2 infections daily. By the OSHA standard, then, he is at high, but not “very high,” risk. Regardless, by the proposed Larochelle risk stratification above, Matt would be category “C” and should not go back to work.

“Shelley” is a 25 year-old woman with a history of type 1 diabetes complicated by neuropathy and kidney disease. So she is medium-risk in spite of her complex medical history, in spite of her young age. She works in a retail setting in Wichita, a city with currently relatively modest levels of community transmission. Therefore her occupational risk would be considered “medium.” This would put her in category “A,” in which Dr. Larochelle recommends that she be able to return to work, albeit likely with fastidious use of personal protective equipment (PPE).

But beyond a strategy to determine the safety of the workplace, we owe it to people of elevated risk, even those working in risky jobs, to work on two additional goals: first, we should conceive strategies to allow people to live a dignified life without hardship while away from work. This is largely a policy position we can support through elected officials at the state and federal level.

Second, we owe it to high-risk people to develop strategies to allow them to eventually return to their jobs, preferably even before the risk of those jobs drops due to decreased community prevalence of the virus. In a widely read piece in The Atlantic a couple weeks ago, Dr. Julia Marcus analogized our current predicament to the HIV/AIDS epidemic of the 1980s and 1990s. It would have been easy, in theory, to stop HIV cold in its tracks: people just needed to stop having sex. But people like having sex, just like they like going to work and eating at restaurants and watching baseball. So public health officials were forced to come up with alternative, innovative strategies like promoting condom use.

Similarly, COVID-19 could be stopped cold, much as Mongolia has accomplished, by instituting strict limits on social interactions. But we’re at a point of quarantine fatigue in which further efforts at social distancing in the immediate future are likely to be met with resistance. And a vaccine is months, if not years, away. This is where testing comes in, especially in regard to risk stratifying people for return to work and social interaction.

The role of testing

In listening or watching the news on testing, you are likely to think that risk is binary: a positive swab test means you have COVID-19, and a negative test means you don’t. Likewise, one might believe, a positive IgG antibody test means that you’re immune to COVID-19, and a negative antibody test means you’re still at risk. But neither of these assertions are true. The “positive predictive” value of a test, meaning the likelihood of a positive test predicting the presence of an actual disease state, depends on the “pre-test probability.” So a person who lives in a community with low prevalence of COVID-19 and has had no known exposure to someone with the disease is unlikely to have immunity, regardless of what her antibody test says. Even with a test that is 90% sensitive and 95% specific, that person likely has only about a 25% chance of having immunity.

This doesn’t only apply to infectious disease testing, by the way, and testing for other conditions has real implications for your employees. It is popular for doctors to routinely check the thyroid blood tests of patients as part of routine medical testing. It is not uncommon for mildly abnormal results of such testing to result in the patient being put on thyroid hormone for life. But mildly abnormal thyroid blood testing in someone who feels well and has no physical signs of thyroid disease does not mean that person has a thyroid problem. It only means the person has about a one in three chance of having a thyroid problem. As with COVID-19 antibody testing, the initial abnormal test result should prompt additional evaluation, not a definitive diagnosis.

So what do we do with the results of COVID-19 antibody testing? CDC suggests that we use them to “risk stratify” people on a population level, not as a marker to indicate safe return to the workplace.

Instead, we should aggressively use nasal testing for the virus itself to determine the status of people with exposure to persons with known or suspected COVID-19, much as we’ve discussed in the past.

Transparency is Trust

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

In 1963, Stanford economist Kenneth Arrow published the landmark paper “Uncertainty and the Welfare Economics of Medical Care.” He argued presciently that health care was an unfair system in which to bargain due to “asymmetric information.” The doctors, hospitals, and nurses simply know more than the patients, and this imbalance in information keeps the patient from being able to comparison shop or argue for fairer prices. If a doctor tells you you need a stent in your heart, after all, don’t you need it?

Equip patients with information and they usually make the right choice

There is data to suggest that patients, when given the right information to work with in a digestible way, make responsible decisions in health care purchasing. My favorite study on the topic looked at parents of children with appendicitis. Parents were randomized to see one of two videos: one group of parents saw a video that simply went over the difference between old-fashioned “open” surgery to remove the appendix and newer laparoscopic surgery that uses small “keyhole” incisions to put a camera and small instruments into the abdomen to remove the diseased organ. The video seen by the other half of parents explained the differences in the surgeries but also explained the price difference between the techniques (laparoscopic surgery is more expensive). Both videos stated that patient outcomes are similar with either procedure.

The parents who saw the video with the charge estimate were 1.8 times as likely to choose the open procedure. In fact, the effect of simply stating the charges in the video reduced the average price of the surgery from $10,477 to $9,949, a difference of $528, since more parents chose the open procedure when presented with good data. And more than a quarter of the parents choosing the open procedure said cost was the primary factor in their decision-making! This point is worth restating: parents, when confronted with a surgical choice in an emergency situation that, if handled incorrectly, could harm their own child, still took cost into account in their decision-making.

Things we’d hoped would work… but didn’t.

Many hoped the internet would solve the knowledge gap in medicine and empower patients. After all, in the business of buying and selling cars, some argue that information asymmetry is long-gone. If I were to buy a new Chevy Bolt today, I would simply choose my desired features on Edmunds.com, print the price sheet, and offer to pay my dealer a price in the ballpark of what Edmunds suggested was fair. But in spite of efforts from companies like Castlight, CashMD, and others, we haven’t seen a big dent in healthcare costs due to transparency alone. Some of this is due to the fact that doctors themselves–outside of the radical transparency of many Direct Primary Care physicians–aren’t always privy to the price of tests, drugs, or even their own services. And even those DPC doctors can’t necessarily share other outcomes we’re interested in, like rates of screening for cancer and metabolic diseases, mortality rates, and other quality indicators.

So the government has tried to step in. The Trump administration released an executive order in fall of 2019 requiring that by 2021 all hospitals must publish their “standard charges” online in a machine-readable format so that other software can begin to compare prices. This is a good start, but it is unlikely to work. Those “standard charges” are, in most cases, “chargemaster” prices that have little bearing on reality. Medicare, for example, pays about 31% of the chargemaster price. Second, patients mostly care about out-of-pocket payments, not insurance payments. To have an idea of their own liability, patients need the “bundled price” for the entire episode, which chargemaster prices do not provide. Instead, the chargemaster prices are for individual charges for materials and procedures

What CAN we do?

But we can’t just throw our hands up in frustration. As employers we should control what we can control. We can control state and federal policy as voters, but our power may be better wielded locally. We’ve pointed out previously in this blog that a lack of transparency was one of the big drivers of health care costs. That transparency extends beyond the operating room, exam room, or pharmacy. It reaches into the relationship between you and your partners, such as your broker, your PBM, and medical providers you may directly contract with. A good first step, if you weren’t able to attend our recent webinar with Dave Chase of Health Rosetta, is to ask for those partners to disclose all their revenue streams. Their undisclosed revenue streams may surprise you. Once everyone’s revenue is transparent, we believe that partners can work together in a more trusting relationship, to the benefit of both parties.

Note: KBGH works with Team IBX to introduce transparency in the insurance RFP process, but Team IBX was not involved in the writing and did not influence this post.

No one is padding numbers to increase COVID-19 case counts

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

I’ve heard a few times over the past couple weeks that hospitals are padding their case counts of COVID-19 patients in order to increase revenue. This is transparently, obviously false, as we’ll get into later. But before we wade into that, let’s take this chance for a quick review of how hospitals and doctors get paid for the care of patients.

The history and process for how physicians are paid

Once upon a time, billing for medical care was very informal. Hospitals and doctors largely set individual, almost artisanal, rates for each patient according to a “sliding scale” of what the patient was expected to be able to pay. Poor patients paid less, and wealthier patients paid more.

Once medical insurance became common, insurance companies, including Medicare, attempted to hold physicians and hospitals to the standard of  “customary, prevailing, and reasonable charges.” Unsurprisingly, this loose standard led to steadily inflated billing, so much so that the passage of Medicare is arguably what vaulted physicians from middle-class professionals into the upper reaches of national income. As early as 1970, congressional testimony referred to federal insurance as the “Goose that laid the golden egg” for physicians and hospitals.

Through a series of reforms in the 1970s, ‘80s, and ‘90s, billing for medical care became much more standardized (and in part led to the administrative bloat that is now the number one source of waste in American health care). Nearly every diagnostic or therapeutic procedure performed by a medical professional is now captured by a “Current Procedural Terminology” (CPT) code. For example, your dermatologist codes a “2029F” for a skin exam. A cardiothoracic surgeon codes a “33945” for a heart transplant. A routine, but fairly comprehensive new visit to a primary care doctor is coded a “99204.” All these codes are reimbursed according to the complexity of the task, taking into account the amount of time a procedure is expected to take, the amount of resources like syringes and protective equipment expected to be consumed, and the skill or level of training required to provide the service.

Hospitals themselves bill not according to CPT codes, but rather according to Diagnosis related groups (DRGs), which were introduced in the 1980s. DRGs are meant to make sure that reimbursement account for the severity and mix of the type of patients the hospital treats, and thus the resources that the hospital needs to treat those patients. For example, someone who presented with fever, cough, and a density on their chest x-ray, and who tested positive for COVID-19, would be coded a discharge diagnosis of “J12.81” for “pneumonia due to SARS-related coronavirus.” If that same patient needed ventilator support during her hospitalization, though, she would be coded “J96.01” for “Acute respiratory failure with hypoxia,” which pays in the ballpark of $54,000 (about three times as much as a COVID-related diagnosis). The additional payment is meant to pay for the increased duration of the visit and the increased intensity of treatment, since patients on ventilators are typically cared for by a single, specialized nurse, a respiratory therapist, a pulmonary physician, and others.

Our healthcare system has some inherent issues

The purpose of this post is not to defend current medical coding and billing. Our system is bizarre by almost any developed country’s standard. Take the way payment is determined for those CPT codes. The American Medical Association owns the Relative Value Scale Update Committee, or “RUC,” which is tasked with updating physician payment for those roughly 4,000 CPT codes. The RUC is powerful. It ultimately guides about 70% of all physician payment in the United States. Most of its 31 members are assigned by professional societies like the American College of Radiology and the American Society of Plastic Surgeons. Therefore, primary care doctors, the most cost-effective and crucial part of the health care workforce, make up only a tiny fraction of the committee. So the natural momentum of the committee is to steadily increase the payment for specialty care, while keeping reimbursement for routine care relatively flat. And the committee arguably works with faulty data. RUC recommendations are based on survey results of only about 2% of physicians, updated only every 5-20 years. Perhaps because of this, estimates of the time it takes to complete a given procedure—a vital component in calculating the complexity of care—are notoriously inaccurate.

In spite of these limitations, RUC recommendations are accepted without change by CMS more than 90% of the time, and commercial insurers largely base their payments on a multiple of the CMS charge as a baseline for negotiations with individual health systems.

Even though doctors can largely set their own rates without competition or pushback, they don’t get off scot-free. Because coding of routine visits is tied directly to the “complexity” of the patient, documentation requirements dictate that the average physician note in the U.S. is four times the length (paywall) of notes in peer countries. This is why you may have found notes from your doctor so long, repetitive, and bewildering. To make this worse, the advent of electronic health records has led to “chart bloat,” a phenomenon in which notes, thanks to cut-and-paste and other features, lead to an illusion of complexity and thus increased charges.

DRG rates, at least, are set by a slightly more predictable, scientific method. This isn’t to say that some gamesmanship doesn’t go into hospital billing; every physician in America has been coached on billing for the exact level of sickness of her patients at some point in her career.  The words, “Don’t bill a uroseptic patient for a simple UTI” still ring in my ears from residency.

So does this mean the number of COVID-19 cases are being inflated?

In spite of these faults, there is no evidence that we’re over-attributing illness to COVID-19. We are still under-testing compared to most of our peer countries, and this is reflected in the mortality data we’re seeing.  The “background” mortality rate in America is about 2.8 million deaths per year, with a little more than half of those deaths from cardiovascular disease and cancer. Deaths are seasonal and pretty steady year-over-year. But right now we’re seeing an excess mortality rate that is roughly double what COVID-19 accounts for. That is, only about half of observed excess premature deaths are in people diagnosed with COVID-19. So if anything, we are under-attributing deaths to COVID-19. After all, a patient who dies of a heart attack brought on by low oxygen levels and sticky blood due to an undiagnosed case of COVID-19 was still killed by COVID-19.

What about those increased payments for COVID-19 patients? It is true that hospitals make about 20% more for a patient infected with SARS-CoV-2. This is the result of the $100 billion slice of the federal stimulus passed in March that is allocated to hospitals. Why did hospitals get their own cut? Because volumes in hospitals are down by more than half as elective procedures like hip replacements and cardiac catheterizations—the lifeblood of hospital systems, for better or for worse—have been delayed or cancelled. Here is Harvard data on ambulatory visit volume through mid-April:

As a result, health care jobs—long considered “recession-proof,” are going away. Almost 43,000 health care jobs were lost in March alone. Health care is such a giant part of the American economy—a stunning $3.5 trillion per year, good for almost a fifth of gross domestic product, again, for better or for worse—that this reduction in health service delivery is thought to account for about half of our current loss of GDP. That’s why you hear our current financial predicament being referred to as a “health care-led recession.”

So if COVID-19 is a huge conspiracy to allow doctors, nurses, and hospitals to make extra money, it isn’t a very good one.