Research roundup: Palliative care and ACOs; employers and Supreme Court case on contraception

Feb 24 2014

Each week, KHN compiles a selection of recently released health policy studies and briefs.

Health Affairs: Care Delivery And Coordination In The Accountable Care Environment
In preparation for the new ACO environment, leaders recognized the contribution palliative care can make to health care "value," especially in the care of our sickest (and most expensive) patients ...  Since PHS [Partners HealthCare] became an ACO, the focus on palliative care integration has increased, and been centered on improving quality by matching a patient's care to his or her individual goals and values. ... Partners' efforts to support and expand palliative have focused on a number of key initiatives: Creating a system of palliative care that allows us to provide integrated, coordinated care across the continuum, meeting patients' needs in all settings of care, from hospital, to clinic, to rehabilitation, home care, and hospice settings ... Pay for Performance initiatives to expand palliative care access, advance care planning , and Medical Orders for Life-Sustaining Treatment (MOLST) implementation ... We have confronted remarkably few barriers in integrating palliative care into our ACO (Block, Jackson and Lee, 2/19).

JAMA Ophthalmology: Eye Care Use Among a High-Risk Diabetic Population Seen In A Public Hospital's Clinics
Little is known regarding eye care use among low-income persons with diabetes mellitus, especially African Americans. ... [Research was conducted] in an outpatient medical clinic of a large, urban county hospital ... There were 867 patients with diabetes identified: 61.9% were women, 76.2% were non-Hispanic African American, and 61.4% were indigent, with a mean age of 51.8 years. Eye care utilization rates were 33.2% within 1 and 45.0% within 2 years. For patients aged 19 to 39 years compared with those aged 65 years or older, significantly decreased eye care utilization rates were observed within 1 year. ... Additional education efforts to increase the perception of need among urban minority populations may be enhanced if focused on younger persons with diabetes (MacLennan, 2/13).

The Kaiser Family Foundation/Health Management Associates: Integrating Physical And Behavioral Health Care: Promising Medicaid Models
Unfortunately, our physical and behavioral health care systems tend to operate independently, without coordination between them, and gaps in care, inappropriate care, and increased costs can result. ... This brief highlights five strategies currently underway in Medicaid: universal screening; navigators; co-location; health homes; and system-level integration. ... No single approach in Medicaid is likely to be a universal solution; rather, a diversity of promising strategies present options for states, health plans, and providers seeking to move further in the direction of integrating care (Nardone, Snyder and Paradise, 2/12). 

JAMA Psychiatry: Use Of Hospital-Based Services Among Young Adults With Behavioral Health Diagnoses Before And After Health Insurance Expansions
Recent calls for increased access to mental health services have raised concern that increases in coverage will fuel unsustainable increases in use and spending. We examined the effects of Massachusetts' health reform, which dramatically increased health insurance coverage, on hospital-based use. We focused on young adults aged 19 to 25 years, a group with relatively high behavioral health needs and low rates of insurance coverage prior to reform, ... Increased insurance coverage post-reform coincided with significant relative declines in inpatient admissions and ED visits for behavioral health overall. ... We also found significant declines in admissions or visits without insurance coverage in both hospital and ED settings. This change resulted from increased coverage through Commonwealth Care, private coverage, and Medicaid. This signifies much lower out of pocket burden for young adults with a behavioral health crisis, as well as less uncompensated care burdening hospitals (Meara et al., 2/19).

Robert Wood Johnson Foundation: Long-Term Care: What Are The Issues?
The vast majority of people have no insurance, either public or private, for long-term care. Private long-term care insurance can pay a set daily benefit to defray the cost of home or residential care, but with an average policy costing a healthy 60-year-old $2,000 or more per year11 (premiums increase with age), many people either can't afford the insurance or worry that limits on benefits might make it not worthwhile. To date, fewer than 10 percent of Americans are saving specifically for long-term care. The result is that family or friends often end up providing informal and unpaid care for older, frail adults for as long as they can. This trend will be magnified as the number of older people needing long-term care increases over time (Freundlich, 2/1).

The Heritage Foundation: Obamacare Anti-Conscience Mandate At The Supreme Court
In February 2012, the U.S. Department of Health and Human Services (HHS) finalized guidelines requiring employers to pay for coverage of contraception, sterilization, and abortion-inducing drugs and granted a narrow exemption for certain religious employers. Many employers believe that complying with this mandate would violate the tenets of their faith, but failure to adhere to the law could result in steep fines ... In an effort to block the anti-conscience mandate, religious organizations and other private employers have filed over 90 lawsuits with more than 300 plaintiffs. The Supreme Court of the United States has agreed to review two of the for-profit cases ... The Court will consider two questions: Does the mandate violate the First Amendment guarantee of the free exercise of religion? Who can exercise religion under the Religious Freedom Restoration Act? (Slattery and Torre, 2/13).

The Urban Institute: The Inevitability Of Disruption In Health Reform
The recent furor over policy cancellations in the individual health insurance market demonstrates a long-standing challenge to the enactment, let alone the implementation, of effective health reform. Disruption of the 84 percent of Americans who have health insurance creates a powerful impediment to the extension of insurance to the 16 percent of Americans without it. ... This brief clarifies the realities and political risks of disruption and places the ACA in context relative to other reform proposals (Feder, 2/18).

Here is a selection of news coverage of other recent research:

Medscape: Intracranial Atherosclerosis A Major Stroke Risk In Whites
Although intracranial carotid artery calcification (ICAC) is a recognized risk factor for stroke in African Americans and Asians, a new study shows that it is also an important cause of strokes among whites. The association between ICAC and stroke shown in the study was independent of conventional cardiovascular risk factors and of calcification in other vessel beds, the researchers note (Anderson, 2/18).

Medscape: Oncologists Can Cut Costs While Maintaining Quality Of Care
The alarmingly high increases in the cost of cancer care can be reined in. However, it will require that the oncology community take responsibility for practice patterns, according to 2 experts. In a report published online in the Lancet Oncology, Thomas Smith, MD, and Ronan Kelly, MD, both from the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, identify 3 major sources of high cancer costs that can be reduced with the least amount of harm (Nelson, 2/14).

MedPage Today: Outpatient Surgery: Is Infection A Real Risk?
The chance of a clinically significant infection after ambulatory surgery is relatively small; nonetheless, outpatient surgery related infections account for roughly one in five healthcare-associated infections. That seeming contradiction is explained by the fact that ambulatory surgery accounts for more than 63% of all operations in the U.S., so the absolute number of affected patients is large, according to Claudia Steiner, MD, of the Agency for Healthcare Research and Quality in Rockville, Md., and colleagues (Smith, 2/18).

Newark, N.J., Star-Ledger: Princeton Expert: Medicaid Rules Keep Poor Women From Getting Sterilized
File this one under the category of "It seemed like a good idea at the time." That time was 1976, when public health officials worried about poor women being permanently sterilized without their consent. The fix was a 72-hour waiting period between when a Medicaid patient consented to a tubal ligation and when the operation was done. Two years later, that waiting period was extended to 30 days. But that has created its own problem, according to researchers at Princeton University's Woodrow Wilson School. Medicaid patients who want to have their tubes tied immediately after having a baby can't do that because of the 30-day rule. If they wait 30 days, some may no longer have Medicaid coverage, since pregnancy-related eligibility ends shortly after delivery (O'Brien, 2/19).

Los Angeles Times: Healthcare Organizations Under Siege From Cyberattacks, Study Says
Add this to the list of things to freak you out: Healthcare organizations of all kinds are being routinely attacked and compromised by increasingly sophisticated cyberattacks. A new study set to be officially released Wednesday found that networks and Internet-connected devices in places such as hospitals, insurance companies and pharmaceutical companies are under siege and in many cases have been infiltrated without their knowledge (O'Brien, 2/18). Health Care Cyberthreat Report is here.

HealthDay: Many U.S. Seniors Get Prescription Painkillers From Multiple Doctors
About one-third of Medicare patients who get prescriptions for powerful narcotic painkillers receive them from multiple doctors, which raises their risk for hospitalization, according to a new study. Narcotics (also called opioids) include painkillers such as hydrocodone (Vicodin), oxycodone (Oxycontin) and morphine. Prescriptions for these drugs have risen sharply in the United States in the past 20 years -- as have overdoses. ... For the study, which was published Feb. 19 in the journal BMJ, the researchers analyzed data from 1.8 million people enrolled in Medicare's prescription benefit (Part D) who filled at least one narcotic prescription in 2010. Medicare is the taxpayer-supported insurance program for the elderly (Preidt, 2/19).