Monday, May 25, 2009

Employers: Rewarding the Healthy

It is well-understood:  being healthy is cheap.  Healthier employees are cheaper employees--less costs fo chronic diseases (e.g. diabetes, obesity, cardiovascular health) and less productivity lost.

Employers really do not have any incentives to provide prevention plans for employees, as the majority of employees don't spend their lifetime at one company and leave for new jobs before employers could reap the financial benefits of investing in preventive behaviors of employees.  Tax benefits for employers could help.  Policymakers are trying to get a larger number of employers to grasp this notion.  A recent survey by Hewitt Associates says that 1/3 of employrs are planning to put more of an emphasis on wellness plans.  Some large corporations already do, such as General MillsDell, and Safeway.  More will like
ly follow suit, especially with the proposed policy changes.  

Sen Baucus (D-MT) and Sen Harkin (D-IA) are propsing tax incentives for employers that offer wellness programs to employees.  This is consistent with Obama's goals for health reform ("invest in prevention and wellness").  A victory for public health--a shift in focus from treating more expensive and downstream diseases, rather than a focus in less-expensive upstream acts of preventing diseases from beginning.  But who loses?
A recent Health Affairs article, "Financial Penalties for the Unhealthy? Ethical Guidelines for Holding Employees Responsible for Their Health," looks at the other side of this issue.  According to federal Health Insurance Portability and Accountability Act (HIPAA) regulations, employers can give rewards/penalties for up to 20% of the total cost of covering an employee.  However, unions and those concerned with personal freedoms are arguing about the blurry ethical line of holding employees responsible and protecting their individual liberties.  Considerations about paternalism, personal choice, privacy protection, access to health promotion, and the complexities of developing obesity are brought up on the opposing side.

Where do you stand?

Tuesday, May 19, 2009

Alzheimer's Project on HBO

HBO aired a  4-part documentary on May 10th, 2009 on Alzheimer's Disease.  The Alzheimer's Project was made in association with the National Institute on Aging at the National Institutes of Health and the  Alzheimer's Association.  The documentary also features Maria Shriver, First Lady of California, as her father is living with Alzheimer's Disease (she also is exec-producer).  

There is no cure for Alzheimer's Disease (AD), although the documentary sheds light on recent research findings and breakthroughs about this devastating disease.  Alzheimer's disease is an irreversible and progressive brain disorder that slowly deteriorates memory, judgement, the ability to carry out daily activities, and produces personality changes.  The risk for developing AD doubles every 5 years after the age of 65 and nearly 50% of people have the disease by the age of 85.  After cancer, it is the most feared disease.

During the time I was obtaining my Master's degree, I was working with the great team at the University of Kansas on both the research and clinical side of Alzheimer's Disease and related dementias.  Information about them and research projects can be found here:

Monday, May 4, 2009

How Many Eggs Do You Have? Scientists Say Females Able to Make Eggs Later in Life.

 I opened up my issue of "Science" magazine from the American Association for the Advancement of Science (AAAS) and saw the article titled, "Study Suggests a Renewable Source of Eggs and Stirs More Controversy."  Wow.  

Apparently some stem cell biologists, Ji Wu and colleagues, at Shanghai Jiao Tong University in China found that adult ovaries have cells that can give rise to new eggs (oocytes) and then turn into offspring.   This really gives a slap in the fact to the idea of females being born with all the eggs they will ever have.   A now heated controversary is emerging in reproductive biology.  The researchers results come from a series of studies on mice, where they removed their ovaries and sorted through cells to find "germline cells" that eventually turned into eggs and offspring.

Much more research is to be done before we can say anything conclusively, but it looks like we might be able to disprove the idea that females cannot make more eggs.  John Tilly, professor of obstetrics and reproductive biology at Harvard Medical School, was not involved with the study, but has also published some controversial ideas about women's ability to produce new eggs.  Scientists and researchers everywhere, whom are already in a crazed controversy, have more science in favor of the fact that women are not born with a finite number of eggs.

So, is the biological clock really a psychological clock?  

Mental Health Parity: Past, Present, & Future


     For decades, there has been unequal treatment of mental health conditions as compared to physical health conditions, specifically regarding health insurance coverage [1].  Researchers, mental health advocates, and patients have fought for parity for quite a while, gaining little ground. 

     Some advances were made in September 1996, when President Clinton signed the federal Mental Health Parity Act, into law.  It prohibited limits on annual and lifetime mental health coverage [2].  However, more needed to be done as limits on visits for outpatient or days for inpatient still existed [2].  Secondly, the law did not apply to substance abuse [4].  The Act expired on September 30, 2001 [3]. 

Present:  2007-2009

     In the fall of 2007, the Senate passed the Mental Health Parity Act and the House of Representatives approved the Paul Wellstone Mental Health and Addiction Equity Act in March 2008 [1].   The two bills were reconciled and Bush signed full mental health parity into law on October 3rd, 2008 to close the discrimination gap for those wanting health insurance coverage for mental health and substance use diseases [6].  The law, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (HR 6983), closes some of the loopholes (e.g. eliminating limits on outpatient visits) from the 1996 Mental Health Parity Act. 

     The new law, effective January 1, 2010, applies to: group health plans with more than 50 employees, Medicaid managed care plans, and some State Children’s Health Insurance Program plans [2, 6].  It is included as an amendment to the Employee Retirement Income Security Act (ERISA).  The Act requires that the financial requirements and treatment limitations can’t be more restrictive for mental health/substance abuse services than for medical/surgical services [6].  Insurers will not be able to limit coverage that is “medically necessary.”  There are some exemption clauses, which should be addressed in future legislation. 

     In July 2008, Congress also passed the Medicare Improvements for Patients and Providers Act, to phase in federally mandated mental health parity for Medicare beneficiaries, although all states except for two (Idaho and Wyoming) have existing mental health parity laws [2].  The current Medicare beneficiary cost for psychotherapy and other mental health services will be reduced to 20% by 2014 [2].  The Medicare Improvements Act also expands Part D benefits regarding mental health, including coverage of two new medication classes:  benzodiazepines and barbiturates [2, 8].

Future:  2010 and beyond

     It is likely that utilization of medially necessary mental health services will increase after January 1, 2010.  [9].

     It is less likely that costs for mental health services will increase.  A study of the Federal Employees Health Benefit (FEHB) Program found that parity in health insurance does not increase costs for behavioral health care [10], and the Congressional Budget Office stated that adding mental health parity will increase health insurance premiums by less than .4% annually [2].  Costs were also reduced with full mental health substance abuse parity for children in the FEHP [12].  However, special attention will need to be paid to keeping costs under control while maintaining and improving upon quality health care services. 

     Despite the promises of the 2008 parity legislation, we are not without a good number of limitations.  First, the insurance parity is limited in scope and does not apply to group health plans with less than 50 employees, Medicare Part A, Medicare managed care, or individual insurance plans [9]. 

     Secondly, only 4 of the 179 quality indicators included in the National Healthcare Quality Report (issued by the Agency for Healthcare Research & Quality) are related to mental illness and the Institute of Medicine (IOM) has suggested new quality measures for mental health care [13, 14].   This will take significant resources, but needs investing in to better assess quality of care for mental health. 

     Third, even if co-payments are made equal for mental health services and medical services, most mental health services cost less than medical health services (e.g. using social workers and group therapy) and therefore may actually still represent higher coinsurance for value of service provided [9]. 

     Mental health parity has been a topic of concern for decades and we are currently making significant strides toward achieving equality of services for mental and substance abuse disorders.  The recently passed Paul Wellstone and Pete Domenici Mental Health and Addiction Equity Act of 2008 provides some promise toward the goal of mental health parity.  However, time will tell the true impact of the Act on equality of mental health and substance abuse services.  There is a great amount future work and implications for researchers, policymakers, professional organizations, patients, providers, and payers.  As our health system enters reform, mental health services will need to be handled with equality to medical services.  

References available upon request, but cut out due to space limitations.  This is an excerpt of a paper I wrote for Managed Care & Health Insurance at Johns Hopkins.  This breakthrough legislation of 2008 is huge for health advocates, patients, and health providers.


Obama "Nudges" Regulatory Czar

Cass Sunstein, the most cited law professor in the US (some say world) was "nudged" by Obama on April 20, 2009 to be the new "regulatory czar," formally, the Administrator of the Office of Information and Regulatory Affairs (OIRA), Office of Management and Budget.

There are a few hot topics of critique about Sunstein's appointment.  One includes his backing of a "senior health discount," an economic method of valuing younger lives more than the elderly.  Secondly, he questions the constitutionality of workplace safety laws and the Clean Air Act.  Third, some consumer groups are afraid he is going to push his animal-rights ideas in the White House (re: Sunstein's 2004 book, "Animal Rights: Current Debates and New Directions").  His appointment is pending Senate approval.

Sunstein is the author of over 400 publications, his most recent book titled, "Nudge:  Improving Decisions About Health, Wealth, and Happiness," coauthored with Richard Thaler.  The book expands Econ 101's notion of individuals making rational choices and taps into the true psyche of humans and how we can design environments to help people make better decisions--behavioral economics.  The authors use examples of things like 401(k) plans, marriage, and organ donations to explain their view of libertarian paternalism (not bigger government, but better governance).  I have yet to read this book, but it is definitely on my to-read list.

More of Sunstein's books include:  "After the Rights Revolution" (1990), "Risk and Reason" (2002), and "Laws of Fear: Beyond the Precautionary Principle" (2005).  He taught for 27 years at University of Chicago Law School, until last year, when he left to become the Felix Frankfurter Professor of Law at Harvard.  He is also the Samuel Rubin Visiting Professor of Law at Columbia.  His expertise lies in constitutional law, administrative law, and risk policies.