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 Mills, Dell, 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?

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:

The University of Kansas Alzheimer & Memory Program (KU-AMP)

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

Past

     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 3^rd, 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.

http://www.whitehouse.gov/the_press_office/President-Obama-Announces-Another-Key-OMB-Post/

http://www.nudges.org/

http://home.uchicago.edu/~csunstei/

Breastfeeding: Benefits to Mothers, Children, Wallets, & Environment

Breastfeeding provides benefits to: mothers and children, as well as family and nationwide cost savings and environmental benefits.  However, only 29% of women are breastfeeding at 6 months after delivery (Healthy People 2010 goal is 50%).  

The benefits for children are: increased immunity and reduced risks of: sudden infant death syndrome (SIDS), obesity, acute otitis media, gastroenteritis, lower respiratory tract infections, asthma, atopic dermatitis, and childhood leukemia. In mothers, there is a decreased risk of type 2 diabetes, cardiovascular disease,  high cholesterol, and breast and ovarian cancer.  There is also a benefit of increased bonding with the mother and baby, which is linked to better brain development and relationship formation in children.  A strong dose-response relationship appears between breastfeeding and infant health in the first year of life. 

Economically speaking, there are no formal studies on cost savings, taking into account time, money on formula, and the cost of medical care.  It has been estimated that bottle-fed infants had US$200 higher medical costs in the first year of life [4].  It is healthier, all-natural, and inexpensive to mothers and families.  At a national level, if we reached the Healthy People 2010 goals of getting 50% of women to  be feeding at 6 months, WIC would save US$6.5million per month!  

There are also benefits to the environment by saving water and eliminating the energy used to create formulas--contributing to waste and air pollution.  Formula tin cans can seep toxic BPA into formula, although there are opinions regarding the levels of potential BPA  on both sides of the argument.   Also, being as formula is dairy or soy-based primarily, the dairy business' pollution needs to be considered, with cows (and their methane), land, resources, and fertilizers providing large emissions.

 Healthy People 2010 goals include getting 75% of women to initiate breastfeeding, 50% to remain feeding for 6 months, and 25% for a full year after delivery.  Breastfeeding is the preferred choice of feeding for all infants, as endorsed by the American Academy of Pediatrics (AAP).   However,  according to a 2002 survey, only 71% of all children had ever been breastfed (16% for a full year).  Late last year the US Preventive Services Task Force came out with their recommendation that primary care providers should encourage and support interventions aimed to increase the prevalence and duration of breastfeeding.  It has also been noted that lay support is extremely effective in getting mothers to initiate and maintain breastfeeding, so programs should be tailored to mothers in this capacity.  The AAP has some great resources for families on their website (below) .  So, the science is there and we're working on the full translation to individual family practice.

Public policy should be more appropriately following the science and should be made to fill in the gaps.  This requires funding support programs and implementing cost-effective breastfeeding intervention programs to encourage more mothers to initiate and maintain breastfeeding activities.  Health insurers also have a role (and I would argue a responsibility) to insure lactation services to produce healthier mothers and children.  Environmental advocacy organizations should bring salience to the environmental costs and benefits for both the public and government.  Researchers have a role in performing some cost-benefit and cost-effectiveness analyses on breastfeeding.

I wanted to make some noise on the breastfeeding horn today.   How many of you were breastfed?  If you are a female, did you, or do you plan to, breastfeed your children?

References:

1) Kuehn BM.  Preventive Services Task Force Endorses Breastfeeding Support in Primary Care.  JAMA 2008;300(22):2598.

2) Chung M, Raman G, Trikalinos T, Lau J, & Ip S.  Interventions in Primary Care to Promote Breastfeeding:  An Evidence Review for the US       Preventive Services Task Force.  Arch Int Med 2008;149(8):565-582.

3) US Preventive Services Task Force (USPSTF).  US Department of Health and Human Services; Agency for Healthcare Research & Quality.  http://www.ahrq.gov/clinic/uspstfix.htm

4) Breastfeeding Initiatives:  Family Resource Guide.  American Academy of Pediatrics.  http://www.aap.org/breastfeeding/familiesResourceGuide.html

5) Bonuck K, Arno PS, Memmott MM, Freeman K, Gold M, & McKee D.  Breast-feeding promotion interventions:  good public health and economic sense.  J Perinatol 2002;22(1):78-81.

Comparative-Effectiveness: Will we have a US-version of NICE?

The American Recovery and Reinvestment Act (ARRA) of 2009 allocated $1.1 billion for comparative effectiveness research (CER) and associated health services research.  This research will provide new information about the strengths and weaknesses of various health care treatments and strategies, although the research explicity is not to "recommend clinical guidelines for payment, coverage, or treatment."  The compartive effectiveness research will specifically include:  comparison of clinical outcomes, effectiveness, appropriateness of services and procedures to prevent, diagnose, or treat health conditions.  It will also fund data registries, networks, and other ways of creating or compiling health outcomes research data.  

The 15-member Federal Coordinating Council for Comparative Effectiveness Research will coordinate and assist the agencies with the research.  The first public listening session of the Coordinating Council was held 4/14/09 and can be heard here:  http://nmr.rampard.com/fcc/20090414/frame/index.html.  

The Institute of Medicine (IOM) was called to create a consensus report by June 30th, 2009 on recommendations for CER.  We'll see this summer how they frame their recommendations for CER in the future. 

The allocation of funds from ARRA for CER is:  $400 million for the Secretary of Health and Human Services (HHS) (Kathleen Sebelius--confirmed 4/21 by Senate Finance Committee); $400 million for National Institutes of Health (NIH); $300 million for the Agency for Healthcare Research & Quality (AHRQ).  [Aside:  AHRQ is the agency I will be working for this summer, my first summer of my PhD program here in the Baltimore/Washington area.  I will be working in the Center for Financing, Access, and Cost Trends working with the Medical Expenditure Panel Survey (MEPS) on costs to families due to mental disorders.]

CER did receive $1.1b, but for perspective, the other areas of spending on improving US health care are:

1) Improving and preserving health care-- $90.1b

2) Health IT--$20.6b

3) Scientific research & facilities--$10.0b

4) Community health care services--$2.8b

5) Comparative effectiveness--$1.1b

6) Prevention & wellness--$1.0b

7) Accountability and IT security--$.1b

Thinking to the future, an idea is that CER could be housed within one center, which could operate to some degree like the National Institute for Health & Clinical Excellence (NICE) in the British National Health Service (NHS). http://www.nice.org.uk

AHRQ has been suggested as the most likely home for the US version of NICE.  However, there is a debate going on around the formation of something like NICE in the US, primarily because it infers a sense of rationing and includes refusal of care for treatments that are not cost-effective.  Given the unique individualist, anti-government culture of the United States, the degree to which a NICE-like institution could be established in the US is questionable.    Here's hoping the future of CER is embraced by the public and adequately promoted and understood within the realm of health care reform. 

 

More information:  http://www.hhs.gov/recovery/

Foods or Pills? Supplements provide little benefit

Several studies have come out with compelling evidence against any benefits of multivitamin or supplement use in benefitting health.  Recently, Neuhouser et al [1] found little or no influence in reducing common cancers, cardiovascular disease (CVD) or total mortality in postmenopausal women, after following them for 8 years.  Muntwyler et al (2002) found no benefit from vitamin E, vitamin C, or mulitivitamins in reducing CVD or coronary heart disease (CHD) in males [2].  A review of all clinical trials and observational studies on supplements yielded an overall consensus that they don't significantly reduce mortality or morbidity [3].

The jury is still out on the benefits of calcium, despite it being the most studied mineral (62,852 Medline articles from 1994-2004) [4].  Sure, we know that calcium helps build strong bones and protects against things like osteoporosis, but other things build strong bones too (e.g. exercise and a healthy diet).  Americans have been trained to think we're supposed to be getting more than 800 mg of calcium per day (approx 3 servings a day), but is that the right amount?  The National Dairy Council (NDC) has strongly pushed and advocated for increasing calcium intake (i.e. "Got Milk?" campaigns), but we don't know for sure if the science matches up.  Recommendations vary widely across countries, ranging from 500-1500 mg for young adults, with the US recommending 1000 mg (daily upper limits to avoid adverse effects are about 2500 mg).  

The FDA does not regulate vitamins, minerals, and supplements.  This is important to remember--anyone can package and sell these things without regulation or proven benefits.  Aware of this or not, about 50% of Americans use vitamin or dietary supplements--contributing to a $20 Billion annual industry.

Do I take a MTV or supplements?  I currently do take a MTV on days when I'm not eating a particulary wide range of healthy foods.  I also take a Calcium/Vit D supplement (Vitamin D assists with absorption of calcium and should be taken in tandem, if taken). 

However, as long as the following criteria are met, dietary supplements are probably not adding any benefit (in some cases, adding harm):

1) Get appropriate levels of physical activity

2) Reduce sodium intake

3) Increase fruit and vegetable consumption

4) Avoid smoking

5) Limit alcohol intake

6) Maintain a healthy body weight

This provides more evidence in support of living a healthy lifestyle and stopping the search for magic pills.  I'm not trying to dissuade anyone from taking supplements, as they are likely to be helpful for those not getting an adequate range of healthy foods and exercise (e.g. developing countries and "unhealthy" individuals).  However, if you live a healthy lifestyle, you're probably wasting your $ on supplements.  

As said by Hippocrates (460-377 BC), "Let food by thy medicine and let medicine be thy food." 

 

References:

1. Neuhouser ML, Wassertheil-Smoller S, Thomson C, Aragaki A, Anderson GL, Manson JE, Patterson RE, Rohan TE, Van Horn L, Shikany JM, Thomas A, LaCroix A, & Prentice RL.  Multivitamin use and risk of cancer and cardiovascular disease in the Women's Health Initiative cohorts.  Arch Intern Med (2009); 169(3):294-304.

2. Muntwyler J, Hennekens CH, Manson JE, Buring JE, & Gaziano M.  Vitamin supplement use in a low-risk population of US male physicians and subsequent cardiovascular mortality.  Arch Intern Med (2002); 162:1472-1476.

3. Prentice RL.  Clinical trials and observational studies to assess the chronic disease benefits and risks of multivitamin-multimineral supplements.  Am J Clin Nutr (2007);85(1):308S-313S.

4. Weaver CM & Heaney RP (Eds).  Calcium in Human Health. Springer, 2006.  

Predisposed to Depression?

Depression, primarily major depressive disorder (MDD), is the leading cause of disability in adults.  MDD is primarily familial, prompting research to the nature-nurture origins of the disease.  How is depression tied genetically or shaped by environmental factors in individuals?

The exact mechanisms by which depression affects the brain are fairly unknown.    We know there are brain abnormalities and differences, but some studies have shown it to be hard to discern if the brain differences were causes or effects of depression.

Peterson et al looked at a three generation cohort of individuals, assessing those with and without major depressive disorder in two successive generations.  The results of their research appear in last week's Proceedings of the National Academy of Sciences issue (epub ahead of print).  Peterson et al, found that people at risk for depression (those with a family history in 2 generations) had 28% more cortical thinning in the right hemisphere of their brains than those not at risk for depression.  The thinning occured in gray matter, the core processing brain center (the neurons) as opposed to in white matter, information transport system (the myelinated axons).  28% is a significant amount of difference, and correlates to similar magnitudes of structural changes seen in Alzheimer's disease, frontotemporal dementia (FTD), and schizophrenia (although in different brain regions).  

The right hemisphere of the brain is responsible for most of the tasks of attention and visuospatial memory.  Inattention and slight memory impairment occur symptomatically in individuals with depression, and was found to be higher in the high risk individuals as compared to the low risk individuals in Peterson et al.'s study.  The authors note that inattention could also be produced for social and emotional stimuli, thus producing depressive symptoms or MDD.  

It might be too early to state any translational or policy implications from this study, however more light is now shed upon the physiological differences in those at risk vs. not at risk for depression.  These results might be of interest for those with a family history of major depressive disorder who are curious about assessing their future risk of depression.  Check your cortical thickness.   Or don't...and hope your positive environment will reduce your risk.

Peterson BS, Warner V, Bansal R, Zhu H, Hao X, Liu J, Durkin K, Adams PB, Wickramaratne P, & Weissman MM.  Cortical thinning in persons at increased familial risk for major depresssion.  Proc Natl Acad Sci USA. 2009 Apr 14;106(15):6273-8

www.pnas.org