John Colbert

February 19, 2019

PUTTING PATIENTS FIRST AND DISPARITIES RESEARCH

John Colbert

February 19, 2019

The Centers for Medicare & Medicaid Services (CMS) collaborated with a wide variety of partners to support work in all three areas of its path to equity: increasing the understanding and awareness of disparities and their causes, developing and disseminating solutions, and implementing sustainable actions. As a way of increasing understanding and awareness of disparities, CMS sponsored the February 2019 issue of the journal Health Services Research, with a goal of contributing to the discussion on health disparities and emphasizing the value of continuing research in this area. An aim is to underscore the importance of identifying groups of patients who do not benefit equally from the health system and also identifying root causes of such differences.

One study in the issue focused on inpatient care experiences that differ by preferred language within racial/ethnic groups. Six composite measures for seven languages (English, Spanish, Russian, Portuguese, Chinese, Vietnamese, and Other) within applicable subsets of five racial/ethnic groups (Hispanics, Asian/ Pacific Islanders, American Indian/Alaska Natives, Blacks, and Whites) were compared. Within each racial/ethnic group, mean reported experiences for non‐English‐preferring patients were almost always worse than their English‐preferring counterparts. Language differences were largest and most consistent for Care Coordination. Within‐hospital differences by language were often larger than between‐hospital differences and were largest for Care Coordination. Where between‐hospital differences existed, non‐English‐preferring patients usually attended hospitals whose average patient experience scores for all patients were lower than the average scores for the hospitals of their English‐preferring counterparts. The investigators concluded that efforts should be made to increase access to better hospitals for language minorities and improve care coordination and other facets of patient experience in hospitals with high proportions of non‐English‐preferring patients A focus should be on cultural competence and language‐ appropriate services.

Return to February 2019 trends

IDENTIFICATION, EVALUATION, AND COMPARISON OF HEALTH DEVICES

John Colbert

February 19, 2019

Trends Archives

The technology marketplace is a veritable paradise for entrepreneurs attracted to electronic devices that can be used by consumers to enhance their personal health status. For example, a patient who has undergone breast cancer surgery may want to engage in the use of wearable sensors and cloud-based apps so that upon returning home after being discharged from the clinical setting, this individual may want to provide daily information to the health care team about her conditions and successes experienced in self-care involving physical exercise, massage, and skin care.

An article published on February 14, 2019 in the journal npj Digital Medicine indicates that recent years have witnessed an explosion in the number of wearable sensing devices and associated apps that target a wide range of biomedical metrics, from actigraphy to glucose monitoring to lung function. It is estimated that the number of connected wearable devices worldwide will increase from 325 million in 2016 to 929 million by 2021. Similarly, the digital health consumer base is growing in tandem, and it is forecasted that by 2021, the number of individuals using remote monitoring programs will grow to 52 million globally. This increased availability and choice of sensors is accompanied by a great challenge to optimize the match between the sensor and a specific application context. A structured approach is needed first to refine the requirements for a specific application, and then to evaluate the available devices against those requirements.

Increased device availability is leading to greater research and commercial opportunity, but it also can create significant confusion, especially for professionals who are attempting to select appropriate technologies that meet the requirements of their specific application for a clinical trial, research study, or a digital health service. The authors posit that there are no standardized methods to help professionals identify, evaluate, and compare the numerous human performance devices available. Consequently, they describe a framework that provides a comprehensive tool to enable users to define their specific requirements, conduct a systematic Web search and complete a holistic desk-based evaluation, to determine whether one or more devices are fit for purpose and worthy of field testing.

Return to February 2019 trends

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

John Colbert

February 19, 2019

Trends Archives

Adoption Of A National System For Electronic Use And Exchange Of Health Information

The Office of the National Coordinator for Health Information Technology (ONC) has released its 2018 Report to Congress. As of 2015, 96% of nonfederal acute care hospitals and 78% of office-based physicians adopted certified health IT, however, hurdles to progress still remain. For example, many certified health IT products lack capabilities that allow for greater innovation in how health information can be securely accessed and easily shared with appropriate members of the care team. Such innovation is more common in other industries. Also, lack of transparent expectations for data sharing and burdensome experiences for health care providers limit the return on investment for health care providers and the value patients are able to gain from using certified health IT. Information not always is accessible across systems and by all end users, such as patients, health care providers, and payers, in the market in productive ways. For example, despite the individual right to access health information about themselves established by the HIPAA Privacy Rule, patients often lack access to their own health information, which hinders their ability to manage their health and shop for medical care at lower prices. Health care providers often lack access to patient data at the point of care, particularly when multiple health care providers maintain different pieces of data, own different systems, or use health IT solutions purchased from different developers. Also, payers often lack access to clinical data on groups of covered individuals to assess the value of services provided to their customers. The report can be obtained here.

Current Status And Response To The Global Obesity Pandemic

On October 9, 2018, the Roundtable on Obesity Solutions, held a public workshop in Washington, DC entitled Current Status and Response to the Global Obesity Pandemic.” The workshop examined the status of the global obesity pandemic and explored approaches used to manage the problem in different settings around the world. The “Proceedings of a Workshop In Brief” highlights presentations that discussed the importance of understanding the obesity epidemic in global context and shared perspectives on the implications of obesity as a global problem for prevention and treatment efforts in the United States, with an emphasis on reducing disparities.

A report was released on January 11, 2019. It can be obtained here.

How Innovation Will Blur Traditional Health Care Boundaries

According to the firm Deloitte, by 2040, health care as known today will no longer exist. A shift will occur from “health care” to “health.” Disease never will be completely eliminated, but through science, data, and technology, it can be identified earlier, proactive interventions can be implemented, and its progression can be understood better. The future will be focused on wellness and managed by companies that assume new roles to drive value in the transformed health ecosystem. Driven by greater data connectivity; interoperable and open, secure platforms; and increasing consumer engagement, 10 archetypes are likely to emerge and will replace and redefine today’s traditional life sciences and health care roles to power the future of health. The 10 archetypes will fall into three distinct, but interconnected, categories: Data and platforms will be the foundational infrastructure that will generate the insights for decision making. Care enablement will be connectors, financers, and regulators that help make the industry’s “engine” run. Well-being and care delivery will be the most health-focused of the three groupings, consisting of care facilities and health communities, both virtual and physical. The report can be obtained here.

Return to February 2019 trends

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

John Colbert

February 19, 2019

Trends Archives

Record Number Of Novel Medical Devices Approved By The FDA In 2018
According to Scott Gottlieb, Commissioner of the U.S. Food & Drug Administration, a record 106 novel medical devices were approved in 2018, surpassing the 40-year approval record set in 2017, which was 99. Innovative new products that have come to market in 2018 as a result of an efficient, risk-based approach to total product life-cycle regulation include: expanded approval of an automated insulin dosing system to include patients with diabetes who are as young as age seven; the world’s smallest heart valve for newborns; the first blood test in the world to evaluate mild traumatic brain injury (“concussion”); the first mobile medical app to help treat substance abuse disorders; technologies using artificial intelligence to detect diabetic retinopathy in adults with diabetes and for aiding providers in the detection of wrist fractures. Additional approvals included the first artificial iris in the U.S. and permitted marketing of a new prescription medical device that measures eye movement as an aid in the diagnosis of concussion.

Nearly One-Quarter Of Antibiotic Prescriptions Filled Are Unnecessary

Of the 15.5 million antibiotic prescriptions filled in 2016 by a population of 19.2 million privately insured children and adults under age 65, nearly one-quarter were unnecessary, according to a study funded by the Agency for Healthcare Research and Quality (AHRQ). Published on January 17, 2019 in the journal BMJ, the results indicate that an additional 36% of antibiotic prescriptions in 2016 were only "potentially appropriate." The analysis provides the most comprehensive estimates to date of inappropriate prescribing of antibiotics among individuals with private, employer-sponsored insurance. Appropriate antibiotic prescribing means that the medication is recommended for the patient's condition. Researchers conducted a combined analysis of a U.S. medical claims database and the 2016 version of an international system for categorizing diseases (ICD-10-CM). The analysis provides the most comprehensive estimates to date of inappropriate prescribing of antibiotics among individuals with private, employer-sponsored insurance.

HEALTH TECHNOLOGY CORNER

Enhanced Toy Dog Robot Includes An Ability To Learn From Its Owners

According to the January 2019 issue of the journal Science Robotics, the return of Aibo, Sony’s toy dog first introduced nearly 20 years ago, is welcomed by many, and not just because of its new appearance, enhanced voice understanding, and its improved ability to learn from its owners. In the new addition, the robot has been developed with Sony’s increasing awareness of the role that robots can play in childhood learning or as a companion for the aged, particularly those with neurodegenerative diseases. Understanding the perception, interaction, and expectations of humans around the robot and developing robot behavior and personality that are context aware (not dependent on pre-scripted programs and with personalization and adaptation) are interesting topics in social robotics. The device was highlighted in the journal as one of 10 Robotic Technologies Of The Year.

Electrical Stimulation Of The Brain During Surgery Produces Immediate Laughter And Calm

Neuroscientists at Emory University School of Medicine have discovered a focal pathway in the brain of a patient that when electrically stimulated causes immediate laughter, followed by a sense of calm and happiness, even during awake brain surgery. The behavioral effects of direct electrical stimulation of the cingulum bundle, a white matter tract in the brain, were confirmed in two other epilepsy patients undergoing diagnostic monitoring. The findings were published on February 11, 2019 in the Journal of Clinical Investigation. The technique is viewed as a potentially transformative way to calm some patients during awake brain surgery, even for individuals who are not especially anxious. For optimal protection of critical brain functions during surgery, patients may need to be awake and not sedated, so that doctors can talk with them, assess their language skills, and detect impairments that may arise from resection. Outside of use during awake surgery, understanding how cingulum bundle stimulation works also could inform efforts to treat depression, anxiety disorders, or chronic pain more effectively via deep brain stimulation.

Return to Feb 2019 trends

DEVELOPMENTS IN HIGHER EDUCATION

John Colbert

February 19, 2019

Trends Archives

The start of the 116th Congress in January 2019 is the first one in which the House and Senate are controlled by different parties since the 113th Congress (2013-2015). A long overdue reauthorization of the Higher Education Act may be one piece of major legislation that could be addressed this year. If so, the following kinds of changes might be considered in the context of making some needed improvements: simplifying the federal student aid application, creating a new income-based repayment plan for borrowers, building a new accountability system for colleges based on whether borrowers actually are repaying their loans, expanding competency-based education programs, requiring colleges to use clearer language in letters telling students about the aid they're receiving, and collecting better data on how much students borrow and how much they earn after graduation. Other possibilities include allowing incarcerated individuals to access Pell Grants and making grants available for shorter academic programs.

More than 104,000 responses recently were generated to comment on proposed Title IX rules by the U.S. Department of Education regarding how schools handle sexual assault allegations. Acknowledging that some would-be respondents may have experienced technical issues involving the website that could have preventing the submission of comments, the site was reopened for the single day of February 15, 2019. Examples of what the controversy entails also are described below:

Reducing Student College Debt

During the last four years, the U.S. Senate Committee on Health, Education Labor & Pensions (HELP) has held 27 hearings on the Higher Education Act. A concern expressed at many of these sessions is the problem of the significant burden of student debt. Approximately 43 million individuals, one in six adult Americans, have federal student loan debt and the federal student loan portfolio currently is approaching $1.5 trillion. A key aspect of the situation is applying for financial aid, a process that may be a suitable candidate for implementing some beneficial modifications.

One possible remedy is reducing the 108 questions to a much smaller number (e.g., 15-25) in the Free Application for Federal Student Aid (FAFSA) that 20 million families must fill out each year if they want a federal grant or loan to help pay for college. Not only does providing answers involve a significant amount of effort, a related issue is that some applicants may be intimidated by the complexity of the required information, making them wary of giving the Education Department data they already have provided to the IRS. Another impediment is that a verification process can suspend Pell Grant payments while a family has to resubmit tax information and wait for the government to check to ensure that the information is correct. To the extent that some students may be unable to attend college because of an inability to obtain financial aid, a solution involving the FAFSA is warranted.

Title IX Proposed Rule Involving Sexual Assault Allegations

Academic institutions are not equivalent to courts of law, yet they are responsible under Title IX to respond to allegations of sexual harassment, including sexual assault. Cases of this nature can be quite difficult to resolve because of differing accounts of what transpired and time lapses between when an event occurred and when it is reported. The challenge in such instances is to adopt processes to ensure that the parties involved are treated fairly and equitably. Depending on one’s perspective, the proposed rule consists of provisions that may be considered:

Helpful (e.g., requires institutions to provide both parties with reasonable time to prepare for any interview or disciplinary hearing).

Not Helpful (e.g., a requirement for a live hearing with cross-examination, which in effect is viewed as the same as legalistic, court-like processes that should not be the responsibility of educational institutions).

Lack Of Clarity (e.g., the term “due process” basically adds to an existing level of confusion).

Return to Feb 2019 trends

HEALTH REFORM DEVELOPMENTS

John Colbert

February 19, 2019

Trends Archives

Although other aspects of health reform occasionally crop up, the Affordable Care Act continues to represent the centerpiece of efforts to transform the delivery of health care, reduce costs, and increase the number of individuals who have an adequate amount of insurance coverage. As the years have gone by, Republicans through legislation introduced in Congress and in law suits filed by Attorneys General in several states have been successful in making some changes, such as eliminating the individual mandate, but they have not been able to repeal and replace this law.

As discussed below, with the passage of time it is relatively easy to lose sight of some of ACA’s elements. An example is the so-called “Cadillac tax.” Originally scheduled for implementation in 2018, postponements have occurred. More recently involving a separate matter, the U.S. Department of Labor in June 2018 was successful in having a rule finalized to expand the ability of employers to join together to offer health coverage through Association Health Plans, which provide short-term limited insurance coverage that may be less adequate in comparison to consumer protections in the ACA. Opposition by Democrats continues to be expressed to making these plans available. Meanwhile, the U.S. Senate maintains an interest in supporting primary care to lower health costs and improve patient outcomes.

The Cadillac Tax As A Means Of Offsetting Health Care Costs

The Cadillac tax is a provision in the ACA that affects high-cost employment-based health plans. It consists of a non-deductible 40% excise tax imposed on the portion of health coverage costs that exceeds $10,200 for single coverage and $27,500 for family coverage. Initially scheduled to become effective last year, it since has been delayed twice and presently is scheduled to take effect in 2022. By that year, the amounts will change to $11,200 for single coverage and $30,150 for family coverage. The original plan was to generate tax revenues that could help mitigate increasing health care costs and assist in financing other ACA provisions. If and when it ever becomes operational, nothing can be known until then regarding whether this tax can lead to the achievement of financial objectives.

Short-Term Association Health Plans And State Regulations

The Commonwealth Fund has issued concerns that short-term policies may be deceptively marketed, with some sellers leading consumers to believe they are buying a comprehensive policy when they are not. Efforts by the states to regulate these plans may be undermined by a loophole that limits their ability to perform basic consumer protection functions because many short-term plans are being sold through out-of-state associations that are exempt from state regulation. These entities are able to file insurance products for approval in one state and then sell the same policies in other states that have exempted policies, such as benefit mandates. In those jurisdictions, the association is then regulated by the state of approval, rather than the state in which the coverage is purchased.

How Primary Care Can Affect Health Care Costs And Outcomes

The U.S. Senate Health, Education, Labor, and Pensions (HELP) Committee held a hearing on February 5, 2019 in Washington, DC to discuss the role of primary care in influencing health care costs and patient outcomes. Individuals offering testimony included:

Tracy Watts, a Senior Partner and U.S. Healthcare Reform Leader at Mercer. Her remarks focused on ways employers are working to improve employee health and manage healthcare costs through onsite clinics and other innovative strategies.
Katherine Bennett, Assistant Professor of Medicine and Program Director of the Geriatric Medicine Fellowship at the University of Washington, described Project ECHO, the Extension for Community Health Outcomes, an effort launched in more than 160 locations in the U.S. to address complex conditions, such as HIV, tuberculosis, and mental illness.
Sapna Kripalani, Assistant Professor of Medicine at Vanderbilt University Medical Center, provided an example of the value of primary care for an obese patient with complex conditions involving diabetes, hypertension, seizure disorder, and bipolar disorder.

Return to February 2019 trends

OPEN SEASON FOR LEGISLATION

John Colbert

February 19, 2019

Trends Archives

The 1st Session of the 116th Congress is off to a brisk start. Given the fact that 2020 will involve an election to determine who will occupy the White House beginning in 2021, Congressional activity can be assessed within that context. Several Capitol Hill Democrats already have announced officially that they are in the race to decide which of them will be that party’s representative in the November election next year. A portion of the appeal of these candidates to voters will rest on legislative proposals that they endorse. Another venue where Congressional officials can operate effectively is as participants in hearings that highlight either defects in current Administration policies or alternative courses of action to adopt, which they espouse.

During his State of the Union Address to Congress on February 5, President Donald Trump served up a menu of examples of bipartisan cooperation that produced meaningful results, while also identifying areas where a reduction in partisan wrangling could lead to even more dramatic improvements in addressing topics of great importance to the nation’s welfare. Clearly, politics will provide a backdrop for what unfolds or fails to materialize between now and next year’s election. Not too surprisingly, the party in power always wants to be in the position of boasting of its enormous achievements, thereby furnishing a rationale why its leadership should be retained. The party out of power cannot be expected to cooperate in the passage of legislation that will burnish their opponents’ claims. Instead, it will redound more to their advantage to focus on the inadequacies of the other party and illustrate to voters in compelling terms why they would be better equipped to achieve more positive results once elected.

The President reminded his listeners on that occasion that both parties in the previous two years had come together: to pass unprecedented legislation to confront the opioid crisis, produce a sweeping new Farm Bill, and achieve historic Veterans Administration reforms. He said that as recently as only weeks ago, Democrats and Republicans united for groundbreaking criminal justice reform. Working closely with both groups, the Administration was able to sign the First Step Act into law, legislation that reformed previous sentencing laws that wrongly and disproportionately have harmed the African-American community. The Act gives non-violent offenders the chance to re-enter society as productive, law-abiding citizens.

Assuming that same cooperative spirit can prevail in the current session of Congress, then it may be possible to pass an infrastructure bill, including investments in cutting edge industries of the future. Along with proposing a nationwide paid family leave so that every new parent has the chance to bond with newborn children, the President identified the following objectives pertaining to health: (1) increase investments in HIV prevention programs, such as the Ryan White HIV/AIDS Program, and direct funding to launch new programs through community health centers to provide preventive medication to high-risk individuals, (2) allocate more than $500 million over the next 10 years to fund research for childhood cancer, (3) lower the cost of healthcare and prescription drugs and protect patients with pre- existing conditions, and (4) expand efforts to reduce “surprise billing” where patients are billed for care that is much more expensive than anticipated or is not covered by their insurance.

It is unclear whether any of these initiatives will see the light of day prior to November 2020. What is certain is that the 116th Congress will be worth monitoring to see what eventually unfolds.

Return to Dec 2018 - Jan 2019 trends

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

John Colbert

February 19, 2019

Trends Archives

By Susan N. Hanrahan, ASAHP President

In my message in the November 2017 issue, I indicated that I will be asking some of you to send a photo and answer a series of “fun” questions to be shared with our membership so that we can continue our collegiality through our newsletter. The 10th of many profiles and the second in 2019 is presented as follows:

Name and Title: Gregory Frazer, Dean and Professor, Covey College of Allied Health Professions

Place of birth: Evansville, Indiana

University: University of South Alabama

How long have you been in your position? 3rd year at USA; 19th year as a dean

What is the value of ASAHP? ASAHP is the preeminent organization for peer administrators and educators that enables collaboration and sharing among those committed to educational and professional excellence.

Your philosophy on education in seven words: Skills and knowledge enable opportunity, achievement and success.

If I could teach in another field, which one and why? Medicine because I have witnessed the dramatic impact of the delivery of care all over the world.

Before I retire I want to: Establish an international learning opportunity in every program I’m responsible for.

In college, I was known for: Being the fraternity social chairman.

What music is playing in my car/office? Luther Vandross

The last book I read for fun was: ”Honoring the Trust” by William Massy

My favorite trip was: Machu Picchu

If I could travel anywhere it would be: Santorini, Greece

Four people I’d take to coffee or have a glass of wine with: Confucius, Rosa Parks, President Obama, and Herb Kelleher

The best advice I ever received was: “Never forget where you came from and those who helped you be where you are today”

My hobby is: Racquetball

My passion is: Photography

My pet peeve is: Dirty car

A perfect day is: Professionally, its graduation. Personally, a sunny day on the beach with family and friends.

Cats or dogs? DOGS

E-book or hardback? Hardback

Beach or mountains? Beach

I wish I could: Share my passion for my work with all of my colleagues.

Only my friends know I: See what a challenge golf is to play.

My favorite saying is: “Fair is a playground term” as in “this policy isn’t fair.”

Return to Feb 2019 trends

THE PERIODIC TABLE OF ELEMENTS

John Colbert

February 19, 2019

Trends Archives

En route to becoming a health professional, the academic preparation of many students will involve enrolling in a course in chemistry. A typical classroom usually features a wall display of the Periodic Table of Elements. Its presence is the result of the work of Dmitri Mendeleev who published it 150 years ago. A show of remarkable prescience on his part, one of its impressive characteristics was the inclusion of gaps waiting to be filled by new elements yet to be discovered that are based on properties he predicted. When initially formulated, the Table contained only 63 elements. Currently, there are 118 of them.

Most elements are found in nature (the number is subject to debate) while others were discovered in laboratories and nuclear accelerators. It is possible that some students enrolled in chemistry offerings at the University of California, Berkeley may have a deeper appreciation of the discovery process because 16 elements were synthesized or discovered on that campus, including Berkelium, Californium, Lawrencium, which honors Professor Ernest Lawrence who invented the cyclotron, and Seaborgium after Berkeley professor Glenn Seaborg.

This brief history of achievements in the physical sciences may serve as a segue into developments that occur in the sphere of health care. Public policy continues to be dominated by discussions regarding how best to achieve accessibility, affordability, and accountability in the provision of health care services. Just as chemical elements are grouped together in the Periodic Table on the basis of shared common properties, it is possible to examine comparable proposals aimed at enhancing accessibility, for example, while recognizing that significant gaps continue to occur between the provision of health care and the attainment of improved health status at both individual and community levels.

One definition of chemistry holds that it is concerned with the transformation of substances and all the energies associated with these transformations. Health care can be transformative either by preventing disease or by halting ill health in its tracks. The term mutability has some relevance in this regard. Race and ethnicity represent an immutable human characteristic. Age is another one, for an 80-year old patient cannot be transformed into a 20-year old individual. Unfortunately, interventions in health care that produce salubrious outcomes for members of one racial/ethnic or age group do not always prove to be as effective with other groups.

Social determinants hugely affect who gains and who loses in the acquisition of high quality health care services. While portions of human existence may be mutable in theory, it remains insurmountably challenging to overcome the effects of poverty, discrimination, joblessness, insufficient formal education, a low level of health literacy, loneliness, and residence in turbulent neighborhoods ravaged by pollution and violence. Such conditions often prove to be highly refractory to generating positive alterations, but change they must if the aims of health care are to be realized. Meanwhile, an understanding both of chemistry and health may be enriched by reading The Periodic Table by Primo Levi, an author who composed a poetic link between the disparate worlds of physical and human nature.

Return to February 2019 trends

PHYSICAL THERAPY AND OCCUPATIONAL THERAPY GUIDELINES

John Colbert

January 22, 2019

Trends Archives

Page four of this newsletter provides information about health reform from the perspective of legislation and regulations that follow the enactment of laws. Since many policy guidelines also are formulated to improve health care by clarifying legislative intent, they may be considered useful aspects of health reform. As described in a manuscript published in the January 2019 issue of the journal Archives of Physical Medicine and Rehabilitation, the objective of a study was to determine if there was a change in the number of outpatient physical therapy (PT) and occupational therapy (OT) visits for Medicare beneficiaries, and in the number of beneficiaries receiving extended courses of >12 therapy visits, after the Jimmo vs Sebelius settlement.

Medicare Part-B helps to cover outpatient physician, PT, OT, speech therapy, and home health services. Policy is designed to cover rehabilitation services that require the skill of a PT or OT to restore function, or when no improvement is expected, to slow deterioration and maintain current levels of functioning. Beneficiaries are able to receive outpatient OT and PT services until a monetary threshold, or cap is reached. If the cap is met, and treatment is medically necessary to further improvement or to prevent a worsening of function, Medicare guidelines state that reimbursement of care can continue. Historically, however, this process was not always followed.

Coverage determination is delegated to Medicare administrative contractors (MACs) who make local decisions to ensure that therapy is medically necessary. Policy manuals developed to help interpret regulations became more restrictive and in some cases contradicted federal regulations. Beneficiaries were being denied access to and payment for therapy if their chronic conditions precluded improvement. Regional local coverage decision manuals for outpatient PT incorrectly noted that coverage depended on the “expectation that the patient’s condition will improve significantly in a reasonable and generally predictable period of time.” If there was no expectation that the condition would improve and there was no measurable change in function, MACs would deny coverage.

After the Jimmo settlement was reached, Part B Medicare beneficiaries were likely to receive about one additional therapy visit per year. An estimate is that at a minimum, the settlement will increase utilization by about 12 million visits per year. Patient therapies help minimize functional decline, avoidable hospitalizations and nursing home admissions, which may result in lower costs.

Return to Dec 2018 - Jan 2019 trends

DETECTING BS IN HEALTH CARE

John Colbert

January 22, 2019

Trends Archives

Given its noticeable abundance, it is likely that even individuals who are barely sensate realize that quite a bit of BS exists in this world, even in health care. Fortunately, Lawton Burns and Mark Pauly from the Department of Health Care Management at The Wharton School University of Pennsylvania have arrived on the scene with a timely remedy in the form of a detection tool to offset a variety of preposterous claims that clutter up the landscape. Their position is buttressed by a belief that in the past several months, they have observed several notable signs of deceptive, misleading, unsubstantiated, and foolish statements that they call “BS” in the health care industry (e.g., fraudulently marketed products, ridiculous assertions of ways to reduce health care costs by huge percentages, and purported wonders that are supposed to occur as a result of business mergers).

A starting point is to ask the question, why does this kind of behavior occur? While flat-out dishonesty for short term financial gains is an obvious answer, a more common explanation is the need to say something positive when there is nothing positive to say. The two researchers present their Top 10 BS candidates, in both pictures and words. Each picture is presented untitled and without text, thereby inviting readers to discern what the BS message is and engage them in the BS detection process. Then, they offer an explanation of what the picture conveys, which aims at helping readers to become more skilled “BS Hunters.” They also note that they reserve the option to expound further since there is a likelihood of the danger of wading into even more BS in the future. (Link to special report)

Return to Dec 2018 - Jan 2019 trends

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

John Colbert

January 22, 2019

Trends Archives

Faculty Attitudes On Academic Technology
Inside Higher Ed’s 7th annual Survey of Faculty Attitudes on Technology aims to understand how professors and digital learning leaders view online learning and other aspects of academic technology. A new report presents findings from a quantitative survey research study that Gallup conducted on behalf of Inside Higher Ed. Some findings are: The proportion of faculty members who have taught online courses continues to increase. Currently, 44% report having taught an online course, up from 30% in 2013. Meanwhile, 38% have taught a hybrid or blended course that has elements of face-to-face and online teaching. The vast majority of instructors who have taught online courses, 89%, say they have been involved in the design of those courses. More than 7 in 10 faculty members who have taught online courses say the experience has taught them skills that have improved their teaching. Most commonly, they say their online teaching has caused them to think more critically about how to engage students with course content and to make better use of multimedia content. The report can be obtained here.

State Strategies For Establishing Connections To Health Care for Justice-Involved Populations: The Central Role Of Medicaid
Prior to the Affordable Care Act, most individuals leaving prison or jail weren't eligible for Medicaid, since coverage generally wasn't available to childless adults. With Medicaid expansion taking hold in more states, health coverage is becoming more available for those upon release from incarceration facilities. With coverage as a foundation, states are seeking to address the complex health and social issues many of these individuals face, including opioid addiction, mental illness, and barriers to stable housing and employment. In a new Commonwealth Fund report, experts with Manatt Health explore the latest developments in comprehensive primary care for adults leaving jail or prison and the role Medicaid can play in financing and supporting the most effective practices. In a number of states, "in-reach" services are helping inmates establish relationships with providers prior to release, identifying health conditions, and setting up community-based care. The report can be obtained here.

Public Health Trends Plaguing The U.S. Population
The United Health Foundation released its annual population health report, documenting a number of concerning public health trends that have continued to plague the U.S. population. The rate of obesity in the U.S. increased by 5% from 2017 to 2018, which equates to one in three Americans being affected by the disease. The increasing prevalence of obesity coincides with a greater number of deaths due to cardiovascular disease (112,403) and other chronic diseases. Mental and behavioral health issues also have been on the rise, as feelings of mental distress were self-reported 7% more often than in 2016. Rising behavioral health issues are exacerbated by the barrier of access to care. Currently, 124 million Americans live in areas where there are shortages of formal mental health care. The report notes various other disparities in health that can be attributed to social determinants of health. It can be obtained here.

Return to Dec 2018 - Jan 2019 trends

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

John Colbert

January 22, 2019

Trends Archives

Lower Wages And Benefits Of Female Health Care Workers
According to a report appearing in the January 2019 issue of the American Journal of Public Health, a study carried out by researchers at Massachusetts General Hospital (MGH) and the Perelman School of Medicine at the University of Pennsylvania finds that low wages and poor benefits leave many female health care workers living below the poverty line. Projecting the survey's results across the entire U.S. population suggests that 5% of all women health care workers, including 10.6% of Black and 8.6% of Latina women health care workers, live in poverty. Overall, 1.7 million women health care workers and their children lived below the poverty line in 2017, accounting for nearly 5% of all individuals living in poverty in the U.S. The researchers also found surprisingly high numbers of female health care workers surveyed lack health insurance. Overall, 7% , projected to represent more than 1 million women nationwide, were uninsured, including more than 10% of Black and Latina women employed in health care.

Physical Therapy In Relation To Opioid Usage
According to a study by researchers at the Stanford University School of Medicine and the Duke University School of Medicine published on December 14, 2018 in JAMA Network Open that was based on an analysis of private health insurance claims for care and prescriptions between 2007 and 2015, patients who underwent physical therapy soon after being diagnosed with pain in the shoulder, low back, or knee were approximately 7 to 16% less likely to use opioids in subsequent months. For patients with shoulder, back, or knee pain who did use opioids, early physical therapy was associated with a 5 to 10 % reduction in how much of the drug they used, the study found. Amid national concern about the overuse of opioids and encouragement from the Centers for Disease Control and Prevention, and other groups to deploy alternatives when possible, the findings provide evidence that physical therapy can be a useful, nonpharmacologic approach for managing severe musculoskeletal pain.

HEALTH TECHNOLOGY CORNER

Robotic Activity Support System For Elderly Patients With Dementia
A robot created by Washington State University (WSU) scientists could help elderly patients with dementia and other limitations to live independently in their own homes by performing basic and instrumental activities of daily living (ADLs). The Robot Activity Support System, or RAS, represents a collaboration between a smart home and a mobile robot. It functions by using sensors embedded in a WSU smart home to determine where its residents are, what they are doing, and when they need assistance with daily activities. RAS combines the convenience of a mobile robot with the activity detection technology of a WSU smart home to provide assistance in the moment, as the need for help is detected. A description of the project appears in advance in the May 2019 issue of the journal Cognitive Systems Research. Technologies that automatically assist with activity of daily living may relieve some of the strain on the health care system as well as caregivers, allowing individuals to remain functionally independent and age in place.

Research On Roundworms May Lead To Motor Function Improvement In Humans
As animals and humans age, motor functions progressively deteriorate. Millimeter-long roundworms called nematodes exhibit aging patterns remarkably similar to those of other animals and they live only about three weeks, making them an ideal model system for studying aging. A report on January 2, 2019 indicated that research from the University of Michigan Life Sciences Institute has uncovered a cause of declining motor function and increased frailty in tiny aging worms and a way to slow it down. The findings, published that day in Science Advances, identify a molecule that can be targeted to improve motor function and indicate that similar pathways may be at play in aging mammals as well. Age-dependent motor activity decline is a prominent feature of normal aging. Motor deficits represent one of the main risk factors for falling in elderly humans, which leads to injury and mortality. It would be beneficial to delay or slow motor aging to improve the quality of life and, ideally, to extend a life span, which has remained a challenge. Using C. elegans as a model, targeting aging motor neurons can slow motor aging and promote longevity.

Return to Dec 2018 - Jan 2019 trends

DEVELOPMENTS IN HIGHER EDUCATION

John Colbert

January 22, 2019

Trends Archives

Similar to legislative and regulatory initiatives pertaining to health reform that are described on the previous page of this newsletter, higher education also is affected by events that occur in those two arenas. A most important piece of legislation in need of concerted action is reauthorization of the Higher Education Act. Last reauthorized in 2008, since 2013 it has been sustained by a series of short-term continuing resolutions (CRs). Whether this important task will be completed in 2019 is uncertain.

One way of assessing what may unfold involving higher education is to chart the activities of key officials when they appear in public to make presentations. Secretary of Education Betsy DeVos on December 19, 2018 met with leaders of the American Council of Education (ACE) at that organization’s headquarters to discuss higher education policy. She used accreditation as an example of how to approach the current educational system. She requested her listeners to rethink which parts of the Department’s accreditation regulations and guidance are related directly to educational quality and student experience, and which parts are ambiguous, repetitious, or unnecessarily burdensome. She also asked how the Department could clarify the roles and responsibilities of each entity within the higher education “triad,” consisting of the federal government (which has a focus on administrative and fiscal integrity of student financial aid programs), state governments (which issue licenses to academic institutions), and accreditation organizations (which assure acceptable levels of quality in teaching and learning).

Rethinking Higher Education

As part of her remarks, the Secretary released the document “Rethinking Higher Education,” which identifies the following goals:

It is time to challenge our past practices, assumptions, and expectations about what “college” is, what it should be, and how it should operate.
It is time to restore institutional autonomy and respect for an institution’s unique mission.
It is time to value the unique goals and challenges that each student brings to the postsecondary experience.
It is time to include in our assessment of institutions the contributions that each school makes to help its students’ success.
It is time to streamline regulations so as to avoid government intrusion.
It is time to promote innovation.
It is time to allow new entrants to educational delivery and reject efforts to maintain the status quo.

Rethinking Higher Education: Accreditation

A second document also was released that outlines some of the following goals:

Restore “substantial compliance” as the standard for recognition.
Restore the regulatory triad by more clearly defining the roles and responsibilities of accreditors, the states, and the Department in oversight of Title IV participating institutions of higher education.
Increase academic and career mobility for students by eliminating artificial boundaries between institutions due to credential levels an institution offers or the agency that accredits the institution or its programs.
Provide greater flexibility for institutions to engage in innovative educational practices and meet local and national workforce needs.
Within the confines of law, protect institutional autonomy, honor individual campus missions, and afford schools the opportunity to build campus communities based on shared values.
Reward institutional value-added, not student selectivity.
Modify “substantive change” requirements to provide greater flexibility to institutions to innovate and respond to the needs of students and employers.
Streamline and clarify the Department’s accreditor recognition process.
Encourage and enable accreditors to support innovative practices, grant limited accreditation to experimental pedagogies, provide support to accreditors when they take adverse actions, and allow sanctions that do not mandate “all or nothing” access to Title IV.

Return to Dec 2018 - Jan 2019 trends

HEALTH REFORM DEVELOPMENTS

John Colbert

January 22, 2019

Trends Archives

It does not amount to the least bit of hyperbole to suggest that a great many pieces of legislation that are enacted into law might conveniently be subtitled: The Attorneys, Accountants, and Lobbyists Relief Act (fill in the year of enactment). The Patient Protection and Affordable Care Act of 2010 (commonly referred to as either the ACA or Obamacare) fits this description perfectly. To cite just one example, in February last year, 20 attorneys general filed a lawsuit claiming that the 2017 Tax Cut law and the Jobs Act’s reduction of the individual responsibility tax penalty to zero, in effect made the ACA’s individual mandate unconstitutional. Proceeding from that line of reasoning, it means that the entire ACA was invalid because of the disappearance of the tax penalty. In December of 2018, a federal court judge in Texas agreed with this argument, entering a judgment that if it is upheld, the entire ACA would become invalidated. What comes as no surprise is that supporters of the Affordable Care Act have mounted their opposition to this ruling. Democratic attorneys general in 17 states have intervened to defend the entirety of the health reform law.

Apart from this specific example, it is worth noting that once it became apparent that Republicans in Congress in 2017 were unable to repeal and replace the ACA, since then the Trump Administration has used its powers to issue several regulations and guiding principles aimed at crippling the law. Opponents have responded by unleashing countersuits to prevent or delay these administrative actions. Thus, it is safe to assume that the future appears to remain quite bright when it comes to the financial health of many law firms and advocacy groups since additional litigation already can be detected hovering on the near horizon.

Administration Initiative To Create Association Health Plans Faces Challenges
One Trump Administration regulatory initiative is aimed at creating Association Health Plans that do not have to comply with either ACA individual or small-group requirements, In June 2018, the Labor Department finalized a rule to expand the ability of employers, including sole proprietors without common law employees, to join together and offer health coverage through Association Health Plans. These short-term limited duration vehicles can be in effect for one year and also be subject to renewal for as many as 36 months while continuing to be exempt from the Affordable Care Act’s consumer protections. Opponents have reacted in New York and other states by bringing a lawsuit to challenge the health plan rule on the basis that it violates the ACA, the Employee Retirement Income Security Act (ERISA) of 1974 that regulates group health plans, and the Administrative Procedures Act. Oral arguments in federal district court for the District of Columbia were scheduled to begin in January 2019.

Transgender Protections And Religious/Moral Objections To Contraception Coverage
Increased attention is being paid by policymakers to the issue of whether the health care needs of transgender individuals are being addressed satisfactorily. One concern is whether current regulations provide adequate protection from discrimination against transgender patients by insurance companies and health care providers. Federal courts have weighed in on this matter in the past and can be expected to continue doing so in the future. Mandated benefits under the ACA sometimes trigger opposition for moral and religious reasons. Contraception coverage offers an example whenever religious groups are compelled to provide this benefit because doing so may conflict with core spiritual beliefs.

Pursuing The Realization Of Health Care Priorities In Congress
Major differences exist between Democrats and Republicans in Congress, and despite that each party enjoys a majority in only one chamber, it still may be possible to achieve bipartisan agreement on certain issues that could be enacted into law. An example is lowering the cost of prescription drugs. President Trump also has signaled his desire to see constructive action taken in that regard. Recent years have involved a series of proposed buy-outs and mergers among drug companies, insurance firms, and health care providers. Through its oversight powers, committees in Congress may be able to work in an effective bipartisan way to determine if such transactions have the potential either to weaken competition or have a negative impact on health care consumers and taxpayers. Fixing a maldistribution of health resources in the form of an insufficient supply of clinicians and health care facilities in rural areas is a chronic problem that also should be of interest to legislators from both political parties.

Return to Dec 2018 - Jan 2019 trends

FEDERAL BUDGET AND THE OPERA

John Colbert

January 22, 2019

Trends Archives

An inability to reach agreement on federal budget priorities resulted in a partial government shutdown to mark the start of the year 2019. The current shutdown occurred because of an inability to reach agreement on how much should be spent and for what purposes to increase security measures along the nation’s southern border with Mexico. This 21st stoppage in the past 43 years conjures up thoughts about how efforts to produce a budget each fiscal year can assume qualities of an operatic nature. As an illustration, divas and divos from both major political parties are accustomed each year to performing dramatic roles involving the equivalent of singing enthusiastic arias that reflect their distress at pet projects being denied adequate funding.

History shines some light on the nature of the basic problem. Only on four occasions since 1977 has Congress been able to pass all 12 appropriations bills on time before a new fiscal year begins on October 1. Another 16 years have been characterized by an inability to pass a single bill on time. The usual remedy is to enact short-term continuing resolutions (CRs) to enable the government to continue operating, but as the present situation exemplifies, even that approach has not been possible on 21 different occasions.

It also is worth acknowledging that squabbles over the federal budget are restricted to only one-fourth of total spending. Referred to as discretionary expenditures, amounts have to be debated and agreed upon for purposes, such as aid to education, the military, National Institutes of Health, and the provision of agricultural subsidies. The remaining three-fourths of the budget essentially is on automatic pilot where spending is allocated among major entitlement programs, including Social Security and Medicare. Once individuals qualify to become recipients, their benefits must be paid as regularly as clockwork. Given the steady numerical and proportional growth in the segment of the population age 65 and older, the provision of adequate support for such programs will continue to pose significant future challenges.

Apart from funding, individual members of Congress either singly or in combination will introduce a large number of bills in 2019. Committees and subcommittees will conduct hearings and also carry out oversight activities of the executive branch. The educational community has been waiting patiently since 2013 for reauthorization of the Higher Education Act (HEA). This major piece of legislation that became law in 1965 last was reauthorized in 2008. Whether agreement can be reached on producing a reauthorization this year remains to be seen.

Both chambers are off to a quick start proposing other legislative action.

Senate:
S.3—stabilize the individual insurance market, make insurance coverage more affordable, lower prescription drug prices, and improve Medicaid.
S.12—improve access to health care through expanded health savings accounts.

House:
H.R. 64—intensify stem cell research showing evidence of substantial clinical benefit to patients, and for other purposes.
H.R. 83—repeal the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010.

Now that Democrats are the majority in the House of Representatives, considerable interest is being expressed in moving toward a single payer system. Expanding Medicare eligibility to a wider segment of the U.S. population would be a step in that direction.

Return to Dec 2018 - Jan 2019 trends

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

John Colbert

January 22, 2019

Trends Archives

By Susan N. Hanrahan, ASAHP President

In my message in the November 2017 issue, I indicated that I will be asking some of you to send a photo and answer a series of “fun” questions to be shared with our membership so that we can continue our collegiality through our newsletter. The 9th of many profiles and the first in 2019 is presented as follows:

Name and Title: Brooke Hallowell, Dean of Health Sciences and Rehabilitation Studies

University: Springfield College

How long have you been in your position? 1 year

If I could teach in another field, which one and why? Counseling/coaching/hypnotism. To be at the heart of empowering people to be their best, authentic selves, thus enhancing their roles as vehicles of service to others.

Before I retire I want to: Start doing a lot of the things I dream of doing after I retire.

In college, I was known for: Being president of our university orchestra.

What music is playing in my car/office? Francis Cabrel

My favorite trip was: In southern India, with my daughter

If I could travel anywhere it would be: Fiji

The best advice I ever received was: Put on your own oxygen mask before assisting others.

My hobby is: Improv acting, arm wrestling, sculpting, collaborative storytelling

My passion is: Hanging out with older people and babies.

Beach or mountains? Both! Why choose?

Only my friends know I: Am a certified heavy equipment operator and an arm-wrestling pro.

My favorite saying is: Choose the joy!

Return to Dec 2018 - Jan 2019 trends

CALLING UNCLE SAM AND ALEXA

John Colbert

January 22, 2019

Trends Archives

Federal programs that include Medicare and Medicaid, along with technology developments in the private sector such as Alexa are two sets of forces that represent enormous influences on the health care domain. Apart from furnishing health services and paying for them, parallel activities by other government entities play essential roles in generating innovations (e.g., National Institutes of Health) and ensuring safety of new health products (e.g., Food and Drug Administration).

The Medicare Board of Trustees reported on June 5, 2018 that in 2017, Medicare covered 58.4 million individuals, 49.5 million aged 65 and older, and 8.9 million who are disabled. Total expenditures in 2017 were $710.2 billion and total income was $705.1 billion. Medicaid is the nation’s public health insurance program for individuals with low income. It covers more than 70 million Americans, including many with complex and costly needs for care. The program accounts for one in six dollars spent on health care in the United States and more than half of all spending for long-term services and supports. Plus, it drives state budgets and is the largest source of federal revenues to states.

Amazon Echo and Dot devices are improving patients’ lives by enabling those who are bedridden and unable to reach a wall thermostat to regulate room temperature. When issuing commands to a device, the software can be rearranged to accommodate whatever words a patient is capable of using to perform various household tasks and set medication reminders. An Alexa app called Marvee can translate voice snippets into text messages and deliver them to pre-specified contacts. Meanwhile, Amazon has filed a patent for the Alexa voice assistant to recognize coughs or colds. That firm also has been exploring options that would allow it to mine medical records to diagnose patients and it has been exploring the possibilities of testing patients for disease at home.

Technology developments impinge on the government both directly and indirectly. For example, the Apple Watch can generate data as a consumer health tracker. The company touts the ability of this device to detect atrial fibrillation, although evidence is gathering that it does so less accurately for users below the age of 55. Efforts currently are underway to determine if private Medicare plans are interested in subsidizing the watch for beneficiaries.

As devices of this nature collect consumer and patient health information, concerns are raised about how adequately current policies protect privacy. Congress could play a useful role by clarifying the amount of authority and ownership patients have over their own records, and the extent to which patient information can be held by a health system. Steady advances in germline gene editing and artificial intelligence also call into question whether existing policies suffice to ensure that patients are protected from possible harm. A congressional in-house think tank, the Office of Technology Assessment (OTA), was disbanded in 1995. As legislators increasingly are called upon to deal with technology issues, restoring the OTA may be warranted as a means of assisting them to perform satisfactorily.

Return to Dec 2018 - Jan 2019 trends

NAVIGATING THE HEALTH FRONTIER

John Colbert

November 26, 2018

Trends Archives

A deeper understanding of consumers’ decision-making processes can equip health care providers to retain and engage them effectively as well as attract new ones. The Deloitte Center for Health Solutions recently surveyed 4,530 U.S. consumers to assess their attitudes, behaviors, and preferences when making decisions about health insurance, health care, and well-being. A segmentation analysis of data, focusing on health care attitudinal and behavior questions rather than demography, offered a richer understanding of consumers than analysis focused solely on demographic factors.

The analysis categorized individuals into four distinct groups that reflect their differences in preferences for managing their health and interacting with various providers. Given its changing and sometimes unknown landscape, the U.S. health care system draws parallels with the Wild West of the 19th century. Personalities of individuals from the American frontier during that time period used to describe the results of segmentation are as follows:

Trailblazers (tech-savvy, self-directed, engaged in wellness, willing to share data)
Prospectors (rely on recommendations from friends/family, use providers as trusted advisors, willing to use technology)
Homesteaders (reserved, cautious traditionalists)
Bystanders (complacent, tech-reluctant, resistant to change, unengaged)

The analysis shows that each group not only has unique needs and expectations, but navigates the health care system differently. Segmentation findings can help tailor more effective interactions with consumers.

Return to November 2018 trends

CELEBRATING ALLIED HEALTH WEEK AT DES MOINES UNIVERSITY

John Colbert

November 26, 2018

Trends Archives

Members of Des Moines University Health Leaders and UnityPoint Clinic staff came together to celebrate Allied Health Week on November 8.

As part of 2018 Allied Health Week on November 4-10, the Des Moines University Health Leaders, an interprofessional student club, brought to campus members of UnityPoint Clinic’s recruitment staff on November 8. They held mock interviews with more than 30 physical therapy, physician assistant, and osteopathic medical students to help them hone their interviewing skills and resumés. The UnityPoint team also gave a presentation on general tips for constructing a strong resumé, the process that occurs from applying for a position to landing an interview, how to come prepared, and insights on contract negotiations. Additional events involved hosting a noon event for students to learn about each program on campus and networking on another evening that week.

Return to November 2018 trends

More Articles from TRENDS February 2019

THE PERIODIC TABLE OF ELEMENTS

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

OPEN SEASON FOR LEGISLATION

HEALTH REFORM DEVELOPMENTS

DEVELOPMENTS IN HIGHER EDUCATION

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

IDENTIFICATION, EVALUATION, AND COMPARISON OF HEALTH DEVICES

More Articles from TRENDS February 2019

THE PERIODIC TABLE OF ELEMENTS

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

OPEN SEASON FOR LEGISLATION

HEALTH REFORM DEVELOPMENTS

DEVELOPMENTS IN HIGHER EDUCATION

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY