Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally

Provided by The Commonwealth Fund

Publication Date:
June 16, 2014

Authors:
Karen Davis, Kristof Stremikis, David Squires, Cathy Schoen

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Executive Summary
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Executive Summary

The United States health care system is the most expensive in the world, but this report and prior editions consistently show the U.S. underperforms relative to other countries on most dimensions of performance. Among the 11 nations studied in this report—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2010, 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last or near last on dimensions of access, efficiency, and equity. In this edition of Mirror, Mirror, the United Kingdom ranks first, followed closely by Switzerland (Exhibit ES-1).

Expanding from the seven countries included in 2010, the 2014 edition includes data from 11 countries. It incorporates patients’ and physicians’ survey results on care experiences and ratings on various dimensions of care. It includes information from the most recent three Commonwealth Fund international surveys of patients and primary care physicians about medical practices and views of their countries’ health systems (2011–2013). It also includes information on health care outcomes featured in The Commonwealth Fund’s most recent (2011) national health system scorecard, and from the World Health Organization (WHO) and the Organization for Economic Cooperation and Development (OECD).

The most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage.5 Other nations ensure the accessibility of care through universal health systems and through better ties between patients and the physician practices that serve as their medical homes. The Affordable Care Act is increasing the number of Americans with coverage and improving access to care, though the data in this report are from years prior to the full implementation of the law. Thus, it is not surprising that the U.S. underperforms on measures of access and equity between populations with above- average and below-average incomes.

The U.S. also ranks behind most countries on many measures of health outcomes, quality, and efficiency. U.S. physicians face particular difficulties receiving timely information, coordinating care, and dealing with administrative hassles. Other countries have led in the adoption of modern health information systems, but U.S. physicians and hospitals are catching up as they respond to significant financial incentives to adopt and make meaningful use of health information technology systems. Additional provisions in the Affordable Care Act will further encourage the efficient organization and delivery of health care, as well as investment in important preventive and population health measures.

For all countries, responses indicate room for improvement. Yet, the other 10 countries spend considerably less on health care per person and as a percent of gross domestic product than does the United States. These findings indicate that, from the perspectives of both physicians and patients, the U.S. health care system could do much better in achieving value for the nation’s substantial investment in health.

Major Findings

• Quality: The indicators of quality were grouped into four categories: effective care, safe care, coordinated care, and patient-centered care. Compared with the other 10 countries, the U.S. fares best on provision and receipt of preventive and patient-centered care. While there has been some improvement in recent years, lower scores on safe and coordinated care pull the overall U.S. quality score down. Continued adoption of health information technology should enhance the ability of U.S. physicians to identify, monitor, and coordinate care for their patients, particularly those with chronic conditions.
• Access: Not surprisingly—given the absence of universal coverage—people in the U.S. go without needed health care because of cost more often than people do in the other countries. Americans were the most likely to say they had access problems related to cost. Patients in the U.S. have rapid access to specialized health care services; however, they are less likely to report rapid access to primary care than people in leading countries in the study. In other countries, like Canada, patients have little to no financial burden, but experience wait times for such specialized services. There is a frequent misperception that trade-offs between universal coverage and timely access to specialized services are inevitable; however, the Netherlands, U.K., and Germany provide universal coverage with low out-of-pocket costs while maintaining quick access to specialty services. 
• Efficiency: On indicators of efficiency, the U.S. ranks last among the 11 countries, with the U.K. and Sweden ranking first and second, respectively. The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of administrative hassles, avoidable emergency room use, and duplicative medical testing. Sicker survey respondents in the U.K. and France are less likely to visit the emergency room for a condition that could have been treated by a regular doctor, had one been available. 
• Equity: The U.S. ranks a clear last on measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year. 
• Healthy lives: The U.S. ranks last overall with poor scores on all three indicators of healthy lives—mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60. The U.S. and U.K. had much higher death rates in 2007 from conditions amenable to medical care than some of the other countries, e.g., rates 25 percent to 50 percent higher than Australia and Sweden. Overall, France, Sweden, and Switzerland rank highest on healthy lives.

Summary and Implications

The U.S. ranks last of 11 nations overall. Findings in this report confirm many of those in the earlier four editions of Mirror, Mirror, with the U.S. still ranking last on indicators of efficiency, equity, and outcomes. The U.K. continues to demonstrate strong performance and ranked first overall, though lagging notably on health outcomes. Switzerland, which was included for the first time in this edition, ranked second overall. In the subcategories, the U.S. ranks higher on preventive care, and is strong on waiting times for specialist care, but weak on access to needed services and ability to obtain prompt attention from primary care physicians. Any attempt to assess the relative performance of countries has inherent limitations. These rankings summarize evidence on measures of high performance based on national mortality data and the perceptions and experiences of patients and physicians. They do not capture important dimensions of effectiveness or efficiency that might be obtained from medical records or administrative data. Patients’ and physicians’ assessments might be affected by their experiences and expectations, which could differ by country and culture.

Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home. Under the Affordable Care Act, low- to moderate-income families are now eligible for financial assistance in obtaining coverage. Meanwhile, the U.S. has significantly accelerated the adoption of health information technology following the enactment of the American Recovery and Reinvestment Act, and is beginning to close the gap with other countries that have led on adoption of health information technology. Significant incentives now encourage U.S. providers to utilize integrated medical records and information systems that are accessible to providers and patients. Those efforts will likely help clinicians deliver more effective and efficient care.

Many U.S. hospitals and health systems are dedicated to improving the process of care to achieve better safety and quality, but the U.S. can also learn from innovations in other countries—including public reporting of quality data, payment systems that reward high-quality care, and a team approach to management of chronic conditions. Based on these patient and physician reports, and with the enactment of health reform, the United States should be able to make significant strides in improving the delivery, coordination, and equity of the health care system in coming years.

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Supreme Court Upholds Entire Affordable Care Act

From Medscape Medical News

Robert Lowes

Posted: 06/28/2012

June 28, 2012 — The Supreme Court today declared in a 5-4 vote that the Affordable Care Act (ACA) — the most significant healthcare legislation since the creation of Medicare — is also a constitutional act.

The ruling comes as a shock to many observers, who predicted the court would strike down the individual mandate to obtain insurance coverage, if not the entire law, after its 5-member conservative wing voiced misgivings about the controversial provision during oral arguments in March. The court decision also represents an early Christmas present for President Barack Obama, who seeks reelection this fall against a Republican opponent committed to rolling back "Obamacare."

The individual mandate was at the core of a lawsuit filed against the ACA by officials from 26 states, all but 1 of whom were Republican, as well as a business association. Similar to their Republican allies in Congress, the plaintiffs claimed that the mandate violated the Constitution's Commerce clause, which empowers Congress to regulate interstate commerce. They argued that although healthcare is a form of interstate commerce, Congress cannot compel "inactive" individuals to engage in commerce; that is, to buy or sell something. To allow the mandate to stand, they said, would open the door to further encroachments on personal liberty.

A federal district court in Florida and a federal appeals court in Georgia sided with the plaintiffs and invalidated the individual mandate. However, the Supreme Court had other precedents to follow.

The majority of lower federal courts that ruled on similar challenges to the ACA gave the mandate a clean bill of health, agreeing with the Obama administration's argument that contrary to the law's critics, individuals foregoing insurance coverage actively participate in the healthcare marketplace because they will eventually require medical attention. Their decision not to get coverage is bad for everyone else because the cost of their free or subsidized care is passed on to others in the form of higher provider costs and higher premiums, according to the administration. In addition, the decision by healthy Americans to go uninsured leaves the existing risk pool of insured Americans smaller and sicker, driving up premiums even more.

The mandate helps cure all these problems, the administration contended, by forcing "free riders" to finance their healthcare now as opposed to later, if at all.

During the oral arguments in March, several conservative Supreme Court justices did not appear to buy into the administration's point of view.

"Here the government is saying that the federal government has a duty to tell the individual citizen that it must act," said Justice Anthony Kennedy, "and that is different from what we have in previous cases, and that changes the relationship of the federal government to the individual in a very fundamental way."

The court's ruling on the ACA addressed more than the mandate. The justices also upheld the constitutionality of the law's dramatic expansion of the Medicaid program, which the plaintiffs had portrayed as a usurpation of states' rights. The court also declared that a penalty levied on individuals who fail to obtain health insurance coverage beginning in 2014 does not bar consideration of the case beforehand. At issue was a law called the Anti-Injunction Act (AIA), which prohibits anyone from challenging a tax in court until it has been paid. A federal district judge in Richmond, Virginia, last year ruled that the ACA penalty amounted to a tax, and thus triggered the AIA.

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UnitedHealthcare and American Gastroenterological Association Announce Collaboration to Improve Patient Care

PRESS RELEASE

April 16, 2012, 8:30 a.m. EDT

UnitedHealthcare is first health care company to partner with the AGA Digestive Health Outcomes Registry(R) to help advance high-quality, cost-effective medical best practices

MINNETONKA, Minn., Apr 16, 2012 (BUSINESS WIRE) -- --Technology platform from MedAssurant, Inc., to gather and analyze data

UnitedHealthcare and the American Gastroenterological Association (AGA) today announced a collaboration designed to improve patient care and outcomes in digestive disorders.

Through this collaboration, UnitedHealthcare will incorporate gastroenterologist (GI) physician data from the AGA Digestive Health Outcomes Registry(R) into its physician performance measurement programs that compare individual treatment practices with national treatment standards created by gastroenterologists. Data from the registry will support UnitedHealthcare's expanding portfolio of physician incentive programs that reward medical groups and physicians who demonstrate high-quality, cost-effective care.

Information obtained from this analysis will help UnitedHealthcare and the AGA promote best practices related to the care of patients with digestive disorders. The registry is certified by the Centers for Medicare & Medicaid Services (CMS), enabling practices to submit data on Medicare beneficiaries with hepatitis C to the CMS Physician Quality Reporting System.

UnitedHealthcare is the first health care company to partner with the AGA Digestive Health Outcomes Registry to help advance high-quality, cost-effective medical best practices

"We support UnitedHealthcare's leadership in promoting quality care and are pleased to partner with them to improve the quality of care that gastroenterologists provide patients," said John I. Allen, M.D., MBA, AGAF, vice president-elect of the AGA Institute and chair of the AGA Registry Executive Management Board. "The AGA Registry is derived from evidence-based clinical guidelines and outcomes measures developed by GI clinicians. It is a powerful tool for gastroenterologists who want to benchmark their practices, proactively manage patient care and ensure the appropriate use of resources."

The AGA Registry has been operational for two years and remains open to new physician members. GI physicians in UnitedHealthcare's care provider network will be able to submit information upon enrollment in the registry.

The AGA Registry contains data from MedAssurant's Medical Outcomes for Research on Economics and Effectiveness Registry(R) (MORE(2) Registry(R)), which includes submissions from practicing gastroenterologists nationwide. MedAssurant's registry division is primarily responsible for the technology platform, collection of information from practicing gastroenterologists, associated analytics, and reporting capabilities to UnitedHealthcare.

"The AGA's national membership of gastroenterologists, together with the combination of our broad national network of 650,000 physicians and other care providers, and our focus on communicating the value of information tied to consumer and physician engagement and incentive programs, enables our organizations to advance safe, timely and effective patient care to improve outcomes," said Sam Ho, M.D., chief clinical officer of UnitedHealthcare. "UnitedHealthcare is committed to working with the AGA and other leading medical organizations to promote the best care possible for patients."

UnitedHealthcare's collaboration with AGA is another example of the company's commitment to help gastroenterologists improve performance and patient care. In 2010, UnitedHealthcare received the Richard L. Doyle Award for Innovation and Leadership in Health Care from Milliman Care Guidelines for working with physicians and other health professionals to identify and employ best practices to prevent complications from major bowel surgery.

Follow this link for more information about the AGA Registry. To learn more about UnitedHealthcare's physician performance measurement programs, visit www.myuhc.com ; for physicians, visit www.unitedhealthcareonline.com .

About the American Gastroenterological Association The American Gastroenterological (GI) Association is the trusted voice of the GI community. Founded in 1897, the American Gastroenterological Association has grown to include 17,000 members from around the globe who are involved in all aspects of the science, practice and advancement of gastroenterology. The AGA Institute administers the practice, research and educational programs of the organization. Learn more at www.gastro.org .

About MedAssurant, Inc. MedAssurant, Inc. is a leading technology-enabled health care solutions provider focused on the importance of health care data and its ability to drive dramatic, objective improvement in clinical and quality outcomes, care management and financial performance throughout the health care community. Proprietary health care datasets, aggregation and analysis capabilities, combined with a national infrastructure of leading-edge technology, clinical prowess and deep human resources, empower MedAssurant's advanced generation of health care assessment and improvement through highly informed solutions. Driven by a mission to improve today's health care landscape, the employees of MedAssurant proudly apply care, ingenuity and dedication to delivering a new approach to health care touching nearly 120 million Americans -- one driven by data and insight -- one resulting in meaningful action. Please visit www.medassurant.com for more information.

About UnitedHealthcare UnitedHealthcare is dedicated to helping people nationwide live healthier lives by simplifying the health care experience, meeting consumer health and wellness needs, and sustaining trusted relationships with care providers. The company offers the full spectrum of health benefit programs for individuals, employers and Medicare and Medicaid beneficiaries, and contracts directly with more than 650,000 physicians and care professionals and 5,000 hospitals nationwide. UnitedHealthcare serves more than 38 million people and is one of the businesses of UnitedHealth Group, a diversified Fortune 50 health and well-being company.

SOURCE: UnitedHealthcare

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The Affordable Care Act: Our Second Most Important Tool for Combating HIV and Ending AIDS

Posted: 03/23/2012 7:49 pm

As the nation turns its eyes toward the Supreme Court and its review of the Patient Protection and Affordable Care Act (the "ACA") this coming week, people living with HIV and their advocates will be among those watching carefully and most anxiously awaiting the outcome. For many of the approximately 1.2 million people with HIV in this country, the Court's decisions will directly affect access to quality care and life-saving treatment. Though not by any means the only group with a great deal at stake here, those affected by HIV present an exceptionally strong example of the positive impact the ACA will have, and a particularly compelling argument for the statute's constitutionality.

People living with HIV have been systematically excluded from the health-care insurance and health-care markets. Only 17 percent of people living with HIV have private health insurance, compared with 67 percent of the general population. While some of the remaining 83 percent have insurance through public programs (e.g., Medicare, Medicaid, the VA, etc.), nearly 30 percent are forced to rely exclusively upon the often spotty benefits provided through the overburdened and underfunded Ryan White programs, or to go without care altogether.

The consequences of this patchwork quilt of health care for people living with HIV are devastating: they discover their status later, go longer without lifesaving care and treatment, suffer greater complications and poorer health outcomes, and continue to die at frustratingly high and unnecessary rates. These negative consequences are more pronounced and concentrated in already marginalized populations, such as low-income communities; the gay, bisexual, and transgender communities; and communities of color -- most acutely, the black community.

We have at our disposal the means to avoid many of these consequences. Antiretroviral medications (ARVs) provide us with the opportunity to seriously impede progression of the disease, especially when it is discovered in a timely fashion, to prevent most of the complications and poor health outcomes associated with an AIDS diagnosis, and to dramatically reduce the number of AIDS-related deaths each year. For those with access to consistent, quality care and treatment, HIV can now be a chronic, manageable condition -- akin to diabetes or high blood pressure.

What's more, quality care and effective treatment for those currently living with HIV will significantly curtail the further spread of HIV. ARVs work by reducing the level of virus in a person's blood to extremely low levels -- and the less virus in the blood, the lower the chances of transmitting the disease. Recent studies show that the already-lower-than-generally-realized risk of contracting HIV sexually is reduced by up to 96 percent when a person's viral load is suppressed to undetectable levels. Not only is near-universal access to quality health care good for people living with HIV, but it is also one of the best prevention tools we have.

The positive effects of the ACA and the near-universal access to health care it will provide to people living with HIV by 2015 are not just theoretical. Massachusetts, where health-care reform similar to the ACA was enacted years ago, experienced a 37-percent reduction in new HIV infections from 2005 to 2008, while the rest of the country experienced an 8-percent increase. And Massachusetts's age-adjusted HIV/AIDS death rate is almost half the national average (2 percent vs. 3.7 percent). These statistics, and the improved circumstances they describe, foretell what the nation can expect when the ACA is fully implemented.

When viewed through the prism of the HIV/AIDS epidemic, the argument for the constitutionality of the ACA's minimum coverage requirement (or "individual mandate") is relatively simple. Congress has the power to address the exclusion of a particular group -- specifically people living with HIV, but more broadly anyone with a pre-existing condition -- from a market that operates in interstate commerce. But the ban on preexisting condition exclusions will not work without the accompanying individual mandate, which requires every American to become a part of the health-care insurance pool regardless of their current health status. For that reason, the individual mandate is a necessary and proper means by which Congress can effectuate its clearly constitutional power to regulate an interstate market under the Commerce Clause.

Full implementation of the ACA is absolutely critical in our battle against HIV/AIDS. Public health authorities are already talking about the "end of AIDS," meaning the ability to prevent a person's progression from HIV-positive to an AIDS diagnosis and the most detrimental effects of the disease. Let's hope the Supreme Court recognizes the constitutionality of the action Congress took when it passed the ACA, which will similarly prevent our nation's broken health-care system from going from bad to worse -- not just for people living with HIV but for all of us.

For a more detailed explanation of the legal arguments discussed above, read the friend-of-the-court brief submitted by Lambda Legal on behalf of 16 HIV advocacy groups, which was subsequently endorsed by 130 more groups.

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Kaiser Permanente Unveils HIV Challenge to Help the U.S. Create Health Equity

PRESS RELEASE

Jan. 26, 2012, 8:00 a.m. EST

Best practices toolkit for health care organizations

WASHINGTON, Jan. 26, 2012 /PRNewswire via COMTEX/ -- Kaiser Permanente announced today the Kaiser Permanente HIV Challenge to help health care providers nationwide improve health equity for people living with HIV by increasing access to HIV care and improving health outcomes.

The HIV Challenge was announced at the Center for Medicare & Medicaid Innovation Care Innovations Summit in Washington, D.C. ( www.hcidc.org ).

Kaiser Permanente, the nation's largest nonprofit health care provider, has treated more than 60,000 people since the HIV epidemic emerged 30 years ago, and has reduced disparities among its current HIV population of more than 20,000 people by working to meet or exceed the objectives of the U.S. National HIV / AIDS Strategy.

The crux of the HIV Challenge (kp.org/hivchallenge) is to challenge other private health care providers and public and community health clinics to increase the number of HIV-positive people getting effective treatment by sharing Kaiser Permanente's toolkit of clinical best practices, provider and patient education materials, mentoring, training and health IT expertise.

http://www.youtube.com/playlist?list=PLFF12EC6E1E6A1EE7

HIV is still an epidemic in the United States, with 56,000 people becoming infected each year and more than 1.1 million Americans living with HIV, but one in five people with HIV don't know they are infected.

"The organizations presenting challenges here today are pushing the best minds in the country to create a better health care system. They represent exciting solutions to help address some of the nation's most urgent health needs," said CMS Acting Administrator Marilyn Tavenner.

Health care disparities are gaps in the quality of care associated with inequities encountered by racial, ethnic, poor and marginalized groups. The HIV Challenge is part of Kaiser Permanente's larger work to identify, measure, research and eliminate disparities in health and health care in the United States. To learn more go to kp.org/healthdisparities.

"Too many people are unaware they have HIV because access to effective prevention and care is insufficient," said Michael Horberg, MD, director of HIV/AIDS for Kaiser Permanente, executive director of research for Mid-Atlantic Permanente Medical Group, and a member of the Presidential Advisory Council on HIV/AIDS. "People with HIV need to get into treatment because quality HIV treatment prevents others from getting infected. Patients on effective therapy and better case management are living longer and more productive lives. However, quality HIV treatment requires effort."

Kaiser Permanente has demonstrated excellence in HIV clinical care outcomes with:

HIV mortality rates that are half the national average

94 percent median treatment adherence among patients regularly in care and on antiretroviral therapy

No disparities among its black and Latino HIV-positive patients for both mortality and medication rates, compared to a 15 percent higher rate in the United States for mortality and for medication

89 percent of its HIV-positive patients are in HIV-specific care within 90 days, compared to 50 percent in the U.S. within one year

69 percent of all its HIV-positive patients have maximal viral control compared to 19 percent to 35 percent nationally

As part of its HIV Challenge effort, Kaiser Permanente is sharing these best practices and tools for private health care providers and community health clinics to replicate: quality improvement programs that measure gaps in care; testing, prevention and treatment guidelines; how to set up multi-disciplinary care team models that emphasize the "medical home" so HIV specialists, care managers, clinical pharmacists and providers work together; and education for both the provider and patient.

For more details on the HIV Challenge, to download the best-practices toolkit and to watch videos of success stories in setting up HIV clinics and reducing disparities, go to: kp.org/hivchallenge

"Our success in the treatment of patients with HIV/AIDS results from the excellence of our clinicians, our advanced IT systems, our integrated delivery system and our effective coordination across specialties," said Robert Pearl, MD, chief executive officer and executive medical director of The Permanente Medical Group and Mid-Atlantic Permanente Medical Group. "In the same way that we have reduced the chances of our patients dying from cardiovascular disease and cancer significantly below the national averages, we have achieved outstanding clinical outcomes for our patients with HIV/AIDS."

The National HIV/AIDS Strategy ( http://www.aids.gov/federal-resources/policies/national-hiv-aids-strategy/ ) calls for increased testing so that all Americans can know their HIV status, increased access to culturally sensitive prevention messages, community-targeted prevention and condom and clean needle access. NHAS also calls for improving access to quality HIV care because HIV medications not only improve individuals' health and extend their life expectancy, they also reduce their risk of transmitting HIV to others. A recent scientific study found that effectively treating HIV patients with antiretroviral medications reduces HIV transmission by 96 percent. The study, known as HPTN 052, found that treating people with antiretroviral drugs before they are symptomatic can reduce the amount of virus in the blood sufficiently to reduce the risk of sexual transmission of HIV to an uninfected partner.

The Kaiser Permanente HIV Challenge is part of Kaiser Permanente's ongoing research of HIV and HIV treatment. Published Kaiser Permanente research studies include:

A study that found there are no disparities by race or ethnicity in risk of AIDS and death among HIV-infected patients in a setting of similar access to care, despite lower anti-retroviral therapy adherence among Latinos and blacks compared to whites.

A study that found HIV-infected patients are at increased risk for cancer as a result of both their impaired immune system and lifestyle factors, such as smoking.

A study that found 17 measures, such as screening and prevention for infections and monitoring of antiretroviral therapy, should be adopted uniformly to improve the quality of HIV care and treatment nationwide.

A study that found that cholesterol medications can work well among certain HIV patients who are at risk for cardiovascular disease.

About the Care Innovations Summit:

Sponsored jointly by the Department of Health and Human Services, the Centers for Medicare & Medicaid Services, Health Affairs, and the West Wireless Health Institute, the Care Innovations Summit brings together more than 1,000 health care leaders, entrepreneurs, innovators, government officials, and finance experts to stimulate investment in a high-quality, sustainable health care system. Made possible by the Affordable Care Act and the Obama Administration's commitment to open government, the Summit represents a new opportunity for industry and government to work together to help spur innovation in the public and private sectors to improve health care quality as never before and lower costs through improvement.

About Kaiser Permanente

Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America's leading health care providers and not-for-profit health plans. Founded in 1945, our mission is to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. We currently serve 8.9 million members in nine states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health. For more information, go to: www.kp.org/newscenter .

For more information Danielle Cass, danielle.x.cass@kp.org, 510-267-5354 Farra Levin, farra.r.levin@kp.org , 510-267-7364

SOURCE Kaiser Permanente

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Insurance status and treatment candidacy of patients with hepatitis C: Analysis of population-based data from the United States

Hepatology
Accepted Article (Accepted, unedited articles published online for future issues)

Maria Stepanova 1,4, Fasiha Kanwal 2, Hashem B. El-Serag 3, Zobair M. Younossi 1,4,*,‡
 
DOI: 10.1002/hep.24131
Copyright © 2010 American Association for the Study of Liver Diseases

Author Information
1 Center for Liver Diseases at Inova Fairfax Hospital, Falls Church, VA
2 John Cochran VA Medical Center and Saint Louis University School of Medicine, St Louis, MO
3 Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX
4 Betty and Guy Beatty Center for Integrated Research, Inova Health System Falls Church, VA, USA
Email: Zobair M. Younossi (zobair.younossi@inova.org)

* Correspondence: Zobair M. Younossi, Center for Liver Diseases, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042
† Conflicts of interest: There are no conflicts of interest for any of the authors.
‡ Ph: (703) 776-2540; Fax: (703) 776-4386

Publication History
Accepted manuscript online: 17 DEC 2010 03:44PM EST
Manuscript Accepted: 9 DEC 2010
Manuscript Revised: 3 DEC 2010
Manuscript Received: 1 SEP 2010

Funded by
Liver Outcomes Research Fund of The Center for Liver Diseases
Inova Fairfax Hospital, Falls Church, Virginia

Abstract
 
Background:
Successful treatment with antiviral therapy could potentially reduce morbidity and mortality in patients with hepatitis C virus (HCV) infection. However, at the population level, these benefits may be offset by limited number of patients who have access to antiviral treatment.

Methods:
Using National Health and Nutrition Examination Survey (NHANES) conducted in 2005-2008, we analyzed health insurance status and treatment candidacy of HCV+ individuals.

Results:
Total 10,582 subjects were examined; of those, 1.16 % had detectable HCV RNA and were defined as HCV+. The HCV+ patients were less likely to be insured than HCV- individuals (61.2% vs. 81.2%, P = 0.004). Among those with health insurance, HCV+ patients were less likely to have private insurance, while the coverage by Medicare/Medicaid and other government-sponsored plans was similar to the rest of the population. In multivariate analysis, HCV infection was an independent predictor of being uninsured even after adjustment for demographic disparity of the HCV+ cohort [odds ratio = 0.43 (95% CI = 0.24-0.78)]. Of all HCV+ patients, 66.7% were eligible for anti-HCV treatment. However, only 54.3% of HCV+ treatment candidates had any type of insurance coverage. Finally, only 36.3% of HCV+ patients were potentially eligible for treatment and had health insurance.

Conclusions:
A high proportion of HCV+ patients are currently uninsured, and many have publicly funded health insurance. Among those who could be candidates for treatment, the rate of insurance coverage is even lower. These findings can have important implications for health insurance coverage of these patients under the new healthcare reform legislation. (HEPATOLOGY 2010.)

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Millions of Americans Are Living with Hidden Epidemics of Hepatitis B and C, Top Experts Warn

Media contacts: Laura Segal (202) 223-9870 x 27 or lsegal@tfah.org or Gregory Bologna 703-299-9766 x 2221 or gbologna@aasld.org

WASHINGTON, D.C., September 27, 2010 – The American Association for the Study of Liver Diseases (AASLD) and the Trust for America’s Health (TFAH) issued a new report today calling for action to be taken to transform how the country deals with viral hepatitis – to help identify millions of Americans who know they are living with chronic forms of hepatitis B and C and to assure access to treatment for all who need it, to prevent even more Americans from becoming infected.

“This report is a critical next step that builds on a recent groundbreaking Institute of Medicine report on viral hepatitis and translates it into a series of action items which will be critically important to control the silent epidemic of viral hepatitis in the US,” said Arun J Sanyal MD, President of AASLD.

The report, HBV & HCV: America’s Hidden Epidemics, examines how new measures included in the Patient Protection and Affordable Care Act (ACA) combined with new scientific advancements could be used to spare millions of Americans from developing cirrhosis, liver cancer, or other life threatening complications as they age – which could also lead to billions of dollars in health care savings.

“HBV and HCV are ticking time bombs. If we don’t act now to diagnose the millions of Baby Boomers and others, we’ll be too late to spare them from developing serious liver diseases. We’ll all end up paying the price, since Medicare and Medicaid will end up picking up the tab for much of the care,” said Jeff Levi, PhD., Executive Director of TFAH. “Health reform and new science give us a once-in-a-generation opportunity to rethink how we deal with these silent killers.”

Some key findings in the report include that:
 
• An estimated 65 to 75 percent of the five million Americans currently infected with the hepatitis B virus (HBV) or hepatitis C virus (HCV) do not even know they have the virus;
 
• The Institute of Medicine (IOM) estimates that 150,000 Americans could die from liver cancer or end-stage liver disease associated with hepatitis B virus (HBV) or hepatitis C virus (HCV) in the next decade;

• The death rate from HCV is expected to triple in the next 10 to 20 years;

• An independent analysis found total medical costs for HCV patients could more than double over the next 20 years – from $30 to $80 billion per year;

• Liver cancer treatment can be more than $62,000 for the first year cost and the first-year cost of a liver transplant can be more than $267,000;

• Two-thirds of HCV cases are Baby Boomers – and if they are left untreated, it could lead to a major increase in upcoming Medicare spending;

• One in 10 Asian and Pacific Islander Americans are estimated to have a chronic HBV infection;

• An estimated 540,000 to 858,000 African Americans are estimated to have a chronic HCV infection;

• Approximately 800 to 1,000 infants in the United States are infected with HBV at birth each year; and

• At least 100,000 patients have been notified about potential exposure to HBV, HCV, and/or HIV while receiving health care since 1998.

Some highlight recommendations from AASLD and TFAH in the report include:

• HBV and HCV screening and HBV vaccination should be the standard of care in the reformed health system;

• All pregnant women should be screened for HBV and appropriate health measures should be taken to prevent perinatal transmission from infected mothers to their newborns. All newborns should receive their initial (birthdose) of hepatitis vaccine within twelve hours of birth;

• Every person diagnosed with HBV or HCV should have access to and receive a minimum standardized level of care and receive support services;

• Strong public education campaigns and improved surveillance must be put in place to help prevent new infections;

• Policies must be established to ensure that health care associated hepatitis infections are treated as a “never event;” and

• The investment in hepatitis-related biomedical and behavior must be significantly increased – and should be more proportionate to the public health threat associated with hepatitis.

The full report is available on AASLD’s website http://www.aasld.org/ and TFAH’s website http://www.healthyamericans.org/.

The American Association for the Study of Liver Diseases (AASLD) is the leading organization of scientists and healthcare professionals committed to preventing and curing liver disease and whose vision is to prevent and cure liver disease through its mission to advance the science and practice of Hepatology, Liver Transplantation and Hepatobiliary Surgery, thereby promoting liver health and optimal care of patients with liver and biliary tract diseases. http://www.aasld.org/

Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. http://www.healthyamericans.org/
 
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San Francisco adapts for health reform

by Bob Roehr
Published 08/26/2010

San Francisco's director of health Dr. Mitch Katz is concerned about how national health reform legislation passed earlier this year is going to affect safety net health care programs for low income people.

He wrote broadly about those challenges and opportunities in JAMA – Journal of the American Medical Association (August 11) and he talked with the Bay Area Reporter about how they specifically apply to San Francisco.

"Safety net systems generally were designed for people who had no choice" about where to go for health care because they lacked health insurance, Katz said. "Now comes health reform and suddenly about half of the people being taken care of by the safety net have a choice."

Research has shown that across the nation, a third of people eligible for Medicaid, called Medi-Cal in California, have never applied for it. "Which means that safety nets are currently losing money because they are not eligiblizing patients for benefits that they are entitled to," Katz said. "This is going to get all the more intense under health reform, because now a larger number of people are going to be eligible for Medicaid, but that doesn't mean they are going to be on it."

Katz's concern is that if all of those people, or even a substantial fraction, opt for private sector health providers, the safety net programs will become hollowed out, unable to support the fixed costs of infrastructure such as facilities and expensive equipment like CT scanners. They could slip into an economic death spiral, unable to cut those costs fast enough.

He fears an exodus will mean that safety net programs "will be left only with those people who are not eligible for health reform, by and large the undocumented." It is a group with little political clout in the struggle for adequate health care resources.

"The question to me is, how to make sure that safety net systems thrive under health reform," said Katz.

Healthy San Francisco

About a third of San Franciscans now receive health care through Kaiser Permanente, a third through other private insurance programs, and a third through safety net programs.

The city's program, Healthy San Francisco, covers 53,000 of the 60,000-70,000 uninsured people. About 55 percent have their medical homes at facilities operated by the Department of Public Health and 45 percent chose a community clinic.

The city is well prepared to not simply survive but to prosper under reform, said Katz.

"It is a system that prides itself on social justice," he said, one that draws upon the medical talent and innovation of UCSF, and that has the benefit of a compact geography. The programs have a good reputation and "in the past when people have gotten insurances under other programs, they have tended to stay with us."

One reason is that safety net providers offer services like language capabilities and links to other programs for low income persons – general assistance, childcare, transportation – that private and small group practitioners cannot.

The Healthy San Francisco program requires that every person using the safety net programs choose a medical home.

"Now, for the first time, we have an unduplicated count of how many uninsured people are in care" at city clinics and other health centers, Katz said. That allows for better planning and allocation of resources.

The Department of Public Health also has created a web-based application process that Katz said has helped it "to identify many clients and their family members who are eligible for other public benefits." That improves the recipient's quality of life and "also ensures the economic viability of our system."

Attitudes also are changing. Katz acknowledged at one point the view was that the poor "are lucky to get care." But that has begun to change and it will accelerate under health reform. The new watchword is "customer service;" responsive to both the needs and desires of patients.

DPH has consolidated its problem-solving to a single telephone number staffed by multilingual personnel. It is implementing an electronic medical records system that will become fully functional next year.

"When people gain Medicaid their utilization will grow. Right now, we don't have as much capacity as we will need. Increasing capacity in cost effective ways is going to require different models of care, not necessarily all of the care delivered between a doctor and a patient," Katz said.

HIV-positive

"Overall, I think health reform is good for people who are HIV-positive because, if they are low income, it is going to make them eligible for Medicaid, regardless of their health status," said Katz, who is openly gay.

Current Medicaid regulations require persons to be both low income and certified as "disabled" in order to receive benefits. In other words, people with HIV infection must progress to an AIDS diagnosis before the program will pay for the drugs that will keep them from becoming sick. This is contrary to treatment guidelines that recommend starting treatment much earlier.

Katz believes that HIV programs offer "some of the best models" for delivering quality care in a cost effective manner. One is better linking patients with pharmacists. "Often pharmacists are better than doctors on drug-drug side effects, when to take medications," he said.

He is particularly keen on support groups at San Francisco General Hospital for people dually infected with HIV and hepatitis B or C.

"I have a number of my patients attend those groups and frankly, they learn more in those groups than they would ever learn from talking one on one with their doctor about treatment options," said Katz. "It is really a question of informed patients making the right decisions for themselves. I think that is a great model."

While Katz worries that some safety net health systems, particularly those in more rural areas, may not be able to respond well to the challenges and opportunities of health reform, he believes that San Francisco can prosper.

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Medicare has feet of clay new CMA head says

Jeffrey Turnbull says system failing to provide timely, fair and cost-efficient care

André Picard Public Health Reporter
Niagara Falls, Ont. — From Thursday's Globe and Mail
Published on Thursday, Aug. 26, 2010 1:58AM EDT
Last updated on Thursday, Aug. 26, 2010 8:37AM EDT

Canada’s medicare system is built on a foundation of lofty principles but, in practice, it is failing to deliver the timely, equitable and cost-efficient care to which patients are entitled, Canada’s top doctor says.

“To my fellow Canadians, I say on behalf of all doctors: You deserve better value. You deserve better service. You deserve better. And we will fight to ensure you get it,” Jeffrey Turnbull said Wednesday in his inaugural address to the Canadian Medical Association.

The new president of the CMA said with $183-billion spent on health care last year, resources are not lacking. And with thousands of dedicated health-care professionals, there is no lack of will to deliver quality health care.

The problem, Dr. Turnbull said, is the “glaring lack of execution” of policies and principles that results in the problems patients experience every day: long waits, shortages of beds, waste and lack of co-ordinated care.

“What we need most – even more than increased funding – is better and more effective systems of management and governance.”

Dr. Turnbull, who is chief of staff at The Ottawa Hospital, used his own hospital to illustrate the need for reform. On Wednesday morning, he revealed, occupancy in the emergency department was 105 per cent. Three patients were admitted to beds located in hallways. Meanwhile, there were 156 patients in the hospital who were supposed to be in long-term care facilities but who could not be moved for lack of space. And, since the beginning of the year, more than 400 surgeries have been cancelled because of staff shortages and conflicting priorities.

In addition to his hospital work, Dr. Turnbull is medical director of the Inner City Health Project, which provides care to Ottawa’s most destitute. Despite living downtown in the capital of one of the world’s richest countries, fewer than one-third of those patients will reach the average life expectancy of 80. Virtually all of them suffer from severe mental health and addiction problems, 80 per cent are infected with hepatitis C, and more than the one-third have HIV-AIDS.

“Canadians value their health care. They cherish the idea that services are provided without regard to income or means – the idea that quality health care is the birthright of all who live here,” Dr. Turnbull said.

“But you can’t be cured by an idea. You can’t be made healthy by a theory. The system needs to work in practice. And, right now, today, in too many places across Canada, health care isn’t working nearly well enough.”

Dr. Turnbull vowed to push for reform that will make the medicare system better in the short-term and sustainable in the long-term.

Earlier this month, the CMA released a report entitled “Health Care Transformation in Canada: Change that Works, Care that Lasts.”

In that document, the group argues that the current health system cannot meet future needs because of the aging population, technological changes and ever-more-demanding consumers. It calls for significant changes, including a universal prescription drug plan, a charter that enshrines the rights of patients, an independent body that can monitor whether health dollars are being spent efficiently, and monetary incentives for doctors and hospitals to treat more patients.

Dr. Turnbull vowed to lobby for those changes and others and said the key to getting politicians to act was engaging the public in a national dialogue.

The CMA’s general council meeting, which wrapped up Wednesday, was notable for the collegial tone of debate. In the past the group has been torn by fierce differences on the relative roles of publicly funded insurance and private for-profit care.

“I don’t think that discussion has died,” Dr. Turnbull said. “But we’ve decided to discuss the fundamentals first.”

Canadians need to clearly define their expectations and they can figure out later how to pay for the system later, he said.

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Health Law Requires Continued Coverage For Patients In Clinical Trials

By Michelle Andrews
Aug 24, 2010

When Richard Crusoe was diagnosed with a rare form of soft tissue cancer called liposarcoma, the retired firefighter and his family pinned their hopes of slowing the cancer's advance on a drug that was being tested in a clinical trial.

Crusoe, then 57, was approved for the trial, and he and his wife flew from their home in Pembroke Pines, Fla., to the MD Anderson Cancer Center in Houston to get the treatment last September. But the day before he was supposed to begin the trial, researchers told the Crusoes that he wouldn't be able to participate after all. The reason: His health plan was refusing to cover his routine medical care during the trial.

The problem wasn't the costs of the clinical trial itself: The cancer center would pay to administer the drug and analyze the results. But if Crusoe participated in the trial, his health plan would stop covering all the other doctor visits, hospital stays, tests and treatment related to treating his cancer.

The Crusoes were stunned. They appealed to his former employer, the city of Pembroke Pines. Like many large employers, the city pays its workers' health claims directly rather than buying insurance. (Because such employers often use insurance companies to administer claims, workers may not realize that the payments are coming from their employer.) More than a month later, after the family enlisted the Patient Advocate Foundation to fight on its behalf, the city relented and granted $250,000 in coverage. But by that time Crusoe had become too weak to participate in the trial. He died a few weeks later.

Crusoe's widow, Debbie, still lives in Pembroke Pines. She says it's hard to pass City Hall every day. The city honored her husband for his firefighting work, she says, but "when it comes time to save his life, they just blocked it." Daniel Rotstein, the city's human resources director, declined to comment on the case.

The new federal health law will prevent such disputes, beginning in 2014. The law requires health plans to pay the routine care costs of patients who participate in clinical trials for the prevention, detection and treatment of cancer and other life-threatening conditions.

Routine patient care refers to the range of medical services people with a particular diagnosis might need. It includes treatment for side effects and other medical issues that might arise as a result of the trial.

Although Medicare and many private health plans already cover such costs, some plans decline to do so on the grounds that clinical trials are experimental, say experts. More than half of states require coverage of routine costs in a clinical trial, but state requirements vary. The new law sets a minimum standard.

Employers and insurers that decline to cover routine care in clinical trials are often concerned about their financial exposure. It's a legitimate concern, says Nancy Davenport-Ennis, founder and chief executive of the Patient Advocate Foundation. Patients in clinical trials are likely to have additional blood work, scans and tests, not to mention side effects that may be expensive to treat. But other plans view clinical trials in a different light. "They see it as a way to get better results at a better cost," says Davenport-Ennis.

The new law applies to all individual and group health plans, whether self-funded as at Pembroke Pines or fully insured. Plans that were in existence when the law was signed this spring and have "grandfathered" status under its provisions are exempt, but policy experts expect many of these plans to lose their special status over time.

Despite cases like Richard Crusoe's, the insurance industry generally supports coverage of routine care costs, up to a point. Clinical trials are conducted in four phases, adding more patients in each round; they are intended to answer different questions about safety, efficacy, side effects and the like. The new law covers care in all phases.

The industry supports coverage of routine care costs in late-phase clinical trials, says Susan Pisano, a spokeswoman for America's Health Insurance Plans, a trade group. However, it has concerns about covering costs during early-phase trials, she says, when researchers may be evaluating whether a drug is safe rather than testing its therapeutic value.

In addition to helping individuals get potentially life-saving treatment, advocates hope the new law will encourage broader participation in clinical trials, which are essential to developing new drugs and therapies. Nearly 20 percent of cancer patients are eligible for cancer clinical trials, for example, but fewer than 5 percent enroll, according to the American Cancer Society's Cancer Action Network. "Even the perception that costs might not be covered is enough to prevent patients from considering it," says Rebecca Kirch, the network's associate director of policy.

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What is a Pre-Existing Condition?

Posted August 18, 2010

By Jay Angoff, Director of the Office of Consumer Information and Insurance Oversight

This is one in a series of Health Care Notes that we’re posting to help respond to the questions and comments consumers are submitting to www.HealthCare.gov.

A number of visitors to http://www.healthcare.gov/ have told us they’d like to know more about pre-existing conditions.

At a very basic level, a pre-existing condition is a physical or mental health condition, disability or illness that you have before you enrolled in a health plan.

I know what you’re thinking: but couldn’t that be almost anything?

There is no one definition of a pre-existing condition. Health insurance issuers and employer plans use different definitions. Depending upon your condition, you may be denied coverage or charged a higher premium.

Some plans consider acne, asthma or high blood pressure a pre-existing condition. Others narrow the definition of pre-existing conditions to cancer or diabetes. Sometimes you might have totally recovered from a condition – like a past bout with depression – and it will still count against you. While some States limit how far back an insurer can look for a pre-existing condition, some States have no limit.

Private insurance companies may choose to deny your application for health coverage because of a pre-existing condition, or agree to sell you a policy, but exclude coverage for benefits associated with certain pre-existing conditions. Or the insurance company may charge you more because of a pre-existing condition.

What this means is that if you have a pre-existing condition, you may have been unable to obtain coverage or afford coverage.

The good news is that, under the Affordable Care Act, denying coverage or excluding benefits due to a pre-existing condition will no longer be allowed. For children under 19, this new protection applies for plan years beginning this fall. For everyone else, this protection will be in place by 2014. After 2014, insurers also will no longer be able to charge higher premiums based on a pre-existing condition. (Note: the exception to this is grandfathered individual family policies.)

For individuals with a pre-existing condition, the new Pre-Existing Condition Insurance Plan (PCIP) program will help to bridge the gap until 2014. Specifically, the PCIP program will make health coverage available to people with a pre-existing condition who have had no health insurance for at least the last 6 months and who have been unable to obtain insurance from private insurance companies because of a pre-existing condition.

Under the PCIP, such individuals will be able to obtain coverage at the same price as would be paid by individuals of average health in their state. And, under the new PCIP program, that coverage will include immediate coverage of health care services linked to your pre-existing condition.

A PCIP is available in every state—but the exact nature of the plan offered by the PCIP, and how eligibility based on a pre-existing condition is to be demonstrated, may vary depending on your state:

◦ In some states, the U.S. Department of Health and Human Services is operating the program. If this is the case in your state and you have been denied enrollment or coverage of specific benefits due to a health condition, you have a pre-existing condition that makes you eligible.

◦ Some states are running their own programs. Different states may use different methods of determining whether you have a pre-existing condition.

The key takeaway here is that if you are interested in the Pre-Existing Condition Insurance Plan, you should contact the program in your state.

Note: Even if you have a pre-existing condition, the PCIP may not be the best insurance option for you. For example, if you already have insurance you would not be eligible to join the PCIP in your state, or you might be eligible for another program like Medicaid which might be a better fit for you.

In general, make sure you check out the Insurance Finder to find out what options are available for you and your family.

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