HEALTH AND SAFETY
More Equitable Medicare Payments
The Centers for Medicare & Medicaid Services (CMS) is moving steadily from payments focused on volume of services provided to value-based payment programs, which align quality care delivery goals with payment to improve health outcomes while also controlling costs. However, Medicare value-based payment programs do not account for social risk factors such as low socio-economic position, residence in disadvantaged neighborhoods, or race or ethnicity, and therefore may underestimate the quality of care provided by health systems serving socially at-risk populations.
A series of five reports, Accounting for Social Risk Factors in Medicare Payment, says that accounting for these factors that make it harder or more costly for providers to achieve performance benchmarks would help minimize influences that are largely beyond providers’ control. The series identifies four goals for adjustments to the payment programs: to reduce disparities in care access, quality, and outcomes; to improve the quality and efficiency of care delivery for all patients; to fairly and accurately report quality and outcome measures; and to compensate providers fairly.
CMS payment programs, the reports say, have several disadvantages, including giving providers and insurers the incentive to avoid serving patients with social risk factors, underpaying providers who disproportionately serve socially at-risk populations, and underinvesting in the delivery of quality care. While accounting for social risk factors in value-based payment programs would likely diminish these harms, it could also potentially introduce new ones, such as reducing incentives to improve care for patients from vulnerable populations. Therefore, it is important to minimize potential harms to patients with social risk factors, and monitor any specific approach for unintended negative effects.
The reports identify criteria to help CMS determine which social risk factors to take into account in Medicare value-based payment programs. In the short term, CMS should consider income, education, and dual eligibility (for Medicare and Medicaid); race, ethnicity, language, and nativity; marital/partnership status and living alone; and neighborhood deprivation and housing. Some additional social risk factors such as wealth or gender orientation present practical challenges for use in Medicare value-based payment programs but are still worthy of consideration.
The committee that wrote the reports identified four strategies to account for social risk factors in Medicare payment and concluded that a combination of reporting and accounting in both performance measures and payment are needed to achieve its four policy goals. Considerations around the trade-offs of various methods are different for cost-related performance and quality performance, and strategies to account for social risk factors for measures of cost and efficiency may differ from strategies to measure good outcomes and improvements in care quality.
Although the reports focus on Medicare, their conclusions and recommendations could apply to other health care payers, such as private insurers.
The Academies’ study was funded by the U.S. Department of Health and Human Services.
A National, Integrated System of Trauma Care
The leading cause of death for Americans under the age of 46 is trauma — a disabling or life-threatening physical injury that results from an event such as a fall, motor vehicle crash, or gun violence. However, significant advances in trauma care have developed over the last decade in response to the large number of U.S. casualties during the wars in Iraq and Afghanistan. The percentage of wounded service members who died of their injuries in Afghanistan decreased by nearly 50 percent between 2005 and 2013.
Given the military’s success in reducing deaths after traumatic injury, the civilian sector stands to reap tremendous benefits if best practices can be reliably adapted from the military, says A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. The report calls on the White House, Congress, and the U.S. Department of Health and Human Services to act and integrate the military and civilian systems for trauma care.
Across both systems, the quality of trauma care varies greatly depending on when and where an individual is injured, placing lives unnecessarily at risk. Of the 147,790 U.S. trauma deaths in 2014, as many as 20 percent — or about 30,000 — could have been preventable after injury with optimal trauma care.
The White House should lead the integration of military and civilian trauma care to establish a national trauma care system and set an aim to achieve zero preventable deaths after injury. In addition, Congress, in consultation with the U.S. Department of Health and Human Services, should help ensure that prehospital care, such as emergency medical services, are included as a seamless component of health care delivery, rather than being viewed and paid as merely transportation providers.
Since the report was released, provisions in National Defense Authorization Act enabled military trauma care specialists to partner with high-volume civilian trauma centers and teaching hospitals to improve education and training.
The Academies’ study was funded by the American College of Emergency Physicians, American College of Surgeons, National Association of EMS Physicians, National Association of Emergency Medical Technicians, Trauma Center Association of America, U.S. Department of Defense, U.S. Department of Homeland Security, and U.S. Department of Transportation.
A Call to Action on Ovarian Cancer
With no distinct early symptoms and no effective screening tests, ovarian cancer is often referred to as a silent killer. It is the fifth-leading cause of cancer deaths among women, with a five-year survival rate of less than 46 percent.
Because ovarian cancer is not a single disease but actually a constellation of different cancers that involve the ovary, researchers do not have a complete understanding of how the many subtypes of ovarian cancer develop and progress. Ovarian Cancers: Evolving Paradigms in Research and Care identifies research opportunities with the greatest potential to reduce the number of women who develop or die from the cancer.
Identifying the cellular origins and biological characteristics of each subtype of ovarian cancer should be a top priority in research, the report says. The more that is understood about the basic biology of various types of ovarian cancers, such as where they originate in the body, the more rapidly advances in prevention, screening, early detection, diagnosis, treatment, and supportive care can be developed.
Innovative strategies to increase genetic counseling and testing for known inherited genetic dispositions to the disease should be developed and implemented. However, the majority of women with an ovarian cancer do not have an inherited gene mutation or a significant family history. A range of potential risk factors for ovarian cancers in addition to genetics — including hormonal, behavioral, social, and environmental factors — should be identified in order to develop a risk assessment tool that accounts for the various ovarian cancer subtypes.
Current screening methods have not had a substantial impact on overall death rates for general or high-risk populations. Early detection strategies that extend beyond current imaging technologies and biomarkers should be developed. In addition, better tools are needed to predict near- and long-term response to treatments for both newly diagnosed and recurrent cancers.
And to reduce disparities in care, current standards of care — such as access to specialists, optimal surgical management, appropriate chemotherapy regimens, and universal genetic testing — should be more consistently implemented.
The Academies’ study was funded by the Centers for Disease Control and Prevention, which has since funded research that was recommended in the report.
Accessible Hearing Health Care
Nearly 30 million Americans experience hearing loss, but only 14 percent to 33 percent of adults 50 and older who could benefit from hearing aids use them. Various factors pose barriers to access of hearing health care, such as the high price, lack of insurance coverage, and limited awareness of available options, as well as the stigma associated with wearing a hearing aid.
To tackle this significant health problem, efforts should be made to provide adults, especially underserved and vulnerable populations, with hearing health care options that are easily accessible and affordable, says Hearing Health Care for Adults: Priorities for Improving Access and Affordability.
Individuals cover the majority of the costs associated with hearing health care out of their pockets. The average price for a pair of hearing aids and the accompanying professional services was $4,700 in 2013. Typically, employers do not provide hearing health care insurance, and Medicare Part B covers only diagnostic hearing tests, not other services or technologies.
To make hearing health care easily available, the report recommends removing the regulation that requires an adult seeking hearing aids to first have medical evaluation by a physician or to sign a waiver of that evaluation. There is no evidence that the regulation provides any clinically meaningful benefit.
Currently, hearing aids are regulated by the Food and Drug Administration as Class 1 or Class 2 medical devices. FDA should establish a new category of over-the-counter hearing devices, intended for use by adults with mild and moderate hearing loss, that meet specific safety and quality standards. Electronic “personal sound amplification” products are available in the range of $50 to more than $500, and provide some or many technological features similar to hearing aids. Current FDA guidelines, however, note that these products cannot be marketed with the purpose of addressing hearing loss.
In addition, Medicare should evaluate options for providing coverage so that treating hearing loss is affordable for beneficiaries, and employers, private health insurance plans, and Medicare Advantage plans should evaluate options for providing their beneficiaries with affordable hearing health care insurance.
Since the report was released, the FDA dropped the requirement for a medical evaluation or waiver. The Academies’ study was funded by the Centers for Disease Control and Prevention, U.S. Department of Defense, U.S. Department of Veterans Affairs, U.S. Food and Drug Administration, Hearing Loss Association of America, National Institute on Aging, and National Institute on Deafness and Other Communication Disorders.
Support for Family Caregivers
Nearly 18 million Americans care for elderly family members with serious health or functioning impairments. By 2030, more than 1 in 5 U.S. citizens will be 65 or older, and the proportion of older adults who are most likely to need intensive support from family caregivers — those in their 80s and beyond — is projected to climb significantly. At the same time, the pool of potential family caregivers is shrinking. Families have fewer children, older adults are more likely to have never married or to be divorced, and adult children often live far from their parents or may be caring for more than one older adult or their own children.
Families Caring for an Aging America examines the prevalence and nature of family caregiving and calls for reforms to the health care system to better account for family caregivers and support their involvement in the care delivery process. Family caregivers need more recognition, information, and support to fulfill their responsibilities and maintain their own health, financial security, and well-being, the report says.
Although individual circumstances vary, family caregiving can negatively affect the mental and physical health of the caregiver and cause economic harm, including loss of income and career opportunities, the report says. Evidence indicates these individuals have higher rates of depressive symptoms, anxiety, stress, and emotional difficulties. The report recommends that the current administration take immediate steps to address the health, economic, and social issues facing family caregivers of older Americans. The secretary of the U.S. Department of Health and Human Services, in collaboration with the secretaries of labor and veterans affairs, other federal agencies, and private-sector organizations, should develop and execute a national family caregiver strategy. The strategy should include measures to adapt the nation’s system for health care, work places, and long-term services and supports to recognize the essential role of family caregivers to the well-being of older adults.
The Academies’ study was funded by the Alliance for Aging Research, Alzheimer’s Association, an anonymous donor, Archstone Foundation, California HealthCare Foundation, the Commonwealth Fund, U.S. Department of Veterans Affairs, the Fan Fox and Leslie R. Samuels Foundation, Health Foundation for Western and Central New York, the John A. Hartford Foundation, May and Stanley Smith Charitable Trust, the Retirement Research Foundation, the Rosalinde and Arthur Gilbert Foundation, Santa Barbara Foundation, and Tufts Health Plan Foundation.
Care for Gulf War Veterans
Almost 700,000 U.S. troops were deployed at the height of the Persian Gulf War in the early 1990s. These service members were exposed to many agents and situations, including chemical and biological agents, smoke from oil-well fires, dust, and high ambient temperatures and heat stress. Although the war was brief with relatively few injuries and deaths, a substantial number of veterans — both from the U.S. and from coalition countries that also deployed troops — suffer from a variety of health problems that have persisted for more than 25 years.
In 1998, Congress passed two laws to attempt to identify health outcomes that might be expected from the environmental agents to which veterans had been exposed during their deployments. In response to these mandates, the National Academies have conducted 10 Gulf War and Health reports as well as additional related studies to look at the veterans’ exposures identified in the legislation.
The 10th report of the series says that although federally funded research on Gulf War veterans totaled more than $500 million between 1994 and 2014 and produced many findings, there has been little substantial progress in the overall understanding of the health effects, particularly Gulf War illness, which is characterized by a cluster of medically unexplained chronic symptoms that can include fatigue, headaches, joint pain, indigestion, insomnia, dizziness, respiratory disorders, and memory problems. As many as one-third to one-half of Gulf War veterans report having some symptoms of this illness.
Gulf War and Health, Volume 10: Update of Health Effects of Serving in the Gulf War, 2016 finds that veterans appear to have an increased risk for Gulf War illness, chronic fatigue, functional gastrointestinal conditions, and mental health disorders. There is some evidence that service during the conflict is linked to amyotrophic lateral sclerosis (ALS), fibromyalgia, chronic widespread pain, and self-reported sexual difficulties, but the data are limited.
The study committee said the Gulf War veteran population is still young with respect to the development of other neurodegenerative diseases. Therefore, the effects of deployment on the incidence and prevalence of those diseases may not yet be obvious. The Department of Veterans Affairs should continue to conduct follow-up assessments of Gulf War veterans for neurodegenerative diseases that have long latencies and are associated with aging, such as ALS, Alzheimer’s disease, and Parkinson’s disease.
Based on available research data, it does not appear that a single mechanism can explain the multitude of symptoms seen in Gulf War illness, and it is unlikely a definitive causal agent or agents can ever be identified, especially this many years after the war. Taking into account the findings from this and previous Academies reports, the report concludes that the health conditions associated with Gulf War deployment are primarily mental health disorders — such as post-traumatic stress disorder, generalized anxiety disorder, depression, and substance abuse — and functional medical disorders, such as irritable bowel syndrome. These associations emphasize the need to consider the interconnectedness of the brain and body when seeking treatments for Gulf War illness. Research efforts should move forward and be realigned to focus on the treatment and management of Gulf War illness rather than its causes.
The Academies’ study was funded by the U.S. Department of Veterans Affairs.
Vietnam Veterans and Agent Orange
U.S. forces sprayed Agent Orange and other defoliants over parts of southern Vietnam and surrounding areas from 1962 to 1971. Concerned about the possible health effects for U.S. military personnel exposed to these herbicides, Congress in 1991 directed the National Academies to provide a comprehensive evaluation of the scientific and medical evidence. The Academies issued their first report in 1994, and since that time have completed 10 biennial updates to incorporate the results of new research and evidence.
The original report and subsequent updates assign health outcomes being studied to one of four categories on the basis of the epidemiologic evidence reviewed: sufficient evidence of an association between exposure to the herbicides and a particular health outcome; limited or suggestive evidence of an association; inadequate or insufficient evidence to determine an association; and limited or suggestive evidence of no association. Although the Academies’ work does not address the likelihood that any one individual’s health problem is associated with or caused by exposure to these herbicides, the reports have helped inform health care coverage decisions concerning Vietnam veterans made by the U.S. Department of Veterans Affairs.
The Academies’ final update in this series, Veterans and Agent Orange: Update 2014 (published in 2016), changed the categories of association with exposure to the herbicides sprayed in Vietnam for three health effects. Bladder cancer and hypothyroidism were moved from “inadequate or insufficient” evidence of association up to “limited or suggestive” evidence of association, while the birth defect spina bifida in the offspring of Vietnam veterans was demoted from “limited/suggestive” to “inadequate/insufficient.” The study committee clarified that Vietnam veterans with “Parkinson’s-like symptoms,” but without a formal diagnosis of Parkinson’s disease, should be considered eligible under the presumption that Parkinson’s disease and the veterans’ service are connected.
The final report also recommends further actions to advance the well-being of Vietnam veterans. The VA should continue epidemiologic studies and develop protocols that could investigate paternal transmission of adverse effects to offspring. The report also calls for a careful review of evidence concerning whether paternal exposure to any toxicant has definitively resulted in abnormalities in the first generation of offspring. In addition, the report identifies methods to improve assembly and evaluation of information necessary for monitoring possible service-related health effects in all military personnel.
The Academies’ study was funded by the U.S. Department of Veterans Affairs.
A Path to Safety From Food Allergies
Food allergy is a complex disease arising from a specific immune response that occurs repeatedly on exposure to a given food. It can affect daily routines and quality of life, and for some individuals, lead to severe allergic reactions and death. Although promising therapeutic approaches are being tested, no effective treatments currently exist.
Finding a Path to Safety in Food Allergy: Assessment of the Global Burden, Causes, Prevention, Management, and Public Policy examines the evidence on food allergy and identifies a roadmap to greater public safety. Because people with food allergies are in different settings throughout their lives, concerted efforts by early care and education systems, schools and universities, food establishments, and the travel industry — in addition to the health care system — are necessary to bring about a safe environment for those with food allergies.
Although there is a widespread perception that food allergy prevalence is on the rise, no study in the U.S. has been conducted with sufficient sample size and in various populations to determine the true prevalence of food allergies. The Centers for Disease Control and Prevention should obtain prevalence estimates in a systematic and statistically sound manner, the report says. Better methods for collecting information about anaphylactic reactions are also needed, as are estimates of the various costs associated with food allergy.
Physicians should use evidence-based, standardized procedures as the basis for food allergy diagnosis. In addition, public health authorities and clinical practice guidelines should provide consistent, clear, and evidence-based advice for families and health care providers, including dietitians, about the potential preventive benefits of introducing allergenic foods at an early age.
The food manufacturing industry, the Food and Drug Administration, and the U.S. Department of Agriculture should work cooperatively to develop a new risk-based food allergy labeling approach. And within the next year, relevant federal agencies should convene a special task force to establish and implement policy guidelines. The guidelines should ensure emergency epinephrine capabilities and first aid training are in place for children and adults in public venues, including schools, early care and education facilities, and airplanes.
The Academies’ study was funded by the following federal sponsors: Food and Drug Administration, Food and Nutrition Service of the U.S. Department of Agriculture, and National Institute of Allergy and Infectious Diseases. Nonfederal sponsors were the Asthma and Allergy Foundation of America, Egg Nutrition Center, Food Allergy Research & Education, International Life Sciences Institute North America, International Tree Nut Council Nutrition Research & Education Foundation, National Dairy Council, National Peanut Board, and the Seafood Industry Research Fund.