Health care fight isn`t over - Bismarck Tribune

  MIKE McCLEARY/Tribune Dr. Ted Fogarty, a radiologist at Medcenter One in Bismarck, looks for signs of a stroke while viewing multiple images of a computed tomography (CT) perfusion study of a patient's brain displayed on a computer screen. The colors in the brain scans show the blood flow in the brain. The use of the CT perfusion study is a helpful tool for physicians in the early diagnosis of a stroke. Preventative care is one of the components emphasized in the implementation of the new national healthcare system. 12-9-2010
Less than a year after it passed, the landmark changes to health care face a repeal by Republicans in the U.S. House. It took months of political maneuvering to even pass the Patient Protection and Affordable Care Act, and then in the fall health care reform helped cost some politicians their seats, including former North Dakota Rep. Earl Pomeroy.
“It pains me so much, all the heat the congressional delegation took for standing up for families like us,” said Brenda Neubauer, whose son had reached the lifetime benefits cap on one insurance plan and was nearing the benefits cap on a second insurance plan.
Her son, Jacob, 16, has hemophilia, a disorder in which his blood does not clot. She spent many years working with North Dakota’s congressional delegation to change the lifetime cap on health insurance. The new health care law finally resolved it.
The federal overhaul of health care is a politically divisive issue that will change options in the country. It will top the agenda of this congressional session and already its  being challenged in court because of the mandate that all Americans purchase insurance. Although the House has enough votes by Republicans to repeal it, the effort will likely fail in the Democrat-controlled Senate.
It will be phased in over the next five years, and parts of it will be challenged in Congress. Most of the changes from the health care reform bill go into effect in 2014, although some started last September.
“When the debate started about the health care system, it was about making it more affordable to Americans, not about expanding access,” North Dakota Insurance Commissioner Adam Hamm said. “The fundamental problem is not access. The fundamental problem is affordability.”
Instead, the bill will likely raise health care costs over time, unless portions of it are changed or repealed, Hamm said. One area where the costs likely will increase is insurance premiums. For instance, Aetna is reprogramming its plans so that it reflects its adoption of the dependent coverage to age 26. Previously, plans covered dependent children until age 22 or 24 if they were students.
The cost of an insurance plan depends on what is covered. Generally, the more covered services, the greater the cost of the plan.
“Insurance premiums will have the greatest impact,” said Brenda Nagel with Aetna. “Health care costs are still rising. No one, as a nation, has addressed health care costs.”
Large employers most likely already offer some of the coverage the law now requires. It is the smaller group plans and individual plan markets that will probably see greater increases because of the need to add coverage to their plans.
For example, Aetna, which has 500 employees in North Dakota, already covers preventive care for its employees. Preventive care includes exams and tests that can help detect potential health issues before they become more costly to treat. Other businesses may not offer this coverage, which is required under the new law.
More importantly, it will change how people get health insurance, and who gets covered; as well as mandate what course of treatment health care facilities provide and to use electronic medical records to exchange patient information.
One of the biggest changes is to health insurance. More people will qualify for Medicare, and people will be required to have health insurance, or face a fine. Tax credits also will be available to some people based on income to help defray the cost of insurance. it also eliminates pre-existing condition exemptions and lifetime caps on coverage, as well as covering dependent children up to age 26.
Businesses need to offer group plans to employees or provide a voucher for employees to buy health insurance elsewhere.
For healthcare providers in North Dakota, the bill is a blessing and a curse. It included a provision that increased Medicare reimbursement rates, but it also has provisions for technology and reporting that will cost the providers additional money in equipment and personnel.
The bill included the frontier states amendment, which raises the Medicare reimbursement rate to the national average for five states, including North Dakota. The change means an extra $65 million a year in Medicare funding for North Dakota, which receives about one-third to one-half less in Medicare reimbursement than what a hospital receives in an urban area.
“Our request all along was for fair reimbursement for Medicare,” said Medcenter One CEO Craig Lambrecht.
Health care facilities will need to adhere to stricter surveillance and auditing, as well as agree to a common course of treatment for certain chronic diseases.
The hospital is anticipating more people will seek health care because they have insurance, said Dr. Anthony Tello, corporate medical director at Medcenter One.
As it is, there are some uninsured people who do not seek health care. In the long run, the uninsured are likely to require more costly medical services because they did not see a doctor before something catastrophic happens. It also is likely to reduce the number of uninsured people who go to the emergency rooms. Instead, those people are likely to go to clinics, Tello said.
Additionally, hospitals will have to report how they manage common chronic medical conditions. People then will be able to search the information through a website.
Facilities also need to implement electronic medical records. For Medcenter One, this is already used in its clinics. It will need to be implemented in the hospital, Tello said.
The law also requires providers to adhere to a common course of treatment for diseases and illnesses. Through the quality control reports, the providers will show what evidenced-based treatment they provide.
Tello worries that increased use will require them to hire more physicians, which is already difficult to do in North Dakota, especially if they are specialists, he said. That is because wages tend to be lower than in more populated parts of the country, and the location does not attract as many job candidates.
There is some fear among North Dakota health care facilities that they will not be able to comply with the mandates and consequently close, said Jerry Jurena, the president of the North Dakota Hospital Association.
“It’s not a perfect bill,” Jurena said.
For the Neubauer family, though, it eases their concerns about how Jacob will continue treatment.
“We worked many, many years and made trips to Washington because it is important,” Neubauer said. “He will have to deal with it for the rest of his life.”
For now, he has the insurance to afford it.
(Reach reporter Sara Kincaid at 250-8251 or sara.kincaid@bismarcktribune.com.)
View the original article here

Circ Feature: FFR-guided PCI is cost savings at one year

Fractional flow reserve (FFR)-guided PCI in patients with multivessel coronary disease is one of those rare situations in which a new technology not only improves outcomes but also saves resources, according to an economic evaluation of the FAME study published in the Dec. 14 issue of Circulation.

The FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study demonstrated significantly improved health outcomes at one year in patients randomized to multivessel PCI guided by FFR, compared with PCI guided by angiography alone. Prior to this study, the economic impact of routine measurement of FFR in this setting was not known.

“The trial design was a one-year analysis from the U.S. healthcare perspective,” William F. Fearon, MD, from the division of cardiovascular medicine at Stanford University Medical Center in Stanford, Calif., told Cardiovascular Business News. “Anytime a new medical technique or technology emerges, it must show that it has the capability of improving patient outcomes. However, given the current economic and healthcare environment, it also is beneficial to show its cost-effectiveness.”

In this study, 1,005 patients were randomly assigned to FFR-guided or angiography-guided PCI and followed up for one year. A prospective cost-utility analysis comparing costs and quality-adjusted life-years (QALYs) was performed with a time horizon of one year. Direct medical costs included those of the index procedure and hospitalization and costs for major adverse cardiac events during follow-up.

They found that the major adverse cardiac events at one year occurred in 13.2 percent of those in the FFR-guided arm and 18.3 percent of those in the angiography-guided arm. QALYs were slightly greater in the FFR-guided arm (0.853 vs. 0.838).

From an economic perspective, they found that the mean overall costs at one year were significantly less in the FFR-guided arm ($14,315 vs. $16,700). Bootstrap simulation indicated that the FFR-guided strategy was cost saving in 90.74 percent and cost effective at a threshold of $50,000 per QALYs in 99.96 percent.

The authors wrote that the “cost savings occur both at the index procedure, primarily owing to a decrease in drug-eluting stent use being a major cost driver, which more than offsets the increased cost of the pressure wire and adenosine, and during follow-up as a result of a decrease in re-hospitalization and fewer major adverse cardiac events.”

Fearon noted that procedural costs accounted for approximately 70 percent of the cost savings, and the follow-up event rates accounted for about 30 percent of the savings.

Overall, the researchers reported that about 90 percent of the total cost occurred at the index hospitalization. However, approximately 30 percent of the overall cost difference between the two strategies is generated during follow-up, indicating increasing cost savings even after the initial procedure.

While the authors mentioned, as a limitation, that the "durability of these findings need to be confirmed after longer follow-up," Fearon hypothesized that the longer-term findings, such as out of five years, may not prove "drastically different," as most of the events and costs occurred during the PCI procedure or soon after the PCI procedure for the FAME patients.

“We were pleased to find out that FFR-guided PCI is not only cost effective, but it also saves money for the U.S. healthcare system,” Fearon said.

Study reveals frequent pediatric rad exposure - Health Imaging & IT

The average child will be exposed to seven procedures using ionizing radiation before the age of 18, while nearly half of children receive a procedure with radiation in any given year, according to a study of more than 350,000 children published in the Archives of Pediatrics and Adolescent Medicine.

"To our knowledge, we report the first large, population-based study examining the use of diagnostic imaging procedures with low-dose ionizing radiation specifically in a pediatric population," wrote Adam L. Dorfman, MD, of the department of pediatrics at the University of Michigan Medical School in Ann Arbor, and co-authors.

Dorfman and colleagues investigated the occurrence of procedures using radiation in 355,088 children enrolled in UnitedHealthcare from 2005 through 2007. The sample included all such enrollees residing in Arizona; Dallas, Texas; Orlando, Florida; south Florida; and Wisconsin, and included plain radiography procedures, CT, fluoroscopy and/or angiography and nuclear medicine scans.

"Among 355,088 children across five large health care markets in the U.S., we found that use of these procedures during a three-year study period was frequent, with at least one of these procedures being performed in 42.5 percent of children. Importantly, many children underwent more than one procedure," the researchers reported.

A total of 436,711 procedures using ionizing radiation were reported over the three-year study. Plain x-rays comprised the most common procedures, with 40 percent of children receiving at least one procedure during the study. Twenty-two percent of children received two or more radiography procedures and 14 percent received three or more.

CT was the second most common procedure, with 8 percent of children receiving at least one over the study period. Two percent of children received one or more fluoroscopy and/or angiography procedures and 1 percent received a nuclear medicine scan. Radiography accounted for a total of 85 percent of all procedures.

"Based on these data, the average child in this study population will have received more than seven procedures by the time he or she reaches age 18 years," Dorfman and colleagues wrote. Overall, male enrollees had higher rates of imaging than females, with 44 percent of boys and 41 percent of girls receiving at least one procedure using radiation. Children over ten years of age also had significantly higher imaging rates.

The authors expressed concern given the National Research Council's findings that any exposure to radiation poses at least some risk, while also citing studies indicating that risk increases linearly with greater exposure to radiation. "Developing tissues in children are more sensitive to radiation and their longer expected life spans also allow additional time for the emergence of detrimental effects," said co-author, Reza Fazel, MD, of the department of cardiology at Emory University School of Medicine in Atlanta.

The authors made no attempts to judge the appropriateness of the procedures, however, while also abstaining from estimating radiation doses due to "a paucity of available data on radiation dosimetry in the pediatric population." They also cautioned that conducting the study in five states and considering only insured children might limit the generalizability of their findings.

"Of course, there is immense life-saving value in medical imaging, so our study doesn't suggest at all that these tests shouldn't be used in children," said co-author Kimberly E. Applegate, MD, vice chair for quality and safety in the department of radiology at Emory.

"It should encourage discussions about the value of each imaging test that is ordered, recognizing that radiation exposure, even in small amounts, may not be risk free," stated Andrew J. Einstein, MD, PhD, a cardiologist at Columbia University in New York City.

Last updated on January 5, 2011 at 9:24 am EST

View the original article here