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News on the state's largest health insurers; the effects of health care reform on coverage; rising premium costs.

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What ‘Bad Dogs’ Can Teach Humans About Compulsive Behavior

Casey was diagnosed with canine compulsive disorder. He’s now on Prozac. (Courtesy)

Casey was diagnosed with canine compulsive disorder. He’s now on Prozac. (Courtesy)

When Casey, a 6-year-old German Shepherd, gets anxious, she chases her tail.

But it’s not the kind of endearing, once-around-and-it’s-done kind of tail-chasing we’ve all seen. Left unchecked, Casey circles around and around, pursuing her tail until she can bite it. Then, even when the blood starts flowing, the dog is driven to continue the chase.

“It’s upsetting,” says Paula Bagge, a Hopkinton, Mass. business owner who has been living with Casey since puppyhood. “And it’s damaging. She hurls herself around the house, and it’s like a big bloody paintbrush spraying the walls.” Once, Bagge tied the dog’s leash to a coffee table in an attempt to control the chasing. But Casey, who weighs about 85 pounds, just started dragging the coffee table around with her. Now, she’s on Prozac.

Dogs, it turns out, can have obsessive-compulsive disorder, just like people. And in a new study, Dr. Nicholas Dodman, a professor of clinical sciences at the Cummings School of Veterinary Medicine at Tufts University, found that structural brain abnormalities in dogs, in this case Doberman pinschers, with canine compulsive disorder (CCD) are similar to those of humans with OCD.

In an earlier study, Dodman, a leading researcher on repetitive behavior in animals, found a specific gene associated with canine OCD.

Studying anxiety disorders in dogs, Dodman says, may ultimately help scientists come up with better therapies and medications to treat OCD and related conditions in people. Current drugs for OCD, such as SSRI’s (or for dogs, a beef-flavored form of Prozac) are notoriously ineffective for many sufferers. Indeed, Dodman says, only around 43 to 60 percent of people suffering from OCD show a postive response from an SSRI; the average reduction of symptoms in people taking these drugs is only about 23 to 43 percent. “Certainly not a panacea,” he says.

So, to further this research, Dodman spends time thinking about bears who pace obsessively, for instance, or parrots unable to stop preening and picking their feathers and beagles who overeat to the point of exploding,

Dodman calls the latest dog-brain imaging study, conducted in collaboration with researchers at McLean Hospital, in Belmont, Mass., “another piece of the puzzle, another brick in the wall.”

He says while more research must be done, it’s becoming increasingly evident that dogs with OCD are a great model for exploring human psychopathology: they show similar behaviors, respond to drugs in comparable ways and now, at least in this small study, seem to have the same brain abnormalities as people with the condition. “When you know what your dealing with it’s much easier to create targeted approaches,” to treatment, Dodman says. “If you don’t know what you’re dealing with it’s just kind of like going with your sense of smell.”

OCD afflicts about 2 percent of the population and often goes untreated or undiagnosed. People suffering from the disorder, marked by intrusive thoughts and repetitive behaviors such as hand washing, locking and unlocking doors, counting, or repeating the same steps, feel these impulses as uncontrollable. And the compulsive rituals, often triggered by stress or trauma, can be incredibly time-consuming, interfering with daily life.

Famously, Lena Dunham, the star and creator of the HBO series “Girls” came out with her own OCD on air, with repetitive tics, obsessive counting and painfully compulsive use of Q-tips. Continue reading

Sebelius, Rolling Stones Fan, Confident On Health Law Deadline

HHS Secretary Kathleen Sebelius

HHS Secretary Kathleen Sebelius

How well do you know your Secretary of Health and Human Services? That’s the big question posed by a quiz today on Politico.  Secretary Kathleen Sebelius, who, according to the quiz, is a high school jock with a soft spot for the Rolling Stones, has been in the news recently about growing concerns around the lagging implementation of the Affordable Care Act.

On Here and Now last week, WBUR’s Meghna Chakrabarti asked Sebelius about glitches in rolling out the national health law.  The HHS secretary also responded to criticism that she’s been involved in the collection of funds from private sources — like health care and insurance providers — via the not-for-profit organization Enroll America.  

Sebelius had this to say:

“Enroll America is not a creation of mine.  Continue reading

Mass. Hospitals Balk At Fees To Access Trove Of Medical Claims Data

The state’s painfully wonky sounding All-Payer Claims Database (APCD) – a catalog of medical, dental and pharmacy claims, as well as other patient-related information — is truly tantalizing in its potential.

For researchers, tapping into this recently released data — a centerpiece of the newly created Center for Health Information and Analysis and part of the state’s overall plan for health care reform and cost control — can offer “a deep understanding of the Massachusetts health care system by providing access to timely, comprehensive, and detailed data,” according to the APCD website. It promises to “be an essential tool to improve quality, reducing costs, and promote transparency.” (Though not necessarily for the average patient: basically, you need an analyst by your side to really comprehend the trove of complex information.)

(401(K) 2012/flickr)

(401(K) 2012/flickr)

But wait a minute. To access this important data for one year will cost a mid-size organization, like a community hospital, about $40,000, according to the Massachusetts Hospital Association, which argues that the fees are too high. “We’re very disappointed,” says the MHA’s Senior Director of Managed Care, Karen Granoff. “I think [the pricing] is going to discourage many providers from trying to access it.”

The Center For Health Information and Analysis says the proposed fee schedule is based on four factors:

(1) the type applicant requesting the data; (2) the type and number of data files requested; (3)the data elements requested; and (4) the number of years of data requested. The Center may reduce or waive the applicable fees for qualified applicants.

(Also, the final fee schedule is still being determined. It’s slated for release around June 1.)

Still, in written testimony to CHIA earlier this month, the hospital association argued that the proposed fee structure is simply unmanageable, particularly when the state is pressuring hospitals and providers to re-invent themselves as Accountable Care Organizations and to provide less costly and higher quality care and patient management.

“It would be an unintended consequence if the Commonwealth’s multi-year, ambitious effort to control healthcare costs were to fail due to barriers to data access set up by the agency itself,” Granoff wrote.

But hospitals already have all the claims data on their own patients, right? So why the brouhaha over the more comprehensive claims data? Here’s why the information is important, says Granoff:

The purpose of APCDs is to support health care transparency, health care reform initiatives, and improve care for patients. Access to data from all payers (commercial and government) will be vital to the successful development of ACOs and other integrated models of care. While it is true that providers may currently have access to data from one payer at a time, the timeframes, content, frequency, and ability to mesh data from different sources does not exist outside of the APCD.

The legislature recognized the importance of the APCD to providers when it included language specifying that:

“CHIA shall, to the extent feasible, make data in the APCD available to payers and providers in real time. Providers and provider organizations, among others, be permitted to have access to de-identified data for the purposes of lowering costs, coordinating care, performing quality analyses, and for administrative or planning purposes, etc.
Providers and provider organizations be given access to data with patient identifiers for the purpose of carrying out treatment and coordinating care.”

Regarding the APCD and its use by providers, it will allow performance analysis based upon previously unavailable data from private and public health insurance plans, including

*Follow-up after medical or surgical hospitalization
*Readmission rates Continue reading

When Nursing Homes Are No Longer The Last Stop For Patients

Two years ago, Dorothy Holmes, then 75, was in the cozy pink bathroom of her mobile home getting ready to shower when she fell. It’s the type of accident that’s pervasive among older Americans — and it’s often the very thing that triggers the end of independence.

“I got a big spot on my head, it almost conked me out,” Holmes said in her soft voice.

She heard her husband come down the hall, “and when he turned the corner all I heard was, ‘Oh God, honey, what did you do now?’ After that I don’t know anything cause I passed out,” Holmes recalled.

Dorothy Holmes shortly after her fall. (Courtesy)

Dorothy Holmes shortly after her fall. (Courtesy)

Holmes spent almost three months in a hospital near her home in Belchertown, Mass. Her heart stopped a few times, she had breathing and memory problems, and doctors removed an ulcer as big as a grapefruit. Even with continuous nursing care, the wound wouldn’t heal.

“Every day the girls came in and changed it and cleaned it. Then I had to take,” Holmes paused, “what do you call it when they help you learn to walk and everything?”

Physical therapy — which continued for more than a year in a nursing home. These days, patients are often transferred from a hospital to a nursing home to recover. But some never leave.

“The only thing I worried about was not getting out. I kept saying to him and one of my daughters, ‘You’re not going to keep me here are you?’ ”

Holmes worried her children and her husband wouldn’t be able to handle her care at home. Continue reading

Mass. Health Cost Watchdog Says Partners Merger Raises Red Flags

The Massachusetts Health Policy Commission (Source: HPC on Twitter)

The Massachusetts Health Policy Commission (Source: HPC on Twitter)

Looks like the health-cost-control rubber is just beginning to hit the road. This just in from the Health Policy Commission, the independent agency created under the 2012 Massachusetts law aimed at containing health costs:

HEALTH POLICY COMMISSION INITIATES FIRST COST & MARKET IMPACT REVIEW

Partners, South Shore Hospital merger to be examined for potential effects on costs and the health care market

BOSTON – Wednesday, May 22, 2013 – The Health Policy Commission (HPC) today initiated its first Cost and Market Impact Review (CMIR) by notifying Partners Healthcare System and South Shore Hospital that it will examine the potential effects of their proposed merger on costs and the health care market.

“CMIRs are an important tool to enhance the transparency of significant changes to our health care system,” said HPC Executive Director David Seltz. “Almost every day we hear about new developments in our health care market. These reviews help us consider the impact of those developments on health care costs and market functioning. We are committed to conducting them on consumers’ behalf in a timely and thorough manner.”

‘Given Partners’ size and high costs, an expansion of that system to include South Shore Hospital, a large, high-cost community hospital, is likely to have a significant impact on the Commonwealth’s ability to meet its health care cost growth goals, and on the competitive market.’

The HPC’s preliminary review of this proposed transaction found that given Partners’ size and high costs, an expansion of that system to include South Shore Hospital, a large, high-cost community hospital, is likely to have a significant impact on the Commonwealth’s ability to meet its health care cost growth goals, and on the competitive market. To enhance public understanding of the potential costs and benefits of this transaction, the HPC is proceeding with a further examination.

“The HPC was set up to be a watchdog to monitor the health care market,” said HPC Chair Dr. Stuart Altman. “CMIRs are one of the ways we will fulfill that important role as we work to build a more affordable, effective, accountable, and transparent system. I look forward to discussing the merits and next steps for this specific review with the commissioners and the public at our June meeting.”

Seltz will report on the CMIR at the Commission’s next public meeting, Wednesday, June 19, 2013, and Commissioners will vote whether to continue with the review. The CMIR will include analyzing information from the parties and other market participants, developing a preliminary report, and issuing a final report. The proposed transaction cannot be completed until 30 days after the HPC issues its final report. The HPC may also refer its findings to the Attorney General for possible further action on behalf of health care consumers.

The response from Partners spokesman Rich Copp: “The proposed affiliation between Partners, Brigham and Women’s Hospital and South Shore Hospital will offer patients in southeastern Massachusetts more coordinated, accessible and affordable health care.  We have always anticipated that the Health Policy Commission would review our proposal, and we look forward to taking this next step forward in the process.”

Looking for fine print? The HPC is here and I just signed up to follow them on Twitter at @Mass_HPC. Anybody else feeling extremely intrigued about how this review will play out, and what it will mean for the state’s efforts to contain health costs?

Mass. Blocks Higher Insurance Charges For Most Smokers

You’ve heard all the campaigns and statistics: Smoking Kills. It’s the leading cause of preventable death in the U.S.

And, it’s expensive.

cigarette

The Centers for Disease Control and Prevention says smoking costs the country $193 billion a year in lost productivity and health care spending. Add another $10 billion for secondhand smoking expenses.

The federal Affordable Care Act says insurers can charge smokers up to 50 percent more for coverage than non-smokers.

So, says Jon Hurst, president of the Retailers Association of Massachusetts, why not ask smokers to pay more for health insurance?

“If we’re ever going to control costs, we’ve got to make sure that we don’t over-socialize the system,” Hurst says. “In other words, we don’t make people pay too much for somebody else’s health care costs.”

Fifty percent more for smokers might be too much, continues Hurst, “but let’s not dismiss outright, the ability for employers to try to incent people to get healthier.”

The debate about whether to make smokers pay more for health insurance has created some unusual alliances. Tobacco companies are working alongside cancer societies and consumer groups to persuade states they should reject higher charges for smokers.

Continue reading

Angelina Jolie’s Double Mastectomy: How Times Have Changed

(Alastair Grant/AP)

(Alastair Grant/AP)

About five years ago a close friend of mine had a prophylactic double mastectomy to lower her extremely high genetic risk of developing breast cancer, which had killed her mother. She begged me to keep the operations a secret: she didn’t want to worry her two young daughters.

Today, in a New York Times opinion piece that is about as out-there and open as it gets, 37-year-old actress and activist Angelina Jolie, who carries the BRCA1 gene which greatly elevates her risk of breast and ovarian cancer, writes that she recently had her breasts surgically removed to lower that risk.

On April 27, I finished the three months of medical procedures that the mastectomies involved. During that time I have been able to keep this private and to carry on with my work.

But I am writing about it now because I hope that other women can benefit from my experience. Cancer is still a word that strikes fear into people’s hearts, producing a deep sense of powerlessness. But today it is possible to find out through a blood test whether you are highly susceptible to breast and ovarian cancer, and then take action.

My own process began on Feb. 2 with a procedure known as a “nipple delay,” which rules out disease in the breast ducts behind the nipple and draws extra blood flow to the area. This causes some pain and a lot of bruising, but it increases the chance of saving the nipple.

Two weeks later I had the major surgery, where the breast tissue is removed and temporary fillers are put in place. The operation can take eight hours. You wake up with drain tubes and expanders in your breasts. It does feel like a scene out of a science-fiction film. But days after surgery you can be back to a normal life.

Nine weeks later, the final surgery is completed with the reconstruction of the breasts with an implant. There have been many advances in this procedure in the last few years, and the results can be beautiful.

I wanted to write this to tell other women that the decision to have a mastectomy was not easy. But it is one I am very happy that I made. My chances of developing breast cancer have dropped from 87 percent to under 5 percent. I can tell my children that they don’t need to fear they will lose me to breast cancer.

Jolie’s mother died of cancer at age 56 and Jolie writes that she didn’t want to put her own kids through that kind of pain if possible. That this highly public figure offers such intimate details about her body and her breasts may be a sign that the taboos around cancer are dwindling. (“On a personal note,” Jolie writes, “I do not feel any less of a woman. I feel empowered that I made a strong choice that in no way diminishes my femininity.”)

Sharon Bober, a clinical psychologist and director of the Dana-Farber Cancer Institute’s Sexual Health Program, who counsels many women who have had similar surgeries, said in an email that Jolie’s honesty is truly refreshing:

Wow!

One thing that strikes me is how times have changed – not that many years ago BRCA carriers would be worried about insurance being dropped, stigma, judgement, (“you are removing healthy breasts?? What are you crazy??”) and now this too is out of the closet. Continue reading

What Mass. Hospitals Charge Vs. What They Get Paid

View map in a larger map

Some people play fantasy football, some knit. We here at CommonHealth sometimes like to play with health care data — most recently, a trove of Medicare numbers released last week on how much hospitals officially charge for common procedures and how much Medicare actually pays for them.

WBUR’s Alex Kingsbury first took a look at the wide range in Massachusetts hospitals’ charges for a single category, treatment of chronic lung disease, here. His map illustrated a strikingly broad range from $8,918 to $52,729. Now, in the map above, he rejiggers his Google Fusion Table to explore a broader question I put to him: How do the hospitals shake out in terms of the percentage of their official charges that they get from Medicare?

And here’s a fun little factoid that emerges from the map: That range goes from procedures for which the Medicare payment amounts to less than 18 percent of the charges billed to well over 100 percent of the charges billed. I’d thought this recalculation of the data might yield some interesting insights — Who most overcharges? Or who might feel most shafted by government payments? — but it runs such a crazy gamut that perhaps it serves mainly as yet another indicator of just how distorted and Byzantine and broken the American health care market is. (Didn’t need any further proof of that? Fine. Just enjoy playing with the map.)

Last week’s release of the Medicare data brought a media splash — particularly among data-visualization fans like the Washington Post — but also a backlash.

Health care economist Uwe Reinhardt pointed out that the official hospital charges are famously irrelevant to the reimbursement that health insurers actually pay, to the point that he called last week’s fuss about the Medicare data laughable. He wrote in The New York Times:

Even funnier are the protestations by hospital executives that hardly anyone ever pays these fictional prices, which prompted me to offer the following technical definition: “ ‘Charges’ are the prices that a totally inebriated foreign billionaire would pay a U.S. hospital if his wife were not around to control the bloke.”

Former Beth Israel Deaconess Medical Center chief Paul Levy also blasted the Medicare data as “useless noise”: Continue reading

Small Biz Insurance Rates Hold Steady In Mass, For Now

The latest small business health insurance rates may be the calm before the storm.

Premiums for small firms are set to increase from a base of 2.5%, on average, in July. That’s slightly less than the average increase of 2.7% this quarter. Employers willing to live with limits on where they and employees receive care could see premiums drop (take a look below at Neighborhood Health Plan and Celitcare). And notice that no one filed (or was approved for) rate increases above 3.6%, the current magic number for health care cost caps in Massachusetts.

July 1 insurance rates for small businesses in MA

July 1 insurance rates for small businesses in MA

But things may look quite different as of January 1st. Very small businesses could see modest increases or perhaps lower rates. But insurers are warning that firms with 20-50 workers could see premiums jump 30% when parts of the federal health care law kick in next year.

“We all thought that Mass. was going to be held harmless under the ACA, but that looks like that’s not going to be the case, at least not for small businesses,” says Jon Hurst, President of the Retailers Association of Massachusetts. “We’re going to be looking at a lot of small businesses getting extreme, double digit increases come next year.” Continue reading

New Fed Data Show Hospital Prices Vary Wildly: The Mass. Version

View map in a larger map

(Data visualization above: Alex Kingsbury, WBUR)

Today is a glorious day for health care wonks who see great founts of Medicare numbers as enticing Big Data playgrounds just begging for the analytical equivalent of gymnastics on the monkey bars.

The federal government has just released hospital prices on 100 common procedures, and though many studies have already documented the dramatic cost variation among hospitals — here’s a recent one — the numbers have never before been this accessible. The Washington Post does a wonderful job of providing context and translating some of the data into visual form here, including a useful feature titled  “How much do providers charge in your state?”

Of course I provincially plugged in Massachusetts, and was surprised to see that though we’re reputed to have among the highest costs in the country, we’re below the national average on the 10 categories shown, ranging from pneumonia to heart failure.

WBUR’s Alex Kingsbury puts his data-visualization talents to excellent use on the Medicare data in the map above, showing the variation in costs for treating one condition, Chronic Obstructive Pulmonary Disease, at each of the state’s hospitals. They range from $8,918 to $52,729. [More on these striking gaps from WBUR's Martha Bebinger here: Crazy, irrational hospital billing (with no connection to quality.)]

Above, click on each blue pin to see what each facility charges. Or if you’re not a geographical type, you can check out the raw Medicare numbers here, and here’s a list of the data points Alex used: Continue reading