Nearly half of sick people report difficulty coughing up money for prescriptions

Slightly over half of Americans reported taking a prescription drug, and while most are able to afford them at least somewhat easily, about a quarter have a difficult time finding the money to pay for them. The number jumps for those in poor health or taking at least four drugs. The Kaiser Family Foundation’s (KFF) August Health Tracking Poll revealed strong public support for policy actions to lower prescription drug costs. The poll also tracked public opinion of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), finding that the public remains divided and mostly unchanged from other recent reporting.

Prescription drug use

Over half of those polled reported taking a prescription drug (54 percent), with over a third of those taking four or more different drugs (37 percent of those taking drugs). Although 7 in 10 said that their drugs are very or somewhat easy to afford, a third of those with household incomes below $40,000 said that affording prescriptions is difficult. A quarter of those taking prescriptions reported that in the past year, either they or a family member have not filled a prescription due to cost, while 19 percent said they either skipped doses or cut pills in half. Those in fair or poor health, or taking 4 or more prescription drugs, are quite a bit more likely than healthier people to say affording medication is difficult. Half of those taking medicines have asked for generic drugs, and 78 percent thought that generic and brand-name drugs were about the same quality.

Lowering drug costs

Nearly three-fourths of the public views prescription drug costs as unreasonable, including 66 percent of those not currently taking prescription drugs. The poll presented several policy options for reducing drug costs, which were well-received. The highest rated option was requiring drug companies to publicly disclose how they set their drug prices, with 86 percent in favor. Closely following was the option of allowing the government to negotiate lower prices for drugs for Medicare beneficiaries, at 83 percent support. Although not quite as popular, many supported limiting the amounts companies could charge for drugs for illnesses such as hepatitis or cancer (76 percent) and allowing Americans to buy drugs imported from Canada (72 percent). Less than half supported requiring patients to pay a higher share if they chose a similar, higher cost drug as opposed to a cheaper treatment.

ACA

About 44 percent have a favorable view of the ACA, with 41 percent unfavorable. According to the report, the views continue to diverge along party lines, with 76 percent of Democrats reporting a favorable view and 71 percent of Republicans reporting unfavorable. Independents are split, 46 percent unfavorable and 39 percent favorable. These opinions are consistent with past polls, as are opinions for the next steps for the ACA. Identical shares (28 percent) hope for expansion of the ACA and complete repeal of the law. A slightly smaller amount (22 percent) want Congress to continue implementing the law as is and 12 percent wish for the law to be scaled back.

Highlight on Maine: addressing seniors, aliens, diabetes, dental health care

Maine has experienced highs and lows in its delivery of health care in the first half of 2015. It has improved its ranking in the nation in terms of care provided to seniors and on seven measures of a health care index report, but it ranks low in dental health care. To help with those dental statistics, Maine received a grant from HHS targeting children’s dental health. Maine also embarked on a diabetes prevention program. Finally, the Maine Superior Court ruled in favor of the Maine Department of Health and Human Services (DHHS) denying General Assistance welfare reimbursement for claims municipalities paid to nonqualified aliens.

Senior health care ranking

Maine is ranked the 11th healthiest state overall for adults aged 65 and older, up from 14th in 2014. It ranked first in the nation for clinical care, according to the third annual Senior Report released by America’s Health Rankings®. The Senior Report provides a comprehensive analysis of senior population health on a national and state by state basis. According to a news release from MaineHealth, an accountable care organization and integrated not-for-profit health care system of providers and other health care organizations working together in their communities, clinical care includes seniors receiving care for heart attack, heart failure, pneumonia, and surgical procedures.

The Senior Report identified Maine’s strengths as follows: (1) high percentage of quality nursing home beds, (2) low percentage of low-care nursing home residents, and (3) low intensive care unit use. Challenges include: (1) low percentage of dental visit, (2) low prescription drug coverage, and (3) high prevalence of full-mouth tooth extraction. Highlights of senior health care in the past year include that: (1) obesity increased from 25.9 percent to 27.2 percent of adults aged 65 and older; (2) pain management decreased from 50.7 percent to 42.9 percent of adults aged 65 and older with joint pain; (3) community support increased from $525 to $639 per adult aged 65 and older in poverty; (4) home health care increased from 106.3 to 137.4 home health care workers per 1000 adults aged 75 and older; and (5) premature death decreased from 1902 to 1692 deaths per 100,000 adults aged 65 to 74.

Diabetes prevention

The Maine Center for Disease Control (CDC) is targeting diabetes prevention at 16 sites across the state that are delivering the National Diabetes Prevention Program, a year-long lifestyle change program designed to help participants decrease their risk of developing Type 2 diabetes, the Maine DHHS reported on June 11, 2015. The Maine CDC noted that less than 7 percent of Maine adults have ever been told they have pre-diabetes (higher than normal blood sugar) even though the United States Center for Disease Control estimates that one of every three adults has this condition. In 2014, 800 Mainers completed the prevention program in which a lifestyle coach works with small groups of individuals to support life style changes such as changing eating habits, managing stress, staying motivated, and increasing physical activity. Data shows that those who have completed the program reduced the likelihood of developing Type 2 diabetes by 58 percent, and many experienced weight loss and a drop in blood pressure.

Children’s oral health

On July 24, 2015, MaineHealth announced that HHS had awarded the health care organization a grant to improve children’s oral health across the state in the amount of $250,000 per year for a total of $1 million over four years. Maine is one of eight states to receive this funding. The grant expands access to oral health care through the From the First Tooth initiative to include pregnant women and enhance the focus on establishing early dental care for babies. From the First Tooth, which is led and administered by MaineHealth in partnership with MaineGeneral Health and Eastern Maine Healthcare Systems (EMHS), is a statewide effort to integrate oral health into primary care delivery systems through early interventions by pediatricians and family physicians. Kneka Smith, MPH, Director of From the First Tooth at MaineHealth, noted that, “tooth decay is one of the largest health problems impacting Maine children.”

Health Index Report

MaineHealth, released its fifth annual Health Index Report on March 25, 2015. The report, which is released in conjunction with the Robert Wood Johnson Foundation’s County Health Rankings, an annual report that compares the overall health of almost every county in the United States, provides community health data specific to Maine. According to MaineHealth, the rankings compare counties on 30 factors that influence health including education, housing, violent crime, jobs, diet, and exercise. The rankings indicated that Sagadahoc is the healthiest county in Maine and Somerset is the least healthy county. The rankings also showed that Oxford County had the most improved health outcomes in the state. The Health Index Report tracks progress on seven high priority issues that have a major impact on Maine’s overall health status, including: childhood immunizations, tobacco use, obesity, preventable hospitalizations, cardiovascular deaths, cancer deaths, and prescription drug abuse and addiction. Key findings in the 2014 report specific to Maine include:

  • up-to-date immunization rates at MaineHealth practices increased from 77 percent in 2012 to 80 percent in 2014;
  • Maine’s youth smoking rate was 13 percent in 2013 versus the 2011 rate of 15.5 percent;
  • 58 percent of Maine’s adult smokers have made a serious attempt to quit in the past 12 months;
  • 78 percent of Maine fifth graders drank zero sugary beverages per day in 2013–an increase of 9 percent since 2009; and
  • In 2010-2012, Maine’s rates for overall cardiovascular death, as well as rates for heart disease, coronary heart disease and heart attack, were significantly lower than the U.S. rates.

The report identifies opportunities for community health improvement and describes how the MaineHealth system and its partners are addressing the high priority issues through clinical, community, and policy strategies.

Welfare to illegal aliens

On June 9, 2015, the Maine Superior Court, issued a ruling that the Maine DHHS cannot withhold all General Assistance funds from municipalities that give the funds to immigrants seeking asylum until the agency follows state law that outlines how rules may be changed; however, the state does not have to reimburse cities and towns for the aid that they give to asylum seekers, Judy Harris reported in the Bangor Daily News. “DHHS has no statutory or regulatory authority to penalize municipalities for noncompliance with DHHS instruction or directive relating to persons who DHHS deems ineligible for general assistance,” according to the opinion. Finally, the court concluded that until the state legislature enacts laws that allow asylum seekers to receive General Assistance funds, they are ineligible under federal law.

The Portland Press Herald reported on July 13, 2015, that a preliminary analysis by city staff found that “as many as one-third of the 900 or so immigrants who live in Portland and have been at the center of a debate about public assistance may be ineligible for city aid because they have expired visas and have not applied for asylum.” An immigration attorney quoted in the article explained that under federal law, only immigrants who have formally applied for asylum are protected from deportation until their final legal status is determined; asylum applicants are considered to be lawfully present while they wait for a decision. The question is whether someone can be described as an asylum seeker without having formally applied, according to the article.

Hospice offers significant nonfinancial benefits but not Medicare savings

The significant rise in the use of the Medicare hospice benefit has not, as previous studies suggested, reduced Medicare spending, according to a report prepared by Direct Research, LLC, for the Medicare Payment Advisory Commission (MedPAC). While the report focused on the impact of the hospice benefit on Medicare costs, it noted that its findings do not focus on the main benefits of hospice, which are not financial, and offer patients individualized, “holistic end-of-life care” that is focused on the management of symptoms and providing psychosocial supports.

Hospice growth

The use of Medicare hospice by elderly fee-for-service decedents almost doubled over the past decade, rising from 26 percent in 2002 to 47 percent in 2012. Hospice currently provides services to the majority of elderly beneficiaries who die from cancer and provides services to a growing percentage of elderly non-cancer beneficiaries.

Methods

A previous study estimated that hospice saved thousands of dollars per patient for even short stays. The Direct Research report reasoned that if this were true, the rapid hospice growth should have reduced last-year-of-life spending. The study took three approaches to determining the effect of the Medicare hospice benefit on spending. It first tracked the trend in end-of-life spending and hospice enrollment over the past decade. It then replicated and reconciled conflicting findings relating to hospice savings or costs. Lastly, it departed from a person-level analysis of the hospice benefit’s impact on Medicare spending in favor of a market-level analysis.

Medicare spending

According to the findings of the report, the “preponderance of evidence” suggests that hospice has not led to reductions in Medicare spending. The report documented the substantial growth in Medicare hospice use over the past decade while finding that Medicare end-of-life costs also grew. Additionally, the report demonstrated that results of previous studies finding hospice cost savings may have resulted from the methodology employed, and another methodology suggests that hospice did not result in costs savings, and may have even led to modestly higher costs, which were concentrated in non-cancer, longer-stay decedents. Finally, the report examined the cost of all decedents at a market level, which validated its prior findings that hospice appears to lead to the modest rise in end-of-life costs, and only reduces the costs for decedents with cancer, but not other individuals who have long stays in hospice.

Physicians positive about negative effects of payment, delivery models

Although it may be too early to determine the quality or cost effects of new primary care payment and delivery models that have emerged under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), according to a Commonwealth Fund survey of over 1,600 primary care physicians and 520 midlevel clinicians (nurse practitioners and physician assistants), the providers have less favorable views of the efforts associated with these new models to improve patient outcomes and lower health care costs. Many of the primary care providers expressed uncertainty about the impact of accountable care organizations (ACO) on quality of care; physicians with an opinion were more likely to say ACOs were a having a negative rather than a positive impact on quality of care. Providers were also more negative about the use of quality metrics to assess their performance, even those providers who received incentive payments based on quality. Nearly half of physicians and about a quarter of nurse practitioners and physician assistants said recent trends in health care are causing them to consider early retirement. However, a large majority of providers report satisfaction with their medical practice overall.

New models of delivery

Whether established or accelerated by the ACA’s enactment, there are several newer models of delivering care specifically created to improve the way care is organized, paid for, and delivered. This includes: (1) the patient-centered medical home (PCMH), a model of care that emphasizes comprehensive care coordination, care teams, patient engagement, and population care management; and (2) the ACO, a model in which several types of health care providers collectively take responsibility for the quality and costs of care for a population of patients.

Twenty-nine percent of all primary care physicians said they participate in an ACO arrangement with Medicare or private insurers; 34 percent of those who accept Medicare also participate in ACOs.

Mixed views of care

Overall, 33 percent of physicians and 40 percent of practitioners and physician assistants said they believe medical homes were having a positive impact on quality of care, while roughly 10 percent said the impact has been negative. About 25 percent of each group said there has been no impact or they are not sure. Among those in practices currently receiving incentives or payments for qualifying as a PCMH, larger percentages expressed positive views of the impact of medical homes—43 percent of the physicians and 63 percent of the nurse practitioners and physician assistants.

Likewise, ACO impact was unsettled. Primary care clinicians’ views were negative regarding financial penalties and the increased use of quality metrics in judging their performance. Physicians were more likely to view the increased prevalence of ACOs as having a negative (26 percent) rather than positive (14 percent) impact on quality of care. Nearly 40 percent of physicians over 50 percent of the nurse practitioners and physician assistants were not sure of ACOs’ effect on the quality of care provided to the nearly 24 million patients enrolled.

Quality care concerns

The survey found that performance assessments and financial penalties tied to patients’ outcomes were unfavorable among providers, with 50 percent of physicians and 40 percent of nurse practitioners and physician assistants believing that quality metrics affected quality of care. Primary care providers also rejected the idea that programs with financial penalties for unnecessary admissions or readmissions contributed to improved quality of care.

Views on insurers

In terms of reimbursement rates and administrative burdens, overall, fewer than half of physicians gave positive ratings to any type of insurer on measures related to reimbursement, though ratings were higher for private insurers and lowest for Medicaid, with Medicare falling in the middle. Nearly 46 percent of physicians accepting private insurance considered these insurers’ payment rates to be good or excellent, with only 11 percent rating Medicaid as highly. Medicare ranked in the middle, with 21 percent of physicians who accept it for payment stating that payment rates are good or excellent.

Exceptions

Health information technology (HIT) received positive views from 50 percent of physicians and 64 percent of midlevel clinicians. Primary care providers generally accept the promise of HIT to improve quality of care even if there is dislike of the process of transitioning from paper-based records. The report authors noted that the survey results also may reflect clinicians’ earlier exposure to certain models and tools, e.g., national adoption of electronic health records received a boost from the Health Information Technology for Economic and Clinical Health (HITECH) Act of the federal stimulus package of 2009, while the four primary care specialty societies announced a joint statement regarding medical homes in February 2007, several years before passage of the ACA.