The CONNECT for Health Act suggests the future isn’t too remote

A new piece of legislation would increase the use of telehealth and remote patient monitoring (RPM) in the Medicare program. The Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act, a bipartisan piece of legislation, is aimed at cutting health care costs while improving care outcomes. The bill is premised on the belief that telehealth is the future of medicine and that the quality of care can be greatly improved, in a cost effective way, through better contact between patients and providers.

Provisions

The CONNECT for Health Act would loosen current restrictions on Medicare reimbursement for telehealth and RPM services. Specifically, the legislation would allow certain providers to use telehealth and RPM without many of the current 42 U.S.C. §1834(m) limitations, which include originating site restrictions, geographic limitations, restrictions on store and forward technologies, limitations on distant site providers, and limitations on covered codes. The act would also permit providers to use telehealth and RPM in alternative payment models without most of the Section 1834(m) restrictions. The act would allow RPM of certain patients with chronic conditions, permit more facilities to serve as originating sites, and enable telehealth and RPM to be considered basic benefits in Medicare Advantage, without most of the Section 1834(m) restrictions.

Response

According to an Avalere study, the bill could save as much as $1.8 billion over the next ten years. The American Medical Association (AMA) has expressed its support for the bill, noting that it stands to strengthen physician-patient relationships and improve care access while maintaining patient safety. The bill was introduced by Senators Brian Schatz (D-Hawaii), Roger Wicker (R-Miss), Thad Cochran (R-Miss), Ben Cardin (D-Md), John Thune (R-SD), and Mark Warner (D-Va). The Senators praised the advances of health information technology and the promise of telehealth, noting the importance of the opportunity to bring together improvements in technology with the prospect of better care quality.

Do voters really care about health care reform?

In April of last year, the Atlantic told readers that this question would be “the most decisive question” of the upcoming 2016 presidential election: “Will you take away my health insurance?” On February 2, 2016, the House of Representatives, voting mostly along party lines, failed to override President Obama’s veto of the latest attempt to repeal the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) in the form of the Restoring Americans’ Healthcare Freedom Reconciliation Act (H.R. 3762). Yet, while attacks on reform efforts are usual rhetoric for Congressional Republicans as well as most of the GOP presidential candidates, a recent study by the Kaiser Family Foundation shows that voters’ interest in health reform as an issue in the presidential primary race is not as strong as some had predicted. Does this mean that voters do not care about health reform as much as we thought? Further, will this trend continue once the primaries are over and the Republican and Democratic candidates go head-to-head?

Kaiser study

A Kaiser Tracking Poll released in January of 2016 revealed that the ACA does not “rank highly as an issue for voters in the presidential primaries.” While the general cost of health care ranked as the third most important issue—with 28 percent of voters stating that that issue would be “extremely important” to their presidential vote—the ACA specifically ranked eighth overall, with 23 percent of respondents stating it was extremely important to their vote. Other issues ranking above the 2010 health reform were terrorism (38 percent), the economy and jobs (34 percent), the federal budget deficit (28 percent), and gun control (27 percent). Moreover, when respondents were asked to choose the single most important issue in the presidential race, only 4 percent chose the ACA.

CNN poll

A less specific question asked in a recent CNN poll ranked health care in general as the third most important issue in the election. When asked how important, on a scale of extremely important to not that important, a list of issues would be in the upcoming election, 35 percent stated health care would be extremely important, 41 percent said it would be very important, and 18 and 6 percent considered it moderately important or not that important, respectively. The poll also revealed that only 39 percent of respondents were aware of President Obama’s recent veto to the ACA-repealing legislation and that opinions are steady and almost evenly split when it comes to satisfaction with the ACA, with 44 percent having an unfavorable view and 41 percent favoring the reform.

Candidates’ opinions

Current Republican front-runners for the presidential nomination, including Senator Ted Cruz (R-Texas), Senator Marco Rubio (R-FL), and Donald Trump, have expressed their intentions to repeal the ACA, if elected. Yet, there is no one replacement plan that all the candidates agree on. While Cruz and Rubio both voted in favor of the recent attempt to repeal the ACA through H.R. 3762, Trump’s views on the reform have been vague. Beyond “bashing the current law” and promising that “everybody’s going to be taken care of” and “the government’s [going to] pay for it,” Trump’s particular stance on health reform is unknown. The lack of a solid position on this issue for the popular candidate has GOP leaders concerned.

On the Democratic side, while former Secretary of State Hillary Clinton has promised to make general improvements in health care costs, she supports a continued implementation of the ACA. Her sole democratic opponent, Bernie Sanders (D-VT), has indicated that, if elected, he intends to pursue replacing the ACA with a “Medicare for all” single payer system.

As the votes for and against the override of the President’s veto of H.R. 3762 show, it appears that support for health care reform is split between party lines. However, in terms of the current presidential candidates, the views on health care reform are not as uniform. Because of the unique circumstances of the current presidential primaries, it may not be clear to what extent health care reform will be a major deciding issue for the race until the primaries are over and the Democratic and Republican nominations are decided.

Zika’s potential impact on abortion legislation in Latin America

The Zika virus has been a hot topic in the news, with reactions varying from panic to dismissal. The biggest concern surrounding the disease is the potential for severe birth defects in children born to women who were infected while pregnant, which has stirred up the always-controversial topics of reproductive rights and decisions.

Virus

Like dengue and chikungunya, Zika is spread through mosquito bites. The virus symptoms themselves are surprisingly mild. The Centers for Disease Control and Prevention (CDC) reports that common symptoms are fever, rash, joint pain, and red eyes lasting up to a week. Only about one in five people who are infected with the virus actually develop Zika, and those that do are simply encouraged to get rest, take acetaminophen, and drink fluids.

Where is it?

Zika outbreaks were noted in Africa, Southeast Asia, and the Pacific Islands prior to 2015. The virus was first identified in Brazil in May 2015, and has been reported in many other South American countries. Although no locally transmitted cases have been noted in the U.S., it has been brought into the country by those infected elsewhere. Local cases in Puerto Rico, the Virgin Island, and American Samoa have been detected.

The particular species of mosquito known to carry Zika, Aedes aegypti, is not as prevalent in the U.S. as more southern countries because it prefers tropical and sub-tropical climates. However, some studies have found that the Aedes is common in Louisiana, Florida, some areas of Texas, and is sometimes seen as far north as New York in the summer.

Pregnancy

The major discussion surrounding Zika has stemmed from reports of a serious birth defect and “other poor pregnancy outcomes” in babies born to mothers who were infected while pregnant. Microcephaly, a condition in which a baby’s head size is significantly reduced, has been linked to the virus. According to the Mayo Clinic, microcephaly usually causes the brain to develop abnormally or fail to grow as expected, often causing developmental delays. As a result of these concerns, the CDC and other agencies recommend that women who are pregnant avoid traveling to areas where Zika is known. The first confirmed pregnancy case in Europe was recently found in Spain, where a woman recently returned from Colombia.

Controversy

The talk of Zika and potential serious birth defects has brought up a discussion regarding abortion laws, especially in heavily religious countries like Brazil where abortion is illegal in most cases. According to the New York Times, a case is already being prepared to fight for pregnant women to have the option for an abortion when microcephaly is discovered, and a judge has already expressed support for that side of the issue. Other groups are speaking up about keeping the restrictions as they currently are, or making abortions still harder to obtain. Some are recalling the legal battles in the U.S. surrounding abortions when it was discovered that contracting rubella during pregnancy would result in “damaged children”—an article published in the Wall Street Journal in 1966 sounds eerily similar to the discussion today. The Therapeutic Abortion Act, enacted during the rubella scares before a vaccine was developed, made California the first state to legalize abortion, with restrictions.

Those pushing for easier access to abortions note that contraception is particularly hard to obtain in Latin America. In addition, the culture often allows men to call the shots on how large a family becomes. Even though El Salvador’s government advised women to postpone pregnancy for two years, those studying family planning in the reason state that such actions are simply not feasible for many women—especially considering that clinics in five countries in the region exhausted their contraceptive supplies in 2015. Maternity and labor and delivery care are also hard to come by especially for the poor, resulting in many women giving birth outside of a medical facility. Sources have reported that millions of women have sought unsafe abortions in the region, often resulting in further health issues.

HELP Committee focuses on access to mental health services

On January 20, 2016, the Senate Committee on Health, Education, Labor, and Pensions (HELP) heard testimony from four experts in the field of mental health with very different perspectives. The three who had been directly involved with patients all testified, however, that there is a dearth of resources for treatment and that serious needs go unmet.

Penny Blake, R.N., C.C.R.N., an emergency room nurse and Chair of the Advocacy Advisory council of the Emergency Nurses Association, told the committee that people with mental health or substance use conditions comprise about 10 percent of the patients that present to the emergency department at the West Palm Beach hospital where she works. The loud noises and chaotic atmosphere of a busy emergency department can be harmful to a patient who may be hallucinating. Because the hospital does not have a psychiatric ward, patients who are dangerous to themselves or others must be transferred to other hospitals. There are so few beds available that they must be “boarded” in the emergency department. Usually the wait is 12 to 24 hours, but it is not unusual for a patient to wait for four days to be transferred.

The need to isolate and observe patients who may require involuntary commitment also diverts staff from other patients who need care. The emergency room physicians lack the experience and expertise to begin treatment of the psychiatric emergency with appropriate medication. Blake attributed the difficulties in accessing treatment to the insufficiency of treatment providers available and the lack of insurance coverage for psychiatric care.

Brian Hepburn, MD, Executive Director of the National Association of State Mental Health Directors, expressed gratitude for the mental health block grant programs and funding for demonstration projects. For example, he believes that the First Episode of Psychosis program, which now receives a 10 percent set-aside from mental health block grants, will make a significant difference. He noted that treatment of serious mental illness is much more likely to be successful when begun in the early stages of the illness. He asked that Congress modify the Medicaid exclusion of services of institutions for mental disease (IMD) to allow payment for adult stays in IMDs. Hepburn also recommended increasing support for monitoring and enforcement of the laws requiring mental health and addiction parity.

Both Hepburn and William W. Eaton, PhD, Professor in the Department of Mental Health at Johns Hopkins University Bloomberg School of Public Health, told the committee that patients with mental illness or substance use disorder also are at higher risk for physical illnesses, such as heart attacks, stroke, or diabetes. Eaton also emphasized the lack of research and resources dedicated to mental illness, especially with respect to public health interventions that could prevent or alleviate mental illness.

Pending legislation

Finally, Hakeem Rahim, representing the National Alliance on Mental Illness, put a human face on the problem by describing the experience of living and coping with psychosis. Rahim told the committee that S. 1893, the Mental Health Awareness Act, which was recently passed by the Senate and is now pending in the House, was a good start. However, he urged the committee to support S. 1945, the Mental Health Reform Act, sponsored by committee members Bill Cassidy (R-La) and Christopher Murphy (D-Conn). S. 1945 would create an Assistant Secretary of Mental Health and Substance Use Disorders and expand funding for many training and treatment programs.