Health Policy

This morning on KQED’s Forum, guests discussed addiction in the wake of the apparent heroin overdose of actor Philip Seymour Hoffman.

During the show, Stanford’s Keith Humphreys, PhD, a professor of psychiatry and behavioral sciences, noted that addiction is a disease:

Addiction is like other chronic disorders that are not curable – I mean, they can be managed, but we can’t eliminate them. Just like diabetes or low back pain or high blood pressure, you can go through treatment periods and recover your function, but that doesn’t mean that it can’t come back. And people are particularly prone to relapse in times of stress, in times of deprivation. Sometimes in also very good times people haven’t learned to celebrate and be happy without reaching for their drug or alcohol.

Humphreys, who recently served as a senior advisor in the Office of National Drug Control Policy in Washington, outlined two common barriers to receiving treatment: “Not having enough money, and being stigmatized.” But he also shared good news on how addiction is being viewed by the American public – and treated as a medical condition worthy of health insurance coverage.

“Several hundred million Americans, although they might not know it, just got better coverage for addiction treatment in their insurance,” Humphreys said. “The Affordable Care Act defines substance abuse for the first time as an essential health-care benefit. So all new plans must offer benefits, and they must offer them at parity.”

Previously: We just had the best two months in the history of U.S. mental-health policy, Is it damaging to refer to addicts as drug “abusers?”, “Brains are unmentionable:” A father reflects on reactions to daughter’s mental illness, Breaking Good: How to wipe out meth labs, How police officers are tackling drug overdose and Addiction: All in the mind?
Photo (modified from original) by vmiramontes

For decades, descriptions of the status of U.S. mental health services have included references to service cuts, funding constraints and poor access to care. That makes it only more astonishing and important that the past two months have witnessed the most expansive support for mental-health services in U.S. history. Three critical pieces of federal legislation are responsible for this remarkable turn of events.

Bipartisan support for mental-health services has probably never been this strong before at the U.S. federal level

In early November, the Obama Administration released the final regulations for implementing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPEA) of 2008. One of the very last laws passed during the George W. Bush Administration, MHPEA affects the more than 100 million Americans who receive their health insurance through large group employers. It mandates that any insurance plan that offers benefits for the treatment of mental-health disorders must make those benefits comparable to those for other medical disorders. In other words, the higher co-pays, more intensive utilization review requirements and lower benefit caps historically applied to mental health care are now illegal.

Just seven weeks after the final MHPEA regulations were issued, Medicare ended its decades-long practice of reimbursing outpatient mental-health care at a lower rate than care for all other disorders. Historically, Medicare had covered 80 percent of all outpatient care except for mental health care, which was reimbursed at only 50 percent. Due to the final implementation of the Medicare Improvements for Patients and Providers Act of 2008 (.pdf), this disparity was eliminated on January 1, 2014. That’s good news for the approximately 50 million Americans who are covered by Medicare.

Last but not least, as everyone knows the remaining provisions of the Affordable Care Act also came into force over the past month. The ACA had already helped families facing mental illness by allowing parents to keep their children on their insurance policies until the age of 26. That was critical because addictive and psychiatric disorders almost always have onset in adolescence or young adulthood. But an even more influential feature of the law is to define substance use disorder and mental-illness treatment as essential health care benefits, and, to specify that those benefits be at parity with benefits for other disorders, such as is specified in MHPEA. This standard will apply to all plans issued through state and federal health insurance exchanges and the Medicaid expansion, as well as to insurance plans to be issued in the future that are subject to ACA regulations. The HHS Office of the Assistant Secretary for Planning and Evaluation projects the impact of these changes as improving mental-health care coverage for more than 60 million Americans.

Of course, while the above changes all were implemented in the past two months, they each were the product of many years of advocacy by office holders, political activists, grassroots organizations, clinicians and researchers. These laws coming to fruition in such a compressed time window was fortuitous in some respects, but it also reflects a new political reality in Washington: Bipartisan support for mental-health services has probably never been this strong before at the U.S. federal level. That augurs well for American families who will face the challenge of mental illness in the coming years.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington. He can be followed on Twitter at @KeithNHumphreys. 

Previously: Managing primary care patients’ risky drinking, Full-length video available for Stanford’s Health Policy Forum on serious mental illness and How states will benefit from Medicaid expansion

In case you haven’t seen it, Foreign Policy magazine recently announced its Top 100 Global Thinkers of 2013. These movers, the piece accompanying the list notes, “have made a measurable difference in politics, business, technology, the arts, the sciences, and more” this year. Stanford Medicine’s Sanjay Basu, MD, PhD, was named one of the top thinkers – alongside luminaries such as Angela Merkel, the Intergovernmental Panel on Climate Change, and Pope Francis. Basu and University of Oxford’s David Stuckler, MPH, PhD, are being honored for research on the public health effects of different economic policy responses to the recession – or as the magazine puts it, “for warning that austerity can be deadly.”

Previously: Could a palm oil tax lower the death rate from cardiovascular disease in India?, Can food stamps help lighten America’s obesity epidemic? and New evidence for a direct sugar-to-diabetes link

As recently written about on Scope, new guidelines on statin use, and an accompanying risk-assessment calculator, have generated much conversation in the medical community. In a new Viewpoint piece in the Journal of the American Medical Association, Stanford professor and health research and policy expert John Ioannidis, MD, DSc, discusses potential implications of the guidelines, which could lead to more widespread use of statins for primary prevention. “It is uncertain whether this would be one of the greatest achievements or one of the worst disasters of medical history,” he writes of potential worldwide “statinization.” Read on to get more of his thoughts.

Previously: Stanford expert weighs in on new guidelines for statin use, The exercise pill: A better prescription than drugs for patients with heart problems?, “U.S. effect” leads to publication of biased research, says Stanford’s John Ioannidis and A call for mega-trials for blockbuster drugs

“You’re going into medicine? Let me give you a piece of advice: Don’t.”

A community physician said those words to me more than three years ago, right before I started medical school, and I’ve heard variations on the theme ever since: Medicine is a thankless profession. Contrary to popular opinion, it’s hardly the path to riches. You can’t spend enough time with patients. It’s depressing.

In recent days, I asked several peers at different medical schools what they thought of the ACA. The overwhelming answer: “I don’t know enough to have an opinion.”

Now I stand poised to enter the world of MDs. And with the passage of the Affordable Care Act, my classmates and I, the newest generation of doctors, look out at the horizon without knowing the shape our careers will have. We are reasonably sure about one thing — along with providing unprecedented access to insurance for Americans, the new health care law will change how we practice medicine, including how many patients we see and possibly how we get reimbursed.

Yet when the endless wave of media coverage crashes over us, it’s rare to find an examination of how the law will affect us, your future health-care providers. Instead, we get a big dose of political posturing from all sides.

Why does this matter? Because the first and probably saddest truth I can tell you is that most medical students know very little about the Affordable Care Act, or about insurance and health economics in general. We get the occasional lecture about health systems, but the information shows up on none of our exams or evaluations. In recent days, I asked several peers at different medical schools what they thought of the ACA. The overwhelming answer: “I don’t know enough to have an opinion.”

I find myself in a unique position. Thanks to Stanford and NBC News, I’m spending the year learning more about health journalism. So I’ve pulled my head out of the textbooks and hospitals and gotten a chance to really see how health-care issues affect communities. If not for this opportunity, I probably would have been one of those students who knew next to nothing about a law that will alter my career.

As medical students, we’re exposed to certain physicians who don’t consider costs and money; they tell us that such thoughts are not only unbecoming of a physician but also a distraction from caring about your patient.

I don’t see it the same way. Physicians are meant to be advocates for patients, and that means pursuing appropriate medical treatment in the context of a patient’s real life. Being uninsured is a health problem, pure and simple. A 2009 study revealed a direct correlation between lack of insurance and increased mortality, suggesting that nearly 45,000 American adults die each year because they have no medical coverage.

Whether or not you support the Affordable Care Act, that figure alone makes it our business to care about this issue.

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Previously on Scope, we discussed a Health Policy Forum on mental illness. As Stanford addiction expert Keith Humphreys, PhD, explained in his post, the goal of the forum – entitled “Serious Mental Illness: How can we balance public health and public safety?” – was to explore issues related to health policies for the mentally ill in a transparent and productive way.

Paul Costello, chief communications officer for the School of Medicine, led the forum’s diverse panel of experts which included:

• Lee Baca, L.A. County Sheriff, head of the L.A. county jail system – the “nation’s largest mental institution“
• Harold Pollack, PhD, Helen Ross Professor at the University of Chicago’s School of Social Service Administration and co-director of the University of Chicago Crime Lab
• Laura Roberts, MD, chairman of the Department of Psychiatry and Behavioral Sciences and chief of the psychiatry service for Stanford’s Hospital and Clinics

The forum addressed several issues related to serious mental illness including violence, life as a mentally ill patient in prison, the stigma of mental illness, and cluster suicides. Costello and the panel bring fresh insights to a topic of longstanding debate; the video is worth a watch.

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: “Brains are unmentionable:” A father reflects on reactions to daughter’s mental illness, Upcoming Stanford Health Policy Forum to focus on mental illness, Examining mental health policies in the wake of school shooting tragedy and Probing the underlying physiological causes of mental illness

As you may have read, the American Heart Association and the American College of Cardiology recently released a new set of guidelines for lowering cholesterol, along with an online risk-assessment calculator. But two independent reviewers found that the calculator’s design was flawed, overestimating many people’s risk for heart problems and potentially driving an over-prescription of statin drugs. (Their comments were posted today on The Lancet.) Controversy about the guidelines and online tool raised questions at the recent annual meeting of the American Heart Association and prompted a press briefing yesterday in which the two issuing organizations stood in support of the risk calculator.

Earlier this year, Mark Hlatky, MD, professor of health research policy and of cardiovascular medicine at Stanford, released a different sort of heart-related calculator, comparing five-year outcomes for two heart-disease interventions. I posed some questions to Hlatky about the the new online tool and guidelines; his answers appear below.

What are your thoughts on the design of the online risk calculator released with the new guidelines?

I’ve tested the spreadsheet in the guideline and agree that the risk estimates appear to be high. There are several possible reasons for this, but a key change is that the current version is to predict the risk of heart attack AND stroke, not just heart attack. So by design all the numbers are higher than prior calculators.

The other issue is that they have used different data than the prior “Framingham risk calculator” to produce these numbers, so there may be additional differences in the estimates from the ones everyone has been using.

A New York Times piece includes comments from Johns Hopkins’ Michael Blaha, MD, who notes that the data sets used, from the 1990s, were too old to be accurate in determining how risk factors such as cholesterol level and blood pressure could lead to heart attacks and strokes in today’s population. Do you agree?

The overall risk of coronary disease in the population has been decreasing over time, so using older data to predict current risk might over-estimate the risk.  This is only a problem if the lower risk is due to factors OTHER than improvements in the traditional cardiac risk factors. For example, rates of smoking have gone down, so overall population risk is going down too. But that’s not necessarily a problem for the risk calculator because smoking is included in the calculator. But if all smokers have been smoking less, the risk attached to being a smoker today might be lower than the risk of being a smoker years ago.

What do you think are the implications of this controversy – for doctors, patients, and the medical research review process?

The controversy might confuse the public, so it’s a shame it couldn’t have been avoided. The review process appears to have been flawed, since this criticism was leveled earlier in the development of the guideline.

On a more substantive level, the risk level is now set so low (7.5 percent over 10 years) that many people in the population who have “optimal risk factor levels” (systolic blood pressure 110 or below, total cholesterol 170 or below, HDL cholesterol of 50 or above, no diabetes and non-smoker) would targeted for statin treatment simply on the basis of their age.  The calculator puts men age 63 and older with “optimal risk factor levels” at elevated risk, and all women age 71 and above with “optimal risk factor levels” at elevated risk. It’s a little hard for many to accept that everyone above a certain age should be on a statin, and there’s no direct evidence to back up this pretty sweeping recommendation.

Previously: Heart bypass or angioplasty? There’s an app for that, Exploring the cost-effectiveness of statin use among kidney patients, Wider statin use may be cost-effective way to prevent heart attack, stroke, New test for heart disease associated with higher rates of procedures, increased spending and Stanford researcher cautions against widespread use of statins
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The current special issue of the Journal of the American Medical Association takes the history and vitals of the U.S. health-care system’s finances. And, as NPR’s Shots blog reports, experts conclude that the cost of “drugs, hospital stays, doctors and bureaucracy” – rather than the number of diagnostic tests ordered or the size of the aging Baby Boomer population – accounts for over 90 percent of spending increases on health care since 2000.

What’s the prognosis? Maybe the large and concentrated market power of “Big Med,” says the Shots piece, borrowing the term from a JAMA analysis. But, like big airlines, the consolidation of services into fewer large bodies could produce better efficiency and safety while leading to a loss of quality in the consumer experience.

Previously: Making health care better and more affordable, The history of U.S. health care in about 1,000 words, An expert’s historical view of health care costs, Stanford expert urges physicians to take the high road in slowing health care spending and Does the Affordable Care Act address our health-cost problem?

Earlier today I testified about methamphetamine laboratories to West Virginia Governor Earl Ray Tomblin’s Advisory Council on Substance Abuse. Like more than a dozen other states in the “meth belt,” my home state is suffering from a wave of explosions, fires, burns, poisonings and environmental destruction stemming from laboratories operated by small-time “meth cooks.”  Fortunately, as I told the Advisory Council, this is a problem that we already know how to solve.

Meth cooks make their drug using pseudoephedrine (PSE), which they extract from certain cold medicines such as Sudafed. The precise proportion of these cold medicines that are purchased to produce methamphetamine is not known, but it is clearly very large. A recent study published in JAMA found that per-capita consumption of PSE-containing medicines in counties with meth labs exceeds that of counties without labs by as much as 565-to-1.

In light of this connection, the states of Oregon and Mississippi returned PSE-containing products to prescription-only status, which was how they were regulated until 1976. Meth labs have virtually disappeared in both states.

Most state legislatures in the meth belt have introduced legislation to copy Oregon and Mississippi’s approach, but these bills have all failed. Part of the reason is intense lobbying by the companies that produce PSE-containing products, but another part is that some voters and legislators believe that cold and allergy sufferers will have a hard time getting relief if a prescription for PSE-containing medications is required.

This worry is not usually well-founded, as there are more than 100 over-the-counter cold medications available which provide relief to almost all people with stuffy noses, fevers and the like. However, in the rare case of an individual who truly needs a PSE-containing medication, innovative biochemistry has come to the rescue with the development of medications that contain PSE that is harder for meth cooks to extract.

These companies created cold medications (e.g., Zephrex-D) which use polymers or lipids to bond with PSE in a fashion that reduces the possibilities for conversions to meth. Even if the possibilities for PSE extraction are reduced by only two-thirds by these new medications, meth cooks would effectively be put out of business because their required materials would exceed the value of the drug they make. Meanwhile, consumers with chronic allergies do not suffer reduced access to PSE-containing products.

The public policy option available to meth belt states is thus something that should satisfy all parties. PSE-containing cold medications would be returned to prescription-status, with an exemption for such medications that independent laboratories prove yield only a de minimus amount of PSE for meth preparation.

It’s a rare opportunity for a clear win-win in public policy. That’s why I strongly encouraged Governor Tomblin’s advisors to pursue it with courage and enthusiasm.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington. Dr. Humphreys has no financial or personal connections to any company that produces cold medications (extraction resistant or not).

Previously: Examining how addiction in the U.S. has changed over the last decade, Can an antidepressant help meth addicts stop using?, The Florida Governor’s questionable actions on drugs and Stanford Health Policy Forum focuses on America’s methamphetamine epidemic
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When it comes to pregnant women, managing abdominal pain and diagnosing appendicitis can be a tricky proposition for doctors. Current practice includes an ultrasound followed by further imaging if the diagnosis remains unclear, but some providers and patients are hesitant to use one common imaging tool – a CT scan. That’s because of its use of radiation, and its possible risk to the fetus.

Zachary Kastenberg, MD, is a general surgery resident at Stanford and reports that he and his colleagues encounter this issue relatively frequently in the emergency department. “We often find ourselves guiding expecting mothers and fathers through difficult, anxiety-provoking decisions with minimal evidence to support differing practitioner perspectives,” he recently told me, noting that acute appendicitis is the most common cause of non-obstetric surgery in pregnant women.

Kastenberg said he wanted to help “influence the management and diagnosis of abdominal pain in pregnant women and to inform practitioners regarding the relative risks of abdominal imaging and fetal radiation during pregnancy.” And so he and colleagues performed a comprehensive cost-effectiveness analysis of the diagnostic strategies for appendicitis during pregnancy. Using a computer-based model, the researchers examined the costs and short- and long-term risks of the interventions, and various quality-of-life measures across the lifetime of a cohort of 25-year-old mothers-to-be and their fetuses.

What the researchers found was that in the vast majority of cases, preoperative imaging is the most prudent choice for managing pregnant women with suspected appendicitis. They also determined that magnetic resonance imaging (MRI) – which doesn’t involve radiation – is the most cost-effective diagnostic strategy, and that CT – even when taking into consideration the potential risks of radiation-associated childhood cancer – is a cost-effective option when MRI isn’t available. The latter finding is particularly important for those hospitals (usually smaller or rural ones) that don’t have an MRI machine or access to skilled MRI interpretation at night or on weekends.

Kastenberg acknowledged that patients may still experience anxiety associated with radiation exposure. But he says he hopes the analysis “will give physicians the confidence to guide patients through an educated discussion of the risks and benefits of preoperative imaging, including CT, when confronted with this difficult clinical situation.”

Kastenberg is a post-doctoral fellow in Stanford’s Center for Health Policy and the Center for Primary Care and Outcomes Research. The research appears in the October issue of the Journal of Obstetrics and Gynecology.

Photo by Daquella Manera