THE BIG STORY: Economic Determinants of Health
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Hospitals Offer Services Moving Upstream to Address Economic Determinants of Health
The Association of American Medical Colleges (here) reports that “Recognizing that poverty can drive poor health and even shorten life expectancy, hospitals are offering a range of financial services, from tax preparation to budgeting.” One program, called StreetCred, is “part of a nationwide, academic medicine-based movement to reduce the economic strain that often fuels ill health. It involves offering financial counseling, tax preparation, and public benefit enrollment, among other services, right alongside blood pressure checks and medication assessments.”
“These programs, called medical financial partnerships (MFPs), help patients — and sometimes hospital staff and community members — navigate a variety of resources that can foster economic stability. ‘Health care has been moving its focus upstream, thinking about social determinants of health,’ says Adam Schickedanz, MD, PhD, co-director of an MFP at Harbor-UCLA Medical Center and other Los Angeles sites. “Now people are realizing that if we want to address the root causes underlying social determinants, we need to address patients’ financial situations directly.”
The AAMC noted “Extensive data highlight the connection between wealth and health. In the United States, the richest 1% of men live on average 15 years longer than the poorest 1%, and the richest 1% of women live about 10 years longer than their poorest peers. Among older individuals, those with the least wealth face a threefold risk of disability compared to those with the most. And child poverty — which disproportionately affects families of color — can undermine brain development, emotional well-being, and other health measures. This reality has spurred the uptick in MFPs. ‘Five years ago, there were just a handful of programs in the country,’ says Lucy Marcil, MD, MPH, StreetCred co-founder and executive director. ‘Today there are probably 20, and interest is growing.’”
A profile (here) of UK researcher Anna Gilmore in The Lancet focuses on the commercial health systems which have helped determine the determinants. “This is a system problem, and we need to try to understand and address it that way . . . our political and economic systems or regulatory systems have been shaped in the interest of the commercial sector rather than in the public interest.”
Kaiser-Geisinger, Atrium-Aurora, UnityPoint-Presbyterian: Cross Market Health System Consolidation Increases
A commentary in JAMA (here) notes that “Historically, prototypical consolidation involved similar-sized hospital systems merging or a larger hospital system acquiring a smaller one, with both organizations located in the same geographic area. However, over the last decade a new type of hospital system merger has become increasingly popular: a merger between hospitals located in geographically separate areas (called ‘cross-market mergers’). This may be partially because hospital markets are already very concentrated, so opportunities to scale require hospital systems to look farther.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Medicaid Work Requirements, Results and Consequences
CBO writes to Congressional leaders (here) on “the budgetary effects of work requirements for the Medicaid program, as provided in H.R. 2811, the Limit, Save, Grow Act of 2023. In the agency’s estimation, under those requirements, federal costs would decrease, the number of people without health insurance would increase, the employment status of and hours worked by Medicaid recipients would be unchanged, and state costs would increase.” The federal cost decrease, in other words, is the direct result of Medicaid beneficiaries not qualifying or not being able to work through the qualification process.
CBO says some of the States could choose to pick up the slack. “States could disenroll people who do not satisfy the requirement or they could maintain those enrollments entirely with state funds . . . CBO expects that about 15 million people could be subject to the Medicaid community engagement requirement each year . . . [and] would decrease federal spending by about $109 billion over the 2023–2033 period.”
HHS has also addressed the work requirement, as reported (here) in InsideHealthPolicy. “Only one state has ever fully implemented work reporting requirements, and nearly 1 in 4 adults subject to the policy lost their health coverage -- including working people and people with serious health conditions -- with no evidence of increased employment . . . research shows that more than 95% of enrollees subject to the policy already met the requirements or should have qualified for an exemption -- but many lost coverage because they couldn’t navigate the red tape.”
“HHS released an accompanying fact sheet showing the state and local impact the Republicans’ proposed work requirements would have on Medicaid beneficiaries’ access to coverage. California, New York, Pennsylvania and Illinois would see the most disenrollments under the proposal with more than 1 million beneficiaries’ coverage at risk in each state.”
IHP quotes Families USA Executive Director Frederick Isasi as saying, “Setting up a maze of confusing, bureaucratic red tape for people to verify their eligibility or work hours is bad for families, no matter if they vote red, blue or purple.”
DRUGS & DEVICES
Expedited Approval for Medical Devices, Direct to CMS Payment
OMB is reviewing a proposal to expedite approval of new medical devices (here), to provide Medicare payment for devices even in advance of FDA approval of device safety and effectiveness. “The upcoming proposed rule is expected to establish criteria for an expedited coverage path for breakthrough devices and build off of prior CMS initiatives . . . CMS may conduct early evidence review before a device receives FDA marketing authorization . . . Senate Finance Committee ranking Republican Mike Crapo (ID) has said one of his priorities is accelerating seniors’ access to what he dubs ‘life-saving medical breakthroughs,’ including streamlining Medicare device coverage.”
Past history does not provide comfort that the trade-off of early approval for safety has been consistently achieved, a trade-off complicated by the fact that almost half of FDA funding for premarket approval now comes from industry fees. A review in JAMA (here) of FDA approval for medical devices from 1976 (when medical devices came under FDA jurisdiction) to 2020 found “From 1987 to 2020, the annual number of novel devices granted premarket approval (which excludes supplements) ranged from 8 to 56 (median, 32), and the number of clearances for 510(k) devices (those that are substantially equivalent to marketed devices) ranged from 2804 to 5762 (median, 3404). User fee funding for devices was established in 2002 and annual fees collected increased from $30 million in 2003 (in 2019 dollars) to more than $208 million in 2019; this represented 43% of FDA funding related to the review of medical devices.”
The review concludes “Although many new devices have led to considerable patient benefit . . . important adverse events caused by some devices, such as an implanted device for birth control and a surgical mesh implant for pelvic organ prolapse [here], have led to calls to reexamine the regulatory system for such products.”
FDA regulation, moreover, has largely (but not completely, see CRS report here) pre-empted litigation rights under State law. Even with litigation, confidential settlements may prevent public knowledge of public health hazards (here). “Courts also frequently ‘seal’ documents that the parties place in the record, keeping those documents out of the public view. As an example . . . a lawsuit centered on an oxycodone hydrochloride product (OxyContin) in which Purdue Pharma ‘produced internal documents detailing how the company downplayed the drug’s risk of abuse and addiction and disregarded concerns about its abuse and diversion.’ Although disclosing these documents would have been in the public interest, a protective order prevented their release.” The ease with which the public can access even publicly filed medical device malfunction reports is compromised by FDA tactics (Kaiser Health News report, here).
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Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org
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