I am Dr Richard Isaacson, director of the Alzheimer’s Prevention Clinic at Weill Cornell Medicine and New York-Presbyterian Hospital in New York City. I want to talk about the contagion theory of Alzheimer disease. Could Alzheimer disease be caused by an infection? Some very interesting research calls into question the precise etiology of Alzheimer disease.
Physicians and scientists have been taught for decades that amyloid causes Alzheimer disease. Although that may be true, different people may take different roads to developing the disease. Some people may be on the metabolic road; for example, having diabetes increases the Alzheimer disease risk twofold.[1] What about hormones and the menopause transition? Maybe women are in the fast lane while men are sitting in traffic. These are all very interesting questions
Recently, some very exciting work has begun on the infectious theory of Alzheimer disease.[2] For example, herpesviruses are ubiquitous. Many people have herpesvirus infections, but in some people, perhaps based on epigenetics and the environmental interaction with a person’s genes, infection with the herpesvirus puts them on the fast track to Alzheimer disease.
For many years, we have thought of amyloid as the primary causative factor for Alzheimer disease. However, amyloid is also released in response to an infection in the brain. So, maybe—just maybe—that virus or another virus, or a bacteria, or another germ that has yet to be isolated, may put someone on that path to Alzheimer disease. Again, this is probably not the only cause—there may be many paths—but it is one that we need to explore.
Could Alzheimer disease be contagious? We all know about prions. Prion proteins are nonliving infectious particles that cause Creutzfeldt-Jakob, or mad cow, disease, as well as a variety of other conditions. What about Alzheimer disease? Could it be contagious? In fact, if you look at the statistics, the spouses of persons with Alzheimer disease are at a 1.6-fold risk of having the disease themselves.[3] Also, neurosurgeons are at a much higher risk for Alzheimer disease than the general population.[4] Why is this? We’re not sure yet.
The goal is to conduct more research and try to isolate the various potential causes. Could it be that in some people, an infection causes an inflammatory cascade, amyloid is released to fight the virus or bacteria, and that is what eventually leads to Alzheimer disease? The infectious hypothesis of Alzheimer disease is one that we definitely should explore and consider. Perhaps using antiviral drugs could be one way to fight the condition. Maybe using antiviral drugs early could even be a way to prevent that condition.
Gina Intinarelli is a true believer in the impact of value-based payment models. She has seen them improve the quality of care for patients while reducing spending. However, just days after the launch of a new federal bundled-payment effort, she worries that her employer, UCSF Medical Center in California, may have to walk away.
The reason: The program is structured in such a way that UCSF is starting out more than $1 million in the hole.
BPCI ROLLOUTJan. 11 : Application portal opened
March 12 : Application period closed
March-August : Applicant screening period
July: Participants reviewed CMS’ program agreement
Oct. 1 : First cohort starts
March 2019 : Participants can exit program
Spring 2019: Next application period opens
January 2020 : Second cohort begins
UCSF, where Intinarelli is executive director of population health and accountable care, is one of the hundreds of organizations that agreed to participate in the Bundled Payments for Care Improvement-Advanced model, which was the first advanced alternative payment model introduced by the Trump administration earlier this year. It launched Oct. 1. and is scheduled to run through Dec. 31, 2023.
The federal rollout was a bumpy one. The CMS was late in giving providers the claims data they needed to decide which care bundles to select under the effort. As a result, it agreed to let providers exit the model in March 2019 if they find it isn’t working for them.
The model includes 32 clinical-care episodes that providers can choose from, 29 of which are in inpatient settings and three in outpatient settings.
Providers had about two months from entering into final contracts in August to going live this month. As Intinarelli and her team started to dig deeper into the data the CMS provided and the target prices her system must meet, she made a startling discovery.
“We’re starting this at least $1 million in the hole that we would have to make up before we would ever get shared savings,” Intinarelli said.
She is trying to remain optimistic, hoping to at least break even under the model, but she is also keeping an eye on the exit just in case the outlook worsens.
BPCI ADVANCED BASICS
A single retrospective bundled payment and one risk track, with a 90-day clinical episode duration
Participants are accountable for one or more of 32 clinical-episode models—29 of which are inpatient, three are outpatient
Qualifies as an advanced alternative payment model for MIPS
Payment is tied to performance on quality measures
Preliminary target prices are provided in advance of the first performance period of each model year
Source: CMS
At issue is how the agency sets target prices. Unlike the original BPCI model, which based targets on an individual provider’s historical spending data, the new model establishes them using a far more complex methodology based on regression models, which adjust for patient case mix and spending trends at peer hospitals.
With the changes in place, the chance for rewards are high. The procedures outlined in the inpatient bundles account for more than 55%, or $70 billion, in annual Medicare spending, according to a January report from Archway Health, which assists providers with implementing bundled-payment initiatives. The model may end up saving the CMS as much as $2 billion and generate up to $15 billion of shared savings for providers.
However, there is some risk. Providers can only make money under BPCI Advanced if they keep total costs below a benchmark price, discounted by 3%. That’s a lower target price than in the current BPCI program, which includes just a 2% discount. They will be at risk for up to 20% of costs that exceed the target price.
“This resetting of targets is a race to the bottom in the sense that there isn’t enough to incentivize providers,” said Dr. Greg Sheff, chief medical officer at AccentCare, a BPCI Advanced convener and a home health and hospice provider. “I understand the desire for Medicare to push risk but at the same time you can’t create a situation where there is not enough viable opportunity.”
Jessica Walradt, program manager of value-based care at Northwestern Medicine in the Chicago area has similar concerns and is helping to lead a group of academic medical centers to lobby the CMS to address the pay issues.
As hospitals improve the care they provide under the bundles, there should be a floor on how low target prices can reach, Walradt said. Without that, they may continue to decrease at an unsustainable rate. “If there’s not a floor, then it’s going to keep moving the goal posts to such an extent that there won’t be sufficient room for providers to produce savings,” she said.
These concerns are causing providers, who previously experienced success in other Medicare bundled-payment models, to scale back or eliminate involvement in BPCI Advanced. “I think people are absolutely going to use the March off-ramp,” Walradt said.
A CMS spokesman did not return a request for comment on industry concerns.
Not everyone is worried about the target prices, with others noting that unlike the original BPCI, at least they know what their goals are. Under the last model, some providers were given initial goals, only for them to change later, according to Carter Paine, chief operating officer for naviHealth, a Brentwood, Tenn.-based convener company with more than 150 hospitals in BPCI Advanced.
Paine says the model is so attractive that around two-thirds of the hospitals his company is working with are entering into value-based care arrangements for the first time. “BPCI has been identified as this way of getting better clinical outcomes and make good money doing it,” Paine said.
Monterey, Calif.-based Montage Health is an example of a health system making its first foray into value-based care under BPCI Advanced.
Montage is the parent company of Community Hospital of the Monterey Peninsula and was drawn to the model after the CMS canceled a mandatory cardiac bundled-payment program that it had prepared to implement last year.
“We have been enhancing our ability to take on episodic risk, and the BPCI Advanced program was a natural opportunity to test those abilities,” said Matt Morgan, vice president of finance at Montage Health.
Others say they’re pleased with improvements made since the launch of the original BPCI. Those include a universal standard over how many days constitutes an episode of care, a streamlined list of bundles to choose from, and recognition that more procedures are taking place in outpatient settings.
Altarum Center for Value in Health Care’s second-quarter Health Sector Trend Report found that healthcare costs increased by 5% year-over-year in the past quarter, outpacing the first quarter (4.6%) and the overall first half of the year (4.8%).
Private payer spending has grown faster than public payers since 2016 though the difference closed slightly in the second quarter compared with the first of 2018, according to the report based on Census data.
Despite the moderate growth rate, Altarum warned several factors could accelerate cost growth, including changes to health insurance laws, an economic downturn and the impact of the aging population.
The health sector continues its stable, moderate growth in spending and hiring. Total spending on healthcare services grew at annual rates of between 4.3% and 4.8% in 2016, 2017 and the first half of 2018, the report said.
Despite the stable health costs, Altarum warned that policies that address problems like surprise billing and out-of-pocket drug costs may provide relief to consumers, but won’t tackle the long-term budgetary challenges.
The report found that healthcare price growth is under control, especially for public payers. Another recent Altarum brief said that private payer spending has grown because of higher price growth and utilization compared to Medicare and Medicaid.
Medicare spending has remained in the 4% to 4.5% range, while private payer has exceeded Medicare’s spending since 2011. Medicaid spending saw huge growth gains with Medicaid expansion taking effect in 2014 and 2015. However, that cost growth nosedived in 2016, partly because of states moving to managed care Medicaid.
The growth gap between private and payer insurers are wider when you remove the effects of enrollment growth. Private spending per enrollee increased by more than 50% since 2009 compared to about 15% for public payers.
The first quarter saw private payer spending growth spike by 7.4% in Q1 while public payer growth averaged just 2.3%. The difference in payer spending growth was closer in Q2. Private payers saw about 6% spending growth in Q2, compared to about 5% for public payers.
A major driver of healthcare spending is money spent on healthcare services. About 70% of healthcare spending comes from services. Healthcare services spending increased by 4.9% in Q2, which was more than the first quarter (4.2%). Spending growth in the quarter exceeded any quarter over the past two years though it’s still not a significant spike. Those increases are still a far cry from the 5.8% growth in 2015, which was the highest increase by far since 2010.
In two pieces of good news, healthcare price growth remains less than inflation and prescription drug costs are on the decline. Healthcare price growth was 2% in the second quarter compared to 1.75% a quarter earlier. Health price growth by quarter hasn’t exceeded 2% since 2012. That price growth has been below inflation in each of the last four quarters.
The proposed mergers of CVS Health-Aetna and Cigna-Express Scripts, as well as payers like Anthem launching their own PBM and the watershed potential of Amazon eyeing the market, may impact drug prices in the coming year.
Private insurance plans are increasingly limiting out-of-network care, especially in the individual market, according to a new Robert Wood Johnson Foundation report.
The report said that only 29% of individual plans provided out-of-network coverage compared to 58% more than three years ago. Small group market plans have cut out-of-network benefits too (64% in 2018 compared to 71% in 2015), but not as commonly as the individual market.
Payers that still offer out-of-network coverage have shifted more costs onto consumers. The individual market’s median out-of-network deductible is about $12,000. Nearly one-third of individual plans with out-of-network coverage have a deductible that’s more than $20,000. Once the deductible is met, members still have to pay more out of pocket, including co-insurance. Many individual plans don’t have maximum out-of-pocket limits for out-of-network care.
With individual market networks narrowing, patients are seeing more bills coming as a surprise.
It’s a bad scenario for both consumers and hospitals: Patients stuck with a massive unexpected bill could skip paying it altogether and leave the hospital without settling up.
A recent Kaiser Family Foundation study found that about 20% of hospital visits in large group plans wind up with an out-of-network bill. Some states are starting to target surprise billing with policy guardrails, but consumer protections are still scant. Congress is also looking at its own legislation on the matter.
Health plans in the individual market and Medicare Advantage have turned to narrow networks as a way to contain health costs. Plus, national payers, which often have broad networks, largely abandoned the ACA marketplace in 2016 and 2017. This exodus left behind Blues and payers that specialize in Medicaid managed care, which often have narrow networks and closed-network plans.
The report said that shift made out-of-network care increasingly rare in those segments.
This is particularly so in the fully insured market, but narrow networks aren’t as common in large employer plans. KFF’s recent annual Kaiser Family Foundation Employer Health Benefits Survey found that only 5% of large companies with health insurance offered a plan with a narrow network. That was a similar percentage the previous two years.
Perhaps not shockingly, health plans with narrow networks can find savings. In its study of 2015 MA plans, KFF found broad-network HMO premiums averaged $54 per month while narrow-network plans cost only $4.
Despite those potential savings, employers have on the whole avoided restricting provider access, concerned about facing employee anger when confronted with fewer care choices — especially in rural care deserts, or with patients with complicated needs.
Retail spending on prescription drugs grew by 3.4% in the second quarter, down from 3.7% in the first quarter and 4.7% for 2017, finds a new study based on data from the Census Bureau.
Overall healthcare costs increased by 5% year over year in the past quarter, outpacing the 4.6% increase seen in the first quarter and the 4.8% increase seen across first half of the year, according to the Altarum Center for Value in Health Care’s second-quarter Health Sector Trend Report.
Prescription spending growth rates may be revised down for 2017 after the Centers for Medicare and Medicaid Services adjusts for prescription drug rebates, Altarum researchers said.
Multi-thousand-dollar price tags for specialty drugs like Gilead Sciences’ Sovaldi (sofosbuvir) contributed to a spike in prescription drug spending of 12.4% in 2014. The hepatitis C treatment’s infamous $84,000 list price, along with dramatic hikes in other off-patent drugs, helped to put a national spotlight on drug prices.
Prescription spending growth has dropped since then to a 10-year low 1.3% in 2016 before rebounding to 4.7% in 2017. Average prices have been more stable, suggesting that increased use has fueled a big part of the spending.
Drugmakers often note correctly that healthcare services account for a bigger slice of overall health spending. About 9.8% of national health spending comes from prescription drugs, the report noted, while about 70% comes from services — a broad category that includes hospital, physician and clinical costs.
Healthcare services spending increased 4.9% in the second quarter, which was more than the 4.2% observed in the first quarter. Spending growth in the second quarter exceeded any quarter over the past two years, though the spike wasn’t particularly significant.
The report found healthcare price growth to be under control, especially for public payers. Another recent Altarum brief said private payer spending has grown because of higher price growth and utilization compared to Medicare and Medicaid.
Medicare spending has remained in the 4% to 4.5% range, while private payer has exceeded Medicare’s spending since 2011. Medicaid spending saw huge growth gains with Medicaid expansion taking effect in 2014 and 2015. However, that cost growth nosedived in 2016, partly because of states moving to managed care Medicaid.
Long-term oxygen therapy does not decrease the risk for hospitalizations or increase life expectancy for many patients with mild to moderate COPD, but may lower their quality of life, according to Mayo Clinic researchers published in The Journal of the American Osteopathic Association.
For decades, physicians have prescribed long-term oxygen therapy to patients with COPD based on research demonstrating that the therapy could extend their lives. However, those studies were conducted in the 1980s and were significantly flawed, according to the study authors. They note that more recent, better designed studies did not replicate the 30-year-old results.
“Throughout medicine there are practices and treatments that continue simply because they have always been done,” says Neera Agrwal, MD, PhD, a hospitalist at Mayo Clinic and co-author on this study. “But physicians have to consider new evidence and adjust accordingly, which is one of the biggest takeaways from this study.”
While there is little evidence of long term oxygen therapy’s efficacy, it definitely comes with challenges. Primarily, it is expensive, at a cost of several hundred dollars per month. Medicare is increasingly reluctant to pay for oxygen therapy, though it spends hundreds of millions on the treatment annually, according to Dr. Agrwal. Thus, many patients pay out of pocket if their physicians recommend this therapy.
Long term oxygen therapy is defined as breathing oxygen for more than 15 hours a day, for more than 90 days. It requires patients to carry a portable oxygen concentrator at virtually all times.
The most current research indicates that patients with mild to moderate hypoxemia do not benefit from oxygen therapy except in a reduced feeling of breathlessness. However, researchers say that measure is subjective and could be a placebo effect.
Also, oxygen concentrator systems typically come in a shoulder bag, weighing about 5 pounds—not an insignificant amount of weight for someone who might be frail and easily exhausted. Dr. Agrwal adds that patients often feel embarrassed or stigmatized because of the visible nasal cannula, the plastic tube channeling oxygen to the nose, which can also cause irritation and nose bleeds.
“It is a huge shortcoming of medicine that we still cannot identify which patients will benefit from oxygen therapy,” says Dr. Agrwal. “We know some definitely do but many more are likely not getting any meaningful treatment.”
The National Institutes of Health report there are nearly 15 million cases of COPD in the U.S. The NIH also suggests there could be an equal number of undiagnosed cases, effectively doubling the COPD patient population.
Researchers say the disease is linked to aging, smoking, pollution and hazardous work environments.
About The Journal of the American Osteopathic Association The Journal of the American Osteopathic Association (JAOA) is the official scientific publication of the American Osteopathic Association. Edited by Robert Orenstein, DO, it is the premier scholarly peer-reviewed publication of the osteopathic medical profession. The JAOA‘s mission is to advance medicine through the publication of peer-reviewed osteopathic research.
