Patients undergoing long-term treatment with steroids may suffer from metabolic side effects. Researchers at the Helmholtz Zentrum München and the Ludwig Maximilians University of Munich (LMU), partners in the German Center for Diabetes Research (DZD), have now pinpointed a mechanism that leads to so-called steroid diabetes. Their findings have been published in Nature Communications.
“Glucocorticoids such as cortisone have been used to treat inflammatory diseases such as asthma or rheumatism for many decades, and they are the most commonly prescribed anti-inflammatory drugs,” explains Prof. Henriette Uhlenhaut, Group Leader at the Institute for Diabetes and Obesity (IDO) at the Helmholtz Zentrum München and the Gene Center of the LMU. “They are also frequently used in autoimmune diseases, organ transplantations and cancer. It is estimated that between one and three percent of the Western population are currently receiving these drugs — which corresponds to more than one million Germans alone.”
However, although glucocorticoids are prescribed for a wide range of conditions, their use is limited by the various side effects — including unwanted metabolic effects — that can occur during treatment. Once the glucocorticoids bind to their receptor inside the cell, the receptor starts switching numerous genes on and off. “These include various metabolic genes, which can consequently cause so-called steroid diabetes,” Henriette Uhlenhaut explains.
In the current study, her team — together with colleagues from the Max Delbrück Center for Molecular Medicine in Berlin, the Salk Institute in San Diego and the University of Freiburg — set out to identify the exact sequence of events that occurs once the steroids bind their receptor.
“What struck us most was the E47 transcription factor, which — along with the glucocorticoid receptor — is responsible for the changes in gene expression, particularly in liver cells,” explains Charlotte Hemmer, a doctoral candidate at the IDO and first author of the current study. “We were able to identify the underlying pathway by conducting genome-wide analyses and genetic studies.”
In order to corroborate their findings, the scientists then proceeded to examine a preclinical model lacking the E47 gene. “The loss of E47 actually protected against the negative impact of glucocorticoids, while an intact E47 gene led to metabolic changes such as high blood sugar, elevated blood fat levels or a fatty liver as a response to steroid treatment,” Charlotte Hemmer adds.
Since the components of the newly discovered mechanism are also conserved in humans, Henriette Uhlenhaut and her team, along with their clinical cooperation partners, would now like to find out whether their results can be translated to human studies. “If this is the case, it could open up new opportunities for therapeutic intervention and the use of safer immuno-suppressants in order to combat the side effects of steroid therapy.”
M. Charlotte Hemmer, Michael Wierer, Kristina Schachtrup, Michael Downes, Norbert Hübner, Ronald M. Evans, N. Henriette Uhlenhaut. E47 modulates hepatic glucocorticoid action. Nature Communications, 2019; 10 (1) DOI: 10.1038/s41467-018-08196-5
A state of emergency was declared on Friday in the western US state of Washington following a measles outbreak that has affected more than two dozen people, the majority of them children.
The disease was declared eliminated in the US in 2000 but has since made a comeback that is tied to imported cases and the rise of the anti-vaccine movement.
“Measles is a highly contagious infectious disease that can be fatal in small children,” Washington Governor Jay Inslee said in a statement. “The existence of more than 26 confirmed cases in the state of Washington creates an extreme public health risk that may quickly spread to other counties.”
The outbreak began near Portland, Oregon, at the start of the year and quickly spread to nearby Clark County and King County, both in Washington.
Health officials have warned that people infected with the disease had visited schools, churches, a dentist’s office, a Costco store, an Ikea store and the Portland airport.
The majority of those infected are children, many of whom have not been immunized against the disease, officials said.
They added the outbreak could still be in its infancy as the incubation period of the virus averages 14 days. Those infected can spread measles to others four days before and four days after the rash appears.
The highly contagious disease can cause severe diarrhea, pneumonia and vision loss, and ultimately can be fatal.
The World Health Organization in November warned that measles cases worldwide had jumped more than 30 percent in 2017 compared to the previous year, in part because of children not being vaccinated.
– Floor-mounted digital radiography system features welcoming design and innovative technology for enhanced patient experience
– Intuitive user interface and graphical program selection can ease technologist workflow
The U.S. Food and Drug Administration (FDA) has cleared the Multix Impact, an affordably priced, floor-mounted digital radiography (DR) system from Siemens Healthineers that expands access to high-quality imaging and enhances the patient experience.
In addition to an intuitive operating system and versatile wireless detectors, the Multix Impact has a free-floating, flat tabletop for easy patient access. The touch user interface on the X-ray tube allows the technologist to remain at the patient’s side for longer periods of time, and when in the control room, the technologist can use the patient positioning camera to continuously monitor the patient, potentially reducing repeat imaging and avoiding excessive patient dose.
The system also has an intuitive user interface with graphical program selection as well as a patient positioning guide on the in-room touchscreen and control room workstation. Additionally, motorization and tracking features help to reduce the physical exertion of staff members.
“The Multix Impact offers healthcare providers advanced new technology in floor-mounted digital radiography,” said Scott Watson, Vice President of X-ray Products at Siemens Healthineers North America. “The system provides patients with greater access to state-of-the-art imaging and makes X-ray exams more comfortable, to transform care delivery while enhancing the patient experience. And the system’s highly competitive price allows more providers to deliver high-quality results and strengthen their reputation as reliable imaging partners.”
Eric Cahan and his business partners opened an art-filled cafe in Manhattan’s East Village on April 10, 2018. Ten days later, Mamacha created a CBD-laced drink to celebrate the marijuana holiday, 420.
Suddenly there was a line out the door.
Cahan and Mamacha’s other owners sensed an opportunity. They learned as much as they could about CBD, reformulated their menu and curated oils, tinctures and other products to sell in the store.
About half of Mamacha’s sales come from CBD drinks and products, with the other half coming from virgin matcha and coffee drinks. The company now plans to introduce in March a line of “functional elixirs” targeted for specific purposes like sleep, focus and anti-inflammation.
Coffee. Cocktails. Lotion. Dog treats. You name it, CBD is probably in it.
CBD, short for cannabidiol, is a compound found in the cannabis plant. It promises to deliver the calming benefits of marijuana without the high that comes from THC. Companies are adding CBD to just about everything — a trend set to accelerate as regulations ease and consumer interest grows.
Finally legal
Most CBD is now federally legal thanks to the farm bill President Donald Trump signed in December. Companies still aren’t supposed to add CBD to food, drinks and dietary supplements, but many are doing it anyway. The Food and Drug Administration has said it plans to continue enforcing this ban but will also look into creating a pathway for such products to legally enter the market.
Some users swear by it, saying it relieves their anxiety, helps them sleep and eases their pain. And forget stoner stereotypes when thinking about CBD. Moms and even pets are experimenting with it. One research firm, Brightfield Group, expects the CBD market to reach $22 billion by 2022.
However, most of our current understanding of CBD is anecdotal — not proven through scientific studies. And because CBD products aren’t yet regulated, the quality can vary widely.
“There’s a lot of interest and excitement, for good reason, but I think people are pushing it too hard, too fast and are overgeneralizing things,” said Ryan Vandrey, a professor at Johns Hopkins who studies the behavioral pharmacology of cannabis.
Clinical evidence
We don’t know what exactly CBD interacts with in the brain or the body, but researchers do know that CBD tends to turn down abnormal signaling in the brain, said Ken Mackie, a psychological and brain sciences professor at Indiana University. That’s why CBD may help with epilepsy, anxiety and sleep.
CBD and other cannabis compounds tweak systems in the body, a process he compares to lowering the volume. Other compounds, like opioids, ketamine and nicotine, simply turn them on and off.
There isn’t much clinical research on the safety and efficacy of CBD. Studying cannabis has been challenging because it’s technically illegal under federal law, meaning researchers must overcome a number of hurdles in order to study it. We don’t know anything about indications like sleep, anxiety or pain, Vandrey said.
We do know it’s safe and effective in treating seizures in children with Lennox-Gastaut syndrome or Dravet syndrome. GW Pharmastudied its CBD-derived drug, Epidiolex, in numerous clinical trials. After reviewing the company’s science, the Food and Drug Administrationapproved Epidiolex in June.
The lack of clinical evidence hasn’t stopped consumers from trying it — and raving about it.
“It’s always nice to have strong proof in placebo controlled trials, but if someone’s taking a drug and feeling any benefit, more power to them,” Mackie said.
We tried CBD-infused cocktails and we couldn’t tell the difference
CBD 101
The Alchemist’s Kitchen in Manhattan’s East Village hosted a CBD 101 class for about a dozen adults in December.
After covering the basics, instructor, Zach Clancy, asked for any questions.
“What’s the modern history?” “Why has it been popular in the last few years?” “What’s a safe dosage?” “What’s the safest way to extract it?” “Will it treat my arthritis?”
One attendee said she first tried CBD in California earlier in the year. She said she struggles to fall and stay asleep, but the CBD helped her with both issues. She declined to be named, citing the compound’s still-taboo reputation.
The farm bill signed in December legalized hemp. Most CBD hitting shelves is derived from the hemp plant, which contains less than 0.3 percent THC, the psychoactive chemical in weed. Hemp’s close cousin, marijuana, can contain upwards of 10 percent THC.
So you can’t get high from CBD products if the proper dosage is followed, but the industry isn’t regulated on a federal level so the amount of THC can vary.
Doses can vary, too. Some shops recommend six milligrams of CBD when taken as a tincture or added to food. Others recommend at least 30. Again, since there isn’t much clinical research on CBD, most of the recommendations are based on trial and error.
As more people dabble with CBD, more people are following the money, worrying some that bad products will enter the market and taint CBD’s allure. Or worse, harm consumers.
“There does need to be some sort of regulatory framework for overall product safety and to protect the customer from purchasing products that contain false advertisements or make unsubstantiated claims,” said Pamela Hadfield, co-founder of HelloMD, a medical cannabis company, while cautioning against strict regulations that would be “too difficult for most manufacturers to comply.”
Trendy right now
Joe Masse, beverage director at The Woodstock bar, added a CBD cocktail to the menu in September. Called The White Rabbit, the drink is made with Bombay Dry Gin, sage simple syrup, honey, fresh lemon juice and 1 milligram of CBD oil.
At first, Masse said he was nervous about putting it on the menu. He worked with a nearby pharmacy that carries CBD oil. Now, the drink is “by far” the bar’s best-selling gin cocktail. He hasn’t yet decided whether he’ll add the oil to any future drinks.
“It’s trendy right now, so I don’t know how it will be in six months when we redo the menu,” Masse said. “A year ago, activated charcoal was popular and now you can’t find it anywhere.”
Loneliness is part of the human condition. A primeval warning sign, like hunger or thirst, to seek out a primary resource: connection. Millions of years of evolution have shaped us into creatures who need social bonds in the same way that we need food and water.
And yet we increasingly find ourselves isolated. Loneliness is no longer a powerful enough driver to break us out of the silos created by modern life. Like our insatiable love of high-calorie foods, what was once an adaptive tool has become so misaligned with the way we live that it’s causing, in the words of the former surgeon general Vivek H Murthy, an “epidemic”.
It’s hard to compare our collective loneliness against that of previous generations, as we simply haven’t been measuring it consistently, but recent estimates suggest that anywhere from 22% to 75% of American adults are persistently lonely. A number of culture-wide structural changes might be to blame: more Americans live alone than ever before; fewer of us are marrying or having children; our average household size is shrinking. In many cases, these changes represent the availability of options where once the only accepted path was marriage and a nuclear family. But they also mean we are spending more time on our own. “Western societies have demoted human gregariousness from a necessity to an incidental,” writes John Cacioppo, a neuroscientist who studied social pain and passed away in March 2018, in his bookLoneliness.
The trouble is that chronic loneliness doesn’t just make you feel terrible – it’s also terrible for you. Loneliness elevates our risk of developing a range of disorders, including cardiovascular disease, neurodegenerative diseases, cognitive decline, and metastatic cancer. It also weakens the immune system, making us more susceptible to infections. Left untended, even situational loneliness can ossify into a fixed state that changes brain structures and processes, says Stephanie Cacioppo, director of the Brain Dynamics Lab at the University of Chicago Pritzker School of Medicine. She is also John Cacioppo’s widow and was his research partner up until his death last year.
As a scientist, Stephanie Cacioppo has often viewed her life as an experiment. When John died, the practical elements of their joint research took on an urgent personal relevance.
People sometimes compare social loss to physical pain, but Stephanie finds the analogy inaccurate. After John’s death, she went on long runs, pushing herself in near-freezing temperatures until her muscles and lungs screamed. “I could handle the pain because I knew it would have an end,” she says. “The physical pain associated with running was less intense than the deep, heartfelt emotional pain of the loss of the love of my life.”
Stephanie says she’s now relying on many of the social fitness exercises that the couple validated together, such as making an effort to express gratitude, doing something nice for someone else without expecting something in return, choosing to engage with strangers, and sharing good news with others. “I am living proof of my science,” she says. “I apply it every day.”
Unlike depression and anxiety, loneliness has no recognized clinical form; there is no available diagnosis or treatment for feeling chronically isolated.She has also found relief in her work and in continuing her husband’s legacy: “If you have a sense of worth and life with a purpose, you will feel less lonely,” Stephanie says. Today, that means continuing a body of research that she and her late husband were beginning to explore: a pill for loneliness.
It’s less science fiction than it sounds. A number of clinical trials – led by Stephanie and others – are already under way, targeting the ways in which chronic loneliness changes the brain, as well as the havoc it unleashes on the nervous system. If there are pharmacological treatments for other social pains like depression and anxiety, why not loneliness?
Like depression and anxiety, loneliness is a universal part of the human experience. Unlike depression and anxiety, loneliness has no recognized clinical form; there is no available diagnosis or treatment for feeling chronically isolated.
Ellen Hendriksen, a clinical psychologist who specializes in anxiety, envisions a future in which that’s no longer the case. Currently, social anxiety is considered a disorder only when it causes enough distress or impairment to interfere with a person’s life. She can see the same distinction working for loneliness: “Maybe we’ll call this social isolation syndrome,” Hendriksen suggests, adding that she thinks many of her patients would fit the criteria. Some people tell her that she’s the only person they interact with for an extended period of time during the week.
Loneliness, according to Stephanie Cacioppo, is the result of biological signals that push us to reach out to others interacting with a dysfunctional mind that perceives social danger everywhere. She’s focused on a promising intervention: a neurosteroid called pregnenolone, which has been shown to improve stress-related disorders and ease the hypervigilance in the brain that arises when a person is exposed to social threats. Cacioppo’s goal is not to make people stop feeling lonely altogether, but to interfere with the ways loneliness affects the brain and body.
When mice are socially isolated, their levels of pregnenolone decrease, a shift that also occurs in lonely humans. In a 2013 study of 31 healthy people, another research team found that giving people oral doses of a compound called allopregnanolone – derived from pregnenolone – had a calming effect on the participants’ amygdala and insula, which are the regions of the brain responsible for threat detection, emotional recall, and the anticipation of unpleasant reactions.
The Cacioppos started focusing on pregnenolone and allopregnanolone after preclinical trials showed that the compound could counteract some of the loneliness-related biological changes in brain and was well-tolerated in humans. Some antidepressants provide a similar effect but come with undesirable side effects, like drowsiness, nausea, and insomnia.
“If we could successfully reduce the alarm system in the minds of lonely individuals, then we could have them reconnect, rather than withdraw from others,” Stephanie says.
That’s the basis for her most recent study, in which researchers administered 400mg oral doses of pregnenolone to lonely but otherwise healthy individuals. The trial ran from May 2017 to June 2019; Stephanie and her team are now in the process of analyzing the data. She’s cautiously optimistic that the results will show significantly reduced perceived loneliness among the people who received pregnenolone versus those who received a placebo. “I’m interested in the effect size of what we are going to find,” she says.
A 2016 review of pharmacological treatments co-authored by the Cacioppos explored the possibility of giving people the hormone oxytocin to combat chronic loneliness. Associated with breastfeeding, giving birth, and physical contact, the release of oxytocin in humans has been shown to “promote pro-social behaviors, affiliation, and trust”, the authors wrote.
Meanwhile, Steve Cole, a professor of medicine, psychiatry, and behavioral sciences at the UCLA School of Medicine who has frequently collaborated with the Cacioppos, is exploring how to mitigate the way loneliness makes the body susceptible to a host of diseases. Beta blockers, heart medications developed in the 1960s, inhibit the body’s response to adrenaline and may also “turn out to be great at disconnecting the psychological experience of social threat and uncertainty from its biological consequences in the periphery”, Cole says. “Even if we can’t stop loneliness with a brain-targeted drug, we might still be able to protect lonely people from the adverse health consequences.”
Cole is hoping to validate the drug’s ability to reduce the impact of stress on the body. At the moment, he is studying the impact of beta blockers on cancer patients, as stress has been shown to exacerbate the spread of the disease. If it is effective, there’s reason to believe beta blockers could alleviate the destructive biological consequences of loneliness.
Given all the ways modern life is designed to make us feel untethered, how do we determine who needs a medical intervention versus who is simply in a social rut?
Just as thirst is a signal that you are dehydrated, loneliness is an indication that you are already suffering from a lack of connection, Stephanie Cacioppo tells me. It’s true that many of us manage to pull ourselves out of a lonely funk, but she argues that we could still benefit from a pharmacological intervention to prevent descent into social isolation.
The vast majority of people experience loneliness in their lives. I ask her: does this mean all of us could benefit from such a treatment?
“Absolutely,” she says.
If that makes you uncomfortable, you’re not alone. “I think we should be cautious about thinking of this as a disorder, and rather thinking about it instead as something that we all need: social connection,” says Julianne Holt-Lunstad, a psychologist at Brigham Young University who has studied social isolation. For many people, it’s perhaps more helpful to view social connection as an integral part of our physical and emotional health, which can be improved through lifestyle adjustments.
I think about what makes us lonely on a recent subway ride from Brooklyn to Manhattan. As the train hurtles over the Manhattan Bridge, the subway car is silent, save for the muffled beats of a pop song. A woman up front is reading a book, and a few commuters are dozing. The rest of us are glued to our devices: heads bent, earbuds in, fingers scrolling. The trains sputters and then stops completely mid-bridge; plugged into our own curated digital landscapes, no one looks up. What was once a period of contemplation, boredom, small talk, confrontations, maybe even some light flirting, has been replaced by screens.
In addition to filling the blank spaces in our day, our phones double as a crutch to “lean on when we are socially anxious or uncomfortable”, says Julia Bainbridge, a freelance writer and editor, who, in 2016, launched The Lonely Hour, a podcast dedicated to exploring the condition. The world is unpredictable, but our screens provide a convenient buffer against the possibility of spontaneous human interaction. Waiting for class to begin or for a friend at a bar? Instead of striking up a conversation with the person next to you and risking awkwardness, it’s easier to simply look down at your screen.
Individually, these moments are innocuous, but Bainbridge worries about their collective weight. “Living is hard sometimes,” she says. “It puts us up for the possibility of rejection, but putting yourself up for that, engaging in that way, is part of a really important piece of human development.”
Technology has sanded away the necessity and inconvenience of interacting with other human beings: we can work from home, order groceries online, stream movies from bed. At the same time, the percentage of Americans who participate in social groups – whether they be social clubs, sports teams, community centers, volunteer organizations, or religious groups – has fallen, Holt-Lunstad says.
In a dizzying number of ways, modern life is designed to disengage us from one another.And with such obvious barriers to connection, it may not seem worthwhile to pursue a pharmaceutical solution. “We are such a medicated, comfortably numb society,” Bainbridge says. In her own life, she sees loneliness not as a problem to be fixed, but a complicated, ambivalent state that adds depth to the experience of being a social creature in a fragmented world.
At least for now, there remain nonpharmacological strategies to rely on. If you’re feeling the pain of social isolation but have a support system, it can pay to tell the people closest to you what you need. Last spring was a particularly lonely time for Bainbridge. She had recently moved from New York City, where she had a solid group of friends, to Atlanta, where she knew virtually no one. And so she requested a favor from her mom. The ask was simple: text her every day in the morning with an update, question, or random thought. The content mattered less than the act itself. “It really helped me,” she says. To this day, her mom still texts every morning.
Actively searching for meaning in your life, whether it’s by joining a volunteer organization, movement, or religious group, also helps. It’s less about meeting other people, at least at first, and more about finding purpose and taking part in something larger than yourself, Cole says. “Self-focus promotes negative emotional states,” while there is robust evidence that the “neurobiology of helping others is one of the most rewarding things a brain can do”.
Stephanie Cacioppo has found a larger purpose in advancing the work she started with John. She recently heard a quote that has stuck with her: “Mozart didn’t die; he became music,” she says. “I believe my husband didn’t die; he became theory. I am applying his theory.”
In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In the UK, Samaritans can be contacted on 116 123. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found here
Ascension, the nation’s largest nonprofit hospital operator, eliminated three executive positions in an attempt to create a “flatter” organization, the company’s CEO Anthony Tersigni said in a statement Tuesday.
Part of the restructuring includes erasing the line between its healthcare and solutions divisions. Many of Ascension’s subsidiaries were organized under the solutions division while its healthcare delivery arm operated under its own umbrella. The realignment, effective immediately, is meant to eliminate silos and improve efficiencies, according to the statement.
Effective July 1, Ascension will eliminate three executive positions: CEO of the healthcare division, CEO of Ascension Holdings and Ascension’s chief clinical officer. Pat Maryland, John Doyle and David Pryor held those roles, respectively. Joseph Impicciche will take on the newly created role of chief operating officer. Impicciche currently serves as general counsel.
The reorganization comes as Ascension moves in a new strategic direction, shifting its focus from inpatient care on its 151 hospital campuses to improving the overall health of its communities through quick and easy access points.
The industry has seen a decline in inpatient admissions over time as more care is delivered outside the walls of a traditional hospital. The system reported declines in key inpatient categories during the first quarter of fiscal year 2019 while noting an uptick in outpatient services. Outpatient services now represents 53% of the system’s overall patient revenue, another illustration of the shift from inpatient to outpatient.
At the same time, non-traditional vendors are threatening to shake up the status quo and siphoning patients away from traditional players like Ascension by providing care faster and cheaper at retail locations.
But Ascension’s new strategic direction came with eliminating positions and cutting millions in costs from its budget. The nonprofit has also faced pushback in D.C. for announcing plans to essentially close its 283-bed hospital. Only limited services will remain as it pivots away from acute care services to population health. After a backlash, Ascension agreed to leave the ER open until April.
The system’s income from operations increased dramatically from $11.5 million during the prior-year period to $36.4 million for the most recent quarter ended Sept. 30.
Providers participating in Medicare’s voluntary bundled payment models often drop out when forced to assume downside risk, according to a new Government Accountability Office report.
Groups did a risk-benefit analysis when deciding to participate in voluntary episode-based payment models in the first place, but when they entered the phase where they face financial penalties for failing to cut costs while providing high-quality care, they were more likely to leave the model altogether, GAO found. Just 39% of hospitals participating in the second iteration of the Bundled Payments for Care Improvement model remained in after crossing that line.
GAO compiled the report from CMS data and stakeholder interviews in response to a request from Sen. Ron Wyden, D-Ore., ranking member of the Senate Finance Committee, in December.
A major focus of the Trump administration’s healthcare agenda has been cost-cutting, whether it be pharmaceutical spending, reducing user fees in the ACA exchanges or, in this case, alternatives to traditional Medicare payments.
HHS Secretary Alex Azar announced in November that the agency was taking a more serious look at mandatory payment models, especially for radiation oncology and cardiac care, though it hasn’t issued anything concrete yet.
This was an about-face for an administration that in 2017 reduced the scope of the Comprehensive Care for Joint Replacement Model (CJR) and halted the launch of other mandatory bundled payment models before they could begin.
But CMS has either tested or is testing six bundled payment models: four versions of Bundled Payments for Care Improvement, the Oncology Care and the CJR models.
Rather than paying providers based on the amount or complexity of service, CMS establishes a target payment amount that encapsulates the total cost of the health “event,” such as a surgery or hospitalization, for a Medicare beneficiary.
Providers that can supply that high-quality service without going over that target get to keep the extra dollars left over.
But provider participation in all but one of the six bundled payment models CMS is currently testing is completely voluntary, with 2016’s ongoing CJR model the only one where 67 hospitals were forced to participate (reduced to 34 in 2017 and none forced in 2018).
In models with upside risk, providers are rewarded financially for keeping spending below the target. In models with downside risk, providers are penalized with reduced payments or other punishments for exceeding the target or not meeting care quality benchmarks.
Stakeholders interviewed by the GAO say the mandatory nature allows the agency to reap data from a more diverse panel of participants for evaluation. Another potential benefit is that participants can’t exit if they get antsy, which is relatively common in voluntary models.
In 2018, when the CJR model became voluntary, all of the eligible safety-net hospitals left the program — save two.
Voluntary models allow CMS to test novel concepts among early adopters without a lot of pressure, GAO found. But such models largely favor participants more as CMS is incentivized to make the models attractive to entice participation, and they can bounce whenever they stop performing well.
GAO also pointed out that CMS must risk-adjust the target prices providers receive to account for differences in health among patient populations. This could cause participating hospitals to eschew sicker patients for healthier ones, a common fear among critics of mandatory APMs.
But two JAMA studies in 2018 cast doubt on that theory and showed bundled payment models resulted in better quality of patient care and lowered unsustainable costs.
GAO also found provider groups participating in the six bundled payment models had larger practices, more beds and higher episode volume on average, and were more likely to be located in urban areas.
