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Saturday, July 20, 2019

UnitedHealth’s political and financial heft just keeps growing

UnitedHealth Group’s stock fell 2.3% yesterday even though the company continues to print money and raised its profit projections for the rest of the year.
The big picture: Wall Street is quibbling over the “quality” of UnitedHealth’s earnings beat, but that doesn’t really matter. UnitedHealth remains the most financially powerful private entity in the U.S. health care system, and any reforms would be up against its growing empire.
By the numbers: UnitedHealth is not just a health insurance company, but that is still its biggest component.
  • 39 million people had full-scale medical coverage through UnitedHealthcare as of June 30. About two-thirds of its insurance premium revenue comes from government programs.
  • UnitedHealth continues to expand OptumRx, which is part of the pharmacy benefits triumvirate that controls how prescription drugs are paid for.
  • Perhaps most importantly, UnitedHealth increasingly is becoming your surgeon or doctor, and now it’s taking over back-end operations for hospitals.
Why it matters: Because UnitedHealth touches almost every part of the health care system, it has every incentive to keep certain policies as they are or push for reforms that benefit its shareholders.
  • UnitedHealth retains 9 outside lobbying firms in addition to its own stable of state and federal lobbyists.
  • On the federal level, they have aggressively worked to eliminate the Affordable Care Act’s tax on health insurers, won the battle over the drug rebate rule and have pushed for other things like expanding short-term plans.
  • UnitedHealth is also part of the national coalition to kill “Medicare for All” and actively denounced Medicare for All earlier this year.
The bottom line: Wall Street’s reactions shouldn’t obscure just how much power UnitedHealth Group has and continues to accumulate.
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Frequent Sleeping Pill Use Linked to Increased Dementia Risk

Frequent use of sleep medications may increase the risk of future cognitive impairment, new research suggests.
Investigators Yue Leng, PhD, and Kristine Yaffe, MD, University of California, San Francisco, found that older adults who reported taking sleep medications often were more than 40% more likely to develop dementia over 15 years than their peers who rarely, or never, took sleeping pills.
“While we don’t know the exact mechanism underlying this association, we hope this research will raise caution among clinicians when prescribing sleep medications to those at high risk for dementia,” said Leng.
She reported the results during a press briefing here at the Alzheimer’s Association International Conference (AAIC) 2019.

Frequently Prescribed Meds

“Sleeping pills are one of the most frequently prescribed medications in the US among older adults. It’s estimated that 1 in every 5 older adults takes sleep medications regularly,” said Leng.
“Surprisingly, the effects of sleep medication use in older adults is poorly understood. Most previous research has focused on short-term adverse events related to use of sleep medications, such as increased risk of falls or increased risk of short-term memory loss. The long-term effects of sleep medication use on cognition is unclear,” Leng noted.
To evaluate ties between sleep medication use and dementia risk, Leng and colleagues examined 3068 black and white community-dwelling older adults without dementia aged 70 to 79 years from the Health, Aging, and Body Composition (Health ABC) study. Participants reported sleep medication use in 1997–1998 and were followed until 2013.
A total of 147 (4.8%) participants reported taking sleep medications “sometimes” (2 to 4 times per month), and 172 (5.6%) reported taking sleep medications “often” (5 to 15 times monthly) or “almost always” (16 to 30 times monthly).
Whites were more likely than blacks to report taking sleep medications “often” or “almost always” (8% vs 3%).  More frequent users were also more likely to be women and have a history of coronary heart disease and depression.
Older adults who reported taking sleep medications “often” or “almost always” were 43% more likely to develop dementia than those who never or rarely used sleep medications (hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.01 – 2.02).
White participants reporting frequent use had a 79% higher dementia risk (HR, 1.79; 95% CI, 1.21 – 2.66). There was no association in blacks (HR = 0.84; 95% CI, 0.38 – 1.83). The association did not differ by sex.
The associations were independent of age, sex, education, socioeconomic status, smoking, alcohol use, body mass index, depressive symptoms, physical activity, comorbidities, APOE 4 genotype and sleep disturbances.

No Cause and Effect

“The use of sleep medication may be a risk factor for later cognitive impairment,” said briefing moderator David Knopman, MD, a clinical neurologist at the Mayo Clinic in Rochester, Minnesota, and member of the Alzheimer’s Association Medical and Scientific Advisory Group.
“Over the lifespan, sleep is clearly a marker of brain health and health generally. Whether sleep is directly related to AD [through] excess accumulation of beta-amyloid and tau proteins, or whether it’s a marker of more general nonspecific health, is something that is a very active area of research,” said Knopman.
While the study shows an association between the use of sleep medications and subsequent cognitive impairment, it does not show causality, he cautioned.
“One cannot say from the study that sleep medication causes future cognitive impairment,” said Knopman. Gaining a better understanding of the mechanisms for this association is a “key issue for future research.”
Support for this research was provided by the National Institute on Aging, the Global Brain Health Institute, the Alzheimer’s Association, and the Alzheimer’s Society. Leng and Knopman have disclosed no relevant financial relationships.
Alzheimer’s Association International Conference (AAIC) 2019: Abstract P2-617. Presented July 15, 2019.
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At-Home Support Intervention Helps Stroke Patients After Hospital Discharge

For stroke patients, an intervention that combines social worker–led case management (SWCM) with access to online stroke-related information facilitates enhanced quality of life and confidence following hospital discharge. The findings of this Michigan State University study were published in Circulation: Cardiovascular Quality and Outcomes.
“These (stroke) patients get great care when they’re in the hospital, but once they get home, they’re often lost,” said Michele Fritz, an epidemiologist and co-author, who worked with lead author Mathew Reeves in MSU’s Department of Epidemiology and Biostatistics in a press release about the study. “It was important for us to really understand what mattered to them and then figure out what kind of support structure could alleviate the worry.”
In this study, called the Michigan Stroke Transitions Trial (MISTT), the research team allocated 265 patients with stroke into three treatment groups: group-1 was given usual care, group-2 comprised social worker–led case management (SWCM), which provided both in-home and phone based case management resources, and group-3 combined SWCM with access to the MISTT website, which provided patient-oriented information on stroke education, prevention, recovery, and community resources. Participants in both intervention cohorts were supplied with resources for up to 90 days. They collected outcome data were by telephone at one week and 90 days. Key outcomes in this study Primary included Patient-Reported Outcomes Measurement Information System Global-10 Quality-of-Life (Physical and Mental Health subscales) and the Patient Activation Measure. The researchers discerned treatment efficacy by comparing the change in average response (90 days minus 7 days) between the three treatment cohorts using a group-by-time interaction. Subjects were aged 66 years on average, 49% were female, 21% nonwhite, and 86% had ischemic stroke.

More Resources Help

Following analysis, the study findings showed statistically significant changes in Patient-Reported Outcomes Measurement Information System Physical Health (P=0.003) as well as Patient Activation Measure (P=0.042). However, there were no notable changes found with respect to Mental Health (P=0.56). The study found that the average change in Patient-Reported Outcomes Measurement Information System Physical Health scores for group-3 were perceptibly higher when juxtaposed to both group-2 (SWCM; difference, +2.4; 95% CI, 0.46–4.34; P=0.02) and group-1 (usual care; difference, +3.4; 95% CI, 1.41–5.33; P<0.001). Moreover, the findings revealed mean change in Patient Activation Measure scores for group-3 was significantly higher than group-2 (+6.7; 95% CI, 1.26–12.08; P=0.02) and marginally higher than group-1 (+5.0; 95% CI, −0.47 to 10.52; P=0.07).
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Sharon Stone Gets Candid About Life After Stroke


Sharon Stone
Sharon Stone is back. And after famously serving as amfAR’s Global Campaign Chair for 15 years, she’s taken on a new role as advocate for brain-aging diseases that disproportionally affect women. Only one third of Alzheimers patients are men, for instance. And don’t even get Stone started on strokes. “This is why I do it: My mother had a stroke. My grandmother had a stroke. I had a massive stroke — and a nine-day brain bleed,” she told Variety at an event she hosted to raise awareness for the Women’s Brain Health Initiative in West Hollywood on Wednesday night.
They say that Hollywood loves a comeback but unfortunately, that has not been Stone’s experience. “People treated me in a way that was brutally unkind,” she said. And she wasn’t referring to men (other than perhaps her ex-husband Phil Bronstein). “From other women in my own business to the female judge who handled my custody case, I don’t think anyone grasps how dangerous a stroke is for women and what it takes to recover — it took me about seven years.”

During that time, Stone suffered insurmountable losses, both professional and personal: “[From] trying to keep custody of my son to just functioning — to be able to work at all,” Stone added. “I was so grateful to [LVMH head and now the second-richest person in the world] Bernard Arnault, who rescued me by giving me a Dior contract. But I had to remortgage my house. I lost everything I had. I lost my place in the business. I was like the hottest movie star, you know?” she said, her voice trailing off. “It was like Miss Princess Diana and I were so famous — and she died and I had a stroke. And we were forgotten.”

But what Stone wants people to remember is her potentially life-saving advice: “if you have a really bad headache, you need to go to the hospital,” she said. “I didn’t get to the hospital until day three or four of my stroke. Most people die. I had a 1% chance of living by the time I got surgery — and they wouldn’t know for a month if I would live.” At the time, Stone wasn’t even aware of how dire her chances for survival were. “No one told me — I read it in a magazine,” she added.
The sister of “Dr. Quinn, Medicine Woman” was another one of the lucky survivors of a brain aneurysm. “She had a massive headache and collapsed,” Jane Seymour told Variety. “She was not expected to live, and they had to close down [the set of] ‘Dr. Quinn.’ I was by her bedside the whole time. But she managed to relearn how to walk, talk and she’s good now. We call her the miracle.”
Even though Stone didn’t initially feel any love from the sisterhood, she was certainly surrounded by admirers on this night. Andie MacDowell, Kelly Lynch, Garcelle Beauvais and Rumer Willis were among the actresses who turned out to show their support at celebrity florist Eric Buterbaugh’s galley. And as far as they’re concerned, Stone is still a hot movie star. “I’ve known Sharon a long time and she is truly powerful woman,” Broadway and film producer Paula Wagner told Variety. “Whatever she undertakes, she does it with great strength and intelligence and brings awareness to it. So it’s wonderful that she is bringing this story openly and honestly. She inspires me.”
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Routine blood tests could predict diabetes

Random plasma glucose tests could be used to predict which patients will develop diabetes, according to a study of Veterans Affairs treatment data. Researchers from several VA systems showed that levels of glucose found during standard outpatient medical testing revealed patients’ likelihood of developing diabetes over the next five years, even when glucose levels did not rise to the level of diabetes diagnosis.
The findings could lead to earlier treatment and better outcomes. The research shows that glucose levels that normally would not be seen as indicating diabetes risk can in fact predict the disease’s development. According to the researchers, using plasma glucose levels in blood samples taken during regular doctor visits “could signal the need for further testing, allow preventive intervention in high risk individuals before onset of disease, and lead to earlier identification of diabetes.”
The results appear in the July 19, 2019, issue of PLOS ONE.
Diabetes is a major health problem in the United States, yet over 7 million Americans with diabetes go undiagnosed, according to the Centers for Disease Control and Prevention. Early diagnosis allows the use of lifestyle changes or medications that could help prevent or delay the progression from prediabetes to diabetes and help keep diabetes from worsening. When diagnosis is delayed, diabetes-related complications could develop before treatment starts.
“Although screening for prediabetes and diabetes could permit earlier detection and treatment, many in the at-risk population do not receive the necessary screening,” notes Dr. Mary Rhee, lead author on the study and a physician-researcher with the Atlanta VA Health Care System and Emory University.
The American Diabetes Association recommends testing for diabetes using a few different methods: a fasting glucose level, an oral glucose tolerance test (which requires fasting and ingestion of a glucose load), a HgbA1c level (a measure of average blood glucose levels over the previous two to three months), or a random plasma glucose when accompanied by symptoms caused by high glucose levels. A random plasma glucose of 200 mg/dL (milligrams per deciliter) or higher is usually the threshold for a diagnosis of diabetes. It can be done at any time, and does not require fasting or withholding meals.
These tests are frequently included in routine labwork patients undergo during or after outpatient medical appointments. However, since many patients are not fasting when they get their blood drawn, routine blood tests with random glucose levels below 200 mg/dL have not previously been deemed useful for diabetes screening.
VA researchers examined data on these routine blood tests to see whether random plasma glucose levels could in fact predict which patients would develop diabetes in the future. They studied data on more than 900,000 VA patients who were not already diagnosed with diabetes. All patients had at least three random plasma glucose tests during a single year. Most of these tests were likely obtained “opportunistically”–that is, during regular doctor visits not specifically related to diabetes screening.
Over a five-year follow-up, about 10% of the total study group developed diabetes. Elevated random plasma glucose levels, though not meeting the diagnostic threshold for diabetes, accurately predicted the development of diabetes within the following five years. Patients with at least two random plasma glucose measurements of 115 mg/dL or higher within a 12-month period were highly likely to be diagnosed with diabetes within a few years. Glucose levels of 130 mg/dL or higher were even more predictive of diabetes.
As expected, demographics and risk factors known to be related to diabetes also predicted development of the disease. Demographic factors included age, sex, and race. Other risk factors that predicted diabetes included a high body mass index (BMI), smoking, and high cholesterol. However, random plasma glucose tests were stronger predictors of diabetes than demographics or other risk factors, alone or combined.
Development of diabetes was infrequent in subjects whose highest random plasma glucose levels were below 110 mg/dL.
In light of these findings, the researchers recommend that patients receive follow-up diagnostic testing for diabetes, such as a fasting glucose or A1c test, if they have two random glucose tests showing levels 115 mg/dL or higher. This approach would very likely be cost-effective, they say, because clinicians can use testing that is already being done during routine outpatient visits. Using random glucose levels for screening could identify patients at higher risk for diabetes, leading to earlier intervention to prevent or control the disease.
“These findings have the potential to impact care in the VA and in the general U.S. population,” explains Rhee, “as random plasma glucose levels–which are convenient, low-cost, and ‘opportunistic’–could appropriately prompt high-yield, focused diagnostic testing and improve recognition and treatment of prediabetes and early diabetes.”
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The study included VA researchers from three VA health care systems: Atlanta, Boston, and Eastern Colorado. Members of the team were also affiliated with Emory University, the University of Colorado, Brigham and Women’s Hospital, Harvard Medical School, and Boston University. The research was funded by VA Clinical Science Research and Development.
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Private practice physicians less likely to maintain electronic records

Modernizing health records by making them electronic has gained momentum as technology evolves and policies push health care toward digital solutions. But the same trend has not been evident for physicians who remain in private practice, new research finds.
The research led by Jordan Everson, PhD, assistant professor in the Department of Health Policy at Vanderbilt University Medical Center (VUMC), finds striking differences in use of electronic health records (EHRs) among more than 291,000 physicians included in the study.
Forty-nine percent of physicians who had remained independent since 2011 and were surveyed in the study attested to Meaningful Use of EHRs, such as electronic prescribing of medications and online patient portals — at least once. In contrast, 70% of doctors in both group practices and working for hospitals during the study’s timeline attested to meaningful use.
Meaningful Use of EHRs was first defined in 2009 by the America Reinvestment & Recovery Act, and financial incentives were offered to physicians and health systems that serve Medicare and Medicaid patients. The program was voluntary, and after 2015 the Centers for Medicare and Medicaid Services (CMS) began reducing payments to providers if there was no expansion in adoption of EHR Meaningful Use practices.
Everson said this can be interpreted in several ways. One is independent doctors have more authority over the technology they use and could simply choose not to continue in the program as opposed to doctors in integrated systems where management could require participation.
“Another way to interpret this is that the cost-benefit equation was worse for independent physicians,” Everson said. “In other words, the financial incentives in later years were not enough to overcome the cost of keeping up with Meaningful Use in addition to the time burden of using EHRs. Financial costs are likely particularly high for independent physicians who can’t spread the cost across a large organization.”
About half of independent physicians who participated in the EHR incentive program in the first years — 2011 through 2013 — left the program by 2015. In the same time frame, less than 20% of physicians who worked for hospitals left the program.
The study highlights other possible factors in this trend, such as an aging independent physician population that is retiring in greater numbers.
And while doctors have been moving into larger, integrated health practices for decades as the U.S. health system has grown more complex, that option might not be available for physicians that haven’t kept up with new technologies. The study showed that independent physicians who participated in Meaningful Use on their own were more likely to later join integrated systems than physicians who did not participate.
“That may mean that physicians who are not technologically savvy do not have the option to join a bigger system to get help with new technologies,” Everson said.
Everson’s research, conducted with Melinda Buntin, PhD, Mike Curb Chair of Health Policy at Vanderbilt, and Michael Richards, MD, PhD, an associate professor at Baylor, is the most recent in a number of studies that have illustrated challenges faced by independent practices in adopting new and costly technology, or what many clinicians describe as physician burnout with electronic records.
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Take a bath 90 minutes before bedtime to get better sleep

Biomedical engineers at The University of Texas at Austin may have found a way for people to get better shuteye. Systematic review protocols — a method used to search for and analyze relevant data — allowed researchers to analyze thousands of studies linking water-based passive body heating, or bathing and showering with warm/hot water, with improved sleep quality. Researchers in the Cockrell School of Engineering found that bathing 1-2 hours before bedtime in water of about 104-109 degrees Fahrenheit can significantly improve your sleep.
“When we looked through all known studies, we noticed significant disparities in terms of the approaches and findings,” said Shahab Haghayegh, a Ph.D. candidate in the Department of Biomedical Engineering and lead author on the paper. “The only way to make an accurate determination of whether sleep can in fact be improved was to combine all the past data and look at it through a new lens.”
The paper explaining their method was recently published in the journal Sleep Medicine Reviews.
In collaboration with the UT Health Science Center at Houston and the University of Southern California, the UT researchers reviewed 5,322 studies. They extracted pertinent information from publications meeting predefined inclusion and exclusion criteria to explore the effects of water-based passive body heating on a number of sleep-related conditions: sleep onset latency — the length of time it takes to accomplish the transition from full wakefulness to sleep; total sleep time; sleep efficiency — the amount of time spent asleep relative to the total amount of time spent in bed intended for sleep; and subjective sleep quality.
Meta-analytical tools were then used to assess the consistency between relevant studies and showed that an optimum temperature of between 104 and 109 degrees Fahrenheit improved overall sleep quality. When scheduled 1-2 hours before bedtime, it can also hasten the speed of falling asleep by an average of 10 minutes.
Much of the science to support links between water-based body heating and improved sleep is already well-established. For example, it is understood that both sleep and our body’s core temperature are regulated by a circadian clock located within the brain’s hypothalamus that drives the 24-hour patterns of many biological processes, including sleep and wakefulness.
Body temperature, which is involved in the regulation of the sleep/wake cycle, exhibits a circadian cycle, being 2-3 degrees Fahrenheit higher in the late afternoon/early evening than during sleep, when it is the lowest. The average person’s circadian cycle is characterized by a reduction in core body temperature of about 0.5 to 1 F around an hour before usual sleep time, dropping to its lowest level between the middle and later span of nighttime sleep. It then begins to rise, acting as a kind of a biological alarm clock wake-up signal. The temperature cycle leads the sleep cycle and is an essential factor in achieving rapid sleep onset and high efficiency sleep.
The researchers found the optimal timing of bathing for cooling down of core body temperature in order to improve sleep quality is about 90 minutes before going to bed. Warm baths and showers stimulate the body’s thermoregulatory system, causing a marked increase in the circulation of blood from the internal core of the body to the peripheral sites of the hands and feet, resulting in efficient removal of body heat and decline in body temperature. Therefore, if baths are taken at the right biological time — 1-2 hours before bedtime — they will aid the natural circadian process and increase one’s chances of not only falling asleep quickly but also of experiencing better quality sleep.
The research team is now working with UT’s Office of Technology Commercialization in the hopes of designing a commercially viable bed system with UT-patented Selective Thermal Stimulation technology. It allows thermoregulatory function to be manipulated on demand and dual temperature zone temperature control that can be tailored to maintain an individual’s optimum temperatures throughout the night.
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