ER Visits for Attempted Suicide Greatly Raise Odds for Future Tragedy

People who wind up in emergency rooms because they tried to kill themselves or contemplated it had a much higher risk of suicide within the year of the visit, new research suggests.

In fact, a study of people who went to California emergency rooms found that those who attempted suicide were 57 times more likely to kill themselves in the following year compared to the general public.

People with suicidal thoughts seen in the emergency room were 31 times more likely to try suicide in the ensuing year, researchers found.

“Until now, we have had very little information on suicide risk among patients after they leave the emergency department because data that link emergency records to death records are rare in the United States,” explained researcher Sidra Goldman-Mellor, an assistant professor of public health at the University of California, Merced.

“Understanding the characteristics and outcomes of people with suicide risk who visit emergency departments is important for helping researchers and practitioners improve treatment and outcomes,” Goldman-Mellor said in a news release from the U.S. National Institute of Mental Health, which funded the study.

For the study, she and her colleagues linked patient records from California residents who went to an emergency room from Jan. 1, 2009, to Dec. 31, 2011, with California death data.

They divided the patients into three groups: There were more than 85,000 people who had attempted suicide; over 67,000 who had thoughts of suicide; and a control group of nearly 500,000 people who went to an emergency room but had no suicide-related thoughts or problems.

The suicide rate for the control group patients was the lowest among all the groups, but it was still double the suicide rate among Californians overall, the researchers noted.

They also found that the risk for death from unintentional injury — such as accidents — was 16 times higher for those who attempted suicide and 13 times higher for those who thought about suicide.

Most deaths due to unintentional injury came from overdose — 72% for those who harmed themselves and 61% for those who thought about killing themselves.

Men and those over 65 had higher suicide rates. Suicide rates were higher for whites than any other group, the researchers found.

Also, those insured by Medicaid had lower suicide rates than people with private or other insurance.

People with chronic medical conditions were at greater risk for suicide. These conditions include bipolar disorder, anxiety disorder, or a psychotic disorder. For patients who thought about suicide, depression was tied to an increased risk for suicide.

People who tried suicide using a gun had a subsequent suicide rate in the following year of 4.4%, which was the highest rate of any other group in the study.

“Our results also highlight the fact that patients with suicidal [thoughts] or self-harming behaviors are at high risk not only for death by suicide, but also for death by accidents, homicide and natural causes. We think this shows the importance of addressing the full spectrum of their health and social needs in follow-up care,” Goldman-Mellor said.

The report was published online Dec. 13 in the journal JAMA Network Open.

https://consumer.healthday.com/general-health-information-16/suicide-health-news-646/er-visits-for-attempted-suicide-greatly-raise-odds-for-future-tragedy-753008.html

HHS seen needing new measures for Medicaid payment errors

The way HHS measures payment errors could lead to widespread misunderstanding about the nature and extent of fraud in the Medicaid program, according to the Medicaid and CHIP Payment and Access Commission (MACPAC).

Members at a meeting on Thursday said that the payment error rate measurement—PERM—provides policymakers and the public with too little, and possibly misleading, information about how and why payment errors occur.

Errors in payments to providers were much higher for fee-for-service compared to managed care, according to the most recent HHS Agency Financial Report. The error rate for fee-for-service Medicaid was 16.30% compared with just 0.12% for managed care Medicaid.

But this year’s report was significant because it’s the first year that Medicaid and Children’s Health Insurance Program estimates incorporated errors based on eligibility since the Affordable Care Act mandated substantial eligibility changes in 2014. The report found an eligibility-based error rate of 8.36% for Medicaid, which led some commentators to say that the program is rife with fraud.

An eligibility error “does not mean in any way, shape or form” that a Medicaid beneficiary has committed fraud or that a provider is billing for a service they didn’t provide, said MACPAC member Dr. Christopher Gorton, a consultant and former president of public plans at Tufts Health Plan. Errors are often due to the complexity of reporting and administrative work required to comply with the rules, he said.

“The improper payment rate is not a measure of fraud,” said Moira Forbes, policy director for MACPAC. “Fraud is a criminal decision that requires investigation. (PERM) is just a measure of improper payments.”

Most Medicaid and CHIP payment errors are due to states’ failure to comply with provider screening, enrollment and national provider identifier requirements, according to HHS’ report. Eligibility errors usually result from a lack of information to determine eligibility such as proof of income. But few errors were due to ineligible beneficiaries, according to MACPAC’s staff. Some CHIP enrollees were determined ineligible because they belonged in Medicaid, not because they were ineligible for benefits.

“Medicaid critics are jumping to the conclusion that when you say, ‘an eligibility error’ that there was intent on someone’s part to commit fraud,” said Tricia Brooks, a research professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.

The payment error rate measurement for eligibility doesn’t include people who were denied coverage, even though they were eligible.

The CMS plans to propose a new rule next spring that “would strengthen the integrity of the Medicaid eligibility determination process including verification, changes in circumstance and redetermination,” according to the Trump administration’s most recent regulatory agenda.

“My sense is that it’s. . . going to tighten up the rules and it’s going to impose more red tape,” said Brooks. “I think that things are going to get worse before they get better as a result of . . . that eligibility rule.”

Both fee-for-service Medicare and Medicaid are inherently high-risk programs because there are more than 100 million beneficiaries and over a million providers, according to William Scanlon, former managing director of health care issues at the U.S. Government Accountability Office and a former member of the Medicare Payment Advisory Commission.

“If you don’t set a lot of relatively detailed specifications for how and what you’re going to pay for, you would be accused of misuse of public funds,” he said. “Therefore, the rules are going to be complicated.”

MACPAC members were also concerned that error rates for fee-for-service Medicaid are not comparable to error rates for managed care payments. The error rate for managed care only measures monthly capitation payments at the state level, which are mostly automated and subject to simple payment rules. It doesn’t look at payments from managed care organizations to providers. Fee-for-service payments are more complex to measure because fees vary based on service, provider and other factors.

“It’s comparing apples and fish,” said Forbes.

Provider screening and enrollment rules are supposed to keep bad actors from participating in Medicaid, said Andy Schneider, an audience members who also is a research professor at the Georgetown University Center for Children and Families. He’s concerned that HHS’ approach to measuring error rate doesn’t capture whether managed care organizations are paying providers correctly, even though many Medicaid beneficiaries are covered by managed care.

“It’s extremely important . . . that the program not be perceived as being overrun by bad actors,” Schneider said. “We have no idea what’s going on in the managed care side . . . it’s a fundamental program integrity matter.”

https://www.modernhealthcare.com/medicaid/macpac-thinks-hhs-needs-new-measures-medicaid-payment-errors

Biotech Develops Prescription Software for Mental Health

The biotech industry is stepping in to help bridge the gap in access to healthcare for mood disorders, addiction, and other common mental health conditions with a new type of treatment — prescription digital therapeutics.

Prescription digital therapeutics, or “PDTs” as they are known in the industry, are a “hybrid of traditional tech and traditional biotech” that can be thought of as “software as a drug,” said Corey McCann, MD, PhD, president and CEO of Pear Therapeutics, a company developing digital products for the treatment of addiction.

“We’re sort of the budding pharma industry within digital,” he said. “This is really the beginning of a whole new treatment modality.”

PDTs include apps, interactive websites, and more comprehensive digital platforms with indications for treating very specific conditions, such as opioid use disorder or depression that’s comorbid with multiple sclerosis, he explained. They must be HIPAA-compliant and are covered by many private and public payers.

The shortage of mental health care providers and facilities in the United States continues to leave millions of Americans without access to the care they need. Although telemedicine is able to address many of these shortfalls, particularly for people in rural areas or other regions with little access to care, huge gaps remain.

The Mental Health Parity Act is very poorly enforced, and so not providing any care is still a reasonably suitable solution for many insurance companies. Dr Corey McCann, president and CEO of
Pear Therapeutics

“The mental health parity act is very poorly enforced, and so not providing any care is still a reasonably suitable solution for many insurance companies,” said McCann, who spoke on a “Slaying Addiction” panel at HLTH: Create Health’s Future 2019, a biotech conference held in Las Vegas.

In addition, “there is sufficient autonomy within mental health that you hear all sorts of non–evidence-based opinions on what people should or should not receive, and they’re rooted in anecdotal evidence — on a good day,” he said.

Pear’s two currently available products, reSET and reSET-O, are rooted as solidly in evidence as any other treatment for addiction, he told Medscape Medical News. reSET is indicated for the treatment of alcohol, cannabis, cocaine, or stimulant substance use disorders, and reSET-O, the first digital therapeutic to receive FDA breakthrough designation, is indicated for treatment of opioid use disorder specifically in combination with buprenorphine.

These software products are prescribed in the same way as prescription drugs and regulated by the FDA as medical devices are, but their function falls somewhere outside both of these categories. They are evidence-based treatments with clinical studies to back them up, but they do not replace therapy sessions or medications, McCann explained. Rather, they are an entirely new tool that complement and supplement usual care.

“The principal problem from our viewpoint is there’s not enough access to treatment,” said Kevin Moore, PsyD, a psychologist and director of integrative medicine at Crossroads Treatment Centers, an opioid-dependency treatment center serving about 25,000 patients across 10 states.

“We scale up as much as we can, but there’s not enough therapy available,” he said. Crossroads has adopted reSET and reSET-O because it “helps to fill this very large treatment gap.”

“The exciting thing about reSET and reSET-O is that they provide cognitive behavioral therapy lessons that people can learn wherever they have their phone and on whatever time schedule works for them,” said Moore. That said, “It’s not a replacement. It’s not a therapy itself. It enhances the types of conversations that I have with patients that I see.”

Customization and Data Collection

In addition to providing easy access to care, PDTs help with another problem. The biggest takeaway from the other speakers at the HLTH 2019 panel was “the degree of heterogeneity that we see within the crisis,” said McCann.

Heterogeneity is a challenge that biotech is well suited to address, since digital products can be customized to very specific populations, he told Medscape Medical News.

Digital therapeutics offer another advantage that drugs, therapy, and traditional medical devices cannot: data collection. In therapy especially, activities such as journaling and tracking cravings can be crucial to improvement, but compliance is low, said Moore.

“I’ve been a therapist for 20 years, and I’ve been trying to get people to collect this data for 20 years,” he said. “To have this information for the first time is hugely helpful to me, and therefore to patients.”

Some of the companies working on digital therapeutics, such as Happify Health, offer nonprescription wellness products which, unlike PDTs, do not require FDA clearance. In a regulatory sense, if a PDT is like a drug, wellness apps are like supplements.

“One of the key differences between a wellness product and an FDA-cleared product is the claims you can make about the impact on the disease and the symptoms,” explained Chris Wasden, EdD, head of Happify Digital Therapeutics Alliance. In addition, FDA-cleared PDTs are integrated into the workflow of physicians, whereas wellness products, such as Happify’s app, are aimed at consumers and don’t require any interaction or coordination with a healthcare provider.

FDA Approval Pathways

The US Food and Drug Administration (FDA) does not recognize or use the term PDT and currently uses the ‘medical device pathways’ to clear software products that require prescriptions for specific indications.

Digital therapeutics fall under class 2 devices. Class 1 devices are low-risk devices like toothbrushes and tongue depressors that don’t need premarket approval, and class 3 are high risk devices, often implantable, which require extensive clinical evidence to show safety and efficacy. Class 2 devices pose moderate risks to patients and require premarket clearance, but they don’t necessarily need multiple studies showing safety and efficacy independent of other similar products.

There are two clearance pathways for Class 2 medical devices: 510(k) and de novo. The 510(k) pathway requires manufacturers to compare their product to “a similar, already FDA-cleared device on the market whose characteristics are similar enough to the new product that the manufacturer can base safety and efficacy claims on the existing predicate product,” according to FDA spokesperson Stephanie Caccomo.

One of the first PDTs to receive FDA clearance through the 510(k) pathway was Welldoc’s BlueStar for type 2 diabetes, cleared in 2013. Welldoc currently has seven FDA-cleared software products on the market. Another company, Palo Alto Health Sciences, has two: Freespira for panic disorder and Freespira for PTSD.

In September 2017, Pear’s reSET was the first mobile medical application to receive FDA clearance through the Class 2 de novo pathway, reserved for products with no predicate device. The reSET-O app was approved 3 months later. Pear is now participating with eight other companies in the FDA’s Software Precertification (Pre-Cert) Pilot Program, a new regulatory framework being tested for future medical software products.

Wasden expects another half dozen PDTs to clear the FDA and hit the market in the next year or two. Pear is already awaiting approval on Somryst for comorbid depression and insomnia and has a product for schizophrenia in a clinical trial. Most of the new therapies are being developed through partnerships with pharmaceutical companies, healthcare systems, or both. Happify, for example, recently announced an agreement with Sanofi to develop a product treating anxiety and depression specifically in people with multiple sclerosis.

“We’ll take an intervention that’s already been shown to work with a clinician and say we want to make this fun and engaging and useful,” Wasden explained. “Now we’re going to apply some of the Happify secret sauce to our gaming — we make it simple and easy and friendly to do — and then we hold you accountable for completing the intervention so you get the therapeutic benefit.”

Wasden said the company has identified 30 therapeutic areas where the intersection of anxiety or depression with an underlying disorder could benefit from a product they develop specifically for that comorbidity. He rattled off some of the conditions linked to comorbid anxiety or depression: chronic obstructive pulmonary disease (COPD), cardiovascular disease, HIV, epilepsy, gastroesophageal reflux disease (GERD), heart failure, chronic kidney disease, and other chronic diseases.

“With some of these diseases, anxiety is higher than depression, and with others, depression is higher than anxiety,” he said. “With MS, depression is higher than anxiety, but with psoriasis or any type of dermatitis, anxiety is higher than depression.”

Happify is already working with pharmaceutical companies in dermatology and in cardiovascular health. Several of the conditions, such as cardiovascular and metabolic ones, have biomarkers that Happify can track in assessing their product’s effect, such as blood sugar and blood pressure.

Less Time, More Patients

Most clinical trials for these products, however, focus on validated mental health endpoints, because both the need and potential are so great in the mental health space.

“What we have seen in healthcare broadly is that there is less time for more patients,” Moore, the psychologist at Crossroads Treatment Centers, told Medscape Medical News.

Therapies like reSET, which use gaming and rewards to guide patients through lessons and encourage them to continue buprenorphine treatment, have the potential to expand providers’ reach and patient compliance simultaneously.

“This makes clinician time more effective because folks have the information. It’s a very natural augmentation that we desperately need,” said Moore.

https://www.medscape.com/viewarticle/922536#vp_1

Prediabetes Is Common in Teens and Young Adults: CDC

Target Audience and Goal Statement: Pediatricians, endocrinologists, family physicians, primary care physicians

The goal of this study was to examine the prevalence of impaired fasting glucose, impaired glucose tolerance, and increased glycated hemoglobin A1c (HbA1c) levels in U.S. adolescents (ages 12-18 years) and young adults (ages 19-34 years) without diabetes.

Question Addressed:

• What were the 2005-2016 prevalence estimates of prediabetes in U.S. adolescents and young adults?

Study Synopsis and Perspective:

Three glucose metabolism dysregulation phenotypes are commonly known as prediabetes. An impaired fasting glucose of 100-125 mg/dL (5.6-6.9 mmol/L), an impaired 2-hour postprandial glucose tolerance of 140-199 mg/dL (7.8-11 mmol/L), and HbA1c values of 5.7%-6.4% are specifically used to define prediabetes.

Action Points

• About one in five adolescents and one in four young adults in the U.S. have prediabetes, based on a nationally representative dataset (National Health and Nutrition Examination Survey) comprising 12 years of data (2005-2016).
• Note that adolescents and young adults with prediabetes have an unfavorable cardiometabolic risk profile and are therefore at increased risk of both type 2 diabetes and cardiovascular diseases.

Prediabetes has frequently been linked with insulin resistance syndrome (metabolic syndrome), which, in turn, is directly involved in the pathogenesis of type 2 diabetes. The three glucose abnormality phenotypes of prediabetes have also been associated with an increased risk for cardiovascular disease (CVD).

Historically, prediabetes estimates in American youths, adults, and seniors (ages ≥65) were 17.4%, 38%, and 50%, respectively. Due to the recent increase in the incidence and prevalence of type 2 diabetes in U.S. adolescents and a projected more than four-fold increase in the coming decades, there remains a need for ongoing monitoring of the prevalence of the three glucose abnormality phenotypes at the population level.

Therefore, CDC researchers led by Linda Andes, PhD, set out to monitor the prevalence of prediabetes among adolescents and young adults using data from the National Health and Nutrition Examination Survey (NHANES) covering the years 2005-2016. Findings were published in JAMA Pediatrics. Adolescents and young adults who were not pregnant; did not have diabetes; and had measurements for fasting plasma glucose, 2-hour plasma glucose after a 75-g oral glucose tolerance test, and HbA1c levels were included in the analysis.

The final analytic sample consisted of 5,786 participants. Researchers looked at adolescents ages 12 to 18 (n=2,606; 45%) and young adults ages 19 to 34 (n=3,180; 55%). Demographic characteristics such as sex and race/ethnicity were similarly distributed across age groups.

Some of the important study findings included:

• Prediabetes prevalence rates were 18% and 24% in adolescents and young adults, respectively; simply put, one in five adolescents and one in four young adults were living with prediabetes
• Prediabetes prevalence was significantly higher in individuals with obesity than in those of normal weight (25.7% vs 16.4% in adolescents and 36.9% vs 16.6% in young adults)
• Among adolescents and young adults, the predictive marginal prevalence of prediabetes was significantly higher in males than in females (22.5% vs 13.4% in adolescents and 29.1% vs 18.8% in young adults)
• Compared with white young adults, Hispanic young adults had higher rates of prediabetes
• Significantly higher cholesterol levels, systolic blood pressure, abdominal fat, and lower insulin sensitivity were observed among adolescents and young adults with prediabetes versus those with normal glucose tolerance; these indicators increased the risk for type 2 diabetes and CVD

Glucose abnormality phenotypes were only measured once, simultaneously with all other biometric indicators, which might have led to misclassification in some cases, the researchers acknowledged. Because of the cross-sectional study design, causality cannot be inferred from the results, they added. Other study limitations included using the Single Point Insulin Sensitivity Estimator as a surrogate of insulin sensitivity, as well as the inability to differentiate between participants with one of the glucose tolerance statuses and those with preclinical type 1 diabetes.

Source Reference: JAMA Pediatrics 2019; DOI: 10.1001/jamapediatrics.2019.4498

Study Highlights and Explanation of Findings:

Based on a nationally representative dataset comprising 12 years of NHANES data (2005-2016), CDC researchers found that prediabetes is highly prevalent in U.S. adolescents and young adults, especially in males and in people with obesity. Youths with prediabetes had an unfavorable cardiometabolic risk profile, which placed them at elevated risk for not only developing type 2 diabetes, but also CVD.

The higher prediabetes prevalence in males was driven by a two-fold difference in the percentage of impaired fasting glucose in male individuals versus female individuals. While the reasons for this finding were not clear, the researchers hypothesized that female sex hormones, mainly estrogen, may contribute to differences in the prevalence of impaired fasting glucose and impaired glucose tolerance between males and females.

“Obesity is a strong predictor of elevated type 2 diabetes risk in adults and probably also plays a major role in the development of the disease at younger ages,” the group wrote. Given the sharp spike in type 2 diabetes cases, the finding that a large proportion of adolescents and young adults with obesity already present glucose metabolism abnormalities serves as a further public health concern.

“The prevalence of prediabetes in adolescents and young adults reinforces the critical need for effective public health strategies that promote healthy eating habits, physical activity, and stress management,” said CDC Director Robert R. Redfield, MD. “These lifestyle behaviors can begin early in a child’s life and should continue through adolescence and adulthood to reduce onset of type 2 diabetes.”

“We’re already seeing increased rates of type 2 diabetes and diabetes-related complications in youth and young adults, and these new findings are evidence of a growing epidemic and a tremendously worrisome threat to the future of our nation’s health,” said Ann Albright, PhD, director of CDC’s Division of Diabetes Translation, in a press release. “Additional research is needed to support the development of interventions for youth and increasing access to programs that we know work for young adults, like the CDC-led National Diabetes Prevention Program [DPP].”

Key aspects of the National DPP involve a lifestyle coach, a CDC-approved curriculum, and group support over the course of a year. A typical curriculum promotes modest weight loss (5%-7%) and increased physical activity through a 12-month lifestyle change program, and also reflects new literature on self-efficacy, physical activity, and diet. The CDC has also developed an array of resources for different healthcare stakeholders, including interactive motivational modules for those with prediabetes. According to related research, structured lifestyle interventions can cut type 2 diabetes risk in half.

Reviewed by Henry A. Solomon, MD, FACP, FACC Clinical Associate Professor, Weill Cornell Medical College

Primary Source

JAMA Pediatrics

Source Reference: Andes LJ, et al “Prevalence of prediabetes among adolescents and young adults in the United States, 2005-2016” JAMA Pediatr 2019; DOI: 10.1001/jamapediatrics.2019.4498.

Secondary Source

MedPage Today

Source Reference: Monaco K “Prediabetes Afflicting One-Fourth of Young Adults” 2019.

https://www.medpagetoday.org/primarycare/diabetes/83897?_ga=2.169538149.575322474.1576380690-1125047970.1528569052

How a protein in your brain could protect against Alzheimer’s

Research shows that white blood cells in the human brain are regulated by a protein called CD33–a finding with important implications in the fight against Alzheimer’s disease, according to a new study by University of Alberta chemists.

“Immune cells in the brain, called microglia, play a critical role in Alzheimer’s disease,” explained Matthew Macauley, assistant professor in the Department of Chemistry and co-author on the paper. “They can be harmful or protective. Swaying microglia from a harmful to protective state could be the key to treating the disease.”

Scientists have identified the CD33 protein as a factor that may decrease a person’s likelihood of Alzheimer’s disease. Less than 10 percent of the population have a version of CD33 that makes them less likely to get Alzheimer’s disease. “The fact that CD33 is found on microglia suggests that immune cells can protect the brain from Alzheimer’s disease under the right circumstances,” said Abhishek Bhattacherjee, first author and postdoctoral fellow in the Macauley lab.

Now, Macauley’s research shows that the most common type of CD33 protein plays a crucial role in modulating the function of microglia.

“These findings set the stage for future testing of a causal relationship between CD33 and Alzheimer’s Disease, as well as testing therapeutic strategies to sway microglia from harmful to protecting against the disease–by targeting CD33,” said Macauley. “Microglia have the potential to ‘clean up’ the neurodegenerative plaques, through a process called phagocytosis–so a therapy to harness this ability to slow down or reverse Alzheimer’s disease can be envisioned.”

Macauley is an investigator with GlycoNet, a Canada-wide network of researchers based at the University of Alberta that is working to further our understanding of biological roles for sugars. GlycoNet provided key funding to get this project off the ground in the Macauley lab and continues to support the ongoing applications of the project.

According to the Alzheimer’s Association, 747,000 Canadians are currently living with Alzheimer’s or another form of dementia. The disease affects more than 44 million people around the world.

###

The paper,”Repression of phagocytosis by human CD33 is not conserved with mouse CD33,” is published in Communications Biology (doi: 10.1038/s42003-019-0698-6).

https://www.eurekalert.org/pub_releases/2019-12/uoa-ha121319.php

Few Medicare Advantage plans add new benefits for serious illness

• A minority of Medicare Advantage plans have added benefits targeted at enrollees with serious chronic illnesses. In 2019, 507 MA plans, or 11% of the total number of plans, offered supplemental benefits. Fewer plans — 377, or 7% — will offer supplemental benefits in 2020, but the reduction is based largely on the actions of one national payer, according to a new study from the Duke Margolis Center for Health Policy.
• The benefits for seriously ill enrollees include: adult daycare (63 plans in 2020), palliative care (23 plans in 2019 and 58 in 2020), non-opioid pain management (24 plans in 2019 and 201 plans in 2020), in-home support services (71 plans in 2019 and 148 in 2020), and caregiver support (389 plans in 2019 and 82 plans in 2020).
• These supplemental benefits for seriously ill enrollees are more likely to be available in urban areas than rural areas or in areas with higher concentrations of Medicare-eligible seniors who are enrolled in MA plans, the study found.

Medicare Advantage plans are popular with payers and beneficiaries. A total of 3,148 MA plans will be available across the country in 2020 — or 414 more plans than in 2019, according to the Kaiser Family Foundation’s Medicare Advantage 2020 Spotlight: First Look. The foundation expects those plans to enroll a third of all Medicare-eligible seniors, or more than 22 million people, in 2020.

MA plans are popular because they offer more types of benefits than traditional Medicare, such as coverage for vision care, dental services, hearing aids and medications.

But beginning in 2019, CMS gave MA plans the flexibility to offer even more benefits, including nonmedical services, to help their members with chronic illnesses maintain their health and ability to live independently.

Some of those options include home-based palliative care, adult day care services, in-home support, personal care services, caregiver support services, medically-approved non-opioid pain management, a memory fitness benefit, and home and bathroom safety devices and modifications, according to the Duke study.

In 2020, CMS identified additional benefits that MA plans could offer enrollees with serious chronic illnesses, which the agency specified as diabetes, dementia, heart failure, and stroke. The additional benefits include food, pest control, indoor air quality equipment, and structural home modifications, according to the Duke Margolis Center.

Researchers at Duke analyzed longitudinal and supplemental benefit data published by CMS. They also interviewed key leaders at health plans in June and July of 2019. They focused their analysis only on benefits that would be targeted at seriously ill beneficiaries.

Interviewees described barriers to implementing the supplemental benefits for enrollees with chronic illnesses, according to the study.

One issue is money. CMS did not provide new funding to pay for the supplemental benefits, making it challenging for the insurers to offer more than a few new benefits.

Another issue is the administrative complexity and cost involved in contracting with local organizations that provide social services such as adult daycare or in-home support services. These organizations may lack the technical sophistication to manage protected health information or carry liability insurance that meets insurers’ rules. As one interviewee told the researchers, “It’s a lot of work to teach organizations how to contract with a health plan.”

There’s also a lack of evidence about how enrollees will use the new benefits, if the benefits will lead to cost savings in future years, or attract different members, potentially altering a plan’s risk pool.

https://www.healthcaredive.com/news/few-medicare-advantage-plans-add-new-benefits-for-serious-illness/568776/

Centene quietly lobbying Congress to let states partially expand Medicaid

Centene, the nation’s largest Medicaid managed care provider, wants Congress to change the eligibility requirements around Medicaid, the government-sponsored safety net program that covers one in five low-income Americans.

Its proposal would ultimately push more people onto the Affordable Care Act exchanges by allowing states to adopt a partial Medicaid expansion, an idea typically embraced by red states.

CEO Michael Neidorff told Healthcare Dive the company has been quietly talking to lawmakers on both sides of the aisle on Capitol Hill about the plan, though he emphasized nothing of substance will happen until after the 2020 election.

Centene says its proposal is an attempt to strengthen the ACA markets by increasing the pool of people while enticing holdout states to partially expand their Medicaid programs.

“I think there’s a way to get it done,” Neidorff told Healthcare Dive. “We have a very powerful Washington office and they’ve been working with leadership and their staff.”

Centene filed lobbying forms totaling about $2 million in spending in the congressional lobbying database for 2019, as of Dec. 11. ​In 2018, the payer reported spending roughly $2.5 million. 

However, policy experts caution that it would result in increased spending for the federal government and fewer protections for those enrolled in Medicaid who are then pushed into the exchanges.

It’s unclear how receptive Congress will be, but experts were skeptical of any consensus on the polarizing health law.

“It would be a very major change. I certainly don’t see that happening. It’s opening up the ACA and as we know from past history, it’s a battle royale when you go into the ACA,” Joan Alker, executive director and co-founder of the Center for Children and Families at Georgetown University, told Healthcare Dive.

Centene’s proposal

Under the ACA, states can expand their Medicaid programs to cover all adults whose annual incomes does not exceed 138% of the federal poverty level, or $17,236 for an individual.

Centene’s proposal calls for lowering that income ceiling from 138% to 100%, or $12,490 for an individual.

That would shrink the pool of who is eligible for Medicaid and push those people into the exchanges. Neidorff said the move would grow the exchange pool and ultimately drive down prices. High costs have attracted criticism as they play a role in forcing those who are not subsidized to leave the market.

Credit: Samantha Liss/Healthcare Dive

For Centene, it would be a notable shift because its core business has long been in Medicaid. The insurance exchanges only became a viable business beginning in 2013 with the advent of the ACA. It’s a nod to how important the exchange business has become for the payer.

Centene arguably stands to benefit the most as the nation’s largest insurer on the exchanges in terms of enrollment, plus the exchanges generate higher profit margins than its Medicaid book of business.

“You move those lives into exchange and your profitability is higher,” David Windley, an analyst with Jefferies, told Healthcare Dive.​

In the states that have not expanded Medicaid, there are about 2 million people with incomes between 100% and 138% of the federal poverty level, according to the Kaiser Family Foundation.

Hospitals and providers are likely to favor the proposal because Medicaid plans tend to pay less than commercial ones. The idea could garner support from states with tight budgets as some, even Massachusetts, have already expressed a desire to adopt a partial expansion. (Both the Trump and Obama’s administrations have denied providing the enhanced match rate for states seeking partial expansions).

https://www.healthcaredive.com/news/centene-quietly-lobbying-congress-to-let-states-partially-expand-medicaid/568742/