Health Policy

Food and Drug Administration Commissioner Scott Gottlieb, MD, on March 20, 2019, called for tighter scrutiny of EHR systems, which have prompted thousands of reports of patient injuries and other safety problems over the past decade.

“What we really need is a much more tailored approach, so that we have appropriate oversight of EHRs when they’re doing things that could create risk for patients,” Dr. Gottlieb said in an interview with Kaiser Health News.

Dr. Gottlieb was responding to “Botched Operation,” a report published March 18 by KHN and Fortune magazine. The investigation found that the federal government has spent more than $36 billion over the past 10 years to switch doctors and hospitals from paper to digital records systems. In that time, thousands of reports of deaths, injuries, and near misses linked to EHRs have piled up in databases – including at least one run by the FDA.

Dr. Gottlieb said Congress would need to enact legislation to define when an EHR would require government oversight. He said that the digital records systems, which store a patient’s medical history, don’t fit neatly under the agency’s existing mandate to regulate items such as drugs and medical devices.

Dr. Gottlieb said the best approach might be to say that an EHR that has a certain capability becomes a medical device. He called EHRs a “unique tool,” noting that the risks posed by their use aren’t the same as for a traditional medical device implanted in a patient. “You need a much different regulatory scheme,” he said.

The 21st Century Cures Act of 2016 excludes the FDA from having oversight over EHRs as a medical device.

At the time, many industry groups argued that FDA regulation would “stifle innovation” and stall the national drive to bring medicine into the modern era. Federal officials responsible for doling out billions in subsidies to doctors and hospitals generally sympathized with that view and were skeptical of allowing the FDA to play a role.

The debate became public in February 2010, when Jeffrey Shuren, MD, an FDA official, testified at a public hearing that the agency had tied 6 deaths and more than 200 injuries to health information technology. In all, the FDA said, it had logged 260 reports in the previous 2 years of “malfunctions with the potential for patient harm.”

The agency said the findings were based largely on reports voluntarily submitted to the FDA and suggested “significant clinical implications and public safety issues.” In one case cited, lab tests done in a hospital emergency department were sent to the wrong patient’s file. Since then, several government and private repositories have associated thousands of injuries, near misses, and deaths to EHR technology.

Dr. Shuren said in 2010 that the agency recognized that health information technology had great potential to improve patient care, but also needed oversight to “assure patient safety.”

While some safety proponents agree that EHRs offer tremendous benefits, they also see a greater opportunities to improve their safety.

Dean Sittig, PhD, a professor of bioinformatics and bioengineering at the University of Texas, Houston, said EHRs have improved safety within the health care system, but they have not eliminated errors to the extent that he would have expected. Federal officials were initially pushing for rapid adoption and ‘there wasn’t a lot of interest in talking about things that could go wrong,’ ” Dr. Sittig told KHN and Fortune.

Earlier in March, Gottlieb announced his resignation from the FDA. His last day is scheduled to be April 5.

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. KHN correspondents Sarah Jane Tribble, Sydney Lupkin, and Julie Rovner contributed to this report.

Food and Drug Administration Commissioner Scott Gottlieb, MD, on March 20, 2019, called for tighter scrutiny of EHR systems, which have prompted thousands of reports of patient injuries and other safety problems over the past decade.

“What we really need is a much more tailored approach, so that we have appropriate oversight of EHRs when they’re doing things that could create risk for patients,” Dr. Gottlieb said in an interview with Kaiser Health News.

Dr. Gottlieb was responding to “Botched Operation,” a report published March 18 by KHN and Fortune magazine. The investigation found that the federal government has spent more than $36 billion over the past 10 years to switch doctors and hospitals from paper to digital records systems. In that time, thousands of reports of deaths, injuries, and near misses linked to EHRs have piled up in databases – including at least one run by the FDA.

Dr. Gottlieb said Congress would need to enact legislation to define when an EHR would require government oversight. He said that the digital records systems, which store a patient’s medical history, don’t fit neatly under the agency’s existing mandate to regulate items such as drugs and medical devices.

Dr. Gottlieb said the best approach might be to say that an EHR that has a certain capability becomes a medical device. He called EHRs a “unique tool,” noting that the risks posed by their use aren’t the same as for a traditional medical device implanted in a patient. “You need a much different regulatory scheme,” he said.

The 21st Century Cures Act of 2016 excludes the FDA from having oversight over EHRs as a medical device.

At the time, many industry groups argued that FDA regulation would “stifle innovation” and stall the national drive to bring medicine into the modern era. Federal officials responsible for doling out billions in subsidies to doctors and hospitals generally sympathized with that view and were skeptical of allowing the FDA to play a role.

The debate became public in February 2010, when Jeffrey Shuren, MD, an FDA official, testified at a public hearing that the agency had tied 6 deaths and more than 200 injuries to health information technology. In all, the FDA said, it had logged 260 reports in the previous 2 years of “malfunctions with the potential for patient harm.”

The agency said the findings were based largely on reports voluntarily submitted to the FDA and suggested “significant clinical implications and public safety issues.” In one case cited, lab tests done in a hospital emergency department were sent to the wrong patient’s file. Since then, several government and private repositories have associated thousands of injuries, near misses, and deaths to EHR technology.

Dr. Shuren said in 2010 that the agency recognized that health information technology had great potential to improve patient care, but also needed oversight to “assure patient safety.”

While some safety proponents agree that EHRs offer tremendous benefits, they also see a greater opportunities to improve their safety.

Dean Sittig, PhD, a professor of bioinformatics and bioengineering at the University of Texas, Houston, said EHRs have improved safety within the health care system, but they have not eliminated errors to the extent that he would have expected. Federal officials were initially pushing for rapid adoption and ‘there wasn’t a lot of interest in talking about things that could go wrong,’ ” Dr. Sittig told KHN and Fortune.

Earlier in March, Gottlieb announced his resignation from the FDA. His last day is scheduled to be April 5.

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. KHN correspondents Sarah Jane Tribble, Sydney Lupkin, and Julie Rovner contributed to this report.

Food and Drug Administration Commissioner Scott Gottlieb, MD, on March 20, 2019, called for tighter scrutiny of EHR systems, which have prompted thousands of reports of patient injuries and other safety problems over the past decade.

“What we really need is a much more tailored approach, so that we have appropriate oversight of EHRs when they’re doing things that could create risk for patients,” Dr. Gottlieb said in an interview with Kaiser Health News.

Dr. Gottlieb was responding to “Botched Operation,” a report published March 18 by KHN and Fortune magazine. The investigation found that the federal government has spent more than $36 billion over the past 10 years to switch doctors and hospitals from paper to digital records systems. In that time, thousands of reports of deaths, injuries, and near misses linked to EHRs have piled up in databases – including at least one run by the FDA.

Dr. Gottlieb said Congress would need to enact legislation to define when an EHR would require government oversight. He said that the digital records systems, which store a patient’s medical history, don’t fit neatly under the agency’s existing mandate to regulate items such as drugs and medical devices.

Dr. Gottlieb said the best approach might be to say that an EHR that has a certain capability becomes a medical device. He called EHRs a “unique tool,” noting that the risks posed by their use aren’t the same as for a traditional medical device implanted in a patient. “You need a much different regulatory scheme,” he said.

The 21st Century Cures Act of 2016 excludes the FDA from having oversight over EHRs as a medical device.

At the time, many industry groups argued that FDA regulation would “stifle innovation” and stall the national drive to bring medicine into the modern era. Federal officials responsible for doling out billions in subsidies to doctors and hospitals generally sympathized with that view and were skeptical of allowing the FDA to play a role.

The debate became public in February 2010, when Jeffrey Shuren, MD, an FDA official, testified at a public hearing that the agency had tied 6 deaths and more than 200 injuries to health information technology. In all, the FDA said, it had logged 260 reports in the previous 2 years of “malfunctions with the potential for patient harm.”

The agency said the findings were based largely on reports voluntarily submitted to the FDA and suggested “significant clinical implications and public safety issues.” In one case cited, lab tests done in a hospital emergency department were sent to the wrong patient’s file. Since then, several government and private repositories have associated thousands of injuries, near misses, and deaths to EHR technology.

Dr. Shuren said in 2010 that the agency recognized that health information technology had great potential to improve patient care, but also needed oversight to “assure patient safety.”

While some safety proponents agree that EHRs offer tremendous benefits, they also see a greater opportunities to improve their safety.

Dean Sittig, PhD, a professor of bioinformatics and bioengineering at the University of Texas, Houston, said EHRs have improved safety within the health care system, but they have not eliminated errors to the extent that he would have expected. Federal officials were initially pushing for rapid adoption and ‘there wasn’t a lot of interest in talking about things that could go wrong,’ ” Dr. Sittig told KHN and Fortune.

Earlier in March, Gottlieb announced his resignation from the FDA. His last day is scheduled to be April 5.

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. KHN correspondents Sarah Jane Tribble, Sydney Lupkin, and Julie Rovner contributed to this report.

End-of-life care for patients with end-stage liver disease cost more than four of the five most expensive chronic medical conditions, according to the findings of a population-based study in Canada.

monkeybusinessimages/Thinkstock

During their final year of life, patients with end-stage liver disease incurred a median of $51,191 Canadian dollars in health care costs (interquartile range, $28,510-$86,659) – approximately $2,360 more than ischemic heart disease, $1,830 more than diabetes, $1,600 more than mental health disorders, and $600 more than congestive heart failure, Erin M. Kelly, MD, of the University of Ottawa, and her associates wrote in Clinical Gastroenterology and Hepatology. Only chronic renal disease cost more (median, $55,453). Most health care costs of end-stage liver disease covered the final 90 days of life and were tied to high use of hospital resources, the researchers said.

In the United States, more than 150,000 patients are hospitalized for end-stage liver disease every year at a price tag of $4 billion, Dr. Kelly and her associates noted. This price tag is expected to rise further because of epidemic levels of obesity and related nonalcoholic fatty liver disease. The shortage of livers for transplantation and the fact that many patients with cirrhosis are not transplantation candidates leave many in end-of-life care. Given the lack of population-level data on costs of this care, the researchers studied data for all individuals who died in Ontario – Canada’s largest province – between April 2010 and March 2013. The data source was the Institute for Clinical Evaluative Sciences, a nonprofit group that tracks diagnoses, health care, outcomes, and costs.

Among 264,723 decedents, 5,087 (1.9%) had a diagnosis of end-stage liver disease. These patients died a median of 15 years earlier than other patients (median age of death, 65 vs. 80 years old). During the last year of life, 99% visited the emergency department or were hospitalized, compared with 86% of other patients. Importantly, health care costs for the two groups were similar up until the final 90 days of life, when there was “a clear divergence,” the researchers said. A total of 51% of the costs of the final 12 months of care related to acute care during the final 90 days of life. Consequently, during their last 3 months, patients with end-stage liver disease cost the health care system 46% more than other individuals, the difference remained statistically significant after accounting for demographics and comorbidities, and the picture changed little after excluding transplantation patients and those with hepatocellular carcinoma.

Medical care for patients with end-stage liver disease is complex – often involving serious infections, gastrointestinal bleeding, renal dysfunction, electrolyte disturbances, and worsening encephalopathy – and often involves frequent hospital readmissions, the researchers noted. Nonetheless, the findings highlight the need to consider steps such as advanced care planning and palliative care to help keep patients with end-stage liver disease from dying in acute care settings, they concluded. Such steps “may direct services toward more appropriate sectors, while reducing costs.”

The Ontario Ministry of Health and Long-Term Care supported the work. The researchers reported having no competing interests.

SOURCE: Kelly EM et al. Clin Gastroenterol Hepatol. 2019 Jan 28. doi: 10.1016/j.cgh.2019.01.046.

End-of-life care for patients with end-stage liver disease cost more than four of the five most expensive chronic medical conditions, according to the findings of a population-based study in Canada.

monkeybusinessimages/Thinkstock

During their final year of life, patients with end-stage liver disease incurred a median of $51,191 Canadian dollars in health care costs (interquartile range, $28,510-$86,659) – approximately $2,360 more than ischemic heart disease, $1,830 more than diabetes, $1,600 more than mental health disorders, and $600 more than congestive heart failure, Erin M. Kelly, MD, of the University of Ottawa, and her associates wrote in Clinical Gastroenterology and Hepatology. Only chronic renal disease cost more (median, $55,453). Most health care costs of end-stage liver disease covered the final 90 days of life and were tied to high use of hospital resources, the researchers said.

In the United States, more than 150,000 patients are hospitalized for end-stage liver disease every year at a price tag of $4 billion, Dr. Kelly and her associates noted. This price tag is expected to rise further because of epidemic levels of obesity and related nonalcoholic fatty liver disease. The shortage of livers for transplantation and the fact that many patients with cirrhosis are not transplantation candidates leave many in end-of-life care. Given the lack of population-level data on costs of this care, the researchers studied data for all individuals who died in Ontario – Canada’s largest province – between April 2010 and March 2013. The data source was the Institute for Clinical Evaluative Sciences, a nonprofit group that tracks diagnoses, health care, outcomes, and costs.

Among 264,723 decedents, 5,087 (1.9%) had a diagnosis of end-stage liver disease. These patients died a median of 15 years earlier than other patients (median age of death, 65 vs. 80 years old). During the last year of life, 99% visited the emergency department or were hospitalized, compared with 86% of other patients. Importantly, health care costs for the two groups were similar up until the final 90 days of life, when there was “a clear divergence,” the researchers said. A total of 51% of the costs of the final 12 months of care related to acute care during the final 90 days of life. Consequently, during their last 3 months, patients with end-stage liver disease cost the health care system 46% more than other individuals, the difference remained statistically significant after accounting for demographics and comorbidities, and the picture changed little after excluding transplantation patients and those with hepatocellular carcinoma.

Medical care for patients with end-stage liver disease is complex – often involving serious infections, gastrointestinal bleeding, renal dysfunction, electrolyte disturbances, and worsening encephalopathy – and often involves frequent hospital readmissions, the researchers noted. Nonetheless, the findings highlight the need to consider steps such as advanced care planning and palliative care to help keep patients with end-stage liver disease from dying in acute care settings, they concluded. Such steps “may direct services toward more appropriate sectors, while reducing costs.”

The Ontario Ministry of Health and Long-Term Care supported the work. The researchers reported having no competing interests.

SOURCE: Kelly EM et al. Clin Gastroenterol Hepatol. 2019 Jan 28. doi: 10.1016/j.cgh.2019.01.046.

End-of-life care for patients with end-stage liver disease cost more than four of the five most expensive chronic medical conditions, according to the findings of a population-based study in Canada.

monkeybusinessimages/Thinkstock

During their final year of life, patients with end-stage liver disease incurred a median of $51,191 Canadian dollars in health care costs (interquartile range, $28,510-$86,659) – approximately $2,360 more than ischemic heart disease, $1,830 more than diabetes, $1,600 more than mental health disorders, and $600 more than congestive heart failure, Erin M. Kelly, MD, of the University of Ottawa, and her associates wrote in Clinical Gastroenterology and Hepatology. Only chronic renal disease cost more (median, $55,453). Most health care costs of end-stage liver disease covered the final 90 days of life and were tied to high use of hospital resources, the researchers said.

In the United States, more than 150,000 patients are hospitalized for end-stage liver disease every year at a price tag of $4 billion, Dr. Kelly and her associates noted. This price tag is expected to rise further because of epidemic levels of obesity and related nonalcoholic fatty liver disease. The shortage of livers for transplantation and the fact that many patients with cirrhosis are not transplantation candidates leave many in end-of-life care. Given the lack of population-level data on costs of this care, the researchers studied data for all individuals who died in Ontario – Canada’s largest province – between April 2010 and March 2013. The data source was the Institute for Clinical Evaluative Sciences, a nonprofit group that tracks diagnoses, health care, outcomes, and costs.

Among 264,723 decedents, 5,087 (1.9%) had a diagnosis of end-stage liver disease. These patients died a median of 15 years earlier than other patients (median age of death, 65 vs. 80 years old). During the last year of life, 99% visited the emergency department or were hospitalized, compared with 86% of other patients. Importantly, health care costs for the two groups were similar up until the final 90 days of life, when there was “a clear divergence,” the researchers said. A total of 51% of the costs of the final 12 months of care related to acute care during the final 90 days of life. Consequently, during their last 3 months, patients with end-stage liver disease cost the health care system 46% more than other individuals, the difference remained statistically significant after accounting for demographics and comorbidities, and the picture changed little after excluding transplantation patients and those with hepatocellular carcinoma.

Medical care for patients with end-stage liver disease is complex – often involving serious infections, gastrointestinal bleeding, renal dysfunction, electrolyte disturbances, and worsening encephalopathy – and often involves frequent hospital readmissions, the researchers noted. Nonetheless, the findings highlight the need to consider steps such as advanced care planning and palliative care to help keep patients with end-stage liver disease from dying in acute care settings, they concluded. Such steps “may direct services toward more appropriate sectors, while reducing costs.”

The Ontario Ministry of Health and Long-Term Care supported the work. The researchers reported having no competing interests.

SOURCE: Kelly EM et al. Clin Gastroenterol Hepatol. 2019 Jan 28. doi: 10.1016/j.cgh.2019.01.046.

WASHINGTON – The Medicare Payment Advisory Commission laid the foundation for developing a proposal to implement reference pricing and binding arbitration for Medicare Part B drugs that are administered in the physician’s office.

Gregory Twachtman/MDedge News

Much of the presentation, offered during the commission’s March meeting, was general ideas with more work to come in terms of fleshing out the details. An ambitious goal of having something ready for the commission’s June 2019 report to Congress was set.

The policy recommendations for reference pricing, to be used when multiple similar drugs are available, and binding arbitration, to be used on new entrants to the market with limited or no competition, are being designed to work with the previously recommended drug value program, but could be implemented on their own.

In general, the reference pricing policy would set a maximum payment rate for a group of drugs with similar health effects based on the minimum, median, or other point along the range of prices for all drugs in that group. Providers would be incentivized to choose a lower-cost alternative when clinically appropriate.

Beneficiaries who still want access to a higher-cost drug would be on the hook for the difference through cost-sharing mechanisms.

MedPAC staff presented two options for setting the reference price. One would be to establish the price based on internal Medicare data. The other would take international pricing into consideration.

Binding arbitration, which is already a component of the drug value program, would be expanded. In the program described by staff, Medicare and the manufacturer would each come to the table with a price and the arbitrator (either an individual or a panel) would set one price.

Potential cost savings from one or both programs was not addressed

“It seems like an important thing for us to understand in order to know the potential impact ... through these two levers that work on different parts of the spend problem,” said Commissioner Dana Safran, head of measurement for the health care venture formed by Amazon, Berkshire Hathaway, and JPMorgan Chase.

Staff said it would work on making that determination.

Commissioners raised additional questions on operational details.

Marjorie Ginsburg, founding executive director of the Center for Healthcare Decisions Inc. in Sacramento, Calif., questioned what would happen if a manufacturer declined to participate in the arbitration process and whether that would mean Medicare would not cover a drug in that circumstance.

Jay Crosson, MD, noted that “Congress would have to … figure out how to deal with that circumstance. ... We would not want to end up with a system that would deny coverage” of effective medications for Medicare beneficiaries.

Another area affecting both issues was the potential for cross subsidization of drugs.

Jonathan Perlin, MD, president of clinical services and chief medical officer of HCA Healthcare of Nashville, Tenn., questioned whether this could open a door for a provider buying at a cheaper government price and using the drugs across patients not from Medicare or whether it could lead to higher prices being charged to commercial payers.

MedPAC staff member Kim Neuman said that “there would need to be some back end reconciliations that would happen to ensure that the stock that was then administered to Medicare patients was provided at a price that was no higher than that ceiling. ... We haven’t scoped out implications for other payers.”

Commissioner Kathy Buto, independent consultant and former vice president of global health policy at Johnson & Johnson, inquired about whether a drug would be made available upon launch while reference pricing or arbitration processes were in progress.

Commissioners also inquired as to how the reference pricing aspects will be operationalized into conversations between the doctor and the patient.

Ms. Buto also cautioned that using a reference pricing scheme could alter the dynamic of pricing competition that has companies competing against a reference price rather than doing what they can to lower prices beyond that.

[email protected]

WASHINGTON – The Medicare Payment Advisory Commission laid the foundation for developing a proposal to implement reference pricing and binding arbitration for Medicare Part B drugs that are administered in the physician’s office.

Gregory Twachtman/MDedge News

Much of the presentation, offered during the commission’s March meeting, was general ideas with more work to come in terms of fleshing out the details. An ambitious goal of having something ready for the commission’s June 2019 report to Congress was set.

The policy recommendations for reference pricing, to be used when multiple similar drugs are available, and binding arbitration, to be used on new entrants to the market with limited or no competition, are being designed to work with the previously recommended drug value program, but could be implemented on their own.

In general, the reference pricing policy would set a maximum payment rate for a group of drugs with similar health effects based on the minimum, median, or other point along the range of prices for all drugs in that group. Providers would be incentivized to choose a lower-cost alternative when clinically appropriate.

Beneficiaries who still want access to a higher-cost drug would be on the hook for the difference through cost-sharing mechanisms.

MedPAC staff presented two options for setting the reference price. One would be to establish the price based on internal Medicare data. The other would take international pricing into consideration.

Binding arbitration, which is already a component of the drug value program, would be expanded. In the program described by staff, Medicare and the manufacturer would each come to the table with a price and the arbitrator (either an individual or a panel) would set one price.

Potential cost savings from one or both programs was not addressed

“It seems like an important thing for us to understand in order to know the potential impact ... through these two levers that work on different parts of the spend problem,” said Commissioner Dana Safran, head of measurement for the health care venture formed by Amazon, Berkshire Hathaway, and JPMorgan Chase.

Staff said it would work on making that determination.

Commissioners raised additional questions on operational details.

Marjorie Ginsburg, founding executive director of the Center for Healthcare Decisions Inc. in Sacramento, Calif., questioned what would happen if a manufacturer declined to participate in the arbitration process and whether that would mean Medicare would not cover a drug in that circumstance.

Jay Crosson, MD, noted that “Congress would have to … figure out how to deal with that circumstance. ... We would not want to end up with a system that would deny coverage” of effective medications for Medicare beneficiaries.

Another area affecting both issues was the potential for cross subsidization of drugs.

Jonathan Perlin, MD, president of clinical services and chief medical officer of HCA Healthcare of Nashville, Tenn., questioned whether this could open a door for a provider buying at a cheaper government price and using the drugs across patients not from Medicare or whether it could lead to higher prices being charged to commercial payers.

MedPAC staff member Kim Neuman said that “there would need to be some back end reconciliations that would happen to ensure that the stock that was then administered to Medicare patients was provided at a price that was no higher than that ceiling. ... We haven’t scoped out implications for other payers.”

Commissioner Kathy Buto, independent consultant and former vice president of global health policy at Johnson & Johnson, inquired about whether a drug would be made available upon launch while reference pricing or arbitration processes were in progress.

Commissioners also inquired as to how the reference pricing aspects will be operationalized into conversations between the doctor and the patient.

Ms. Buto also cautioned that using a reference pricing scheme could alter the dynamic of pricing competition that has companies competing against a reference price rather than doing what they can to lower prices beyond that.

[email protected]

WASHINGTON – The Medicare Payment Advisory Commission laid the foundation for developing a proposal to implement reference pricing and binding arbitration for Medicare Part B drugs that are administered in the physician’s office.

Gregory Twachtman/MDedge News

Much of the presentation, offered during the commission’s March meeting, was general ideas with more work to come in terms of fleshing out the details. An ambitious goal of having something ready for the commission’s June 2019 report to Congress was set.

The policy recommendations for reference pricing, to be used when multiple similar drugs are available, and binding arbitration, to be used on new entrants to the market with limited or no competition, are being designed to work with the previously recommended drug value program, but could be implemented on their own.

In general, the reference pricing policy would set a maximum payment rate for a group of drugs with similar health effects based on the minimum, median, or other point along the range of prices for all drugs in that group. Providers would be incentivized to choose a lower-cost alternative when clinically appropriate.

Beneficiaries who still want access to a higher-cost drug would be on the hook for the difference through cost-sharing mechanisms.

MedPAC staff presented two options for setting the reference price. One would be to establish the price based on internal Medicare data. The other would take international pricing into consideration.

Binding arbitration, which is already a component of the drug value program, would be expanded. In the program described by staff, Medicare and the manufacturer would each come to the table with a price and the arbitrator (either an individual or a panel) would set one price.

Potential cost savings from one or both programs was not addressed

“It seems like an important thing for us to understand in order to know the potential impact ... through these two levers that work on different parts of the spend problem,” said Commissioner Dana Safran, head of measurement for the health care venture formed by Amazon, Berkshire Hathaway, and JPMorgan Chase.

Staff said it would work on making that determination.

Commissioners raised additional questions on operational details.

Marjorie Ginsburg, founding executive director of the Center for Healthcare Decisions Inc. in Sacramento, Calif., questioned what would happen if a manufacturer declined to participate in the arbitration process and whether that would mean Medicare would not cover a drug in that circumstance.

Jay Crosson, MD, noted that “Congress would have to … figure out how to deal with that circumstance. ... We would not want to end up with a system that would deny coverage” of effective medications for Medicare beneficiaries.

Another area affecting both issues was the potential for cross subsidization of drugs.

Jonathan Perlin, MD, president of clinical services and chief medical officer of HCA Healthcare of Nashville, Tenn., questioned whether this could open a door for a provider buying at a cheaper government price and using the drugs across patients not from Medicare or whether it could lead to higher prices being charged to commercial payers.

MedPAC staff member Kim Neuman said that “there would need to be some back end reconciliations that would happen to ensure that the stock that was then administered to Medicare patients was provided at a price that was no higher than that ceiling. ... We haven’t scoped out implications for other payers.”

Commissioner Kathy Buto, independent consultant and former vice president of global health policy at Johnson & Johnson, inquired about whether a drug would be made available upon launch while reference pricing or arbitration processes were in progress.

Commissioners also inquired as to how the reference pricing aspects will be operationalized into conversations between the doctor and the patient.

Ms. Buto also cautioned that using a reference pricing scheme could alter the dynamic of pricing competition that has companies competing against a reference price rather than doing what they can to lower prices beyond that.

[email protected]

Patients will actively choose lower-cost options for certain health care services if their employers reward them for doing so.

ThinkStock

“In the first 12 months of the rewards program, we observed a 2.1% relative reduction in prices across all services eligible for the program,” according to Christopher Whaley, PhD, an associate policy researcher at the RAND Corporation, and his colleagues. “This effect was most evident for MRIs, for which there was a 4.7% reduction in prices.”

The rewards program offered $25-$500 for making lower-cost choices among 131 elective services. Rewards value was based on the provider’s price and service, yielding savings of $2.3 million, or roughly $8 per person across the 269,875 employees and dependents eligible for the rewards program.

Patients who were willing to price-shop chose to save money on imaging tests including ultrasounds, mammograms, and MRIs, Dr. Whaley and his colleagues wrote.

However, initial results showed very little impact in pricing for surgical procedures, including minor (such as breast biopsy), moderate (such as arthroscopy), and major (such as hip and knee replacements), covered by the rewards program.

“There are several potential explanations for this variation across types of services,” the authors wrote. “To receive a reward, patients may need to receive care from a provider different from the one their physician initially recommended. Compared to circumstances where they need an invasive procedure, patients may feel more comfortable asking the provider for a new referral for imaging services.”

An established doctor/patient relationship could have dimmed patient interest in seeking lower cost surgical procedures.

“There is also the complexity of switching their care,” the authors wrote. “For a surgical procedure, switching providers is particularly complex, as it requires identifying a lower-price provider and potentially getting another preoperative visit.”

Quality, while also playing a role in patient choice, is not a factor in the how the rewards program is structured.

“Patients may view imaging services more as commodity services and therefore may be more likely to switch, while patients may be more worried about the quality of lower-price surgeons.”

Building further on that, Dr. Whaley said in an interview that if the program becomes more widely used and successful, it could start to instill more price-shopping for procedures and create levers for pricing wars among local physicians.

“We don’t know if there will be an impact for procedural services in later years,” he said. “On one hand, patients simply may not be willing to price shop for these services. On the other hand, patients may learn about price-shopping for these services or the insurance company might continue to develop the model and try to get patients to shop.”

This, in turn, could potentially affect the dynamic of negotiations between providers and insurance companies for network placement, Dr. Whaley noted.

“It could be a ‘stick’ for insurers to use for negotiations with higher-priced providers. Insurers could say, ‘unless you lower your prices, we’ll pay patients to go to your competitor,’” something he said could ultimately be beneficial to lower-cost providers.

Dr. Whaley also noted that there was a small reduction (0.3 percentage points) in overall health care use among patients using reward-eligible services.

“The intervention population still had to pay their usual out-of-pocket payments, and a patient’s out-of-pocket expense was much higher than the reward amount, on average,” he said. “Therefore, this reduction in utilization may be due to patients’ using the price-shopping tool, becoming more aware of these out-of-pocket liabilities, and deciding to not get care from any provider.”
 

[email protected]

SOURCE: Whaley C et al. Health Aff (Millwood). 2019 Mar;38(3):440-7.

Patients will actively choose lower-cost options for certain health care services if their employers reward them for doing so.

ThinkStock

“In the first 12 months of the rewards program, we observed a 2.1% relative reduction in prices across all services eligible for the program,” according to Christopher Whaley, PhD, an associate policy researcher at the RAND Corporation, and his colleagues. “This effect was most evident for MRIs, for which there was a 4.7% reduction in prices.”

The rewards program offered $25-$500 for making lower-cost choices among 131 elective services. Rewards value was based on the provider’s price and service, yielding savings of $2.3 million, or roughly $8 per person across the 269,875 employees and dependents eligible for the rewards program.

Patients who were willing to price-shop chose to save money on imaging tests including ultrasounds, mammograms, and MRIs, Dr. Whaley and his colleagues wrote.

However, initial results showed very little impact in pricing for surgical procedures, including minor (such as breast biopsy), moderate (such as arthroscopy), and major (such as hip and knee replacements), covered by the rewards program.

“There are several potential explanations for this variation across types of services,” the authors wrote. “To receive a reward, patients may need to receive care from a provider different from the one their physician initially recommended. Compared to circumstances where they need an invasive procedure, patients may feel more comfortable asking the provider for a new referral for imaging services.”

An established doctor/patient relationship could have dimmed patient interest in seeking lower cost surgical procedures.

“There is also the complexity of switching their care,” the authors wrote. “For a surgical procedure, switching providers is particularly complex, as it requires identifying a lower-price provider and potentially getting another preoperative visit.”

Quality, while also playing a role in patient choice, is not a factor in the how the rewards program is structured.

“Patients may view imaging services more as commodity services and therefore may be more likely to switch, while patients may be more worried about the quality of lower-price surgeons.”

Building further on that, Dr. Whaley said in an interview that if the program becomes more widely used and successful, it could start to instill more price-shopping for procedures and create levers for pricing wars among local physicians.

“We don’t know if there will be an impact for procedural services in later years,” he said. “On one hand, patients simply may not be willing to price shop for these services. On the other hand, patients may learn about price-shopping for these services or the insurance company might continue to develop the model and try to get patients to shop.”

This, in turn, could potentially affect the dynamic of negotiations between providers and insurance companies for network placement, Dr. Whaley noted.

“It could be a ‘stick’ for insurers to use for negotiations with higher-priced providers. Insurers could say, ‘unless you lower your prices, we’ll pay patients to go to your competitor,’” something he said could ultimately be beneficial to lower-cost providers.

Dr. Whaley also noted that there was a small reduction (0.3 percentage points) in overall health care use among patients using reward-eligible services.

“The intervention population still had to pay their usual out-of-pocket payments, and a patient’s out-of-pocket expense was much higher than the reward amount, on average,” he said. “Therefore, this reduction in utilization may be due to patients’ using the price-shopping tool, becoming more aware of these out-of-pocket liabilities, and deciding to not get care from any provider.”
 

[email protected]

SOURCE: Whaley C et al. Health Aff (Millwood). 2019 Mar;38(3):440-7.

Patients will actively choose lower-cost options for certain health care services if their employers reward them for doing so.

ThinkStock

“In the first 12 months of the rewards program, we observed a 2.1% relative reduction in prices across all services eligible for the program,” according to Christopher Whaley, PhD, an associate policy researcher at the RAND Corporation, and his colleagues. “This effect was most evident for MRIs, for which there was a 4.7% reduction in prices.”

The rewards program offered $25-$500 for making lower-cost choices among 131 elective services. Rewards value was based on the provider’s price and service, yielding savings of $2.3 million, or roughly $8 per person across the 269,875 employees and dependents eligible for the rewards program.

Patients who were willing to price-shop chose to save money on imaging tests including ultrasounds, mammograms, and MRIs, Dr. Whaley and his colleagues wrote.

However, initial results showed very little impact in pricing for surgical procedures, including minor (such as breast biopsy), moderate (such as arthroscopy), and major (such as hip and knee replacements), covered by the rewards program.

“There are several potential explanations for this variation across types of services,” the authors wrote. “To receive a reward, patients may need to receive care from a provider different from the one their physician initially recommended. Compared to circumstances where they need an invasive procedure, patients may feel more comfortable asking the provider for a new referral for imaging services.”

An established doctor/patient relationship could have dimmed patient interest in seeking lower cost surgical procedures.

“There is also the complexity of switching their care,” the authors wrote. “For a surgical procedure, switching providers is particularly complex, as it requires identifying a lower-price provider and potentially getting another preoperative visit.”

Quality, while also playing a role in patient choice, is not a factor in the how the rewards program is structured.

“Patients may view imaging services more as commodity services and therefore may be more likely to switch, while patients may be more worried about the quality of lower-price surgeons.”

Building further on that, Dr. Whaley said in an interview that if the program becomes more widely used and successful, it could start to instill more price-shopping for procedures and create levers for pricing wars among local physicians.

“We don’t know if there will be an impact for procedural services in later years,” he said. “On one hand, patients simply may not be willing to price shop for these services. On the other hand, patients may learn about price-shopping for these services or the insurance company might continue to develop the model and try to get patients to shop.”

This, in turn, could potentially affect the dynamic of negotiations between providers and insurance companies for network placement, Dr. Whaley noted.

“It could be a ‘stick’ for insurers to use for negotiations with higher-priced providers. Insurers could say, ‘unless you lower your prices, we’ll pay patients to go to your competitor,’” something he said could ultimately be beneficial to lower-cost providers.

Dr. Whaley also noted that there was a small reduction (0.3 percentage points) in overall health care use among patients using reward-eligible services.

“The intervention population still had to pay their usual out-of-pocket payments, and a patient’s out-of-pocket expense was much higher than the reward amount, on average,” he said. “Therefore, this reduction in utilization may be due to patients’ using the price-shopping tool, becoming more aware of these out-of-pocket liabilities, and deciding to not get care from any provider.”
 

[email protected]

SOURCE: Whaley C et al. Health Aff (Millwood). 2019 Mar;38(3):440-7.

Almost 70% of adults believe that the Food and Drug Administration should raise the legal age to purchase e-cigarettes and tobacco, according to a new survey by NORC at the University of Chicago, a nonpartisan research institution.

“Americans are particularly concerned about teens becoming newly addicted to e-cigarettes, and they support a range of actions the federal government could take to make vaping products less available, less addictive, and less appealing,” Caroline Pearson, senior vice president at NORC, said in a written statement.

The AmeriSpeak Spotlight on Health Poll, conducted Feb. 14-18, 2019 (margin of error, plus or minus 4.12%), showed that 69% of adults strongly or somewhat support raising the age limit to purchase e-cigarettes and tobacco and 55% support restricting sales of flavored e-cigarettes, NORC reported. Almost 40% of the 1,004 respondents expressed support for a complete ban on e-cigarettes.

Despite FDA efforts under Commissioner Scott Gottlieb, MD, to raise awareness of teen vaping, only 21% of those surveyed correctly responded that e-cigarettes generally contain more nicotine that regular cigarettes. Dr. Gottlieb announced his resignation recently, “but he indicated that the Trump Administration will continue efforts to increase regulation of e-cigarettes,” NORC said.

[email protected]

Almost 70% of adults believe that the Food and Drug Administration should raise the legal age to purchase e-cigarettes and tobacco, according to a new survey by NORC at the University of Chicago, a nonpartisan research institution.

“Americans are particularly concerned about teens becoming newly addicted to e-cigarettes, and they support a range of actions the federal government could take to make vaping products less available, less addictive, and less appealing,” Caroline Pearson, senior vice president at NORC, said in a written statement.

The AmeriSpeak Spotlight on Health Poll, conducted Feb. 14-18, 2019 (margin of error, plus or minus 4.12%), showed that 69% of adults strongly or somewhat support raising the age limit to purchase e-cigarettes and tobacco and 55% support restricting sales of flavored e-cigarettes, NORC reported. Almost 40% of the 1,004 respondents expressed support for a complete ban on e-cigarettes.

Despite FDA efforts under Commissioner Scott Gottlieb, MD, to raise awareness of teen vaping, only 21% of those surveyed correctly responded that e-cigarettes generally contain more nicotine that regular cigarettes. Dr. Gottlieb announced his resignation recently, “but he indicated that the Trump Administration will continue efforts to increase regulation of e-cigarettes,” NORC said.

[email protected]

Almost 70% of adults believe that the Food and Drug Administration should raise the legal age to purchase e-cigarettes and tobacco, according to a new survey by NORC at the University of Chicago, a nonpartisan research institution.

“Americans are particularly concerned about teens becoming newly addicted to e-cigarettes, and they support a range of actions the federal government could take to make vaping products less available, less addictive, and less appealing,” Caroline Pearson, senior vice president at NORC, said in a written statement.

The AmeriSpeak Spotlight on Health Poll, conducted Feb. 14-18, 2019 (margin of error, plus or minus 4.12%), showed that 69% of adults strongly or somewhat support raising the age limit to purchase e-cigarettes and tobacco and 55% support restricting sales of flavored e-cigarettes, NORC reported. Almost 40% of the 1,004 respondents expressed support for a complete ban on e-cigarettes.

Despite FDA efforts under Commissioner Scott Gottlieb, MD, to raise awareness of teen vaping, only 21% of those surveyed correctly responded that e-cigarettes generally contain more nicotine that regular cigarettes. Dr. Gottlieb announced his resignation recently, “but he indicated that the Trump Administration will continue efforts to increase regulation of e-cigarettes,” NORC said.

[email protected]

Nearly 6 million veterans get health care scheduling reminders via VEText, an interactive mobile program launched a year ago. More than 70 million text messages later, how is VEText doing? Apparently, well. The VA says an “overwhelming majority” of veterans like the enhanced access. Only 4% have opted out.

The VA has worked to improve the user experience along the way. The latest enhancement allows the VA to send facility and clinic location in the unsecured text message appointment reminders. One user, James Preston, interviewed for a VA article, says at the Loma Linda VA Medical Center veterans still had to use the information desk to find out exactly where they needed to go. “Now it’s almost perfect,” he says, “because it provides all the necessary information.” Deanna Callahan, innovation specialist and National Program Manager for VEText, says before VEText, the VA was relying on phone calls, robocalls, and mail. “We wanted to modernize our efforts to not only bring text message appointment reminders but go above and beyond and positively affect the No Show rate.” It worked—the No Show rate has dropped from 13.7% to 11.7% in the year the program has been active.

The system automatically enrolls veterans based on phone information already on file, but they can opt out by replying STOP to a reminder. Accidentally opting out is easily reversed by replying START to a previous reminder. Reminders are sent for clinical appointments at local medical centers and outpatient clinics, but not for Lab, Community Care, Research, Telephone Clinics, or Home-based Primary Care. (The reminders are additional—they do not replace letters, postcards, or automated phone call reminders.) VEText itself does not cost the veteran anything, but text messaging rates may apply, depending on individual cell phone plans. For more information, go to www.va.gov/HEALTH/vetext_faqs.asp.

Nearly 6 million veterans get health care scheduling reminders via VEText, an interactive mobile program launched a year ago. More than 70 million text messages later, how is VEText doing? Apparently, well. The VA says an “overwhelming majority” of veterans like the enhanced access. Only 4% have opted out.

The VA has worked to improve the user experience along the way. The latest enhancement allows the VA to send facility and clinic location in the unsecured text message appointment reminders. One user, James Preston, interviewed for a VA article, says at the Loma Linda VA Medical Center veterans still had to use the information desk to find out exactly where they needed to go. “Now it’s almost perfect,” he says, “because it provides all the necessary information.” Deanna Callahan, innovation specialist and National Program Manager for VEText, says before VEText, the VA was relying on phone calls, robocalls, and mail. “We wanted to modernize our efforts to not only bring text message appointment reminders but go above and beyond and positively affect the No Show rate.” It worked—the No Show rate has dropped from 13.7% to 11.7% in the year the program has been active.

The system automatically enrolls veterans based on phone information already on file, but they can opt out by replying STOP to a reminder. Accidentally opting out is easily reversed by replying START to a previous reminder. Reminders are sent for clinical appointments at local medical centers and outpatient clinics, but not for Lab, Community Care, Research, Telephone Clinics, or Home-based Primary Care. (The reminders are additional—they do not replace letters, postcards, or automated phone call reminders.) VEText itself does not cost the veteran anything, but text messaging rates may apply, depending on individual cell phone plans. For more information, go to www.va.gov/HEALTH/vetext_faqs.asp.

Nearly 6 million veterans get health care scheduling reminders via VEText, an interactive mobile program launched a year ago. More than 70 million text messages later, how is VEText doing? Apparently, well. The VA says an “overwhelming majority” of veterans like the enhanced access. Only 4% have opted out.

The VA has worked to improve the user experience along the way. The latest enhancement allows the VA to send facility and clinic location in the unsecured text message appointment reminders. One user, James Preston, interviewed for a VA article, says at the Loma Linda VA Medical Center veterans still had to use the information desk to find out exactly where they needed to go. “Now it’s almost perfect,” he says, “because it provides all the necessary information.” Deanna Callahan, innovation specialist and National Program Manager for VEText, says before VEText, the VA was relying on phone calls, robocalls, and mail. “We wanted to modernize our efforts to not only bring text message appointment reminders but go above and beyond and positively affect the No Show rate.” It worked—the No Show rate has dropped from 13.7% to 11.7% in the year the program has been active.

The system automatically enrolls veterans based on phone information already on file, but they can opt out by replying STOP to a reminder. Accidentally opting out is easily reversed by replying START to a previous reminder. Reminders are sent for clinical appointments at local medical centers and outpatient clinics, but not for Lab, Community Care, Research, Telephone Clinics, or Home-based Primary Care. (The reminders are additional—they do not replace letters, postcards, or automated phone call reminders.) VEText itself does not cost the veteran anything, but text messaging rates may apply, depending on individual cell phone plans. For more information, go to www.va.gov/HEALTH/vetext_faqs.asp.

In 1973, the Supreme Court of the United States recognized a constitutional right to abortion in the landmark case of Roe v Wade. The Court held that states may regulate, but not ban, abortion after the first trimester, for the purpose of protecting the woman’s health. The Court further indicated that states’ interest in “potential life” could be the basis for abortion regulations only after the point of viability, at which point states may ban abortion except when necessary to preserve the life or health of the woman.¹ In 1992, the Court decided Planned Parenthood v Casey and eliminated the trimester framework while upholding women’s right to abortion.² As with Roe v Wade, the Casey decision held that there must be an exception for the woman’s health and life.

Fast forward to 2019

New York passed a law in 2019,³ and Virginia had a proposed law that was recently tabled by the House of Delegates,⁴ both related to abortions performed past the first trimester.

New York. The New York law supports legal abortion by a licensed practitioner within 24 weeks of pregnancy commencement. After 24 weeks’ gestation, if there is “an absence of fetal viability, or the abortion is necessary to protect the patient’s life or health” then termination is permissible.³

Virginia. Previously, Virginia had abortion laws that required significant measures to approve a third-trimester abortion, including certification by 3 physicians that the procedure is necessary to “save mother’s life or [prevent] substantial and irremediable impairment of mental or physical health of the mother.”⁵ Violation included potential for jail time and a significant monetary fine.

The proposed bill, now tabled, was introduced by delegate Kathy Tran (House Bill 2491) and would have rolled back many requirements of the old law, including the 24-hour waiting period and mandate for second-trimester abortions to occur in a hospital.

The controversy centered on a provision concerning third-trimester abortions. Specifically, the proposed bill would only have required 1 doctor to deem the abortion necessary and would have removed the “substantially and irremediably” qualifier. Thus, abortions would be allowed in cases in which the woman’s mental or physical health was threatened, even in cases in which the potential damage may be reversible.⁵
 

The facts

Misconceptions about abortion care can be dangerous and work to further stigmatize our patients who may need an abortion or who have had an abortion in the past. The American College of Obstetricians and Gynecologists (ACOG) recently published a document discussing facts regarding abortion care later in pregnancy. The document (aptly named “Facts are Important”) enforces that policy be based on medical science and facts, and not simply driven by political beliefs.⁶

Fact. The majority of abortions occur prior to 21 weeks, before viability:

• 91.1% of abortions occur at or before 13 weeks’ gestation⁷
• only 1.3% of abortions occur at or after 21 weeks’ gestation⁷
• abortions occurring later in the second trimester or in the third trimester are very uncommon.

Fact. The language “late-term abortion” has no medical definition, is not used in a clinical setting or to describe the delivery of abortion care later in pregnancy in any medical institution.⁶

Fact. Many of the abortions occurring later in pregnancy are due to fetal anomalies incompatible with life. Anomalies can include lack of a major portion of the brain (anencephaly), bilateral renal agenesis, some skeletal dysplasias, and other chromosomal abnormalities. These are cases in which death is likely before or shortly after birth, with great potential for suffering of both the fetus and the family.

Fact. The need for abortion also may be due to serious complications that will likely cause significant morbidity or mortality to the woman. These complications, in turn, reduce the likelihood of survival of the fetus.

It is thus vital for women to have the freedom to evaluate their medical circumstance with their provider and, using evidence, make informed health care decisions—which may include abortion, induction of labor, or cesarean delivery in some circumstances. Access to accurate, complete information and care is a right bestowed amongst all women and “must never be constrained by politicians.”⁶ We must focus on medically appropriate and compassionate care for both the family and the fetus.

Use your voice

As clinicians, we are trusted members of our communities. The New York law and the prior proposed Virginia law emphasize important access to care for women and their families. Abortions at a later gestational age are a rare event but are most often performed when the health or life of the mother is at risk or the fetus has an anomaly incompatible with life.

We urge you to use your voice to correct misconceptions, whether in your office with your patients or colleagues or in your communities, locally and nationally. Email your friends and colleagues about ACOG’s “Facts are Important” document, organize a grand rounds on the topic, and utilize social media to share facts about abortion care. These actions support our patients and can make an impact by spreading factual information.

For more facts and figures about abortion laws, visit the website of the Guttmacher Institute.

In 1973, the Supreme Court of the United States recognized a constitutional right to abortion in the landmark case of Roe v Wade. The Court held that states may regulate, but not ban, abortion after the first trimester, for the purpose of protecting the woman’s health. The Court further indicated that states’ interest in “potential life” could be the basis for abortion regulations only after the point of viability, at which point states may ban abortion except when necessary to preserve the life or health of the woman.¹ In 1992, the Court decided Planned Parenthood v Casey and eliminated the trimester framework while upholding women’s right to abortion.² As with Roe v Wade, the Casey decision held that there must be an exception for the woman’s health and life.

Fast forward to 2019

New York passed a law in 2019,³ and Virginia had a proposed law that was recently tabled by the House of Delegates,⁴ both related to abortions performed past the first trimester.

New York. The New York law supports legal abortion by a licensed practitioner within 24 weeks of pregnancy commencement. After 24 weeks’ gestation, if there is “an absence of fetal viability, or the abortion is necessary to protect the patient’s life or health” then termination is permissible.³

Virginia. Previously, Virginia had abortion laws that required significant measures to approve a third-trimester abortion, including certification by 3 physicians that the procedure is necessary to “save mother’s life or [prevent] substantial and irremediable impairment of mental or physical health of the mother.”⁵ Violation included potential for jail time and a significant monetary fine.

The proposed bill, now tabled, was introduced by delegate Kathy Tran (House Bill 2491) and would have rolled back many requirements of the old law, including the 24-hour waiting period and mandate for second-trimester abortions to occur in a hospital.

The controversy centered on a provision concerning third-trimester abortions. Specifically, the proposed bill would only have required 1 doctor to deem the abortion necessary and would have removed the “substantially and irremediably” qualifier. Thus, abortions would be allowed in cases in which the woman’s mental or physical health was threatened, even in cases in which the potential damage may be reversible.⁵
 

The facts

Misconceptions about abortion care can be dangerous and work to further stigmatize our patients who may need an abortion or who have had an abortion in the past. The American College of Obstetricians and Gynecologists (ACOG) recently published a document discussing facts regarding abortion care later in pregnancy. The document (aptly named “Facts are Important”) enforces that policy be based on medical science and facts, and not simply driven by political beliefs.⁶

Fact. The majority of abortions occur prior to 21 weeks, before viability:

• 91.1% of abortions occur at or before 13 weeks’ gestation⁷
• only 1.3% of abortions occur at or after 21 weeks’ gestation⁷
• abortions occurring later in the second trimester or in the third trimester are very uncommon.

Fact. The language “late-term abortion” has no medical definition, is not used in a clinical setting or to describe the delivery of abortion care later in pregnancy in any medical institution.⁶

Fact. Many of the abortions occurring later in pregnancy are due to fetal anomalies incompatible with life. Anomalies can include lack of a major portion of the brain (anencephaly), bilateral renal agenesis, some skeletal dysplasias, and other chromosomal abnormalities. These are cases in which death is likely before or shortly after birth, with great potential for suffering of both the fetus and the family.

Fact. The need for abortion also may be due to serious complications that will likely cause significant morbidity or mortality to the woman. These complications, in turn, reduce the likelihood of survival of the fetus.

It is thus vital for women to have the freedom to evaluate their medical circumstance with their provider and, using evidence, make informed health care decisions—which may include abortion, induction of labor, or cesarean delivery in some circumstances. Access to accurate, complete information and care is a right bestowed amongst all women and “must never be constrained by politicians.”⁶ We must focus on medically appropriate and compassionate care for both the family and the fetus.

Use your voice

As clinicians, we are trusted members of our communities. The New York law and the prior proposed Virginia law emphasize important access to care for women and their families. Abortions at a later gestational age are a rare event but are most often performed when the health or life of the mother is at risk or the fetus has an anomaly incompatible with life.

We urge you to use your voice to correct misconceptions, whether in your office with your patients or colleagues or in your communities, locally and nationally. Email your friends and colleagues about ACOG’s “Facts are Important” document, organize a grand rounds on the topic, and utilize social media to share facts about abortion care. These actions support our patients and can make an impact by spreading factual information.

For more facts and figures about abortion laws, visit the website of the Guttmacher Institute.

In 1973, the Supreme Court of the United States recognized a constitutional right to abortion in the landmark case of Roe v Wade. The Court held that states may regulate, but not ban, abortion after the first trimester, for the purpose of protecting the woman’s health. The Court further indicated that states’ interest in “potential life” could be the basis for abortion regulations only after the point of viability, at which point states may ban abortion except when necessary to preserve the life or health of the woman.¹ In 1992, the Court decided Planned Parenthood v Casey and eliminated the trimester framework while upholding women’s right to abortion.² As with Roe v Wade, the Casey decision held that there must be an exception for the woman’s health and life.

Fast forward to 2019

New York passed a law in 2019,³ and Virginia had a proposed law that was recently tabled by the House of Delegates,⁴ both related to abortions performed past the first trimester.

New York. The New York law supports legal abortion by a licensed practitioner within 24 weeks of pregnancy commencement. After 24 weeks’ gestation, if there is “an absence of fetal viability, or the abortion is necessary to protect the patient’s life or health” then termination is permissible.³

Virginia. Previously, Virginia had abortion laws that required significant measures to approve a third-trimester abortion, including certification by 3 physicians that the procedure is necessary to “save mother’s life or [prevent] substantial and irremediable impairment of mental or physical health of the mother.”⁵ Violation included potential for jail time and a significant monetary fine.

The proposed bill, now tabled, was introduced by delegate Kathy Tran (House Bill 2491) and would have rolled back many requirements of the old law, including the 24-hour waiting period and mandate for second-trimester abortions to occur in a hospital.

The controversy centered on a provision concerning third-trimester abortions. Specifically, the proposed bill would only have required 1 doctor to deem the abortion necessary and would have removed the “substantially and irremediably” qualifier. Thus, abortions would be allowed in cases in which the woman’s mental or physical health was threatened, even in cases in which the potential damage may be reversible.⁵
 

The facts

Misconceptions about abortion care can be dangerous and work to further stigmatize our patients who may need an abortion or who have had an abortion in the past. The American College of Obstetricians and Gynecologists (ACOG) recently published a document discussing facts regarding abortion care later in pregnancy. The document (aptly named “Facts are Important”) enforces that policy be based on medical science and facts, and not simply driven by political beliefs.⁶

Fact. The majority of abortions occur prior to 21 weeks, before viability:

• 91.1% of abortions occur at or before 13 weeks’ gestation⁷
• only 1.3% of abortions occur at or after 21 weeks’ gestation⁷
• abortions occurring later in the second trimester or in the third trimester are very uncommon.

Fact. The language “late-term abortion” has no medical definition, is not used in a clinical setting or to describe the delivery of abortion care later in pregnancy in any medical institution.⁶

Fact. Many of the abortions occurring later in pregnancy are due to fetal anomalies incompatible with life. Anomalies can include lack of a major portion of the brain (anencephaly), bilateral renal agenesis, some skeletal dysplasias, and other chromosomal abnormalities. These are cases in which death is likely before or shortly after birth, with great potential for suffering of both the fetus and the family.

Fact. The need for abortion also may be due to serious complications that will likely cause significant morbidity or mortality to the woman. These complications, in turn, reduce the likelihood of survival of the fetus.

It is thus vital for women to have the freedom to evaluate their medical circumstance with their provider and, using evidence, make informed health care decisions—which may include abortion, induction of labor, or cesarean delivery in some circumstances. Access to accurate, complete information and care is a right bestowed amongst all women and “must never be constrained by politicians.”⁶ We must focus on medically appropriate and compassionate care for both the family and the fetus.

Use your voice

As clinicians, we are trusted members of our communities. The New York law and the prior proposed Virginia law emphasize important access to care for women and their families. Abortions at a later gestational age are a rare event but are most often performed when the health or life of the mother is at risk or the fetus has an anomaly incompatible with life.

We urge you to use your voice to correct misconceptions, whether in your office with your patients or colleagues or in your communities, locally and nationally. Email your friends and colleagues about ACOG’s “Facts are Important” document, organize a grand rounds on the topic, and utilize social media to share facts about abortion care. These actions support our patients and can make an impact by spreading factual information.

For more facts and figures about abortion laws, visit the website of the Guttmacher Institute.

At 8:07 am on January 13, 2018, people in Hawaii received an emergency alert advising them to seek shelter from an incoming ballistic missile.

A very long 38 minutes later, the message was retracted via the same systems that had sent it—the Wireless Emergency Alert system, which sends location-based warnings to wireless carrier systems, and the Emergency Alert System, which sends television and radio alerts.

The Federal Communications Commission report that covered the debacle noted that, among other errors, the employee responsible for triggering the false alert believed the missile threat was real. Moreover, the exercise plans did not document a process for disseminating an all-clear message. And on top of that, the established ballistic missile alert checklist did not include a step to notify the Hawaii Emergency Management Agency’s public information officer responsible for communicating with the public, media, other agencies, and other stakeholders during an incident.

Researchers from the CDC and Hawaii Department of Health analyzed tweets sent during 2 periods: early (8:07-8:45 am), the 38 minutes during which the alert circulated; and the late period (8:46-9:24 am), the same amount of elapsed time after the correction had been issued.

They found 4 themes dominated the early period: information processing, information sharing, authentication, and emotional reaction (shock, fear, panic, terror). Information processing was defined as any indication of initial mental processing of the alert. Many of the tweets dealt with coming to terms with the threat.

During the late period, information sharing and emotional reaction persisted, but they were joined by new themes that, according to the researchers, were “fundamentally different” from the early-period themes and reflected reactions to misinformation: denunciation, insufficient knowledge to act, and mistrust of authority. “Insufficient knowledge to act” involved reacting to the lack of a response plan, particularly not knowing how to properly take shelter. Denunciations blamed the emergency warning and response, especially the time it took to correct the mistake. Mistrust of authority involved doubting the emergency alert system or governmental response.

How can a situation like this be better handled? The researchers say public health messaging during an emergency is complicated. For instance, it is influenced by how messages are perceived and interpreted by different people, and by the fact that messages need to be sent over multiple platforms to ensure that the information is disseminated accurately and quickly.

Which is why social media is both a handicap and a boon in public health emergencies. Tweets spread misinformation as fast as information (if not faster), so the first messages are critical. In addition to conveying timely messages, the researchers advise, public health authorities need to address the reactions during each phase of a crisis. They also need to establish credibility to prevent the public from mistrusting the public health message and its issuers.

Most important, perhaps: Alerts should carry clear instructions for persons in the affected area to carry out during an emergency.

At 8:07 am on January 13, 2018, people in Hawaii received an emergency alert advising them to seek shelter from an incoming ballistic missile.

A very long 38 minutes later, the message was retracted via the same systems that had sent it—the Wireless Emergency Alert system, which sends location-based warnings to wireless carrier systems, and the Emergency Alert System, which sends television and radio alerts.

The Federal Communications Commission report that covered the debacle noted that, among other errors, the employee responsible for triggering the false alert believed the missile threat was real. Moreover, the exercise plans did not document a process for disseminating an all-clear message. And on top of that, the established ballistic missile alert checklist did not include a step to notify the Hawaii Emergency Management Agency’s public information officer responsible for communicating with the public, media, other agencies, and other stakeholders during an incident.

Researchers from the CDC and Hawaii Department of Health analyzed tweets sent during 2 periods: early (8:07-8:45 am), the 38 minutes during which the alert circulated; and the late period (8:46-9:24 am), the same amount of elapsed time after the correction had been issued.

They found 4 themes dominated the early period: information processing, information sharing, authentication, and emotional reaction (shock, fear, panic, terror). Information processing was defined as any indication of initial mental processing of the alert. Many of the tweets dealt with coming to terms with the threat.

During the late period, information sharing and emotional reaction persisted, but they were joined by new themes that, according to the researchers, were “fundamentally different” from the early-period themes and reflected reactions to misinformation: denunciation, insufficient knowledge to act, and mistrust of authority. “Insufficient knowledge to act” involved reacting to the lack of a response plan, particularly not knowing how to properly take shelter. Denunciations blamed the emergency warning and response, especially the time it took to correct the mistake. Mistrust of authority involved doubting the emergency alert system or governmental response.

How can a situation like this be better handled? The researchers say public health messaging during an emergency is complicated. For instance, it is influenced by how messages are perceived and interpreted by different people, and by the fact that messages need to be sent over multiple platforms to ensure that the information is disseminated accurately and quickly.

Which is why social media is both a handicap and a boon in public health emergencies. Tweets spread misinformation as fast as information (if not faster), so the first messages are critical. In addition to conveying timely messages, the researchers advise, public health authorities need to address the reactions during each phase of a crisis. They also need to establish credibility to prevent the public from mistrusting the public health message and its issuers.

Most important, perhaps: Alerts should carry clear instructions for persons in the affected area to carry out during an emergency.

At 8:07 am on January 13, 2018, people in Hawaii received an emergency alert advising them to seek shelter from an incoming ballistic missile.

A very long 38 minutes later, the message was retracted via the same systems that had sent it—the Wireless Emergency Alert system, which sends location-based warnings to wireless carrier systems, and the Emergency Alert System, which sends television and radio alerts.

The Federal Communications Commission report that covered the debacle noted that, among other errors, the employee responsible for triggering the false alert believed the missile threat was real. Moreover, the exercise plans did not document a process for disseminating an all-clear message. And on top of that, the established ballistic missile alert checklist did not include a step to notify the Hawaii Emergency Management Agency’s public information officer responsible for communicating with the public, media, other agencies, and other stakeholders during an incident.

Researchers from the CDC and Hawaii Department of Health analyzed tweets sent during 2 periods: early (8:07-8:45 am), the 38 minutes during which the alert circulated; and the late period (8:46-9:24 am), the same amount of elapsed time after the correction had been issued.

They found 4 themes dominated the early period: information processing, information sharing, authentication, and emotional reaction (shock, fear, panic, terror). Information processing was defined as any indication of initial mental processing of the alert. Many of the tweets dealt with coming to terms with the threat.

During the late period, information sharing and emotional reaction persisted, but they were joined by new themes that, according to the researchers, were “fundamentally different” from the early-period themes and reflected reactions to misinformation: denunciation, insufficient knowledge to act, and mistrust of authority. “Insufficient knowledge to act” involved reacting to the lack of a response plan, particularly not knowing how to properly take shelter. Denunciations blamed the emergency warning and response, especially the time it took to correct the mistake. Mistrust of authority involved doubting the emergency alert system or governmental response.

How can a situation like this be better handled? The researchers say public health messaging during an emergency is complicated. For instance, it is influenced by how messages are perceived and interpreted by different people, and by the fact that messages need to be sent over multiple platforms to ensure that the information is disseminated accurately and quickly.

Which is why social media is both a handicap and a boon in public health emergencies. Tweets spread misinformation as fast as information (if not faster), so the first messages are critical. In addition to conveying timely messages, the researchers advise, public health authorities need to address the reactions during each phase of a crisis. They also need to establish credibility to prevent the public from mistrusting the public health message and its issuers.

Most important, perhaps: Alerts should carry clear instructions for persons in the affected area to carry out during an emergency.

The use of prior authorization for prescriptions and medical services has continued to increase in recent years, despite the consequences to continuity of care, according to a survey by the American Medical Association.

Half of the 1,000 practicing physicians who responded said that prior authorization (PA) for prescriptions have increased significantly over the last 5 years, and 41% said that PA for medical services has done the same. The corresponding numbers for 5-year decreases in PAs were 2% and 1%, the AMA reported March 12.

Results of the survey, conducted in December 2018, also show that 85% of physicians believe that prior authorization sometimes, often, or always has a negative effect on the continuity of patients’ care. Almost 70% of respondents said that it is somewhat or extremely difficult to determine when PA is required for a prescription or medical service, and only 8% reported contracting with a health plan that offers programs to exempt physicians from the PA process, the AMA said.

“Physicians follow insurance protocols for prior authorization that require faxing recurring paperwork, multiple phone calls, and hours spent on hold. At the same time, patients’ lives can hang in the balance until health plans decide if needed care will qualify for insurance coverage,” AMA President Barbara L. McAneny, MD, said in a statement.

In January 2018, two organizations representing insurers – America’s Health Insurance Plans and the Blue Cross Blue Shield Association – signed onto a joint consensus statement with the AMA and other health care groups that provided five areas for improvement of the PA process. The current survey results show that “most health plans are not making meaningful progress on reforming the cumbersome prior authorization process,” the AMA said.

[email protected]

The use of prior authorization for prescriptions and medical services has continued to increase in recent years, despite the consequences to continuity of care, according to a survey by the American Medical Association.

Half of the 1,000 practicing physicians who responded said that prior authorization (PA) for prescriptions have increased significantly over the last 5 years, and 41% said that PA for medical services has done the same. The corresponding numbers for 5-year decreases in PAs were 2% and 1%, the AMA reported March 12.

Results of the survey, conducted in December 2018, also show that 85% of physicians believe that prior authorization sometimes, often, or always has a negative effect on the continuity of patients’ care. Almost 70% of respondents said that it is somewhat or extremely difficult to determine when PA is required for a prescription or medical service, and only 8% reported contracting with a health plan that offers programs to exempt physicians from the PA process, the AMA said.

“Physicians follow insurance protocols for prior authorization that require faxing recurring paperwork, multiple phone calls, and hours spent on hold. At the same time, patients’ lives can hang in the balance until health plans decide if needed care will qualify for insurance coverage,” AMA President Barbara L. McAneny, MD, said in a statement.

In January 2018, two organizations representing insurers – America’s Health Insurance Plans and the Blue Cross Blue Shield Association – signed onto a joint consensus statement with the AMA and other health care groups that provided five areas for improvement of the PA process. The current survey results show that “most health plans are not making meaningful progress on reforming the cumbersome prior authorization process,” the AMA said.

[email protected]

The use of prior authorization for prescriptions and medical services has continued to increase in recent years, despite the consequences to continuity of care, according to a survey by the American Medical Association.

Half of the 1,000 practicing physicians who responded said that prior authorization (PA) for prescriptions have increased significantly over the last 5 years, and 41% said that PA for medical services has done the same. The corresponding numbers for 5-year decreases in PAs were 2% and 1%, the AMA reported March 12.

Results of the survey, conducted in December 2018, also show that 85% of physicians believe that prior authorization sometimes, often, or always has a negative effect on the continuity of patients’ care. Almost 70% of respondents said that it is somewhat or extremely difficult to determine when PA is required for a prescription or medical service, and only 8% reported contracting with a health plan that offers programs to exempt physicians from the PA process, the AMA said.

“Physicians follow insurance protocols for prior authorization that require faxing recurring paperwork, multiple phone calls, and hours spent on hold. At the same time, patients’ lives can hang in the balance until health plans decide if needed care will qualify for insurance coverage,” AMA President Barbara L. McAneny, MD, said in a statement.

In January 2018, two organizations representing insurers – America’s Health Insurance Plans and the Blue Cross Blue Shield Association – signed onto a joint consensus statement with the AMA and other health care groups that provided five areas for improvement of the PA process. The current survey results show that “most health plans are not making meaningful progress on reforming the cumbersome prior authorization process,” the AMA said.

[email protected]

The U.S. military is devising major reductions in its medical corps, unnerving the system’s advocates who fear the cuts will hobble the armed forces’ ability to adequately care for health problems of military personnel at home and abroad.

The move inside the military coincides with efforts by the Trump administration to privatize care for veterans. The Department of Veterans Affairs in February proposed rules that would allow veterans to use private hospitals and clinics if government primary care facilities are not nearby or if they have to wait too long for an appointment.

Shrinking the medical corps within the armed forces is proving more contentious and complex. In 2017, a Republican-controlled Congress mandated changes in what a Senate Armed Services Committee report described as “an under-performing, disjointed health system” with “bloated medical headquarters staffs” and “inevitable turf wars.” The directive sought a greater emphasis for military doctors on combat-related needs while transferring other care to civilian providers.

Details of reductions have yet to be finalized, a military spokeswoman said. But within the system and among alumni, trepidation has increased since Military.com, an online military and veterans organization, reported in January that the Department of Defense had drafted proposals to convert more than 17,000 medical positions into fighting and support positions – a 13 percent reduction in medical personnel.

“That would be a drastic first cut,” said Dr. David Lane, a retired rear admiral and former director of the Walter Reed National Military Medical Center in Bethesda, Md.

At most risk in the current planning are positions that aren’t considered essential to troops overseas, such as training spots for new doctors and jobs that can be outsourced to private physicians and hospitals – obstetricians and primary care doctors, for example. The reductions may also limit the military’s medical humanitarian assistance and relief for foreign natural disasters and disease outbreaks.

Even in war zones, Lane warned, it would be a mistake to downplay the importance of contributions by doctors who do not specialize in trauma. In the 1991 invasion of Kuwait, for instance, cases of diseases and non-battle injuries rather than combat injuries created the most medical work, he said.

Doctors who train in the military’s highly regarded medical school – who have committed to serve in the armed forces after training – and those who do military residencies account for much of the staff serving troops overseas. A major deployment could leave the military flatfooted, said Dr. John Prescott, a former Army physician.

“The majority of folks in the military don’t stay in for their whole career, they stay in for a few years,” Prescott said. “I’m concerned there will be a very small cohort that will be available for deployment in the future.”

The military health system is responsible for more than 1.4 million active-duty and 331,000 reserve personnel, with 54 hospitals and 377 military clinics around the world. Split among the Navy, Army and Air Force, each with its own doctors and hospitals, the service has been targeted for years for overhaul to reduce redundancies and save costs.

The department has already started moving administrative functions under one bureaucracy, called the Defense Health Agency, which is slated to take over the service branch hospitals in 2021.

The budget for the next fiscal year is still being developed and final decisions have not yet been made, a Department of Defense spokeswoman, Lt. Col. Carla Gleason, said in an email. “Any reforms that do result will be driven by the Department’s efforts to ensure our medical personnel are ready to provide battlefield care in support of our forces, and to provide the outstanding medical benefits that Service members, retirees and their families deserve,” she said.

For years, critics of the broad role of the military health services have argued that many medical corps services – such as maternity care and pediatrics on bases – could be provided more effectively by civilian doctors and hospitals.

But Lane said there is too much focus on the high-profile trauma cases on the battlefield “that at the end of the day are a small portion” of medical care. “When we’re trying to put things back together that got broken during a war,” he said, “that’s what you need the most of – pediatricians, public health doctors, primary care doctors.”

Some studies commissioned by the department have concluded private hospitals could deliver less costly care, in part because doctors at hospitals take care of more patients. But the Congressional Budget Office said savings were not at all certain and that military hospitals might be less expensive if the government arranged for greater use of them.

Brad Carson and Morgan Plummer, who held senior jobs in the Department of Defense during President Barack Obama’s administration, argued in a 2016 essay that the military isn’t the best training for surgeons because it doesn’t provide them with a sufficient number of cases to develop expertise.

The military health system “has too much infrastructure, the wrong mix of providers, and predominantly serves the needs of beneficiaries who could easily have their health care needs satisfied by civilian providers at far less cost and with equal or better quality,” they wrote.

The government this year is spending $50 billion on the military health system, including Tricare insurance for more than 9 million active-duty service members, veterans, families and survivors, according to Congress’ budget office. That is roughly a tenth of the military budget. The CBO projected costs are on track to increase to $63 billion in 2033.

Defenders of the system reject the idea that non-wartime jobs can be eliminated without it hurting that core mission.

“Military health care providers between deployments maintain their clinical skills by treating service members and millions of beneficiaries,” Dr. Arthur Kellermann, dean of the school of medicine at the Uniformed Services University in Bethesda, wrote in a 2017 Health Affairs article. “Military hospitals provide valuable platforms for teaching the next generation of uniformed health care professionals and standby capacity for combat casualties.”

Prescott, the former Army doctor, said that the military may have trouble turning to civilian doctors in some regions given physician shortages, which he said the military cuts would exacerbate.

“Most hospitals are already pretty full, most health care providers are pretty busy,” said Prescott, now chief academic officer at the Association of American Medical Colleges.

Doctor shortages would increase if the military cut the slots it now has to train doctors, because there wouldn’t be new civilian residencies created to compensate. “Those positions basically disappear,” he said.

Kathryn Beasley, a retired Navy captain who is director of government relations for health affairs at the Military Officers Association of America, said she was also concerned with unforeseen consequences of dramatic cuts.

“Everything’s tied together, there’s a lot of interdependencies in these things,” she said. “You pull a string on one and you might feel it in an area you don’t expect.”
 

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

The U.S. military is devising major reductions in its medical corps, unnerving the system’s advocates who fear the cuts will hobble the armed forces’ ability to adequately care for health problems of military personnel at home and abroad.

The move inside the military coincides with efforts by the Trump administration to privatize care for veterans. The Department of Veterans Affairs in February proposed rules that would allow veterans to use private hospitals and clinics if government primary care facilities are not nearby or if they have to wait too long for an appointment.

Shrinking the medical corps within the armed forces is proving more contentious and complex. In 2017, a Republican-controlled Congress mandated changes in what a Senate Armed Services Committee report described as “an under-performing, disjointed health system” with “bloated medical headquarters staffs” and “inevitable turf wars.” The directive sought a greater emphasis for military doctors on combat-related needs while transferring other care to civilian providers.

Details of reductions have yet to be finalized, a military spokeswoman said. But within the system and among alumni, trepidation has increased since Military.com, an online military and veterans organization, reported in January that the Department of Defense had drafted proposals to convert more than 17,000 medical positions into fighting and support positions – a 13 percent reduction in medical personnel.

“That would be a drastic first cut,” said Dr. David Lane, a retired rear admiral and former director of the Walter Reed National Military Medical Center in Bethesda, Md.

At most risk in the current planning are positions that aren’t considered essential to troops overseas, such as training spots for new doctors and jobs that can be outsourced to private physicians and hospitals – obstetricians and primary care doctors, for example. The reductions may also limit the military’s medical humanitarian assistance and relief for foreign natural disasters and disease outbreaks.

Even in war zones, Lane warned, it would be a mistake to downplay the importance of contributions by doctors who do not specialize in trauma. In the 1991 invasion of Kuwait, for instance, cases of diseases and non-battle injuries rather than combat injuries created the most medical work, he said.

Doctors who train in the military’s highly regarded medical school – who have committed to serve in the armed forces after training – and those who do military residencies account for much of the staff serving troops overseas. A major deployment could leave the military flatfooted, said Dr. John Prescott, a former Army physician.

“The majority of folks in the military don’t stay in for their whole career, they stay in for a few years,” Prescott said. “I’m concerned there will be a very small cohort that will be available for deployment in the future.”

The military health system is responsible for more than 1.4 million active-duty and 331,000 reserve personnel, with 54 hospitals and 377 military clinics around the world. Split among the Navy, Army and Air Force, each with its own doctors and hospitals, the service has been targeted for years for overhaul to reduce redundancies and save costs.

The department has already started moving administrative functions under one bureaucracy, called the Defense Health Agency, which is slated to take over the service branch hospitals in 2021.

The budget for the next fiscal year is still being developed and final decisions have not yet been made, a Department of Defense spokeswoman, Lt. Col. Carla Gleason, said in an email. “Any reforms that do result will be driven by the Department’s efforts to ensure our medical personnel are ready to provide battlefield care in support of our forces, and to provide the outstanding medical benefits that Service members, retirees and their families deserve,” she said.

For years, critics of the broad role of the military health services have argued that many medical corps services – such as maternity care and pediatrics on bases – could be provided more effectively by civilian doctors and hospitals.

But Lane said there is too much focus on the high-profile trauma cases on the battlefield “that at the end of the day are a small portion” of medical care. “When we’re trying to put things back together that got broken during a war,” he said, “that’s what you need the most of – pediatricians, public health doctors, primary care doctors.”

Some studies commissioned by the department have concluded private hospitals could deliver less costly care, in part because doctors at hospitals take care of more patients. But the Congressional Budget Office said savings were not at all certain and that military hospitals might be less expensive if the government arranged for greater use of them.

Brad Carson and Morgan Plummer, who held senior jobs in the Department of Defense during President Barack Obama’s administration, argued in a 2016 essay that the military isn’t the best training for surgeons because it doesn’t provide them with a sufficient number of cases to develop expertise.

The military health system “has too much infrastructure, the wrong mix of providers, and predominantly serves the needs of beneficiaries who could easily have their health care needs satisfied by civilian providers at far less cost and with equal or better quality,” they wrote.

The government this year is spending $50 billion on the military health system, including Tricare insurance for more than 9 million active-duty service members, veterans, families and survivors, according to Congress’ budget office. That is roughly a tenth of the military budget. The CBO projected costs are on track to increase to $63 billion in 2033.

Defenders of the system reject the idea that non-wartime jobs can be eliminated without it hurting that core mission.

“Military health care providers between deployments maintain their clinical skills by treating service members and millions of beneficiaries,” Dr. Arthur Kellermann, dean of the school of medicine at the Uniformed Services University in Bethesda, wrote in a 2017 Health Affairs article. “Military hospitals provide valuable platforms for teaching the next generation of uniformed health care professionals and standby capacity for combat casualties.”

Prescott, the former Army doctor, said that the military may have trouble turning to civilian doctors in some regions given physician shortages, which he said the military cuts would exacerbate.

“Most hospitals are already pretty full, most health care providers are pretty busy,” said Prescott, now chief academic officer at the Association of American Medical Colleges.

Doctor shortages would increase if the military cut the slots it now has to train doctors, because there wouldn’t be new civilian residencies created to compensate. “Those positions basically disappear,” he said.

Kathryn Beasley, a retired Navy captain who is director of government relations for health affairs at the Military Officers Association of America, said she was also concerned with unforeseen consequences of dramatic cuts.

“Everything’s tied together, there’s a lot of interdependencies in these things,” she said. “You pull a string on one and you might feel it in an area you don’t expect.”
 

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

The U.S. military is devising major reductions in its medical corps, unnerving the system’s advocates who fear the cuts will hobble the armed forces’ ability to adequately care for health problems of military personnel at home and abroad.

The move inside the military coincides with efforts by the Trump administration to privatize care for veterans. The Department of Veterans Affairs in February proposed rules that would allow veterans to use private hospitals and clinics if government primary care facilities are not nearby or if they have to wait too long for an appointment.

Shrinking the medical corps within the armed forces is proving more contentious and complex. In 2017, a Republican-controlled Congress mandated changes in what a Senate Armed Services Committee report described as “an under-performing, disjointed health system” with “bloated medical headquarters staffs” and “inevitable turf wars.” The directive sought a greater emphasis for military doctors on combat-related needs while transferring other care to civilian providers.

Details of reductions have yet to be finalized, a military spokeswoman said. But within the system and among alumni, trepidation has increased since Military.com, an online military and veterans organization, reported in January that the Department of Defense had drafted proposals to convert more than 17,000 medical positions into fighting and support positions – a 13 percent reduction in medical personnel.

“That would be a drastic first cut,” said Dr. David Lane, a retired rear admiral and former director of the Walter Reed National Military Medical Center in Bethesda, Md.

At most risk in the current planning are positions that aren’t considered essential to troops overseas, such as training spots for new doctors and jobs that can be outsourced to private physicians and hospitals – obstetricians and primary care doctors, for example. The reductions may also limit the military’s medical humanitarian assistance and relief for foreign natural disasters and disease outbreaks.

Even in war zones, Lane warned, it would be a mistake to downplay the importance of contributions by doctors who do not specialize in trauma. In the 1991 invasion of Kuwait, for instance, cases of diseases and non-battle injuries rather than combat injuries created the most medical work, he said.

Doctors who train in the military’s highly regarded medical school – who have committed to serve in the armed forces after training – and those who do military residencies account for much of the staff serving troops overseas. A major deployment could leave the military flatfooted, said Dr. John Prescott, a former Army physician.

“The majority of folks in the military don’t stay in for their whole career, they stay in for a few years,” Prescott said. “I’m concerned there will be a very small cohort that will be available for deployment in the future.”

The military health system is responsible for more than 1.4 million active-duty and 331,000 reserve personnel, with 54 hospitals and 377 military clinics around the world. Split among the Navy, Army and Air Force, each with its own doctors and hospitals, the service has been targeted for years for overhaul to reduce redundancies and save costs.

The department has already started moving administrative functions under one bureaucracy, called the Defense Health Agency, which is slated to take over the service branch hospitals in 2021.

The budget for the next fiscal year is still being developed and final decisions have not yet been made, a Department of Defense spokeswoman, Lt. Col. Carla Gleason, said in an email. “Any reforms that do result will be driven by the Department’s efforts to ensure our medical personnel are ready to provide battlefield care in support of our forces, and to provide the outstanding medical benefits that Service members, retirees and their families deserve,” she said.

For years, critics of the broad role of the military health services have argued that many medical corps services – such as maternity care and pediatrics on bases – could be provided more effectively by civilian doctors and hospitals.

But Lane said there is too much focus on the high-profile trauma cases on the battlefield “that at the end of the day are a small portion” of medical care. “When we’re trying to put things back together that got broken during a war,” he said, “that’s what you need the most of – pediatricians, public health doctors, primary care doctors.”

Some studies commissioned by the department have concluded private hospitals could deliver less costly care, in part because doctors at hospitals take care of more patients. But the Congressional Budget Office said savings were not at all certain and that military hospitals might be less expensive if the government arranged for greater use of them.

Brad Carson and Morgan Plummer, who held senior jobs in the Department of Defense during President Barack Obama’s administration, argued in a 2016 essay that the military isn’t the best training for surgeons because it doesn’t provide them with a sufficient number of cases to develop expertise.

The military health system “has too much infrastructure, the wrong mix of providers, and predominantly serves the needs of beneficiaries who could easily have their health care needs satisfied by civilian providers at far less cost and with equal or better quality,” they wrote.

The government this year is spending $50 billion on the military health system, including Tricare insurance for more than 9 million active-duty service members, veterans, families and survivors, according to Congress’ budget office. That is roughly a tenth of the military budget. The CBO projected costs are on track to increase to $63 billion in 2033.

Defenders of the system reject the idea that non-wartime jobs can be eliminated without it hurting that core mission.

“Military health care providers between deployments maintain their clinical skills by treating service members and millions of beneficiaries,” Dr. Arthur Kellermann, dean of the school of medicine at the Uniformed Services University in Bethesda, wrote in a 2017 Health Affairs article. “Military hospitals provide valuable platforms for teaching the next generation of uniformed health care professionals and standby capacity for combat casualties.”

Prescott, the former Army doctor, said that the military may have trouble turning to civilian doctors in some regions given physician shortages, which he said the military cuts would exacerbate.

“Most hospitals are already pretty full, most health care providers are pretty busy,” said Prescott, now chief academic officer at the Association of American Medical Colleges.

Doctor shortages would increase if the military cut the slots it now has to train doctors, because there wouldn’t be new civilian residencies created to compensate. “Those positions basically disappear,” he said.

Kathryn Beasley, a retired Navy captain who is director of government relations for health affairs at the Military Officers Association of America, said she was also concerned with unforeseen consequences of dramatic cuts.

“Everything’s tied together, there’s a lot of interdependencies in these things,” she said. “You pull a string on one and you might feel it in an area you don’t expect.”
 

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.