Last week, President Obama signed long-awaited legislation that will put an end to periodic panic at the prospect of massive, sudden cuts to Medicare physician payments. The bipartisan “doc fix” bill repeals the Sustainable Growth Rate formula that aimed, but failed, to control growth in Medicare physician payments (Medicare Part B).
When it was first adopted in 1997, the SGR probably seemed like a good idea for controlling spending growth. When total Medicare Part B payments exceeded the targeted amounts, the SGR mechanism was supposed to automatically reduce physician payment rates. But each time the spending exceeded its target, Congress instead stepped in to prevent the automatic reduction – spending a total of nearly $170 billion in the process. With each of these patches, the gulf widened between the amount physicians were supposed to be getting paid and the amount Congress temporarily agreed to pay them. This year, Congressional inaction would have resulted in a 24% cut in physicians’ Medicare payments.
Congress’s habit of temporarily averting scheduled payment cuts also meant a flurry of lobbying activity as each patch neared expiration. Vox’s Sarah Kliff reports that Congress has enacted 17 different patches since 2002. I’m sure physician practices spent hundreds of hours worrying and making contingency plans each time a deadline approached, as well as time re-doing financial plans each time payment specifics were announced. This was an inefficient use of time for doctors’ offices and Congressional committees alike.
Under the new law, Medicare physician payments will increase 0.5% a year for five years. In the meantime, explains a summary from the staff of the House Energy and Commerce and Ways and Means Committees, we’ll see a transition to a new system that “moves Medicare away from a volume-based system towards one that rewards value, improving the quality of care for seniors.” Mary Agnes Carey of Kaiser Health News writes:
The measure, which builds upon last year’s legislation from the House Energy and Commerce and Ways and Means committees and the Senate Finance Committee, would encourage better care coordination and chronic care management, ideas that experts have said are needed in the Medicare program. It would reward providers who receive a “significant portion” of their revenue from an “alternative payment model” or patient-centered medical home with a 5 percent payment bonus. It would also allow broader use of Medicare data for “transparency and quality improvement” purposes.
… A “technical advisory committee” will review and recommend how to develop alternative payment models. Measures will be developed to judge the quality of care provided and how physicians will be rewarded or penalized based on their performance. While the law lays out a structure on how to move to these new payment models, much of their development will be left to future administrations and federal regulators. Expect heavy lobbying from the physician community on every element of implementation.
At Vox, Sarah Kliff describes some of the challenges in developing a new payment system:
The law doesn’t say which quality metrics the government ought to use in measuring quality. And for some specialties, this is very tough: how do you measure if a radiologist, for example, is doing a great job? Mostly by if they read image scans right — but Medicare doesn’t get that information in patient claims.
“We’re inherently limited by what we’re able to measure,” Bob Berenson, a health economist at the Urban Institute, says.
There’s already worry about the metric-setting process: it requires the federal government to use quality indicators that doctor groups suggest to the health and human services secretary. The secretary can add her own metrics to the list — but doctors are then free to pick and choose which metrics they want to be judged on.
The new law also extends some other programs that many providers and advocates were worried about losing. These include permanently extending the transitional medical assistance program, which lets low-income families maintain Medicaid coverage for up to a year as they transition to work, and two-year extensions of the following:
- The Children’s Health Insurance Program, which covers eight million low-income children and pregnant women whose income is above their states’ Medicaid cutoffs (Kim Krisberg covered CHIP’s looming expiration for The Nation’s Health);
- The Maternal, Infant, and Early Childhood Home Visiting Program (I wrote about that program here); and
- Funding for community health centers, the National Health Service Corps (NHSC) and the Teaching Health Centers Graduate Medical Education Program (which the New York Times covered here).
The total package will cost about $210 billion, and the law includes measures to offset about $70 billion of that. These include requiring higher-income beneficiaries to pay higher premiums for Medicare Part B and Part D (Part D is Medicare’s prescription-drug program), and requiring beneficiaries with Medigap insurance to pay the Part B deductible (currently $147 per year). In FY 2018, Medicare will also limit to 1% reimbursement increases for post-acute care providers like long-term care and inpatient rehab hospitals.
When the bill was under consideration, it faced some pushback because the increased expenditures weren’t fully covered by revenue increases or spending reductions. Given that the SGR has led to so much wasted time and money as Congress kicked the can down the road year after year, this was a worthwhile item to exempt from to pay-as-you-go requirements. I’m glad Congress has finally addressed this long-standing problem, and I hope the process for developing a new system that pays for quality rather than just quantity will result in better health as well as controlled Medicare spending.
In just a year, electronic cigarette use has tripled among American teens. And considering that no one really knows what the related health impacts are and any regulatory framework is lagging far behind the growing popularity of e-cigarettes, public health advocates say it’s time for action.
Earlier this week, the Centers for Disease Control and Prevention released new data from the 2014 National Youth Tobacco Survey finding that current e-cigarette use among high school students, which is defined as using at least once in the prior 30 days, nearly tripled — from 4.5 percent in 2013 to 13.4 percent in 2014. In sheer numbers that means e-cigarette use grew from about 660,000 high school students to 2 million. Among middle school students, e-cigarette use more than tripled, from 1.1 percent in 2013 to 3.9 percent in 2014. CDC reports that for the first time since the youth survey began collecting information on the new trend, current e-cigarette use has officially surpassed the use of every other tobacco product. E-cigarettes are battery-powered devices that heat up liquid mixtures usually containing nicotine and other flavorings and produce a vapor that users inhale.
While the CDC data did find declines in cigarette smoking among high school students — the 2014 rate was 9.2 percent, a new low — increases in e-cigarette and hookah use offset those gains, resulting in no real change in overall tobacco use among high school and middle school students. Overall, about 4.6 million middle and high school students currently use some type of tobacco product. The new data were published in this week’s issue of CDC’s Morbidity and Mortality Weekly Report.
In reacting to the new data, Matthew Myers, president of the Campaign for Tobacco-Free Kids, said:
The dramatic decline in youth cigarette smoking is terrific news for our nation’s health and shows that the fight against tobacco is winnable if we do what we know works. However, the skyrocketing use of e-cigarettes is frightening and threatens this progress. It should spur strong and prompt action to prevent kids from using any tobacco product, not just cigarettes. We cannot allow the tobacco industry to keep addicting kids and create another epidemic with a new generation of tobacco products.
These survey results show why the Food and Drug Administration must act with urgency to protect our kids and issue a final rule to regulate all tobacco products, including e-cigarettes, cigars and hookah. We again call on the FDA and the Obama Administration to issue a final rule by April 25 — one year after the FDA issued a proposed rule — and to close gaps in the rule by cracking down on marketing and flavors that appeal to kids. The FDA first announced in early 2011 that it planned to regulate e-cigarettes, cigars and other unregulated tobacco products, so these important public health protections are long overdue. We cannot afford more delays that allow the tobacco industry to continue targeting our kids with unregulated tobacco products.
And in a similar reaction from the American Lung Association, CEO and President Harold Wimmer said:
Previous studies should have served as warning bells to the federal government that FDA oversight of all tobacco products was urgently needed. Today’s study highlights the consequences of allowing these products to remain without oversight.
April 25 will mark the one-year anniversary from when FDA’s proposed rule was released, and over four years after FDA first announced its plan to oversee cigars, e-cigarettes and hookah. It is time for the Obama Administration to act with urgency.
The new CDC data found that in 2014, the most commonly used tobacco products among high school students were e-cigarettes, followed by hookahs (9.4 percent), cigarettes (9.2 percent), cigars (8.2 percent), smokeless tobacco (5.5 percent), snus (1.9 percent) and pipes (1.5 percent). Hookah use about doubled among middle school students, from 1.1 percent in 2013 to 2.5 percent in 2014, and among high school students, from 5.2 percent in 2013 to 9.4 percent in 2014. Overall, there were about 1.6 million young hookah users in 2014.
Research on the short- and long-term effects of e-cigarettes, which often contain a mixture of chemicals and flavorings, is still very much emerging, but most researchers agree that whether or not the novelty products are less harmful than cigarettes is yet to be known. One research article published just this week in the journal Tobacco Control found that “some flavour chemicals in e-cigarette fluids are sufficiently high for inhalation exposure by vaping to be of toxicological concern.” (And this recent in-depth investigation into worker exposure to diacetyl, a chemical that can permanently damage the lungs, also explored the chemical’s use in e-cigarettes.) However, one issue advocates are quick to point out is that the e-cigarette industry is using many of the same tactics to appeal to young people as Big Tobacco did. For instance, many e-cigarette flavors seem eerily kid-friendly, with flavors such as cotton candy, banana split and cherry crush.
Today, FDA only regulates e-cigarettes that are marketed for therapeutic purposes; however, the agency will be collecting public comments on its third and final public workshop on e-cigarettes and public health through July 2. For more on the June 1-2 FDA workshop and info on submitting comments, click here.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
The AFL-CIO outlined in an April 13 letter the “serious flaws and deficiencies” in a bill introduced by Senators David Vitter (R-LA) and Tom Udall (D-NM) to reform the Toxic Substances Control Act (TSCA). The country’s largest labor federation noted its deep involvement in the passage of TSCA in 1976, but its disappointment that the 40 year old law has “failed to provide meaningful and effective regulation” of toxic substances. (Even efforts to ban asbestos failed under the law.)
The labor federation has an important voice and perspective when it comes to chemical hazards. Workers are the guinea pigs for exposure to toxic chemicals and are often exposed to the highest concentrations of them.
The AFL-CIO indicates its support for major legislative reform of TSCA, but it outlines several defects in the Vitter/Udall (S. 697) bill. For example, the bill would restrict states from taking action to limit exposures to toxic substances. The AFL-CIO writes that States would be:
“preempted from acting once EPA designates a chemical as a high priority, years before there is any binding federal action to limit exposures, with no guarantee that EPA will actually take final regulatory action. In addition, states are prohibited from even co-enforcing standards that are identical to federal rules, a total departure from the shared state-federal enforcement responsibilities under TSCA and other environmental laws.”
A “fatal defect” in the bill, the AFL-CIO notes, is the missing definition for the legislation’s term “unreasonable risk.”
“What is unreasonable – is it a risk of harm of one in a thousand, one in ten thousand, one in a million or some other level of risk? The failure to establish a clear standard for protection will result in endless litigation to define what is meant by ‘unreasonable risk’ and thwart effective regulation.”
Their letter includes an attachment outlining nine problems with the Vitter/Udall bill. Among them:
“The inability of EPA to ban asbestos is recognized to be one of the most glaring failures of the current TSCA law.”
Yet the Vitter/Udall bill fails to fix that problem.
The AFL-CIO joins a growing list of organizations which have raised serious concerns about this TSCA reform bill. The groups include the Natural Resources Defense Council, Breast Cancer Fund (here), Safer Chemicals Healthy Families, Clean Water Action (here), Center for Environmental Health (here), Healthcare without Harm, and Physicians for Social Responsibility.
Last month, David McCumber of Hearst Newspapers reported on the American Chemistry Council’s intimate involvement in drafting the Vitter/Udall bill.
- the incident happened “when a modular home [MacKnight] was helping to move fell on top of him”
- the incident occurred “at the Westwood Village mobile home retirement community at 12:25 pm local time”
- MacKnight and a co-worker “had the home up on jacks” and they were underneath it.
- “Either the jack failed or it came off of the jacks and it ended up coming down on top of him,” according to Lieutenant Lane Findlay of the Weber County Sheriff’s Department.
- The Sheriff’s Office also told ABC4News “some of the other workers were related to Macknight.”
- “The crew was from Awnings and More, a family owned and operated business from North Ogden that provides mobile home relocation and setup.”
- ”The workers had transported the first part of the modular home to another location and were getting ready to move the second part. …[the workers] were maneuvering jacks and securing the mobile home from underneath when the trailer shifted and crushed the man.”
MacKnight’s employer, Awnings and More, was cited in July 2013 by Utah OSHA for a serious safety violation. The company had failed to have proper fall protection for employees working on a steep roof. The company settled with Utah OSHA and paid a $750 penalty.
Each year, about 40 workers in Utah are fatally injured on-the-job. The Bureau of Labor Statistics reports 37 work-related fatal injuries in Utah during 2013 (preliminary data, most recent available.) Nationwide, at least 4,405 workers suffered fatal traumatic injuries in 2013.
The AFL-CIO’s annual Death on the Job report notes:
- Utah OSHA has 22 inspectors to cover more than 70,000 workplaces.
- The average penalty for a serious workplace safety violation in Utah is $1,053.
Utah OSHA has until mid-October 2015 to issue any citations and penalties related to the incident that stole Ronald Lee MacKnight’s life. It’s likely they’ll determine that MacKnight’s death was preventable. It was no “accident.”
Read the interview.
There’s a lot of griping in Washington DC about businesses being burdened by too many federal regulations. The gripers and their friends on Capitol Hill have introduced legislation with snappy names, such as the SCRUB Act (Searching for and Cutting Regulations that are Unnecessarily Burdensome), the REINS Act (Regulations from the Executive in Need of Scrutiny) and the ALERT Act (All Economic Regulations are Transparent). But there’s no doubt these laws are designed to put the skids on the rulemaking process. For some agencies, including OSHA, they’ve already been riding the regulatory brake for the last couple of decades. There hasn’t been a gusher of new regulations. OSHA regulations, in particular, take far too long to be developed and put in place.
Thankfully, one OSHA regulation that’s been in the pipeline for decades—yes, decades—may finally be issued. The White House’s Office of Information and Regulatory Affairs (OIRA) completed its review on April 3 of a final OSHA regulation to protect construction workers from confined space hazards. Vessels, tanks, vents and other small spaces can be deadly hazards for workers because they can be oxygen-deficient, explosive, or configured in such a way that a worker could get trapped. It really has taken decades to get us to this point. Here’s some of the long history:
It was 1975 when OSHA first indicated the need for a regulation to address confined space hazards for workers in all industries, including construction. In a 1975 advanced notice of proposed rulemaking (ANPRM), OSHA noted it had:
“received several petitions and other recommendations concerning the need for a revision of the existing standards for work in confined spaces, such as tanks, boilers, sewer vaults, manholes, pressure vessels, trenches, and other confined compartments, or for a standard for work in these environments applicable to all industries.”
In March 1980 in a follow-up ANPRM, the agency said:
“Based on information available to the Agency, OSHA believes that the hazards of work in confined spaces are also significant in the construction industry. Therefore, OSHA is developing a proposal to revise its existing standards in order to effectively cover hazards connected with these activities in construction.”
During May 1980, the agency held public hearings in Houston, Denver and Washington DC to receive input on the need for the standard and how it could be designed to meet workers’ and employers’ needs. Then came the Reagan Administration. Work at OSHA on a confined space regulation went dormant.
The proposal was resurrected during the George H.W. Bush Administration. In June 1989—14 years after OSHA’s first ANPRM on the topic and nine years after those public hearings, the agency formally proposed a rule to address confined space hazards for workers. Among other data, the agency reported that between 1985 and 1990 there were at least 63 fatalities and nearly 6,000 lost-work day incidents related to confined space environments.
OSHA’s proposed rule did not, however, apply to the construction industry. OSHA asserted:
“…confined space standards for agriculture, construction, and shipyard work should be addressed separately so that the Agency can focus on aspects of permit space safety that are specifically appropriate for these areas.” (4470)
That decision was controversial and not well received by some. One (unnamed) commenter said:
“I find it a grave error not to include construction in the proposed rulemaking. As your statistics succinctly point out, between 1974 and 1977, 276 confined space accidents claimed 234 lives and injured an additional 193 individuals. …Based upon these figures, why would you want to exclude construction?”
Three and one-half years later, in January 1993, OSHA’s final rule on confined space for general industry workers was issued. It happened just days before the Clinton Administration was poised to take office. Both industry and labor groups challenged the OSHA rule. Some argued it went too far, others argued it didn’t go far enough. By September 1994, all the objections had been addressed through settlement agreements.
In OSHA’s settlement agreement with the United Steelworkers Union, the agency made a big promise:
OSHA agreed to issue a confined space standard that would apply to workers in the construction industry.
The agreement did not, however, give OSHA a deadline for completing the task.
Here’s what has transpired in the 21 years since to fulfill that promise:
- In February 1994, OSHA asked its Advisory Committee for Construction Safety and Health (ACCSH) to provide feedback on a draft proposed standard addressing the hazards of confined spaces for construction workers. ACCSH formed a working group which ultimately develop a draft proposed standard. In late 1996, ACCSH recommended that OSHA use their draft standard as the agency’s proposed rule.
- OSHA determined that the ACCSH document was not wholly appropriate as a proposed rule, in particular for small construction firms.
- OSHA held public hearings in October 2000 to receive feedback from the construction industry on draft provisions of the proposed rule.
- In late 2003, OSHA convened a panel of small business representatives (as required by the Small Business Regulatory Enforcement Fairness Act (SBREFA)) to receive formal comments on its draft proposed rule.
- Between 2004 and 2007, OSHA’s semi-annual regulatory agendas indicated that a proposed rule on this topic was forthcoming. In the fall of 2004, the agency said the public could expect it in March 2005. In Spring 2005, the agency said the public could expect it in December 2005, etc., etc.
- OSHA submitted the proposed rule to the White House’s OIRA in July 2007. OIRA completed its review and returned the proposal to OSHA in October 2007. The proposal was published by OSHA in November 2007.
- OSHA held public hearings on the proposal and the comment period closed in October 2008.
- In 2010, the Obama Administration indicated that work on the final rule was nearly complete. OSHA’s Fall 2010 regulatory agenda indicated the final rule would likely be published by November 2011. Between late 2010 and late 2014, the agency suggested the final rule was forthcoming. In the fall of 2011, the agency said the public could expect it in June 2012. In the spring of 2013, the agency said the public could expect it in December 2013, etc., etc.
- In November 2014, OSHA submitted its draft final rule to OIRA for review. OIRA completed its review after about 120 days and returned the final rule to OSHA on April 3, 2015.
OSHA is likely putting finishing touches on the final rule and preparing to release it in the weeks ahead. Once it is issued, I won’t be surprised if I hear complaints about it from certain lawmakers and those who oppose federal regulations. They may claim it’s an example of Obama’s avalanche of regulations, but it’s much more an example of something else: without a binding deadline, it can take OSHA decades to issue a new worker safety regulation.
Poorer health, shorter lives and lower incomes: ‘We don’t really appreciate the magnitude of the problem’
Low income and poor health tend to go hand in hand — that’s not a particularly surprising or new statement. However, according to family medicine doctor Steven Woolf, we have yet to truly grasp the extent to which income shapes a person’s health and opportunity to live a long life. And if we don’t confront the widening income inequality gap, he says things will only get worse.
“There’s a general awareness that people who have poor education or low incomes have worse health outcomes, but our sense is that we don’t really appreciate the magnitude of the problem,” Woolf told me. “Every time I look at these data, I am still stunned at how dramatic the differences are.”
Woolf, who serves as director of the Center on Society and Health at Virginia Commonwealth University and is a professor in the Department of Family Medicine and Population Health, recently co-authored a series of reports on the connections between income, education and health under the umbrella of two related efforts: The Education and Health Initiative and the Income and Health Initiative. This week, Woolf and his colleagues released two new reports, “How Are Income and Wealth Linked to Health and Longevity?” and “Can Income-Related Policies Improve Population Health?” Woolf said while both reports don’t necessarily contain new information, they were specifically designed to “connect the dots and help the public and policymakers appreciate the fact that decisions about the economy and jobs have big implications not only for the health of Americans, but also for the rising cost of health care.”
“It’s not like we as a society are ignoring the economy,” Woolf said. “But whichever approach you take, we have to understand that there are implications for health and for health care costs.”
The information gathered in “How Are Income and Wealth Linked to Health and Longevity?” is particularly galvanizing. In it, co-authors Woolf, Sarah Simon, Laudan Aron, Emily Zimmerman, Lisa Dubay and Kim Luk write:
The greater one’s income, the lower one’s likelihood of disease and premature death. Studies show that Americans at all income levels are less healthy than those with incomes higher than their own. Not only is income (the earnings and other money acquired each year) associated with better health, but wealth (net worth and assets) affects health as well.
Though it is easy to imagine how health is tied to income for the very poor or the very rich, the relationship between income and health is a gradient: they are connected step-wise at every level of the economic ladder. Middle-class Americans are healthier than those living in or near poverty, but they are less healthy than the upper class. Even wealthy Americans are less healthy than those Americans with higher incomes.
In a table illustrating the burden of various diseases by income in 2011, the differences are striking. For example, 8.1 percent of adults with an annual family income of less than $35,000 have coronary heart disease, compared to 4.9 percent of adults with an annual family income of $100,000 or more; 11 percent of adults in the less than $35,000 category have diabetes, compared to 5.9 percent of adults in the $100,000 or more category; 3 percent of adults in the less than $35,000 category have kidney disease, compared to 0.9 percent of adults in the $100,000 or more category; and 11.6 percent of adults in the less than $35,000 category have no teeth, compared to 4.1 percent of adults in the $100,000 or more category. Children living in low-income families face higher rates of disease as well — more asthma, more hearing problems, more heart conditions and higher blood lead levels — all of which affect their opportunity to do well in school and heightens their risk of poor health in adulthood.
Income is linked with life expectancy as well. The report tells us that by age 25, Americans in the highest income group can expect to live about six years longer than their poorer peers. Woolf tells me that such income differences explain many of the documented health disparities among U.S. racial and ethnic groups. He said: “Even after we adjust for other factors, (income and education) account for a huge part — it’s really about the life circumstances people face.”
So, how exactly do income and wealth impact a person’s health? The first and probably most obvious answer is access to health care. People with low incomes are less able to afford health care services, health insurance, co-payments, deductibles and medicines (though the Affordable Care Act is aimed at removing or lessening the access obstacle). But the health-income association is bigger than access to health care; the report argues that those with higher incomes also enjoy the benefits of healthier community assets. The report states:People with higher incomes are more likely to experience place-based health benefits, meaning that their health is positively influenced by the conditions and assets in their living environment. In other words, even after adjusting for income and other attributes of individuals and households, health benefits appear to be associated with where people reside. …
The socioeconomic status of individuals and neighborhoods are intertwined with individual and population health because the local economy determines access to jobs, commerce, schools, and other resources that enable families to enjoy economic success and place-based health benefits. For example, one study found that “healthy adults residing in socioeconomically deprived neighborhoods died at a higher rate than did people in relatively less deprived areas, even after accounting for individual-level socioeconomic status, lifestyle practices, and medical history.” Smoking, diabetes, and other conditions are more common for people living in poor neighborhoods, independent of their income.
Along with the health and longevity report, the Income and Health Initiative also released “Can Income-Related Policies Improve Population Health?” That report explores ways to reduce income-related obstacles to better health through three types of policies: those that address early childhood, those that provide income support, and those that improve community and neighborhood conditions. Within these categories, the report addresses a variety of specific policies, such as the Earned Income Tax Credit and the Supplemental Nutrition Assistance Program as well as private and public sector efforts to improve community conditions, such building affordable housing or developing safe recreational areas for children. However, no intervention “seems more promising than education, especially early childhood education,” the report stated.
As a physician, Woolf told me that clinical interventions often have marginal impacts when compared to the effects of social determinants. For example, rates of diabetes — a growing and major source of suffering and cost within the health care system — are about twice as high among low-income people than among those with higher incomes.
“So it stands to reason that the economic burden of treating the disease could be substantially lowered if these people had better economic circumstances,” he said. “Of all the things we do for diabetes in the clinic, we’re not often thinking about how to help people with their educational and economic circumstances…that would probably save more lives than what we do at the bedside.”
So, if income and education are key to better health and lower health care costs, what can physicians and public health practitioners do? First, Woolf said be aware of the connections when working with patients and clients. (“I tell my students that if they don’t understand where their patients live or what kind of economic challenges they’re facing, they can’t expect their clinical plans to produce good outcomes,” he said.) Second, get active in your community — help fellow residents and decision-makers understand that while decisions about education and economic development may not seem connected to health on the surface, such decisions have a direct impact on people’s health and on health care costs. At the national level, do a better job of packaging the data in a way that resonates with policymakers, he said.
While taking to the streets certainly has a role in driving meaningful social change, Woolf said scientists may be most helpful by sticking to and advocating for the science.
“The social justice arguments are very important to many of us, but they don’t always move the needle in the policy world,” he said. “Other kinds of arguments are now taking center stage, like analyses by major economists…showing that income inequality has reached a point that’s so severe that it’s undermining our economy and putting America at a competitive disadvantage. …We live in a cynical society where we need to point out those particular arguments to get the attention of policymakers.”
To download all the reports from the two initiatives, including a series of reports on the economic and health benefits of investing in education, visit the Center on Society and Health.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.