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Health Care Reform Memo: August 20, 2012

Deloitte Center for Health Solutions publication

The health care reform memos are issued on a weekly basis, highlighting news from the previous week's activities in the administration and implications for the C-suite and various stakeholder groups.

My take: mental health: a necessary element for the pursuit of health and happiness

From Paul Keckley, Executive Director, Deloitte Center for Health Solutions

When Harvey Ball introduced the smiley face in 1963, little did he know how aptly it would characterize our insatiable pursuit of happiness. “Happy Meals” followed in 1979, permanently etching happiness in the U.S. persona along with all manner of songs, self-help books, and music.

I don’t know what the Declaration framers had in mind in declaring “the pursuit of happiness” as an inalienable right” but it’s clearly top of mind in our society.

Historian Peter Stearns has observed that in 18th and 19th century America, the quest for happiness was subdued.1 In 1893, the Hill sisters, Patty and Mildred, penned “Good Morning to All”—which would eventually turn into “Happy Birthday to You”—signifying the change. Today, social scientists relate happiness to work place effectiveness, lasting relationships in the home, and even our politics. It gets lots of attention as do its opposites—sadness, depression, and in some cases self-destructive behaviors.

The World Health Organization (WHO) defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Mental health is a key element. Albeit, not everyone who is unhappy has a mental health disorder, happiness is a challenge when mood and anxiety disorders dominate. In the Affordable Care Act (ACA, see table below) mental health is a central ingredient of “essential health benefits” and “preventive health”—appropriately so. Ten percent of kids have a serious mental health disorder. Suicide is the third leading cause of death among youth in our society and stress/mood disorders impact three in ten adults at some point in their lifetime. And all too frequently, serious mental illness is missed until it’s too late. The movie goers in Aurora and high school students in Columbine know firsthand.

The fact is each of us struggles from time to time with mental health issues. We all want to be happy. Stress, anxiety, and sadness seem a way of life for many; self-care is the norm for most as only a few get professional help. If you’re poor, or unhealthy, or facing uncertainty at work or home, mental health issues—stress, depression, addictions—are constant companions. And if you’re accomplished but insecure, or in work or home settings where relationships are strained or appreciation is not felt, the pain is no less. Not all mental health issues are circumstantial: clinical research has made, and is continuing to make, amazing strides in identifying signs and symptoms of mental health disorders—just like physical problems are studied. Having health insurance is no guarantee of being stress free about health: 23 percent of seniors enrolled in Medicare do not think they are financially prepared to handle their health bills and one in five with commercial coverage is confident they can manage a high cost health event. Interestingly, the most secure and least anxious consumers about health care are those enrolled in military health and seniors and many among them worry nonetheless2.

Stress, mood, and anxiety problems are widespread in our society. Coping mechanisms are quite personal—some bury themselves in addictions to work or substances or try to “tough it out.” Some get support from family or friends. Some seek counsel from school counselors, clergy, and medical professionals. And some deny there’s a problem. Mental illness is a respecter of no persons. It is essential to physical health for better outcomes and lower costs. It is highly correlated to a person’s health status, adherence to treatment recommendations, and productivity.

In the current debate about the future of Medicare, the passion of seniors about the program’s sustainability is understandable: it is key to their sense of health and happiness. And it’s legitimately a concern to younger consumers: their anxieties are about the economy they’ll inherit and their prospects for a happy life. That does not discount its fiscal cliff; it punctuates the need for policymakers and health providers to innovate solutions and set aside partisan bickering. It means the mental health community must coalesce around solutions and avoid its tendency to get mired in intramural turf wars—medical vs. therapeutic models, roles of primary care clinicians and mid-level counselors, and the role of spirituality in health. And it forces each of us to step back and think differently about what makes us happy and fulfilled.

Mental health is a big deal. And, like every medical condition, the severity of mental illness ranges widely—it's complicated stuff. Wellness and healthy living are unattainable for many due to circumstances they believe are out of their control. It’s time we take a fresh look at mental health and its relevance to our “pursuit of happiness.” It’s worth the effort. Clearly, it’s a central element in health reform and in building a sustainable health system for generations to come.

Paul Keckely

Paul Keckley, Ph.D., Executive Director, Deloitte Center for Health Solutions

P.S. Stan Nelson, a venerable hospital executive and founder of the Scottsdale Institute, died suddenly August 3 in Minneapolis. He was 85, but you’d never know it. He was a happy man who made others happy, offering affirmation when discouraged and challenge to those up to a task. His legacy as CEO of Parkview, Abbott Northwestern and another health system bore testimony to his capability, but his wide circle of friends was stronger evidence. His life was celebrated last Sunday, appropriately on his birthday. A life well-lived; one of a kind.

1Peter N. Stearns, Harvard Business Review, “The History of Happiness: How the Pursuit of contentment has shaped the west’s culture and economy,” January-February 2012
2
Deloitte Center for Health Solutions, “2012 Survey of U.S. Health Care Consumers”

Provisions of the ACA affecting behavioral health care services

Section Provision Importance for behavioral health care
1321 Affordable Insurance Exchanges  Establishes access to Qualified Health Plans (QHPs) for small businesses, families, and individuals QHPs in exchanges must provide mental health services.
1302 Essential health benefits in qualified health plans (QHPs) Establishes ten key services that must be covered by plans offered in affordable insurance exchanges and included in the benchmark plans made available to individuals in states opting to expand Medicaid coverage. Mental health and substance use disorder services must be offered at parity with other medical/surgical care, prevention services, and rehabilitative services.
2501 Medicare drug coverage Establishes increased rebate percentages for covered outpatient drugs dispensed to Medicaid patients and extends prescription drug rebates to covered outpatient drugs dispensed to enrollees of Medicaid managed care organizations (MCOs). Drugs include anti-depressants, anxiety disorders, etc.
1101 Preexisting conditions Establishes immediate access to insurance for uninsured individuals with preexisting conditions including diagnosed mental health problems.
2711 Lifetime or annual limits Prevents group health plans from placing lifetime limits on the dollar value of benefits for any participant or beneficiary or from placing unreasonable annual limits on the dollar value of benefits for any participant or beneficiary. Expenditures for mental health services are included in calculations of lifetime limits.
2001 Medicaid expansion Provides states the option to expand their Medicaid program to cover all individuals below 133 percent FPL with 100 percent federal match until 2016, dropping to 90 percent in 2020. Uninsured individuals below 133 percent FPL with mental health disorders will benefit from expansion.
10503/
2303
Community Health Centers and National Health Service Corps Fund Establishes a Community Health Centers and National Health Service Corps Fund and increases mandatory funding for community health centers to $11 billion over five years (fiscal year [FY] 2011 – FY2015). Community health centers and community mental health centers provide a wide range of mental health services to underserved populations.
5601 Spending for Federally Qualified Health Centers (FQHC) Authorizes additional funding for FQHCs as follows: FY2010 - $2.98B; FY2011 - $3.86B; FY2012 - $4.99B; FY 2013 - $6.44B; FY2014 - $7.33B; FY2015 - $8.33B. FQHCs may provide mental health services to underserved populations.
5604 Co-locating primary and specialty care in community-based mental health settings  Provides award grants and cooperative agreements to entities to establish demonstration projects for coordinated services to special populations through the co-location of primary and specialty care services in community-based mental and behavioral health settings.

Implementation update

Physician-owned hospital restrictions in ACA upheld in Texas court challenge

Last week, the U.S. Court of Appeals in Houston dismissed an appeal from the Physician Hospitals of America and the 20-bed Texas Spine & Joint Hospital in Tyler challenging the restriction on expansion by physician-owned hospitals in the ACA (Section 6001 limits the ability of physician-owned hospitals to expand existing facilities or add new ones). The appeals court ruled that the district court lacked subject-matter jurisdiction in the case.

Background: Texas Spine & Joint was in the process of a $37 million expansion when ACA passed in March 2010. The hospital was unable to complete the project before the law's cutoff date of December 31, 2010. The hospital argued that it was incurring losses because if it finished the project, it ran the risk of stiff penalties and millions in lost revenue from a completed but empty facility.

Note: physician ownership is included in the ACA’s “Protecting Medicare Integrity” section that addresses self-referrals and transparency in their relationships and performance. When the law passed in March 2010, per the Public Health Act, 269 physician-owned hospitals were impacted plus 71 under construction or planned. At the deadline of December 31, 2010, 47 of these were completed, and 24 suspended. The ACA terms restrict growth of physician equity ownership and limit what hospitals may do to support a facility.

Study: 65 percent of hospitals could face penalties for avoidable readmissions

An analysis of the Centers for Medicare & Medicaid Services (CMS) Medicare hospital data found that over 2,000 hospitals will be penalized beginning October 1 for excessive readmissions involving 2 million Medicare beneficiaries readmitted within 30 days of release. This is expected to add $17.5 billion in hospital costs per year. According to the report, 278 (8.3 percent) of hospitals will forfeit the maximum 1 percent of their base Medicare reimbursements, while 1,933 (57 percent) hospitals will receive penalties of less than 1 percent of their base Medicare reimbursements.

Background: Per Section 3025 of the ACA, beginning in FY2012, CMS will report data about hospital avoidable readmissions on its Hospital Compare website. Starting in FY2013, hospitals with readmission rates above a certain threshold will have payments for the original hospitalization reduced by 20 percent if a patient with any one of the eight conditions chosen is re-hospitalized with a preventable readmission within seven days and by 10 percent if a patient with a selected condition is re-hospitalized with a preventable readmission within 15 days. Hospitals with readmissions above the 75th percentile (based on 30-day rates) for selected conditions shall be subject to readmissions payment policy related to the selected conditions. Calculation of percentiles shall be based on prior year’s performance. Three years after implementation, the Department of Health and Human Services (HHS) Secretary shall have the authority to expand the policy to other conditions selected based on: high spending on readmissions or high rates of readmissions; and other criteria determined by the Secretary. Per the Congressional Budget Office (CBO), the program is expected to save Medicare $7.1 billion.

Related: as of July 2012, the Robert Wood Johnson Foundation’s Aligning Forces for Quality Hospital Quality Network pilot reported that 60 percent of participating hospitals cut 30-day readmission rates for patients with heart failure and avoided a total of nearly 500 readmissions. Nearly 60 percent of hospitals in the project were also able to cut boarding time in their emergency departments by an average of 30 minutes.

Community-based Care Transition awards

CMS announced 17 sites selected to participate in the Community-based Care Transitions Program (CCTP). Together with the first 30 participants, the CCTP now includes 200 acute care hospitals partnering with community-based organizations across 47 sites to provide care transitions services for an estimated 185,800 Medicare beneficiaries annually residing in 21 states.

Background: CCTP is a five-year program created by the ACA (Section 3026). Participants sign two-year program agreements with CMS, with the option to renew each year for the remainder of the program based on their success. Participants work with local hospitals and social service providers to support Medicare patients at increased risk of being readmitted to the hospital while transitioning from hospital stays to other care settings, such as their homes or nursing homes. The program can spend up to $500 million over five years under the ACA. The Center for Consumer Information and Insurance Oversight (CCIIO) will continue to accept applications as long as funding is available. Most awardees are alliances of community-health agencies and hospitals that aspire to manage care for Medicare enrollees in a coordinated model to avoid hospital re-admissions.

Cohen to head CCIIO, succeeds Larsen

Friday, CMS Acting Administrator Marilyn Tavenner named Gary Cohen to succeed Steve Larsen as Director of CCIIO. He most recently was chief counsel to the California Health Benefits Exchange Board and previously served as director of the oversight group at CCIIO.

Note: CCIIO is the entity within HHS that sets and enforces standards for health insurance that promote fair and reasonable practices to ensure that affordable, quality health coverage is available to all Americans. The Center also provides consumers with comprehensive information on coverage options currently available so they may make informed choices on the best health insurance for their family. It has four divisions: oversight (medical loss ratio, premium increases), consumer support (Healthcare.gov, appeals process), insurance programs (pre-existing condition, early retiree program), and health insurance exchanges.

House Republicans request information about CDC Prevention Fund Grants

Republican members of the House Energy and Commerce Committee sent a letter to HHS Secretary Kathleen Sebelius last week expressing concern about the Centers for Disease Control and Prevention (CDC) Communities Putting Prevention to Work Program (CPPW). The letter requested information on CDC’s grantees including applications, reviews, and any communication to CDC employees or CPWW grantees providing guidance on lobbying restrictions.

Background: ACA authorized $15 billion over ten years to the Prevention and Public Health Fund for investment in prevention and public health programs. Under the program, the CDC awards competitive grants to local governmental agencies and community-based organizations for the implementation of evidence-based community prevention health activities. The HHS Office of Inspector General (OIG) issued a report last April evaluating whether 31 of the grants were in accordance with terms and conditions of funding opportunity announcements and with grant administration requirements.

Related: HHS also announced $68 million in ACA funding to 114 community-based organizations, university hospitals, and health departments nationwide to provide support services for women, infants, children, and youth living with HIV/AIDS. The funds were granted through the Health Resources and Services Administration’s (HRSA) Ryan White HIV/AIDS Program to assist those who lack sufficient health care coverage or financial resources to manage HIV.

HHS announces collaboration with retail pharmacies to educate Medicare beneficiaries about ACA free services

Last week, HHS announced partnerships with retail pharmacies nationwide to help educate Medicare beneficiaries on new health benefits available to them under the ACA. The retailers agreed to provide information about free preventive services offered under ACA, as well as possible savings on drugs through the donut hole coverage gap. The partners include CVS Caremark, Walgreens, Thrifty White, Wal-Mart, and Sam’s Club.

Report: being “old” ain’t what it used to be

Seniors are living longer, healthier lives but rising obesity rates and high housing costs take a toll on their longevity gains and sense of security.

The U.S. Federal Interagency Forum on Aging-Related Statistics study examined 37 indicators of well-being to assess how older Americans are faring as they age including population, economics, health status, health risks and behaviors, health, and end of life care. Key findings:

  • Obesity is an increasingly prevalent among seniors: 38 percent of people age 65 and older (and 29 percent older than 75) were obese in 2009 vs. 22 percent between 1988 and 1994
  • Cost of housing: in 2009, 40 percent of households with people age 65 or older spent more than 30 percent of their income on housing and utilities vs. 30 percent in 1985
  • Working seniors: the number of women between age 62 and 64 with jobs outside their homes jumped from 29 percent in 1963 to 45 percent in 2011, including 27 percent of women age 65 and older and 8 percent of those age 70 and older
  • Poverty: between 1974 and 2010, the proportion of older people with incomes below the Federal Poverty Level (FPL, $10,458 in 2010) fell from 15 percent to 9 percent. Seniors living on low incomes—ranging between $10,458 and $20,916—fell from 35 percent to 26 percent and the proportion of seniors with high incomes ($41,832 and above in 2010) increased from 18  percent to 31 percent
  • End of life care: the percentage of older people who receive specialized care increased from 19 percent in 1999 to 43 percent in 2009. Fewer older Americans died in hospitals: the percent of seniors who died at home increased from 15 percent in 1999 to 24 percent in 2009. Meanwhile, the percent of older people who died in the hospital fell from 49 percent to 32 percent

In 2010, seniors age 65 and older were 13 percent of the total U.S. population. This is anticipated to increase to 20 percent by 2030. (Source: Federal Interagency Forum on Aging-Related Statistics, “Older Americans Living Longer, But Becoming More Obese,” August 2012)

Legislative update

FTC has no plans to challenge the Generic Pharmaceutical Association’s Accelerated Recovery Initiative

Wednesday, Representative Ed Markey (D-MA) and Senator Jeff Merkley (D-OR) sent a letter to FDA requesting the agency update its Recalls and 510(k) Premarket Notification database to provide information on whether a device was recalled due to a serious design flaw or whether it was cleared on the basis of a predecessor design flaw that affected its safety or effectiveness. The letter urged the agency to include this information in order to “enhance the transparency of the 510(k) process and help manufacturers avoid using recalled devices as predicates that may put their own devices at risk for future enforcement action.” It went on to urge the FDA to update the database retrospectively, and to provide information that dates several years back.

Note: Class Two devices, those with moderate risk requiring special controls (e.g., CT scanners) represent 47 percent of all device approvals. Historically, approvals were obtained via an accelerated review process (510(k) since these devices in earlier forms are already on the market. Recently, intensified scrutiny has given to requiring manufacturers to provide increased scientific support for their devices. The FDA has overseen device safety and effectiveness since 1976.

Major government agencies focused on mental health

Federal agencies addressing issues involving individuals with mental disorders
U.S. Department of Health and Human Services (HHS)

U.S. Substance Abuse and Mental Health Services Administration (SAMHSA)

U.S. National Institutes of Health (NIH)

U.S. National Institute of Mental Health (NIMH)

U.S. Centers for Medicare & Medicaid Services (CMS)

U.S. Center for Disease Control and Prevention (CDC)

U.S. Department of Justice (DOJ), Civil Rights Division
U.S. Department of Housing and Urban Development (HUD)
U.S. Department of Veterans Affairs (VA)
U.S. Department of Education (DOE)

State update

Medicaid system modernization still required if state does not expand enrollment

Speaking last week in a regional forum, Cindy Mann, director for Medicaid and Child Health Insurance Program (CHIP) Services at CMS said states not participating in the Medicaid expansion will be required to upgrade their Medicaid eligibility and enrollment systems by 2014.

Background: Per the ACA, states are required to establish a single, online application system with links to the state-based insurance exchange as well as Medicaid and CHIP. States not participating in the Medicaid expansion will be able to take advantage of matching funds CMS is making available to assist states to design and build the new eligibility and enrollment systems. Until 2015, CMS will pay for 90 percent of a state's costs in building the new system, she said. CMS also will provide 75 percent of the state's system maintenance costs on a continuing basis.

CCIIO issues “blueprint” for state health exchanges, reinforces federal flexibility

Tuesday, HHS began a series of briefings about implementation of health insurance exchanges (HIX). CCIIO Director Mike Hash released the blueprint for exchange certification to states, and the agency is still “exploring options” for financing its federally facilitated exchange. Notable takeaways include:

  • A streamlined application process will be used for all applicants.
  • The federal exchange will mirror a state run exchange: states choosing the federal exchange will not be required to return establishment grants.
  • Qualified Health Plan (QHP) certification will be on an annual basis to prevent QHPs from coming in and out of exchange during a plan year.
  • Future guidance will be provided on stand-alone dental options, Basic Health Program, segregation of funds for pregnancy termination benefits.
  • The actuarial value (AV) calculator will be released with comment period before finalized.
  • State-run exchanges will have the option of allowing the federal government to conduct eligibility determinations for tax credits and cost-sharing reductions for low- and moderate-income consumers.
  • States may allow the federal government to make determinations about exemptions from the “individual mandate” insurance coverage requirements for hardship or other reasons.
  • The federal government will operate risk adjustment and re-insurance programs for state-run exchanges at the option of the states.
  • States that form partnerships with the federal government to operate exchanges have the option of conducting plan management functions—certifying QHPs that will be offered in the exchanges—or they could conduct consumer outreach functions, or do both.
  • Small Business Health Options Program (SHOP) exchanges can be created as separate exchanges by states for businesses with up to 100 employees, or merged with exchanges for the individual insurance market. In 2014 and 2015, states may limit the SHOP exchanges to businesses with less than 50 employees. (Small employers that participate in SHOP exchanges are eligible for small business tax credits to cover up to 50 percent of the cost of covering employees in 2014 and 2015 is the average income of the employees for the firm do not exceed $25,000).
  • The requirement in the proposed blueprint May, 2012 that states move 80,000 people from high-risk pools into the exchanges in 2014 was deleted in the final blueprint.

Note: As of August 1, HHS had received 13 letters from governors who made a commitment to submit applications to establish state-based exchanges. The states are Colorado, Maryland, Massachusetts, Minnesota, New York, Oregon, Rhode Island, Washington, California, Connecticut, Hawaii, Kentucky, and Vermont. Thirty-five states and the District of Columbia received $850 million in exchange establishment grants.

Politico: governors’ races will impact ACA implementation

“Forget about the presidential race just for a moment. Even if President Barack Obama gets to keep his Pennsylvania Avenue address, gubernatorial elections could have a major influence on how his health care law is implemented. While the administration likes to highlight how much flexibility it has given states, that same flexibility has been a major weakness. If more power shifts to Republican governors, they’ll have more power to minimize the law’s reach. Republicans’ last major hope for overturning the health law lies in the Nov. 6 elections. If the national results indicate the Affordable Care Act’s future is secure, states have just 10 days to let the Obama administration know if they’ll run their own health insurance exchange or reach out to the feds for some help. There is no such deadline for the other big decision they face: whether to expand Medicaid.”—Jason Millman, Politico, August 17, 2012

Note: in the 2012 election cycle, Governor’s races are on the ballot in 11 states; seven with incumbents running for re-election.

Industry update

Consumer advocates encourage HHS to standardize insurance plan eligibility, rate setting and enrollments to align with ACA

Twenty consumer advocacy organizations issued a 56-page report last week encouraging HHS to establish a standardized approach for implementing the age-rating limits in the ACA so as to mitigate aging consumers' potential “rate shock.” The group’s recommendations also include:

  • Gradual increases in premiums: HHS should require insurers to slowly increase premiums as a person ages rather than allowing large increases to hit overnight.
  • Standardization and alignment of enrollment timing: HHS needs to “adopt standardized, national age bands to implement the ACA's age rating requirements” and establish a standardized open enrollment period for the fully insured market outside of the exchange to align with the exchange open enrollment period (begins October 1, 2013 and ends March 31, 2014).
  • Stop loss insurance definition for small businesses: HHS, the U.S. Department of Labor (DOL) and the U.S. Department of Treasury (DOT) should define “self-insured” and “issuer offering group health insurance coverage” so that small employers can only be self-insured if they bear adequate risk.
  • Essential health benefits restrictions: HHS should prohibit insurers' use of benefit substitutions in the ten prescribed benefit categories and clarify that states can decide to prohibit or restrict benefit substitutions.
  • Limitation on waiting periods: HHS, DOL and DOT should clarify that insurers cannot apply benefit-specific waiting periods.
  • Pre-existing condition exclusions: in eligibility determinations, HHS should prohibit insurers from using any factors related to a person's health status/pre-existing condition not reflected in the ACA.
  • Risk adjustment: HHS should develop a methodology that results in accurate collections and payments, encourages efficiency, and discourages fraud and abuse.

(Source: National Association of Insurance Commissioners, “Implementing the Affordable Care Act’s Insurance Reforms: Consumer Recommendations for Regulators and Lawmakers,” August 2012)

Study: hospitals not inclined to pursue ACOs

Seventy-five percent of hospitals do not anticipate developing an Accountable Care Organization (ACO, Section 3022 of ACA, “Medicare Shared Savings Program”) vs. 13 percent who are underway or planning toward implementation. More than half (51 percent) of ACOs are joint endeavors of physicians and hospitals while 20 percent are physician-only. (Source: Commonwealth Fund, “2011 National Survey of Hospital Readiness to Participate in an Accountable Care Organization,” based on input from 1,672 hospitals out of 4,937 contacted between May and September 2011)

Note: the survey was conducted prior to the issuance of a Final Rule on ACOs from CMS that made many modifications to the proposed rule, including electronic health records (EHR) use is no longer a condition for participation, fewer measures to assess quality (from 65 measures in five domains in the proposed rule to 33 measures in four domains in the final), and a longer phase-in of measures over course of agreement…According to CMS, 154 groups are currently underway in ACO efforts.

GAO: health risks of mobile devices needs attention

On August 7, the Government Accountability Office (GAO) released a report concluding that while scientific research has not conclusively demonstrated adverse human-health effects of exposure to radio-frequency energy from cellphone use, research is still “ongoing” and may “increase understanding of any possible effects.”

The limits the Federal Communications Commission (FCC) established in 1996 for such exposure “may not reflect the latest research, and testing requirements may not identify maximum exposure in all possible usage conditions.” CTIA-The Wireless Association, which represents wireless carriers such as AT&T Inc., Sprint Nextel Corporation, and others, said the industry welcomes further review of the standards.

Quotable

“Scaling good ideas has been one of our deepest problems in medicine. Regulation has had its place, but it has proved no more likely to produce great medicine than food inspectors are to produce great food. During the era of managed care, insurance-company reviewers did hardly any better. We’ve been stuck. But do we have to be?...The critical question is how soon that sort of quality and cost control will be available to patients everywhere across the country. We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous.”

— Atul Gawande, The New Yorker, “Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?” August 12, 2012

“Hospital management and payers must partner collaboratively and transparently with physicians to help them improve rather than merely issue incentive schemes… The US health care system should reinforce the tendency for physicians to act as knights who are motivated by professional values. When the health care system treats physicians as pawns—passive respondents to their circumstances—their motivation to take on challenging complex problems and play a leadership role in improving quality declines.”

— Cassel and Jain, Journal of the American Medical Association, “Assessing Individual Physician Performance,” June 27, 2012

“It is probably much easier…to talk in an opinion survey about quitting than it is actually to walk away from net practice incomes that even at their lower ranges place American doctors among the top 5 percent of families in the nation’s income distribution. That place is unlikely to change under the health care law. Would all these disillusioned doctors find lucrative employment in the already shrinking financial sector, the only other industry in which they could assuredly garner such high (or even higher) incomes, as some people with medical degrees now do?”

— Uwe E. Reinhardt, New York Times, “Health-Care Reform and the ‘Doctor Shortage,’” August 17, 2012

Fact file

  • Obesity: in 2011, the South had the highest percentage of obese individuals (29.5 percent) followed by the Midwest (29 percent), and West (24.3 percent). Mississippi ranked the highest at 34.9 percent and Colorado the lowest at 20.7 percent. No state has less than 20 percent obesity in its population. (Source: CDC, “Behavioral Risk Factor Surveillance System,” 2011)
  • Poll about public concerns: the top national economic issues of concern to Republicans are the federal budget deficit (56 percent) unemployment (55 percent), and the cost of health care (41 percent) while Democrats indicated unemployment (63 percent), the cost of health care (49 percent) and the cost of college education (28 percent). (Source: Kaiser Family Foundation, “Kaiser Health Tracking Poll,” August 2012)
  • Retail clinic visits: retail clinics in in pharmacies, supermarkets, and shopping malls saw visits increase from 1.48 million in 2006 to 5.97 million in 2009: 64.5 percent do not have a primary care physician and 70.5 percent have some type of insurance. 44 percent of clinic visits occurred when physicians’ offices were likely to be closed (weekday evenings and weekends). (Source: Health Affairs Blog, “Retail Clinic Visits Increased Four-Fold Between 2007 and 2009,” August 16, 2012)
  • Government audits of health care organizations: non-profit health care organizations undergo more government audits than do for-profit organizations averaging six during a 12-month period, versus four by for-profit health care providers. Additionally, larger companies underwent more audits than smaller companies (76 percent of those with 5,000+ employees reported at least one Medicare recovery audit-contractor review vs. 30 percent of organizations with 250 or less employees). (Source: Health Care Compliance Association, “Auditing the Auditors,” August 2012)

Fact file special: Mental Health

  • Cost in workplace: “severely and moderately depressed workers missed work more than non-depressed workers. Monthly salary equivalent lost for severely depressed ($199) and moderately depressed ($188) was also significantly higher than for non-depressed workers.” Monthly depression-related worker productivity losses projected to the U.S. workforce had human capital costs of nearly $2 billion annually. (Source: SAMHSA, “Employer Burden of Mild, Moderate, and Severe Major Depressive Disorder: Mental Health Services Utilization and Costs, and Work Performance,” August 2009)
  • Daily moods: the Well-Being Index’s daily mood measure, which reports the average amount of happiness and enjoyment respondents experience without a lot of stress or worry, is typically in the 40 percent range on weekdays and the high-50 percent range on weekends. This pattern was fairly steady until it fell to 37 percent on September 17, 2008, the same day the Dow dropped 449 points. Happiness dropped to 37 percent several more times throughout the fall of 2008 as the dire economic news continued and hit an all-time low of 35 percent on December 11—the day that new jobless claims reached a 26-year high. Those who make $90,000 or more per year have the highest Well-Being Index score among all demographic and socioeconomic groups associated with lower levels of obesity and chronic illness, and their better health habits. (Source: Gallup-Healthways Well-Being Index)
  • Global prevalence: depression-related disorders will be the single leading cause of global disease burden by the year 2020. (Source: Murray and Lopez, World Health Organization)
  • Incidence in U.S.: 19.9 percent of adults 18 years and older had any mental illness and 4.8 percent had a serious mental illness in 2009. 13 percent of children 8 to 15 years old had a diagnosable mental disorder in past year. (Source: SAMHSA and NIMH)
  • Lifetime prevalence of mood and anxiety disorders among youth and adults in the U.S.

Any Mood Disorder in Children

Source: NIMH Statistics, “Any Mood Disorder in Children”

  • Substance use disorders among individuals with serious mental illnesses in the U.S., 2009

Mental Health United States, 2010

Source: SAMHSA, Mental Health United States, 2010

  • Past month illicit drug use in the U.S., 2009 and 2010

Results from the 2010 National Survey on Drug Use and Health: Summary of Findings

Source: SAMHSA, Results from the 2010 National Survey on Drug Use and Health: Summary of Findings

  • Behavioral and physical health care occupations: median salaries in 2011

Mental Health United States, 2010
Source: SAMHSA, Mental Health United States, 2010

National health reform: What now?

National health reform: What now?

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