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May 14, 2009 Volume V, No. 52

HIN Communications Editor Laura Greene

Dear Healthcare Intelligence Network Client,

Healthcare costs are rising in the United States — surpassing $2 trillion in 2006, almost triple the $714 billion spent in 1990, and over eight times the $253 billion spent in 1980. With these figures in mind, it's refreshing to hear there are still some healthcare expenditures on the decline. Read on to find out which ones. Also in this issue of the DM Update, find out how high healthcare costs are preventing some patients from getting mental health treatments they need.

Your colleague in the business of healthcare,
Laura Greene, Editor

This week's disease management news:

Table of Contents

  1. Obesity Surgery Costs
  2. Budgets Must Meet Mental Health Treatment Needs
  3. Medical Home IT
  4. Measuring Medication Compliance
  5. Medical Home Models
  6. Chronic Infections
  7. Uninsured & Underinsured

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Costs, Complications Slim Down for Obesity Surgery

Between 2002 and 2006, hospital payments for bariatric surgery patients fell from $29,563 to $27,905 and dropped from $41,807 to $38,175 for patients who experienced complications, according to a study by the HSS' Agency for Healthcare Research and Quality (AHRQ). Hospital payments for the most expensive patients — those who had to be readmitted because of complications — fell from $80,001 to $69,960, as the complication rate among patients initially hospitalized for bariatric surgery dropped from approximately 24 percent to roughly 15 percent. Much of this was driven by a reduction in the post-surgical infection rate, which plummeted 58 percent. Abdominal hernias, staple leakage, respiratory failure and pneumonia fell by between 50 percent and 29 percent.

AHRQ researchers led by Senior Economist William E. Encinosa, Ph.D., compared complication rates among more than 9,500 patients under age 65 who underwent obesity surgery at 652 hospitals between 2001 and 2002 and between 2005 and 2006. They found that the complication rate fell in spite of an increase in the percentage of older and sicker patients having the operations. The proportion of patients over age 50 operated on by bariatric surgeons increased from 28 percent to 44 percent during the period, and the average number of underlying illnesses in patients operated on by bariatric surgeons, such as diabetes, high blood pressure or sleep apnea, more than doubled. The 6-month post-surgical death rate for patients operated on between 2005 and 2006 was 0.5 percent, statistically about the same as that of patients who had bariatric surgery between 2001 and 2002. Hospital readmissions because of complications fell 31 percent, from roughly 10 percent to 7 percent, while complication-caused same-day hospital outpatient clinic visits declined from approximately 15 percent to 13 percent.

"People considering an elective procedure need unbiased, science-based evidence of its benefits and risks," said AHRQ Director Carolyn M. Clancy, M.D. "All surgeries involve risks, but as newer technologies emerge and surgeons and hospitals gain experience, as this study shows, risks can decrease."

According to Dr. Encinosa, the improvements are largely due to a combination of three factors — increased use of laparoscopy, a technology that allows physicians to operate through small incisions; increased use of banding procedures without gastric bypass, such as vertical-banded gastroplasty and lap band; and increased surgeon experience arising from the growth in the number of bariatric surgeries performed by hospitals. For example, laparoscopy reduced the odds of having a complication by 30 percent and drove down hospital payments by 12 percent, while banding reduced hospital payments by 20 percent.

To learn more about this research, please visit: http://www.ahrq.gov/news/press/pr2009/barsurgpr.htm

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Framework for Constructing a Medical Home Model

Implementing an EHR into your organization is not the same as implementing a patient-centered medical home (PCMH) model of care, according to Dr. James Crawford, senior vice president for laboratory services and chair of the department of pathology and laboratory medicine at North Shore-Long Island Jewish Health System. In order for it to be a PCMH, the practice workflow has to change, as well. In this podcast, Dr. Crawford discusses the key process change that has to accompany the adoption of health IT by a PCMH as well as health IT's impacts on care coordination and findings from the PCPCC's survey of physician practices on their use of health IT in support of the PCMH model.

To listen to this complimentary HIN podcast, please visit: http://www.hin.com/podcasts/podcast.htm#87

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Measuring Medication Compliance

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's expert is James Hardy, senior vice president of care management services with McKesson Health Solutions.

Question: How do you determine compliance for medication adherence? Is it patient self-report, claims data or other sources of data?

Response: We’re evolving to using the data. One of the things about pharmacy data is that claims are adjudicated at point of service. This keeps the data that we get from the state relatively fresh and accurate. Right now we’re focused on refills in order to know the standard dates of fill, so we can look and say, “Boy, there wasn’t a claim for this person.” It’s a combination of that and talking to the consumer, but having that claims data and seeing the absence of the refill is a powerful tool.

For more details on comorbidity care models, please visit: http://store.hin.com/product.asp?itemid=3892

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Budgets Must Meet Mental Health Treatment Needs

Between 1996 and 2006, prescriptions for mental health medications increased significantly across all age groups: 100 percent increase in the elderly population, 73 percent increase among adults and 50 percent increase for children. In the same time period, per-capita spending for mental healthcare rose by more than 30 percent, which is primarily attributed to psychiatric drug costs, according to studies funded by the John D. and Catherine T. MacArthur Foundation and the National Institute of Mental Health.

“It is encouraging to know that psychiatric medications are helping individuals of all ages with various mental disorders to manage these potentially debilitating illnesses and rebuild their lives,” said Debra L. Wentz, Ph.D., CEO of the New Jersey Association of Mental Health Agencies, Inc. (NJAMHA). “Mental illnesses are affecting a greater number of people, especially as the recession continues and people are struggling with the loss of jobs, homes and savings. Access to medications, as well as psychosocial therapies, is critical and must never be restricted, regardless of the state’s or nation’s fiscal challenges.”

While more and more people are receiving psychiatric drug prescriptions, some are not taking these medications as directed because of the high cost, especially if they do not have health insurance. For example, the Kaiser Family Foundation recently reported that 20 percent of Americans reduce or skip doses of prescribed medications. “This problem would be exacerbated if New Jersey’s FY 2010 budget includes co-pays for Medicaid FFS and managed care and Medicare Part D recipients,” Dr. Wentz said. “Another obstacle to accessing prescriptions is New Jersey’s proposed reduction of reimbursement rates to pharmacies serving Medicaid beneficiaries. As a result, small pharmacies won’t carry all prescriptions and patients will be discouraged from getting them filled.”

According to Dr. Wentz, the potential $6 million increase in state revenue from co-pays would be dwarfed by the inevitable costs of emergency treatment, hospitalization and other services to treat individuals whose conditions worsen because they discontinue medications. The same is true about savings from reductions in wholesale prices to pharmacies. “Co-pays and reimbursement reductions impose a barrier for individuals who already struggle to pay for rent, food and utilities. The state should not further burden them with co-pays, forcing them to choose between prescriptions and other needs,” she said.

To learn more about this research, please visit:

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Medical Home Models: Improving Quality & Reducing Costs in Healthcare

The PCMH model of care — an approach embraced by thousands of healthcare organizations — focuses on improving care quality and reducing costs for the chronically ill. According to a 2004 report in the Annals of Family Medicine, if every American had a medical home, healthcare costs would decrease by 5.6 percent, resulting in national savings of $67 billion per year and improved care. This white paper summarizes the results from HIN’s Medical Homes in 2009 e-survey in which more than 220 healthcare organizations described the role of the PCMH in their organizations.

To download this complimentary white paper, please visit:

Additional white papers: Nearly 300 healthcare professionals share how they are managing — and working to prevent — the growing problem of obesity.

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Key Protein Keeps Chronic Infection in Check

Why is the immune system able to fight off some viruses but not others, leading to chronic, life-threatening infections like HIV and hepatitis C? A UCLA AIDS Institute study suggests the answer lies in a protein called interleukin-21 (IL-21), a powerful molecule released by immune cells during chronic infection. The finding could explain how the immune system limits viral replication, restricting a virus's spread through the body.

Researchers looked at two types of T-cells — CD4 T-cells and CD8 T-cells — which are immune cells that play an important role in the body's response to infection. The CD4 T-cells help the immune system by producing IL-21 during chronic infection, bolstering the CD8 T-cells' ability to fight off the virus. The scientists tested each strain on two groups of mice. One group was normal and the other was bred without IL-21 receptors. In the normal mice, the first strain elicited a strong T-cell response that completely eliminated the virus in 10 days. The second strain caused a chronic infection that exhausted the T-cells, hampering their ability to fight the virus. The UCLA team detected high levels of IL-21 in these mice, suggesting that the protein plays a crucial role in sustaining the T-cells' ability to mount an immune response during long-lasting infection. When the scientists infected the mice that lacked IL-21 receptors with the chronic infection strain, something curious happened. The majority of virus-fighting CD8 T-cells disappeared, preventing the immune system from containing the spread of the virus. When the scientists infected the mice that lacked IL-21 receptors with the chronic infection strain, something curious happened. The majority of virus-fighting CD8 T-cells disappeared, preventing the immune system from containing the spread of the virus. Without IL-21, the CD8 T-cells dwindled, even when the CD4 T-cells produced a robust response. The result indicates that the T-cells rely on IL-21 to resolve persistent infection.

"IL-21 fuels CD8 T-cells' ability to function," said David Brooks, assistant professor of microbiology, immunology and molecular genetics at the David Geffen School of Medicine at UCLA. "These immune cells are running a long-distance race to contain the virus before it spreads. If they don't get fed, they collapse on the track. After the immune system loses CD8 T-cells, it's unable to clear the virus. This tells us that IL-21 is a critical player in the body's fight against chronic infection."

To learn more about this research, please visit:

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Uninsured & Underinsured

So far, more than 70 healthcare organizations have answered this month's e-survey on healthcare's response to the growing numbers of uninsured and underinsured, from strategies to reduce the financial impact of these populations to ways to make healthcare more accessible and affordable for them. There's still time to share the impact of the uninsured and underinsured on your organization by completing HIN's Survey of the Month. You'll receive a free executive summary of the compiled results, and your responses will be kept strictly confidential.

To participate in this survey and receive its results, please visit: http://www.surveymonkey.com/s.aspx...

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