Category Archives: Affordable Care Act
With the passage of the Mental Health Parity Act and the implementation of the Affordable Care Act (ACA), behavioral health experts are pushing to improve the quality of that care so that people seeking help—some for the first time—receive evidence-based care that best suits their individual needs. As part of that conversation, the U.S. Senate Health, Education, Labor and Pension committee held a hearing this week on mental health treatment trends in the United States.
Sen. Tom Harkin (D-Iowa) the committee chair opened the hearing by “pointing to disturbing new trends [including]...significant increases in the prescribing of psychotropic medications, while the use of behavioral and psychological treatments among children and youth has increased only slightly, and has actually decreased among adults.”
According to committee research on recent use of psychotropic drugs, use of antipsychotic medications has increased eight-fold among children and five-fold among adolescents, and has doubled among adults between 1993 and 2009.
The key witness at the hearing was William Cooper, MD, MPH, a professor of pediatrics and health policy at the Vanderbilt University School of Medicine who conducts population-based studies of medication use in children. Cooper told the committee about a nine-year-old boy he treated for weight gain—which turned out to be a side effect of a psychotropic drug the child had been prescribed by a primary care provider given for disturbing the classroom. No mental illness diagnosis had been made for the child, and no mental illness was detected after evaluation at Vanderbilt.
Cooper said that in recent years the United States has seen a tremendous increase in the numbers of children diagnosed with mental health disorders.
“Whether this is a result of increased awareness, improved diagnosis, or other factors is not clearly understood,” said Cooper, who added that “while we must acknowledge that a part of the increase could be due to over-diagnosis, there is no disputing the fact that a large number of children and their families suffer significantly because of mental illness.”
Furthermore, added Cooper, given the fact that suicide is the second leading cause of death for children ages 12-17, “tragic consequences of childhood mental health disorders highlight our sense of urgency in addressing this important problem.”
Cooper added that treating mental health disorders can be challenging and that 50-75 percent of the care for children with mental health disorders occurs in primary care settings “making it critical that consultation and communication between primary care professionals and experts in mental health be enhanced.”
Significantly, Cooper told the panel that despite guidelines, much of the mental health care for children occurs in a manner “inconsistent with optimal practice,” including:
- Use of medications for diagnoses for which there is little evidence of benefit.
- Use of multiple medications at the same time, especially among particularly vulnerable children such as children in foster care, where a recent study found multiple psychiatric medications in up to 75 percent of children being treated.
- Use of medications alone without proven psychotherapies.
Cooper attributed the problems to several factors, among them:
- Many general practice doctors are unaware of current mental health treatment guidelines.
- Inadequate mental health resources to provide best treatments.
- Too few professionals with training in providing mental health care to children.
- Barriers to treatment, including cost or the need to travel long distances.
- Stigma associated with mental illness, which may reduce families’ willingness to acknowledge a mental health disorder and seek treatment.
The HELP committee plans to hold additional hearings to address mental health issues. Other attention to the issues addressed at the hearing include a recent meeting in Washington, D.C. among professionals who conduct psychiatric clinical trials. They stressed the need to involve patients and families more in trial design and access, as well as to work with trial designers on mental health needs not currently being met.
The Substance Abuse and Mental Health Services Administration, a federal agency, recently announced several new funding grants to help individual groups facing mental health concerns including:
- A grant program for residential treatment of pregnant and postpartum women.
- A grant program to expand and sustain comprehensive community mental health services for children and their families, in order to improve behavioral health outcomes for children and youth with serious emotional disturbances, as well as improve the health and well-being of their families.
- A grant program to provide tribal and urban American Indian and Alaskan Native communities with tools and resources to plan and design a holistic, community-based coordinated system of care approach to support mental health and wellness for children, youth and families.
Read more about mental health on NewPublicHealth.
PSA Campaigns Uses Pets to Remind Uninsured People of Deadline to Enroll Under the ACA
With research showing that more than 80 percent of Americans are unaware of the March 31 deadline to sign up for health coverage under the Affordable Care Act, Enroll America has partnered with the Ad Council on the launch of a new national campaign to raise awareness, educate and motivate people to enroll. The “Take Care, People” national multimedia public service advertising (PSA) campaign, which is focuses on women ages 18-34, took a somewhat unusual approach when it came to selecting spokespeople: pets. “We needed a familiar face that would stand out amidst all the noise to communicate to all Americans the benefits of enrolling for health insurance in a way that’s entertaining, relatable and easy to digest,” said Creative Director Rodrigo Butori of La Comunidad, which created the PSAs along with Razorfish. “We thought about pets. Why? Two thirds of American homes have pets. They have been the recipient of people’s love and care for ages. So it’s time for them to return the favor. It’s time for pets to take care of people for a change.” Read more on the Affordable Care Act.
PHLR Online Database Brings Together Experts and Peer-reviewed Publications
Public Health Law Research (PHLR), a program of the Robert Wood Johnson Foundation, has launched the new PHLR SciVal Expert Community to allow users to discover existing and emerging evidence on laws and legal practices that improve health, to identify experts in the area and to pursue new collaborations. The searchable database currently includes 240 expert public health law researchers and more than 16,000 of their peer-reviewed publications covering a range of topics, from alcohol, tobacco and other drugs to occupational safety and health, oral health and preparedness. Read more on research.
Study: Healthy Eating on Weekdays the Key to Losing Weight
The key to losing weight and keeping it off may be healthier eating on weekdays rather than weekends, according to a new study in the journal Obesity Facts. Knowing that most people tend to gradually lose weight during the week and then gain it back on the weekends, researchers tracked the eating habits of 80 people ages 25 to 62, having them weigh themselves before breakfast every day for anywhere from two weeks to nearly a year. The study found that everyone experienced weight fluctuations, but that the people who consistently lost weight tended to compensate more strictly during the week for their weekend weight gain, with their weight decreasing immediately on Monday and continuing downward until Friday. "The ones who are big winners are those who lose a little bit of weight from Monday to Tuesday to Wednesday to Thursday," said study co-author Brian Wansink, a professor of consumer behavior at Cornell University. Read more on obesity.
NIH, Industry and Non-profits Form Partnership to Speed Drug Development
The National Institutes of Health (NIH), 10 biopharmaceutical companies and several non-profit organizations have launched the Accelerating Medicines Partnership (AMP) to identify and validate the most promising biological for several diseases. The first set of disease targets will be Alzheimer’s disease, type 2 diabetes, rheumatoid arthritis and lupus. Through the foundation for the NIH, AMP partners will invest more than $230 million over five years in the first drug projects. Read more on partnerships.
CDC: Child passenger Deaths Decrease 43 Percent from 2002-2011
While car crash deaths among children age 12 and younger dropped by 43 percent from 2002 to 2011, more than 9,000 children died in crashes during that time period, according to a new Vital Signs report from the U.S. Centers for Disease Control and Prevention. The report found that 45 percent of black children and 46 percent of Hispanic children who died in crashes were not buckled up, compared to 26 percent of white children. Read more on injury prevention.
New Survey Finds Skepticism about Health Law Continues for Many Adults
Analysis of a new Health Reform Monitoring Survey, funded in part by the Robert Wood Johnson Foundation, finds that more and better outreach is needed to educate uninsured people about free or low-cost health insurance through expanded Medicaid programs or subsidies to help them purchase health insurance in the new marketplaces. Among the survey findings:
- On seven measures of health care quality, access, and cost, the majority of adults expect to be neither better-off nor worse-off in 2014 than in 2013, but of those expecting a change in 2014; more expect to be worse-off than better-off.
- Adults are more pessimistic about health-related costs in 2014 than about health care quality and access.
- Compared with insured adults, a higher share of the uninsured—expects to be better-off in 2014.
- Younger adults tend to be more optimistic than older adults about overall health care quality, access, and cost.
In an effort to help more people seek out health insurance coverage, Enroll America in partnership with the Ad Council, just launched “Take Care, People,” a national multimedia public service advertising (PSA) campaign to raise awareness, educate and motivate uninsured Americans to get health insurance for themselves and their families under the Affordable Care Act (ACA).
The campaign uses pets to tell people it’s time to take care of themselves, with a particular focus on women ages 18 to 34. Research by Enroll America finds that that women are more likely than men to do investigate health insurance options, enroll and encourage others to seek out information. Enroll America research also shows that 81 percent of people who are uninsured are unaware of the March 31 deadline to enroll in coverage for 2014 and 69 percent don’t know that financial assistance is available to help pay for their coverage. The PSAs were produced in both English and Spanish. Read more on the Affordable Care Act.
While behavioral and physical health have generally been separate entities in the United States, new rules under the Affordable Care Act are bringing them together—both to reduce costs and to integrate care in millions of people who face behavioral and physical health issues.
Experts at last week’s Healthy Communities Initiative forum, convened by the National Association of Counties (NACo), and this week’s AcademyHealth National Policy Conference, meeting in Washington D.C., presented strategies for combining the two. Some pilot projects are beginning. The pace is picking up largely because many people now covered under the states that have created Medicaid expansion have a range of behavioral and physical health needs. They will benefit from integration because the two are often connected—for example, diabetes has been linked to depression—and because connecting the two can reduce health care costs and reduce the number of provider visits a patient has to make.
“Behavioral health is a driving force in why people don’t get where they want to be,” said Donna Skoda, Assistant Health Commissioner of Summit County, Ohio, who spoke at the NACo forum.
Several public health officers at the forum presented ideas of what works in their communities, including:
- Hiring nurses to be care providers to assess both behavioral and physical health needs
- Retraining behavioral health specialists, including psychiatrists, to use blood pressure cuffs and other medical equipment
- Integrating patient files with information on mental and physical health baselines and changes
- Opting, when possible, to deliver care in physical health offices rather than counseling offices, since physical practitioner clinics already have devices needed such as scales
Presenters at the AcademyHealth policy conference stressed cost savings. For example, Washington state will participate in a federal demonstration project for beneficiaries dually eligible for Medicare and Medicaid. Under the demonstration, the health plans will be responsible for a full range of services—including mental health; chemical dependency; long-term services and supports; and medical care—under a single capped rate.
“Integrated care needs to be the rule, not the exception,” said Charlene Le Fauve, a deputy director of the National Institute of Mental Health.
Le Fauve said new technologies can be an important factor in delivering care including mobile devices and internet tools, which can be used at provider offices, clinics, and in homes if communities provide those services.
Other ideas being funded include training community workers for brief interventions which may be able to keep many people with mental illness out of both the emergency room and the hospital. Phone intervention is also being studied, said Le Fauve.
Caring for the millions of people acquiring health coverage under the Affordable Care Act will require many more primary care providers than are currently available. At a session today on New Models and Workforce Innovations for Primary Care Access at the 2014 National Health Policy Conference convened by AcademyHealth, presenters talked about emerging specialists for primary care, including nurses, physician assistants and care coordinators, who are also known as community health workers.
Pharmacists are also included in that provider model. Jeffrey Kang, MD, MPH, senior vice president of health and wellness at Walgreens, presented data on a model program the pharmacy chain has at more than a dozen hospitals which is helping reduce hospital readmissions. Walgreens has pharmacies at dozens of hospitals across the United States and with its pilot program, called WellTransitions, works with hospital discharge staff on medicine instructions and then follows up with phone calls once patients are home.
Kang said a key question is whether someone is taking the right medicine. In the medication orders system there is no procedure, other than patient initiative, for stopping a previously prescribed medication. For example, if a patient had been taking a blood pressure medication before a hospital stay and then is prescribed a new one in the hospital, they may still have vials of the drug at home, and studies show they commonly continue taking the drug, either instead of, or in addition to the drug prescribed during the recent hospital stay.
With the WellTransitions program, drugs are delivered to the patient before discharge, avoiding a trip to the pharmacy, and pharmacists follow up at 9 days and 25 days.
Walgreens launched the program in 2012 and released data late last year that showed that early results indicate that within the first 6 months that WellTransitions was operational in five hospitals, the 30-day readmission rate for patients in the program was 9.4 percent, compared with 14.3 percent for patients not participating in the program.
HHS: 2.2M Enrolled for Coverage Under Affordable Care Act Through December
Despite a glitch-filled October 1 launch that saw only about 27,000 people enroll in the first month, by December 28 an estimated 2.2 million Americans had enrolled for health coverage available through the Affordable Care Act, according to the latest data from the U.S. Department of Health and Human Services. The state and federal online marketplaces enrolled nearly 1.8 million in December alone. Of the 2.2 million enrollees:
- 54 percent are female and 46 percent are male
- 30 percent are age 34 and under
- 24 percent are between the ages of 18 and 34
- 60 percent selected a Silver plan, while 20 percent selected a Bronze plan
- 79 percent selected a plan with Financial Assistance
Read more on the Affordable Care Act.
Task Force Recommends All Pregnant Women Be Screened for Gestational Diabetes
The U.S. Preventive Services Task Force is now recommending that all pregnant women be screened for gestational diabetes after 24 weeks of pregnancy. Gestational diabetes can increase the risk of pregnancy complications (such as preeclampsia) and labor complications, due to the baby growing larger than normal. Newborns are also at higher risk of low blood sugar levels after being exposed to the mother’s high blood sugar. Early diagnosis and treatment—lifestyle changes, blood sugar monitoring and insulin—can reduce the risks for both mother and child. "The number of women who have gestational diabetes is rising, and gestational diabetes has effects not only on the mother, but also on the baby," said task force chairwoman Virginia Moyer, MD, vice president for maintenance of certification and quality at the American Board of Pediatrics. "We want to prevent adverse outcomes for both of them." Read more on maternal and infant health.
West Virginia Closer to Restoring Safer Tap Water After Chemical Leak
About 35,000 people in the area of Charleston, West Virginia, can now drink their tap water safely after it was declared usable again, according to West Virginia American Water. More than 300,000 customers were told their water was unsafe to drink and or use for washing after it was discovered last week that as much as 7,500 gallons of 4-methylcyclohexane methanol, or crude MCHM, from Freedom Industries had leaked into the Elk River. Officials estimate it will take a few more days before the entire system is once again safe. MCHM-tainted water can cause nausea, vomiting, dizziness, diarrhea, rashes and reddened skin; 231 people visited emergency departments with symptoms and 14 were admitted. Read more on water and air quality.
Study: School Assaults Lead to Nearly 90,000 ER Visits Annually
Assaults at school account for almost 90,000 emergency-room visits annually, according to a new study in the journal Pediatrics. In a review of data on students ages 5-19, researchers determined that an average of 92,000 annual emergency visits were a result of deliberate injury, with student-on-student assault accounting for about 88,000. About 40 percent of the injuries were bruises or scratches, with few leading to later hospitalization. "[The number of injuries] appears to be concerningly high, especially when you realize that such a substantial number of injuries are occurring in the school setting, where safety measures are already in place," said lead author Siraj Amanullah, MD, an assistant professor of emergency medicine and pediatrics at Brown University's Alpert Medical School. "There is a need to continue addressing this issue at various levels—at home, at school and in the medical care setting—and there is a need to ramp up our existing prevention and safety strategies.” Read more on violence.
WHO: India Can Now Be Declared Polio-Free
With now three years passed since its last reported cased of polio—January 13, 2011—the country of India can now be declared polio-free, according to the World Health Organization (WHO). The certification process should be completed by the end of March. The country’s last victim was a two-year-old girl in West Bengal. This now leaves Afghanistan, Pakistan and Nigeria as the only countries where polio remains endemic. As part of our recent Outbreak Week, NewPublicHealth recently spoke with Sona Bari, WHO’s senior communications officer, about the efforts underway to eradicate polio globally. Read more on infectious disease.
Translation Errors Plague ACA’s Spanish-language Site, Impede Enrollment
Problems with the Spanish-language version of the Affordable Care Act’s website are making it difficult for many of the site’s users to navigate the site and enroll for coverage. In addition to launching late and sending users to English-language forms when they are clearly looking for Spanish-language content, CuidadoDeSalud.gov is also full of grammatical and other language mistakes. "When you get into the details of the plans, it's not all written in Spanish. It's written in Spanglish, so we end up having to translate it for them," said Adrian Madriz, a health care navigator who helps with enrollment in Miami. Several states with large Hispanic populations have fallen short in their goals to enroll Spanish-speakers, with critics pointing to the website as a major impediment. For example, while it’s not know how many of California’s 4.3 million residents who only speak Spanish intend to seek coverage under the Affordable Care Act, through the end of November only 5,500 had successfully enrolled. Read more on the Affordable Care Act.
Late last year the Grand Rounds program of the U.S. Centers for Disease Control and Prevention (CDC) held a webinar on water fluoridation, a public health intervention that has been a priority in the United States for nearly seventy years.
Fluoridation, which has been shown to significantly reduce cavities in children, has been recognized by the CDC as one of 10 great public health achievements of the 20th century. Despite the benefits such as cost savings, however, CDC says there are ongoing challenges in promoting and expanding fluoridation.
NewPublicHealth recently spoke with Barbara Gooch, DMD, MPH, Associate Director for Science in the Division of Oral Health at CDC’s National Center for Chronic Disease Prevention and Health Promotion, about the challenges and benefits of water fluoridation and other emerging oral health improvement opportunities.
NewPublicHealth: What has been the historical impact of fluoridating water in the United States?
Dr. Barbara Gooch: All water generally contains fluoride, but usually at a level too low to prevent tooth decay, so community water fluoridation is a controlled adjustment of fluoride in a public water supply to an optimum concentration for the prevention of tooth decay.
That optimal concentration has historically been set at about 1 milligram (mg) of fluoride per liter of water, or 1 part per million. Fluoride was first introduced in the United States in Grand Rapids, Mich., in 1945. For cities that implemented community water fluoridation in the 1940s and 1950s, there was a dramatic reduction in tooth decay among children. Sometimes that reduction was greater than 50 percent. It has really been a major factor leading to the improvement in U.S. oral health.
When we compare the National Health and Nutrition Examination Survey done in the early 1970s with one conducted from 1999 to 2004, we found that the percentage of adolescents with one or more decayed teeth decreased from 90 percent in the early 1970s to 60 percent in the ’99-’04 National Survey. And while the number of teeth affected by tooth decay was an average of six in the 1970s survey, the instance was reduced to fewer than three in the later survey.
NPH: There are other sources of fluoride now, such as toothpaste. Is community water fluoridation still important?
Gooch: Current studies indicate that community water fluoridation increases the prevention of tooth decay by an additional 25 percent despite other sources. But the other very important factor about community water fluoridation is in order to receive its benefits, if you live in a fluoridated community. all you have to do is drink the tap water. And we can also show cost savings. One study estimates that for every dollar spent on community water fluoridation, you save about $38 in dental treatment costs.
Study: Newly Insured Visit Emergency Departments More Often
While some experts have speculated that expanded insurance under the Affordable Care Act would decrease the rate of emergency department visits, a new study in the journal Science indicates that newly insured people actually visit the departments significantly more than people who were uninsured. The study of 25,000 Medicaid lottery participants in Oregon in 2008 found that people who received expanded coverage increased their visits by 40 percent—or 0.41 visits—over a period of 18 months. The visits encompassed all manner of health issues, included issues that could have been treated by a primary care physician and would have been covered by the insurance. Read more on access to health care.
Electronic Media Use During Family Meals Tied to Poorer Nutrition and Communication
The use of electronic devices—including television, music with headphones and texting—by teens during meals is linked to less nutritious food and poorer family communication, according to a new study in the Journal of the Academy of Nutrition and Dietetics. In a survey of more than 1,800 parents, researchers asked how often adolescent children used a variety of electronics during family meals, whether they had any rules regarding their use and whether they felt family meals were important; the children were asked questions about family communication, such as how often they discussed their problems with their parents. The study found that two thirds of the teens watched television or movies some of the time, with one quarter watching frequently. Other electronic activities were less common, occurring 18 to 28 percent of the time. About 75 percent of the families had limits on mealtime media. "There is no magic number of how many (family meals) to have, not all food at meals has to be 100% healthy and having electronic media at meals is not all bad (e.g., an occasional movie night with dinner) if it facilitates family time," said lead author Jayne A. Fulkerson. "But, parents can take small steps to have quality time with their children by reducing media use at mealtimes." Read more on nutrition.
Smoking Adds $17 Billion to Post-Surgery Costs Each Year
Smoking-related complications following surgery—for both current and former smokers—add an estimated $17 billion in direct U.S. medical costs each year, according to a new study in JAMA Surgery. The study, led by David Warner, MD, of the Mayo Clinic, looked at surgical patients between April 2008 and December 2009. While the costs for initial hospitalizations was relatively consistent for current smokers, former smokers and people who never smoked, post-surgery costs were an estimated $400 higher for current smokers and $273 higher for former smokers. Read more on tobacco.
More Than One Million People Now Enrolled for Health Insurance Coverage under the Affordable Care Act
The Centers for Medicare and Medicaid Services (CMS), which administers the health insurance provisions of the Affordable Care Act (ACA) reported late last week that more than one million people have now enrolled for coverage under the ACA.
CMS also reported that December enrollment as of December 27 was seven times that of October and November. Open enrollment will continue through March, with rolling dates for first day of coverage. Read more on the Affordable Care Act.
U.S. Flu Cases on the Rise
The Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota reported last week that rates of flu are on the rise in the United States, with the 2009 H1N1 virus the predominant strain. The good news is that this year’s flu vaccine is protective against H1N1.
According to CIDRAP, officials from the Centers for Disease Control and Prevention have said that the 2009 H1N1 virus has a greater impact on younger adults and older children than seasonal flu strains typically do.
The numbers of U.S. flu cases are usually highest January through March, which means that people who have not had flu shots yet still have time to protect themselves. Full immunity from the vaccine can take up to two weeks from the time of the injection. Use the CDC’s Flu Vaccine Finder to find a flu shot in your neighborhood. Read more on outbreaks.
New Orleans Health Commissioner to become Federal Health IT Administrator
New Orleans Health Commissioner Karen DeSalvo, MD, has been appointed the new National Coordinator for Health Information Technology (IT), replacing Farzad Mostashari, who left the position earlier this year. In a memo to employees of the U.S. Department of Health and Human Services (HHS), which oversees the office of the National Coordinator, HHS Secretary Kathleen Sebelius noted that Dr. DeSalvo boosted the use of health IT as "a cornerstone of [New Orleans’s] primary care efforts and a key part of the city's policy development, public health initiatives and emergency preparedness." Dr. DeSalvo will begin her post in mid-January. Under Dr. DeSalvo's leadership, New Orleans also received the inaugural Robert Wood Johnson Foundation Roadmaps to Health Prize.