Managed Healthcare Executive May Issue

In a week when the CDC was taken to task for being misleadingly cautious and sometimes contradictory in its COVID-19 advice, the agency’s director announced that fully vaccinated people can stop wearing masks in most circumstances.

Reaction to the CDC’s announcement that vaccinated people can go maskless in most situations

Smartphone use before bedtime has been linked with lower-quality sleep, but a new study suggests a popular feature designed to combat the problem is ineffective.

, found the use of Apple’s “Night Shift” feature did not have a significant impact on a patient’s sleep quality. However, avoiding phone use in the last hour before bedtime did make a difference, though only in the study volunteers who were not sleep deprived.

Apple’s iPhone includes a mode called “Night Shift.” The feature, and similar features on other smartphones, reduces short-wavelength light emissions in the minutes before sleep based on the theory that such “blue light filtering” can reduce the negative sleep impacts of screen exposure before bed.

, Ph.D., of Cincinnati Children’s Hospital Medical Center, and colleagues, wanted to understand how, if at all, such features can affect sleep quality in young adults. To find out, the investigators recruited 167 young adults between the ages of 18 and 24. Participants were instructed to spend at least eight hours in bed at night and placed in one of three phone-usage groups. One group was told not to use their phones in the hour before bed. A second group was told they could use their phones with Night Shift enabled in the hour before bed. The final group was told to use their phones normally, without Night Shift. The participants’ sleep was tracked using wrist-worn accelerometers and their iPhone use was monitored using the commercially available “Moment” app.

The results showed a clear trend, but it had nothing to do with Night Shift.

“[D]espite having instructed all study participants to spend at least eight hours in bed with the intention to sleep, we observed that the total average sleep duration for this population was 6.82 hours during our sleep modification window,” the investigators wrote. The sleep amount did not significantly vary based on device use. Patients who didn’t use their phones before sleep averaged 400.79 minutes of sleep per night, those who used Night Shift had 406.93 minutes, and those who used their phone normally slept an average of 404.80 minutes. Sleep latency, a measure of how long it takes to fall asleep, was also similar among the groups.

The participants’ average sleep efficiency, the time spent in bed versus time spent sleeping, was under 85%. Such low sleep efficiency is generally categorized as “poor” sleep, though the authors said the low percentage could be because the study required them to stay in bed longer than they normally would.

“Contrary to our original hypotheses, we did not detect differences in sleep outcomes across the three experimental groups,” Duraccio and her colleagues wrote. “Our three study groups demonstrated comparable means for total sleep time, time taken to fall asleep, amount of time spent awake after falling asleep, and sleep efficiency regardless of their group assignment.”

However, the investigators said their findings might merely be evidence that when a person is sleep deprived, the lack of sleep overrides any sleep differences that might be caused by phone use.

When the analysis was restricted only to participants who got more sleep than the population average, the investigators started to see a difference. In participants with higher-than-average sleep, no phone use led to significantly better sleep quality (more efficient sleep and less time awake during sleeping hours). Yet, even in the group of longer sleepers, there was no significant difference between those who used their phones with Night Shift and those who did not; the impact was only seen when participants avoided phone use altogether.

Duraccio and colleagues said their study shows that the problem of smartphones impacting sleep is more complicated than blue light.

“We conclude that aspects of phone use beyond short-wavelength light must be contraindicative to sleep, such as engagement in stimulating activities (e.g., social networking, texting) that increases physiological arousal that makes sleep difficult,” they said. “Future research that examines these unique contributions of phone use on sleep outcomes is critical.”

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Young adults did not have significantly better sleep when using blue light filters on their smartphones in the hour before bed, according to a new study.

Study Suggests ‘Night Shift’ Feature on iPhone Does Not Help Sleep Quality

Five years ago, Prime Therapeutics, a fast-growing pharmacy benefit manager (PBM) owned by 19 Blues plans, realized that its portfolio of leased office spaces had grown expensive and unwieldy. The company’s leaders decided to consolidate its four Twin Cities offices at a gleaming new headquarters in nearby Eagan, Minnesota, and keep seven floors of offices at a location in another suburb.

An analysis had revealed that much of the existing space went unused, so company executives designed the Eagan building with flexible workspaces to encourage collaboration and meeting spaces that could be made smaller or larger as required, says Kim Gibson, assistant vice president of real estate and facilities at Prime. They suspected telecommuting would become a growing trend and felt the new building could accommodate such a transition, she says.

Then the pandemic hit. A change intended to be gradual took place almost instantaneously and worked out better than expected. In a mid-2020 poll, almost all (93%) of Prime’s employees said they were faring well at home, and two-thirds wanted a hybrid arrangement that would allow working remotely part time when the Prime offices eventually reopen.

Thus was born the “hub and home” strategy. Prime recently announced that employees will work from home 50%-65% of the time when reopening occurs, rotating into the office on set days of the week or month. With teams sharing spaces, Prime will be able to vacate the Bloomington offices by mid-2022 when the lease expires, reducing its footprint by one-third.

“To be an employer of choice, we’ve got to listen to our employees and bring the work to them, and I think this hub-and-home model does that,” Gibson says. “I would even say that if we didn’t offer something like this, we might be losing out on talent in the future. I’d say it’s critical to our future. I would suspect other organizations are considering the same.”

Indeed they are. Many health insurers and PBMs have not announced plans, but those contacted by 

® indicated that they are either proceeding with or contemplating remote and hybrid work schedules.

“They’re definitely not planning to get everyone back in the office,” says Lisa Slattery, vice president of accreditation and recognition operations for the National Committee for Quality Assurance (NCQA), the nonprofit accrediting organization for health plans. “We hear some will be selling off properties, reducing footprint and continuing a lot of work from home. A lot of leaders didn’t think things could be as effective from a work-from-home perspective, but they’re seeing this is a viable solution that was accelerated by the pandemic.”

Companies in the healthcare industry that do not involve direct patient-clinician interactions are a microcosm of what is happening nationally. Target Corporation, headquartered in Minneapolis, announced that it will shed nearly 1 million square feet of office space, shifting 3,500 employees into other buildings and having many work from home. Michigan-based Ford Motor Company has announced plans to shed a significant office space.

A survey conducted by PwC in November and December 2020 showed that fewer than 1 in 5 executives wanted to return to the office as it was pre-pandemic. Most (87%) executives expected shifts in their real estate strategy, including consolidations, although many said they would open new satellite locations. Results of a June 2020 Gartner Inc. survey showed that 82% of company leaders intended to permit remote arrangements some of the time as employees return to the workplace.

Blue Cross and Blue Shield of North Carolina is among the handful of companies talking openly about upcoming shifts in their real estate. The company has allowed some office lease spaces to expire and will make real estate decisions based on how employees are working, not on cost.

“We do not anticipate ever going back to the traditional, pre-pandemic way of thinking that being in the office every day is necessary and/or expected,” the company said in a statement. Employees will work remotely at least through June.

Independence Blue Cross faces a major crossroads. In June 2020, it paid $360 million to repurchase its Philadelphia headquarters building, which it sold to Prudential Insurance Co. in the 1990s. The 45-story tower — the city’s eighth tallest building — houses 2,500 employees. Officials say they are not ready to announce plans.

“We are committed to this region and here for the long term,” the company said in a statement. “Purchasing our building at 1901 Market St. last summer was a further demonstration of that commitment.” The company did say employees would return in a phased approach.

Other companies are similarly reticent, perhaps to keep their options open. Optum, the PBM and care services subsidiary of UnitedHealth Group, said in a statement that they are “using this time to listen to our employees at all levels of the organization to best understand their preferences for the post-pandemic work environment. We are not rushing into any long-term decisions.”

A spokesperson for Centene Corporation, a publicly traded health insurer with headquarters in St. Louis, says the company will begin returning a small number of employees to the office Sept. 13. Employee schedules will include remote and in-person time as well as flexible start and end times.

Erin Feigal, Prime Therapeutics’ chief human resources officer, says that a key part of the reopening plan involved a team designed to connect with employees, collect feedback and ensure that employees felt ownership of the hub-and-home approach. “It was an evolutionary process,” she says.

As a result, 2,200 workers local to Minnesota will cycle through the single Eagan campus, including 700 shifting over from Bloomington, Gibson says. Each team will have its own hub area and can adjust the space as needed on in-office days. Some workstations were replaced with team-centric furniture so that teams can shift tables, whiteboards and video systems and collaborate as best works for them.

Companies looking to follow Prime’s lead should test their technology and have it ready to operate efficiently across divisions, Gibson says. That means getting laptops into employees’ hands and adequately training employees to use video technology. “Gaps in technology will hurt you as an organization if you don’t get that right,” Gibson says.

The other key area to address is expectations, she says. “You have to address new working norms, understanding what expectations are — to show up online every day,” she says.

NCQA, which is headquartered in Washington, D.C., is dealing with the pandemic realignment not only in its role as an accrediting organization but also internally. The organization was unintentionally almost pandemic-ready, says chief operating officer Tom Fluegel. Two-thirds of employees were either part- or full-time remote before COVID-19 hit, and NCQA was preparing to offer an all-virtual option to health plans undergoing accreditation review. By having companies send screenshots and other documentation electronically, the organization has been able to perform accreditation work without conducting onsite visits.

Pattie Graves, human resources knowledge adviser for the Society for Human Resource Management (SHRM), says the healthcare sector and industries in general that perform office work are on the same wavelength. Companies are regularly making inquiries to SHRM about transitioning to hybrid work plans, and she sees no turning back: “I think it’s going to be the future.”

There’s no going back to the ways of working before COVID-19’s arrival, say many in the industry. Insurers and PBMs are reducing their footprint as work becomes part remote, part in person.

It Will Not Be Your Pre-pandemic Office 

Copay accumulators are a common feature in health insurance plans sold on the ACA exchanges, according to a recent report from an AIDS advocacy group that wants the Biden administration to reverse a decision made by the Trump administration that allowed continued use of accumulators.

The AIDS Institute issued a report in March that says that at least two-thirds of the ACA health plans in 35 states include a copay accumulator and that in 14 states, every plan does.

Copay accumulators remove any copay assistance that members receive from spending that would count toward a health plan’s deductible. Patient advocacy groups say accumulators undermine copay assistance and protection against the high cost of drugs. And the AIDS Institute says in its report that they doubly benefit insurers and PBMs because they receive the copay assistance funds and then the amount the member spends until the plan’s out-of-pocket maximum is reached. The counterargument from insurers and PBMs is that accumulators sabotage formularies and wind up making healthcare and premiums more expensive.

Last year, the Trump administration moved to limit accumulators and then reversed course. The AIDS Institute wants the Biden administration to change the Trump administration’s policy and rein in the use of accumulators.

AIDS Group Says ACA Plan Copay Accumulators are More Common Than Not 

Senior vice president and chief strategy officer

The intricacies of data are both an opportunity and challenge for the healthcare ecosystem. While having accurate data is one piece of the puzzle, providers and payers must also have the right tools, processes and expertise to analyze, secure and implement this data effectively. In addition to accurate data, data sharing can also be a hurdle. Per a Center for Connected Medicine and HIMSS Media 

, almost one-third of hospitals indicate their data-sharing efforts are insufficient, even within their own organizations, and fewer than 4 in 10 say they’re successfully sharing data with other health systems.

With these challenges in mind, paired with the ongoing economic, operational and care delivery challenges posed by the COVID-19 pandemic, what can providers and payers do to minimize financial risk, increase patient and member engagement, and ensure cost efficiencies?

Healthcare Data Priorities: Insights From Providers and Payers

, explores data utilization patterns and organizational priorities for leaders within healthcare provider and payers. The report details the gaps and opportunities that exist in access to accurate and reliable data, as well as resources and expertise, which can detrimentally impact care quality and cost outcomes for all stakeholders.

Some of the report’s key takeaways and strategies for the healthcare industry include:

Providers and payers lack confidence in the accuracy of their patient/member demographic information

According to the report, only 37% of payers and 58% of healthcare providers are very confident their member/patient demographic information is correct. This percentage is concerning as inaccurate data can lead to further challenges in payment, patient/member experiences and care outcomes.

Inaccurate data can also cause a disconnect in the relationship between provider, patient, and payer. In a recent TransUnion Healthcare 

, 132,000 records were reviewed for patient/member contact information. Across best contact points for address, phone and email, 60%-263% additional contacts were uncovered across these categories. This is an example of how data inaccuracies may be quietly lurking in the background at the expense of the best clinical and financial outcomes for providers and payers.

Quality data also delivers a more comprehensive view of each individual’s unique situation, enabling providers and payers to better manage payment risk and spot opportunities to provide more individualized care.

Data priorities for healthcare leaders include improving the patient experience and data efficiencies.

In today’s healthcare environment, gaining a holistic picture of a patient’s social, clinical and financial situation is absolutely integral to addressing healthcare challenges for providers and payers. It’s critical to have access to comprehensive, validated data in order to most effectively serve both patients and members.

According to the study, 63% of providers and 53% of payers ranked improving data efficiencies among their top three priorities. And 51% of providers and payers ranked positive patient or member experiences among their top three.

Data helps the healthcare system identify trends in patient care, address equitable and timely care delivery shortfalls, and determine affordability gaps. All of this ultimately helps minimize financial risk for providers and payers. Taking the time to ensure that data — such as patient/member contact information —- is in fact correct, can ensure timely communications and enhance engagement for the payers’ members they serve.

An important success factor for achieving the best patient/member, provider and payer outcomes involves building trust. Data can help inform more personalized, individualized care, coverage, and payment which can lead to enhanced loyalty. This is especially important as the industry recovers and rebuilds from the pandemic.

Putting an emphasis on data efficiencies to improve patient/member engagement, while also finding ways to help reduce their costs to obtain quality care, will lead to long-term benefits for payers and providers. It can also make all the difference when it comes to seeing 

patient visits return to pre-pandemic levels

. The new normal will consider the patient, payer, and provider as equally important stakeholders in the process – and having accurate, actionable datasets will ensure desirable outcomes for all parties.

is senior vice president and chief strategy officer at TransUnion Healthcare.

Emphasizing data efficiencies and quality will benefit payers and providers — and patients.  

Maximizing Outcomes for Patients, Payers and Providers with Data Accuracy and Efficiency

States asking for small fraction of their vaccine allotments

Demand for the COVID-19 vaccines is waning, according to an 

 story today (May 8). “From South Carolina to Washington, states are requesting the Biden administration send them only a fraction of what’s been allocated to them,” the AP says. Examples include Wisconsin, which has asked for just 8% of the 162,680 doses it was entitled to next week, and Iowa,which has asked for 29% of its allocation.

Pfizer seeking full-fledged FDA approval…

Pfizer and its partner in developing its COVID-19 vaccine, BioNTech, announced early Friday (May 7) that they are seeking 

The vaccine was the first to get the go ahead from the FDA on Dec. 11, 2020, but that was a provisional emergency use authorization.

“Pfizer executives have said that the emergency-use authorization limits what they can do to raise awareness about the benefits of the vaccine and instill confidence in its safety and effectiveness, amid hesitancy by many Americans,” the 

The press release from the companies says they will submit data on a rolling basis and that the PDUFA date for an FDA will be set once that the 

 for the vaccine is finished and formally accepted by the FDA.

 reported on Monday (May3) that the FDA is getting to approve an emergency use authorization for the Pfizer vaccine in adolescents, ages 12-15.

Advisory Committee on Immunization Practices

 (ACIP) is scheduled to meet this coming Wednesday (May 12) starting at 11 a.m. The safety, immunogenicity and efficacy of the Pfizer vaccine in 12- 15-year-olds is the top item on the 

Lower antibody levels among vaccinated transplant recipients

It remains an open question how much protection people with compromised immune systems get from the COVID-19 vaccines. Research findings reported in 

 on Wednesday (May 5)showed that among solid organ (kidney, liver, heart, lung, pancreas, multiorgan) transplant recipients, just 15% of the 658 participants in a study of transplant recipients had a measureable antibody response 21 days after the first dose of the vaccine. That increased to 57% after the second dose but that means a sizable minority don’t have an antibody response.

“Although no threshold has been established for protective immunity, antibody levels were well below that which has been observed in immunocompetent vaccines,” wrote 

, M.D., Ph.D., and his Johns Hopkins colleagues, although as they acknowledge antibody levels aren’t necessarily the full story when it comes to immunity because memory B cell and T cells may also be a factor.

A second wave of vaccines may be on its way

, a small German biotech company, may announce results from late-stage results this week, the 

, a company based in Gaithersburg, Maryland, is ramping up for emergency use application in the next couple of weeks, according to the newspaper. 

Other companies working on vaccines that might be part of this second wave include Sanofi and GlaxoSmithKline, who are cooperating on vaccine that has had some setbacks but could enter the approval process later this year, and

Biden administration backs patent waivers; industry objects

On Wednesday (May 5), the first day of two-day meeting of the World Trade Organization, U.S. Trade Representative Katherine Tai announced the administration’s support of a 

 for the COVID-19. “The Administration believes strongly in intellectual property protections, but in service of ending this pandemic, supports the waiver of those protections for COVID-19 vaccines,” said her prepared statement.

Global public health experts and several governments (India, South Africa) say the patent waivers would ramp up the global supply of the vaccines and are critical to curbing the pandemic is medium- and low-income countries.

Not so, say vaccine makers and some governments (notably Germany), who see the waivers as undercutting private industry's response to the pandemic and the successful efforts at developing safe and effective vaccines quickly. PhRMA and its CEO, Stephen Ubel, issued a statement on Wednesday that said “this decision [by the Biden administration] will sow confusion between public and private partners, further weaken already strained supply chains and foster the proliferation of counterfeit vaccines.”

 pointed out that Tai's statement indicated support only for waiving patent rights on vaccines, not COVID-19 treatments or diagnostic tests.

It is far from certain, though, whether the waiver will ever come to pass. Members of the World Trade Organization would have to unanimously agree on the proposal.

HHS announces new coverage assistance fund

On Monday, HHS a new coverage assistance fund (CAF) that will pay providers for administrating vaccines to patients whose health plans don’t cover the shots or do so with patient cost sharing.

“On top of increasing reimbursement rates tied to administering the shots, we are closing the final payment gap that resulted as vaccines were administered to underinsured individuals. No healthcare provider should hesitate to deliver these critical vaccines to patients over reimbursement cost concerns,” the announcement said.

, which is $28 for a single-dose vaccine (the Johnson & Johnson vaccine is the currently the only single-dose vaccine available) and the $80 for the two-dose vaccines (Pfizer and Moderna’s).ps, the CAF will be compensating providers for eligible claims, at national Medicare rate

Jennifer Garner Instagram Live chats with Walensky about vaccine safety, boosters

 with large social media followings have become a prominent part of the public health messaging about the COVID-19 vaccine, so it made sense that CDC Director Rochelle Walensky joined Jennifer Garner  and her 10.8 million followers for a live Instagram interview on Friday (May 7).

 talked about the safety of the vaccines for pregnant women and children (Walensky gave assurances that they are) and booster shots. Walensky said the research into boosters in case of waning immunity or the need for protection against variants is ongoing. If they are needed, she said, “the vision would be to do in the same way we do flu vaccine. We do that every season. We hope we don’t have to do that [vaccinate against COVID-19] every season but we are preparing in case we do.”

States Asking for Fraction of Their Vax Supply, Pfizer Seeking Full Approval, Biden Administration Favors Patent Waivers (PhRMA Doesn't), Jennifer Garner Talks Boosters With CDC Director on Instagram and Other COVID-19 Vaccine News This Week

One of the arguments for urgent care centers is that they help people avoid time-consuming, costly trips to hospital emergency departments for relatively minor injuries and illnesses. But findings reported in the April issue of 

 suggest that decreases in emergency department visits may be offset by large increases in the use of urgent care centers.

One less emergency department visit for a low-acuity problems was associated with 37 additional urgent care center visits, according to a research team that included Ateev Mehrotra, M.D., M.P.H., an associate professor at Harvard Medical School and a member of the 

® editorial advisory board. Emergency department visits cost 10 times more than urgent care visits, but because of the increase in urgent care centers, Mehrotra and his colleagues found that each $1,646 in savings from an emergency department visit not occurring was associated with a $6,327 increase in urgent care center costs.

Other studies have found that less expensive care, if it is more convenient, can lead to greater utilization, thereby blunting expectations that the less expensive care is going to translate into cost savings. Mehrotra and his colleagues say their findings argue for a comprehensive approach and not just simply depending on urgent care center centers to reduce emergency department visits for care that could occur elsewhere. They mention triage lines staffed by nurses, augmented by machine learning, as way to direct patients to the appropriate care setting.

The study did not encompass primary care visits. As Mehrotra and his co-researchers acknowledge, urgent care visits may replace primary care visits, not just trips to the emergency department, and that substitution, which could result in some cost savings, was beyond the scope of their research.

Mehrotra and his colleagues used a database of healthcare claims from a large national healthcare insurer to conduct their study. They looked at the relationship between the number of lower-acuity (rashes, muscle strains) emergency department visits per enrollee to the number of urgent care visits. The association between increasing urgent care visits with decreasing emergency department visits was strongest in urban and high-income ZIP codes and in those with higher baseline use of emergency department visits.

Researchers find that it is quite the opposite.

Urgent Care a Bargain? 

The identification and management of sleep disturbance in older patients is a critical, but often overlooked, aspect of offering high-quality care for this population. In fact, 40-70% of older adults have chronic sleep issues, with up to 

 found that the risk of dementia was higher and associated with adults in their 50s and 60s with a sleep duration of less than six hours. This emphasizes the importance for older adults to not only be screened for sleep disorders, but also to maintain and improve their sleep quality.

 to chronic inflammation, which can lead to functional impairment and declining health. One 

 found that cognitive impairment was a key predictor for placing older adults into a long-term care facility. What’s more, frequent nocturnal wakefulness increases caregiver burden and stress.

 among older adults include snoring, pain and discomfort, nighttime urination, SBD, OSA,restless leg syndrome, REM sleep behavior disorder (RBD), medication side effects and

Sleep disorders are often associated with breathing issues, such as sleep disordered breathing 

 in which breathing repeatedly stops and starts—and obstructive sleep apnea (OSA)—repeated collapse or partial collapse of the upper airway.

Health leaders and healthcare professionals should take sleep issues into consideration when providing “whole patient” care and understand the impact of breathing issues that often lie at the root of disrupted sleep.

 to increased risk of developing chronic conditions, such as obesity, diabetes, high blood pressure, heart disease, stroke and mental illness. It has also been 

 with growth hormone deficiency and elevated cortisol levels, both of which have been linked to obesity.

Poor sleep quality can also impair metabolism and lead to significantly increased risk for 

. Shorter sleep times in individuals treated with both insulin and oral glucose-lowering medication have been associated with 

 of all-cause and cardiovascular disease mortality.

Nonpharmacological approaches to treating sleep issues among older adults include relaxation techniques, improving sleep hygiene and cognitive behavioral therapy (CBT). These 

 can be effective even for older adults with cognitive impairment.

CBT should consist of 6 to 10 sessions with a trained therapist that focuses on cognitive beliefs and counterproductive behaviors that interfere with sleep. Relaxation techniques include progressive muscle tensing and relaxing, guided imagery, paced diaphragmatic breathing or meditation.

Common among older people, SDB can lead to cognitive impairment, mood changes, compromised quality of life—often attributed to reduced social functioning and vitality—and higher risk of stroke and comorbidities, with up to 

 of patients with mild symptomatic chronic heart failure having SDB. Untreated 

can lead to Type 2 diabetes, high blood pressure, congestive heart failure, atrial fibrillation, stroke and other cardiovascular problems.

Treatments for breathing issues include weight loss, smoking cessation and increased cardiovascular exercise, enhanced sleep opportunity and environment, optimized medical management of comorbidities, and reduction in caffeine, alcohol and sedatives.

Continuous positive airway pressure (CPAP) therapy is a common treatment for OSA. 

 pushes air into the airways to keep them open with a pump that controls airflow, a tube carrying air from the machine to the user, and a mask that goes over the mouth, nose or both. 

 with CPAP, however, include discomfort, leaky mask, trouble falling asleep, stuffy nose and a dry mouth. Other treatments include oral appliances, surgery and sleep aid devices.

Sleep aid devices, such as airway stents that are inserted in the nose for up to 18 hours, support natural nasal breathing and 

ing, warming and humidifying inhaled air. This protects the lungs, leads to better oxygen supply to the body, stimulates the calming nervous system, and reduces snoring and SDB. All of these factors contribute to a stronger immune system and improve quality of life.

Stents enable better airflow for easier breathing during the day or night and representative a promising alternative to sedatives, which impair memory and focus among older adults.They have also been shown to mitigate symptoms of chronic sinusitis and other quality of life conditions, such as allergies, rhinitis, chronic rhinitis, sinusitis, allergic rhinitis and many autoimmune diseases.

Sleep problems are associated with increased risk of chronic diseases.

Breathing Issues Linked to Disrupted Sleep Among Older Adults 

When younger women show up at the emergency room with chest pain, they wait longer to be seen, have fewer tests, and are less likely to be admitted than men, according to new research.

The study, which will be presented next week during the 70th American College of Cardiology Scientific Session, is the first to examine how chest pain is managed among adults who are too young for Medicare. This study looked at adults age 18-55 years. Heart disease is the leading cause of death for women, and it’s showing up more frequently 

, with a 2019 study citing rising obesity and diabetes rates as culprits. Roughly one-third of women hospitalized for a heart attack are younger than 55.

Darcy Banco, M.D.,the study’s lead author and a resident at NYU Langone Health, said women should seek care at the first sign of trouble, which can include chest pain, nausea, vomiting, fatigue, sweating, back pain, or trouble breathing. 

Besides getting less attention once they arrive at the ER, Banco said earlier research shows women wait longer than men to seek care when they have heart attack symptoms.

“The most important thing a woman can do is to seek medical care if she is worried and to ask specific questions of her doctor,” she said.

The new findings are derived from data collected from 2014-2018 by the CDC, through the National Hospital Ambulatory Medical Care Survey. From this survey data, researchers estimated that 29 million visits to the ER for chest pain involve adults aged 18-55, and women accounted for 57% of these visits.

Women were just as likely as men to come to the hospital by ambulance, but once there, took longer to be triaged and tested. Banco’s study found women waited longer to be seen by a clinician, and were less likely to receive an electrocardiogram, or EKG, the test used to diagnose a heart attack.

Women were triaged as urgent or emergent 57.1% of the time, compared with 63.0% of the time in men.

Women waited 45 minutes on average to see a doctor, compared with 37 minutes for men, and a cardiology consult happened with 12.3% of men compared with 8.5% of women.

EKG testing happened in 78.8% of men, compared with 74.2% of women versus 78.8% of men.

Only 12.4% of the women were admitted for observation, compared with 17.9% of men.

The study did not look into why women with chest pain are treated differently, and Banco said it’s more likely that outdated notions about risk, instead of overt discrimination, play a role. While heart attacks have historically been more common in older men, the rates are rising among women. But the lower rates of testing and admission could point to heart attacks that are being missed, she said.

She pointed to data showing a steady rise in heart attack rates among younger women over 20 years, with serious consequences. Compared to young men, “They have a higher mortality and poor physical and mental health after heart attack,” she said. “They’re less likely to return to work within 12 months after their heart attack.”

When a heart attack is suspected, minutes matter. Guidelines call for patients with a possible heart attack to have an EKG within 10 minutes of reaching the ER. “The longer people wait, the worse their outcomes can be,” Banco said.

The study will be presented May 15 during ACC, which will be in a virtual format for the second consecutive year due to COVID-19.

The study, which will be presented next week during the 70th American College of Cardiology Scientific Session, is the first to examine how chest pain is managed among adults who are too young for Medicare.

Fewer Tests, Longer Waits for Women in ER With Chest Pain

The global Covid-19 pandemic has further exposed and exacerbated the fractures within our healthcare and social delivery 

 particularly with regard to behavioral health (mental health and substance use) 

This is especially concerning given a Kaiser Family Foundation (KFF) report suggesting that a third of U.S. adults now report symptoms consistent with an anxiety and/or depressive disorder. More specifically, a KFF analysis of U.S. Census Bureau survey data published in June 2020 indicated 36.5% of U.S. adults reported anxiety or depressive disorder symptoms, a troubling increase from the already substantial statistic of 11% in 

. Specific to the pandemic, a KFF poll reported that 53% of adults indicated their mental health has been negatively impacted due to worry and stress related to 

 of Covid-19 on healthcare professionals and 

, who may be vulnerable to anxiety, depression, grief, substance abuse, and post-traumatic stress related to caring for patients and families impacted by Covid-19, as well as concerns regarding risks of infection for themselves and their families.

Also of grave concern is the potential for a dramatic increase in “deaths of despair”— deaths by suicide, alcohol, or other substance misuse commonly associated with the extreme distress resulting from natural disasters and 

. Studies have found that job loss, debt, and foreclosure increase the risk for suicidal 

; indeed, the rates of suicide and the proportion of alcohol-involved suicides rose during the Great Recession of 

Recently, the U.S. Centers for Disease Control and Prevention (CDC) released its own findings detailing the damaging impact of the Covid-19 pandemic on mental health in vulnerable populations. Close to 11% of adults seriously considered suicide during June 2020, according to CDC data. In addition, the risk for suicidal ideation was heightened among respondents between ages 18 and 25 (25.5%), Hispanic respondents (18.6%), Black respondents (15.1%), unpaid adult caregivers (30.7%), and 

Without rapid and robust intervention, it is estimated that an additional 75,000 lives could be lost in the United States alone to alcohol and drug misuse and suicide associated with 

. As examples of this trend, Shelby County, Tennessee, saw 391 suspected overdoses and 58 deaths over a 1-month span in April and May, while Milwaukee and parts of Ohio are seeing opioid overdoses and deaths also spike 

. In July, the American Medical Association (AMA) sounded the alarm about opioid overdoses, noting a rising number of reports from more than 35 states of increases in opioid-related mortality—particularly from illicitly manufactured fentanyl and fentanyl analogs. Also of note is the September, 2020 U.S. Food and Drug Administration (FDA) update to the Boxed Warning for benzodiazepines, often abused and misused with 

Given the present epidemiologic climate, it is not surprising that addiction experts consider the Covid-19 pandemic a risk factor for substance abuse relapse, leading the 

 to refer to this pandemic as “a national 

 trigger.” Anaha Ortiz, MD, who practices in Franklin County, which includes Columbus, Ohio, stated, “Covid-19 has showed us the vulnerabilities and deficiencies in our addiction services—in addition, it has increased the mental health needs of this 

In short, most Americans or someone they know has or will be impacted by behavioral health conditions associated with Covid-19 stressors, and some populations, such as those with pre-existing behavioral health conditions, marginalized communities of color, families living in poverty, and those previously traumatized by violence or natural disaster, may be particularly vulnerable to Covid-19 

. The practice of trauma-informed care has never been more imperative.

As the world continues to grapple with the Covid-19 pandemic, it is important to take a closer look at our nation’s health systems, integrated delivery networks and health plans, and the resulting re-prioritizations that have occurred in addressing behavioral health concerns during the pandemic. This article will share recently collected survey data on the shifting priorities of health plans and health systems pertaining to behavioral health conditions since the onset of Covid-19. The paper further offers some observations and suggestions for opportunities for plans, delivery systems, and pharmaceutical manufacturers to address these “epidemics within a pandemic.”

TM tool to survey healthcare access decision makers. Objectives were to gain insights into the current and expected future impact of the Covid-19 pandemic on payers’ and health systems’ population health priorities and how these priorities are affecting administrative, care management, and population health practices during the Covid-19 pandemic. Included in the survey were questions about behavioral health conditions and relevant care management and population health practices. Respondents (N=30) represented health plans (n=16) and health systems (n=14) and comprised medical, pharmacy, quality, and population health directors, providing services for an estimated 95 million 

Not surprisingly, the majority of survey respondents (67%) reported that mental health conditions have risen in priority since the onset of Covid-19. However, 

opioid conditions had decreased in priority

 since Covid-19 began. Taken together with the AMA’s report of increased opioid 

and with an historic 400,000 or more U.S. deaths since 1996 related to opioids, these statistics represent a clarion call for concerted action to address this epidemic within a pandemic. Further, since substance use disorders often co-occur with other behavioral health 

 (eg, anxiety, depression, bipolar disorder, schizophrenia), an approach that prioritizes integrated care for all behavioral health conditions (mental health and substance use) is imperative to promoting physical health, responsible health behavior, and resilience during a time of greatly heightened isolation and uncertainty.

Opportunities also exist during the pandemic for population health management collaboration among health plans, health systems, and pharmaceutical manufacturers. Survey results found that health plans and health systems indicated current or planned collaborations, or willingness to collaborate with pharmaceutical manufacturers on areas such as medication adherence management (87%), patient outreach/engagement (83%), and supporting quality 

 (83%). These findings shine a strategic spotlight on opportunities for collaboration to better address the behavioral health epidemics within the pandemic and to direct resources to synergistically address concerns.

Healthcare delivery is experiencing a crisis of tremendous magnitude, and given that other conditions, notably infectious disease and respiratory conditions, have risen in priority since the onset of 

, a not surprising result of an overburdened system is deprioritization of other chronic conditions, such as opioid use disorders. However, this is proving to be misguided, in light of the recent AMA brief regarding increases in opioid-related mortality, and the rise in mental health conditions, which will likely include an exacerbation or emergence of new substance use disorders. These circumstances present opportunities for stakeholders, such as plans, health systems, and pharmaceutical manufacturers to facilitate behavioral health recovery through focused, individual, and synergistic efforts. Potential opportunities for stakeholders to address these conditions arise through strategic focus upon 3 areas: access, analytics, and amplification.

Although 76% of Americans think mental health is as important as physical health, lack of awareness of and limited care options, cost, stigma, and wait times all create barriers to behavioral 

. Below are actions stakeholders can consider to facilitate access now and beyond the Covid-19 pandemic.

Patients with substance use disorders must have access to effective, evidence-based treatments such as methadone and buprenorphine, and many providers are modifying their practices to support continuity of care and optimized outcomes for these patients. Greater flexibility is required to appropriately provide take-home medications, alternative home delivery, and telehealth services for patients, and guidance may be taken from the 

American Society for Addiction Medicine (ASAM)

Substance Abuse and Mental Health Services Administration (SAMHSA)

Similarly, individuals receiving long-acting injectables (LAIs) for behavioral health conditions merit additional consideration due to the elevated stressors often experienced by psychiatric patients associated with the pandemic. This has been noted by the American Psychiatric Association, which has issued Covid-19 guidance encouraging “hospitals and other facilities to include the ongoing use of LAIs for patients with high-risk chronic illness as a necessary 

Health plans can encourage access through activities such as:

Reviewing the utilization of mental health and addiction services and parity 

 to ensure that adaptations designed to facilitate expanded access to services and medications for physical health conditions are also being leveraged to expand access for behavioral healthcare and therapies. Examples include patient outreach (eg, well-being checks), virtual visits, and expanded care management programs.

Aggressive monitoring of network adequacy during the pandemic to promote access to culturally competent care, access to behavioral health services such as medication-assisted treatment (MAT), and monitoring of behavioral health bed capacity, which may be further strained due to Covid-19. Special consideration should also be given to the needs of children and youth with special healthcare needs, and to their parents, all of whom may need additional support during the 

Promotion of electronic newsletters, blogs, and webinars specific to managing stress associated with Covid-19, and promotion of no-charge 24/7/365 

Deaths by suicide and by substance use disorders have reached epidemic proportions, creating the tragic “perfect storm” of epidemics within a pandemic. A survey conducted by PRECISIONvalue of population health priorities among health systems and health plans since the onset of Covid-19 suggests that while mental health conditions have risen in priority, opioid use disorders have become alarmingly deprioritized.