is an independent journalist in the Philadelphia area who writes about healthcare and other issues. Aine Cryts contributed reporting.

Robert Calandra

home

authors

robert-calandra

Maintaining optimal levels of low-density lipoprotein (LDL) cholesterol from early adulthood through middle age may reduce the risk of developing coronary heart disease later in life, results of a recent study show.

LDL cholesterol levels usually can be kept low through exercise, a heart-healthy diet and other lifestyle modifications, according to the study’s authors. But for young adults with high LDL levels that don’t respond to lifestyle changes, cholesterol-lowering statin drugs may be necessary.

“For these individuals, pharmacological therapy to lower LDL cholesterol levels earlier in the life course when atherosclerosis is less advanced may be a more successful way to reverse the disease course and prevent future CVD (cardiovascular) events,” Yiyi Zhang, Ph.D., M.S., of Columbia University Medical Center and her co-authors wrote in the September 2021 issue of JAMA Cardiology. If clinicians were to follow their suggestions, many more Americans could be taking statins starting at much younger age.

Lowering LDL cholesterol, often by taking a statin, has been a tenet of cardiovascular disease prevention in the United States for decades, but most of the prescriptions are written for older people with a history of heart attack, stroke or another major cardiovascular event.

The editor’s note accompanying the study noted that current hypertension guidelines recommend treating all adults with high blood pressure despite a dearth of evidence that lowering blood pressure in young adults translates into a health benefit. “If the clinical community can support treating hypertension early in life to prevent the long-term risks of elevated blood pressure, the findings in the study by Zhang et al. suggest that a similar paradigm (for cholesterol lowering) should be considered,” wrote Ann Marie Navar, M.D., Ph.D., and Gregg C. Fonarow, M.D., associate editors at 

But the emphasis that has been put on LDL cholesterol levels also has been questioned. Rita F. Redberg, M.D., a cardiologist at the University of California, San Francisco, and editor of 

, has said that an LDL cholesterol level should be seen as marker of potential cardiovascular disease rather than a target for treatment. Speaking on the Healthy Skeptic MD podcast earlier this year, Redberg said focusing on LDL cholesterol is “misguided.” Instead, she said, doctors should instruct patients to eat a healthy diet and get regular physical activity. “If you have a healthy diet and your cholesterol is high, that’s OK,” she said. “If you have an unhealthy diet and your cholesterol is low, that’s not so good. You really have to focus on lifestyle and stop focusing on lab values.” Redberg also said that the side effects of statins — muscle aches, fatigue — may actually contribute to heart health issues.

By pooling four prospective cohort studies, the study researchers had data from more than 18,000 study participants to evaluate. Using accepted statistical techniques, they calculated the participants’ cumulative exposure to cholesterol levels. The study results suggest that exposure to high levels was associated with a greater likelihood of experiencing coronary heart disease but not stroke or heart failure.

Zhang and her colleagues discussed possible explanations for cumulative high LDL cholesterol levels increasing the likelihood of coronary heart disease. Small particles of LDL cholesterol may lodge inside arterial walls starting in young adulthood. Some research suggests that those retained particles go through various modifications, including oxidation, which can lead to an inflammatory response and vascular injury and atheroma formation. The accumulated particles, teaming up with circulating LDL cholesterol, may develop atherosclerotic plaque. Thus, keeping LDL cholesterol levels low may prevent that process from starting.

Introduced in 1987, statins are among the most prescribed medications in the world. They are routinely prescribed for patients 55 and older who have had a heart attack or stroke or who have elevated LDL cholesterol levels. Prescribing statins for younger adults was mentioned by the American College of Cardiology and the American Heart Association in their 2019 guidelines on the primary prevention of cardiovascular disease. The guidelines say for young and middle-aged adults, the 30-year and lifetime risk of cardiovascular disease are reasons for reinforcing a lifestyle recommendation and, for some, medication. Still, the vast majority of statin prescriptions are written for older patients. Zhang’s study is far from the final word on prescribing statins for younger people, but it may seed more research and discussion of looking at LDL
cholesterol through the lens of lifetime exposure.

is an independent journalist in the Philadelphia area who writes about healthcare and other topics.

Articles

Treating high levels of low-density lipoprotein cholesterol in young people may reduce lifetime exposure and lead to fewer cases of coronary heart disease. 

Seeing LDL Cholesterol in a New Light

When Terri Kirkpatrick, a community health worker, meets a new client, the first question she asks is, “how are you feeling today?”

The question isn’t just an icebreaker. It’s laying the foundation for the relationship Kirkpatrick hopes to build with her clients. She knows how vulnerable and anxious women coming into Strong Beginnings feel. She was once a client of the program for pregnant Black mothers with behavioral health needs.

“I can truly say that I was born to be community health worker,” Kirkpatrick says, adding that she has an experiential understanding of the disparities the program’s clients live with.

Kirkpatrick has been a Strong Beginnings community health worker for 23 years. The program, a partnership between Spectrum Health, a Michigan-based managed care organization, and nine community organizations, facilitates home visits by nurses, nutritionists and community health workers.

Like most community health workers, Kirkpatrick has a job that takes her outside the traditional boundaries of healthcare. She helps the women in the program with whatever needs they might have, including food and housing, job and career support. “Whatever their priority is, that’s what I focus on,” she says. “I’m here for them.”

The community health worker model has been around, in one form or another, for 100 years, says Scott Tornek, chief strategy officer for the Penn Center for Community Health Workers at the Penn Medicine. “It’s not a new concept,” says Tornek. “It has gone through boom-and-bust cycles for decades.”

Now it is booming. It started after passage of the ACA in 2010 and the subsequent move toward risk-based contracts that create incentives to reduce the cost of care and prevent illness. According to the CDC, more than 23 states have or are considering community health worker programs.

Yet community health workers have not been fully embraced by the U.S. healthcare system. Even if they result in overall savings, the programs can be expensive to operate. Pilot projects may get off to a good start but then shut down when the funding runs out.

But many experts, physicians and healthcare executives see the community health workers as a way to deal with much-talked-about social determinants of health. The question, then, concerns how hospitals, health systems, payers and government health officials can make community health workers part of the everyday reality of American healthcare. “It’s a complicated question,” Tornek says. “But I think it starts with sustainable funding, especially for Medicaid and for people who are underserved — marginalized people who are in those insurance groups.”

About a decade ago, Shreya Kangovi, M.D., M.S., a pediatrician caring for patients in West Philadelphia, asked herself that same question. In the ensuing years, Kangovi, along with a team of researchers from the Perelman School of Medicine at the University of Pennsylvania, created the Individualized Management for Patient-Centered Targets, or IMPaCT, program. Some key aspects of IMPaCT were developed based on interviews with more than 1,500 patients. Each was asked what was stopping them from staying healthy. The answers: food, housing, transportation and other problems. Next, an operational program was designed. Kangovi and her colleagues tested IMPaCT in randomized controlled trials and published the results.

Tornek says the key to the program’s success is hiring the right people. “We look for people who reflect the patients we serve, who are from the same communities, who have shared life experiences, who are naturally empathetic, who are good listeners, and who will bring food to a neighbor in need who is sick,” Tornek says. “You can’t train for that.”

The IMPaCT program involves training community health worker managers, most of whom have a background in social work. The program integrates community health workers with the patient’s care team. Patient satisfaction with IMPaCT is high, Tornek says, and employee turnover is a low 2%.

Community health worker salaries can vary. In large cities, starting salaries range from the high-$20,000s to the mid-$30,000s. An experienced community health worker can make up to $52,000 a year, according to the website Explorehealthcarecareers.org.

“The community health worker quarterbacks the nonclinical and nonmedical relationship with the patient,” Tornek says. “The community health worker in our model helps patients set and achieve their goals to get back on track quickly. How does that translate into health? It could be controlling their diabetes by shopping for healthier foods so they stay out of the hospital.” 

Three controlled, randomized studies showed positive results. But a study showing that community health workers could save money had not been done. That changed in February 2020, when Kangovi, now the executive director of the Penn Center, reported results in 

. The study followed 302 patients considered at high risk for health problems between July 2013 and October 2014.

The patients were randomly divided: 150 in an intervention group that received services from the community health workers and 152 in a control group. All patients came from “high-poverty neighborhoods” and each had at least two chronic diseases. At the study’s one-year follow-up, 98 patients in the control group had been hospitalized, compared with 68 patients in the intervention group. The total inpatient and outpatient bill for intervention patients was about $ 2.5 million compared with $3.9 million for the control group. Kangovi and her co-investigators reported that the team of community health workers saved Medicaid $1.4 million. They calculated that the savings divided by program expenses ($567,950.82) yielded a return on investment within a single fiscal year of $2.47 for every dollar invested.

Over the past seven years, IMPaCT and Penn Center’s 30 community health workers have seen 13,000 patients. Depending on the goals they are trying to achieve, most patients work with program’s community health workers for three to six months. Some return, but most don’t.

Penn has exported its IMPaCT program to 20 states and 50 healthcare organizations, large health systems, payers, nonprofit organizations and departments of health. The adopters include ChristianaCare in Delaware, BJC HealthCare in St. Louis and Blue Cross Blue Shield of North Carolina.

But even successful programs like Penn Center and Strong Beginnings are constantly concerned about funding. Strong Beginnings runs on an annual budget of $2 million and includes funding from federal and state sources plus a $500,000 contribution from Spectrum Health. Penn Center does not publish its annual budget, but Tornek says the organization’s external work is self-funded and that Penn Medicine pays for the patients it refers. “We are doing a lot with pretty limited resources, quite frankly,” Tornek says.

Community health worker programs need to be on a firm financial footing to help vulnerable patients and reduce admissions, Tornek says. He would like to see Congress and the federal government’s various health agencies increase funding and help build a sustainable, long-term infrastructure to support community health programs.

“It’s a compressed question,” Tornek says. “There is institutional racism and health equity issues. How do we level the playing field? It’s a complicated question, but I think it starts with sustainable funding.”

Community health workers can address social determinants of health, and some programs have been shown to reduce healthcare costs.

Healthcare and More, by and for the Community

Decades of stagnant wages, a rapidly changing job market, the erosion of employer-based health benefits, and the steadily rising cost of healthcare are leading more Americans to carefully choose which medical treatments they will utilize.

According to results from a recent Brookings study, “Income Volatility and Healthcare Decision-Making,” fluctuating monthly income combined with out-of-pocket costs and high deductibles have become significant factors in the healthcare decisions Americans make. The findings showed that seesawing monthly income and financial navigation through healthcare is a reality for insured people in the middle class, not only for those with low incomes or without insurance.

 survey findings indicate that 40% of nonelderly adults with employer-based health insurance have difficulty paying their medical bills. Half of those respondents said they or a family member has skipped or postponed healthcare in the past year because of the cost.

“What I hope the audience takes away is just how big a problem (income volatility) is and how widespread financial precarity is throughout the U.S. and that it is creating big problems for many, many people,” said Lisa Servon, Ph.D., the Brookings study co-author and chair of the Department of City and Regional Planning at the University of Pennsylvania Weitzman School of Design, during a recent webinar introducing the study. To understand the effect of income volatility on healthcare decisions, Servon and co-author Mina Addo, a Ph.D. research fellow at the University of Pennsylvania School of Social Policy & Practice, interviewed 33 working adults between the ages of 27 and 55.

The solidly middle-class households (median income between $60,000 and $70,000) had two adults working full time. In half the families surveyed, one of the two working adults also had a part-time job. Ninety percent of the families had health insurance, of which 75% was employment based. The researchers reported that each family, on average, experienced income volatility — that is, five months during the year their income unexpectedly increased or decreased.

On the whole, the families found their copays for primary care affordable. But larger copays or healthcare not covered or partially covered by insurance — dental, vision care, physical therapy, diagnostic testing, serious injury or illness, and chronic issues such as diabetes — presented financial problems.

Some families had health savings accounts to help with bills, whereas others used a credit card. But generally, they simply declined treatment, even for chronic conditions. According to results of a 2018 survey, approximately 60% of Americans said they or someone in their family had a chronic condition and 35% struggle to pay their medical bills.

“I think the eye opener is this is a middle-income, middle-class population,” Addo said of the study’s families during the webinar. “These are a number of people who have done … the right thing. They pursued education, tried to invest in a home. That pathway used to be, I think we would call it, the American Dream.”

Historian James Truslow Adams coined the term “American Dream” in his 1931 book “Epic of America.” Anyone in the United States who had ambition and was willing to work, Adams maintained, could climb their way up the socioeconomic ladder to a “better and richer and fuller life for everyone, with opportunity for each according to ability or achievement.”

If that was ever true, the climb has become steeper and the ladder, more rickety. Since the ’80s, middle-class wages have risen 6%, whereas upper-class wages jumped 31%. The median house price over that time has climbed 400%. And between 2004 and 2018, out-of-pocket costs for employer-based health insurance rose from $2,600 to $5,000.

Then came the pandemic, the shutdown of in-person activities, and job losses, although some of the overall economic indicators for this year indicate that the economy has rebounded. If there is a winter-gray (not silver) lining to the pandemic, it also has irrefragably revealed that a majority of Americans are living paycheck to paycheck. In fact, almost two-thirds of Americans say they have been living paycheck to paycheck since the beginning of the pandemic, according to results from a November 2020 survey conducted by Highland, a Chicago-based research and design firm.

“With healthcare costs growing faster than wages for several decades, we always knew that the middle class would be squeezed more and more by healthcare as costs grew,” says David T. Grande, M.D., M.P.A., director of policy at Leonard Davis Institute of Health Economics at the University of Pennsylvania. “I think we are getting closer to the point where that squeeze is hitting enough people that costs are a bigger and bigger policy issue.”

Consumers, Grande says, are frustrated with increasing out-of-pocket costs, limited insurance and narrow networks that can lead to surprise billing from out-of-network providers. Those tactics have probably wrung dry all available savings anyway. So what other solutions do policy makers and insurers have?

The Biden administration is not prioritizing major healthcare reform so far. Even if it were, the chances of a public option or lowering the age of Medicare eligibility would be remote and those for broader Medicare buy-in or Medicare for all, vanishingly small. Medicare expansion of almost any stripe would likely afford some protection against high healthcare costs for the added beneficiaries. 

“Moving coverage to Medicare means moving some costs to the government and determining how to price that coverage for newly eligible adults,” says Grande. “So the details would really determine what that would mean for consumer costs. But there is a lot of reason to believe that consumers would save money if they gained Medicare coverage.”

There are less ambitious and divisive options pricing transparency rules. Beginning this year, hospitals are required to list the cost for many procedures. Next year the same goes for health insurers, who will have to show how much they pay for services. Will price transparency make a dent in costs?

“It seems obvious that we need more price transparency,” says Grande. “However, by itself I don’t think it will solve our cost issues. A great deal of healthcare spending occurs on services that are not really shoppable and well beyond when people have maxed out their deductibles.” The execution of price transparency also leaves a lot to be desired. Hospitals are showing prices, but how transparent (or intelligible) they are is a different matter.

For its part, the Biden administration chipped in by making access to health insurance easier. In March, as part of its American Rescue Plan Act, the administration increased insurance subsidies to people with incomes above 400% of the poverty level who buy health coverage on the ACA exchanges. It also increased the amount of financial assistance for those with lower incomes who were already eligible under the ACA.

Addo would like to see insurers step up and help people find a plan that provides more coverage. “Based on research, some existing plans that are most affordable for consumers (high-deductible plans) do not provide enough coverage to ensure that people can affordably access the care they need,” Addo wrote in an email. Insurers, she says, could improve the situation by helping consumers identify plans that better meet their needs. Grande would like to see the government reach some agreement on a minimum amount of coverage for all Americans, including adjustments to out-of-pocket costs that hinge on income. But is that realistic, given our current health insurance system? “We have to understand that if we choose as a country to continue to rely on a system of private insurance, then insurers will always work to limit spending,” Grande says. “That is the system we have. If consumers want a system that looks more like Medicare, they will have to demand it.” 

is an independent journalist in the Philadelphia area who covers healthcare.

Researchers are documenting how income volatility is affecting the middle class and healthcare decisions of its members. 

Robert Calandra

Articles

Seeing LDL Cholesterol in a New Light

Healthcare and More, by and for the Community

With Income Ups and Downs, Americans Scrimp on Healthcare