Cholesterol Limbo...How low can you go? *Obsesity Limbo:...In the middle ground, how much coverage? * Obesity drugs * Weight loss programs * Concierge services at work * JCAHO hospital ratings * The co-pay ripple effect...
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Recommended levels of LDL cholesterol are being pushed lower and lower for people at moderate, high, and very high risk for major coronary events. If the new guidelines are closely followed, millions more patients will be starting cholesterol-reducing therapy with statinsor getting a higher dosage if they are already taking those drugs, with significant implications for health care plans..
In late July, the National Heart Lung and Blood Institute, American Heart Association and Z issued an unscheduled update to the guidelines, prompted by the results of five major clinical trials published this Spring. Those trials underscored the benefits of aggressive treatment of elevated cholesterol.
The new guidelines say that people at high risk for major coronary events should have their LDL (bad) cholesterol reduced to 100 mg/dL. The old standard: 130. Those at moderately high risk have a "therapeutic option" to go this low as well.
For people at "very high" riskthose with already-diagnosed heart disease along with such calamity factors as diabetes, high blood pressure, or smoking, LDLs as low as 70 are "a therapeutic option, ie, a reasonable clinical strategy." The old standard: 100.
The updated guidelines also say that people at moderate to high risk should have their LDL lowered by 30-40% as a rule of thumb (Circulation 2004;110:227-239.) For another perspective, see the editorial by Wilbert S. Aronow, MD, "Dont trust an LDL over 70?" in the May 2004 issue of Geriatrics (www.geri.com).
Medicare is no longer describing obesity as a "non-disease." But the government isnt quite ready to call it a bona fide disease yet, either.
In terms of insurance coverage, obesity will occupy what can truthfully be called an expanding middle ground. Right now, Medicare does in fact pay for some obesity-related treatments, but only when obesity is a co-morbid condition (with diabetes, hypertension, etc.)
The new interpretation will open the door to coverage for some treatments for obesity itself. The Medicare Coverage Advisory Committee, in considering requests, will have to review the scientific evidence and determine whether an obesity-related treatment actually improves health outcomes.
First step: The Committee will meet this fall to review the evidence on obesity-related surgeries that are designed to reduce the risk of heart disease and other illnesses.
For more on the decision making process, go to www.cms/gov/coverage.
Despite the HHS decision to redefine (or take the kibosh off) obesity, weight loss drugs will not qualify for Medicare coveragethat was specifically banned by the big Medicare drug bill passed in 2003.
On the other hand, Medicare coverage could be extended to dietary counseling and cognitive therapy programs, or to comprehensive weight loss programs.
Corporate weight loss programs, meanwhile, are proliferating. One, called Realize, rewards employees who manage to obey the fundamental mantra of weight losseat less and exercise more. Employees log on to a secure Web site and monitor their caloric intake from diet and their caloric expenditure from exercise. They are then assigned a wellness score ranging from 0 to 100 and assigned a target score as well. Incentives are offered for reaching ones personal goals.
The goals are to lower rates of healthcare utilization, reduce absenteeism, and enhance productivity. For details, go to www.realize-health.com.
The average employee spends an hour of his or her workday on personal matters, according to FamilyCare Inc. On the theory that helping them deal quickly with those issues and get back to the job at hand will actually improve productivity, "concierge services" are now springing up in US businesses.
More than 25% of the "100 Best Companies to Work for in America," as named by Fortune Magazine, offer concierge services, which may offer anything from making restaurant reservations to finding a plumber or mechanic for a household job. Cathy Leibow, President of FamilyCare, believes that concierge services are "the next wave of employee benefit services." In addition to helping employees focus on their jobs, concierge services may be seen as a "give back" to compensate for reductions in medical and other benefits.
The Joint Commission on Accreditation of Healthcare Organizations has posted on its Web site (www.jcaho.org) quality report cards for more than 16,000 hospitals, nursing homes, and other accredited facilities. Each place is rated on how well it handles heart attacks, heart failure, pneumonia, and pregnancy. Also included: how well the facility is doing when it comes to preventing medical errors.
Meanwhile, the Leapfrog Group, a coalition of US businesses focused on healthcare quality, has launched its own hospital rating survey, expanding from its original classic three criteriacomputerized physician order entry, use of intensive care specialists in critical care units, and volume of medical proceduresto a total of 30.
When co-pays for diabetes, asthma, and gastroesophageal medications go up, patient usage goes down. So says a Rand Corporation study published in the Journal of the American Medical Association (JAMA 2004;291:2344-2350). Doubling the co-pay reduced drug usage by 23% for diabetes patients, 22% for those with asthma, and 17% for patients suffering from gastric acid disorders. As medication usage dropped, visits to ERs went up among these patient populations, as did hospital stays.
Co-pays have, of course, been climbing steadily in recent years. The average co-pay for a preferred Rx drug jumped 46%, to $19, between 2000 and 2003, reports the Kaiser Family Foundation, and the average co-pay for a nonpreferred prescription drug shot up 76%, to $29.
The trend toward increased patient cost-sharing is continuing apace, according to an industry-wide review of drug benefit plan design, co-pay and coinsurance features, and utilization management by health plans, large employers, and pharmacy benefit managers.
The data are set forth in the Spring 2004 Drug Co-pay Service: Pharmacy Benefit Design Trends, published by Health Industries Research Companies (HIRC).
The findings: Fixed tier and percentage co-pays are up, as is the use of medication exclusions and benefit caps, says Karen Lucas, Director of Research for HIRC. The upshot: "A drop in prescription fill and refill rates, and increases in skipped days and pill-splitting." Patients are also asking about for alternative medications that cost less.
For details, go to www.hirc.com.
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