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3 posts from April 2019


Are Federal Regulators Panicked Over the Increased Use of E-Cigarettes Among Adolescents: A Conversation With Prof. David Abrams (April 23rd)

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The e-cigarette market, or what the FDA formally terms Electronic Nicotine Delivery Systems or ENDS, has grown since 2004 to approximately 11 million American consumers.  Recent survey data published in February in JAMA has shown use of e-cigarettes (or vaping) among underage youths or middle and high school students has increased significantly since 2011.   Beyond potentially serving as a gateway to the use of combustible or tobacco cigarettes, there is research to suggest nicotine can harm developing adolescent brains and the exhaled aerosol can also pose a public health threat.   Beyond the significant increase in under age use there is also concern recent investments in the e-cigarette industry by tobacco manufacturers, specifically Altria's December investment in e-cigarette manufacturer, JUUL, will result in e-cigarette users transitioning to tobacco cigarettes.  Recently resigned FDA Commissioner, Scott Gotlieb, made e-cigarette regulation a priority throughout his two-year tenure.  The question begged is will FDA's e-cigarette regulatory actions prove productive, will they prevent or inhibit current and future consumers of nicotine from taking up of combustible/tobacco cigarettes and/or allow or encourage current tobacco cigarette consumers to transition to e-cigarettes a far safer product.    

During this 30 minute conversation Professor Abrams critiques the evidence to date that rising use of e-cigarettes among middle and high school students is necessarily a cause for concern, i.e., that e-cigarettes or vaping is a gateway to use of combustible or tobacco cigarettes.  We briefly discuss how underage youths are able to acquire e-cigarettes.  Moreover our discussion focuses on related regulatory actions under the FDA, i.e., is limiting access and use of e-cigarettes or youth addition to nicotine commensurate with the potential massive public health gain.  Are these actions commensurate with the potential to reduce adult combustible cigarette use that remains the leading cause of preventable death in the US at nearly half a million deaths per year (and estimated to kill 1 billion throughout the world this century).  We also discuss Altria (manufacturer of Marlboros) recent $13 billion investment in JUUL, the leading e-cigarette manufacturer or what it may mean, reducing nicotine content in cigarettes, raising the minimum age requirement from 18 to 21 to buy tobacco cigarettes and related issues.    

Dr. Abrams is currently Profess of Social and Behavioral Sciences at New York University.  Dr. Abrams was a professor and founding director of the Centers for Behavioral and Abrams-David-Center
Preventive Medicine at Brown University Medical School.  He then directed the Office of Behavioral and Social Sciences Research at the National Institutes of Health (NIH).  Until 2017, he was Professor of Health Behavior and Society at Johns Hopkins Bloomberg School of Public Health and the founding Executive Director of the Schroeder National Institute of Tobacco Research and Policy Studies at Truth Initiative (formerly the American Legacy Foundation).  Dr. Abrams has published over 250 peer reviewed scholarly articles and been a Principal Investigator on numerous NIH grants.  He is lead author of The Tobacco Dependence Treatment Handbook: A Guide to Best Practices.  He has served on expert panels at NIH and National Academies of Sciences, Engineering and Medicine on Obesity, Alcohol Misuse and Ending the Tobacco Problem: A Blueprint for the Nation. He has also served on the Board of Scientific Advisers of the National Cancer Institute (NIH-NCI) and was President of the Society of Behavioral Medicine.

For information concerning the FDA's regulation of tobacco products go to: https://www.fda.gov/TobaccoProducts/default.htm  

The JAMA studied discussed during this interview, "The Association of Electronic Cigarettes Use with Subsequent Initiation of Tobacco Cigarettes in US Youths," is at: 


Ann Neumann Discusses Mercy Killings or Suicide-Homicides (April 15th)

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In 2017 more than 47,000 Americans committed suicide.  While suicide rates decreased during the 1980s and 1990s, they have increased by 33% over the past two decades.  Today they are one of the top ten causes of death.  Suicide or suicide-homicides, where the spouse or partner kills their loved one and frequently and immediately themselves, are unsurprising for several reasons.  Among others, the US has no universal long term care policy.   (The ACA attempted to create a voluntary long term care provision, termed the CLASS Act, but it was never implemented having found to be financially non-viable - some would say intentionally so.)  Medicare does not provide long term coverage.  The Medicare hospice benefit is de facto time limited (Medicare hospice providers have an annual per beneficiary reimbursement cap, the only Medicare program to impose a spending cap), one has to meet a poverty threshold to qualify for long term care under Medicaid and commercial long term care insurance, if available, is unaffordable for many seniors.  This last fact is largely explained by the reality that a quarter of Medicare beneficiaries have annual incomes below $15,000 and an equal percent have savings totaling less than $15,000 and over half of these have no savings or are in debt.   Concerning medical aid in dying laws, that present their own limitations, currently only eight states (NJ as of this past week) and DC allow for it. 

During this 27 minute conversation, Ms. Neumann discusses her recent  Harper's Magazine essay titled, "Going to Extremes, Are Homicides Among the Elderly Acts of Mercy or Acts _50A9718_HR_4of Malice?"  The conversation begins with Ms. Neumann's account of Philip Benight and Becky Golden's experience around which the essay is focused.  Ms Neumann moves on to discuss how these acts are addressed by prosecutors, what explains a not uncommon precipitating event, that is terminally ill patients being held in acute or in-patient settings against their will, how and why the health care industry fails to meet the needs of seriously/terminally ill individuals and whether mercy killings can be defined as rational suicides or whether they are acts of mercy or malice.        

Ms. Ann Neumann is the author of The Good Death: An Exploration of Dying in America and a nonfiction contributing editor at Guernica magazine.  Ms. Neumann was a visiting scholar at The Center for Religion and Media at New York University until 2018 and has written about religion and health care for Harper's Magazine, The New York Times, The Washington Post, Virginia Quarterly Review, The Baffler and other publications.  Ms. Neumann is currently working on a book about grief and travel. 

Ms. Neumann's February Harper's Magazine essay is at: https://khn.org/news/suicide-seniors-long-term-care-nursing-homes/

The Kaiser Health News April 9th report noted in the introduction of this podcast and titled, "Lethal Plans: When Seniors Turn to Suicide in Long-Term Care," is at: https://khn.org/news/suicide-seniors-long-term-care-nursing-homes/


Harold Miller Discusses Improving Medicare's Alternative Payment Models (April 9th)

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Medicare's Fee for Service Alternative Payment Models (APMs), a creation of 2015 MACRA legislation, currently 12 in number with participation largely voluntary, requires Medicare providers to assume financial risk, based on historical spending and quality measurement performance, beyond a "nominal amount."  The flagship APM is the ACA's Medicare Shared Savings Program, more commonly termed Accountable Care Organizations (ACOs).  Though in its 8th year, the ACO program, that currently provides care to over 10 million assigned Medicare beneficiaries, has not produced meaningful savings (estimates are 1 to 2% annually).  Nor have other APMs, largely bundled payment arrangements, produced substantial savings.  The Medicare Advantage program (with one-third of Medicare beneficiaries), defined as administrative pricing, does not formally score savings.  Over the past few years per capita Medicare spending has been limited, however, program growth or beneficiary enrollment (via the aging baby boomer population) is causing Medicare spending, in sum, to increase substantially.  In addition, the soon-to-be-published annual Medicare Trustee's report will show the program will become insolvent within the next few years. 

During this 26 minute discussion, Mr. Miller provides an overall assessment of APM performance to date.  He moreover discusses the shortcomings in APM design or the barriers APM providers face in improving care, e.g., as ostensibly Fee for Service APMs are not reimburse for valuable non-medical services such as social service supports and ways to improve these models.  We conclude the discussion with his views on the ACA-created PTAC (the Physician-Focused Payment Model Technical Advisory Committee), that has reviewed to date over 30 submitted APM proposals, none of which have been chosen by Secretary Azar for testing as a Medicare demonstration.    

Mr. Harold D. Miller is the President and CEO of the Center for Healthcare Quality and Payment Reform.  In this role he has worked in more than 40 states and metropolitan regions to help physicians, hospitals, employers, health plans, and government agencies design and implement payment and delivery system reforms.  He is also currently one of eleven HaroldMillermembers of the PTAC.  He also serves as Adjunct Professor of Public Policy and Management at Carnegie Mellon University.  Mr. Miller has written a number of widely-used papers and reports on health care payment and delivery reform.  He has assisted numerous professional organizations in developing alternative payment models designed to support better care for patients at lower cost.  From 2008 to 2013, Mr Miller served as the President and CEO of the Network for Regional Healthcare Improvement (NRHI), the national association of Regional Health Improvement collaboratives.  He served as a member of the Board of Directors of the National Quality Forum from 2009 to 2015.  From 2006 to 2010, Mr. Miller served as the Strategic Initiatives Consultant to the Pittsburgh Regional Health Initiative (PRHI).  In 2007, he served as the Facilitator for the Minnesota Health Care Transformation Task Force.  In previous positions, Mr. Miller served as the Director of the Pennsylvania Governors Office of Policy Development, Associate Dean of the Heinz School of Public Policy and Management at Carnegie Mellon University, Executive Director of the Pennsylvania Economy League - Western Division, Director of the Southwestern Pennsylvania Growth Alliance and President of the Allegheny Conference on Community Development.

For information on the Center for Healthcare Quality and Payment Reform, go to: http://www.chqpr.org/ 

Per my mention of Dr. Robert Berenson's recent (February) essay concerning improving the Medicare Fee for Service schedule, go to: https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05411