The Medical Care Blog http://www.themedicalcareblog.com The official blog of the peer-reviewed journal Medical Care, sponsored by the Medical Care Section of the American Public Health Association Tue, 15 Aug 2017 19:01:15 +0000 en-US hourly 1 https://i2.wp.com/www.themedicalcareblog.com/wp-content/uploads/2016/02/cropped-MC-e1455246578252.jpg?fit=32%2C32 The Medical Care Blog http://www.themedicalcareblog.com 32 32 106482678 Universal Health Coverage? A Response http://www.themedicalcareblog.com/universal-health-insurance-response/ Tue, 15 Aug 2017 14:00:30 +0000 http://www.themedicalcareblog.com?p=2179&preview=true&preview_id=2179 Read More »

Author information

Richard Alterbaum

Richard Alterbaum

Richard Alterbaum, MPP, MBA is a research economist at RTI International, an independent, non-profit research institute. Richard's research interests include Medicare policy, Medicaid policy, health care financing and economics, as well as health care payment and delivery system reform. Prior to joining RTI, Richard worked at the Citizen's Budget Commission in New York as well as the Massachusetts Health Policy Commission. He received his Bachelor's and Master's Degrees from Brandeis University in Waltham, MA.

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In a recent Health Affairs blog post, Universal Health Coverage? Why?, Walter McClure, Alain Enthoven, and Tim McDonald make a convincing case for expanding health insurance coverage in the United States. They argue that universal coverage is a “wise public investment” that “expands the workforce and makes it more productive,” similar to universal public education. Moreover, such a system can make long-term investments in prevention, wellness, and the overall health of people that over time can reduce costs as well as the severity and incidence of chronic diseases.

While their points on the merits of universal coverage are convincing, the authors are less clear about how the United States can achieve this goal. Their main recommendation is to create a system of managed competition between integrated provider networks. Competition between these systems based on price and quality theoretically improve the efficiency of the health care system. Also, they claim it would eliminate, or at least reduce the effect of, some of the perverse incentives associated with fee-for-service medicine that produce waste and drive up costs.

What this type of competition does not necessarily do – and here is the disconnect between the article’s initial premise and recommendation – is lead to universal health insurance coverage. Providers are already consolidating into systems such as Accountable Care Organizations, which in turn are attracting and competing for patients on the metrics the authors describe. Moreover, efforts are underway to enhance price and quality transparency among both public and private payers, though more work needs to be done on this front. Why then are nearly 30 million people still left uninsured?

The authors fail to consider the type of changes in health care financing that would guarantee more affordable access to the services the integrated delivery systems provide. The authors do describe what they are against – a pure private market, single payer, as well as public programs such as Medicare, which they argue has done little to curb uncontrollable costs.  The authors do not make clear, however, what kind of financing system can complement the type of managed competition they describe and better guarantee equity, efficiency, sustainability, and value.

The authors also contend that Medicare is a single payer system, but this is arguably not the case. It is true that nearly all legal US residents over age 65 are covered by Medicare. However, that alone does not make a single payer. In a real single-payer system, the payer is strong enough to negotiate favorable terms for what it purchases. True single-payer systems are quite rare, but what is not rare in the rest of the world is the government’s willingness to set prices.  While Medicare uses its market power to set rates and fee schedules for providers under Medicare Parts A and B, it does not set prices in Medicare Part D or Medicare Advantage.  Instead, private plans fulfill this function.

True single-payer systems have many other features that Medicare lacks, such as the ability to make coverage determinations based on cost-effectiveness (which Medicare is barred from doing).  Also, under these systems, coverage spans across all age groups, which spreads risk and creates strong incentives to cover prevention across the lifespan.  If Medicare were expanded to cover all groups, then these features would become a reality for the program–but currently, they are not.  Also, single-payer systems lack the public-private partnership structure that is incorporated into Medicare Advantage and Medicare Part D.

Some, including McClure and colleagues, argue that the magic bullet must be to give health care consumers more information, so they know which providers provide “better care for less,” coupled with incentives, financial or otherwise, to choose those networks. Unfortunately, patients already have access to substantial information about the quality of various types of providers, but few actually use such information.  It is unclear if the types of incentives the authors envision would make a significant difference in the preferences of patients.  It is worth noting that certain CMS demonstration programs, such as Next Generation ACO, have experimented with offering payments to beneficiaries who select preferred participating providers.  The program has yet to be evaluated.

The public/private mix that we currently have is not working to ensure access to care for all. Reforms are needed to enhance competition and transparency beyond the status quo, but that alone will not be sufficient to achieve universal coverage.

Author information

Richard Alterbaum

Richard Alterbaum

Richard Alterbaum, MPP, MBA is a research economist at RTI International, an independent, non-profit research institute. Richard's research interests include Medicare policy, Medicaid policy, health care financing and economics, as well as health care payment and delivery system reform. Prior to joining RTI, Richard worked at the Citizen's Budget Commission in New York as well as the Massachusetts Health Policy Commission. He received his Bachelor's and Master's Degrees from Brandeis University in Waltham, MA.

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Despite ACA mandates for states to streamline renewal, many beneficiaries still need assistance to retain Medicaid coverage http://www.themedicalcareblog.com/medicaid-coverage-discontinuity/ Thu, 10 Aug 2017 14:15:00 +0000 http://www.themedicalcareblog.com?p=2014&preview=true&preview_id=2014 Read More »

Author information

Holly Stockdale

Holly Stockdale

Holly Stockdale, MPH,MPP is a research associate in the Division for Health Services and Social Policy at RTI International, an independent, non-profit research organization. At RTI, she has contributed to the design and implementation of evaluations related to state health care transformation, health care organization and delivery, and Medicaid.

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Enrollment in Medicaid has been shown to enhance access to health care for our nation’s most vulnerable citizens. Yet despite these benefits, a substantial number of beneficiaries lose coverage at the time of renewal. An article by Xu Ji and colleagues, published in this month’s issue of Medical Care, demonstrates how critical maintaining continuous Medicaid coverage is for beneficiaries with mental health conditions.

Ji and colleagues found that adults with major depression who lost Medicaid coverage for a period of months and then re-enrolled were more likely to visit the emergency department and use inpatient hospital services than those who remained continuously enrolled. These increases in utilization translated into higher monthly acute care costs for state Medicaid programs.

In the Spring of 2017, we conducted a series of telephone interviews with state Medicaid officials, providers, and consumer advocates in 5 states implementing the Medicaid expansion (Michigan, Rhode Island, Oregon, New Mexico, and West Virginia).  During interviews, we discussed states’ progress implementing the Affordable Care Act’s (ACA’s) streamlined renewal policies and their initial impact on beneficiaries.  We found that ACA policies that simplified renewal processes helped keep Medicaid beneficiaries enrolled, but challenges remain – especially for people with mental illness and other vulnerable populations who often need one-on-one assistance to maintain coverage.

ACA mandates to enhance retention in Medicaid

The ACA includes several provisions to simplify the renewal process for Medicaid beneficiaries:

  • First, states are required to review data from other human service programs to confirm eligibility prior to requesting documentation from the beneficiary.
    • If a beneficiary is found eligible after reviewing state data sources, the recipient does not need to take any additional action to remain enrolled.
  • When passive renewal is not possible, states must send beneficiaries a pre-populated renewal form with a clear request for any additional documentation.
  • The law also required that states implement 12-month renewal cycles and allow individuals 90 days to re-enroll without completing a new application if they miss the renewal deadline.
  • Finally, in keeping with the ACA’s goal of encouraging states to modernize their IT systems, the law requires Medicaid agencies to provide the option to enroll and renew coverage online.

Our discussions with stakeholders revealed that these reforms have helped keep people enrolled, but barriers to retaining continuous Medicaid coverage remain, and they are especially likely to affect those with mental health and other behavioral health conditions.

Barriers to renewal for individuals with mental illness

Although passive renewal substantially reduces the likelihood of losing Medicaid coverage at renewal, it is not always possible. In some of our case study states, large percentages of beneficiaries were not passively renewed. When passive renewal is not possible, the state must be able to contact a beneficiary to verify eligibility. This poses challenges for state Medicaid agencies, which have traditionally relied on paper mailings to inform beneficiaries that they need to renew coverage. Unfortunately, many individuals with a mental health disorder experience bouts of homelessness throughout their lifetime. Some experts estimate that about one-third of the homeless population has an untreated mental illness [PDF]. Because homeless individuals lack a permanent address, they are more likely to lose coverage at renewal. Many of these individuals often re-enroll when they visit a community health center or social service organization, but they typically must reapply for coverage because they have missed the 90-day window for reinstatement.

Understanding renewal notices poses another considerable barrier for individuals with mental disorders. Pre-populated renewal forms are intended to make it easier for enrollees to update and verify information, but notices can be multiple pages long and often contain technical language that is not easily understood. Although states are working to simplify these forms, many Medicaid recipients need individual assistance interpreting and responding to renewal notices. People with mental illness are especially likely to need this help.

States have made substantial progress in developing web-based application and enrollment systems. In many states, Medicaid beneficiaries now have the option to both apply for and renew coverage on-line. For beneficiaries with access to the internet and some level of technological savvy, this is a definite improvement. But for enrollees with mental illness, navigating the internet and technology, which requires keeping track of user IDs and passwords, can be challenging. Enrollment assisters and application counselors play an active role in helping many individuals both understand and complete on-line renewal forms.

One-one-one assistance still important for maintaining coverage

The Ji, et al. study demonstrates that maintaining continuous Medicaid coverage can prevent hospitalizations and unnecessary emergency department visits for individuals with mental illness. To improve coverage continuity in Medicaid and facilitate access to care, the authors call attention to the importance of streamlined re-enrollment policies. The ACA simplification requirements are a step in the right direction. However, even with streamlined renewal processes in place it’s clear that certain populations, many who have serious mental health conditions, will continue to need individual assistance to maintain Medicaid coverage.

Author information

Holly Stockdale

Holly Stockdale

Holly Stockdale, MPH,MPP is a research associate in the Division for Health Services and Social Policy at RTI International, an independent, non-profit research organization. At RTI, she has contributed to the design and implementation of evaluations related to state health care transformation, health care organization and delivery, and Medicaid.

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2014
Getting recommended preventive care: costs aren’t the only barrier http://www.themedicalcareblog.com/prevention-under-aca/ Thu, 03 Aug 2017 09:00:08 +0000 http://www.themedicalcareblog.com?p=2013&preview=true&preview_id=2013 Read More »

Author information

Lisa Lines

Lisa Lines

Health services researcher at RTI International

Lisa M. Lines, PhD, MPH is a health services researcher at RTI International, an independent, non-profit research institute. She is also an Instructor in Quantitative Health Sciences at the University of Massachusetts Medical School. Her research focuses on quality of care, care experiences, and health outcomes among people with chronic illnesses; emergency department utilization; and person-centered care and patient-centered medical homes, among other topics. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She also serves as chair of the APHA Medical Care Section's Health Equity Committee. In 2015, Dr. Lines was appointed to a 3-year term on the National Quality Forum's Neurology Standing Committee.

Views expressed are the author's and do not necessarily reflect those of RTI or UMass Medical School.

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Annual routine check-ups, flu shots, and mammograms are among the basic preventive services for which the Patient Protection and Affordable Care Act of 2010 established a mandate for insurance plans: full coverage, with no out-of-pocket costs. In making it a little easier for some parts of the US population to access basic services, did the ACA result in increased uptake of these services? A new article just out in this month’s issue of Medical Care has some answers.

The researchers, led by Young-Rock Hong at the University of Florida, used Medical Expenditure Panel Survey (MEPS) data from 2007-2014 to study two cohorts of people aged 18-64: those who were continuously enrolled in private insurance, and those who were continuously uninsured. Then, they used a difference-in-differences (DiD) design to examine rates of preventive care between those cohorts from 2007-2010 (pre-ACA) and 2011-2014 (post-ACA).

Looking only at the significant results, the authors found that:

  • Flu vaccinations increased slightly among the privately insured and decreased slightly among the uninsured, resulting in a DiD effect of 5.9 percentage points. This was the only outcome that significantly changed both pre-post and between the two cohorts.
  • Blood pressure evaluations  increased slightlyamong private insurees relative to the uninsured (3.3 points)
  • Routine checkups also  increased slightlyamong private insurees relative to the uninsured (2.7 points)
  • Cholesterol checks increased slightly among private insurees pre-post (3 points)
  • The rates for Pap smears and mammograms decreased slightly among private insurees pre-post (-3.1 and  -4.7 points, respectively)
  • Turing to costs, the privately insured group had significantly higher total healthcare costs after the ACA (pre-post, mean total costs increased from $5,031 to $5,138), but lower out-of-pocket costs (decreased from $721 pre-ACA to $638 post-ACA).

These moderate positive effects are somewhat encouraging, but the negative effects on cancer screening are unfortunate. Type of insurance is another concern–earlier work showed some differences in response to cost based on plan type. However, it is not just cost that acts as a barrier to accessing preventive care. Other countries that have adopted national cancer screening programs, such as Australia, have provided workable models for increasing cancer screening. Reducing cost barriers is just the start.

In another analysis, using 2006-07 MEPS data, my coauthors and I found that intermittent insurance was a significant predictor of lack of preventive care. During that time period, about 1 in 5 individuals aged 18-64 had a gap in coverage. Since the ACA allowed coverage lapses of up to 3 months without a tax penalty, gaps in coverage have continued to be common: in 2013, 27% of people under age 65 (73.0 million individuals) were uninsured for 1 or more months.

People with lapses in coverage were excluded from the study by Hong and colleagues. More research is needed in this area, especially since the prevalence of intermittent insurance is likely to increase without enforcement of the ACA’s individual mandate.

In addition, the future of these coverage benefits remains murky, since some conservatives see the mandates as governmental overreach. Various Republican proposals have removed the mandates or would allow insurers to offer plans without them. But even without legislation, the Trump administration has the ability to make changes through the regulatory process.

Some argue that waiving co-payments for these relatively inexpensive, routine preventive services is the opposite of what insurance should do — that insurance should be reserved for catastrophic and unexpected costs. But from a population health perspective, removing barriers to access is a strategy that clearly can work to increase uptake of screening.

Author information

Lisa Lines

Lisa Lines

Health services researcher at RTI International

Lisa M. Lines, PhD, MPH is a health services researcher at RTI International, an independent, non-profit research institute. She is also an Instructor in Quantitative Health Sciences at the University of Massachusetts Medical School. Her research focuses on quality of care, care experiences, and health outcomes among people with chronic illnesses; emergency department utilization; and person-centered care and patient-centered medical homes, among other topics. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She also serves as chair of the APHA Medical Care Section's Health Equity Committee. In 2015, Dr. Lines was appointed to a 3-year term on the National Quality Forum's Neurology Standing Committee.

Views expressed are the author's and do not necessarily reflect those of RTI or UMass Medical School.

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2013
The Prevention and Public Health Fund: Investing in Health Equity http://www.themedicalcareblog.com/the-prevention-and-public-health-fund/ Fri, 28 Jul 2017 09:00:00 +0000 http://www.themedicalcareblog.com?p=2157&preview=true&preview_id=2157 Read More »

Author information

Selena Ortiz

Selena Ortiz, Ph.D., MPH, is the Gregory H. Wolf Assistant Professor of Health Policy and Administration at The Pennsylvania State University. Broadly, Dr. Ortiz's research examines the determinants of population health policy formation, including problem recognition, the formulation of policy proposals, and politics. Her work focuses on the social determinants of health, health disparities, and health equity.

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The pursuit of health equity – ensuring equal access to opportunities that enable all communities to lead healthy lives – is a critical task for the U.S. The direct and indirect medical costs associated with sickness and premature death resulting from health care inequities are enormous (estimated to be $230 billion and $1.24 trillion, respectively, for the years 2003 through 2006). A key institution in the struggle to attain health equity is the American public health system. That institution is under attack.

Recent legislative proposals to repeal and replace the Patient Protection and Affordable Care Act (ACA) have included the elimination of the Prevention and Public Health Fund (Prevention Fund), a vital source of state funding awarded through the Department of Health and Human Services and its centers. Established in 2010 by Section 4002 of the ACA, the Prevention Fund enables public and private organizations within states to design and conduct prevention, wellness, and public health activities that focus on disease prevention and strengthen public health infrastructure. The core objectives of the Prevention Fund are twofold: 1) institutionalizing annual investment to improve population health while 2) restraining private and public health care costs.

The Prevention Fund also enables the public health system to cement a highly-visible platform from which to alter social and economic norms that influence health equity [PDF]. Health inequity arises when social and economic determinants of health (e.g. lack of affordable and quality housing, unsafe neighborhoods, poor education, and non-living wages) lead to significant disparities in disease burden and health outcomes among different populations. The Prevention Fund has dispersed over $7 billion since 2010 to support health equity-oriented activities that provide health-promoting opportunities for vulnerable populations. Some of these activities include establishing community coalitions to build and measure the success of strategies to eliminate health disparities; creating and disseminating evidence-based nutrition and physical activity interventions targeting obesity within workplaces; and developing and strengthening relationships between the health care system and low-income and racial/ethnic groups challenged by problematic social, economic, and cultural risk factors. Prevention funds have also been used to strengthen and diversify the public health workforce, which may lead to increased health services to racial/ethnic and low-income populations.

Achieving health equity relies heavily on a public health system that adopts integrative approaches to addressing the social determinants of health, “not only in how it actively organizes, funds, and delivers health care”, [PDF] but how it works with and influences other sectors to address health inequalities. Our public health system has produced remarkable feats in health promotion and sickness prevention. Universal childhood vaccination, surveillance for foodborne illnesses, the fluoridation of drinking water, and the implementation of motor vehicle safety policies, are but a few examples of public health’s achievements. These and many other advances in population health have been possible because of a well-integrated public health system that works cooperatively with numerous partners, including federal agencies, state and local governments, businesses, non-profit organizations, academia, and the media.

The Congressional Budget Office (CBO) estimates that eliminating the Prevention Fund will reduce direct spending by $9 billion over the 2017 – 2026 period. However, achieving total health equity in the U.S. requires addressing health disparities and the social and economic determinants of health in tandem with a well-financed public health system. Without such, interventions and policies intended to eradicate health inequities may prove ineffectual, irrespective of how concerted or cogent the effort. Currently, only 3% of total health expenditures in the U.S. are dedicated to disease prevention and public health, an astonishing amount if one considers that 86% of total health care costs are associated with preventable conditions. The Institute of Medicine and The New York Academy of Medicine have each declared the deleterious effects of long-term inadequate financial investment in public health, especially on its ability to perform essential duties, such as enforcing public health laws and regulations, assuring a competent public health care workforce, and evaluating the effectiveness and quality of health care services.

The Prevention Fund essentially buttresses against further destabilization of the public health system. In FY 2016, three agencies – the Administration for Community Living, the Centers for Disease Control and Prevention, and the Substance Abuse and Mental Health Services Administration – received nearly $932 million in prevention funds to award to community-based public health initiatives in all 50 states. Many of these initiatives are geared towards strengthening infrastructure to enhance health service delivery, such as improving public health systems to increase vaccines to children, adolescents, and adults and creating rapid response networks to effectively combat infectious disease threats and childhood lead poisoning. Others focus on health promotion and injury prevention among at-risk populations, including developing and implementing youth suicide prevention and early intervention programs and expanding specialty services to individuals living with Alzheimer’s and dementia.

In the face of numerous ongoing public health crises across the U.S. (e.g. the water catastrophe in Flint, Michigan; the opioid epidemic across rural areas; the Zika virus outbreak; etc.), disavowing the Prevention Fund may pose further health risks to all American residents, not just those most susceptible to the interactive effects of adverse social and economic circumstances and disproportionate disease burden. Legislative jettisoning of the Prevention Fund at this inopportune moment will not only disrupt vital prevention efforts, but also undermine the hard work achieved by Prevention Fund collaborations. One-time budgetary allotments (such as a proposed $422 million supplement in community health center funding in fiscal year 2017) do little to compensate forfeiture of steady and secure investment in the public health system.

The good news is that the pursuit of health equity will (and should) carry on at multiple levels, regardless of the fate of the Prevention Fund. Health care organizations, through support from the Centers for Medicare and Medicaid Services’ Accountable Health Communities program, are partnering with social service providers to respond to patient’s unmet health-related social needs. Community agencies, many with private support from foundations such as the Robert Wood Johnson Foundation, are forming alliances with other non-profit organizations and academia to implement and evaluate initiatives that mitigate the health impacts of disadvantageous environments.

Achieving health equity in the U.S. requires long-term, binding public health investment in cooperative and complementary strategies. Legislation that falls short of this guarantee otherwise suggests that our commitment to ensuring a robust public health system to achieve health equity is uncertain.

Author information

Selena Ortiz

Selena Ortiz, Ph.D., MPH, is the Gregory H. Wolf Assistant Professor of Health Policy and Administration at The Pennsylvania State University. Broadly, Dr. Ortiz's research examines the determinants of population health policy formation, including problem recognition, the formulation of policy proposals, and politics. Her work focuses on the social determinants of health, health disparities, and health equity.

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Falls and the rise of wearable sensors http://www.themedicalcareblog.com/falls-and-the-rise-of-wearable-sensors/ Thu, 27 Jul 2017 13:00:00 +0000 http://www.themedicalcareblog.com?p=1787&preview=true&preview_id=1787 Read More »

Author information

Jennifer Lyden

Jennifer Lyden

Jennifer T. Lyden, MPH, PMP is a public health analyst for the End-of-Life, Palliative and Hospice Care (EPHC) Program at RTI International. , She is currently working on a Centers for Medicare & Medicaid Services (CMS)-funded hospice quality measure development projects. Jen is trained in qualitative data collection methodologies with a background in data collection, data management, and logistics planning and execution.

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“I’ve fallen, and I can’t get up!” Remember that catchphrase of the late 1980s and early 1990s, based on the television commercial for LifeCall? Well, the Mrs. Fletcher of yesterday would be amazed by the wearable devices of today – they might even be able to prevent her fall in the first place!

According to the CDC, falls are a leading cause of injury and death in older Americans.  More than 10,000 Americans turn 65 every day, the number of fall-related injuries and deaths are on the rise. In response to their fear of falling, older adults limit their activities which result in the physical decline, depression, isolation, and feelings of helplessness. This, in turn, increases health care utilization and cost and decreases the quality of life for older adults. Perhaps wearable devices could be used to reduce this fear and prevent falls.

This brings us back to Mrs. Fletcher and her LifeCall pendant.  Unfortunately, the pendant was not a fall prevention strategy, it was a system that allowed users to request help after a fall. Times have changed since the LifeCall commercials aired in the late 1980s. Wearable devices hold great promise to prevent falls in older Americans. My 86 year old grandmother is living alone 700 miles from her family. I would find great comfort in knowing that she could put on a sensor that would alert her to an impending fall.  Without getting into the biomedical engineering details of this technology, these wearable sensors capture motion characteristics which are used to estimate the likelihood of a fall and alert the user in real time. Carnegie Mellon engineers have developed fall-prevention sensors to monitor gait and send mobile alerts not only to nurses and caregivers but also to the individual if their gait changes threateningly.  The goal of these sensors is to anticipate and prevent falls.  The technology is programmed to immediately notify someone if individual experience a sudden fall. These wearable sensors integrate fall detection and fall prevention technologies which the LifeCall system lacked.

The United States is facing an unprecedented demographic transition due to the aging of the baby boom generation (those born from 1946 through 1964) which is further magnified by increasing life expectancy. As of November 2016, the United States has reached a new population milestone – a population of over 50 million seniors for the first time in history. This population increase will undoubtedly result in more Medicare beneficiaries and higher Medicare spending while fewer citizens are paying into the system.  This changing population dynamic presents a myriad of challenges including the devastating impact of falls.

Fall prevention is one of the many benefits of wearable sensors.  These devices also collect data that can be used by healthcare providers to inform medication adjustments, signal that an office visit is needed, suggest disease progression, etc. The usefulness of this data is not only limited to healthcare providers. Dashboards could be monitored by aging adults and their caregivers. I know I would be interested in monitoring my grandmother’s dashboard. While wearables are not the only solution to prevent falls, they are one tool to be included in a multifactorial fall prevention program.  My hope is that the continued development of wearable sensors will minimize the Medicare costs associated with falls while increasing the quality of the life of older Americans.

Author information

Jennifer Lyden

Jennifer Lyden

Jennifer T. Lyden, MPH, PMP is a public health analyst for the End-of-Life, Palliative and Hospice Care (EPHC) Program at RTI International. , She is currently working on a Centers for Medicare & Medicaid Services (CMS)-funded hospice quality measure development projects. Jen is trained in qualitative data collection methodologies with a background in data collection, data management, and logistics planning and execution.

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New methods in risk modeling: does adding EHR data improve predictions? http://www.themedicalcareblog.com/new-methods-risk-modeling/ Thu, 20 Jul 2017 14:00:45 +0000 http://www.themedicalcareblog.com?p=2006&preview=true&preview_id=2006 Read More »

Author information

Lisa Lines

Lisa Lines

Health services researcher at RTI International

Lisa M. Lines, PhD, MPH is a health services researcher at RTI International, an independent, non-profit research institute. She is also an Instructor in Quantitative Health Sciences at the University of Massachusetts Medical School. Her research focuses on quality of care, care experiences, and health outcomes among people with chronic illnesses; emergency department utilization; and person-centered care and patient-centered medical homes, among other topics. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She also serves as chair of the APHA Medical Care Section's Health Equity Committee. In 2015, Dr. Lines was appointed to a 3-year term on the National Quality Forum's Neurology Standing Committee.

Views expressed are the author's and do not necessarily reflect those of RTI or UMass Medical School.

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One of the challenges in delivering efficient medical care is identifying people who are at risk of a negative outcome, so we can focus our efforts on screening and treating those at elevated risk. We do this in individual face-to-face encounters through clinical, diagnostic processes: taking a patient’s history, performing a physical examination, recording signs and symptoms. Across populations, we do it by using data collected in these encounters over time to develop algorithms and predictive statistical models. For me personally, these risk stratification, prediction, and adjustment models are some of the most interesting tools used in health services research.

Over the past decade or more of transitioning to electronic health records (EHRs) in the US, one of the biggest promises for research has been the idea of using the rich, clinical detail available from EHRs to enhance the standard claims and administrative data we’ve traditionally used to build risk models. In fact, we were lucky enough to be able to construct a linked EHR-claims database for one of my dissertation papers (co-authored with my advisor, Arlene Ash, and another member of my committee), published this year, in which we predicted emergency department visits.

And that brings us to a new article, published in the August issue of Medical Care: Comparing Population-based Risk-stratification Model Performance Using Demographic, Diagnosis and Medication Data Extracted from Outpatient Electronic Health Records versus Administrative Claims.

In this paper, a team from Johns Hopkins (first author: Hadi Kharrazi, MD, PhD) evaluates the possibility of using EHR data in addition to (or instead of) administrative claims for risk stratification. They sought to predict two different outcomes: hospitalization (excluding childbirth-related stays) and being in the top 1% of costs. They studied a sample of 85,581 individuals (all under age 65), continuously enrolled in both 2011 and 2012, who visited a primary care clinic associated with HealthPartners (a Bloomington, MN integrated delivery network) at least once in at least 1 year of the study period. The authors used the Johns Hopkins Adjusted Clinical Group (ACG) system, which has been validated for risk stratification.

They noted that about 46% of diagnoses were listed only in claims, while about 7% were listed only in the EHR. The overlap between claims and EHR data, regarding reported chronic conditions, was about 58%. Combining EHR and claims data:

  • increased identification of cancer by 12%
  • increased identification of diabetes by 10%
  • increased identification of hypertension by 3%
  • increased identification of depression by 3%

Turning to the accuracy of the models, assessed using R2 and area under the receiver operating characteristic curve (AUC):

  • When predicting cost, adding EHR to claims data actually lowered the Rby a small amount.
  • When predicting both cost and hospitalization, using both EHR and claims data slightly increased the AUCs across both outcomes for concurrent outcomes (this year’s outcomes predicted using this year’s data).
    • The AUC did not change or decreased when predicting prospective outcomes (next year’s outcomes predicted using this year’s data).

The authors conclude that, while risk stratification using EHR data was feasible, it was less accurate than claims-based models in predicting hospitalization and high costs, although it increased the ability to identify some important conditions.

Their findings suggest that EHRs, at least in this study, contain more outdated and/or inaccurate data than do claims. Additionally, even in an integrated delivery network, the available claims data could have been incomplete (especially for mental health utilization). EHR-derived medication data also represents prescriptions, while claims represent actual medication fills. Mismatches could be related to nonadherence or to individuals paying out of pocket (for example, using online pharmacies) instead of paying for medications with their insurance.

As usual, more research is needed to understand how best to deliver on the promise of EHR data’s usefulness.

Author information

Lisa Lines

Lisa Lines

Health services researcher at RTI International

Lisa M. Lines, PhD, MPH is a health services researcher at RTI International, an independent, non-profit research institute. She is also an Instructor in Quantitative Health Sciences at the University of Massachusetts Medical School. Her research focuses on quality of care, care experiences, and health outcomes among people with chronic illnesses; emergency department utilization; and person-centered care and patient-centered medical homes, among other topics. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She also serves as chair of the APHA Medical Care Section's Health Equity Committee. In 2015, Dr. Lines was appointed to a 3-year term on the National Quality Forum's Neurology Standing Committee.

Views expressed are the author's and do not necessarily reflect those of RTI or UMass Medical School.

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2006
Cancer care: sometimes less is more http://www.themedicalcareblog.com/overuse-in-cancer-care/ Thu, 13 Jul 2017 14:00:00 +0000 http://www.themedicalcareblog.com?p=1774&preview=true&preview_id=1774 Read More »

Author information

Lisa Lines

Lisa Lines

Health services researcher at RTI International

Lisa M. Lines, PhD, MPH is a health services researcher at RTI International, an independent, non-profit research institute. She is also an Instructor in Quantitative Health Sciences at the University of Massachusetts Medical School. Her research focuses on quality of care, care experiences, and health outcomes among people with chronic illnesses; emergency department utilization; and person-centered care and patient-centered medical homes, among other topics. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She also serves as chair of the APHA Medical Care Section's Health Equity Committee. In 2015, Dr. Lines was appointed to a 3-year term on the National Quality Forum's Neurology Standing Committee.

Views expressed are the author's and do not necessarily reflect those of RTI or UMass Medical School.

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Preparing for radiation. Photo: Russ Scalf

Cancer is a dreaded disease – and in the US, a typical response to a cancer diagnosis is to try every treatment available in hopes that something might work. Understandable! But cancer overtreatment is a serious problem that drives up costs, causes avoidable morbidity and mortality, and reduces the quality of care.

What is overtreatment? Simply defined, it is medical care that has no benefit, or for which harms outweigh potential benefits. According to some estimates, about 30% of all US medical expenditures are attributable to overtreatment.

But is overtreatment common in cancer care? This month’s issue of Medical Care includes a systematic literature review answering that question. The review, by Dr. Shrujal Baxi and colleagues at Sloan Kettering and other institutions, is a well-conducted, focused review of recent studies of cancer overtreatment.

The authors found 59 articles meeting their review inclusion criteria–almost all focusing on adult and geriatric populations–that assessed the overuse of 154 distinct services associated with cancer diagnosis (56% of services), surveillance (23%), active treatment (19%), and end of life (1%). Consistent with the emphasis on diagnosis and surveillance, imaging was the most frequently studied service (71%), followed by radiation (6%), hormonal therapy (5%), chemotherapy (3%), targeted therapy (1%) and other therapies (6%).

Most studies reported the overuse rate as the percentage of the population receiving a non-recommended service, with ranges from 0 to 100% across the services. Many studies (46%) used claims data to identify overuse. Three studies looked at two types of data, claims and either chart review or clinical data. One of those (Hahn 2015), found that among women receiving imaging for low-risk breast cancer, the services received were documented as clinically relevant (and guideline-concordant) about half the time–although, as Baxi and colleagues note in their excellent discussion of the methodological issues involved in this area of research, it is impossible to know how much of the documentation is accurate.

Another interesting study (Weeks 2014), looking at National Comprehensive Cancer Network data on over 25,000 patients, found that overtreatment rates for chemotherapy were around 40% in patients with metastatic lung cancer and poor performance status, 36% in postmenopausal women with limited metastatic breast cancer, and 55% in premenopausal women with limited metastatic breast cancer.

These rates are especially concerning given that these data were from major cancer centers, presumably the best places to get cancer care, yet overtreatment was rampant. Note that in comparison, a French study using data from 2 academic centers reported that about 21% of all chemotherapy administered was non-concordant with national guidelines–this is not just a US problem.

Given the high costs of cancer treatment, it is regrettable that so few recent studies have focused on costs of overuse in general, and particularly overuse during the active treatment phase. It is also unfortunate that few have studied interventions to reduce overuse, especially since one intervention led to reductions in both overuse and recommended services. Across populations, the “right” amount of treatment is hard to define and measure, and perhaps even harder to achieve.

For more information on overtreatment, check out the Choosing Wisely campaign. They provide evidence-based recommendations, organized in lists for both doctors and patients, to help make decisions about appropriate and necessary treatment.

Author information

Lisa Lines

Lisa Lines

Health services researcher at RTI International

Lisa M. Lines, PhD, MPH is a health services researcher at RTI International, an independent, non-profit research institute. She is also an Instructor in Quantitative Health Sciences at the University of Massachusetts Medical School. Her research focuses on quality of care, care experiences, and health outcomes among people with chronic illnesses; emergency department utilization; and person-centered care and patient-centered medical homes, among other topics. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She also serves as chair of the APHA Medical Care Section's Health Equity Committee. In 2015, Dr. Lines was appointed to a 3-year term on the National Quality Forum's Neurology Standing Committee.

Views expressed are the author's and do not necessarily reflect those of RTI or UMass Medical School.

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Patterns of Opioid Use and Risk of Opioid Overdose http://www.themedicalcareblog.com/patterns-of-opioid-use-and-risk-of-opioid-overdose/ Thu, 06 Jul 2017 14:00:00 +0000 http://www.themedicalcareblog.com?p=1781&preview=true&preview_id=1781 Read More »

Author information

Audrey Provenzano

Audrey Provenzano

Audrey M. Provenzano, MD, MPH is a General Internist in the Boston area. She cares for patients in a community health center and works in quality improvement. She is interested in primary care practice reform and quality improvement and healthcare policy. She is the host and producer of the primary care and health policy podcast Review of Systems, which can be found at www.rospod.org.

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Opiate overdose is now the leading cause of accidental death in the United States, killing more than 50,000 people in 2015. About 20,000 of those deaths were attributed to the use of prescription opiate medications.

As a physician, I want to alleviate my patients’ pain, but I have also taken an oath to do my patients no harm. Clearly, based on these statistics, far too many people have been harmed by prescription opiate medications, either by developing an addiction or through a fatal overdose. We must better understand why this is happening and what we can do to stop it.

Renu K. Garg and colleagues at the University of Washington set out to illuminate risk factors for opioid overdose death among a Medicaid population in their paper, published in this month’s issue of Medical Care: Patterns of Opioid Use and Risk of Opioid Overdose Death Among Medicaid Patients.

The researchers initially looked at all adult Medicaid enrollees in the state of Washington from 2006 to 2010 who had one or more opioid prescriptions, a sample of 328,445 individuals. After removing patients with cancer, methadone maintenance, and other exclusion factors, they were left with a sample of 150,821 patients. Garg and colleagues then identified overdose by reviewing those death certificates and identified 316 with a cause of death attributed to prescription opiate overdose.

They examined each patient’s average daily dose of opiate medication, use of long-acting or short-acting medication, duration of use, as well as recent and concurrent sedative-hypnotic and other sedating medications such as skeletal muscle relaxants. You can find a complete list of the medications analyzed here [Word file].

They found, intuitively, that individuals on higher doses of opiates had higher rates of overdose death, demonstrating a clear dose-response relationship. Compared to the lowest dose category of less than 20 mg/day, patients taking 50 mg/day or more had a significantly higher risk of death (see figure below).

Source: Created for the blog from data in Table 3 of Garg et al., Med Care. 2017:55(7);661–668.

They also found that patients concurrently taking sedative-hypnotics and muscle relaxants had a substantially higher risk of overdose death, even among patients taking less than 20 mg/d of opiates. This finding is extremely important and is thought to be the first report of increased overdose death with these drug combinations.

Clinicians often try to take a multi-pronged approach to pain, and muscle relaxants and benzodiazepines are sometimes used to alleviate muscle spasm in combination with opiates. Benzodiazepines are also used in anxiety disorders, which can be co-morbid with chronic pain. Garg and colleagues’ findings illuminate the very real risks of using these medications in combination, and may allow us to alter our prescribing habits as well as counsel patients on these risks.

Furthermore, we are learning in this epidemic that many medications aside from opiates have a street value – meaning, patients may give away or sell pills remaining after they have used what they need for their pain or anxiety, and others may use them recreationally. This is particularly true of the benzodiazepines that Garg and colleagues studied. Discretion in prescribing appropriate quantities is part of our responsibility as clinicians.

Almost every state maintains an online database that tracks prescriptions of controlled substances to assist us in that task. This allows prescribers to ensure that patients aren’t getting controlled substances from multiple doctors and increases the safety of prescribing these medications.

Starting in August, Massachusetts will also track prescriptions for gabapentin, an anti-convulsant (anti-seizure medication) that is also widely used for neuropathic pain. Individuals sometimes use it with opiates to augment or prolong a high. I am unaware of any studies demonstrating whether gabapentin does indeed increase the risk of overdose, but based on these findings, I suspect it may. Further studies on this question are needed.

Lastly, we must continue to work toward ending the stigma against individuals suffering from substance use disorders. Such stigma is preventing the provision of a database of controlled substances for clinicians in Missouri, the only state without one, where a legislator once stated that overdose “removes them from the gene pool.”

A friend recently sent me an obituary for a young man, Garrett R. Moody, who died of an overdose. His courageous and loving family wrote beautifully about him and his struggle, words that we all must keep in our hearts: “It’s important to not allow addiction to define a person. An addict is a person with a disease. They are someone’s child, sibling, significant other, best friend – they mean something to someone.”

Author information

Audrey Provenzano

Audrey Provenzano

Audrey M. Provenzano, MD, MPH is a General Internist in the Boston area. She cares for patients in a community health center and works in quality improvement. She is interested in primary care practice reform and quality improvement and healthcare policy. She is the host and producer of the primary care and health policy podcast Review of Systems, which can be found at www.rospod.org.

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The Past, Present, and Future of Risk Adjustment: An Interview with Arlene Ash http://www.themedicalcareblog.com/risk-adjustment-interview-with-arlene-ash/ Mon, 26 Jun 2017 14:00:59 +0000 http://www.themedicalcareblog.com?p=2048&preview=true&preview_id=2048 Read More »

Author information

Lisa Lines

Lisa Lines

Health services researcher at RTI International

Lisa M. Lines, PhD, MPH is a health services researcher at RTI International, an independent, non-profit research institute. She is also an Instructor in Quantitative Health Sciences at the University of Massachusetts Medical School. Her research focuses on quality of care, care experiences, and health outcomes among people with chronic illnesses; emergency department utilization; and person-centered care and patient-centered medical homes, among other topics. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She also serves as chair of the APHA Medical Care Section's Health Equity Committee. In 2015, Dr. Lines was appointed to a 3-year term on the National Quality Forum's Neurology Standing Committee.

Views expressed are the author's and do not necessarily reflect those of RTI or UMass Medical School.

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Recently, I sat down to talk with Arlene Ash, PhD about risk adjustment. Dr. Ash is Professor and Chief of the Division of Biostatistics and Health Services Research, Department of Quantitative Health Sciences at the University of Massachusetts Medical School. As a methods expert on risk adjustment in health services research, she has pioneered tools for using administrative data to monitor and manage health care delivery systems, including those now relied upon by various federal programs, including  CMS’ Medicare Advantage. About one-third of Medicare’s beneficiaries are currently enrolled in Medicare Advantage,  a privately administered managed care program run by dozens of insurance companies in different regions.

We started talking about a recent Medicare Advantage fraud class-action law suit in which the government and others allege that UnitedHealth systematically gamed the risk adjustment system and fraudulently collected millions of dollars through “upcoding” — essentially claiming that their enrollees were sicker than they were. Two Florida Medicare Advantage plans, Freedom Health and Optimum Healthcare, have recently settled a similar lawsuit by paying $32 million. By one estimate, unjustified coding intensity in Medicare Advantage could cost Medicare $200 billion over the next 10 years.

I asked Dr. Ash about the problem of upcoding, as well as what the future of risk adjustment might be. What follows is an edited transcript of Arlene’s comments.


Arlene Ash: The goal of Medicare Advantage’s risk adjusted payment method is to give more money to plans that enroll sicker people, and we only know how sick someone is from the medical diagnoses that plans submit.  That is, we give plans a huge incentive to code aggressively. We’ve always known that we need checks against fraud.

Since the beginning, CMS has studied trends in upcoding, watching continuously enrolled people in both Medicare Advantage plans and traditional (fee-for-service) Medicare, and comparing trends in risk scores. They’ve seen a greater year-over-year increase in risk scores for Advantage enrollees, leading them to apply a coding intensity adjustment that reduces payments to the Advantage program as a whole.

However, CMS has also seen big differences in risk score growth across Medicare Advantage plans, and — whatever adjustors are applied across the board — the more that an individual plan upcodes, the more money it gets.

When Washington State adopted diagnosis-based risk adjustors for its Medicaid program in the mid-1990s, it decided to try to level the playing field by teaching everyone to code as aggressively as could be legally justified. But how do we distinguish legitimate upcoding from fraud? Broadly, it is only legal to submit codes that relate to conditions that are addressed during at least one face-to-face encounter with a clinician during a year. If the code for diabetes, say, does not appear during the next year, the diabetes-related payment will go away, since we don’t want to pay more for a person with diabetes who isn’t actually being treated for the disease.

When payment became linked to these coding rules, some plans started looking at their data and found that many people with a diabetes code in one year had none the next. Digging deeper, they saw that this wasn’t careless coding — many of these people had not had their diabetes addressed for over 12 months! A plan could respond by improving care — seeing to it that people with a serious chronic disease were seen more regularly — and thus justifying the disease-associated payment bump. This is a win for  quality. However, if it simply carries forward the diagnosis whether or not there was a diabetes-related visit that would be fraud.

Aside from fraud, a problem with the current methodology is that if really good care made a health problem disappear, the plan’s payment would be reduced. On the one hand, if the person is less sick, less money it may take fewer resources to care for them. However, such payment rules obviously don’t encourage the best possible care; we should separately reward exemplary management of chronic illness, especially when a serious medical problem, such as Type II diabetes, can be entirely eliminated.

The Future of Risk Adjustment

When an entire health sector (here, Medicare Advantage) documents an exceptionally rapid accrual of serious illnesses (compared to traditionally-insured Medicare enrollees), that is not reassuring. Of course we should pay more when a plan “takes on” caring for sick people, and we should pay for  finding and treating previously unrecognized underlying illness. But at some point, increasing risk scores start to suggest less benign causes: inadequate care or fraudulent upcoding. We could address these concerns by monitoring changes in risk measures, and introducing both incentives that reward decreases in risk and fraud surveillance systems that look for suspicious “risk accrual” patterns.

These concerns arise for any program that contracts with managed care entities, such as MassHealth (Massachusetts’ Medicaid program), with which our team has been working. Most managed care organizations in our State have been anchored in hospitals that don’t have strong relationships with the non-medical supportive services community. The new Delivery System Reform Incentive Payment (DSRIP) program (part of our State’s 1115 Waiver) will, among other things, include funding to strength relationships with “Community Partners” to coordinate crucial “wraparound” services that can help avert medical emergencies. Will Accountable Care Organizations (ACOs) and Managed Care Organizations (MCOs) be able to provide good care for many of those sickest Medicaid beneficiaries who have previously been cared for through fee-for-service arrangements? Risk-adjusted payments should encourage MCOs to enroll these people, and the State’s DSRIP money will be used to help set up the infrastructure to enable providing all needed services.

Along with other State reforms, the risk-based payment model for MCOs and ACOs that we built for MassHealth now adjusts not only for age, sex and medical diagnoses, but also for social risks (including disability, housing problems and neighborhood indicators of economic stress). We’re proud of that refinement. However, while really good risk adjustment is necessary, it is not sufficient. Will paying for social risk result in managed care organizations engaging in activities that address social risks? Our payment system allocates Medicaid funds in a way that should help, but can MassHealth use CMS’ DSRIP investment to encourage, support, and even push MC organizations to successfully transform? We certainly hope so – and we’ll be watching carefully to see what happens.


To read more from Arlene on delivery system reform, check out this series on risk adjustment in Medical Care.

Author information

Lisa Lines

Lisa Lines

Health services researcher at RTI International

Lisa M. Lines, PhD, MPH is a health services researcher at RTI International, an independent, non-profit research institute. She is also an Instructor in Quantitative Health Sciences at the University of Massachusetts Medical School. Her research focuses on quality of care, care experiences, and health outcomes among people with chronic illnesses; emergency department utilization; and person-centered care and patient-centered medical homes, among other topics. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She also serves as chair of the APHA Medical Care Section's Health Equity Committee. In 2015, Dr. Lines was appointed to a 3-year term on the National Quality Forum's Neurology Standing Committee.

Views expressed are the author's and do not necessarily reflect those of RTI or UMass Medical School.

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The Intersection of Religion, Female Empowerment, and Access to Reproductive Healthcare http://www.themedicalcareblog.com/intersection_religion_female_empowerment_access_to_reproductive_healthcare/ Thu, 22 Jun 2017 14:00:37 +0000 http://www.themedicalcareblog.com?p=1773&preview=true&preview_id=1773 Read More »

Author information

Rebekah Rollston

Rebekah Rollston

Rebekah L. Rollston, MD, MPH, is a Family Medicine Resident at Tufts University at Cambridge Health Alliance in Massachusetts. She earned her Medical Degree from East Tennessee State University James H. Quillen College of Medicine and her Master of Public Health from The George Washington University Milken Institute School of Public Health. Her professional interests include increasing access to primary care, health disparities among marginalized women, gender-based violence & intimate partner violence, access to contraception, adolescent pregnancy prevention, transgender health, self-esteem development, addiction medicine, and international health.

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Reproductive rights have been a topic for policy making and legal jurisprudence throughout much of the past century. As the healthcare system of the United States continues to evolve, women’s health and reproductive rights remain central to the debate.

A recent policy update by Aishwarya Rajagopalan and Lisa Lines here at The Medical Care Blog discusses the draft of an interim final rule by the Trump Administration, which would likely result in loss of contraceptive coverage for millions of women in the United States.

Also earlier this month, Timothy Jost wrote in the Health Affairs Blog that the draft interim final rule would expand the earlier exemption to the contraceptive mandate present under the Obama Administration, such that “all employers that have a religious or moral objection to the provision of all or a subset of contraceptives, or to sterilization or related patient education and counseling,” are exempt from providing contraceptive coverage to their employees (or students, in the case of universities), including for-profit corporations. The Trump Administration will accept comments on the draft interim final rule for sixty days, after which the rule will be effective upon publication.

Burwell v. Hobby Lobby is a landmark United States Supreme Court case from 2014 in which the majority ruled in Hobby Lobby’s favor:

“finding that ‘closely held’ for-profit employers had religious free exercise rights, that the contraceptive mandate substantially burdened these rights, and that — although the contraceptive rule might serve a compelling governmental interest — the religious organization accommodation rule demonstrated that the federal government could in fact accommodate the interest of for-profit employers.”

Religious organizations that are anti-contraception often claim this on the basis that some, or all, forms of contraception are abortifacients, and that this goes against a religious or moral belief. This was indeed the argument in the case of Hobby Lobby.

However, such organizations seem to contravene scientific research and medical facts in their arguments. Emergency contraception and intrauterine devices (IUDs) are the forms of contraception most often claimed to act as abortifacients. However, the primary mechanism of action for emergency contraception (also known as Plan B) is to inhibit ovulation, an analogous mechanism of action to that of most other estrogen-progesterone and progestin-only oral contraceptives. Note that inhibition of ovulation occurs prior to fertilization.

The primary mechanism of action for the hormonal IUD is to thicken cervical mucus, thereby acting as a physical barrier to prevent sperm from reaching an oocyte. Hormonal contraception has mechanisms of action that occur prior to fertilization and thus, is not in conflict with even the most conservative beliefs of when life begins.

Next, access to reproductive healthcare is key to the social and economic empowerment of women in society.

  • Women are empowered in society through education; access to contraception plays a significant role in this empowerment, as it increases the odds that women will graduate from high school, college, and professional programs.
    • The Guttmacher Institute reports that access to contraception has resulted in more women pursuing and graduating from college, which results in increased earning power and a decreased gender pay gap.
    • Access to contraception has also been found to be a catalyst for women pursuing careers in dentistry, medicine, and law.
  • Financial and geographic access to contraception is widely accepted as the primary mechanism for reduction and prevention of adolescent pregnancy.
    • The Centers for Disease Control and Prevention (CDC) states that adolescent pregnancy is a significant contributor to high school dropout rates for young women.
    • CDC states that approximately 50% of adolescent mothers achieve a high school diploma by the age of 22 years old, whereas 90% of female students who are not adolescent mothers graduate from high school.

Importantly, the American Public Health Association supports “protection and fulfillment of universal rights to safe, voluntary, confidential access to the full range of contraceptive methods” and “urges governments and international organizations to respect, protect, and fulfill sexual and reproductive health and rights.”

Reproductive health has been the subject of debate by politicians and religious leaders alike for much of the past century. However, we must consider the ethics of the restrictive measures often placed on reproductive rights. The guiding principles of bioethics include autonomy, beneficence, utility, and justice. With these principles in mind, I argue that the interim final rule is another step towards further oppression of women, as well as ideologically and economically hurtful to society. Access to reproductive healthcare affects all genders; reproductive freedom is a human rights issue.

Author information

Rebekah Rollston

Rebekah Rollston

Rebekah L. Rollston, MD, MPH, is a Family Medicine Resident at Tufts University at Cambridge Health Alliance in Massachusetts. She earned her Medical Degree from East Tennessee State University James H. Quillen College of Medicine and her Master of Public Health from The George Washington University Milken Institute School of Public Health. Her professional interests include increasing access to primary care, health disparities among marginalized women, gender-based violence & intimate partner violence, access to contraception, adolescent pregnancy prevention, transgender health, self-esteem development, addiction medicine, and international health.

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