User login
Official Newspaper of the American College of Surgeons
Defining quality in lung cancer surgery
Implementing quality initiatives and creating reporting mechanisms for lung cancer patients can lead to better outcomes, including overall survival. While barriers exist – namely the conflicting perspectives of providers, payers, hospitals, and patients – thoracic oncologic surgeons should seize the opportunity to establish robust quality and value metrics for lung cancer programs, said Whitney S. Brandt, MD, and her coauthors in an expert opinion in the Journal of Thoracic and Cardiovascular Surgery (2017;154:1397-403).
Dr. Brandt, a surgeon at Memorial Sloan Kettering Cancer Center in New York, and her coauthors examined the key elements of quality and value initiatives, categorizing them into preoperative, intraoperative, and postoperative components and primarily focusing on early stage lung cancer. The National Institutes of Health/National Cancer Center provided a grant for the authors’ work.
The preoperative evaluation should at least include CT imaging of the tumor and, for smokers, smoking cessation, said Dr. Brandt and her coauthors. All candidates for pulmonary lung resection should have spirometry and diffusion capacity tests; furthermore, both predicted postoperative forced expiratory volume in 1 second and diffusing capacity of the lungs for CO should be calculated. “Patients with a predicted postoperative value less than 40% for either measurement should be considered high risk for lobectomy and should be offered either sublobar resection or nonsurgical therapy,” they recommended.
Dr. Brandt and her colleagues also clarified preoperative management of patients with cardiac disease. Only patients with significant cardiac disease risk factors need to undergo cardiac testing before lung surgery, and patients with stable cardiac disease do not require revascularization beforehand.
For preoperative staging, the most comprehensive clinical guidelines come from the National Comprehensive Cancer Network, they stated. The guidelines recommend that all patients with a small cell lung cancer or stage II to IV non–small cell lung cancer (NSCLC) receive a brain MRI or – if that’s not available – a head CT with contrast to assess for brain metastasis.
Intraoperative quality measures take into account the surgical approach, including cost, resection and margins, and lymph node evaluation. With regard to surgical approach, trials have shown traditional video-assisted surgery (VATS) lobectomy results in shorter hospital stays and thereby lower costs, as well as fewer complications and deaths, than thoracotomy, said Dr. Brandt and her coauthors. But that cost advantage has not yet carried over to robotic-assisted VATS. That said, “robotic-assisted VATS remains a relatively new technology, and with time and increased robotic platform competition, costs will likely decrease.”
Dr. Brandt and her coauthors also noted that clinical trials support resection margins of 2 cm in patients having surgery for NSCLC and that adequate lymph node evaluation is a critical component of a lung cancer quality initiative. “Regardless of whether lymph nodes are sampled or dissected, we believe that systematic acquisition of mediastinal nodal tissue based on nodal station(s) is a useful quality metric, and, therefore, we recommend each program adopt a preferred approach and track adherence,” they said.
As for postoperative quality metrics, the most obvious are morbidity and mortality. “A quality program should track 30-day or in-hospital mortality, as well as 90-day mortality, following lung cancer resection.” Such metrics can serve as “starting points” for quality improvement initiatives. Length of stay has also emerged as an important metric because it is a surrogate of other metrics, such as patient comorbidities, age, and socioeconomic status. “Length-of-stay metrics likely need to be risk-stratified on the basis of these and other variables to be meaningful to a practicing surgeon,” Dr. Brandt and her coauthors said, adding that: “Studying the effectiveness of enhanced recovery after surgery programs in thoracic surgical oncology poses an opportunity for a well-designed trial.”
Two other key quality metrics for lung cancer programs that need further development were pointed out in the paper: hospital readmissions and tracking of adjuvant therapies. “Programmatic oncologic quality metrics to track appropriate and inappropriate referrals for adjuvant therapy and the number of patients who complete such therapy are important,” they said.
Another step programs should take: Participating in a national or regional database, as recommended by the Society of Thoracic Surgeons, and taking advantage of the “clear benefits to benchmarking your program to others.”
Dr. Brandt and her coauthors reported having no financial disclosures. The National Institutes of Health/National Cancer Center provided grant support.
Whitney S. Brandt, MD, and her coauthors pointed out the difficulty of finding a comprehensive quality metric because of the multitude of contributing indicators, said Alessandro Brunelli, MD, of St. James University Hospital in Leeds, England, in his invited commentary (J Thorac Cardiovasc Surg. 2017;154:1404-5). But he added that two nonclinical indicators needed further consideration: patient perspectives and costs.
“Satisfaction with care depends on multiple subjective factors and is affected by different socioeconomic and cultural backgrounds,” Dr. Brunelli said. “There have been very few attempts to use patient satisfaction scales as a measure of quality in our specialty.” Residual quality of life after surgery is another key measure of patient perspective. “Long-term survival in fact cannot be assessed in isolation and without taking into consideration the actual quality of life of the cancer survivors,” he said. That information would help inform surgical decision-making.
To be meaningful as a quality metric, cost requires clinical risk adjustment, Dr. Brunelli wrote, and surgeons should take the lead here “to prevent misleading evaluations by third parties.” He added, “There have been few studies reporting on financial risk models in our specialty, and more research is needed in this field.”
Dr. Brunelli reported having no financial disclosures.
Whitney S. Brandt, MD, and her coauthors pointed out the difficulty of finding a comprehensive quality metric because of the multitude of contributing indicators, said Alessandro Brunelli, MD, of St. James University Hospital in Leeds, England, in his invited commentary (J Thorac Cardiovasc Surg. 2017;154:1404-5). But he added that two nonclinical indicators needed further consideration: patient perspectives and costs.
“Satisfaction with care depends on multiple subjective factors and is affected by different socioeconomic and cultural backgrounds,” Dr. Brunelli said. “There have been very few attempts to use patient satisfaction scales as a measure of quality in our specialty.” Residual quality of life after surgery is another key measure of patient perspective. “Long-term survival in fact cannot be assessed in isolation and without taking into consideration the actual quality of life of the cancer survivors,” he said. That information would help inform surgical decision-making.
To be meaningful as a quality metric, cost requires clinical risk adjustment, Dr. Brunelli wrote, and surgeons should take the lead here “to prevent misleading evaluations by third parties.” He added, “There have been few studies reporting on financial risk models in our specialty, and more research is needed in this field.”
Dr. Brunelli reported having no financial disclosures.
Whitney S. Brandt, MD, and her coauthors pointed out the difficulty of finding a comprehensive quality metric because of the multitude of contributing indicators, said Alessandro Brunelli, MD, of St. James University Hospital in Leeds, England, in his invited commentary (J Thorac Cardiovasc Surg. 2017;154:1404-5). But he added that two nonclinical indicators needed further consideration: patient perspectives and costs.
“Satisfaction with care depends on multiple subjective factors and is affected by different socioeconomic and cultural backgrounds,” Dr. Brunelli said. “There have been very few attempts to use patient satisfaction scales as a measure of quality in our specialty.” Residual quality of life after surgery is another key measure of patient perspective. “Long-term survival in fact cannot be assessed in isolation and without taking into consideration the actual quality of life of the cancer survivors,” he said. That information would help inform surgical decision-making.
To be meaningful as a quality metric, cost requires clinical risk adjustment, Dr. Brunelli wrote, and surgeons should take the lead here “to prevent misleading evaluations by third parties.” He added, “There have been few studies reporting on financial risk models in our specialty, and more research is needed in this field.”
Dr. Brunelli reported having no financial disclosures.
Implementing quality initiatives and creating reporting mechanisms for lung cancer patients can lead to better outcomes, including overall survival. While barriers exist – namely the conflicting perspectives of providers, payers, hospitals, and patients – thoracic oncologic surgeons should seize the opportunity to establish robust quality and value metrics for lung cancer programs, said Whitney S. Brandt, MD, and her coauthors in an expert opinion in the Journal of Thoracic and Cardiovascular Surgery (2017;154:1397-403).
Dr. Brandt, a surgeon at Memorial Sloan Kettering Cancer Center in New York, and her coauthors examined the key elements of quality and value initiatives, categorizing them into preoperative, intraoperative, and postoperative components and primarily focusing on early stage lung cancer. The National Institutes of Health/National Cancer Center provided a grant for the authors’ work.
The preoperative evaluation should at least include CT imaging of the tumor and, for smokers, smoking cessation, said Dr. Brandt and her coauthors. All candidates for pulmonary lung resection should have spirometry and diffusion capacity tests; furthermore, both predicted postoperative forced expiratory volume in 1 second and diffusing capacity of the lungs for CO should be calculated. “Patients with a predicted postoperative value less than 40% for either measurement should be considered high risk for lobectomy and should be offered either sublobar resection or nonsurgical therapy,” they recommended.
Dr. Brandt and her colleagues also clarified preoperative management of patients with cardiac disease. Only patients with significant cardiac disease risk factors need to undergo cardiac testing before lung surgery, and patients with stable cardiac disease do not require revascularization beforehand.
For preoperative staging, the most comprehensive clinical guidelines come from the National Comprehensive Cancer Network, they stated. The guidelines recommend that all patients with a small cell lung cancer or stage II to IV non–small cell lung cancer (NSCLC) receive a brain MRI or – if that’s not available – a head CT with contrast to assess for brain metastasis.
Intraoperative quality measures take into account the surgical approach, including cost, resection and margins, and lymph node evaluation. With regard to surgical approach, trials have shown traditional video-assisted surgery (VATS) lobectomy results in shorter hospital stays and thereby lower costs, as well as fewer complications and deaths, than thoracotomy, said Dr. Brandt and her coauthors. But that cost advantage has not yet carried over to robotic-assisted VATS. That said, “robotic-assisted VATS remains a relatively new technology, and with time and increased robotic platform competition, costs will likely decrease.”
Dr. Brandt and her coauthors also noted that clinical trials support resection margins of 2 cm in patients having surgery for NSCLC and that adequate lymph node evaluation is a critical component of a lung cancer quality initiative. “Regardless of whether lymph nodes are sampled or dissected, we believe that systematic acquisition of mediastinal nodal tissue based on nodal station(s) is a useful quality metric, and, therefore, we recommend each program adopt a preferred approach and track adherence,” they said.
As for postoperative quality metrics, the most obvious are morbidity and mortality. “A quality program should track 30-day or in-hospital mortality, as well as 90-day mortality, following lung cancer resection.” Such metrics can serve as “starting points” for quality improvement initiatives. Length of stay has also emerged as an important metric because it is a surrogate of other metrics, such as patient comorbidities, age, and socioeconomic status. “Length-of-stay metrics likely need to be risk-stratified on the basis of these and other variables to be meaningful to a practicing surgeon,” Dr. Brandt and her coauthors said, adding that: “Studying the effectiveness of enhanced recovery after surgery programs in thoracic surgical oncology poses an opportunity for a well-designed trial.”
Two other key quality metrics for lung cancer programs that need further development were pointed out in the paper: hospital readmissions and tracking of adjuvant therapies. “Programmatic oncologic quality metrics to track appropriate and inappropriate referrals for adjuvant therapy and the number of patients who complete such therapy are important,” they said.
Another step programs should take: Participating in a national or regional database, as recommended by the Society of Thoracic Surgeons, and taking advantage of the “clear benefits to benchmarking your program to others.”
Dr. Brandt and her coauthors reported having no financial disclosures. The National Institutes of Health/National Cancer Center provided grant support.
Implementing quality initiatives and creating reporting mechanisms for lung cancer patients can lead to better outcomes, including overall survival. While barriers exist – namely the conflicting perspectives of providers, payers, hospitals, and patients – thoracic oncologic surgeons should seize the opportunity to establish robust quality and value metrics for lung cancer programs, said Whitney S. Brandt, MD, and her coauthors in an expert opinion in the Journal of Thoracic and Cardiovascular Surgery (2017;154:1397-403).
Dr. Brandt, a surgeon at Memorial Sloan Kettering Cancer Center in New York, and her coauthors examined the key elements of quality and value initiatives, categorizing them into preoperative, intraoperative, and postoperative components and primarily focusing on early stage lung cancer. The National Institutes of Health/National Cancer Center provided a grant for the authors’ work.
The preoperative evaluation should at least include CT imaging of the tumor and, for smokers, smoking cessation, said Dr. Brandt and her coauthors. All candidates for pulmonary lung resection should have spirometry and diffusion capacity tests; furthermore, both predicted postoperative forced expiratory volume in 1 second and diffusing capacity of the lungs for CO should be calculated. “Patients with a predicted postoperative value less than 40% for either measurement should be considered high risk for lobectomy and should be offered either sublobar resection or nonsurgical therapy,” they recommended.
Dr. Brandt and her colleagues also clarified preoperative management of patients with cardiac disease. Only patients with significant cardiac disease risk factors need to undergo cardiac testing before lung surgery, and patients with stable cardiac disease do not require revascularization beforehand.
For preoperative staging, the most comprehensive clinical guidelines come from the National Comprehensive Cancer Network, they stated. The guidelines recommend that all patients with a small cell lung cancer or stage II to IV non–small cell lung cancer (NSCLC) receive a brain MRI or – if that’s not available – a head CT with contrast to assess for brain metastasis.
Intraoperative quality measures take into account the surgical approach, including cost, resection and margins, and lymph node evaluation. With regard to surgical approach, trials have shown traditional video-assisted surgery (VATS) lobectomy results in shorter hospital stays and thereby lower costs, as well as fewer complications and deaths, than thoracotomy, said Dr. Brandt and her coauthors. But that cost advantage has not yet carried over to robotic-assisted VATS. That said, “robotic-assisted VATS remains a relatively new technology, and with time and increased robotic platform competition, costs will likely decrease.”
Dr. Brandt and her coauthors also noted that clinical trials support resection margins of 2 cm in patients having surgery for NSCLC and that adequate lymph node evaluation is a critical component of a lung cancer quality initiative. “Regardless of whether lymph nodes are sampled or dissected, we believe that systematic acquisition of mediastinal nodal tissue based on nodal station(s) is a useful quality metric, and, therefore, we recommend each program adopt a preferred approach and track adherence,” they said.
As for postoperative quality metrics, the most obvious are morbidity and mortality. “A quality program should track 30-day or in-hospital mortality, as well as 90-day mortality, following lung cancer resection.” Such metrics can serve as “starting points” for quality improvement initiatives. Length of stay has also emerged as an important metric because it is a surrogate of other metrics, such as patient comorbidities, age, and socioeconomic status. “Length-of-stay metrics likely need to be risk-stratified on the basis of these and other variables to be meaningful to a practicing surgeon,” Dr. Brandt and her coauthors said, adding that: “Studying the effectiveness of enhanced recovery after surgery programs in thoracic surgical oncology poses an opportunity for a well-designed trial.”
Two other key quality metrics for lung cancer programs that need further development were pointed out in the paper: hospital readmissions and tracking of adjuvant therapies. “Programmatic oncologic quality metrics to track appropriate and inappropriate referrals for adjuvant therapy and the number of patients who complete such therapy are important,” they said.
Another step programs should take: Participating in a national or regional database, as recommended by the Society of Thoracic Surgeons, and taking advantage of the “clear benefits to benchmarking your program to others.”
Dr. Brandt and her coauthors reported having no financial disclosures. The National Institutes of Health/National Cancer Center provided grant support.
FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: Quality and value initiatives in lung cancer surgery are complex and multifaceted.
Major finding: Expert opinion identifies quality and value strategies for the preoperative, intraoperative, and postoperative stages.
Data source: Review of elements of quality and value for lung cancer surgery, including the Donabedian classification of structure, process and outcomes.
Disclosures: Dr. Brandt and co-authors reported having no financial disclosures. The National Institutes of Health/National Cancer Center provided grant support.
From the Washington Office: Year Two of MIPS …The song remains the same (largely)
The interim final rule for the second year of Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) was released on November 2, 2017. This rule will apply to performance and reporting for calendar year 2018 and impact payment in 2020. Below, I have highlighted a few of the key components of the 1,653-page rule with special attention to the Merit-based Incentive Payment System (MIPS).
To briefly review, there are two pathways for participation in the QPP, namely MIPS and the Advanced Alternative Payment Models (A-APMs). For 2018, we still expect that the majority of surgeons eligible to participate in the QPP will do so via the MIPS pathway. That said, and for reasons discussed below, CMS estimates that approximately half of the 1.2 million MIPS-eligible clinicians will be required to submit MIPS data in 2018. In addition, CMS estimates that approximately 200,000 eligible clinicians will participate in the QPP in 2018 via the A-APMs.
1) Quality – For 2018, CMS continues to require reporting on six measures, one of which must be an outcome measure or other high-priority measure. Should surgeons choose to report on more than six measures, CMS will use the six with the highest score for purposes of calculating their score for the Quality component. However, CMS did increase the percentage of patients on which reporting is required, aka the completeness threshold, in 2018 to 60%. Measures submitted that fall below the completeness threshold will receive one point. Small practices will receive three points for measures that fail to meet the completeness threshold. Multiple options remain available for submission of data, i.e., electronic health record (EHR), Medicare claims, a qualified registry or a qualified clinical data registry (QCDR). For 2018, the Quality component will make up 50% of the MIPS final score.
Cost
Those familiar with the 2017 version of MIPS will remember that the Cost component was weighted at zero for the first year of the program. CMS discussed, and indeed, initially proposed, to continue weighing cost at zero for 2018. However, because current law requires CMS to weigh cost at 30% beginning with the 2019 performance period, CMS finalized a 10% weight for cost in 2018 with the goal of making the impact of the transition in 2019 less dramatic. CMS will base its calculation of the cost component on the total per capita costs for all beneficiaries attributed to a provider and the Medicare Spending per Beneficiary measure for the entirety of the 2018 performance period. CMS intends to provide performance feedback on both measures by July 1, 2018. Surgeons are not required to submit data for purposes of cost component.
Advancing Care Information (ACI)
There are no major changes to the scoring policy for 2018 and all the applicable Base Score measures must still be reported in order to receive a score for the ACI component. The performance period requirement remains a minimum of 90 continuous days. For 2018, both 2014 Edition and 2015 Edition certified electronic health record technology (CEHRT) remain acceptable. However, those using only a 2015 Edition will be eligible for a 10% bonus. Regardless of edition used , bonus points are also available for reporting to a public health agency or clinical data registry and for the completion of an Improvement Activity (IA) using CEHRT. A significant hardship exemption remains available for those in small practices. As was the case in 2017, the ACI component represents 25% of the final score. However, as was also the case in 2017, one is not required to have an electronic health record to avoid a penalty in 2018.
Improvement Activities
The weight assigned to the IA component remains at 15%. CMS added 21 new IAs in the final rule, bringing the number of IA available from which to choose up to well over 110. CMS also made changes to 27 activities previously adopted. Reporting remains a simple attestation of participation in the activity for 90 continuous days. To receive full credit for the IA component, most surgeons will be required to attest to having participated in two, three, or four activities depending on whether the activities chosen are of medium value or high value. This is not a change. However, those in small or rural practices must only participate in one or two activities to receive full credit. It should be noted that for 2018, one will be able to avoid a penalty in 2020 solely by fulfillment of the requirements imposed by the Improvement Activities component.
As mentioned above, CMS estimates that only approximately 622,000 providers out of the 1.2 million eligible will be required to submit data under MIPS. Many providers are excluded from MIPS based on the low-volume threshold. For 2018, CMS set this threshold at less than or equal to $90,000 in Medicare Part B charges OR less than or equal to 200 Medicare Part B beneficiaries. The effect of this change, compared to the values set for 2017 low-volume threshold, is to exclude more providers from MIPS reporting.
Lastly, many will remember that for 2017, the performance threshold was set at three points, and thus, required only minimal reporting in either quality, ACI, or IA to avoid a penalty. It was expected that the threshold necessary to avoid a penalty for 2018 performance would be increased and indeed, CMS has set that value at 15. Those scoring above 15 will be eligible for a positive update in their Medicare payments in 2020, while those scoring below 15 will receive a penalty. Those who choose to not participate in 2018 will receive a 5% penalty in 2020. However, two points made above warrant reiteration:
a) By fully participating in the IA component, one can accrue the 15 points necessary to avoid a penalty.
b) An EHR is not required to avoid a penalty.
In the coming weeks, we will be updating the QPP website (www.facs.org/qpp) to reflect the changes in the program for 2018. New videos will be available as will be new electronic and print materials to assist Fellows to participate in the program.
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
The interim final rule for the second year of Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) was released on November 2, 2017. This rule will apply to performance and reporting for calendar year 2018 and impact payment in 2020. Below, I have highlighted a few of the key components of the 1,653-page rule with special attention to the Merit-based Incentive Payment System (MIPS).
To briefly review, there are two pathways for participation in the QPP, namely MIPS and the Advanced Alternative Payment Models (A-APMs). For 2018, we still expect that the majority of surgeons eligible to participate in the QPP will do so via the MIPS pathway. That said, and for reasons discussed below, CMS estimates that approximately half of the 1.2 million MIPS-eligible clinicians will be required to submit MIPS data in 2018. In addition, CMS estimates that approximately 200,000 eligible clinicians will participate in the QPP in 2018 via the A-APMs.
1) Quality – For 2018, CMS continues to require reporting on six measures, one of which must be an outcome measure or other high-priority measure. Should surgeons choose to report on more than six measures, CMS will use the six with the highest score for purposes of calculating their score for the Quality component. However, CMS did increase the percentage of patients on which reporting is required, aka the completeness threshold, in 2018 to 60%. Measures submitted that fall below the completeness threshold will receive one point. Small practices will receive three points for measures that fail to meet the completeness threshold. Multiple options remain available for submission of data, i.e., electronic health record (EHR), Medicare claims, a qualified registry or a qualified clinical data registry (QCDR). For 2018, the Quality component will make up 50% of the MIPS final score.
Cost
Those familiar with the 2017 version of MIPS will remember that the Cost component was weighted at zero for the first year of the program. CMS discussed, and indeed, initially proposed, to continue weighing cost at zero for 2018. However, because current law requires CMS to weigh cost at 30% beginning with the 2019 performance period, CMS finalized a 10% weight for cost in 2018 with the goal of making the impact of the transition in 2019 less dramatic. CMS will base its calculation of the cost component on the total per capita costs for all beneficiaries attributed to a provider and the Medicare Spending per Beneficiary measure for the entirety of the 2018 performance period. CMS intends to provide performance feedback on both measures by July 1, 2018. Surgeons are not required to submit data for purposes of cost component.
Advancing Care Information (ACI)
There are no major changes to the scoring policy for 2018 and all the applicable Base Score measures must still be reported in order to receive a score for the ACI component. The performance period requirement remains a minimum of 90 continuous days. For 2018, both 2014 Edition and 2015 Edition certified electronic health record technology (CEHRT) remain acceptable. However, those using only a 2015 Edition will be eligible for a 10% bonus. Regardless of edition used , bonus points are also available for reporting to a public health agency or clinical data registry and for the completion of an Improvement Activity (IA) using CEHRT. A significant hardship exemption remains available for those in small practices. As was the case in 2017, the ACI component represents 25% of the final score. However, as was also the case in 2017, one is not required to have an electronic health record to avoid a penalty in 2018.
Improvement Activities
The weight assigned to the IA component remains at 15%. CMS added 21 new IAs in the final rule, bringing the number of IA available from which to choose up to well over 110. CMS also made changes to 27 activities previously adopted. Reporting remains a simple attestation of participation in the activity for 90 continuous days. To receive full credit for the IA component, most surgeons will be required to attest to having participated in two, three, or four activities depending on whether the activities chosen are of medium value or high value. This is not a change. However, those in small or rural practices must only participate in one or two activities to receive full credit. It should be noted that for 2018, one will be able to avoid a penalty in 2020 solely by fulfillment of the requirements imposed by the Improvement Activities component.
As mentioned above, CMS estimates that only approximately 622,000 providers out of the 1.2 million eligible will be required to submit data under MIPS. Many providers are excluded from MIPS based on the low-volume threshold. For 2018, CMS set this threshold at less than or equal to $90,000 in Medicare Part B charges OR less than or equal to 200 Medicare Part B beneficiaries. The effect of this change, compared to the values set for 2017 low-volume threshold, is to exclude more providers from MIPS reporting.
Lastly, many will remember that for 2017, the performance threshold was set at three points, and thus, required only minimal reporting in either quality, ACI, or IA to avoid a penalty. It was expected that the threshold necessary to avoid a penalty for 2018 performance would be increased and indeed, CMS has set that value at 15. Those scoring above 15 will be eligible for a positive update in their Medicare payments in 2020, while those scoring below 15 will receive a penalty. Those who choose to not participate in 2018 will receive a 5% penalty in 2020. However, two points made above warrant reiteration:
a) By fully participating in the IA component, one can accrue the 15 points necessary to avoid a penalty.
b) An EHR is not required to avoid a penalty.
In the coming weeks, we will be updating the QPP website (www.facs.org/qpp) to reflect the changes in the program for 2018. New videos will be available as will be new electronic and print materials to assist Fellows to participate in the program.
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
The interim final rule for the second year of Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) was released on November 2, 2017. This rule will apply to performance and reporting for calendar year 2018 and impact payment in 2020. Below, I have highlighted a few of the key components of the 1,653-page rule with special attention to the Merit-based Incentive Payment System (MIPS).
To briefly review, there are two pathways for participation in the QPP, namely MIPS and the Advanced Alternative Payment Models (A-APMs). For 2018, we still expect that the majority of surgeons eligible to participate in the QPP will do so via the MIPS pathway. That said, and for reasons discussed below, CMS estimates that approximately half of the 1.2 million MIPS-eligible clinicians will be required to submit MIPS data in 2018. In addition, CMS estimates that approximately 200,000 eligible clinicians will participate in the QPP in 2018 via the A-APMs.
1) Quality – For 2018, CMS continues to require reporting on six measures, one of which must be an outcome measure or other high-priority measure. Should surgeons choose to report on more than six measures, CMS will use the six with the highest score for purposes of calculating their score for the Quality component. However, CMS did increase the percentage of patients on which reporting is required, aka the completeness threshold, in 2018 to 60%. Measures submitted that fall below the completeness threshold will receive one point. Small practices will receive three points for measures that fail to meet the completeness threshold. Multiple options remain available for submission of data, i.e., electronic health record (EHR), Medicare claims, a qualified registry or a qualified clinical data registry (QCDR). For 2018, the Quality component will make up 50% of the MIPS final score.
Cost
Those familiar with the 2017 version of MIPS will remember that the Cost component was weighted at zero for the first year of the program. CMS discussed, and indeed, initially proposed, to continue weighing cost at zero for 2018. However, because current law requires CMS to weigh cost at 30% beginning with the 2019 performance period, CMS finalized a 10% weight for cost in 2018 with the goal of making the impact of the transition in 2019 less dramatic. CMS will base its calculation of the cost component on the total per capita costs for all beneficiaries attributed to a provider and the Medicare Spending per Beneficiary measure for the entirety of the 2018 performance period. CMS intends to provide performance feedback on both measures by July 1, 2018. Surgeons are not required to submit data for purposes of cost component.
Advancing Care Information (ACI)
There are no major changes to the scoring policy for 2018 and all the applicable Base Score measures must still be reported in order to receive a score for the ACI component. The performance period requirement remains a minimum of 90 continuous days. For 2018, both 2014 Edition and 2015 Edition certified electronic health record technology (CEHRT) remain acceptable. However, those using only a 2015 Edition will be eligible for a 10% bonus. Regardless of edition used , bonus points are also available for reporting to a public health agency or clinical data registry and for the completion of an Improvement Activity (IA) using CEHRT. A significant hardship exemption remains available for those in small practices. As was the case in 2017, the ACI component represents 25% of the final score. However, as was also the case in 2017, one is not required to have an electronic health record to avoid a penalty in 2018.
Improvement Activities
The weight assigned to the IA component remains at 15%. CMS added 21 new IAs in the final rule, bringing the number of IA available from which to choose up to well over 110. CMS also made changes to 27 activities previously adopted. Reporting remains a simple attestation of participation in the activity for 90 continuous days. To receive full credit for the IA component, most surgeons will be required to attest to having participated in two, three, or four activities depending on whether the activities chosen are of medium value or high value. This is not a change. However, those in small or rural practices must only participate in one or two activities to receive full credit. It should be noted that for 2018, one will be able to avoid a penalty in 2020 solely by fulfillment of the requirements imposed by the Improvement Activities component.
As mentioned above, CMS estimates that only approximately 622,000 providers out of the 1.2 million eligible will be required to submit data under MIPS. Many providers are excluded from MIPS based on the low-volume threshold. For 2018, CMS set this threshold at less than or equal to $90,000 in Medicare Part B charges OR less than or equal to 200 Medicare Part B beneficiaries. The effect of this change, compared to the values set for 2017 low-volume threshold, is to exclude more providers from MIPS reporting.
Lastly, many will remember that for 2017, the performance threshold was set at three points, and thus, required only minimal reporting in either quality, ACI, or IA to avoid a penalty. It was expected that the threshold necessary to avoid a penalty for 2018 performance would be increased and indeed, CMS has set that value at 15. Those scoring above 15 will be eligible for a positive update in their Medicare payments in 2020, while those scoring below 15 will receive a penalty. Those who choose to not participate in 2018 will receive a 5% penalty in 2020. However, two points made above warrant reiteration:
a) By fully participating in the IA component, one can accrue the 15 points necessary to avoid a penalty.
b) An EHR is not required to avoid a penalty.
In the coming weeks, we will be updating the QPP website (www.facs.org/qpp) to reflect the changes in the program for 2018. New videos will be available as will be new electronic and print materials to assist Fellows to participate in the program.
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
Bilateral ACP shown similar to unilateral in arch replacement study
What may be the largest study comparing unilateral and bilateral antegrade cerebral perfusion during total arch replacement for type A aortic dissection has reported that outcomes between the two approaches are comparable, although the bilateral approach showed some advantages during the operation itself, investigators from China reported in the Journal of Thoracic and Cardiovascular Surgery (2017;154:767-75).
The effectiveness of bilateral antegrade cerebral perfusion (b-ACP) vs. unilateral antegrade cerebral perfusion (u-ACP) has been the focus of extensive debate, lead study author Guang Tong, MD, of the Guangzhou (China) General Hospital, and coauthors said. They compared outcomes in six different metrics, ranging from cardiopulmonary bypass time to length of stay (LOS) in the ICU and hospital, in 203 patients with type A aortic dissection who had total aortic arch replacement with hypothermic circulatory arrest over an 8-year period ending in August 2014; 121 had b-ACP and 82 had u-ACP. “The issue of u-ACP vs. b-ACP has been examined in aortic arch surgery, but few reports have focused on type A aortic dissection,” Dr. Tong and coauthors wrote.
They acknowledged that some surgeons are reluctant to use b-ACP because of its complexity, but their study found no increase in cross-clamp time, cardiopulmonary bypass time, or surgery time in the b-ACP group. They cited another reason surgeons give for avoiding b-ACP: the risk of embolic injury caused by canulating the left common carotid artery in an atheromatous aorta. “In the present study, this risk was avoided by attaching the left common carotid artery to the four-branched prosthetic graft for left hemisphere perfusion,” Dr. Tong and coauthors wrote.
Key outcomes that the researchers found not statistically significant were:
- Overall 30-day mortality (11.6% for b-ACP vs. 20.7% for u-ACP; P = .075).
- Prevalence of postoperative permanent neurologic dysfunction (8.4% vs. 16.9%; P = .091).
- Average ICU LOS (16 ± 17.75 days vs. 17 ± 11.5 days, P =.454).
- Average hospital LOS (26.5 ± 20.6 days vs. 24.8 ± 10.3 days, P = .434).
However, average ventilation time was lower in the b-ACP group (95.5 hours vs. 147 hours; P less than or equal to.001).
Dr. Tong and coauthors used an aggressive approach, as advocated by Dhaval Trivedi, MD, and colleagues (Ann Thorac Surg. 2016;101:896-903), and had a total arch replacement rate of 57.8%. This rate is higher than most published series in the west but comparable to other studies from China, perhaps because of the relatively young age of this study cohort – an average age of 51 years – compared to data sets other studies have used. Dr. Tong and coauthors used a b-ACP strategy that established both cerebral perfusion routes before circulatory arrest.
Rates of the following complications were also not significantly different across the study population: paraplegia (2.8% for b-ACP vs. 3.1% for u-ACP), temporary neurologic dysfunction (4.7% vs. 9.2%), permanent neurologic dysfunction (8.4% vs. 16.9%), renal failure (18% vs. 23.1%), reoperation for bleeding (2.8% vs. 4.6%), and mediastinal infection (3.7% vs. 6.2%).
While b-ACP patients did not have a statistically significant lower incidence of TND, Dr. Tong and coauthors noted the shorter time on ventilation and significantly lower tracheostomy rates for the b-ACP patients, 3.7% vs. 16.9% for the u-ACP group (P = .003). “In our institute, protocols to wean patients from ventilation were normally initiated as soon as consciousness was regained,” Dr. Tong and coauthors wrote.
Among the study limits Dr. Tong and coauthors acknowledged were its retrospective, nonrandomized, single-center nature, and the fact that the surgeries were performed over an 8-year period representing different eras.
The investigators reported having no relevant financial disclosures.
The study by Dr. Tong and coauthors adds to the discussion between the “bilateralists” and “unilateralists,” as Jean Bachet, MD, called the two prevailing camps on cerebral perfusion strategies in his invited commentary (J Thorac Cardiovasc Surg. 2017;154:765-6). And while most clinical reports find outcomes similar between the two approaches, the evidence favors the bilateral approach for total arch replacement.
Citing how the study implied mortality and neurologic morbidity rates almost half those for unilateral perfusion, but not reaching statistical significance, Dr. Bachet said, “The statisticians would say that this is only a trend and no proof, but some trends might be indicative, and significance might only be a matter of number in each arm of the comparison.”
Dr. Bachet raised a question about the unilateral approach – that once the arch is opened it takes a minute or so to insert the small balloon canula into the origin of the left carotid artery or divided vessel and start bilateral perfusion. “A major question arises,” said Dr. Bachet: “Why should we expose our patients to any undue risk just to avoid a simple maneuver, to spare a little time, or for any other fancy and questionable reason?”
Cardiologists have raised that question for more than 20 years. Said Dr. Bachet, “We still wait for the answer.”
Dr. Bachet is a cardiac surgeon in Surgenes, France. He reported having no financial relationships to disclose.
The study by Dr. Tong and coauthors adds to the discussion between the “bilateralists” and “unilateralists,” as Jean Bachet, MD, called the two prevailing camps on cerebral perfusion strategies in his invited commentary (J Thorac Cardiovasc Surg. 2017;154:765-6). And while most clinical reports find outcomes similar between the two approaches, the evidence favors the bilateral approach for total arch replacement.
Citing how the study implied mortality and neurologic morbidity rates almost half those for unilateral perfusion, but not reaching statistical significance, Dr. Bachet said, “The statisticians would say that this is only a trend and no proof, but some trends might be indicative, and significance might only be a matter of number in each arm of the comparison.”
Dr. Bachet raised a question about the unilateral approach – that once the arch is opened it takes a minute or so to insert the small balloon canula into the origin of the left carotid artery or divided vessel and start bilateral perfusion. “A major question arises,” said Dr. Bachet: “Why should we expose our patients to any undue risk just to avoid a simple maneuver, to spare a little time, or for any other fancy and questionable reason?”
Cardiologists have raised that question for more than 20 years. Said Dr. Bachet, “We still wait for the answer.”
Dr. Bachet is a cardiac surgeon in Surgenes, France. He reported having no financial relationships to disclose.
The study by Dr. Tong and coauthors adds to the discussion between the “bilateralists” and “unilateralists,” as Jean Bachet, MD, called the two prevailing camps on cerebral perfusion strategies in his invited commentary (J Thorac Cardiovasc Surg. 2017;154:765-6). And while most clinical reports find outcomes similar between the two approaches, the evidence favors the bilateral approach for total arch replacement.
Citing how the study implied mortality and neurologic morbidity rates almost half those for unilateral perfusion, but not reaching statistical significance, Dr. Bachet said, “The statisticians would say that this is only a trend and no proof, but some trends might be indicative, and significance might only be a matter of number in each arm of the comparison.”
Dr. Bachet raised a question about the unilateral approach – that once the arch is opened it takes a minute or so to insert the small balloon canula into the origin of the left carotid artery or divided vessel and start bilateral perfusion. “A major question arises,” said Dr. Bachet: “Why should we expose our patients to any undue risk just to avoid a simple maneuver, to spare a little time, or for any other fancy and questionable reason?”
Cardiologists have raised that question for more than 20 years. Said Dr. Bachet, “We still wait for the answer.”
Dr. Bachet is a cardiac surgeon in Surgenes, France. He reported having no financial relationships to disclose.
What may be the largest study comparing unilateral and bilateral antegrade cerebral perfusion during total arch replacement for type A aortic dissection has reported that outcomes between the two approaches are comparable, although the bilateral approach showed some advantages during the operation itself, investigators from China reported in the Journal of Thoracic and Cardiovascular Surgery (2017;154:767-75).
The effectiveness of bilateral antegrade cerebral perfusion (b-ACP) vs. unilateral antegrade cerebral perfusion (u-ACP) has been the focus of extensive debate, lead study author Guang Tong, MD, of the Guangzhou (China) General Hospital, and coauthors said. They compared outcomes in six different metrics, ranging from cardiopulmonary bypass time to length of stay (LOS) in the ICU and hospital, in 203 patients with type A aortic dissection who had total aortic arch replacement with hypothermic circulatory arrest over an 8-year period ending in August 2014; 121 had b-ACP and 82 had u-ACP. “The issue of u-ACP vs. b-ACP has been examined in aortic arch surgery, but few reports have focused on type A aortic dissection,” Dr. Tong and coauthors wrote.
They acknowledged that some surgeons are reluctant to use b-ACP because of its complexity, but their study found no increase in cross-clamp time, cardiopulmonary bypass time, or surgery time in the b-ACP group. They cited another reason surgeons give for avoiding b-ACP: the risk of embolic injury caused by canulating the left common carotid artery in an atheromatous aorta. “In the present study, this risk was avoided by attaching the left common carotid artery to the four-branched prosthetic graft for left hemisphere perfusion,” Dr. Tong and coauthors wrote.
Key outcomes that the researchers found not statistically significant were:
- Overall 30-day mortality (11.6% for b-ACP vs. 20.7% for u-ACP; P = .075).
- Prevalence of postoperative permanent neurologic dysfunction (8.4% vs. 16.9%; P = .091).
- Average ICU LOS (16 ± 17.75 days vs. 17 ± 11.5 days, P =.454).
- Average hospital LOS (26.5 ± 20.6 days vs. 24.8 ± 10.3 days, P = .434).
However, average ventilation time was lower in the b-ACP group (95.5 hours vs. 147 hours; P less than or equal to.001).
Dr. Tong and coauthors used an aggressive approach, as advocated by Dhaval Trivedi, MD, and colleagues (Ann Thorac Surg. 2016;101:896-903), and had a total arch replacement rate of 57.8%. This rate is higher than most published series in the west but comparable to other studies from China, perhaps because of the relatively young age of this study cohort – an average age of 51 years – compared to data sets other studies have used. Dr. Tong and coauthors used a b-ACP strategy that established both cerebral perfusion routes before circulatory arrest.
Rates of the following complications were also not significantly different across the study population: paraplegia (2.8% for b-ACP vs. 3.1% for u-ACP), temporary neurologic dysfunction (4.7% vs. 9.2%), permanent neurologic dysfunction (8.4% vs. 16.9%), renal failure (18% vs. 23.1%), reoperation for bleeding (2.8% vs. 4.6%), and mediastinal infection (3.7% vs. 6.2%).
While b-ACP patients did not have a statistically significant lower incidence of TND, Dr. Tong and coauthors noted the shorter time on ventilation and significantly lower tracheostomy rates for the b-ACP patients, 3.7% vs. 16.9% for the u-ACP group (P = .003). “In our institute, protocols to wean patients from ventilation were normally initiated as soon as consciousness was regained,” Dr. Tong and coauthors wrote.
Among the study limits Dr. Tong and coauthors acknowledged were its retrospective, nonrandomized, single-center nature, and the fact that the surgeries were performed over an 8-year period representing different eras.
The investigators reported having no relevant financial disclosures.
What may be the largest study comparing unilateral and bilateral antegrade cerebral perfusion during total arch replacement for type A aortic dissection has reported that outcomes between the two approaches are comparable, although the bilateral approach showed some advantages during the operation itself, investigators from China reported in the Journal of Thoracic and Cardiovascular Surgery (2017;154:767-75).
The effectiveness of bilateral antegrade cerebral perfusion (b-ACP) vs. unilateral antegrade cerebral perfusion (u-ACP) has been the focus of extensive debate, lead study author Guang Tong, MD, of the Guangzhou (China) General Hospital, and coauthors said. They compared outcomes in six different metrics, ranging from cardiopulmonary bypass time to length of stay (LOS) in the ICU and hospital, in 203 patients with type A aortic dissection who had total aortic arch replacement with hypothermic circulatory arrest over an 8-year period ending in August 2014; 121 had b-ACP and 82 had u-ACP. “The issue of u-ACP vs. b-ACP has been examined in aortic arch surgery, but few reports have focused on type A aortic dissection,” Dr. Tong and coauthors wrote.
They acknowledged that some surgeons are reluctant to use b-ACP because of its complexity, but their study found no increase in cross-clamp time, cardiopulmonary bypass time, or surgery time in the b-ACP group. They cited another reason surgeons give for avoiding b-ACP: the risk of embolic injury caused by canulating the left common carotid artery in an atheromatous aorta. “In the present study, this risk was avoided by attaching the left common carotid artery to the four-branched prosthetic graft for left hemisphere perfusion,” Dr. Tong and coauthors wrote.
Key outcomes that the researchers found not statistically significant were:
- Overall 30-day mortality (11.6% for b-ACP vs. 20.7% for u-ACP; P = .075).
- Prevalence of postoperative permanent neurologic dysfunction (8.4% vs. 16.9%; P = .091).
- Average ICU LOS (16 ± 17.75 days vs. 17 ± 11.5 days, P =.454).
- Average hospital LOS (26.5 ± 20.6 days vs. 24.8 ± 10.3 days, P = .434).
However, average ventilation time was lower in the b-ACP group (95.5 hours vs. 147 hours; P less than or equal to.001).
Dr. Tong and coauthors used an aggressive approach, as advocated by Dhaval Trivedi, MD, and colleagues (Ann Thorac Surg. 2016;101:896-903), and had a total arch replacement rate of 57.8%. This rate is higher than most published series in the west but comparable to other studies from China, perhaps because of the relatively young age of this study cohort – an average age of 51 years – compared to data sets other studies have used. Dr. Tong and coauthors used a b-ACP strategy that established both cerebral perfusion routes before circulatory arrest.
Rates of the following complications were also not significantly different across the study population: paraplegia (2.8% for b-ACP vs. 3.1% for u-ACP), temporary neurologic dysfunction (4.7% vs. 9.2%), permanent neurologic dysfunction (8.4% vs. 16.9%), renal failure (18% vs. 23.1%), reoperation for bleeding (2.8% vs. 4.6%), and mediastinal infection (3.7% vs. 6.2%).
While b-ACP patients did not have a statistically significant lower incidence of TND, Dr. Tong and coauthors noted the shorter time on ventilation and significantly lower tracheostomy rates for the b-ACP patients, 3.7% vs. 16.9% for the u-ACP group (P = .003). “In our institute, protocols to wean patients from ventilation were normally initiated as soon as consciousness was regained,” Dr. Tong and coauthors wrote.
Among the study limits Dr. Tong and coauthors acknowledged were its retrospective, nonrandomized, single-center nature, and the fact that the surgeries were performed over an 8-year period representing different eras.
The investigators reported having no relevant financial disclosures.
FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: Clinical outcomes were comparable between groups who underwent unilateral or bilateral antegrade cerebral perfusion in total arch replacement for type A aortic dissection.
Major finding: Overall 30-day mortality was 11.6% in the bilateral ACP group vs. 20.7% for unilateral ACP (P =.075).
Data source: Population of 203 patients who had aortic arch replacement surgery for type A aortic dissection between September 2006 and August 2014.
Disclosures: Dr. Tong and coauthors reported having no relevant financial disclosures.
Kidney transplant for GPA boosts survival
SAN DIEGO – Receiving a kidney transplant increased the likelihood of survival in patients with end-stage renal disease (ESRD) due to granulomatosis with polyangiitis, a study showed.
“We found that there was a huge survival advantage of having a renal transplant,” lead author Zachary S. Wallace, MD, MS, of Harvard Medical School, Boston, said in an interview. “In addition, this improvement in survival seems to be due to a dramatic reduction in death due to cardiovascular disease.”
An estimated 25% of patients with GPA develop ESRD, according to Dr. Wallace, who also works at the vasculitis and glomerulonephritis center at Massachusetts General Hospital, Boston. “GPA and ANCA [antineutrophil cytoplasmic autoantibody]–associated vasculitis in general have a propensity to affect the kidneys, and the reason for that is not entirely known,” he said during the interview. “In the kidney, it most commonly causes a rapidly progressive glomerulonephritis which can cause irreversible renal failure if not aggressively treated.”
Dr. Wallace and his colleagues launched their study to better understand the impact of kidney transplants. “We know that patients with ESRD from more common causes – such as diabetes and hypertension – benefit in terms of survival and quality of life from transplantation,” he said in the interview. “It was unknown if GPA patients similarly benefit. Often, GPA patients have fewer comorbidities than patients with ESRD due to diabetes or hypertension. Since they may be relatively healthier, one might wonder if the survival benefit would be as great in ESRD patients with GPA.”
Dr. Wallace and his colleagues tracked 2,471 cases of ESRD due to GPA from the U.S. Renal Data System. All were wait-listed for a kidney transplant from 1995 to 2014, and the researchers tracked them as late as Jan. 1, 2016. Of the patients studied, 946 received a transplant. The study’s participants tended to be male (59%) and white (86-87%), and they rarely had comorbidities outside of diabetes (64-67%).
There were 438 deaths in the entire group. Those who received transplants were much less likely to die than those who didn’t (adjusted hazard ratio, 0.30; 95% confidence interval, 0.25-0.37; P less than .001), he reported at the annual meeting of the American College of Rheumatology.
Also, those who received transplants were much less likely than those who didn’t to die of cardiovascular disease (adjusted HR, 0.13; 95% CI, 0.08-0.22; P less than .001) and infection (adjusted HR, 0.61; 95% CI, 0.34-1.08; P = .09). There was no statistically significant difference between the groups in terms of deaths from cancer.
“The improvement in survival seems to be due to a dramatic reduction in death due to cardiovascular disease,” Dr. Wallace said in the interview. “While cardiovascular disease is a common cause of death in GPA and ESRD due to other causes, this was not known specifically in patients with ESRD due to GPA.”
The findings provide the following messages to rheumatologists: Renal transplantation in patients with ESRD due to GPA offers a significant survival benefit, and it is important to refer patients early to a renal transplant center, he noted.
“[Rheumatologists] should work closely with primary care physicians and nephrologists to make sure that the patient’s cardiovascular disease risk is being assessed – checking lipids, A1c, etc. – and addressed as necessary,” Dr. Wallace added.
The study authors reported no relevant financial disclosures. Funding included support from the Rheumatology Research Foundation, the Executive Committee on Research at Massachusetts General, and the National Institutes of Health Loan Repayment Program.
SAN DIEGO – Receiving a kidney transplant increased the likelihood of survival in patients with end-stage renal disease (ESRD) due to granulomatosis with polyangiitis, a study showed.
“We found that there was a huge survival advantage of having a renal transplant,” lead author Zachary S. Wallace, MD, MS, of Harvard Medical School, Boston, said in an interview. “In addition, this improvement in survival seems to be due to a dramatic reduction in death due to cardiovascular disease.”
An estimated 25% of patients with GPA develop ESRD, according to Dr. Wallace, who also works at the vasculitis and glomerulonephritis center at Massachusetts General Hospital, Boston. “GPA and ANCA [antineutrophil cytoplasmic autoantibody]–associated vasculitis in general have a propensity to affect the kidneys, and the reason for that is not entirely known,” he said during the interview. “In the kidney, it most commonly causes a rapidly progressive glomerulonephritis which can cause irreversible renal failure if not aggressively treated.”
Dr. Wallace and his colleagues launched their study to better understand the impact of kidney transplants. “We know that patients with ESRD from more common causes – such as diabetes and hypertension – benefit in terms of survival and quality of life from transplantation,” he said in the interview. “It was unknown if GPA patients similarly benefit. Often, GPA patients have fewer comorbidities than patients with ESRD due to diabetes or hypertension. Since they may be relatively healthier, one might wonder if the survival benefit would be as great in ESRD patients with GPA.”
Dr. Wallace and his colleagues tracked 2,471 cases of ESRD due to GPA from the U.S. Renal Data System. All were wait-listed for a kidney transplant from 1995 to 2014, and the researchers tracked them as late as Jan. 1, 2016. Of the patients studied, 946 received a transplant. The study’s participants tended to be male (59%) and white (86-87%), and they rarely had comorbidities outside of diabetes (64-67%).
There were 438 deaths in the entire group. Those who received transplants were much less likely to die than those who didn’t (adjusted hazard ratio, 0.30; 95% confidence interval, 0.25-0.37; P less than .001), he reported at the annual meeting of the American College of Rheumatology.
Also, those who received transplants were much less likely than those who didn’t to die of cardiovascular disease (adjusted HR, 0.13; 95% CI, 0.08-0.22; P less than .001) and infection (adjusted HR, 0.61; 95% CI, 0.34-1.08; P = .09). There was no statistically significant difference between the groups in terms of deaths from cancer.
“The improvement in survival seems to be due to a dramatic reduction in death due to cardiovascular disease,” Dr. Wallace said in the interview. “While cardiovascular disease is a common cause of death in GPA and ESRD due to other causes, this was not known specifically in patients with ESRD due to GPA.”
The findings provide the following messages to rheumatologists: Renal transplantation in patients with ESRD due to GPA offers a significant survival benefit, and it is important to refer patients early to a renal transplant center, he noted.
“[Rheumatologists] should work closely with primary care physicians and nephrologists to make sure that the patient’s cardiovascular disease risk is being assessed – checking lipids, A1c, etc. – and addressed as necessary,” Dr. Wallace added.
The study authors reported no relevant financial disclosures. Funding included support from the Rheumatology Research Foundation, the Executive Committee on Research at Massachusetts General, and the National Institutes of Health Loan Repayment Program.
SAN DIEGO – Receiving a kidney transplant increased the likelihood of survival in patients with end-stage renal disease (ESRD) due to granulomatosis with polyangiitis, a study showed.
“We found that there was a huge survival advantage of having a renal transplant,” lead author Zachary S. Wallace, MD, MS, of Harvard Medical School, Boston, said in an interview. “In addition, this improvement in survival seems to be due to a dramatic reduction in death due to cardiovascular disease.”
An estimated 25% of patients with GPA develop ESRD, according to Dr. Wallace, who also works at the vasculitis and glomerulonephritis center at Massachusetts General Hospital, Boston. “GPA and ANCA [antineutrophil cytoplasmic autoantibody]–associated vasculitis in general have a propensity to affect the kidneys, and the reason for that is not entirely known,” he said during the interview. “In the kidney, it most commonly causes a rapidly progressive glomerulonephritis which can cause irreversible renal failure if not aggressively treated.”
Dr. Wallace and his colleagues launched their study to better understand the impact of kidney transplants. “We know that patients with ESRD from more common causes – such as diabetes and hypertension – benefit in terms of survival and quality of life from transplantation,” he said in the interview. “It was unknown if GPA patients similarly benefit. Often, GPA patients have fewer comorbidities than patients with ESRD due to diabetes or hypertension. Since they may be relatively healthier, one might wonder if the survival benefit would be as great in ESRD patients with GPA.”
Dr. Wallace and his colleagues tracked 2,471 cases of ESRD due to GPA from the U.S. Renal Data System. All were wait-listed for a kidney transplant from 1995 to 2014, and the researchers tracked them as late as Jan. 1, 2016. Of the patients studied, 946 received a transplant. The study’s participants tended to be male (59%) and white (86-87%), and they rarely had comorbidities outside of diabetes (64-67%).
There were 438 deaths in the entire group. Those who received transplants were much less likely to die than those who didn’t (adjusted hazard ratio, 0.30; 95% confidence interval, 0.25-0.37; P less than .001), he reported at the annual meeting of the American College of Rheumatology.
Also, those who received transplants were much less likely than those who didn’t to die of cardiovascular disease (adjusted HR, 0.13; 95% CI, 0.08-0.22; P less than .001) and infection (adjusted HR, 0.61; 95% CI, 0.34-1.08; P = .09). There was no statistically significant difference between the groups in terms of deaths from cancer.
“The improvement in survival seems to be due to a dramatic reduction in death due to cardiovascular disease,” Dr. Wallace said in the interview. “While cardiovascular disease is a common cause of death in GPA and ESRD due to other causes, this was not known specifically in patients with ESRD due to GPA.”
The findings provide the following messages to rheumatologists: Renal transplantation in patients with ESRD due to GPA offers a significant survival benefit, and it is important to refer patients early to a renal transplant center, he noted.
“[Rheumatologists] should work closely with primary care physicians and nephrologists to make sure that the patient’s cardiovascular disease risk is being assessed – checking lipids, A1c, etc. – and addressed as necessary,” Dr. Wallace added.
The study authors reported no relevant financial disclosures. Funding included support from the Rheumatology Research Foundation, the Executive Committee on Research at Massachusetts General, and the National Institutes of Health Loan Repayment Program.
AT ACR 2017
Key clinical point:
Major finding: Compared with patients who were wait-listed for a transplant but didn’t receive one, those who got transplants were much less likely to die during the study period (adjusted HR, 0.30; 95% CI, 0.25-0.37; P less than .001).
Data source: 2,471 patients with ESRD due to GPA who were wait-listed for a kidney transplant from 1995 to 2014 and tracked as late as 2016; 946 received a transplant.
Disclosures: The study authors reported no relevant financial disclosures. Funding included support from the Rheumatology Research Foundation, the Executive Committee on Research at Massachusetts General, and the National Institutes of Health Loan Repayment Program.
Marketplace confusion opens door to questions about skinny plans
Consumers coping with the high cost of health insurance are the target market for new plans claiming to be lower-cost alternatives to the Affordable Care Act that fulfill the law’s requirement for health coverage.
But experts and regulators warn consumers to be cautious – and are raising red flags about one set of limited benefit plans marketed to individuals for as little as $93 a month. Offered through brokers and online ads, the plans promise to be an “ACA compliant, affordable, integrated solution that help ... individuals avoid the penalties under [the health care law].”
Such skinny plans – sold for the first time to individuals – come amid uncertainty over the fate of the ACA and whether the Trump administration will ease rules on plans for individuals. Dozens of brokers are offering the plans.
“The Trump administration is injecting a significant amount of confusion into the implementation of the ACA,” said Kevin Lucia, project director at Georgetown University’s Health Policy Institute. “So it doesn’t surprise me that we would have arrangements popping up that might be trying to take advantage of that confusion.”
Apex Management Group of the Chicago area and Pennsylvania-based Xpress Healthcare have teamed up to offer the plans, and executives from both companies say they don’t need approval from state regulators to sell them. They are selling the policies across the country, although their websites note one state – Massachusetts – where the plans are not offered.
David Shull, Apex’s director of business development, said “this is not insurance” and the plans are designed to meet the “bulk of someone’s day-to-day needs.”
Legal and policy experts have raised concerns that the new plans could leave buyers incorrectly thinking they are exempt from paying a penalty for not having coverage. Additionally, they say, plans sold to individuals must be state-licensed – and one regulator has already asked for an investigation.
“Generally speaking, any entity selling health insurance in the state of California has to have a license,” Dave Jones, the Golden State’s insurance commissioner, said earlier this month. “I have asked the Department of Insurance staff to open an investigation with regard to this company to ascertain whether it is in violation of California law if they are selling it in California.”
Asked about a possible investigation, Apex owner Jeffrey Bemoras emailed a statement last week saying the firm is not offering plans to individuals in California. He also noted that the individual market accounts for only 2% of the company’s business.
“To be clear, Apex Management group adheres closely to all state and federal rules and regulations surrounding offering a self-insured MEC [minimal essential coverage] program,” he wrote. “We are test marketing our product in the individual environment. If at some point it doesn’t make sense to continue that investment we will not invest or focus in on that market.”
Price-tag appeal, but what about coverage?
The new plans promise to be a solution for individuals who say that conventional health insurance is too expensive. Those looking for alternatives to the ACA often earn too much to qualify for tax subsidies under the federal law.
Donna Harper, an insurance agent who runs a two-person brokerage in Crystal Lake, Ill., found herself in that situation. She sells the Xpress plans – and decided to buy one herself.
Ms. Harper says she canceled her BlueCross BlueShield plan, which did meet the ACA’s requirements, after it rose to nearly $11,000 in premiums this year, with a $6,000 annual deductible.
“Self-employed people are being priced out of the market,” she said, noting the new Xpress plan will save her more than $500 a month.
The Xpress Minimum Essential Coverage plans come in three levels, costing as little as $93 a month for individuals to as much as $516 for a family. They cover preventive care – including certain cancer screenings and vaccinations – while providing limited benefits for doctor visits, lab tests, and lower-cost prescription drugs.
There is little or no coverage for hospital, emergency room care, and expensive prescription drugs, such as chemotherapy.
Ms. Harper said she generally recommends that her clients who sign up for an Xpress plan also buy a hospital-only policy offered by other insurers. That extra policy would pay a set amount toward inpatient care – often ranging from $1,500 to $5,000 or so a day.
Still, experts caution that hospital bills are generally much higher than those amounts. A three-day stay averages $30,000, according to the federal government’s insurance website. And hospital plans can have tougher requirements. Unlike the Xpress programs, which don’t reject applicants who have preexisting medical conditions, hospital-only plans often do. Ms. Harper says she personally was rejected for one.
“I haven’t been in the hospital for 40 years, so I’m going to roll the dice,” she said. And if she winds up in the hospital? “I’ll just pay the bill.”
About 100 brokers nationwide are selling the plans, and interest “is picking up quick,” said Edward Pettola, co-owner and founder of Xpress, which for years has sold programs that offer discounts on dental, vision, and prescription services.
Caveat emptor
Experts question whether the plans exempt policyholders from the ACA’s tax penalty for not having “qualified” coverage, defined as a policy from an employer, a government program or a licensed product purchased on the individual market.
The penalty for tax year 2017 is the greater of a flat fee or a percentage of income. The annual total could range from as little as $695 for an individual to as much as $3,264 for a family.
President Trump issued an executive order in October designed to loosen insurance restrictions on lower-cost, alternative forms of coverage, but the administration has not signaled its view on what would be deemed qualified coverage.
Responding to questions from KHN, officials from Apex and Xpress said their plans are designed to be affordable, not to mimic ACA health plans.
“If that is what we are expected to do, just deliver what every Marketplace plan or carriers do, provide a Bronze, Silver Plan, etc., it would not solve the problem in addressing a benefit plan that is affordable,” the companies said in a joint email on Nov. 14. “Individuals are not required to have an insurance plan, but a plan that meets minimum essential coverage, the required preventive care services.”
Mr. Bemoras, in a separate interview, said his company has been selling a version of the plan to employers since 2015.
“As we see the political environment moving and wavering and not understanding what needs to be done, the individual market became extremely attractive to us,” Mr. Bemoras said.
Still, experts who reviewed the plans for KHN said policies sold to individuals must cover 10 broad categories of health care to qualify as ACA-compliant, including hospitalization and emergency room care, and cannot set annual or lifetime limits.
The Xpress/Apex programs do set limits, paying zero to $2,500 annually toward hospital care. Doctor visits are covered for a $20 copayment, but coverage is limited to three per year. Lab tests are limited to 5 services annually. To get those prices, patients have to use a physician or facility in the PHCS network, which says it has 900,000 providers nationwide. Low-cost generics are covered for as little as a $1 copay, but the amount patients pay rises sharply for more expensive drugs.
“I’m very skeptical,” said attorney Alden J. Bianchi of Mintz Levin, who advises firms on employee benefits. “That would be hard [to do] because in the individual market, you have to cover all the essential health benefits.”
The details can be confusing, partly because federal law allows group health plans – generally those offered by large employers – to provide workers with self-funded, minimal coverage plans like those offered by Apex, Mr. Bianchi said.
Apex’s Mr. Shull recently said in an email that the firm simply wants to offer coverage to people who otherwise could not afford an ACA plan.
“There will be states that want to halt this. Why, I do not understand,” he wrote. “Would an individual be better off going without anything? If they need prescriptions, lab or imaging services subject to a small copay, would you want to be the one to deny them?”
Some consumers might find the price attractive, but also find themselves vulnerable to unexpected costs, including the tax liability.
Ms. Harper, the broker who signed up for one of the plans, remains confident: “As long as Xpress satisfies the [mandate], which I’m told it does, my clients are in good hands. Even if it doesn’t, I don’t think it’s a big deal. You are saving that [the tax penalty amount] a month.”
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
Consumers coping with the high cost of health insurance are the target market for new plans claiming to be lower-cost alternatives to the Affordable Care Act that fulfill the law’s requirement for health coverage.
But experts and regulators warn consumers to be cautious – and are raising red flags about one set of limited benefit plans marketed to individuals for as little as $93 a month. Offered through brokers and online ads, the plans promise to be an “ACA compliant, affordable, integrated solution that help ... individuals avoid the penalties under [the health care law].”
Such skinny plans – sold for the first time to individuals – come amid uncertainty over the fate of the ACA and whether the Trump administration will ease rules on plans for individuals. Dozens of brokers are offering the plans.
“The Trump administration is injecting a significant amount of confusion into the implementation of the ACA,” said Kevin Lucia, project director at Georgetown University’s Health Policy Institute. “So it doesn’t surprise me that we would have arrangements popping up that might be trying to take advantage of that confusion.”
Apex Management Group of the Chicago area and Pennsylvania-based Xpress Healthcare have teamed up to offer the plans, and executives from both companies say they don’t need approval from state regulators to sell them. They are selling the policies across the country, although their websites note one state – Massachusetts – where the plans are not offered.
David Shull, Apex’s director of business development, said “this is not insurance” and the plans are designed to meet the “bulk of someone’s day-to-day needs.”
Legal and policy experts have raised concerns that the new plans could leave buyers incorrectly thinking they are exempt from paying a penalty for not having coverage. Additionally, they say, plans sold to individuals must be state-licensed – and one regulator has already asked for an investigation.
“Generally speaking, any entity selling health insurance in the state of California has to have a license,” Dave Jones, the Golden State’s insurance commissioner, said earlier this month. “I have asked the Department of Insurance staff to open an investigation with regard to this company to ascertain whether it is in violation of California law if they are selling it in California.”
Asked about a possible investigation, Apex owner Jeffrey Bemoras emailed a statement last week saying the firm is not offering plans to individuals in California. He also noted that the individual market accounts for only 2% of the company’s business.
“To be clear, Apex Management group adheres closely to all state and federal rules and regulations surrounding offering a self-insured MEC [minimal essential coverage] program,” he wrote. “We are test marketing our product in the individual environment. If at some point it doesn’t make sense to continue that investment we will not invest or focus in on that market.”
Price-tag appeal, but what about coverage?
The new plans promise to be a solution for individuals who say that conventional health insurance is too expensive. Those looking for alternatives to the ACA often earn too much to qualify for tax subsidies under the federal law.
Donna Harper, an insurance agent who runs a two-person brokerage in Crystal Lake, Ill., found herself in that situation. She sells the Xpress plans – and decided to buy one herself.
Ms. Harper says she canceled her BlueCross BlueShield plan, which did meet the ACA’s requirements, after it rose to nearly $11,000 in premiums this year, with a $6,000 annual deductible.
“Self-employed people are being priced out of the market,” she said, noting the new Xpress plan will save her more than $500 a month.
The Xpress Minimum Essential Coverage plans come in three levels, costing as little as $93 a month for individuals to as much as $516 for a family. They cover preventive care – including certain cancer screenings and vaccinations – while providing limited benefits for doctor visits, lab tests, and lower-cost prescription drugs.
There is little or no coverage for hospital, emergency room care, and expensive prescription drugs, such as chemotherapy.
Ms. Harper said she generally recommends that her clients who sign up for an Xpress plan also buy a hospital-only policy offered by other insurers. That extra policy would pay a set amount toward inpatient care – often ranging from $1,500 to $5,000 or so a day.
Still, experts caution that hospital bills are generally much higher than those amounts. A three-day stay averages $30,000, according to the federal government’s insurance website. And hospital plans can have tougher requirements. Unlike the Xpress programs, which don’t reject applicants who have preexisting medical conditions, hospital-only plans often do. Ms. Harper says she personally was rejected for one.
“I haven’t been in the hospital for 40 years, so I’m going to roll the dice,” she said. And if she winds up in the hospital? “I’ll just pay the bill.”
About 100 brokers nationwide are selling the plans, and interest “is picking up quick,” said Edward Pettola, co-owner and founder of Xpress, which for years has sold programs that offer discounts on dental, vision, and prescription services.
Caveat emptor
Experts question whether the plans exempt policyholders from the ACA’s tax penalty for not having “qualified” coverage, defined as a policy from an employer, a government program or a licensed product purchased on the individual market.
The penalty for tax year 2017 is the greater of a flat fee or a percentage of income. The annual total could range from as little as $695 for an individual to as much as $3,264 for a family.
President Trump issued an executive order in October designed to loosen insurance restrictions on lower-cost, alternative forms of coverage, but the administration has not signaled its view on what would be deemed qualified coverage.
Responding to questions from KHN, officials from Apex and Xpress said their plans are designed to be affordable, not to mimic ACA health plans.
“If that is what we are expected to do, just deliver what every Marketplace plan or carriers do, provide a Bronze, Silver Plan, etc., it would not solve the problem in addressing a benefit plan that is affordable,” the companies said in a joint email on Nov. 14. “Individuals are not required to have an insurance plan, but a plan that meets minimum essential coverage, the required preventive care services.”
Mr. Bemoras, in a separate interview, said his company has been selling a version of the plan to employers since 2015.
“As we see the political environment moving and wavering and not understanding what needs to be done, the individual market became extremely attractive to us,” Mr. Bemoras said.
Still, experts who reviewed the plans for KHN said policies sold to individuals must cover 10 broad categories of health care to qualify as ACA-compliant, including hospitalization and emergency room care, and cannot set annual or lifetime limits.
The Xpress/Apex programs do set limits, paying zero to $2,500 annually toward hospital care. Doctor visits are covered for a $20 copayment, but coverage is limited to three per year. Lab tests are limited to 5 services annually. To get those prices, patients have to use a physician or facility in the PHCS network, which says it has 900,000 providers nationwide. Low-cost generics are covered for as little as a $1 copay, but the amount patients pay rises sharply for more expensive drugs.
“I’m very skeptical,” said attorney Alden J. Bianchi of Mintz Levin, who advises firms on employee benefits. “That would be hard [to do] because in the individual market, you have to cover all the essential health benefits.”
The details can be confusing, partly because federal law allows group health plans – generally those offered by large employers – to provide workers with self-funded, minimal coverage plans like those offered by Apex, Mr. Bianchi said.
Apex’s Mr. Shull recently said in an email that the firm simply wants to offer coverage to people who otherwise could not afford an ACA plan.
“There will be states that want to halt this. Why, I do not understand,” he wrote. “Would an individual be better off going without anything? If they need prescriptions, lab or imaging services subject to a small copay, would you want to be the one to deny them?”
Some consumers might find the price attractive, but also find themselves vulnerable to unexpected costs, including the tax liability.
Ms. Harper, the broker who signed up for one of the plans, remains confident: “As long as Xpress satisfies the [mandate], which I’m told it does, my clients are in good hands. Even if it doesn’t, I don’t think it’s a big deal. You are saving that [the tax penalty amount] a month.”
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
Consumers coping with the high cost of health insurance are the target market for new plans claiming to be lower-cost alternatives to the Affordable Care Act that fulfill the law’s requirement for health coverage.
But experts and regulators warn consumers to be cautious – and are raising red flags about one set of limited benefit plans marketed to individuals for as little as $93 a month. Offered through brokers and online ads, the plans promise to be an “ACA compliant, affordable, integrated solution that help ... individuals avoid the penalties under [the health care law].”
Such skinny plans – sold for the first time to individuals – come amid uncertainty over the fate of the ACA and whether the Trump administration will ease rules on plans for individuals. Dozens of brokers are offering the plans.
“The Trump administration is injecting a significant amount of confusion into the implementation of the ACA,” said Kevin Lucia, project director at Georgetown University’s Health Policy Institute. “So it doesn’t surprise me that we would have arrangements popping up that might be trying to take advantage of that confusion.”
Apex Management Group of the Chicago area and Pennsylvania-based Xpress Healthcare have teamed up to offer the plans, and executives from both companies say they don’t need approval from state regulators to sell them. They are selling the policies across the country, although their websites note one state – Massachusetts – where the plans are not offered.
David Shull, Apex’s director of business development, said “this is not insurance” and the plans are designed to meet the “bulk of someone’s day-to-day needs.”
Legal and policy experts have raised concerns that the new plans could leave buyers incorrectly thinking they are exempt from paying a penalty for not having coverage. Additionally, they say, plans sold to individuals must be state-licensed – and one regulator has already asked for an investigation.
“Generally speaking, any entity selling health insurance in the state of California has to have a license,” Dave Jones, the Golden State’s insurance commissioner, said earlier this month. “I have asked the Department of Insurance staff to open an investigation with regard to this company to ascertain whether it is in violation of California law if they are selling it in California.”
Asked about a possible investigation, Apex owner Jeffrey Bemoras emailed a statement last week saying the firm is not offering plans to individuals in California. He also noted that the individual market accounts for only 2% of the company’s business.
“To be clear, Apex Management group adheres closely to all state and federal rules and regulations surrounding offering a self-insured MEC [minimal essential coverage] program,” he wrote. “We are test marketing our product in the individual environment. If at some point it doesn’t make sense to continue that investment we will not invest or focus in on that market.”
Price-tag appeal, but what about coverage?
The new plans promise to be a solution for individuals who say that conventional health insurance is too expensive. Those looking for alternatives to the ACA often earn too much to qualify for tax subsidies under the federal law.
Donna Harper, an insurance agent who runs a two-person brokerage in Crystal Lake, Ill., found herself in that situation. She sells the Xpress plans – and decided to buy one herself.
Ms. Harper says she canceled her BlueCross BlueShield plan, which did meet the ACA’s requirements, after it rose to nearly $11,000 in premiums this year, with a $6,000 annual deductible.
“Self-employed people are being priced out of the market,” she said, noting the new Xpress plan will save her more than $500 a month.
The Xpress Minimum Essential Coverage plans come in three levels, costing as little as $93 a month for individuals to as much as $516 for a family. They cover preventive care – including certain cancer screenings and vaccinations – while providing limited benefits for doctor visits, lab tests, and lower-cost prescription drugs.
There is little or no coverage for hospital, emergency room care, and expensive prescription drugs, such as chemotherapy.
Ms. Harper said she generally recommends that her clients who sign up for an Xpress plan also buy a hospital-only policy offered by other insurers. That extra policy would pay a set amount toward inpatient care – often ranging from $1,500 to $5,000 or so a day.
Still, experts caution that hospital bills are generally much higher than those amounts. A three-day stay averages $30,000, according to the federal government’s insurance website. And hospital plans can have tougher requirements. Unlike the Xpress programs, which don’t reject applicants who have preexisting medical conditions, hospital-only plans often do. Ms. Harper says she personally was rejected for one.
“I haven’t been in the hospital for 40 years, so I’m going to roll the dice,” she said. And if she winds up in the hospital? “I’ll just pay the bill.”
About 100 brokers nationwide are selling the plans, and interest “is picking up quick,” said Edward Pettola, co-owner and founder of Xpress, which for years has sold programs that offer discounts on dental, vision, and prescription services.
Caveat emptor
Experts question whether the plans exempt policyholders from the ACA’s tax penalty for not having “qualified” coverage, defined as a policy from an employer, a government program or a licensed product purchased on the individual market.
The penalty for tax year 2017 is the greater of a flat fee or a percentage of income. The annual total could range from as little as $695 for an individual to as much as $3,264 for a family.
President Trump issued an executive order in October designed to loosen insurance restrictions on lower-cost, alternative forms of coverage, but the administration has not signaled its view on what would be deemed qualified coverage.
Responding to questions from KHN, officials from Apex and Xpress said their plans are designed to be affordable, not to mimic ACA health plans.
“If that is what we are expected to do, just deliver what every Marketplace plan or carriers do, provide a Bronze, Silver Plan, etc., it would not solve the problem in addressing a benefit plan that is affordable,” the companies said in a joint email on Nov. 14. “Individuals are not required to have an insurance plan, but a plan that meets minimum essential coverage, the required preventive care services.”
Mr. Bemoras, in a separate interview, said his company has been selling a version of the plan to employers since 2015.
“As we see the political environment moving and wavering and not understanding what needs to be done, the individual market became extremely attractive to us,” Mr. Bemoras said.
Still, experts who reviewed the plans for KHN said policies sold to individuals must cover 10 broad categories of health care to qualify as ACA-compliant, including hospitalization and emergency room care, and cannot set annual or lifetime limits.
The Xpress/Apex programs do set limits, paying zero to $2,500 annually toward hospital care. Doctor visits are covered for a $20 copayment, but coverage is limited to three per year. Lab tests are limited to 5 services annually. To get those prices, patients have to use a physician or facility in the PHCS network, which says it has 900,000 providers nationwide. Low-cost generics are covered for as little as a $1 copay, but the amount patients pay rises sharply for more expensive drugs.
“I’m very skeptical,” said attorney Alden J. Bianchi of Mintz Levin, who advises firms on employee benefits. “That would be hard [to do] because in the individual market, you have to cover all the essential health benefits.”
The details can be confusing, partly because federal law allows group health plans – generally those offered by large employers – to provide workers with self-funded, minimal coverage plans like those offered by Apex, Mr. Bianchi said.
Apex’s Mr. Shull recently said in an email that the firm simply wants to offer coverage to people who otherwise could not afford an ACA plan.
“There will be states that want to halt this. Why, I do not understand,” he wrote. “Would an individual be better off going without anything? If they need prescriptions, lab or imaging services subject to a small copay, would you want to be the one to deny them?”
Some consumers might find the price attractive, but also find themselves vulnerable to unexpected costs, including the tax liability.
Ms. Harper, the broker who signed up for one of the plans, remains confident: “As long as Xpress satisfies the [mandate], which I’m told it does, my clients are in good hands. Even if it doesn’t, I don’t think it’s a big deal. You are saving that [the tax penalty amount] a month.”
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
Robotic hysterectomy plus mini-lap outperformed open procedure
NATIONAL HARBOR, MD. – Robotic hysterectomy combined with extraction of the uterus via mini-laparotomy led to significantly shorter lengths of stay, lower estimated blood loss, and fewer postoperative complications compared with open hysterectomy when the uterus weighed more than 250 grams.
Gynecologic surgeons are seeking ways to safely perform minimally invasive hysterectomy on patients with larger uteri in light of the 2014 Food and Drug Administration admonition regarding power morcellation. To this end, Natasha Gupta, MD, and her colleagues at the University of Tennessee, Chattanooga, retrospectively reviewed all patients with uterine sizes larger than 250 grams undergoing hysterectomy at their institution between 2012 and 2015.
“For the mini-laparotomy, the technique utilizes a customized incision connecting the two left port sites, followed by the removal of the specimen via this incision,” Dr. Gupta said at the AAGL Global Congress.
Patient factors and outcomes were compared via Student t-tests and Chi-square analysis.
Mean length of stay was significantly shorter for patients who underwent robotic hysterectomy/mini-laparotomy, at 1.4 days vs. 5.4 days for those with open hysterectomy (P = .000) as was mean estimated blood loss – 119.9 mL vs. 547.5 mL, respectively (P = .000). Postoperative complications were seen in fewer patients who underwent robotic hysterectomy/mini-laparotomy, 9 of 82 patients vs. 15 of 58 open hysterectomy patients.
Mean operative time was significantly longer in robotic hysterectomy/mini-laparotomy patients – 191.6 minutes vs. 162.8 minutes (P = .005) – but that was expected, Dr. Gupta noted. Patient factors such as hypertension, diabetes, history of spontaneous vaginal delivery and/or cesarean delivery, and body mass index, as well as uterine pathology, were not significantly different between the groups.
“Mini-laparotomy combined with minimally invasive hysterectomy is a very safe and feasible technique for tissue extraction where contained morcellation is either not preferred or not available,” Dr. Gupta said.
Dr. Gupta reported having no relevant financial conflicts of interest.
[email protected]
On Twitter @denisefulton
NATIONAL HARBOR, MD. – Robotic hysterectomy combined with extraction of the uterus via mini-laparotomy led to significantly shorter lengths of stay, lower estimated blood loss, and fewer postoperative complications compared with open hysterectomy when the uterus weighed more than 250 grams.
Gynecologic surgeons are seeking ways to safely perform minimally invasive hysterectomy on patients with larger uteri in light of the 2014 Food and Drug Administration admonition regarding power morcellation. To this end, Natasha Gupta, MD, and her colleagues at the University of Tennessee, Chattanooga, retrospectively reviewed all patients with uterine sizes larger than 250 grams undergoing hysterectomy at their institution between 2012 and 2015.
“For the mini-laparotomy, the technique utilizes a customized incision connecting the two left port sites, followed by the removal of the specimen via this incision,” Dr. Gupta said at the AAGL Global Congress.
Patient factors and outcomes were compared via Student t-tests and Chi-square analysis.
Mean length of stay was significantly shorter for patients who underwent robotic hysterectomy/mini-laparotomy, at 1.4 days vs. 5.4 days for those with open hysterectomy (P = .000) as was mean estimated blood loss – 119.9 mL vs. 547.5 mL, respectively (P = .000). Postoperative complications were seen in fewer patients who underwent robotic hysterectomy/mini-laparotomy, 9 of 82 patients vs. 15 of 58 open hysterectomy patients.
Mean operative time was significantly longer in robotic hysterectomy/mini-laparotomy patients – 191.6 minutes vs. 162.8 minutes (P = .005) – but that was expected, Dr. Gupta noted. Patient factors such as hypertension, diabetes, history of spontaneous vaginal delivery and/or cesarean delivery, and body mass index, as well as uterine pathology, were not significantly different between the groups.
“Mini-laparotomy combined with minimally invasive hysterectomy is a very safe and feasible technique for tissue extraction where contained morcellation is either not preferred or not available,” Dr. Gupta said.
Dr. Gupta reported having no relevant financial conflicts of interest.
[email protected]
On Twitter @denisefulton
NATIONAL HARBOR, MD. – Robotic hysterectomy combined with extraction of the uterus via mini-laparotomy led to significantly shorter lengths of stay, lower estimated blood loss, and fewer postoperative complications compared with open hysterectomy when the uterus weighed more than 250 grams.
Gynecologic surgeons are seeking ways to safely perform minimally invasive hysterectomy on patients with larger uteri in light of the 2014 Food and Drug Administration admonition regarding power morcellation. To this end, Natasha Gupta, MD, and her colleagues at the University of Tennessee, Chattanooga, retrospectively reviewed all patients with uterine sizes larger than 250 grams undergoing hysterectomy at their institution between 2012 and 2015.
“For the mini-laparotomy, the technique utilizes a customized incision connecting the two left port sites, followed by the removal of the specimen via this incision,” Dr. Gupta said at the AAGL Global Congress.
Patient factors and outcomes were compared via Student t-tests and Chi-square analysis.
Mean length of stay was significantly shorter for patients who underwent robotic hysterectomy/mini-laparotomy, at 1.4 days vs. 5.4 days for those with open hysterectomy (P = .000) as was mean estimated blood loss – 119.9 mL vs. 547.5 mL, respectively (P = .000). Postoperative complications were seen in fewer patients who underwent robotic hysterectomy/mini-laparotomy, 9 of 82 patients vs. 15 of 58 open hysterectomy patients.
Mean operative time was significantly longer in robotic hysterectomy/mini-laparotomy patients – 191.6 minutes vs. 162.8 minutes (P = .005) – but that was expected, Dr. Gupta noted. Patient factors such as hypertension, diabetes, history of spontaneous vaginal delivery and/or cesarean delivery, and body mass index, as well as uterine pathology, were not significantly different between the groups.
“Mini-laparotomy combined with minimally invasive hysterectomy is a very safe and feasible technique for tissue extraction where contained morcellation is either not preferred or not available,” Dr. Gupta said.
Dr. Gupta reported having no relevant financial conflicts of interest.
[email protected]
On Twitter @denisefulton
AT AAGL 2017
Key clinical point:
Major finding: Mean length of stay was 1.4 days with robotic hysterectomy/mini-laparotomy vs. 5.4 days for open hysterectomy (P = .000).
Data source: A single-center retrospective review of all hysterectomies with uteri larger than 250 grams from the period of 2012-2015.
Disclosures: The study had no outside funding. Dr. Gupta reported having no relevant conflicts of interest.
REBOA improves survival for trauma patients
SCOTTSDALE, ARIZ. – In a small, single-center study of patients with subdiaphragmatic hemorrhage, resuscitative endovascular balloon occlusion of the aorta (REBOA) improved hemodynamic status and 30-day survival rates, compared with resuscitative thoracotomy (RT).
Although the technique was first developed during the Korean War, REBOA never really caught on, possibly because of limitations in endovascular technology. But recent advances in surgical technique have revitalized interest.
Despite the success of the study, some audience members expressed concerns about the skill set required. One questioner pointed out that emergency department physicians may be tempted to use the technique, even though they may not possess the requisite catheter and wire skills. That is a legitimate concern, according to senior author R. Stephen Smith, MD, FACS, professor of acute care surgery at the University of Florida, Gainesville. But this is already happening, he said. “They’ve already done it in the field in Britain, and most are placed by nonsurgeons in Japan. Frankly, we need to pay particular attention to the skills of those emergency medicine physicians, because the average emergency medicine physician at this point really doesn’t have the catheter or wire-based skills to do this safely,” Dr. Smith said at the annual meeting of the Western Surgical Association.
The researchers examined outcomes in patients who underwent REBOA versus RT over a 21-month (2015-2017) period at their institution. Before adopting REBOA, attending surgeons and senior surgical residents attended a 1.5-hour slide presentation combined with simulation training. No external course was required. Operating room personnel received a 30-minute slide presentation. The procedures were conducted in a dedicated trauma operating room equipped with imaging.
Sixteen patients underwent REBOA during the study period, with a mean injury severity score of 38.6. Preoperative hemoglobin levels ranged from 5 to 14.4 mg/dL, and the majority were acidotic because of trauma.
Fourteen of the 16 patients who underwent REBOA survived the operative procedure, and 6 survived to 30 days. By contrast, 8 patients were treated with RT, and none survived to 30 days. Ten of the 16 patients who underwent REBOA experienced an improvement in hemodynamic status, with systolic blood pressure improving to a mean of 131.83 mm Hg (±8.24) and improvement of heart rate to 87.5 (±5.47). One survivor developed a common femoral pseudoaneurysm.
Compared with nonsurvivors, REBOA patients who survived had a significant increase in Initial Glasgow Coma scores (15.0 vs. 6.18; P less than .05), and higher initial platelet counts (276.40 vs. 124.75; P = .01). Survivors also had higher initial postoperative systolic blood pressure (151.40 mm Hg vs. 112.33; P = .05), and a higher mean postoperative arterial blood pressure (109.00 mm Hg vs. 72.78; P = .01).
Overall, the findings were similar to those reported in previous multicenter trials.
The researchers pointed out that REBOA does not replace RT. The latter procedure is still appropriate for some moribund patients with super-diaphragmatic injury and in patients who require open cardiac massage.
The techniques are not mutually exclusive – two patients in the sample were treated with both techniques.
The researchers also mentioned some future possibilities for REBOA. Research in animals has demonstrated the promise of partial REBOA, in which an automated system can partially inflate the balloon and gradually deflate it as the patient’s vital signs improve. That can lighten the load for surgeons and anesthesiologists, according to Dr. Smith. “We look forward to developing that technology in the future,” he said.
The funding source was not disclosed. Dr. Smith is on the speakers bureau for Prytime Medical and is a consultant for Boehringer Laboratory LLC.
SCOTTSDALE, ARIZ. – In a small, single-center study of patients with subdiaphragmatic hemorrhage, resuscitative endovascular balloon occlusion of the aorta (REBOA) improved hemodynamic status and 30-day survival rates, compared with resuscitative thoracotomy (RT).
Although the technique was first developed during the Korean War, REBOA never really caught on, possibly because of limitations in endovascular technology. But recent advances in surgical technique have revitalized interest.
Despite the success of the study, some audience members expressed concerns about the skill set required. One questioner pointed out that emergency department physicians may be tempted to use the technique, even though they may not possess the requisite catheter and wire skills. That is a legitimate concern, according to senior author R. Stephen Smith, MD, FACS, professor of acute care surgery at the University of Florida, Gainesville. But this is already happening, he said. “They’ve already done it in the field in Britain, and most are placed by nonsurgeons in Japan. Frankly, we need to pay particular attention to the skills of those emergency medicine physicians, because the average emergency medicine physician at this point really doesn’t have the catheter or wire-based skills to do this safely,” Dr. Smith said at the annual meeting of the Western Surgical Association.
The researchers examined outcomes in patients who underwent REBOA versus RT over a 21-month (2015-2017) period at their institution. Before adopting REBOA, attending surgeons and senior surgical residents attended a 1.5-hour slide presentation combined with simulation training. No external course was required. Operating room personnel received a 30-minute slide presentation. The procedures were conducted in a dedicated trauma operating room equipped with imaging.
Sixteen patients underwent REBOA during the study period, with a mean injury severity score of 38.6. Preoperative hemoglobin levels ranged from 5 to 14.4 mg/dL, and the majority were acidotic because of trauma.
Fourteen of the 16 patients who underwent REBOA survived the operative procedure, and 6 survived to 30 days. By contrast, 8 patients were treated with RT, and none survived to 30 days. Ten of the 16 patients who underwent REBOA experienced an improvement in hemodynamic status, with systolic blood pressure improving to a mean of 131.83 mm Hg (±8.24) and improvement of heart rate to 87.5 (±5.47). One survivor developed a common femoral pseudoaneurysm.
Compared with nonsurvivors, REBOA patients who survived had a significant increase in Initial Glasgow Coma scores (15.0 vs. 6.18; P less than .05), and higher initial platelet counts (276.40 vs. 124.75; P = .01). Survivors also had higher initial postoperative systolic blood pressure (151.40 mm Hg vs. 112.33; P = .05), and a higher mean postoperative arterial blood pressure (109.00 mm Hg vs. 72.78; P = .01).
Overall, the findings were similar to those reported in previous multicenter trials.
The researchers pointed out that REBOA does not replace RT. The latter procedure is still appropriate for some moribund patients with super-diaphragmatic injury and in patients who require open cardiac massage.
The techniques are not mutually exclusive – two patients in the sample were treated with both techniques.
The researchers also mentioned some future possibilities for REBOA. Research in animals has demonstrated the promise of partial REBOA, in which an automated system can partially inflate the balloon and gradually deflate it as the patient’s vital signs improve. That can lighten the load for surgeons and anesthesiologists, according to Dr. Smith. “We look forward to developing that technology in the future,” he said.
The funding source was not disclosed. Dr. Smith is on the speakers bureau for Prytime Medical and is a consultant for Boehringer Laboratory LLC.
SCOTTSDALE, ARIZ. – In a small, single-center study of patients with subdiaphragmatic hemorrhage, resuscitative endovascular balloon occlusion of the aorta (REBOA) improved hemodynamic status and 30-day survival rates, compared with resuscitative thoracotomy (RT).
Although the technique was first developed during the Korean War, REBOA never really caught on, possibly because of limitations in endovascular technology. But recent advances in surgical technique have revitalized interest.
Despite the success of the study, some audience members expressed concerns about the skill set required. One questioner pointed out that emergency department physicians may be tempted to use the technique, even though they may not possess the requisite catheter and wire skills. That is a legitimate concern, according to senior author R. Stephen Smith, MD, FACS, professor of acute care surgery at the University of Florida, Gainesville. But this is already happening, he said. “They’ve already done it in the field in Britain, and most are placed by nonsurgeons in Japan. Frankly, we need to pay particular attention to the skills of those emergency medicine physicians, because the average emergency medicine physician at this point really doesn’t have the catheter or wire-based skills to do this safely,” Dr. Smith said at the annual meeting of the Western Surgical Association.
The researchers examined outcomes in patients who underwent REBOA versus RT over a 21-month (2015-2017) period at their institution. Before adopting REBOA, attending surgeons and senior surgical residents attended a 1.5-hour slide presentation combined with simulation training. No external course was required. Operating room personnel received a 30-minute slide presentation. The procedures were conducted in a dedicated trauma operating room equipped with imaging.
Sixteen patients underwent REBOA during the study period, with a mean injury severity score of 38.6. Preoperative hemoglobin levels ranged from 5 to 14.4 mg/dL, and the majority were acidotic because of trauma.
Fourteen of the 16 patients who underwent REBOA survived the operative procedure, and 6 survived to 30 days. By contrast, 8 patients were treated with RT, and none survived to 30 days. Ten of the 16 patients who underwent REBOA experienced an improvement in hemodynamic status, with systolic blood pressure improving to a mean of 131.83 mm Hg (±8.24) and improvement of heart rate to 87.5 (±5.47). One survivor developed a common femoral pseudoaneurysm.
Compared with nonsurvivors, REBOA patients who survived had a significant increase in Initial Glasgow Coma scores (15.0 vs. 6.18; P less than .05), and higher initial platelet counts (276.40 vs. 124.75; P = .01). Survivors also had higher initial postoperative systolic blood pressure (151.40 mm Hg vs. 112.33; P = .05), and a higher mean postoperative arterial blood pressure (109.00 mm Hg vs. 72.78; P = .01).
Overall, the findings were similar to those reported in previous multicenter trials.
The researchers pointed out that REBOA does not replace RT. The latter procedure is still appropriate for some moribund patients with super-diaphragmatic injury and in patients who require open cardiac massage.
The techniques are not mutually exclusive – two patients in the sample were treated with both techniques.
The researchers also mentioned some future possibilities for REBOA. Research in animals has demonstrated the promise of partial REBOA, in which an automated system can partially inflate the balloon and gradually deflate it as the patient’s vital signs improve. That can lighten the load for surgeons and anesthesiologists, according to Dr. Smith. “We look forward to developing that technology in the future,” he said.
The funding source was not disclosed. Dr. Smith is on the speakers bureau for Prytime Medical and is a consultant for Boehringer Laboratory LLC.
AT WSA 2017
Key clinical point: REBOA improved hematological outcomes and survival rates, compared with resuscitative thoracotomy.
Major finding: Six of 16 patients in the REBOA group survived to 30 days, compared with none of the 8 resuscitative thoracotomy patients.
Data source: Retrospective analysis of 24 patients at a single center.
Disclosures: The funding source was not disclosed. Dr. Smith is on the speakers bureau for Prytime Medical and is a consultant for Boehringer Laboratory LLC.
Hispanics trail blacks, whites in bariatric surgery rates
SAN DIEGO – A study of procedures at academic centers provides evidence that obese Hispanics in the United States undergo bariatric surgery at a much lower rate than whites and blacks. It also reveals marked regional variations in overall weight-loss surgery.
“Our findings do suggest that severely obese Hispanics are utilizing bariatric surgery much lower than other ethnic groups,” said study coauthor Ninh T. Nguyen, MD, FACS, chair of the department of surgery at the University of California Irvine Medical Center, in an interview. “Our research does not specifically address the reasons for this gap in the delivery of care. Further research will need to be done to understand the reasons and the ways to close this gap.”
According to Dr. Nguyen, the researchers undertook the study to better understand how bariatric surgery is delivered across ethnicities and geographic regions in the United States.
The researchers analyzed statistics from the Vizient health care performance database for the years 2013-2015. They focused on patients at about 120 academic centers who underwent 73,119 laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding procedures. The patients were stratified by race and region.
Researchers found that bariatric procedures were performed at a much higher rate in the Northeast academic centers (2.21 per 1,000 obese persons), compared with the Midwest (0.73), South (0.50), and West (0.33).
In regard to race, the rates for blacks and whites were fairly similar in the Northwest (2.02 and 2.35 bariatric procedures per 1,000 obese persons, respectively), the South (0.59 and 0.63, respectively) and the West (0.45 and 0.43, respectively). There was a wider gap in the Midwest, with whites at 0.69 and blacks at 1.07.
Across the country, however, obese Hispanics were less likely than persons of the other two races to undergo weight-loss surgery. The gap was fairly small in the Northeast, where 1.74 per 1,000 obese Hispanics underwent weight-loss surgery, compared with rates of 2.02 and 2.35 among whites and blacks, respectively. But the disparity was much larger in the other parts of the country, with rates at 0.14 in the West, 0.11 in the South and 0.33 in the Midwest, compared with rates from 0.43 to 1.07 among blacks and whites.
The reasons for the surgery gap are unknown. Dr. Nguyen pointed to several possible explanations: “lack of education of obesity as a disease by the primary care providers and the need for referral to a bariatric surgeon for patients with body mass index greater than 40 kg/m2 or 35 kg/m2 with obesity-related comorbidities; poor understanding of the benefits of bariatric surgery and its low risk; lack of understanding of the urgency for treatment by the patient and provider; and hurdles in obtaining coverage for the operation by insurers.”
John Magaña Morton, MD, FACS, chief of bariatric and minimally invasive surgery at Stanford (Calif.) University School of Medicine and past president of the American Society for Metabolic and Bariatric Surgery, doesn’t think discrimination is causing the disparity.
“It’s probably a reflection of insurance status – Hispanics tend to be less insured than Caucasian or African American patients – as well as preference for patients to go to nonacademic centers,” he said.
Indeed, a Kaiser Family Foundation analysis found that 21% of the 52 million Hispanics younger than 65 years in the United States were uninsured in 2015, compared with 9% of whites and 13% of blacks. Only Native Americans/Alaska Natives had an uninsured rate as high as Hispanics.
“In terms of need [for weight-loss features], it’s certainly there for Hispanics,” said Dr. Morton. “[Hispanic patients] have high rates of obesity and diabetes, both of which are helped by bariatric surgery.”
He said about 40% of patients in his Palo Alto, Calif., practice are Hispanic, reflecting the high number in the local population.
It helps that Dr. Morton and several of his partners speak Spanish. “If you have a welcoming environment,” he said, “that can make a difference.”
The study authors and Dr. Morton report no relevant disclosures. No specific study funding is reported.
SAN DIEGO – A study of procedures at academic centers provides evidence that obese Hispanics in the United States undergo bariatric surgery at a much lower rate than whites and blacks. It also reveals marked regional variations in overall weight-loss surgery.
“Our findings do suggest that severely obese Hispanics are utilizing bariatric surgery much lower than other ethnic groups,” said study coauthor Ninh T. Nguyen, MD, FACS, chair of the department of surgery at the University of California Irvine Medical Center, in an interview. “Our research does not specifically address the reasons for this gap in the delivery of care. Further research will need to be done to understand the reasons and the ways to close this gap.”
According to Dr. Nguyen, the researchers undertook the study to better understand how bariatric surgery is delivered across ethnicities and geographic regions in the United States.
The researchers analyzed statistics from the Vizient health care performance database for the years 2013-2015. They focused on patients at about 120 academic centers who underwent 73,119 laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding procedures. The patients were stratified by race and region.
Researchers found that bariatric procedures were performed at a much higher rate in the Northeast academic centers (2.21 per 1,000 obese persons), compared with the Midwest (0.73), South (0.50), and West (0.33).
In regard to race, the rates for blacks and whites were fairly similar in the Northwest (2.02 and 2.35 bariatric procedures per 1,000 obese persons, respectively), the South (0.59 and 0.63, respectively) and the West (0.45 and 0.43, respectively). There was a wider gap in the Midwest, with whites at 0.69 and blacks at 1.07.
Across the country, however, obese Hispanics were less likely than persons of the other two races to undergo weight-loss surgery. The gap was fairly small in the Northeast, where 1.74 per 1,000 obese Hispanics underwent weight-loss surgery, compared with rates of 2.02 and 2.35 among whites and blacks, respectively. But the disparity was much larger in the other parts of the country, with rates at 0.14 in the West, 0.11 in the South and 0.33 in the Midwest, compared with rates from 0.43 to 1.07 among blacks and whites.
The reasons for the surgery gap are unknown. Dr. Nguyen pointed to several possible explanations: “lack of education of obesity as a disease by the primary care providers and the need for referral to a bariatric surgeon for patients with body mass index greater than 40 kg/m2 or 35 kg/m2 with obesity-related comorbidities; poor understanding of the benefits of bariatric surgery and its low risk; lack of understanding of the urgency for treatment by the patient and provider; and hurdles in obtaining coverage for the operation by insurers.”
John Magaña Morton, MD, FACS, chief of bariatric and minimally invasive surgery at Stanford (Calif.) University School of Medicine and past president of the American Society for Metabolic and Bariatric Surgery, doesn’t think discrimination is causing the disparity.
“It’s probably a reflection of insurance status – Hispanics tend to be less insured than Caucasian or African American patients – as well as preference for patients to go to nonacademic centers,” he said.
Indeed, a Kaiser Family Foundation analysis found that 21% of the 52 million Hispanics younger than 65 years in the United States were uninsured in 2015, compared with 9% of whites and 13% of blacks. Only Native Americans/Alaska Natives had an uninsured rate as high as Hispanics.
“In terms of need [for weight-loss features], it’s certainly there for Hispanics,” said Dr. Morton. “[Hispanic patients] have high rates of obesity and diabetes, both of which are helped by bariatric surgery.”
He said about 40% of patients in his Palo Alto, Calif., practice are Hispanic, reflecting the high number in the local population.
It helps that Dr. Morton and several of his partners speak Spanish. “If you have a welcoming environment,” he said, “that can make a difference.”
The study authors and Dr. Morton report no relevant disclosures. No specific study funding is reported.
SAN DIEGO – A study of procedures at academic centers provides evidence that obese Hispanics in the United States undergo bariatric surgery at a much lower rate than whites and blacks. It also reveals marked regional variations in overall weight-loss surgery.
“Our findings do suggest that severely obese Hispanics are utilizing bariatric surgery much lower than other ethnic groups,” said study coauthor Ninh T. Nguyen, MD, FACS, chair of the department of surgery at the University of California Irvine Medical Center, in an interview. “Our research does not specifically address the reasons for this gap in the delivery of care. Further research will need to be done to understand the reasons and the ways to close this gap.”
According to Dr. Nguyen, the researchers undertook the study to better understand how bariatric surgery is delivered across ethnicities and geographic regions in the United States.
The researchers analyzed statistics from the Vizient health care performance database for the years 2013-2015. They focused on patients at about 120 academic centers who underwent 73,119 laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding procedures. The patients were stratified by race and region.
Researchers found that bariatric procedures were performed at a much higher rate in the Northeast academic centers (2.21 per 1,000 obese persons), compared with the Midwest (0.73), South (0.50), and West (0.33).
In regard to race, the rates for blacks and whites were fairly similar in the Northwest (2.02 and 2.35 bariatric procedures per 1,000 obese persons, respectively), the South (0.59 and 0.63, respectively) and the West (0.45 and 0.43, respectively). There was a wider gap in the Midwest, with whites at 0.69 and blacks at 1.07.
Across the country, however, obese Hispanics were less likely than persons of the other two races to undergo weight-loss surgery. The gap was fairly small in the Northeast, where 1.74 per 1,000 obese Hispanics underwent weight-loss surgery, compared with rates of 2.02 and 2.35 among whites and blacks, respectively. But the disparity was much larger in the other parts of the country, with rates at 0.14 in the West, 0.11 in the South and 0.33 in the Midwest, compared with rates from 0.43 to 1.07 among blacks and whites.
The reasons for the surgery gap are unknown. Dr. Nguyen pointed to several possible explanations: “lack of education of obesity as a disease by the primary care providers and the need for referral to a bariatric surgeon for patients with body mass index greater than 40 kg/m2 or 35 kg/m2 with obesity-related comorbidities; poor understanding of the benefits of bariatric surgery and its low risk; lack of understanding of the urgency for treatment by the patient and provider; and hurdles in obtaining coverage for the operation by insurers.”
John Magaña Morton, MD, FACS, chief of bariatric and minimally invasive surgery at Stanford (Calif.) University School of Medicine and past president of the American Society for Metabolic and Bariatric Surgery, doesn’t think discrimination is causing the disparity.
“It’s probably a reflection of insurance status – Hispanics tend to be less insured than Caucasian or African American patients – as well as preference for patients to go to nonacademic centers,” he said.
Indeed, a Kaiser Family Foundation analysis found that 21% of the 52 million Hispanics younger than 65 years in the United States were uninsured in 2015, compared with 9% of whites and 13% of blacks. Only Native Americans/Alaska Natives had an uninsured rate as high as Hispanics.
“In terms of need [for weight-loss features], it’s certainly there for Hispanics,” said Dr. Morton. “[Hispanic patients] have high rates of obesity and diabetes, both of which are helped by bariatric surgery.”
He said about 40% of patients in his Palo Alto, Calif., practice are Hispanic, reflecting the high number in the local population.
It helps that Dr. Morton and several of his partners speak Spanish. “If you have a welcoming environment,” he said, “that can make a difference.”
The study authors and Dr. Morton report no relevant disclosures. No specific study funding is reported.
AT THE ACS CLINICAL CONGRESS
Key clinical point: At academic centers, obese Hispanics undergo bariatric surgery at a much lower rate than blacks and whites. U.S. regions outside the Northeast have lower rates of weight-loss procedures overall.
Major finding: Outside the Northeast, the bariatric surgery rate per 1,000 obese people is much lower for Hispanics (range, 0.11-0.33) than for blacks and whites (range, 0.43-1.07).
Data source: Analysis of 73,119 bariatric procedures from 2013-2015 at about 120 academic centers.
Disclosures: The study authors report no relevant disclosures. No specific study funding is reported.
CMS to enlist Medicare Part D plans to combat opioid abuse
The Centers for Medicare & Medicaid Services aims to enlist the help of Medicare Part D plan sponsors in fighting opioid abuse, under a proposed rule scheduled for publication in the Federal Register on Nov. 28.
The agency is proposing to expand monitoring of patients taking opioids in its current Part D Opioid Drug Utilization Review (DUR) and Overutilization Monitoring System (OMS). To do so, officials would like to extend the use the criteria for overutilizers to identify at-risk beneficiaries. Part D plans then would be allowed to restrict at-risk beneficiaries’ access to opioids to a selected prescriber and/or network pharmacy, according to a fact sheet on proposal, which is part of the proposed 2018 update to regulations governing Medicare Advantage and Medicare Part D.
Under the proposal, plans would not be required to use these tools. However, CMS expects they will.
“While plan sponsors would have the option to implement a drug management program, our proposal codifies a framework that would place requirements upon such programs,” according to the proposal. “We foresee that all plan sponsors will implement such drug management programs based on our experience that all plan sponsors’ are complying with the current policy as laid out in guidance, the fact that our proposal largely incorporates the CARA [Comprehensive Addiction and Recovery Act of 2016] drug management provisions into existing CMS and sponsor operations, and especially, in light of the national opioid epidemic and the declaration that the opioid crisis is a nationwide Public Health Emergency.”
According to the proposal, potentially at-risk and at-risk beneficiaries would be identified based on the type and frequency of prescriptions. Those include the use of opioids with an average daily morphine milligram equivalent (MME) greater than or equal to 90 mg for any duration during the most recent 6 months and either four or more opioid prescribers plus four or more opioid-dispensing pharmacies or six or more opioid prescribers, regardless of pharmacies.
CMS notes in the regulation that, if the proposed 2019 criteria were used against those enrolled in Medicare Part D in 2015, it would have identified as at-risk about 33,000 Part D beneficiaries, or 0.08% of the 42 million people enrolled at that time. The agency said this population should be manageable for oversight by Part D plan sponsors, noting that, in Medicaid in 2015, 0.37% were included in some kind of pharmacy/prescriber lock-in program.
The proposed regulation includes an exemption for patients diagnosed with cancer, those in hospice, and those in a long-term care facility. CMS also plans to limit the availability of the special enrollment period for dual-eligible beneficiaries (those who qualify for both Medicare and Medicaid) and those who receive the low-income subsidy who are identified as at risk or potentially at risk.
Beneficiaries would be allowed to appeal their at-risk/potential at-risk determination under the proposal.
The Centers for Medicare & Medicaid Services aims to enlist the help of Medicare Part D plan sponsors in fighting opioid abuse, under a proposed rule scheduled for publication in the Federal Register on Nov. 28.
The agency is proposing to expand monitoring of patients taking opioids in its current Part D Opioid Drug Utilization Review (DUR) and Overutilization Monitoring System (OMS). To do so, officials would like to extend the use the criteria for overutilizers to identify at-risk beneficiaries. Part D plans then would be allowed to restrict at-risk beneficiaries’ access to opioids to a selected prescriber and/or network pharmacy, according to a fact sheet on proposal, which is part of the proposed 2018 update to regulations governing Medicare Advantage and Medicare Part D.
Under the proposal, plans would not be required to use these tools. However, CMS expects they will.
“While plan sponsors would have the option to implement a drug management program, our proposal codifies a framework that would place requirements upon such programs,” according to the proposal. “We foresee that all plan sponsors will implement such drug management programs based on our experience that all plan sponsors’ are complying with the current policy as laid out in guidance, the fact that our proposal largely incorporates the CARA [Comprehensive Addiction and Recovery Act of 2016] drug management provisions into existing CMS and sponsor operations, and especially, in light of the national opioid epidemic and the declaration that the opioid crisis is a nationwide Public Health Emergency.”
According to the proposal, potentially at-risk and at-risk beneficiaries would be identified based on the type and frequency of prescriptions. Those include the use of opioids with an average daily morphine milligram equivalent (MME) greater than or equal to 90 mg for any duration during the most recent 6 months and either four or more opioid prescribers plus four or more opioid-dispensing pharmacies or six or more opioid prescribers, regardless of pharmacies.
CMS notes in the regulation that, if the proposed 2019 criteria were used against those enrolled in Medicare Part D in 2015, it would have identified as at-risk about 33,000 Part D beneficiaries, or 0.08% of the 42 million people enrolled at that time. The agency said this population should be manageable for oversight by Part D plan sponsors, noting that, in Medicaid in 2015, 0.37% were included in some kind of pharmacy/prescriber lock-in program.
The proposed regulation includes an exemption for patients diagnosed with cancer, those in hospice, and those in a long-term care facility. CMS also plans to limit the availability of the special enrollment period for dual-eligible beneficiaries (those who qualify for both Medicare and Medicaid) and those who receive the low-income subsidy who are identified as at risk or potentially at risk.
Beneficiaries would be allowed to appeal their at-risk/potential at-risk determination under the proposal.
The Centers for Medicare & Medicaid Services aims to enlist the help of Medicare Part D plan sponsors in fighting opioid abuse, under a proposed rule scheduled for publication in the Federal Register on Nov. 28.
The agency is proposing to expand monitoring of patients taking opioids in its current Part D Opioid Drug Utilization Review (DUR) and Overutilization Monitoring System (OMS). To do so, officials would like to extend the use the criteria for overutilizers to identify at-risk beneficiaries. Part D plans then would be allowed to restrict at-risk beneficiaries’ access to opioids to a selected prescriber and/or network pharmacy, according to a fact sheet on proposal, which is part of the proposed 2018 update to regulations governing Medicare Advantage and Medicare Part D.
Under the proposal, plans would not be required to use these tools. However, CMS expects they will.
“While plan sponsors would have the option to implement a drug management program, our proposal codifies a framework that would place requirements upon such programs,” according to the proposal. “We foresee that all plan sponsors will implement such drug management programs based on our experience that all plan sponsors’ are complying with the current policy as laid out in guidance, the fact that our proposal largely incorporates the CARA [Comprehensive Addiction and Recovery Act of 2016] drug management provisions into existing CMS and sponsor operations, and especially, in light of the national opioid epidemic and the declaration that the opioid crisis is a nationwide Public Health Emergency.”
According to the proposal, potentially at-risk and at-risk beneficiaries would be identified based on the type and frequency of prescriptions. Those include the use of opioids with an average daily morphine milligram equivalent (MME) greater than or equal to 90 mg for any duration during the most recent 6 months and either four or more opioid prescribers plus four or more opioid-dispensing pharmacies or six or more opioid prescribers, regardless of pharmacies.
CMS notes in the regulation that, if the proposed 2019 criteria were used against those enrolled in Medicare Part D in 2015, it would have identified as at-risk about 33,000 Part D beneficiaries, or 0.08% of the 42 million people enrolled at that time. The agency said this population should be manageable for oversight by Part D plan sponsors, noting that, in Medicaid in 2015, 0.37% were included in some kind of pharmacy/prescriber lock-in program.
The proposed regulation includes an exemption for patients diagnosed with cancer, those in hospice, and those in a long-term care facility. CMS also plans to limit the availability of the special enrollment period for dual-eligible beneficiaries (those who qualify for both Medicare and Medicaid) and those who receive the low-income subsidy who are identified as at risk or potentially at risk.
Beneficiaries would be allowed to appeal their at-risk/potential at-risk determination under the proposal.
For women with RA, small-joint surgery rate nearly twice that of men
SAN DIEGO – but the rate of small-joint procedures is declining for both sexes. However, no differences in rates of large-joint procedures between sexes were observed during the same time period.
Those are key findings from a retrospective study which set out to determine if there are sex differences in the incidence and trends of large- versus small-joint surgery rates in rheumatoid arthritis over time. “Why is orthopedic surgery important to rheumatology? The main reason is because it’s a surrogate for failed medical management,” lead study author Michael D. Richter, MD, said at the annual meeting of the American College of Rheumatology.
Dr. Richter, an internal medicine resident at Mayo Clinic, Rochester, Minn., said that women with RA generally present with more severe symptoms and higher rates of disability, while men have a better treatment response and a higher remission rate. For example, results from the multinational Quantitative Standard Monitoring of Patients with RA study found that remission rates were around 30% in men and 17% in women (Arthritis Res Ther. 2009;11[1]:R7). “However, a lot of these studies are criticized because it’s thought that gender can play a role in the disease measures,” he said. “By looking at joint surgery we have an objective outcome, and we can look at differences in treatment efficacy.”
Dr. Richter and his associates drew from the Rochester Epidemiology Project to identify 1,077 patients from Olmstead County, Minn., who fulfilled ACR criteria for RA between 1980 and 2013, and who were followed up until death, migration, or July 1, 2016. They classified surgeries as small joint (wrist, hand, or foot) or large joint (shoulder, elbow, hip, knee, or ankle). A majority of the patients (70%) were women. Compared with women, men were slightly older at diagnosis (a mean of 58 years vs. 55 years, respectively), were more likely to have a history of smoking (67% vs. 46%), and were more likely to have large-joint swelling upon initial presentation (49% vs. 42%). The mean follow-up was 12 years. No differences between men and women were noted in obesity, inflammatory biomarkers, or seropositivity.
During the study period, 112 patients underwent at least one small-joint surgery, 90 of whom were women (80%). The cumulative incidence of small-joint surgery at 15 years was nearly double that of men: 14.4% vs. 7.6%, respectively (P = .008). “Prior to the year 2000 there were no significant trends in the rate of small-joint surgery but it was more common in women,” he said. “After 2000 there was a significant decline for men and women (P = .002), but no significant difference between sexes.”
At the same time, 204 patients underwent at least one large-joint surgery during the time period, 141 of whom were women (69%). The cumulative incidence of large-joint surgery at 15 years was 20.2% for women and 18.8% for men, which was statistically similar (P = .55). “We saw no significant change over time in the rate of large-joint surgery from 1980 to 2016,” Dr. Richter said. “This is in contrast to what we see in the general population, where orthopedic procedures for osteoarthritis are more common.”
He acknowledged certain limitations of the study, including its retrospective design and the fact that the researchers were unable to include specific surgical indications in the analysis. “This becomes particularly important for the large-joint procedures,” he said. “We don’t know if osteoarthritis or chronic inflammatory arthritis is leading to the large-joint procedure.”
The National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institute on Aging funded the study. Dr. Richter reported having no financial disclosures.
SAN DIEGO – but the rate of small-joint procedures is declining for both sexes. However, no differences in rates of large-joint procedures between sexes were observed during the same time period.
Those are key findings from a retrospective study which set out to determine if there are sex differences in the incidence and trends of large- versus small-joint surgery rates in rheumatoid arthritis over time. “Why is orthopedic surgery important to rheumatology? The main reason is because it’s a surrogate for failed medical management,” lead study author Michael D. Richter, MD, said at the annual meeting of the American College of Rheumatology.
Dr. Richter, an internal medicine resident at Mayo Clinic, Rochester, Minn., said that women with RA generally present with more severe symptoms and higher rates of disability, while men have a better treatment response and a higher remission rate. For example, results from the multinational Quantitative Standard Monitoring of Patients with RA study found that remission rates were around 30% in men and 17% in women (Arthritis Res Ther. 2009;11[1]:R7). “However, a lot of these studies are criticized because it’s thought that gender can play a role in the disease measures,” he said. “By looking at joint surgery we have an objective outcome, and we can look at differences in treatment efficacy.”
Dr. Richter and his associates drew from the Rochester Epidemiology Project to identify 1,077 patients from Olmstead County, Minn., who fulfilled ACR criteria for RA between 1980 and 2013, and who were followed up until death, migration, or July 1, 2016. They classified surgeries as small joint (wrist, hand, or foot) or large joint (shoulder, elbow, hip, knee, or ankle). A majority of the patients (70%) were women. Compared with women, men were slightly older at diagnosis (a mean of 58 years vs. 55 years, respectively), were more likely to have a history of smoking (67% vs. 46%), and were more likely to have large-joint swelling upon initial presentation (49% vs. 42%). The mean follow-up was 12 years. No differences between men and women were noted in obesity, inflammatory biomarkers, or seropositivity.
During the study period, 112 patients underwent at least one small-joint surgery, 90 of whom were women (80%). The cumulative incidence of small-joint surgery at 15 years was nearly double that of men: 14.4% vs. 7.6%, respectively (P = .008). “Prior to the year 2000 there were no significant trends in the rate of small-joint surgery but it was more common in women,” he said. “After 2000 there was a significant decline for men and women (P = .002), but no significant difference between sexes.”
At the same time, 204 patients underwent at least one large-joint surgery during the time period, 141 of whom were women (69%). The cumulative incidence of large-joint surgery at 15 years was 20.2% for women and 18.8% for men, which was statistically similar (P = .55). “We saw no significant change over time in the rate of large-joint surgery from 1980 to 2016,” Dr. Richter said. “This is in contrast to what we see in the general population, where orthopedic procedures for osteoarthritis are more common.”
He acknowledged certain limitations of the study, including its retrospective design and the fact that the researchers were unable to include specific surgical indications in the analysis. “This becomes particularly important for the large-joint procedures,” he said. “We don’t know if osteoarthritis or chronic inflammatory arthritis is leading to the large-joint procedure.”
The National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institute on Aging funded the study. Dr. Richter reported having no financial disclosures.
SAN DIEGO – but the rate of small-joint procedures is declining for both sexes. However, no differences in rates of large-joint procedures between sexes were observed during the same time period.
Those are key findings from a retrospective study which set out to determine if there are sex differences in the incidence and trends of large- versus small-joint surgery rates in rheumatoid arthritis over time. “Why is orthopedic surgery important to rheumatology? The main reason is because it’s a surrogate for failed medical management,” lead study author Michael D. Richter, MD, said at the annual meeting of the American College of Rheumatology.
Dr. Richter, an internal medicine resident at Mayo Clinic, Rochester, Minn., said that women with RA generally present with more severe symptoms and higher rates of disability, while men have a better treatment response and a higher remission rate. For example, results from the multinational Quantitative Standard Monitoring of Patients with RA study found that remission rates were around 30% in men and 17% in women (Arthritis Res Ther. 2009;11[1]:R7). “However, a lot of these studies are criticized because it’s thought that gender can play a role in the disease measures,” he said. “By looking at joint surgery we have an objective outcome, and we can look at differences in treatment efficacy.”
Dr. Richter and his associates drew from the Rochester Epidemiology Project to identify 1,077 patients from Olmstead County, Minn., who fulfilled ACR criteria for RA between 1980 and 2013, and who were followed up until death, migration, or July 1, 2016. They classified surgeries as small joint (wrist, hand, or foot) or large joint (shoulder, elbow, hip, knee, or ankle). A majority of the patients (70%) were women. Compared with women, men were slightly older at diagnosis (a mean of 58 years vs. 55 years, respectively), were more likely to have a history of smoking (67% vs. 46%), and were more likely to have large-joint swelling upon initial presentation (49% vs. 42%). The mean follow-up was 12 years. No differences between men and women were noted in obesity, inflammatory biomarkers, or seropositivity.
During the study period, 112 patients underwent at least one small-joint surgery, 90 of whom were women (80%). The cumulative incidence of small-joint surgery at 15 years was nearly double that of men: 14.4% vs. 7.6%, respectively (P = .008). “Prior to the year 2000 there were no significant trends in the rate of small-joint surgery but it was more common in women,” he said. “After 2000 there was a significant decline for men and women (P = .002), but no significant difference between sexes.”
At the same time, 204 patients underwent at least one large-joint surgery during the time period, 141 of whom were women (69%). The cumulative incidence of large-joint surgery at 15 years was 20.2% for women and 18.8% for men, which was statistically similar (P = .55). “We saw no significant change over time in the rate of large-joint surgery from 1980 to 2016,” Dr. Richter said. “This is in contrast to what we see in the general population, where orthopedic procedures for osteoarthritis are more common.”
He acknowledged certain limitations of the study, including its retrospective design and the fact that the researchers were unable to include specific surgical indications in the analysis. “This becomes particularly important for the large-joint procedures,” he said. “We don’t know if osteoarthritis or chronic inflammatory arthritis is leading to the large-joint procedure.”
The National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institute on Aging funded the study. Dr. Richter reported having no financial disclosures.
AT ACR 2017
Key clinical point: Women with RA had a higher rate of small-joint surgery, compared with men.
Major finding: The cumulative incidence of small-joint surgery was significantly higher among women, compared with men (14.4% vs. 7.6%, respectively), but there were no differences between sexes in the rates of large-joint surgery.
Study details: A retrospective, population-based study of 1,077 patients with RA.
Disclosures: The National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institute on Aging funded the study. Dr. Richter reported having no financial disclosures.