Wednesday, August 31, 2022

Hot topics in health policy

Last night, in a short talk to medical students and residents on "Health Policy in Family Medicine," I outlined three paths to become involved in the health policy space as a family physician, paralleling the ways that policy has intersected with my own career:

1. Clinical guidance and practice guidelines. How do research findings make their way into clinical practice recommendations? Where evidence is lacking or inconclusive, how are the judgment calls made and who gets to make them? Examples include my experiences as a medical officer for the U.S. Preventive Services Task Force, a guideline panelist for the American Academy of Family Physicians and collaborating specialty groups, and a member of the HHS Secretary's Advisory Committee on Breast Cancer in Young Women.

2. Advocacy for patients and population health. Advocacy can take many forms: interpersonal (e.g., lobbying local, state, or federal officials), writing opinion pieces, or serving as a source for a news story. I consider Common Sense Family Doctor and my Twitter account to be my main advocacy platforms, though on occasion I've written editorials in high-profile publications such as JAMA. During the COVID-19 pandemic, I spent a good deal of time pushing back against vaccine hesitancy and anti-vax sentiments in my community and online.

3. Advocacy for health professionals and primary care. While at Georgetown, I directed a health policy fellowship that trained recent family medicine residency graduates in research that demonstrated the value (and financially undervalued nature) of primary care. I continue to support the Robert Graham Center's work by publishing an ongoing series of Policy One-Pagers in American Family Physician.

Health policy isn't an abstract subject for me. In my medical career, I've seen firsthand the benefits to patients of the 2003 Medicare Modernization Act (which provided prescription drug coverage to millions of older adults), the 2010 Affordable Care Act (which extended access to affordable health insurance to tens of millions and provided consumer protections and guaranteed preventive services to all), and this year's Inflation Reduction Act, which allows Medicare to negotiate the prices of a limited number of expensive drugs, caps Medicare patients' out-of-pocket insulin costs at $35 per month and their total prescription out-of-pocket costs at $2000 per year. In addition, the IRA extended enhanced health insurance marketplace subsidies that were set to expire this year through 2025, which will preserve the affordability of private plans for lower-income patients who are self-employed or work for small employers that don't offer health care benefits. This legislation will make a major difference in many of my patients' lives by making it easier for me to provide them with the best care possible.

Friday, August 19, 2022

Diabetes is an increasingly common pregnancy complication

My clinical experiences suggest that more pregnant patients have been developing diabetes over the past several years, and it turns out this is a national phenomenon. A recent report from the Centers for Disease Control and Prevention documented a precipitous rise in the rate of gestational diabetes in the U.S. from 2016 to 2020, based on data collected from birth certificates. In 2020, gestational diabetes affected 7.8% of all pregnancies, reflecting a 13% increase since 2019 and a 30% increase since 2016. Prevalence increased with increasing age (2.5% in patients younger than 20 years and 15.3% in those aged 40 or older) and increasing pre-pregnancy body mass index (BMI). Both factors are likely driving the overall rise in gestational diabetes; the median age at which U.S. women gave birth reached an all-time high of 30 years in 2019 and only 2 in 5 women with a live birth in 2020 had a normal BMI prior to pregnancy.

The U.S. Preventive Services Task Force (USPSTF) recommends screening for gestational diabetes in asymptomatic pregnant patients at or after 24 weeks of gestation. Although the USPSTF did not identify a preferred test, a previously discussed study suggested that the two-step approach (a non-fasting 50 gram oral glucose challenge test followed by a fasting 100 gram glucose tolerance test if the first test is positive) "produces equivalent benefits, and fewer harms, than the one-step approach."

Adverse outcomes associated with gestational diabetes include gestational hypertension, preeclampsia, shoulder dystocia, macrosomia, and Cesarean delivery. Gestational diabetes also confers a 7-fold greater maternal risk of developing type 2 diabetes later in life and 1.5 times greater risk of the child being overweight in childhood or adolescence. Management of gestational diabetes begins with glucose self-monitoring and lifestyle modifications, followed by oral medication or insulin if target blood glucose levels are not achieved.

Prevention of gestational diabetes includes counseling on appropriate weight gain goals based on pre-pregnancy BMI, which can generally be achieved by averaging "350 to 450 calories per day above the previous intake (e.g., two slices of bread with half an avocado, ¾ cup of Greek yogurt or 1 cup of blueberries with two hard-boiled eggs)." Additionally, "patients should be encouraged to engage in moderate aerobic activity most days of the week for at least 20 to 30 minutes at a time, for a total of at least 150 minutes per week." The USPSTF recommends offering behavioral counseling interventions for healthy weight and weight gain in pregnancy; effective interventions generally started at the end of the first trimester and varied in duration and intensity (from 15 to 120 minutes and from 1 to more than 12 total contacts).


This post first appeared on the AFP Community Blog.

Monday, August 8, 2022

Preventive services mandate can be improved, but eliminating it isn't the answer

Over the past 12 years since the Affordable Care Act became law, individuals, business groups, and state officials who object to one or more of its provisions have filed a lengthy list of mostly unsuccessful lawsuits seeking to have part or all of it declared unconstitutional by the courts. The latest legal challenge involves the requirement that private health insurers cover without patient cost-sharing all evidence-based preventive services, defined as more than 100 services recommended by the Advisory Committee on Immunization Practices, the U.S. Preventive Services Task Force, Bright Futures, or the Women's Preventive Service Initiative. When I went to my family doctor last month and received screening tests for colorectal cancer, high blood pressure, and cholesterol, these tests were all covered under the ACA's preventive services mandate. When I take my kids to receive their school-required vaccinations, those shots are fully covered too. The same goes for the costs of clinicians counseling pregnant patients about healthy weight and weight gain to prevent complications such as gestational diabetes, and similar counseling for to midlife women (aged 40 to 60 years) to maintain weight or limit weight gain to prevent obesity.

Why would anyone have a problem with requiring insurers to cover preventive services? Some employers have religious or ideological objections to paying for birth control and sterilization, preexposure prophylaxis for HIV prevention, or testing for sexually transmitted diseases. Others might oppose the increased employer or government contribution to insurance premiums that may result from mandating that these services be covered, though in reality the types of health care that drive up premiums tend to be pricey procedures and medications such as the Alzheimer's drug Aduhelm, whose initial projected price of $56,000 per year drove the highest-ever increase in Medicare premiums from 2021 to 2022.

Ensuring that patients can afford preventive services is only the first step toward getting them done. Only about two-thirds of eligible adults are up-to-date on colorectal cancer screening, for example, and a much lower percentage of current or past heavy smokers over age 50 have been offered or received lung cancer screening. Behavioral health preventive services such as screening for depression, intimate partner violence, and unhealthy alcohol use can be difficult to fit into clinical practice workflows that rely on dysfunctional electronic health records (systems that are optimized for billing rather than patient care).

The narrow focus of the ACA's preventive services mandate on health care services also leaves out other private and public programs that can have large benefits on disease prevention and care. For example, the final report of the National Clinical Care Commission included population-level diabetes prevention recommendations involving the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, and the Department of Housing and Urban Development. A related analysis article in Health Affairs bemoaned the fragmented state of US health care and policy that has stalled progress in preventing and controlling type 2 diabetes:

At the population level, fragmentation and lack of shared population health goals across stakeholders mean that there is no ownership for large segments of the population who are at risk for or have diabetes. Payers carry the liability for the health service costs of their beneficiaries and can track utilization. Enrollee churn reduces payers' incentives to take on long-term responsibility or investments in higher-quality preventive services for which returns are only realized in the long term. ... Similarly, the movement of people between health systems undermines incentives for long-term, high-value care.

So you'll get no pushback from me if you observe that there are lots of flaws and loopholes in the preventive services mandate (beginning with the fact that it doesn't even apply to half of Americans who are either publicly insured or uninsured). But getting rid of it is throwing the baby out with the bathwater: an exceedingly dumb and harmful proposition that would result in more preventable illness and poorer quality of life for millions of Americans.