News & Analysis Medical News & Perspectives.....p1604
Health Agencies Update .............p1608
News From the CDC ......................p1610
Filling the Gaps in Preventive Care Services for Older Adults
Report Outlines Benefits of Raising Minimum Age to Buy Cigarettes
Five-Year US Cancer Survival Is 65%
The JAMA Forum .........................p1606
Billions Recovered by Anti–Health Care Fraud Effort
Payment Reform Is About to Become a Reality
Depression More Prevalent in Unemployed Young Adults
Antiherpes Drug May Suppress HIV Levels
Clinical Trials Update ...................p1609 Meditation Promotes Better Sleep in Older Adults New HPV Vaccine Provides Wider Protection Consuming—Not Avoiding—Peanuts Leads to Fewer Peanut Allergies in Kids Hepatitis E Vaccine Effective for 4.5 Years
Medical News & Perspectives
Filling the Gaps in Preventive Care Services for Older Adults Rita Rubin, MA
O
n Election Day 2012, voters at polling places in 48 US states could choose not only a presidential candidate but whether to get a flu vaccination. More than 9000 voters opted to be immunized through the “Vote and Vax” program that year, and more than half of them reported that they did not regularly get flu shots (Shenson D et al. Am J Public Health. doi:10.2105/AJPH.2015.302628 [published online April 16th 2015]). While likely not the first setting that comes to mind, the polling place represents a logical location for efforts to boost the rate of older individuals who are up-todate on core preventive services such as immunization. After all, more than half of the more than 120 million voters in a US presidential election are 50 years or older, said Douglas Shenson, MD, MPH, national director of Vote and Vax. There’s definitely room for improvement, especially considering the “silver tsunami,” consisting mostly of aging baby boomers. The US population 65 years or older is expected to more than double between 2010 and 2050, when it will swell to nearly 89 million (Ogden LL et al. Am J Public Health. 2012;102[3]:419-425). Today in the United States, fewer than half of people aged 65 years and older are up-to-date on the core set of clinical preventive services: screening tests, immunizations, health behavior counseling, and pre1604
ventive medications. Only a quarter of those aged 50 to 64 years meet preventive services recommendations (http://1.usa.gov /1MUJN7B). And black and Hispanic older adults are even less likely to receive preventive services than their white peers (http://1 .usa.gov/1FsnzV8). For example, the proportion of people 60 years and older in the United States who reported receiving a herpes zoster vaccination, as recommended for that age group, was only 24.2% in 2013—below the Healthy People 2020 goal of 30%, according to a recent report from the Centers for Disease Control and Prevention (CDC) (Williams WW et al. Morb Mortal Wkly Rep. 2015;64[4]:95-102). Similarly, for those 65 years and older, the recommended age group for the pneumococcal vaccine, 59.7% reported having gotten that shot—again, far below the Healthy People 2020 goal of 90%. Some Healthy People 2020 goals related to preventive services for older adults, such as having a mammogram within the past 2 years and having been screened for colorectal cancer, have already been met. But the United States still falls short of reaching 2020 targets for other preventive services, as well as the goal of having 46% of men and 43.1% of women 65 years and older up-to-date on all of the core services (http: //1.usa.gov/1NzFtYV and http://1.usa.gov /1LGY5aA).
“When we’re less than 50%, we have a long way to go,” Lynda Anderson, PhD, director of the CDC’s Healthy Aging Program, said in an interview. “It’s interesting that people who are getting some of these (services) aren’t getting all of them.” Research shows that only a minority of Medicare enrollees take advantage of the free annual preventive visits the program began offering in 2011, and even those older adults who see a doctor regularly are not upto-date on preventive services. Typically, chronic conditions get the most attention at older patients’ medical appointments, Anderson said. “A lot of the preventive issues don’t rise to the top,” she said. “If their provider isn’t telling them it’s important to get that vaccination, inadvertently it does send the message that it’s not important.” Shenson, an associate clinical professor of epidemiology at the Yale School of Medicine who has studied the issue for nearly 20 years, says conventional wisdom used to place the blame squarely on physicians and patients: physicians didn’t place a high priority on preventive care, patients didn’t ask for it or weren’t receptive to it, and physicians’ offices neglected to flag the records for patients who hadn’t received a particular vaccine or screening. No question, all of those factors play a role. But the roots of the problem extend beyond the physician’s office to a US health
JAMA April 28, 2015 Volume 313, Number 16 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of California - San Diego User on 06/03/2015
jama.com
News & Analysis
care system that is designed to care for sick patients, not help prevent them from getting sick in the first place, Shenson said, who also serves as associate director of clinical preventive services at the Yale-Griffin Prevention Research Center. Time is certainly an issue, too. “The doctor’s visit is so short,” Shenson said. “It’s not surprising that we don’t do better. We’ve sort of breathed down the neck of physicians and said, ‘You’ve got to do this, you’ve got to do that.’” During his internal medicine residency, Shenson said, “I found it very challenging to find enough time to explain to every one of my patients over age 50 why screening for colon cancer is so important and potentially life-saving.” The topic of colon cancer screening is off-putting to many people, he said, so “this is not a conversation you can rush through. And that’s why I’m hoping the recent changes in Medicare reimbursement and preventive service visits will make an important difference.”
Checking Up on Checkups Under the Affordable Care Act (ACA), Medicare began fully covering annual preventive care visits in 2011. And since 2005, the program has offered new enrollees a 1-time initial preventive “Welcome to Medicare” visit, at which physicians are expected to discuss advanced directives, create a written plan of needed preventive services, screen for depression and safety, check vision and blood pressure, and calculate body mass index (http://1.usa.gov/1DaNQVm). But only 3% of eligible enrollees in 2006 and 2007 had such a visit, which must be made in the first year after Medicare enrollment, health care researcher Sukyung Chung, PhD, of the Palo Alto Medical Foundation, said in an interview. “Patients didn’t know much about it, and the window was really narrow.” Although more beneficiaries are scheduling preventive care visits since Medicare began covering them, many still do not, Chung and her coauthors found in a recent study (Chung S et al. Health Aff. 2015;34[1]: 11-20). Chung’s team analyzed 2007 to 2013 data from primary care patients 65 years and older at the Palo Alto Medical Foundation, which serves people in 4 counties near San Francisco. Before implementation of the ACA, only 1.4% of Medicare fee-for-service jama.com
patients, who represent the majority of enrollees, had a preventive visit each year, the authors found. After ACA implementation, that proportion jumped to 27.5%, but it was still 10 to 20 percentage points lower than that for people 65 years and older who were insured through their employer or those in a Medicare health maintenance organization (HMO), which has traditionally encouraged preventive visits as potentially cost-saving as well as necessary to adhere to medical guidelines. The annual rate of preventive visits was somewhat lower in seniors insured through their employer than those in a Medicare HMO, the authors wrote, possibly because they didn’t give preventive care as high a priority or they had a tough time fitting an appointment into their busy schedules. Even seniors who get routine checkups don’t necessarily receive preventive services, Shenson, Anderson, and their coauthors found (Shenson D et al. J Fam Pract. 2011;60[1]:E1-E10). They assessed 2006 data from telephone surveys conducted by the CDC’s Behavioral Risk Factor Surveillance System (http://1.usa.gov/17AYMmF). The data covered approximately 80 000 randomly selected individuals 65 years and older from all 50 US states and the District of Columbia. Most were fully insured, had a personal physician, reported no cost barrier to seeing that physician, and had recently had a routine checkup. Yet only 44.8% of men and 36.8% of women who’d had a recent checkup were up-to-date on the recommended preventive services, the researchers found. “Our
study indicates that increasing the use of routine medical checkups will have a negligible impact on the delivery of preventive services,” they wrote. Even fewer Medicare beneficiaries appear to be taking advantage of another free preventive health service that became available in 2011 under the ACA. Citing federal data, Kaiser Health News reported that only 50 000 of 13 million obese seniors sought free weight loss counseling in 2013 (http: //bit.ly/1DUWRY7). Weight loss specialists told Kaiser Health News that low awareness of the service among both beneficiaries and physicians was due to the fact that it is available only in primary care offices. Medicare reimburses neither dietitians nor endocrinologists or other specialists who care for obese patients for weight loss counseling. More recently, some experts have challenged the overall benefits of screening tests. One review of meta-analyses and randomized trials related to 19 different diseases with US Preventive Services Task Force (USPSTF) statements found that several screening tests did not reduce all-cause mortality, and reductions in disease-specific mortality estimates were reported only for mammography for breast cancer and fecal occult blood test and flexible sigmoidoscopy for colorectal cancer (Saquib N et al. Int J Epidemiol. 2015;44[1]: 264-277). While the USPSTF recommends screening people aged 50 to 75 years for colorectal cancer (http://bit.ly/1GKsp46) and women aged 50 to 74 years for breast cancer (http://bit.ly/1wC81yv), it does not advise screening for most of the other diseases considered in the analysis.
The National Report Card on Healthy Aging: How Healthy Are Older Adults in the United States? Preventive Care and Screening Indicator
Data for Adults Aged 65 Years or Older, %
Data Year
Healthy People 2020 Target, %
Flu vaccine in past year Ever had pneumonia vaccine
66.9 68.1
2010 2010
90.0 90.0
Not Met Not Met
Mammogram within past 2 years
82.9
2010
70.0
Met
Colorectal cancer screening
73.1
2010
70.5
Met
Men
48.5
2010
50.9
Not Met
Women
48.5
2010
52.7
Not Met
Score Target Met or Not Meta
Up-to-date on select preventive servicesb
Data Source: Centers for Disease Control and Prevention, Behaviorial Risk Factor Surveillance System, 2009-2010. Data for all indicators depict the mean for all 50 states and the District of Columbia. a Score is based on attainment of Healthy People 2020 targets among the older adult population. Some targets are for all adults 18 years or older, not just those 65 years or older. This table only reports data for older adults. b For men, 3 services are included: flu vaccine in past year, ever had pneumonia vaccine, and colorectal cancer screening. For women, these same 3 services are included, plus a mammogram within past 2 years. Source: The State of Aging and Health in America 2013. Centers for Disease Control and Prevention. http://www.cdc.gov/aging
(Reprinted) JAMA April 28, 2015 Volume 313, Number 16
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of California - San Diego User on 06/03/2015
1605
News & Analysis
“It’s important to realize that, as with checkups, mortality is not the only outcome that matters,” Aaron Carroll, MD, MS, vice chair for health policy and outcomes research in the Indiana University School of Medicine’s pediatrics department, wrote recently in the JAMA Forum about the screening review (http://bit.ly /1Arjz33). “Trying to improve quality of life or reduce morbidity are also important outcomes.”
Out of the Clinic and Into the Community Although the physician-patient encounter should be the centerpiece for the delivery of preventive services, Shenson said, “clinicians are focused on their patient panels and do not feel that their role is a public health role. We need to bridge that gap.” The best way to do that? “Getting out to where people are in their daily life,” said Kathryn Kietzman, PhD, MSW, a University of California, Los Angeles, research scientist who directs the ongoing Community Health Innovations in Prevention for Seniors (CHIPS) project, funded by the CDC. “If somebody’s already thinking about prevention by going into the pharmacy to get a flu shot, that’s a great opportunity to tap into the mindset of that individual.” For
example, besides administering a flu shot, the pharmacist could ask whether the customer has been screened for colorectal cancer, Kietzman noted. A program in San Francisco did just that, according to a recent CHIPS report (Policy Brief UCLA Cent Health Policy Res. 2014;[PB2014-6]:1-8). The program sought to promote colorectal cancer screening among people recruited at flu immunization clinics in select pharmacies. It compared providing home screening kits with only providing education about colorectal cancer screening and found that the former was more effective in raising screening rates (Potter MB et al. J Am Pharm Assoc. 2010;50[2]:181-187). Another of the many programs described in the CHIPS report is one that enlists black women who’ve had breast and cervical cancer to bear witness at their churches about the importance of screening and refers women to low-cost mammography and cervical cancer screening (Erwin DO et al. Cancer Control. 2003;10[5 suppl]:13-21). Launched in rural Arkansas more than 20 years ago, the Witness Project is now a national nonprofit with 18 active sites, said cofounder Deborah Erwin, PhD, director of the office of cancer health disparities research at the Roswell Park Cancer Institute.
A third program mentioned in the CHIPS report is Vote and Vax, one of the biggest projects of Sickness Prevention Achieved Through Regional Collaboration (SPARC), a Connecticut-based nonprofit agency working on expanding the population-wide use of preventive care (http://bit.ly/17yGdj1). Vote and Vax, funded by the CDC, partnered with local pharmacies around the country to administer flu vaccine, for a fee. Some of the vaccination clinics were adjacent to the polls,whileotherswereinnearbypharmacies. Because it falls in November, Election Day is the perfect time to immunize people against the flu, Shenson noted. Besides 2012, Vote and Vax also operated during elections in multiple states in 2004, 2006, 2008, and 2010, taking 2014 off to analyze the data it had collected, Shenson said. “We are definitely hoping to be active in 2016,” he said. “We’re now ramping up our search for funding.” Shenson sees no reason to stop at flu shots. Vote and Vax also could offer pneumococcalvaccinationandtheopportunityforvoters to make appointments for screening tests. “I’m not diminishing the role of the doctor-patient connection within the clinician’s office,” Shenson said. But he said, “we will not protect everyone as best we can if we rely exclusively on that model.”
The JAMA Forum
Payment Reform Is About to Become a Reality David M. Cutler, PhD
1606
ments tied to quality or value in some fashion by the end of 2016. Make no mistake: this is major news. Medicare is the largest health care purchaser in the country, so these changes matter a lot. In addition, many private insurers that have been hesitant about payment reform are likely to follow Medicare’s lead. Payment reform is about to become a reality.
Cautious Reactions Secretary Burwell did not announce specifics about new payment models. This lack of specificity may explain the cautious reaction of professional societies to the news. The president of the American Medical Association, Robert M. Wah, MD, stated
American Medical Association
T
he US Department of Health and Human Services (HHS) continues to take major steps toward transforming the payment system for Medicare. After hinting about a new payment reform plan in September (http://bit.ly/17cQ2mz), HHS Secretary Sylvia Mathews Burwell put out more specifics in late January. Secretary Burwell’s proposal calls for 30% of Medicare payments to be based on non–fee-for-service models by the end of 2016, and 50% to be so by the end of 2018 (http://bit.ly/15LuMEh). By comparison, such payments did not exist in 2011 and account for about 20% of Medicare payments today. In addition, the Secretary intends to have 85% of Medicare fee-for-service pay-
David M. Cutler, PhD
JAMA April 28, 2015 Volume 313, Number 16 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of California - San Diego User on 06/03/2015
jama.com
Health Agencies Update .............p1608
News From the CDC ......................p1610
Filling the Gaps in Preventive Care Services for Older Adults
Report Outlines Benefits of Raising Minimum Age to Buy Cigarettes
Five-Year US Cancer Survival Is 65%
The JAMA Forum .........................p1606
Billions Recovered by Anti–Health Care Fraud Effort
Payment Reform Is About to Become a Reality
Depression More Prevalent in Unemployed Young Adults
Antiherpes Drug May Suppress HIV Levels
Clinical Trials Update ...................p1609 Meditation Promotes Better Sleep in Older Adults New HPV Vaccine Provides Wider Protection Consuming—Not Avoiding—Peanuts Leads to Fewer Peanut Allergies in Kids Hepatitis E Vaccine Effective for 4.5 Years
Medical News & Perspectives
Filling the Gaps in Preventive Care Services for Older Adults Rita Rubin, MA
O
n Election Day 2012, voters at polling places in 48 US states could choose not only a presidential candidate but whether to get a flu vaccination. More than 9000 voters opted to be immunized through the “Vote and Vax” program that year, and more than half of them reported that they did not regularly get flu shots (Shenson D et al. Am J Public Health. doi:10.2105/AJPH.2015.302628 [published online April 16th 2015]). While likely not the first setting that comes to mind, the polling place represents a logical location for efforts to boost the rate of older individuals who are up-todate on core preventive services such as immunization. After all, more than half of the more than 120 million voters in a US presidential election are 50 years or older, said Douglas Shenson, MD, MPH, national director of Vote and Vax. There’s definitely room for improvement, especially considering the “silver tsunami,” consisting mostly of aging baby boomers. The US population 65 years or older is expected to more than double between 2010 and 2050, when it will swell to nearly 89 million (Ogden LL et al. Am J Public Health. 2012;102[3]:419-425). Today in the United States, fewer than half of people aged 65 years and older are up-to-date on the core set of clinical preventive services: screening tests, immunizations, health behavior counseling, and pre1604
ventive medications. Only a quarter of those aged 50 to 64 years meet preventive services recommendations (http://1.usa.gov /1MUJN7B). And black and Hispanic older adults are even less likely to receive preventive services than their white peers (http://1 .usa.gov/1FsnzV8). For example, the proportion of people 60 years and older in the United States who reported receiving a herpes zoster vaccination, as recommended for that age group, was only 24.2% in 2013—below the Healthy People 2020 goal of 30%, according to a recent report from the Centers for Disease Control and Prevention (CDC) (Williams WW et al. Morb Mortal Wkly Rep. 2015;64[4]:95-102). Similarly, for those 65 years and older, the recommended age group for the pneumococcal vaccine, 59.7% reported having gotten that shot—again, far below the Healthy People 2020 goal of 90%. Some Healthy People 2020 goals related to preventive services for older adults, such as having a mammogram within the past 2 years and having been screened for colorectal cancer, have already been met. But the United States still falls short of reaching 2020 targets for other preventive services, as well as the goal of having 46% of men and 43.1% of women 65 years and older up-to-date on all of the core services (http: //1.usa.gov/1NzFtYV and http://1.usa.gov /1LGY5aA).
“When we’re less than 50%, we have a long way to go,” Lynda Anderson, PhD, director of the CDC’s Healthy Aging Program, said in an interview. “It’s interesting that people who are getting some of these (services) aren’t getting all of them.” Research shows that only a minority of Medicare enrollees take advantage of the free annual preventive visits the program began offering in 2011, and even those older adults who see a doctor regularly are not upto-date on preventive services. Typically, chronic conditions get the most attention at older patients’ medical appointments, Anderson said. “A lot of the preventive issues don’t rise to the top,” she said. “If their provider isn’t telling them it’s important to get that vaccination, inadvertently it does send the message that it’s not important.” Shenson, an associate clinical professor of epidemiology at the Yale School of Medicine who has studied the issue for nearly 20 years, says conventional wisdom used to place the blame squarely on physicians and patients: physicians didn’t place a high priority on preventive care, patients didn’t ask for it or weren’t receptive to it, and physicians’ offices neglected to flag the records for patients who hadn’t received a particular vaccine or screening. No question, all of those factors play a role. But the roots of the problem extend beyond the physician’s office to a US health
JAMA April 28, 2015 Volume 313, Number 16 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of California - San Diego User on 06/03/2015
jama.com
News & Analysis
care system that is designed to care for sick patients, not help prevent them from getting sick in the first place, Shenson said, who also serves as associate director of clinical preventive services at the Yale-Griffin Prevention Research Center. Time is certainly an issue, too. “The doctor’s visit is so short,” Shenson said. “It’s not surprising that we don’t do better. We’ve sort of breathed down the neck of physicians and said, ‘You’ve got to do this, you’ve got to do that.’” During his internal medicine residency, Shenson said, “I found it very challenging to find enough time to explain to every one of my patients over age 50 why screening for colon cancer is so important and potentially life-saving.” The topic of colon cancer screening is off-putting to many people, he said, so “this is not a conversation you can rush through. And that’s why I’m hoping the recent changes in Medicare reimbursement and preventive service visits will make an important difference.”
Checking Up on Checkups Under the Affordable Care Act (ACA), Medicare began fully covering annual preventive care visits in 2011. And since 2005, the program has offered new enrollees a 1-time initial preventive “Welcome to Medicare” visit, at which physicians are expected to discuss advanced directives, create a written plan of needed preventive services, screen for depression and safety, check vision and blood pressure, and calculate body mass index (http://1.usa.gov/1DaNQVm). But only 3% of eligible enrollees in 2006 and 2007 had such a visit, which must be made in the first year after Medicare enrollment, health care researcher Sukyung Chung, PhD, of the Palo Alto Medical Foundation, said in an interview. “Patients didn’t know much about it, and the window was really narrow.” Although more beneficiaries are scheduling preventive care visits since Medicare began covering them, many still do not, Chung and her coauthors found in a recent study (Chung S et al. Health Aff. 2015;34[1]: 11-20). Chung’s team analyzed 2007 to 2013 data from primary care patients 65 years and older at the Palo Alto Medical Foundation, which serves people in 4 counties near San Francisco. Before implementation of the ACA, only 1.4% of Medicare fee-for-service jama.com
patients, who represent the majority of enrollees, had a preventive visit each year, the authors found. After ACA implementation, that proportion jumped to 27.5%, but it was still 10 to 20 percentage points lower than that for people 65 years and older who were insured through their employer or those in a Medicare health maintenance organization (HMO), which has traditionally encouraged preventive visits as potentially cost-saving as well as necessary to adhere to medical guidelines. The annual rate of preventive visits was somewhat lower in seniors insured through their employer than those in a Medicare HMO, the authors wrote, possibly because they didn’t give preventive care as high a priority or they had a tough time fitting an appointment into their busy schedules. Even seniors who get routine checkups don’t necessarily receive preventive services, Shenson, Anderson, and their coauthors found (Shenson D et al. J Fam Pract. 2011;60[1]:E1-E10). They assessed 2006 data from telephone surveys conducted by the CDC’s Behavioral Risk Factor Surveillance System (http://1.usa.gov/17AYMmF). The data covered approximately 80 000 randomly selected individuals 65 years and older from all 50 US states and the District of Columbia. Most were fully insured, had a personal physician, reported no cost barrier to seeing that physician, and had recently had a routine checkup. Yet only 44.8% of men and 36.8% of women who’d had a recent checkup were up-to-date on the recommended preventive services, the researchers found. “Our
study indicates that increasing the use of routine medical checkups will have a negligible impact on the delivery of preventive services,” they wrote. Even fewer Medicare beneficiaries appear to be taking advantage of another free preventive health service that became available in 2011 under the ACA. Citing federal data, Kaiser Health News reported that only 50 000 of 13 million obese seniors sought free weight loss counseling in 2013 (http: //bit.ly/1DUWRY7). Weight loss specialists told Kaiser Health News that low awareness of the service among both beneficiaries and physicians was due to the fact that it is available only in primary care offices. Medicare reimburses neither dietitians nor endocrinologists or other specialists who care for obese patients for weight loss counseling. More recently, some experts have challenged the overall benefits of screening tests. One review of meta-analyses and randomized trials related to 19 different diseases with US Preventive Services Task Force (USPSTF) statements found that several screening tests did not reduce all-cause mortality, and reductions in disease-specific mortality estimates were reported only for mammography for breast cancer and fecal occult blood test and flexible sigmoidoscopy for colorectal cancer (Saquib N et al. Int J Epidemiol. 2015;44[1]: 264-277). While the USPSTF recommends screening people aged 50 to 75 years for colorectal cancer (http://bit.ly/1GKsp46) and women aged 50 to 74 years for breast cancer (http://bit.ly/1wC81yv), it does not advise screening for most of the other diseases considered in the analysis.
The National Report Card on Healthy Aging: How Healthy Are Older Adults in the United States? Preventive Care and Screening Indicator
Data for Adults Aged 65 Years or Older, %
Data Year
Healthy People 2020 Target, %
Flu vaccine in past year Ever had pneumonia vaccine
66.9 68.1
2010 2010
90.0 90.0
Not Met Not Met
Mammogram within past 2 years
82.9
2010
70.0
Met
Colorectal cancer screening
73.1
2010
70.5
Met
Men
48.5
2010
50.9
Not Met
Women
48.5
2010
52.7
Not Met
Score Target Met or Not Meta
Up-to-date on select preventive servicesb
Data Source: Centers for Disease Control and Prevention, Behaviorial Risk Factor Surveillance System, 2009-2010. Data for all indicators depict the mean for all 50 states and the District of Columbia. a Score is based on attainment of Healthy People 2020 targets among the older adult population. Some targets are for all adults 18 years or older, not just those 65 years or older. This table only reports data for older adults. b For men, 3 services are included: flu vaccine in past year, ever had pneumonia vaccine, and colorectal cancer screening. For women, these same 3 services are included, plus a mammogram within past 2 years. Source: The State of Aging and Health in America 2013. Centers for Disease Control and Prevention. http://www.cdc.gov/aging
(Reprinted) JAMA April 28, 2015 Volume 313, Number 16
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of California - San Diego User on 06/03/2015
1605
News & Analysis
“It’s important to realize that, as with checkups, mortality is not the only outcome that matters,” Aaron Carroll, MD, MS, vice chair for health policy and outcomes research in the Indiana University School of Medicine’s pediatrics department, wrote recently in the JAMA Forum about the screening review (http://bit.ly /1Arjz33). “Trying to improve quality of life or reduce morbidity are also important outcomes.”
Out of the Clinic and Into the Community Although the physician-patient encounter should be the centerpiece for the delivery of preventive services, Shenson said, “clinicians are focused on their patient panels and do not feel that their role is a public health role. We need to bridge that gap.” The best way to do that? “Getting out to where people are in their daily life,” said Kathryn Kietzman, PhD, MSW, a University of California, Los Angeles, research scientist who directs the ongoing Community Health Innovations in Prevention for Seniors (CHIPS) project, funded by the CDC. “If somebody’s already thinking about prevention by going into the pharmacy to get a flu shot, that’s a great opportunity to tap into the mindset of that individual.” For
example, besides administering a flu shot, the pharmacist could ask whether the customer has been screened for colorectal cancer, Kietzman noted. A program in San Francisco did just that, according to a recent CHIPS report (Policy Brief UCLA Cent Health Policy Res. 2014;[PB2014-6]:1-8). The program sought to promote colorectal cancer screening among people recruited at flu immunization clinics in select pharmacies. It compared providing home screening kits with only providing education about colorectal cancer screening and found that the former was more effective in raising screening rates (Potter MB et al. J Am Pharm Assoc. 2010;50[2]:181-187). Another of the many programs described in the CHIPS report is one that enlists black women who’ve had breast and cervical cancer to bear witness at their churches about the importance of screening and refers women to low-cost mammography and cervical cancer screening (Erwin DO et al. Cancer Control. 2003;10[5 suppl]:13-21). Launched in rural Arkansas more than 20 years ago, the Witness Project is now a national nonprofit with 18 active sites, said cofounder Deborah Erwin, PhD, director of the office of cancer health disparities research at the Roswell Park Cancer Institute.
A third program mentioned in the CHIPS report is Vote and Vax, one of the biggest projects of Sickness Prevention Achieved Through Regional Collaboration (SPARC), a Connecticut-based nonprofit agency working on expanding the population-wide use of preventive care (http://bit.ly/17yGdj1). Vote and Vax, funded by the CDC, partnered with local pharmacies around the country to administer flu vaccine, for a fee. Some of the vaccination clinics were adjacent to the polls,whileotherswereinnearbypharmacies. Because it falls in November, Election Day is the perfect time to immunize people against the flu, Shenson noted. Besides 2012, Vote and Vax also operated during elections in multiple states in 2004, 2006, 2008, and 2010, taking 2014 off to analyze the data it had collected, Shenson said. “We are definitely hoping to be active in 2016,” he said. “We’re now ramping up our search for funding.” Shenson sees no reason to stop at flu shots. Vote and Vax also could offer pneumococcalvaccinationandtheopportunityforvoters to make appointments for screening tests. “I’m not diminishing the role of the doctor-patient connection within the clinician’s office,” Shenson said. But he said, “we will not protect everyone as best we can if we rely exclusively on that model.”
The JAMA Forum
Payment Reform Is About to Become a Reality David M. Cutler, PhD
1606
ments tied to quality or value in some fashion by the end of 2016. Make no mistake: this is major news. Medicare is the largest health care purchaser in the country, so these changes matter a lot. In addition, many private insurers that have been hesitant about payment reform are likely to follow Medicare’s lead. Payment reform is about to become a reality.
Cautious Reactions Secretary Burwell did not announce specifics about new payment models. This lack of specificity may explain the cautious reaction of professional societies to the news. The president of the American Medical Association, Robert M. Wah, MD, stated
American Medical Association
T
he US Department of Health and Human Services (HHS) continues to take major steps toward transforming the payment system for Medicare. After hinting about a new payment reform plan in September (http://bit.ly/17cQ2mz), HHS Secretary Sylvia Mathews Burwell put out more specifics in late January. Secretary Burwell’s proposal calls for 30% of Medicare payments to be based on non–fee-for-service models by the end of 2016, and 50% to be so by the end of 2018 (http://bit.ly/15LuMEh). By comparison, such payments did not exist in 2011 and account for about 20% of Medicare payments today. In addition, the Secretary intends to have 85% of Medicare fee-for-service pay-
David M. Cutler, PhD
JAMA April 28, 2015 Volume 313, Number 16 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of California - San Diego User on 06/03/2015
jama.com
