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FDA proposes new fluoride standard for bottled water

The US Food and Drug Administration is proposing a lower concentration level normal for fluoride in bottled drinking water, however some scientists and environmental teams believe that the planned limit remains too high and poses a danger to human health.

If finalized, the new regulation can lower allowable levels of fluoride in domestically prepacked and foreign drinking water to 0.7 milligrams per liter, a small reduction from the present normal range of between 0.8 and 1.7 milligrams per liter allowed by the government agency.

The planned standard would apply solely to bottled drinking water with additional fluoride, and would not have an effect on allowable levels of fluoride in bottled drinking water which contains fluoride from source water.

Dental health

The FDA’s projected rule aligns with a 2015 recommendation from the US Public Health Service, a part of the US Department of Health and Human Services, that implies that 0.7 milligrams per liter is the best fluoride concentration for community water systems that add fluoride.

The new rule “is supported by findings from evolving analysis on the best concentrations of fluoride that balances fluoride’s advantages in preventing decay without the risk of inflicting dental fluorosis, a condition most frequently characterized by white patches on teeth,” the Food and Drug Administration said in its statement. Dental fluorosis is caused by taking in an excessive amount of fluoride over an extended amount of time while adult teeth are forming underneath the gums.

But some scientists’ issues extend way beyond fluorosis.

Flourosis“Given that fluoride can harm brain development, I advocate that the most fluoride concentration in drinking water be kept at a lower level than 0.7 mg/L,” Dr. Philippe Grandjean, an Adjunct Professor of Environmental Health at the Harvard TH Chan School of Public Health, wrote in associate degree email.

Christopher Neurath, research director of the American Environmental Health Studies Project, that is connected to the Fluoride Action Network, an environmental support organization, said “currently, there are speedily increasing scientific studies showing neurotoxicity to fluoride,” with analysis showing an immediate link between children’s intelligence quotient and their level of fluoride exposure within the womb: “That is our largest concern.”

The american Dental Association noted that “science-based organizations,” together with itself and the american Academy of pediatrics, “fully support the general public health advantages of community water fluoridation.” The association conjointly noted that the recently planned level helps stop decay, while not increasing the chance of dental fluorosis, that among Americans is primarily a cosmetic condition that does not have an effect on the health or function of teeth.

“Even with the supply of alternative sources of fluoride, community water fluoridation prevents decay by at least 25% in both kids and adults,” the association said.

Behavioral and cognitive health effects

Morteza Bashash, an assistant professor in the Dalla Lana School of Public Health at the University of Toronto, found that higher fluoride levels as measured in urine samples of pregnant women are related to both lower ratio and exaggerated risk of attention-deficit disorder disorder among children in Mexico.

Specifically, Bashash found a decline in children’s scores on intelligence tests for each 0.5 milligram-per-liter increase in fluoride exposure beyond 0.8 milligrams per liter detected in a pregnant mother’s urine. it’s not clear whether or not this can be analysis applicable to the US population, he said.

In Mexico, as an example, the government delivers cavity-reducing fluoride by adding it to salt, not water, as many of us avoid drinking tap water.

Still, his analysis findings were “based on a verity measuring of fluoride absorbed within the body.” A Canadian study given at a conference last year and studies conducted in China showed intelligence quotient losses associated with fluoride levels at intervals in an identical order of magnitude.

Due to similar fluoride sources, laws and diet, Canada’s findings in urine levels, are in all probability, the same as those in America, Bashash said.

Neurath trusts that both the Mexican and Canadian study results would typically apply to the united states as a result of “urine fluoride is best measure of total fluoride intake.”

Canadian information from the past fifteen years has shown women living in cities with fluoridated water supplies had “almost double” urine fluoride concentrations levels as women living in non-fluorinated cities. “Drinking water fluoride is the major supply of fluoride for these women,” he said.

The impact of prenatal exposure to fluoride on intelligence quotient is “very massive,” Neurath believes. “And on a population basis, that is terribly concerning.”

Proposed rule might not be adequate

Floride Water

Neurath revealed in a study of dental fluorosis this year, based on National Health and Nutrition Examination Survey information, a “dramatic increase in fluorosis” over results from a decade ago. (The study, although published in a peer-reviewed journal, is co-authored by attorney representing the Fluoride Action Network in proceedings concerning the regulation of fluoridation chemicals by the US Environmental Protection Agency.)

More than thirty percent of adolescents within the study showed moderate to severe dental fluorosis (an extra thirty fifth of kids showed lesser signs of the condition), “a immense increase” over a survey conducted a couple of decade prior, Neurath said. He believes that the planned standard is unlikely to cut back dental fluorosis to acceptable levels.

However, he includes a larger concern. “Dental fluorosis is a visible sign of overexposure to fluoride, however there are different nonvisible signs and adverse health effects that are far more serious,” Neurath said based on the work of Bashash and Grandjean.

Grandjean’s work was funded by the National Institute of Environmental Health Sciences. “Our review of studies from China and our own field study is in accordance with a recent study by US researchers administered in Mexico that elevated exposure to fluoride throughout pregnancy is related to toxicity to brain development.

“Given that fluoride is added to toothpaste to secure that the enamel surface of the teeth is correctly protected against tooth decay, there’s no need to supplement the dietary fluoride intake,” he said.

Alternatively, Bashash said, fluoride in water is considered one of the “biggest public health victories” in preventing cavities.

While his job as a man of science is to review a given topic, it’s the duty of policymakers to come up with the general understanding of what is necessary. The Food and Drug Administration looks “at the big picture” by gathering the proof and evaluating the pros and cons based on national priorities. “This has been a hot topic for sixty years.”

Linda Birnbaum, director of the National Institute of Environmental Health Sciences, explained that a “large, cross-government operating group” checked out the information on the market in 2010 to 2011 and concluded that 0.7 milligrams per liter was the suitable level of fluoride concentration in bottled drinking water, one that “balances protection from tooth decay while limiting the risk from dental fluorosis.”

The institute has funded studies that explore different health effects, she said, “and we are observing the data in a very systematic review currently.”

The International bottled water Association, a trade group, said it supports the FDA proposal to revise the standard of quality for fluoride added to drinking water.

“Most corporations are well below” the recently planned limit, according to Jill Culora, a spokesperson for the association. “The planned rule takes into account the various sources of halide in people’s diets and can any cut back the chance of dental pathology, whereas still providing associate degree best level of halide to assist stop decay.”

Cavities don’t seem to be the sole concern, Neurath said: “The projected rule isn’t adequate.”

AHA 2019 Rural Report

Challenges Facing Rural Communities and the Roadmap to Ensure Local Access to High-quality, Affordable Care

Hospitals are cornerstones of their communities, serving as principal access points to care for the nearly 20 percent of Americans who live in rural areas. They maintain timely access to services through local, on-site care and connect patients to more distant providers via telehealth or care networks.

In addition, hospitals are the leading employers in rural areas, furnishing critical financial support to the communities they serve. Beyond delivering health care services, they provide employment opportunities and contributions to the local economy, both of which promote community growth and development.

Recommendations for Action

In light of the ongoing challenges confronting rural providers and new challenges ahead, the AHA believes that federal policies must be updated and new investments made in order for rural communities to thrive in the health care system of the 21st century. To this end, the AHA is working to advance policy priorities across several key areas for rural health, including:

  • Fair and adequate reimbursement that updates Medicare and Medicaid payment rates to cover the cost
    of care.
  • New models of care that improve financial predictability and include rural providers in the movement
    toward value-based care.
  • Regulatory relief from antiquated requirements that do not improve patient care.
  • Expanded access to telehealth services and ensuring health information technology costs and
    compliance requirements are addressed to ease the burden on rural hospitals.
  • Workforce programs targeting rural areas that continue to be hard hit by provider shortages.
  • Prescription drug price concerns, including unsustainable high drug costs and attacks on the 340B
    program, which supports vulnerable communities.

Conclusion

Although rural hospitals have long faced unique circumstances that can complicate health improvement efforts, more recent and emergent challenges are exacerbating their financial instability – and by extension, the economic health of their community. Individually, these are complex, multi-faceted challenges.

Taken together, they are immense, requiring policymakers, stakeholders and communities to work together, innovate and embrace value-based approaches to improving health in rural communities. The federal government must play a principal role by updating policies and investing new resources in rural communities.

To see the full Rural Report, visit www.aha.org/ruralhealth

Telehealth Delivers Benefits for Rural Women

Telehealth is a modern-day solution to health problems both old and new. Though it presents benefits to a variety of patients, rural patients likely experience the richest benefits. As Health Resources & Services Administration (HRSA) notes, it can sometimes be difficult to determine whether an area is urban or rural.1 In fact, the term “rural” is not even defined by the Census Bureau—it is considered to encompass “all population, housing, and territory not included within an urban area.” Essentially, according to this definition, whatever is not urban is considered rural. There are two types of urban areas identified by the Census Bureau: 1) Urbanized Areas (UAs) of 50,000 or more people and 2) Urban Clusters (UCs) of at least 2,500 and less than 50,000 people.1Generally, rural areas are characterized by low population and lack of access to critical resources such as medical care.

Rural individuals face many health disparities compared to urban individuals. Poverty and poor access to healthcare contribute greatly to these disparities. Overall, rural communities are in poorer health than others. According to the Centers for Disease Control and Prevention, rural Americans are at higher risk of death from five leading causes: heart disease, cancer, unintentional injuries, chronic lower respiratory disease, and stroke.3 In addition, rural areas have higher rates of preterm births and infant mortality.

Telehealth has helped combat these rural disparities through the following four modalities:

  • Live video, which uses audiovisual telecommunications technology;
  • Store-and-forward, which involves transmission of health information such as x-rays and other images through a secure electronic communications system to a healthcare provider;
  • Remote patient monitoring, which involves electronic transmission of health data from a patient in one location to a provider in another location; and
  • Mobile health (mHealth), which includes healthcare and education supported by mobile devices such as tablets and cell phones.
  • Although there are some barriers to successfully implementing telehealth, it is generally regarded as a convenient and cost-effective way to provide subspecialty healthcare that is not available locally. This is true in obstetrics and gynecology. In obstetrics, telehealth can be used for both low-risk and high-risk pregnancies, and in gynecology, it is used for both routine and specialty examinations.

Telehealth benefits and considerations

Healthcare in America is becoming too expensive for companies, individuals, and taxpayers. Technology offers the potential to offer increased access to care at a better value. In utilizing telehealth, the overall healthcare system benefits from lower costs, less travel, improved health outcomes, and reduced emergency room utilization.9 Although there are numerous benefits to telehealth, there are also many things to consider when beginning or expanding a telehealth program or clinic, including for obstetrics and/or gynecology (see box below).

FULL ARTICLE >>>> SOURCE: Contemporary OB/GYN

Rural hospital closures spike this summer

Over the last two months, the number of rural hospital closures has risen rapidly to 87 total closures (since 2010). In rural America, health care is a pillar of the community. It helps to create and foster a sustainable and livable environment for rural Americans, and without health care, without a hospital, a rural community will crumble.

Here in our home state, Twin Rivers Regional Medical Center, a 116 bed PPS Hospital in Kennett, Missouri closed on June 12, the fourth rural hospital in Missouri to close. Just before its closures ad decision was made for Twin Rivers Regional Medical Center to consolidate operations with Poplar Bluff (Mo.) Regional Medical Center.

“As healthcare delivery evolves and medical innovation makes inpatient services less needed, consolidating operations with the larger resources of Poplar Bluff Regional Medical Center became the most sustainable plan for the future,” Twin Rivers Regional Medical Center CEO Christian Jones said in a statement to KAIT. “We plan to continue offering excellent outpatient care locally, which is how 95 percent of our patients’ medical needs were provided last year.”

Twin Rivers Regional Medical Center’s 259 employees will be laid off when the hospital closes, according to a Worker Adjustment and Retraining Notification Act notice filed April 30. However, those employees had the opportunity to meet with representatives of Poplar Bluff Regional Medical Center last week to help them identify positions they may be able to transfer to, according to the report.

As access to care in rural communities disappears, we need the support of Congress now more than ever to stop the flood of hospital closures and create an environment in which innovation can thrive. A multifaceted approach is necessary to address the struggles of rural health care providers including hospitals:

  • The first prong of this approach is to ensure rural providers reimbursement rates are sufficient to allow them to keep their doors open.
  • second prong is to support measures that reduce the cost of providing care including through regulatory relief efforts that reduce costs without negatively impacting patient care.
  • The third prong of this approach is to support new models that allow communities to retain necessary access to local care including a local emergency room while right sizing their facilities to flexibly meet the needs of the specific community.

Together, these policies can all begin to bring rural health care into the 21stCentury and ensure its successful future.

Infusion Express Opens It’s Kirksville Location

PSN is excited to announce that our partner, Infusion Express, just expanded into a new state-of-the-art facility in Kirksville!  The new location opened yesterday in the Physicians & Surgeons Building located at 1108 E. Patterson, Kirksville, MO, and is the company’s first rural location in the country.

Infusion Express has additional locations in Kansas City, MO, Chicago, IL, Philadelphia, PA, and San Francisco, CA.

Their vision for coming to rural Missouri is “Start a business in a location where you find a need.”  The business offers IV drug treatments mostly to patients suffering from chronic conditions like M.S. and Crohn’s disease.

Story by Louis Finley/KTVO

Don Peterson, Infusion Express’s CEO says:

We heard people, through Dr. Jackson, that they were driving 50 to 100 miles one way just to get a regular infusion, and that’s a huge inconvenience and when access is that challenging, people tend not to go.

Peterson said treatments are cheaper than hospitals, and it gets those who are mobile out of their houses, working around their schedules.

Infusion Express offers the IV therapy you need in a place and time that works for you. They work around your schedule by offering weekday, evening and Saturday appointments.  All of their patients are treated in private suites fully equipped with WiFi, flat screen TVs, and comfortable recliners and friends and family members are encouraged to come with you. They are committed to making you better in a better way!

10 Tips for Staying Effective

Burnout is defined as emotional exhaustion, feelings of cynicism and detachment, and a sense of ineffectiveness at work. The inverse of burnout is engagement — a persistent, upbeat sense of fulfillment characterized by vigor, dedication, and absorption. I haven’t seen that doctor in the hospital lounge in a long time.

I am a neurologist practicing for 25 years in both academic and community hospital settings. I have a busy outpatient practice, take calls at two hospitals and serve a leadership role within our regional health care system.

I found I was becoming less enthusiastic about the practice of medicine. I was rushing to stay on time, to finish electronic records, complete inbox tasks of patient phone calls, emails, result notifications, disability forms, pre-authorizations for MRIs and medication, and pharmacy requests. Daily practice was becoming a grind; I was neither burnt out nor fired up.

The tipping point was the introduction of Press Ganey patient satisfaction scores. My initial scores were abysmal. Patients didn’t like the long wait times, delays in responding to calls, and they felt I wasn’t listening to their concerns. This was not the caring and engaged doctor I thought I saw in the mirror every day. For the first time, I began to consider other avenues such as an MBA, a full-time administrative role or locum tenens practice.

But here is my confession:

I love my job. At least most of the time. I love the sigh of relief when the patient hears the hand tremor isn’t Parkinson disease or poor memory may be due to depression and not dementia. I love the challenge of staying current on an ever-expanding knowledge base. I am grateful and honored to be in a respected and well-compensated profession.

I am a mostly happy doctor. Despite the frustrations of everyday practice, is there anything more fulfilling than caring for people? I had thought I was doing a good job, but my patients were telling me a different story. The body language of watching a computer is all wrong. Patients don’t believe I am listening if I’m glued to my screen. I needed to resolve the competing demands for documentation and the need to demonstrate presence to my patients’ concerns.

If you are one of the 60 percent of doctors who have experienced symptoms of burnout, here are ten changes I made that have helped reduce resentment and restore a sense of control, engagement and gratitude in clinical practice.

Ten simple changes to defeat physician burnout:

1. Patients complete a card with three questions for the doctor. I make sure we have addressed every issue on the card. No longer does the patient say, “one more thing” as my hand is on the doorknob because all issues have been addressed.

2. The two-minute rule. I spend the first two minutes with direct eye contact and try not to interrupt while asking the patient to tell me their story.

3. After a few minutes of listening, I ask permission to look away and take some notes on the screen.

4. I reassure that the patient is in the right place for their medical concern. I eliminate comments that suggest frustration with the EMR. I thank the patient for entrusting their care to me, offering email contact and regular follow-up and communication until the problem is resolved.

5. Optimize the EMR’s strengths. The EMR can gather data from other physicians, test results and can serve as an educational tool. Use the EMR to demonstrate images and reports to the patient, adding medical articles, online resources for exercise equipment, sleep hygiene courses, etc.

6. I end all encounters with the question: “Is there anything else I can help you with today?” Most of the time, the patient gratefully acknowledges that all questions have been answered.

7. Close the encounter before the patient leaves the room. The note, after visit summary (AVS), orders and letter to the referring provider are completed before the patient leaves the room. Avoid the temptation to complete records in bed or while on vacation.

8. I often finish with a request: “May I give you a hug?” While embracing, I will say a secular blessing, “Be well.” It is a simple act in the doctor-patient relationship that expresses empathy and support. There are caveats, especially in our current cultural awareness of sexual harassment: I always ask permission. An older female is generally safe; a younger female is embraced with caution or not at all, always with family in room; a male — generally not. A hug has the power to lighten the mood, to convey intimacy during a brief encounter and to share the burden of illness.

9. If the patient is smiling at the end of the encounter, I will encourage them to complete the survey. I may also request that they write a review on an online rating service.

10. I maintain resilience for the demands of practice with an intensive regimen of exercise. I became a group fitness instructor, teaching 3-4 classes a week of indoor cycling, including weightlifting and planks. In addition to the personal benefits, teaching has made me a more enthusiastic advocate for exercise with my patients.

What have I learned?

Since the electronic medical record and patient-driven quality metrics are unlikely to disappear soon, I have learned to use them to become a better doctor. The focus has become communication skills- demeanor, physical and emotional presence, listening and explanation of the evaluation and treatment plan. This has lead to a dramatic improvement in patient and physician satisfaction.

The physical contact has changed me more than my patients. I have moved from resentment to gratitude for a deeper relationship I thought wasn’t possible during a brief encounter.

Anticipating the offer of an embrace at the end prepares me to like the patient at the beginning. It opens me to want to know them personally, not simply collect data about their symptoms. Even though we may share hard truths about diagnosis, treatment, and necessary lifestyle changes, the patient may feel that we are in it together.

PSN Provider, Laurence Kinsella is a neurologist, and wrote this article for the KevinMD’s website.

Gordon Alloway Joins PSN as Telemedicine Consultant

Gordon AllowayGordan Alloway, healthcare delivery expert, has recently joined PSN as a telehealth and telemedicine adviser. Gordon has served as the Project Director for the Heartland Telehealth Resource Center, one of 14 federally-funded Telehealth Resource Centers across the U.S. coordinating assistance provided in Kansas, Missouri and Oklahoma.

He has also served as a staff member at the University of Kansas Medical Center, a research associate and project manager for the KU Center for Telemedicine and Telehealth in Kansas City, KS and has managed multiple grant-funded projects.

“Telemedicine” is most commonly used to refer to two-way, interactive video conferences that allow patients to “see” their doctor without being in the same room. This helps increase access to medical care, especially for patients living in rural areas.

As with many other technologies, additional devices can be attached to the videoconferencing system to enhance the patient experience. Some of these devices include a digital stethoscope or a dermatology camera that can record a patient’s vitals or health information so that a doctor can assess from a distance.

However, telemedicine is not limited to video conferencing. Remote patient monitoring, store-and- forward and mHealth are other common types of telemedicine.

Through PSN, Alloway will be providing both healthcare providers and facilities with education and assistance to get up to speed on the rules, regulations and technology information that is needed to start or expand telemedicine programs.

PSN’s goal is to show how to make these programs sustainable and assist with providing hands-on training designed to help a practice, clinic or organization provide the best care for patients via telemedicine.

According to Alloway, integrating telemedicine into the everyday workflow is essential to assuring that the technology will be used to the fullest.

“We’ve seen cases where a facility invests the time and start-up costs in the technology, but then the people who are trained on it move on to other jobs and after that it collects dust,” Alloway shared. That’s why it’s important to create a work plan and get everyone using the technology as part of the culture. Using telemedicine should become as routine as making patient referrals.

Mr. Alloway earned both his Bachelor’s and Master’s degrees in Journalism from the University of Kansas and possesses considerable experience as a long-time marketing executive and health care entrepreneur. He resides in Overland Park, KS.

Reaching Patients Who Lack Access to Care

Across the country, more rheumatology practices are employing telemedicine to treat patients, particularly physicians at academic medicine centers that have the resources to launch comprehensive units.

The technology is a way to bridge the shortage of rheumatologists in rural areas and reach patients who cannot access specialty care for rheumatic conditions, proponents say.

A 2013 study in Arthritis & Rheumatism found that many towns and small cities with populations up to 50,000 have no practicing rheumatologists, with some patients having to travel more than 200 miles to get specialty care.

Telemedicine is growing by leaps and bounds, and rheumatology is a key specialty in which to use the technology, said Jonathan Linkous, chief executive officer for the American Telemedicine Association.
“Telemedicine is expanding both in terms of the number of consultations and the breadth of services involved,” he said. “Tele-rheumatology was certainly not a big area to be looked at in years past, but it’s one more area that is starting to expand.”

For most of doctors and patients involved in the study, tele-rheumatology visits were positive and aided patient access.

Tele-rheumatology: Is it effective?

Research is lacking regarding how prevalent tele-rheumatology has become in the United States and whether it’s as effective as face-to-face visits.

In a recent analysis of 1,468 potentially eligible tele-rheumatology studies and literature, only 20 addressed direct provider to patient contact that influenced or had the potential to influence clinical care, according to a November 2016 review in Arthritis Care & Research.

Of the 20 studies, the majority of articles involved tele-rheumatology use in Europe or Great Britain, said study author John Allen McDougall, MD, a postdoctoral fellow at Yale University, New Haven, Conn.

“The first major finding was that there’s really not much out there as far as high quality research that supports or contradicts the use of tele-rheumatology in wide distribution,” Dr. McDougall said. However, “in general, the conclusion of the authors was a qualified, ‘Yes,’ that [tele-rheumatology] has potential and should go forward.”

According to the literature, the most common condition treated through telemedicine was rheumatoid arthritis. Little information existed on telemedicine use for gout or the treatment of connective tissue diseases, Dr. McDougall said.

Best uses of technology for Tele-rheumatology

In order for more practices to consider tele-rheumatology, more research about cost-effectiveness and best uses of the technology use would be useful, Dr. McDougall said.

“The main question that policy makers are going to want to answer is, ‘What’s the return on investment? Does this make sense for my practice?’ ” he said. “The methods reporting in tele-rheumatologist [literature] is lacking.” But regardless of barriers, telemedicine experts say the technology will likely continue to expand and transform the way rheumatologists are practicing and patients are receiving care.

“Tele-rheumatology will never replace an in-person exam,” Dr. Ferucci said.

“But my vision is that it will be able to improve the quality of care for patients living in rural and remote locations, by allowing for more frequent visits and adjustment of medications, which are necessary to achieve the goal of treat-to-target for RA and other rheumatologic conditions.”

The Rheumatologist has an excellent article online that compliments this story.

Critical Access Status With Surgical Outcomes

According to a study by Dr. Ibrahim and colleagues on critical access status, Medicare beneficiaries undergoing common surgical procedures, patients admitted to critical access hospitals compared with non–critical access hospitals had no significant difference in 30-day mortality rates, decreased risk-adjusted serious complication rates, and lower-adjusted Medicare expenditures.

IMPORTANCE:

Critical access hospitals are a predominant source of care for many rural populations. Previous reports suggest these centers provide lower quality of care for common medical admissions. Little is known about the outcomes and costs of patients admitted for surgical procedures.

OBJECTIVE:

To compare the surgical outcomes and associated Medicare payments at critical access hospitals vs non-critical access hospitals.

DESIGN, SETTING, AND PARTICIPANTS:

Cross-sectional retrospective review of 1,631,904 Medicare beneficiary admissions to critical access hospitals (n = 828) and non-critical access hospitals (n = 3676) for 1 of 4 common types of surgical procedures-appendectomy, 3467 for critical access and 151,867 for non-critical access; cholecystectomy, 10,556 for critical access and 573,435 for non-critical access; colectomy, 10,198 for critical access and 577,680 for non-critical access; hernia repair, 4291 for critical access and 300,410 for non-critical access-between 2009 and 2013. We compared risk-adjusted outcomes using a multivariable logistical regression that adjusted for patient factors (age, sex, race, Elixhauser comorbidities), admission type (elective, urgent, emergency), and type of operation.

EXPOSURES:

Undergoing surgical procedures at critical access vs non-critical access hospitals.

MAIN OUTCOMES AND MEASURES:

Thirty-day mortality, postoperative serious complications (eg, myocardial infarction, pneumonia, or acute renal failure and a length of stay >75th percentile). Hospital costs were assessed using price-standardized Medicare payments during hospitalization.

RESULTS:

Patients (mean age, 76.5 years; 56.2% women) undergoing surgery at critical access hospitals were less likely to have chronic medical problems, and they had lower rates of heart failure (7.7% vs 10.7%, P < .0001), diabetes (20.2% vs 21.7%, P < .001), obesity (6.5% vs 10.6%, P < .001), or multiple comorbid diseases (% of patients with ≥2 comorbidities; 60.4% vs 70.2%, P < .001). After adjustment for patient factors, critical access and non-critical access hospitals had no statistically significant differences in 30-day mortality rates (5.4% vs 5.6%; adjusted odds ratio [OR], 0.96; 95% confidence interval [CI], 0.89-1.03; P = .28). However, critical access vs non-critical access hospitals had significantly lower rates of serious complications (6.4% vs 13.9%; OR, 0.35; 95% CI, 0.32-0.39; P < .001). Medicare expenditures adjusted for patient factors and procedure type were lower at critical access hospitals than non-critical access hospitals ($14,450 vs $15,845; difference, -$1395, P < .001).

CONCLUSIONS AND RELEVANCE:

Among Medicare beneficiaries undergoing common surgical procedures, patients admitted to critical access hospitals compared with non-critical access hospitals had no significant difference in 30-day mortality rates, decreased risk-adjusted serious complication rates, and lower-adjusted Medicare expenditures, but were less medically complex.

SOURCE: JAMA
Andrew M. Ibrahim, MD; Tyler G. Hughes, MD,  Jyothi R. Thumma, MPH; Justin B. Dimick, MD, MPH

Budget Savings Should Offset the Cost of Expanding Medicaid

The 31 states and District of Columbia that have expanded Medicaid are saving millions — and in some cases, tens of millions — compared to states that have not adopted the federal program, according to a report released Tuesday by the Robert Wood Johnson Foundation.

The report was prepared by Manatt Health, a consulting firm with the law offices of Manatt, Phelps & Phillips in Washington, D.C.

In January, Manatt Attorney Cindy Mann said hospitals in expansion states fare better financially than providers in states without the Affordable Care Act initiative. Specifically, hospitals in expansion states have less uncompensated care due to a rise in the number of patients covered, said Mann, who formerly directed the Medicaid program for the Centers for Medicare and Medicaid Services.

The newly-released report confirmed that hospitals’ uncompensated care costs are estimated to have been $7.4 billion, or 21 percent less in 2014 than they would have been in the absence of Medicaid expansion.

In 2014, expansion states saw a reduction in uncompensated care costs of 26 percent, compared to a 16 percent reduction in non-expansion states, the report said.

As of September 2015, the percentage of rural hospitals at risk of closure is about twice as high in non-expansion states in comparison to expansion states, it said.

The report identifies several sources of savings and new revenue for expansion states: less state spending on programs for the uninsured; more federal dollars coming to the state for newly eligible Medicaid enrollees — including funds to cover typically expensive beneficiaries such as pregnant women and high-need populations; and increased revenue from existing insurer and provider taxes.

Most of the 19 states that have not expanded Medicaid have Republican governors or legislatures controlled by the GOP. Some policymakers in those states have said they don’t want taxpayers to foot the 10 percent of the cost after federal funds for expansion are reduced to 90 percent.

Report researchers, however, said budget savings should offset the cost of expanding Medicaid through 2021.

“As some states continue to debate whether or not to expand, they need only look as far as their neighbors for evidence of the economic benefits that result,” “said John Lumpkin, MD, senior vice president at the Robert Wood Johnson Foundation.

States that have expanded Medicaid generate savings and revenue which can be used to finance other state spending priorities or offset much, if not all, of the state costs of expansion, according to the report.

For instance, the report said: California saved $250 million in spending on its low income health program in 2015; Colorado saved $96 million in spending in 2015 on childless adults newly eligible for Medicaid; Kentucky saved $21 million on mental health services in 2015; Maryland saved nearly $14 million on uncompensated hospital care in 2015; Michigan saved $19 million on prison health services in 2015; and Pennsylvania saved nearly $108 million in state spending in 2015 because of expansion.

Between 2014 and 2015, Medicaid spending in expansion states grew by half as much as spending in non-expansion states, 3.4 percent compared to 6.9 percent, the report said.

The report is an update to an April 2015 Robert Wood Johnson Foundation State Health Reform Assistance Network issue brief on the impact of Medicaid expansion, examining the budget effects of expansion in a sample of 11 states from all regions of the country, as well as in the District of Columbia.

SOURCE: Healthcare IT News