Healthcare Financing and Sustainability

When looking at Healthcare Financing and Sustainability – I think about the cost of care and being good stewards of resources. “Rising healthcare costs and their consequences for Medicare and Medicaid constitute the nation’s central fiscal challenge. Without changes to federal law, the government’s spending on those two programs is on a path that cannot be sustained” from the Congressional Budget Office in 2009 (Longest, 2010; Appendix 8 p 313).

It is estimated that nearly $3.6 TRILLION was spent in 2018 in the U.S., significantly more than any other nation. The concern is that healthcare costs have been and continue to be unsustainable. There is the added concern regarding disparities in health. Though the U.S. is spending trillions of dollars, there are still many Americans who are un- or under- insured.

Impacting Health Policy

When looking to change healthcare policy, specifically Medicare, one must stop to consider, where does the money come from?

Financing of Medicare Part B is primarily achieved through the general fund of the U.S. Treasury, which is funded by Social Security Administration, which is funded by tax dollars (1.45% of your earnings) (Longest, 2010; CNN, 2018). There is also a monthly premium paid by enrollees that contributes to the funding.

Thus, to request that Medicare cover prophylactic mastectomies – this added benefit may come as an additional cost in tax dollars or and increase in the premium paid by Medicare beneficiaries.

Herein lies the challenge, without a clearly documented benefit of prophylactic mastectomies for Medicare aged women or a defined cost savings for this age group, it is highly unlikely that I will be able to garner enough support from the Health and Human Services committee to move forward with an amendment to Medicare due to the potential increase in spending.

Sustainability

Policy change must be sustainable and cannot only add cost to the current healthcare system, some benefit (decreased cost, improved outcomes) must also be realized. Though I believe that prophylactic mastectomies should be a provided benefit, it will likely come at the cost of the American people.

Perhaps the next best step would be to continue to try to engage with special interest groups, to instill passion and a consensus of the public that breast cancer patients need to have access to prophylactic mastectomies, before attempting to change policy.

References

CNN (2018). Ultimate guide to retirement: Who pays for Medicare? [webpage]. Retrieved from: https://money.cnn.com/retirement/guide/insurance_health.moneymag/index13.htm?iid=EL

Longest, B. B. (2010). Health policymaking in the United States (5^th ed.). Chicago, IL: Health administration press.

Sammour, T. (2018, January 25). Healthcare: it is a right or a luxury? A TEDx Adelaide talk . Retrieved from: https://www.youtube.com/watch?v=jCVmY1iOJQs

Schreck, R. (2019, December). Overview of health care financing [webpage]. Retrieved from: https://www.merckmanuals.com/professional/special-subjects/health-care-financing/overview-of-health-care-financing

The electronic medical record (EMR) for most of us has been a game changer in caring for patients.  The EMR has allowed for the ease of sharing information, the ability to review historical information, and for multiple providers to be interacting with patient information at the same time. I know I would not want to go back to the world of a paper chart!  

               Additionally, the EMR allows for the use of technology to aide in the care of our patients.  The data of nearly 380,000 patients, obtained from the EMR, was entered into a database to develop, implement, and validate an automated early warning score to identify patients who will likely deteriorate within the next 12 hours (Kipnis et al., 2016). Another study reviewed the hospital records of 565 hematology patients, specifically laboratory values and vital signs, to develop a neural network to review the multiple data points entered in the EMR to predict and alert significant patient decline (Hu, Wong, Correa, Li, & Deng, 2016). Fernandez (2019) anticipates the key components of EMR use will be clinical decision supports and the ability to track compliance with regulations. Access to these large datasets and the common place use of the EMR is changing the way we care for our patients. But what are the risks?

One risk is the potential breach of data. In 2016, 3.7 million patients were affected by the breach at Banner Health, potentially costing the corporation $6 million.  Not to mention the additional costs of improved data security.  A breach is defined as the “an impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of the protected health information”.  The HIPAA Breach Notification Rule (45 CFR §§ 164.400-414) requires entities to notify when a breach has occurred (U.S. Department of Health & Human Services, n. d.). Another potential risk is the inadvertent use of patient information.  Though most would agree, reviewing the EMR and large databases to improve the way in which we care for patients is permissible, however we are also accessing protected PHI.  When using large databases to complete retroactive studies or evaluate trends, we must be sure that we are following the national guidelines (HIPPA) and if applicable international guidelines (GDPR) that are more strict.

Specifically, regarding providing prophylactic mastectomies as a benefit for Medicare patients, there is little information available about the benefit in this specific population.  Additional research is needed regarding cost and survival benefits. The ability to utilize large databases from the EMR or a system like The Oncology Research Information Exchange Network (ORIEN) improves access to the needed data points to evaluate the survival or treatment benefits. Overall, as healthcare providers, we must always consider that this data is PHI, private details of a persons illness and experience. We need to remain diligent in it’s protection, and respectful of it’s use.

References:

Anonymous (2020, March 2). National Breast Cancer Coalition. Email correspondence.

Davis, J. (2019, December 9). Proposed $6M settlement reached in Banner Health data breach lawsuit [webpage]. Retrieved from https://healthitsecurity.com/news/proposed-6m-settlement-reached-in-banner-health-data-breach-lawsuit

Fernandez, M. (2019). Clinical decision support systems revolutionize the EMR to become the leader for patient empowerment [webpage]. Retrieved from: https://ww2.frost.com/news/press-releases/clinical-decision-support-systems-revolutionize-the-emr-to-become-the-leader-patient-empowerment/

Kipnis, P., Turk, B., Wulf, D., Laguardia, J., Liu, V., Churpek, M., . . . Escobar, G. (2016). Development and validation of an electronic medical record-based alert score for detection of inpatient deterioration outside the ICU. Journal of Biomedical Informatics, 64, 10-19. DOI: 10.1016/j.jbi.2016.09.013

M2Gen (2020). Oncolocy Research Information Exchange Network [webpage]. Retrieved from: https://www.oriencancer.org/

Hu, S., Wong, D., Correa, A., Li, N., & Deng, J. (2016). Prediction of Clinical Deterioration in Hospitalized Adult Patients with Hematologic Malignancies Using a Neural Network Model. PLoS One, 11(8), E0161401. DOI: 10.1371/journal.pone.0161401

U.S. Department of Health & Human Services (n. d.). Health Information Privacy [webpage]. Retrieved from https://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html

Wyllie, D., & Davies, J. (2015). Role of data warehousing in healthcare epidemiology. Journal of Hospital Infection, 89(4), 267-270. DOI: 10.1016/j.jhin.2015.01.005

“The important thing in science is not so much to obtain new facts as to discover new ways of thinking about them.”― Sir William Bragg

From the week 9 article readings a common thread is the sharing of information to gain knowledge and improve the care of patients, through open data bases, artificial intelligence, and sharing of research information. For anyone who has worked or followed the continuing advancements in oncology care, it is easy to see how the open sharing of knowledge between providers and researchers could significantly impact care.  Oncology care continues to rapidly change as new knowledge is learned – from increased understanding at the molecular level, novel therapies, targeted therapies, and harnessing the immune system to fight cancer (DeVito, Leavitt, & Saleh, 2019).

Karen Olsen, PhD interviewed oncology experts regarding what to expect in 2020. One expert discussed continued study and advancements in the understanding and utilization of the immune system to treat cancer is predicted – immunotherapy. Additionally, another expert described the focus of individualized medicine or precision medicine where treatments are modeled after the specific pathology, tumor, and the specifics of the cancer identified with the help of technology.

Sounds AMAZING, right? But how do we get there? Knowledge. Clinicians and researchers need to share knowledge, as proposed as the ability to create a large data base where data can be compiled but to be successful requires identification of the best way with regulatory support in this data sharing (Olsen, 2020).

        There are hundreds of clinical trials being completed all over the globe to advance our knowledge of cancer biology and treatments, imagine if collaboration was fostered. The Oncology Research Information Exchange Network (ORIEN) has sought to do just that. There are 19 cancer centers in the US listed as members of ORIEN. Described as a team environment of collaboration with the ability to use the strength of larger data sets to impact cancer care. Patients consent to share their clinical and molecular data with ORIEN.

         For women with breast cancer, though a common disease with approximately 325,000 new cases of breast cancer (invasive and in-situ) estimated for 2020 by ACS, additional research is needed to better understand the potential survival benefit of prophylactic mastectomy, the reasons women chose to undergo a preventative mastectomy, and any potential cost savings to both the patient and the health care system. Specifically, in relation to prophylactic mastectomy benefits for medicare beneficiaries. A private sector collaborative entity like ORIEN would allow for sharing of data and findings of women across the US as opposed to the longer process of conducting multiple clinical trials. Thus potentially positively impacting the ability to affect legislation for the care of breast cancer patients in less time.

References:

American Cancer Society (2020). About breast cancer. [webpage]. Retrieved from: https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html

DeVito, T., Leavitt, J., & Saleh, N. (2019, January 17). Key advances in oncology, 2018. Oncology Journal, 33(1), 6-8. Retrieved from: https://www.cancernetwork.com/oncology-journal/key-advances-oncology-2018

LibQuotes (2020). William Lawrence Bragg quotes [webpage]. Retrieved from: https://libquotes.com/william-lawrence-bragg

M2Gen (2020). Oncolocy Research Information Exchange Network [webpage]. Retrieved from: https://www.oriencancer.org/

Olsen, K. (2020, January 10). Experts forecast cancer research and treatment advances for 2020. American Association for Cancer Research [webpage]. Retrieved from: https://www.aacr.org/professionals/blog/experts-forecast-cancer-research-and-treatment-advances-in-2020/

Medicare was first inacted in 1965 to provide health care coverage to American’s aged 65 and older (Longest, 2010). Once a person reaches age 65 they are eligible to enroll in Medicare or choose to defer these benefits if they have health care insurance through their employer (Roberts, 2018). However, social security benefits cannot be utilized if the person is not enrolled in Medicare (Montgomery, 2020).  

Why does Medicare coverage matter for breast cancer patients?

Age, is a known risk factor for breast cancer as seen in the graph below. The incidence of breast cancer begins to rise for women in their 40’s with incidence increasing with age. The majority of women diagnosed with breast cancer are age 65-80.

Medicare Part B covers medical services, including outpatient surgery, but for the procedure to be covered it must be either medically necessary or a prescribed preventative benefit (Longest, 2010).  A prophylactic mastectomy is defined as a “cosmetic” procedure according to Medicare and not covered.

Financing of Medicare Part B is primarily financed through the general fund of the U.S. Treasury, which is funded by Social Security Administration, which is funded by tax dollars (1.45% of your earnings) (Longest, 2010; CNN, 2018). There is also a monthly premium paid by enrollees that contributes to the funding.

As for spending, Medicare covers cancer treatments including inpatient care, provider visits, chemotherapy, and radiation along with other services. Though patients need to be prepared to pay their 20% deductible.

Inciting change

Medicare is managed at the federal level, thus changes in coverage and policy must occur at the federal level. Questions to be answered would include what is the potential increase in spending? If so, where does the extra money come from? Is there any cost saving benefit? Where is the proof that a prophylactic mastectomy is medically necessary?

I would argue that firstly a prophylactic mastectomy for a breast cancer survivor is not a “cosmetic” procedure.  This is a woman who had made the difficult decision to remove a part of her body in the hopes to decrease her cancer risk. Secondly, that prophylactic mastectomy would not cause significant increase in care, as patients with breast cancer require close follow up with mammograms, ultrasounds, and potentially MRIs. One study found that lifetime costs were decreased in women who underwent a prophylactic mastectomy compared to those completing recommended surveillance (Mattos et al., 2015). However, the potential cost savings would need to be further explored with the Medicare aged patients.  

There is no black and white answer to is a prophylactic mastectomy medically necessary. There is both support and opposition for this procedure. Like many things in health care, it is a personal, case dependent, decision. However, for a 70-year-old woman on Medicare, this decision is not hers – it was made for her.

And if you think 70 is old or frail.. here are some 70-year old’s – Meryl Streep, Jane Fonda, Tina Turner, Diana Ross, and Cher!

References:

CNN (2018). Ultimate guide to retirement: Who pays for Medicare? [webpage]. Retrieved from: https://money.cnn.com/retirement/guide/insurance_health.moneymag/index13.htm?iid=EL

Longest, B. B. (2010). Health policymaking in the United States (5^th ed.). Chicago, IL: Health administration press.

Mattos, D. G., Gfrerer, L. S., Reish, R. M., Hughes, K. J., Cetrulo, C. C., Colwell, A., & Liao, E. (2015). Lifetime Costs of Prophylactic Mastectomies and Reconstruction versus Surveillance. Plastic and Reconstructive Surgery, 136(6), 730e-740e. Doi:10.1097/PRS0000000000001763

Montgomery, K. (2020). Why are you being forced into Medicare at age 65? [webpage]. Retrieved from: https://www.verywellhealth.com/why-am-i-being-forced-into-medicare-at-age-65-1738542

The most stunning women in Hollywood over 70 (2020) [webpage]. Retrieved from: https://www.wonderwall.com/celebrity/photos/most-stunning-women-hollywood-over-70-3011024.gallery

Roberts, D. K. (2018). Is it mandatory to sign up for Medicare at age 65? [webpage]. Retrieved from: https://boomerbenefits.com/is-it-mandatory-to-sign-up-for-medicare-at-age-65/

Roberts, D. K. (2019). How does Medicare cover cancer treatment? [webpage]. Retrieved from: https://boomerbenefits.com/medicares-coverage-for-cancer/

U.S. Cancer Statistics Working Group (2019). U.S. Cancer Statistics Data Visualizations Tool, based on November 2018 submission data (1999-2016): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute. Retrieved from www.cdc.gov/cancer/dataviz

Initiate a change to health policy regarding Medicare, where do I even begin? In utilizing the Congress.gov current legislation search function, there are no bills or amendments currently listed that address prophylactic mastectomies. So, to explore the process of policy change for breast cancer patients a current law Women’s Health and Cancer Rights Act (WHCRA) and bill Breast Cancer Patient Equity Act (H.R.1370 and S.562) will be used.

Who decides?

It takes more than a problem, even with a potential solution to garner legislative action. Most often it is the problems that are identified as important or urgent by policy makers that put into action (Longest, 2010). Additionally, legislators are influenced by the number of potential solutions, inciting interest groups (being positive or negative), and public opinion (Longest, 2010). However, the President can significantly influence what problems are focused upon through agenda setting and involvement (Kingdon, 2003).  As Medicare is overseen by the federal government a bill or amendment would need to be approved by both the House and Senate, then signed into law by the President. More specifically, Centers for Medicare & Medicaid Services (CMS) is a federal agency within the Department of Health and Human Services, that was created to administer Medicare and Medicaid services, and continues to serve as the implementing organization (Longest, 2010).  The WHCRA both state and government plans are regulated by CMS (CMS, n.d).

According to Levine (2017) bills are introduced by a sponsor, or two to be bi partisan, either in the House or Senate, and others can show their support by being co-sponsors, with more co-sponsors the bill may receive higher priority. Additionally, a companion bill may be utilized where the same bill is introduced by both the House and Senate (Levine, 2017).

Two Examples:

The Women’s Health and Cancer Rights Act (WHCRA) and the Breast Cancer Patient Equity Act are amendments to current approved legislation, not newly proposed bills. Each of theses bills can be followed on the Congress.gov page and were transferred from one committee or sub-committee to the next. The Breast Cancer Patient Equity Act appears to be a bill that was introduced at the same time in the House and Senate.

Overall, trying to find information about legislation that impacts breast cancer, was a daunting task, the websites are not user friendly and information was hard to find. Is there a better way to learn about breast cancer policy? One of the other impacts to legislation are special interest groups which in turn impact public opinion, another deciding factor for legislators. Longest (2010) describes special interest groups as organized and intensely focused on influencing development and implementation of policy.

Special Interest Groups

What happens every October?  No, not Halloween.  Everything goes PINK from the NFL to items in your local grocery store, porch lights to business lights, all to benefit breast cancer awareness.  I would venture to say that it is these special interest groups that have had the greatest impact on educating the public, increasing awareness, and may be a better route when looking to impact policy regarding prophylactic mastectomy.

Here are two special interest groups to check out:

Susan G Komen – https://ww5.komen.org/

National Breast Cancer Foundation, Inc. – https://www.nationalbreastcancer.org/

References:

Centers for Medicare and Medicaid (n.d.) Women’s Health and Cancer Rights Act (WHCRA): The Center for consumer information & insurance oversight [webpage]. Retrieved from: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/whcra_factsheet

Good Morning America (2019). GMA’ goes pink for Breast Cancer Awareness Month . Retrieved from: https://www.youtube.com/watch?v=9bUTY5jElVI

Levine, R. A. (2017) The difference between a House and Senate Bill: How legislation becomes law [webpage]. Retrieved from: http://familybuilding.resolve.org/site/PageServer?pagename=advday_difference

Library of Congress (n.d.) Bill search on Congress.gov [webpage]. Retrieved from: https://www.congress.gov/search?q={%22congress%22:%22116%22,%22source%22:%22legislation%22}&searchResultViewType=expanded&KWICView=false

Library of Congress (n.d.) H.R.1370 – Breast cancer patient equity act [webpage]. Retrieved from: https://www.congress.gov/bill/116th-congress/house-bill/1370/titles?q=%7B%22search%22%3A%5B%22mastectomy%22%5D%7D&r=1&s=2

Library of Congress (n.d.) S.562 – Breast cancer patient equity act [webpage]. Retrieved from: https://www.congress.gov/bill/116th-congress/senate-bill/562/text?q=%7B%22search%22%3A%5B%22mastectomy%22%5D%7D&r=2&s=2

Longest, B. B. (2010). Health policymaking in the United States (5^th ed.). Chicago, IL: Health administration press.

Kingdon, J. W. (2003). Agendas, alternatives, and public policies. New York, NY:Addison-Wesley educational publishers inc.

Rogers, K. (n. d.). Breast cancer awareness month. Encyclopedia Britannica [webpage].  Retrieved from: https://www.britannica.com/science/notifiable-disease

Ethics and Politics

Ethics – good, just, moral, fair.

Politics – crooked, dirty, dubious, divided.

Ethics and politics are often described at opposite ends of the spectrum, but is there common ground where ethically and politically the goals align?  In making decisions and formulating the laws that affect access to medical care I hope that ethics and policy go hand in hand, focusing on beneficence and justice.  Quick decisions can be made in policy as described by Kingdon (2003) when Medicare coverage for dialysis and kidney transplant were approved in part due to media coverage of the ethical dilemma of patients not having access to these novel and life saving therapies. However, little thought was given to the significant cost of these treatments. The ethical principle of beneficence should also encompass financial harm. Is the treatment, procedure, or policy cost-effective? As health care providers we must be aware of potential physical, psychological, spiritual, and financial harm. How should ethics influence policy? Universal access, equitable access, affordable access, quality, and choice are the key ethical principles proposed by Gostin (2017) to guide health policy.

So, what about prophylactic mastectomies for women, is there an ethical or political barrier? Yes! Some women choose to have a prophylactic mastectomy if they are at high risk for developing breast cancer (due to genetic mutation). However, more women with breast cancer choose to have a double mastectomy to decrease risk of breast cancer or for other reasons: to avoid radiation, to not have surveillance testing (mammograms, MRI, ultrasounds), or for the peace of knowing that the breast (risk) is removed. I have met women who have had mastectomies to decrease risk, to not have to undergo follow up testing, or for personal reasons. Breast cancer affects women across multiple ages from 40 to 80 as depicted below.  

These women will only have the option of a double or prophylactic mastectomy dependent upon their insurance coverage, for those who are 65 with Medicare a prophylactic mastectomy is not an option that is covered. I find it unethical to base treatment options first by what the insurance will cover and second by the goals of the patient. Bound by my nursing ethical principals I believe that these women should have the right to choose the treatment option that best aligns with their goals. Policy for Medicare should be reformed to allow for justice, quality, and the choice for these women in the treatment or prevention of breast cancer.

References

American Cancer Society (2019). Breast cancer facts & figures 2019-2020. Atlanta: American Cancer Society, Inc. Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2019-2020.pdf

Caruso, C. (2017). Why a growing number of women with breast cancer are choosing double mastectomy. STAT+. Retrieved from https://www.statnews.com/2017/08/29/double-mastectomy-breast-cancer/

Gostin, L. (2017). Five ethical values to guide health system reform. JAMA, 318(22), 2171-2172.

Kingdon, J. W. (2003). The policy primeval soup, In Agendas, alternatives, and public policies. New York, NY:Addison-Wesley educational publishers inc.

1 in 8 women will be diagnosed with breast cancer, with the primary risk factors being female gender and increasing age. Some women who have high risk genetic factors, the BRCA1 or BRCA2 gene mutation, without a diagnosis of breast cancer elect to undergo a preventative mastectomy, perhaps you recall the story of Angelina Jolie. Only 5-10% of breast cancers arise from the BRCA1 or BRCA2 gene mutation. Some women who have been diagnosed with breast cancer in one breast seek to decrease their risk of cancer recurrence in the unaffected breast and opt to have a preventative or prophylactic mastectomy. I just recently learned from my preceptor that Medicare does not cover prophylactic mastectomy in many cases. Through diligent searching of Medicare.Gov I was unable to find any statements regarding mastectomy coverage. Other websites state No, medicare does not cover preventative mastectomy and for coverage the procedure needs to be medically necessary and reviewed case by case. Susan G Komen states that there are no federal laws to require insurance providers to cover prophylactic mastectomy, and that some state laws require coverage of preventative mastectomy but that it varies from state to state. Women should have the ability to chose to have a preventative mastectomy after adequate counseling and decision making with their oncologist.

References

ABC News (2013. May 14). Inside Angelina Jolie’s double mastectomy decision . Youtube. https://www.youtube.com/watch?v=wVC0dBGJXZ8

American Cancer Society (2019). Breast cancer facts & figures 2019-2020. Atlanta: American Cancer Society, Inc. Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2019-2020.pdf

Does Medicare cover preventative mastectomies when testing indicates a patient is at risk for developing breast cancer or when the patient has a genetic mutation (2019, December 2). Retrieved from https://www.palmettogba.com/palmetto/providers.nsf/DocsR/Providers~JJ%20Part%20B~Browse%20by%20Topic~Frequently%20Asked%20Questions~General~BD4KEA7031?open#

Jolie, A. (2013. May 14). My medical choice. The New York Times. Retrieved from https://nyti.ms/19l8bbY

Preventative surgery (2019, March 22). Retrieved from  https://ww5.komen.org/BreastCancer/PreventiveSurgery.html

U.S. breast cancer statistics (2019, February 13). Retrieved from https://www.breastcancer.org/symptoms/understand_bc/statistics