PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.
This week’s topics include incentivizing healthy behaviors, bundling hip and knee replacements, the cost of a new cholesterol medication, and compliance with cancer screening and mortality.
0:48 Incentivizing healthy behaviors
1:48 May provide money to lower premiums
2:46 Patients didn’t understand well
3:36 Adherence to cancer screening and mortality
4:35 Mortality among nonadherents
5:32 Nonadherence identifies them at higher risk
6:35 In observational studies we pick healthier people
7:21 Antibody for cholesterol lowering PCSK9 inhibitor
8:21 Are they cost effective?
9:22 Price has to drop to $1100 per year
10:00 Bundled knee and hip replacements and impact on cost
11:00 Didn’t discharge to post procedure care facilities
12:00 Didn’t measure patient factors
Elizabeth Tracey: Compliance with cancer screening and mortality.
Rick Lange, MD: Are the new cholesterol-lowering medications cost effective?
Elizabeth: What happens if we bundle joint replacement treatments?
Rick: Do Medicaid healthy behavior incentive programs actually reduce cigarette smoking or [increase] weight loss?
Elizabeth: That’s what we’re talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a medical journalist at Johns Hopkins, and this will be posted on January 4th, 2019.
Rick: I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine, and Happy New Year to our listeners!
Elizabeth: Happy New Year! We discussed a few of our hopes and dreams for 2019. I know many people share that sentiment. Let’s first let you go, I think, because you moved things around just a little bit on me. In JAMA Network Open, you selected a study talking about incentivizing healthy behaviors.
Rick: In states that have not expanded Medicaid, there’s a waiver program that they can apply to that is meant to either improve patients’ health or to prevent diseases. One of these things is called the Healthy Behavior Incentive Program. It’s what’s called a Section 1115 demonstration waiver, and it’s meant that states can apply for these incentive programs to do one of three things: reduce cigarette smoking, to reduce obesity, or to improve annual preventive health visits. These investigators looked at four states: Florida, Indiana, Iowa, and Michigan, that had implemented these behavior-specific health behavior incentive programs and followed them for 2 years.
How do these incentive programs work? What happens is they provide either the patient money to help lower their premiums either now or in the future or do other things to financially incentivize these individuals. What they determined was when they looked at the Medicaid population that had an annual income of less than $25,000 or segmented it by whether they had a high school education or not, they determined these healthy behavior incentive programs did not reduce cigarette smoking. They did not reduce the incidence of obesity, and they only modestly improved the annual preventive health visits.
Elizabeth: Terribly, terribly disappointing, of course, and also runs counter to studies we’ve reported in the past, where financial incentives did prove efficacious, at least with regard to cigarette smoking cessation.
Rick: People said, “In light of these smaller pilot studies, why wasn’t this larger program effective?” In the smaller studies, the incentive was much bigger. It was as much as $800 per patient, and these incentives are actually pretty small, $5 to $10 to as much as $50. Secondly, sometimes these programs were much more complex so that the patients didn’t understand it and the physicians didn’t understand it, and it wasn’t communicated well with the patient. Sometimes these incentives weren’t given in a timely fashion, so the patient would have to apply for it months later, 4 to 5 months, and it may be a future incentive to lower future premiums. As a result, these larger programs aren’t effective.
Elizabeth: Are you suggesting, then, that one strategy might be to increase the amount of the incentives and also to give them in a more timely fashion?
Rick: One certainly needs to look at that, Elizabeth. Among those possibilities, have higher-value incentives that are provided near the time of completing the health and behavior and is communicated better, both to the clinicians and to the patients. In fact, we need to make sure that the financial incentive we’re providing is of value to the patient. If we’re just decreasing premiums, they may not find that valuable when they need to eat or need to pay for rent.
Elizabeth: Let’s turn to JAMA Internal Medicine, something that’s kind of corollary to this. This, I thought, was a pretty interesting study relative to cancer screening. What they were looking at was, “Gosh, let’s take a look at the people who did not adhere to the cancer screening recommendations as a part of this study.” This study specifically was looking at, “If we take a look at chest radiographs, flexible sigmoidoscopy for both sexes, PSA, digital rectal exams, and cancer antigen 125 for ovarian cancer and transvaginal ultrasound for women, what’s the impact of those things?”
What they did was take a look at the folks who were enrolled as part of this trial, but who did not comply with the cancer screening recommendations; 55,000+ people actually adhered to the guidelines, while almost 11% did not adhere to the baseline screening protocol.
They followed them up for 10 years, and they took a look at “What’s the mortality among those folks who did not adhere to the screening guidelines?” They found, basically, a 50% increased risk of mortality that was not related to the cancers that were being screened for. It could have been other things, cardiovascular disease or whatever, that ultimately resulted in mortality. With the editorialists saying, “There’s still a compliance bias that’s inherent in the findings of this study.” It’s unclear exactly what they mean.
Rick: In the almost 11% that did not do any of the cancer screening had a higher non-cancer mortality. This suggests that the non-adherence with the cancer also predicts which patients are involved in other unhealthy behaviors that may not be screened for, for example, high blood pressure- or cholesterol-lowering, or they may not be involved in other healthy lifestyles like a better diet, stopping cigarette smoking, and physical activity. Just by the fact that they don’t adhere to cancer screening identifies a higher-risk individual that has a 50% increased mortality due to non-cancer-related causes.
Elizabeth: It’s really interesting, but I think the question is, what do you do about this? That’s one thing, and then my other question about it is these people voluntarily enrolled in this trial. Why would you not comply if you wanted to be a part of the trial? [Laughter]
Rick: That goes to the fact that adherence has a lot of different factors that include either patient-level demographic or sociocultural or behavioral factors, even as well as external factors such as the complexity of the regimen, whether people have access to it, whether they have to take off work to do these kinds of things. There are a lot of different things that affect cancer screening that probably also affect the management of chronic diseases as well, and we need to recognize them and address them.
Elizabeth: Okay, so what’s your bottom line? What is the take-home with regard to what you can do with this data?
Rick: A couple things. One is I think that it tells us that an observational study, it’s not a randomized, controlled trial, but in observational studies, oftentimes we pick a healthier patient population. They take their medications. They do what they’re supposed to do, and that’s a sign that their lifestyle and their behavior, maybe not particular treatment is actually affecting their overall outcome. We need to recognize that.
The second thing is, if you’ve got a patient population and you know they’re not being adherent to cancer screening, then you can assume that they also have non-adherence to other behaviors as well. We need to identify those higher-risk patients and address it in a way where they will actually adhere to the healthy lifestyle behaviors.
Elizabeth: I agree with that and I would also just remind you of the study we started with “How do you get people to do that?” I think that’s an open question. We don’t know the answer to that yet. Let’s turn from here to your second one, and that is another really fascinating study in Annals of Internal Medicine. Gosh, when somebody has got high cholesterol and we’re trying to bring it down, we’ve used statins and we’ve done all kinds of things. What about this antibody? Is it cost-effective?
Rick: This is a new class of cholesterol-lowering medications called PCSK9 inhibitors. The particular one we’re talking about is alirocumab that was approved by the FDA in 2016. They’re very effective in lowering cholesterol. They lower it by about 50% to 60%, and there are other ones out on the market. Recent studies have shown that they reduce not only cholesterol, but cardiovascular outcomes and in higher-risk populations can actually reduce cardiovascular mortality by 15%. But the annual cost of these is $14,000. That’s always a moving target, because as soon as someone announces that, they lower the price to make it a little bit more cost reasonable.
But what this study did was they said, “Let’s look at available medications at the current prices to lower cholesterol and find out whether they’re cost effective.” These are people already taking a statin, so if we add a second agent, ezetimibe, or the PCSK9 inhibitors, what’s the cost? In general, we say, “If the cost is below $50,000 per quality-adjusted life year, quality, we consider that cost effective.” Compared with a statin alone, adding ezetimibe costs about $81,000 per quality-of-life-adjusted year. Using the PCSK9, it was $308,000.
In fact, if you compared the combination of statin and ezetimibe and replacing ezetimibe with alirocumab, that cost was almost a million dollars per quality-of-life- adjusted years. That suggests that at their current price they’re not very cost-effective in terms of lowering cholesterol and improving cardiovascular outcomes.
Elizabeth: Right, so of course, this has to be juxtaposed against these really pretty impressive results with regard to further lowering of cholesterol in people who are at risk.
Rick: Yeah, they did a further analysis and what would the price have to drop to for it to be cost-effective? The study suggests that the price has to drop to a little over $1,100 per year for the PCSK9 inhibitors to provide good value in terms of secondary prevention.
Elizabeth: I think this is all really quite fascinating, especially within the context of the ostensible federal oversight of a lot of pharmaceutical pricing.
Rick: In fact, that’s why these medications, although they’re very effective, have not seen general acceptance by clinicians or patients.
Elizabeth: All right, since we’re talking about price, let’s turn to the New England Journal of Medicine, this analysis of the Medicare-implemented comprehensive care for joint replacement. This was a national mandatory bundled payment model for hip and knee replacement in randomly selected metropolitan areas.
What happened is these hospitals got bonuses or pay penalties based on Medicare spending per hip or knee replacement episode. That was the hospitalization plus 90 days after discharge. They took a look between 2015 through 2017 at 280,000+ hip or knee replacement procedures in 803 hospitals and treatment areas, and compared those with almost 400,000 procedures in just under a thousand hospitals in control areas.
What they found was that there were greater decreases in institutional spending per joint replacement episode in the treatment areas, not really terribly surprising. This was less $812, or 3.1%. It was largely driven — I thought this was really interesting — in the percentage of patients who were discharged to post-acute-care facilities. It seems to me it didn’t really impact too much on the hospital itself.
The program did not result in higher rates of complications or in the percentage of joint replacement procedures performed in high-risk patients. What it suggests is that it is effective in reducing spending on hip and knee replacement episodes. As I suggested to you, I would also say that this is kind of an intermediary point. I don’t think we know the full answer on this yet, but I think as time goes on and we gather more data it’s going to become more robust.
Rick: This bundled payment model, where the hospital is responsible not only for the surgery, but for the first 90 days of care and they receive a lump sum, and they have to decide how they’re going to allocate it, was meant to drive the hospitals to reduce the cost. It didn’t reduce the cost of the physicians or the surgery or the joint. What the hospitals did was they provided less post-hospital care.
Now, the complications that they measured were death and infection. They didn’t measure patient satisfaction or patient pain or how quickly they ambulated afterwards, so it’s very difficult to say whether this reduction in post-hospitalization care was unnecessary or whether it was necessary, but they just didn’t measure it afterwards. Even though it saved $800 per hospitalization, after they paid the incentives, it only saved about $200 per patient, so it was really a very modest decrease overall.
Elizabeth: That’s one of the reasons I suggested this has kind of been an intermediary point. We don’t really know the full answer for this yet. Moreover, as you suggest, I think that some kind of reduction has got to be appropriate, and somehow I think the hospital needs to figure out how to contain its costs, too.
Rick: I think that there’s some enthusiasm for doing that, but this follows on other bundled payment programs that really showed the same thing. It really doesn’t reduce the hospital cost. It reduced the post-hospital care and the post-hospital cost. If we can target that to individuals that receive the most benefit from it or that need it the most, we can help reduce cost in that manner.
Elizabeth: I’m sure that’s going to be an important consideration. I wonder how many times in 2019 we’re going to be talking about that. That’s a look, then, at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: I’m Rick Lange. Y’all listen up and make healthy choices.