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Perspectives

Technology and medical care are evolving rapidly...so why aren’t we living longer?

Health Care Current | December 18, 2018

This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies, and provides updates and insights on policy, regulatory, and legislative changes.

My Take

Technology and medical care are evolving rapidly...so why aren’t we living longer?

By Sarah Thomas, managing director, Deloitte Center for Health Solutions, Deloitte Services LP

As was reported in the news this month, longevity rates are heading downward—primarily due to an increase in deaths among younger people from suicide and drug overdoses. While this is a gloomy note on which to end the year, I’m optimistic that technology from the private sector, combined with recent policy decisions that target the opioid crisis, could turn this trend around.

Last week, the US Centers for Disease Control & Prevention (CDC) released three reports that provided the most recent information (for 2017) on mortality rates, life expectancy, and causes of death in the United States. One report looks at the overall picture, while the other two provide more detail on premature deaths. Many of us have come to expect steady gains in life expectancy. The US spends more per capita on health care than any other industrialized country, and the vast majority of the population has access to health insurance and medical care.1 Moreover, researchers and biopharmaceutical companies continue to develop new innovations, including gene editing, immunotherapies, and digital therapeutics. The CDC’s report is sobering, as it underscores how many targets we still have to address.

Here are a few insights from the reports:

  • Life expectancy: In 2017, life expectancy at birth was 78.6 years for the total US population. As in the past, women live longer than men. The life expectancy for men is 76.1 years compared with 81.1 years for women.
  • Death rates: The report provides details on the death rate (i.e., deaths per 100,000 people). The overall rate was 731.9 in 2017, with significant variation by race and age. The highest death rate is for non-Hispanic black males at 1,083.3, and the lowest is Hispanic females at 434.2. Looking at age groups, the older the group, the higher the death rate. While that conclusion seems obvious, there has been an increase in the death rate for adults between the ages of 25 and 44, and the oldest group—those age 85 and older. The death rate has gone down for people age 45-54.
  • Leading cause of death: Cancer and heart disease remain the leading causes of death in the US. However, we are making progress in lowering the death rate for cancer, which is good news, and the death rate for heart disease is holding steady. Death rates are rising for quite a few diseases on the list of major causes of death. These include chronic lower respiratory diseases, stroke, Alzheimer’s disease, diabetes, and influenza.
  • Drug-overdose deaths: In 2017, 70,237 people died from drug overdoses—the age-adjusted rate was 9.6 percent higher than in 2016. The rates were highest for adults between the ages of 25 and 54. The highest rates of overdose deaths in 2017 were in West Virginia (57.8 per 100,000), Ohio (46.3), Pennsylvania (44.3), and the District of Columbia (44.0).

The statistics for overdose deaths include all types of drugs, but the report notes that the rate of overdose deaths involving fentanyl, fentanyl analogs, tramadol, and similar drugs increased by 45 percent between 2016 and 2017.

The decline in overall life expectancy is also being observed outside of the US. A recent analysis found that life expectancies for women have declined in 12 out of 17 countries, while life expectancies have fallen for men in 11 countries.2 When researchers looked into what was driving these trends, some differences emerged. In the non-US countries, the decline in life expectancy was seen primarily among older individuals. The researchers attributed this to a particularly deadly influenza season. But in the US, the decline was tied primarily to people in their 20s and 30s.3

At the same time, another study highlights the importance of understanding the broader trends that might be causing mortality rates to increase among young adults. Researchers at Virginia Commonwealth University confirmed that opioid deaths drove the increase in mortality among this population. They also found alarming trends that suggest an increase in alcohol-related deaths, suicides, and organ diseases.4

What is being done to address the opioid crisis?
As sad as I find these statistics, I think there is hope from both public-sector policies and from the private sector, particularly when it comes to reducing opioid-related deaths.

A study conducted by the Deloitte Center for Health Solutions provides some ideas for how the private sector can help address the opioid epidemic. We found that while a holistic solution remains elusive, health plans and pharmacy benefit managers (PBMs) are evolving their use of data analytics and technology to improve prevention and treatment among their members and within their communities. Data analytics might help health care stakeholders bridge some of those gaps.

On the policy side, Congress passed, and the president signed, bipartisan opioid legislation in October. The legislation includes more than $3.3 billion in authorized spending over 10 years. The law expands the use of opioid alternatives for pain management, includes policies to increase access to effective treatment within Medicaid and Medicare, targets providers to reduce over-prescribing, provides funding to educate patients, and identifies best practices for stemming the epidemic, among other policies. Congress also passed the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act. The legislation gives health plans new tools and strategies to manage care more effectively for patients who have chronic conditions and other complex health needs. The CHRONIC Care Act also expands access to telehealth services by allowing Medicare Advantage (MA) plans to cover additional telehealth services beyond what is covered under traditional Medicare.

These policy developments show that policymakers are recognizing that factors outside of the traditional health care system can impact our health and lives.

How might the Future of Health change this picture?
As my colleague Doug Beaudoin wrote last month, we probably won’t ever be able to eliminate disease in the future, but technology might help reduce the volume of disease and lessen the severity. We will likely be able to identify disease earlier, intervene proactively, and better understand disease progression to help consumers more effectively sustain their well-being.

The future of health is likely to see stakeholders leveraging technology to:

  • Identify markers for mental illness and disease earlier, and to make sure interventions are provided to people who have a genetic or other predisposition to behavioral health problems
  • Accelerate the science of therapeutic discovery to provide treatments to people who do develop diseases
  • Create virtual and geographic support communities to address depression and addiction
  • Make health care more efficient and affordable by adopting technologies that reduce repetitive work and migrate out of expensive institutions

We hope that once we reach the year 2040, we will have come a long way toward switching the balance of activity away from healing people who are ill to instead keeping people healthy and thriving in their communities. Despite the declining life expectancy, I’m optimistic that we will see that trend reverse in the future.

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1 The Organization for Economic Co-operation and Development, 2017 data
Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Italy, Japan, the Netherlands, Norway, Portugal, Spain, Sweden, Switzerland, and the United Kingdom
https://www.bmj.com/content/362/bmj.k2562
https://www.bmj.com/content/362/bmj.k3096

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In the news

Without individual mandate penalty, ACA is unconstitutional, federal judge rules

On December 14—one day before the open-enrollment season ended for the federal insurance exchange—a US District Court judge ruled that the Affordable Care Act (ACA) is unconstitutional because the individual mandate penalty has been eliminated. This ruling does not affect 2019 enrollment. The White House indicated that it expects the court’s decision will be appealed before heading to the Supreme Court. It is unclear when—or if—the high court would take up the case. In the meantime, the law remains in effect.

The penalty for not having health coverage was zeroed out in last year’s tax legislation (see the November 8, 2018 My Take). The judge ruled that the mandate and the penalty are distinct but interrelated. He argued that when the penalty was removed, the individual mandate no longer met the requirements of the ACA, which made the entire law unconstitutional. The ruling was in response to a lawsuit brought forth by 20 Republican attorneys general. Following the lawsuit, the US Department of Justice (DOJ) stated it would not defend the law in court.

CMS issues risk-adjustment program final rule

The US Centers for Medicare and Medicaid Services (CMS) will continue normal operations of the risk-adjustment program after issuing the final rule on December 7. The Patient Protection and Affordable Care Act; Methodology for the HHS-operated Permanent Risk Adjustment Program for 2018 final rule keeps the risk-adjustment methodology for the 2018 benefit year.

The risk-adjustment program pays health insurers that enroll a disproportionate number of high-risk enrollees, and insurers pay into the program if they have a disproportionate number of low-risk enrollees. This methodology lets health plans set premium rates that are based on the average health of the overall population.

In February, a district court in New Mexico vacated the use of statewide average premium-setting in the HHS methodology for the 2014-2018 benefit years, but allowed the program to go forward once CMS published more detail on its methodology (see the August 21, 2018 Health Care Current). The latest rule goes into effect February 2019.

(Source: CMS, CMS finalizes rule on the risk adjustment program for the 2018 benefit year, December 7, 2018)

Some HIPAA provisions could hinder transition to value-based care, HHS says

HHS is seeking to reduce regulatory burdens associated with the Health Insurance Portability and Accountability Act (HIPAA), particularly the HIPAA Privacy Rule. On December 12, HHS and its Office for Civil Rights (OCR) released a 32-page request for information (RFI) to help identify obstacles that might make it difficult for stakeholders to move to a value-based health care system.

HIPAA was enacted in 1996 to protect health information privacy and security interests for patients, while allowing information to be shared for certain purposes. According to OCR, certain aspects of the law might limit or discourage information-sharing that is needed for coordinated care or to facilitate the transformation to value-based health care. Fear of violating HIPAA, for example, could keep some covered entities from sharing important information with a patient’s family members. This reluctance could hinder effective coordination of care and case management that involves family members and friends who provide care to the patient.

Because access to this information could help people caring for individuals who have substance-use disorders (including opioid-use disorder), OCR is considering separate rulemaking to encourage covered entities to share protected health information with family members and caregivers.

The deadline for submission of information to the RFI is February 12, 2019.

Related: On December 11, the House Energy and Commerce Subcommittee on Health held a hearing with Donald Rucker, the head of the Office of the National Coordinator for Health IT (ONC), to discuss the agency’s implementation of aspects of the 21st Century Cures Act. The hearing focused on provisions of the law that are related to the interoperability and functionality of various health IT systems.

During the hearing, Rucker mentioned that his agency is working with OCR to examine potential changes to HIPAA that might improve care coordination for patients with substance-use disorders. When asked about the future of health care technology, Rucker noted that authentication for individual users, authorization for viewing physician information, and content (from a patient’s point-of-view) are areas for improvement. He stressed the need to balance security measures with usability, as added security can complicate user experience.

Rucker said that the Center for Medicare and Medicaid Innovation (CMMI) is looking at ways to leverage its authority to improve and catalyze health IT interoperability and adoption. According to the 2018 Deloitte Survey of US Physicians, 62 percent of physicians indicated that EHR interoperability is an area that needs improvement.

Real-world data will play key role in 2019 regulatory framework, FDA says

Leveraging real-world data (RWD) and real-world evidence (RWE) to improve regulatory decisions is “a top strategic priority” for the US Food and Drug Administration (FDA), the agency said December 6. RWD can come from a variety of sources, including electronic health records (EHRs), medical claims, product and disease registries, lab test results, and technology that is paired with consumer mobile devices, the agency explained. Stakeholders use the RWD to develop information and RWE to inform regulatory decisions, the agency said in announcing the framework for its Real-Word Evidence Program.

FDA has already begun to incorporate RWE into its regulatory decisions. The 21st Century Cures Act required the agency to release a comprehensive plan for how it advances those efforts. Biopharmaceutical companies are also increasing their reliance on RWE to optimize the design of clinical trials, according to Deloitte’s second annual RWE benchmarking survey report.

(Source: Statement from FDA Commissioner Scott Gottlieb on FDA’s new strategic framework to advance use of real-world evidence to support development of drugs and biologics)

FDA plans to reclassify insulin as a biologic to increase competition, affordability

Insulin, growth hormones, and substances made from living cells would be classified as biologics under new FDA guidance. Presently, insulin is classified as a drug, and there are no approved generic versions. This guidance would allow manufacturers to bring biosimilar insulin products to market, starting as early as March 2020.

In a statement, FDA Commissioner Scott Gottlieb said the agency hopes reclassifying insulin as a biologic will lead to more competition from biologics producers and more affordable options for patients. Insulin will not get 12-year market exclusivity, which is standard for new biologics.

The reclassification of insulin as a biologic follows the release of the FDA Biosimilars Action Plan in July. FDA approved seven biosimilar products in 2018.

(Source: Statement from FDA Commissioner Scott Gottlieb, on new actions advancing the agency’s biosimilars policy framework)

Subsidies could mean free coverage for 4.2 million uninsured, but out-of-pocket costs could be high

About 4.2 million people who lack health coverage could enroll in a bronze-level health plan and pay nothing in premiums after factoring in federal subsidies, according to a December 11 analysis from the Kaiser Family Foundation (KFF). However, the cost of medical care could still be high with bronze coverage: the average annual deductible for a bronze-level health plan is $6,258.

Despite the bronze coverage being essentially free from a premium perspective, researchers noted that people might be better off financially if they paid the premium for silver-level plans, which have lower deductibles.

The open-enrollment period for the 2019 plan year ended December 15 for HealthCare.gov. Some state-based exchanges have longer enrollment periods. Researchers determined that more than half of the nation’s 15.9 million exchange-eligible uninsured live in four states, including Florida (623,434), North Carolina (296,892), and Georgia (254,296).

Related: As of December 8, 4.1 million people had signed up for 2019 health coverage through HealthCare.gov, the public insurance exchange that operates in 39 states. With only one week left in the open-enrollment period, the pace of sign-ups increased by more than 20 percent compared to the prior week, according to the latest data from CMS. However, enrollments are down 13 percent compared to the same period a year ago.

(Source: KFF, How Many of the Uninsured Can Purchase a Marketplace Plan for Free?, December 11, 2018)

Chronic opioid users have higher medical costs, more hospital stays, study finds

Patients who regularly use prescribed opioids to manage non-cancer-related pain had longer hospital stays and higher annual health care expenses—more than $4,600—than patients who did not use the drugs for an extended period, according to a report published in The American Journal of Accountable Care. Patients who transitioned to chronic-opioid therapy (COT), defined as daily or near-daily use of opioids for at least 90 days, were more likely to use inpatient services. The study is based on a random sample of commercial claims from 3,776 adult COT patients and 16,425 non-COT patients.

(Source: The American Journal of Accountable Care, Increased Healthcare Utilization and Expenditures Associated With Chronic Opioid Therapy, December 5, 2018)

Breaking Boundaries

Health care organizations are preparing for blockchain, though not all are ready to implement it, study finds

Blockchain has been popping up in the news quite a bit over the past few years as a promising technology for health care. While many stakeholders are considering health care applications for blockchain, implementation appears to be somewhat limited among health systems, according to a recent report. HIMSS Analytics surveyed hospitals and other health care organizations to find out where they stood in blockchain adoption, and in what areas they expected to see the most near-term impact.

The survey of 159 hospitals and non-provider health care organizations found that fewer than 15 percent of respondents considered themselves to be well prepared for blockchain, while 60 percent said they were moderately prepared. Twenty-seven percent of respondents said they were not prepared for the technology. When asked what use case for blockchain would have the most immediate impact, survey respondents pointed to interoperability. Other potential uses for blockchain include data transfer, securing medical records, giving patients more control over their own health information, and improving the efficiency of claims adjudication.

RELATED: A growing number of financial organizations and health care companies are joining blockchain consortiums to invest in and implement the technology. Health plans, health systems, diagnostic lab companies, and other health care stakeholders are launching pilots to learn how blockchain technology can help improve data quality and reduce administrative costs around provider data management. For example, one goal for some health plans is to help consumers find accurate information about physicians, including data on credentialing and licensing. Many health plans, health systems, and credentialing organizations collect and maintain information about physicians and other providers. By participating in a consortium, these stakeholders can explore how blockchain technology can help reduce redundancies and ensure that accurate and up-to-date information is available in provider directories. They can also determine if using blockchain to share data can improve accuracy, increase access to care, and streamline administrative processes.

To learn more: Deloitte has a video explaining how blockchain is changing the life sciences and health care industry in new and unexpected ways. Our video explores how blockchain can help bring speed, security, and accuracy to data-sharing in the life sciences and health care industry.

(Source: Tom Sullivan, Blockchain: Three charts highlight today’s infrastructure, interest and initial use cases, Healthcare IT News, December 3, 2018)

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