2017’s most important healthcare stories summarized, from politics to public health, new advances to growing threats. See what happened and look ahead to the future.
Repeal, Replace, Reroute
Widespread agitation over the status of the Affordable Care Act shook nerves raw at the start of 2017. No version of the repeal-replace scenario ever came to pass. But by the close of the year, Congress did vote in a new tax bill that’s poised to strike a blow to Obamacare through a back route. By pulling out the individual mandate for coverage, ACA opponents may unravel the legislation they couldn’t repeal. But if there’s one thing we did learn this year, it’s that Americans will go to the mat to keep some things intact, like coverage for pre-existing conditions. And when the year is done, ACA sign-ups for 2018 will have held steady as well, despite an enrollment period that was only half as long. It seems when it comes to the ACA, there may be some willpower that doesn’t yield to predictions.
Final Rule on Employer Wellness Programs
Wondering what ‘final’ means when it comes to drawing the line between encouragement and coercion in an employer wellness program? You’ll have to stay tuned. In 2016, employers were given guidance on how to keep a wellness program voluntary under the Americans with Disabilities Act (ADA) and the Genetic Information Nondiscrimination Act (GINA). But on December 20, 2017 a judge ordered those 2016 rules vacated no later than January 1, 2019. The AARP, an advocacy group for people over 50, sued the government over the rules, citing civil rights concerns. So, in 2018, expect to see clarification on how wellness programs can pursue the simultaneous goals of promoting health, remaining voluntary and assuring privacy.
U.S. Life Expectancy Is Declining, Overdoses Bear the Blame
Underscoring the reality of the opioid crisis we’re facing in the U.S. right now, the CDC released its statistics on life expectancy in late December, 2017. It’s been more than 50 years since we’ve seen a back-to-back yearly decline in our life expectancy, and back then it was a deadly epidemic flu. This epidemic is opioid overdose. The rate of drug overdose deaths rose 21% in a single year, with 63,600 people losing their lives. Deaths from fentanyl and other synthetic opioids accelerated fastest, with more than double the number of overdose fatalities. Heroin deaths were up almost 20% and deaths from other opioid painkillers like hydrocodone and oxycodone were up 14%.
Heart disease and stroke death continued to decline, but more slowly than in prior years.
“The increase in death rates among younger Americans may be explained in part by the earlier onset of high blood pressure, diabetes, obesity and other conditions that may lead to heart disease and stroke,” said researcher Pradeep Natarajan, director of preventive cardiology at Massachusetts General Hospital in Boston.
Lower Your Blood Pressure
If you thought your blood pressure was good at 120/79, 2017 says it’s time to walk off that complacency. We learned for sure that even mild elevations in blood pressure can mean major increases in cardiovascular risk. Half of American adults need to lower their blood pressure, based on new guidelines adopted by a panoply of groups that includes the American College of Cardiology and American Heart Association. Does that mean more medicine for everyone? It does not. The most widespread change in prescription sounds very familiar: improve diet, exercise more, lose weight, drink less alcohol, reduce sodium intake, and lower stress.
Did you know? The usual impact of each lifestyle change we just listed is a 4-5 mm Hg decrease in systolic blood pressure and 2-4 mm Hg decrease in diastolic blood pressure. Meanwhile, a diet low in sodium, saturated fat, and total fat and increase in fruits, vegetables, and grains may decrease systolic blood pressure by approximately 11 mm Hg.
Back Pain? A Yoga Pose Beats a Pain Pill
Lower back pain is so common that more than half of us have suffered from it in the last year. It’s also a prime example of low-value health care. We spend a lot trying to treat lower back and neck pain – an estimated $86 billion a year, behind only diabetes and heart disease. But the care we get for the money doesn’t deliver much by way of reduced pain or increased mobility. Someone going to the doctor for back pain stands a surprisingly good chance of getting treatment that won’t work. And in too many cases, that ineffective treatment can lead to unintended outcomes like opioid addiction.
In April 2017, The American College of Physicians (ACP) released new guidelines to present evidence and provide clinical recommendations on noninvasive treatment of low back pain – acute, subacute or chronic. They made strong recommendations with a simple message: Avoid prescription painkillers. Try exercise, yoga and massage first.
More than 10% of the World is Obese
Even in regions such as Africa that have historically suffered food shortages, obesity is skyrocketing. Rates have doubled or more in 73 countries around the globe, while not a single country has reduced its overweight or obesity levels. Excess weight played a role in 4 million premature deaths worldwide from cardiovascular disease, kidney disease and diabetes. Most shockingly, 40 percent of those deaths were among people whose BMI of 25-29 classified them as overweight but not obese.
Researchers at the Institute for Health Metrics and Evaluation at the University of Washington analyzed more than 1,800 data sets from around the world. They note that the general slowdown in physical activity predates skyrocketing obesity, so moving less is probably not the cause. The researchers point instead to the changed food environment.
“We have more processed food, more energy-dense food, more intense marketing of food products, and these products are more available and more accessible. The food environment seems to be the main driver of obesity,” said Dr. Ashkan Afshin, assistant professor at the Institute for Health Metrics and Evaluation and lead author of the study.
90% of Us Don’t Get Our Fruits and Veggies
The amount of fruit and vegetables you need to eat depends on your age, sex, and level of physical activity. But the bottom line is that only 1 in 10 of us are getting enough, says the Centers for Disease Control (CDC). Men, younger adults and people living in poverty fare worst, with barriers that include high cost and limited availability. A perceived lack of cooking and prep time may also explain at least in part why people tend to eat even fewer vegetables than fruit, which is easier to grab and go. Bottom line: we need more of each in our diets to protect against heart disease, diabetes, cancer and obesity.
The Sugar Industry Paid Scientists to Shift the Blame to Fats
What happened in this story took place 50 years ago, but documents discovered in 2017 shed more light on the long-term Sugar strategy to hook a nation. When a spate of scientific articles came out in the 1960s linking sugar to coronary heart disease, the industry worked to change the narrative. The Sugar Research Foundation (now the Sugar Association) secretly paid three Harvard scientists to publish a review of the literature on health effects of sugar. When it was done, the head of the Sugar Research Foundation called the review “quite what we had in mind.” If a study connected sugar to heart disease, it was found flawed. But the same standards of scrutiny weren’t applied to studies about fat. Ultimately, the paid researchers said there was “no doubt” that cutting out fat was the best way to prevent heart disease. With Americans convinced that a low-fat diet is healthier, the way was cleared to replace that fat with – more sugar.
As a side note, we now also know that not all fats are created equal. For a roundup of the good, the bad and the in-between of fats, click here.
To Screen or Not to Screen? When is That Still a Question?
It’s easy to understand why we associate regular cancer screenings with quality medical care. But once we reach a certain age, overscreening, far from being helpful, is looking for trouble. What happens when we detect a slow-growing tumor that would never have impacted the length or quality of a person’s life? The results are often anxiety, invasive follow-up procedures and harsh treatments that are likely to do more harm than good.
That’s how, in November of 2017, PSA screening in men over 75 made the dubious Top Five list of low value healthcare services from the Task Force on Low Value Care. Other potential candidates for overscreening and overdiagnosis among older adults are breast cancer, cervical cancer and colon cancer.
PSA Screening Gets More Attention than Clarity
Back in 2012, The U.S. Preventive Services Task Force made a controversial recommendation against routine PSA screening at any age. In April, 2017 they released a draft guideline recommendation saying that clinicians should inform men aged 55-69 about the potential benefits and harms of PSA screening. The recommendation is basically for shared decision-making about screening or non-screening. For men at higher risk, including African American men and for men with a family history of prostate cancer, the level of concern is higher. The Task Force said that research on prostate cancer in African-American men "should be a national priority."
The guideline from the American Cancer Society remains as follows: Asymptomatic men who have at least a 10-year life expectancy have an opportunity to make an informed decision with their health care provider about screening for prostate cancer after they receive information about the uncertainties, risks, and potential benefits associated with prostate cancer screening.
Age Matters in Cervical Cancer Screening.
Draft guideline recommendations released in September 2017 from the U.S. Preventive Services Task Force recommend against screening for cervical cancer in women over age 65 (unless they lacked prior screening). For other age groups, recommendations are: every 3 years with a Pap Test for ages 21 to 29; and either every three years with a Pap Test or every 5 years with a high-risk human papillomavirus (HPV) test for ages 30 to 65. Screening under age 21 is not recommended at all, and the HPV test isn’t recommended under age 30 because it may detect the common HPV virus before it has a chance to clear on its own. For more information, click here.
STD Prevention is Urgent: New Cases at an All Time High
The CDC reported in September, 2017 that new cases of chlamydia, syphilis and gonorrhea have topped 2 million in the United States. There are 110 million sexually transmitted infections in the U.S. at any given time. As the STD epidemic accelerates in multiple populations, the CDC is calling on providers across the country to make STD screening and timely treatment a standard part of medical care.
Syphilis, for example, has increased in every population group. Most cases were seen in men, but in a single year there was also a 36 percent increase among women and a 28 percent increase in syphilis among newborns (congenital syphilis). “Every baby born with syphilis represents a tragic systems failure,” said Gail Bolan, director of CDC’s Division of STD Prevention. “All it takes is a simple STD test and antibiotic treatment to prevent this enormous heartache and help assure a healthy start for the next generation of Americans.”
One Pill a Day Could Change the Face of HIV Treatment
Around the globe, only 19.5 million of the 37 million men, women and children infected with HIV receive antiretroviral treatment. Soon, in South Africa and Kenya, a single-day pill will be able to treat an infected person at the cost of only $75 per year. The pill, introduced in September, 2017 at a UN General Assembly meeting, is expected to be available in 2018. It contains a “best-in-class” combination of three antiretroviral drugs.
The pill offers powerful HIV suppression in a form that’s easy to use. If people can stay on this treatment for their lifetime, and the virus stays under control, the chance of resistance to the drugs goes down. This is seen as a major shift in the approach to controlling AIDS worldwide – moving beyond pushing for access to treatment to a focus on getting the highest quality medicine to everyone.
For relative cost as well as information on medication adherence issues in the United States, visit here.
Who’s Paying for Specialty Drugs?
You’d be hard-pressed to find someone in August, 2017 who didn’t think that Martin Shkreli, the “Pharma Bro” of Turing Pharmaceuticals, deserved prison. Ironically, he wasn’t on trial for the thing that made him the most hated man in America. Overnight, he had raised the price of an HIV drug he had a monopoly on from $13.50 to $750 a pill. It fanned the flames of national outrage about pharmaceutical prices. Shkreli was on trial for an unrelated securities fraud case in 2017, but it didn’t seem to matter. He had become the face of greed to Americans feeling out of control over specialty drug prices.
In truth, coping with rising specialty drug prices is a top concern these days for everyone that manages benefits or needs them. As specialty drug prices continue to rise, a Pharmacy Benefit Management Institute survey reveals that for the first time in 2017, more employers use a coinsurance cost-sharing design (53%) than a copayment structure (43%). The 2017 Trends in Specialty Drug Benefit Report – sponsored by Walgreens – further notes that 27% of employers are using a high deductible plan with coinsurance as part of their specialty drug benefit.
Horizontal Mergers - No. Vertical Mergers - Maybe.
In February, 2017, two big insurance company mergers were called off in one day. Anthem was set to buy Cigna for $54 billion and Aetna was set to buy Humana for $37 billion. The U.S. Justice Department stopped the deals on antitrust grounds, saying the mergers would restrict competition. The Justice Department said the mergers would “give tremendous power over the nation’s health insurance industry to just three large companies.” (UnitedHealthcare would be the third.) Cigna and Humana were cited as innovative competitors whose presence put pressure on the market to develop new models of care designed to keep Americans healthier, deliver care more efficiently, and control costs.
Now, in 2017’s largest corporate acquisition, CVS Health is buying Aetna for $69 billion. The deal sparked rumors that Wal-Mart would try to buy Humana.
The CVS/Aetna deal would combine one of the nation’s largest pharmacy benefits managers (PBMs) and pharmacy operators with its third largest health insurer. It could give CVS a more captive audience for its services among Aetna’s 23 million members. Still, it’s not seen as unfair industry consolidation the way the Anthem-Aetna deal was viewed. Regulators may need to be convinced that the merger won’t block Aetna customers from frequenting other pharmacies or contracting with other PBMs. But even if certain conditions must be met, the deal doesn’t seem to be in jeopardy from antitrust forces.
Not Your Whole Paycheck Anymore?
When Amazon bought Whole Foods in August, 2017, one of its prime promises was that prices would go down. Prices did drop the Monday after the deal closed. This could be great news for far more Americans than you might have thought. Did you know that more than half of American households have an Amazon Prime membership?
Beyond making whole and organic foods more accessible, this deal raises a lot of speculation about whether Amazon and Whole Foods will also get also into the retail pharmacy business. That may take several years to develop, but people are certainly tracing the footprints of the legwork that’s being done already.
The Usual Suspects Making the Rounds
Once a year, the Culinary Institute of America, in collaboration with the Harvard Chan School of Public Health, invites over 400 physicians, dietitians and other health professionals to their Healthy Kitchens, Healthy Lives conference. There were 19 take-home messages in 2017. They centered around what foods to encourage or discourage; and intentions, behaviors and perceptions. These aren’t revolutionary messages, but we think this roundup is well worth the read, wrapping up 2017 with our best wishes for a happy and healthy 2018! Click here.