Is Medicare Clearing Better Pathways to Wellness for Men With Depression?

You would expect Medicare to spend about the same for a man with heart, lung, or kidney disease as it does for a woman.  And if you looked at the actual numbers, you would not be surprised.  On average, it does. 

So why does Medicare spend so much more on men when you couple these disease with depression? That is a question that deserves an answer.

The startling numbers, which show just how wide the disparity is, are in the chart accompanying this column.  They are very similar to some others that I shared in my column last week.

They all come from the 2010 CMS Medicare public use data files, the most recent ones available.  The CMS file includes information on all 48 million Medicare recipients. 

Last week, I wrote that men with depression in the 65-69 year old age group enjoyed an 11% Medicare spending advantage over women in the same age group.  (The men were those on Medicare only, not both Medicare and Medicaid.)  I also wrote that the disparity persisted both as they aged and when they were diagnosed as having both depression and dementia.

That column raised at least one troubling question – why are women with depression being undertreated relative to men, when they are two to three times more likely to be diagnosed with it?

I received a number of possible answers to that question, but the most common one was that perhaps men’s needs are more intensive.  Because they are diagnosed less frequently, they may simply be sicker by the time they are, and therefore need more treatment.

The Medicare data do not include a severity measure, so there is no way to tell for sure.  But there is at least some indirect empirical evidence for this. The Medicare spending gap in favor of men is wider for hospital care (Part A) than it is for outpatient treatment of drugs (Parts B/D).

If there were an intensity advantage, however, it should disappear as people get sicker.

But it doesn’t. If anything, it may get a little wider. 

This week, I looked at some groups with greater health needs – Medicare recipients in the 65-69 year old age group who were dually diagnosed with depression plus heart disease, depression plus lung disease, depression plus kidney disease, or depression plus cancer.  In every case, being sicker (i.e., having a second diagnosis of depression on top of the other chronic disease) led to a wider gap in spending.

Three of the examples are captured in the chart.  As expected, there’s very little gender bias in Medicare spending on heart disease (2% more on men), lung disease (1% more on men), or kidney disease (4% more on men).  There is a gender bias in spending on cancer, but it favors women (Medicare pays 26% less on men with cancer).

When you add depression to these conditions, the spending tilts in favor of men again.  

• The 2 percent difference in spending favoring men with heart disease grew to 9 percent when the men and the women had both heart disease and depression. 
• The 1 percent difference in spending on lung disease expanded to 13 percent when both lung disease and depression were present. 
• And the 4 percent difference in spending favoring men with kidney disease ballooned to 30 percent when both kidney disease and depression were present.

And the cancer spending gap dropped from 26 percent down to just 15 percent.

The difference is clearly the depression.

Medicare simply spends less on women with depression, even when they have other serious chronic conditions.  You can decide for yourself about the reason.  Are men underdiagnosed? Are women overdiagnosed?  Are men overtreated? Are women undertreated?

The CMS data set does not answer those questions.

But it does tell us this – Medicare-eligible men and women with depression, at least in this age group, are clearly being treated differently.  For whatever reason, the men are getting more, and the women are getting less.

Today is the start of Mental Health Month.  This year’s theme is “Pathways to Wellness.”  So here’s my question, similar to last week’s.   Is Medicare clearing better pathways to wellness for men with depression than it is for women?

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

Women and Depression - Stoicism or Neglect?

Are women with depression more stoic than men, or are men just getting preferential treatment?

According to the National Institute on Mental Health, women are 70 percent more likely than men to experience depression during their lifetime.  Depression hits women harder than men in nearly every age group.

But if some fascinating data from the Centers for Medicare and Medicaid Services are any indication, we also spend a lot less on treating them than we do men.   

Are women more stoic, or are we just neglecting their mental health needs?

The data that shed some disturbing light on this subject come from the CMS Chronic Conditions Public Use Files.  These files include data for every 2010 Medicare beneficiary – approximately 48 million people.

In 2010, according to the CMS data, 9296 men between the ages of 65 and 69 who were newly-enrolled in Medicare Part B had depression and no other chronic condition.  And so did many more newly-enrolled women in the same age group - 23953 to be exact.

Medicare spent an average of $4650 (Part A, Part B, and Part D combined) on newly-eligible and enrolled 65-69 year old men with depression.  But it spent an average of only $4010 on women with depression in the same age group. 

In other words, Medicare spent 16 percent more on the men than it did on the women.

It is possible that those first-year data were an anomaly.  After all, they represented an average of just seven months of coverage.  It is possible that the men just got earlier, more aggressive treatment for depression when they first enrolled in Medicare, and that the women caught up later on in the year.

But this wasn’t the case.  When I looked at men and women in the same age group who had a full year of Medicare coverage in 2010, the disparity persisted. 

The numbers were just bigger.  There were around 35,000 men and over 85,000 women enrolled in both Parts A and B, and around half those numbers in Part D.  And we did spend more on women with depression - $5761 on average.  But we spent $6386 – or 11 percent more than that – on men.

The difference could be explained in part because men got more hospital-based care.  Medicare spent almost 50 percent more on Part A services, on average, for men.  But it still spent more on their Part B (physician/community) and Part D (prescription drug) care, too.

And here’s the interesting thing – the disparity seemed to persist as men and women aged.

I looked fifteen years down the road, at the 80-84 year old population.  Because women live longer, there were around three times as many women with depression in this age group as there were men.  But we were still spending more on the men.

Among 80-84 year olds with depression and no other chronic condition, Medicare spent 14 percent more overall on men than it did on women – an average of $7141 versus $6247.

And the disparity in spending also persisted when men and women had depression plus certain other chronic conditions – Alzheimer’s Disease and related disorders, and diabetes.

For example, Medicare paid out 23 percent more in first-year care for a 65-69 year old male with depression plus Alzheimer’s Disease or other dementia than it did for a 65-69 year old woman with the same two diseases.  And the difference over a full year was still 10 percent.

And Medicare paid out 34 percent more in the first-year care for a 65-69 year old male with depression plus diabetes than it did for a 65-69 year old woman with same two diseases.  And while that vast difference narrowed over a full year, it was still 7 percent.

These differences also persisted as people aged.  In the 80-84 age group, Medicare paid 22 percent more for men with depression plus diabetes than it did for women, and 7 percent more for depression plus dementia than it did for women.

This disparity cannot be explained away by suggesting that the men might also have other chronic conditions complicating their cases.  These are equivalent groups – neither the men nor the women had any other diagnoses at the time.

So as we enter another Mental Health Month and strive to strip away the stigma and misconceptions related to mental illnesses, perhaps one question we should be asking ourselves is this. 

Is stoicism or stigma the reason we spend less on mental health care for women with depression?

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

In the Aftermath of the Boston Marathon, Thank Goodness for Level I Trauma Centers

The Boston marathon bombing is a horrifying, ongoing tragedy this week.

Three people died when the bombs exploded, and scores of others were maimed or otherwise injured.

But there was one bright spot for the wounded and their families.  According to the American Trauma Society, “it now appears that every one of the wounded alive when rescuers reached them will survive.”

The reason for this is that they were all fortunate to have almost immediate access to some of the finest, most extensive trauma services in the nation. 

According to an interview with the chief of medicine of one of the area hospitals, there were four Level I trauma centers within a mile or so of the marathon finish line – Boston Medical Center, Brigham and Women’s, Mass General, and Tufts Medical Center.  They were already treating victims within thirty minutes of the blast.

There are five levels of trauma centers in the United States and there are slight differences in how these are designated in different states.  But there is general agreement about one thing – if you receive a life-threatening injury, either accidental or intentional, your best hope for survival is to be as close as possible to a Level I or Level II trauma center.

So what would have happened if this bombing had taken place during some other marathon?

I have run in two marathons in my life, both in Austin.  Austin has one verified Level I trauma center – University Medical Center.  Expected to serve the Austin area’s million plus residents, it would probably be overwhelmed with victims in the aftermath of a similar tragedy.

And I have run a half marathon as part of the Palm Beach County marathon.  For its million plus residents, Palm Beach County has no Level I trauma centers. According to Tallahassee Memorial Healthcare Center, it does have two Level II trauma centers – St. Mary’s Medical Center in West Palm Beach and Delray Medical Center in Delray Beach.  

The American College of Surgeons does not designate, but it does verify, the presence of Level 1 and Level II trauma centers in all fifty states.  It has a list of verified centers on its website. The four Boston centers are all on the list.  The only ACS independently-verified Level I center in the entire state of Florida is in Tampa.

The truth is that having Level I trauma centers nearby saved lives in Boston this week. And their families and friends understand that the higher prices they pay for one of the finest health care systems in the world paid off big time when they needed it.

But we were also sadly reminded this week that mass injuries are not just tied to acts of terrorism.  The fertilizer plant explosion in West, Texas, leveled so much of that community, took too many lives, and left scores more injured, too.

So just how accessible was Level I trauma care to the people of West, Texas, and how accessible would it be to the rest of us if we were to face such horrifying mass tragedies as the people of Texas and Massachusetts faced?  The American Trauma Society has a set of maps on its web site for you to look at.

They are scary.

Here’s one for the country as a whole, identifying those areas that are within 45 minutes by ambulance or helicopter of a Level I or Level II trauma center.  Over 30 percent of our population does not have access.

 And here is one for Massachusetts, looking at just those areas within 45 minutes by ambulance of a Level I or II Center.

 And here is one for Florida, where I currently live.

 And one for Connecticut, where I grew up and most of my family still lives.

 And, finally, one for Texas, where I lived for four years and where most of my wife's family still lives.

Keep these maps in mind the next time someone tries to argue with you:

• That services are pretty much the same in all areas of the country.
• That spending more for access to high-quality healthcare doesn’t make a difference.
• That having teaching and highly-specialized hospitals aren’t worth the investment.
• That no matter where you live you will have plenty of access to trauma care if you ever need it.

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

Where Do We Draw the Line on Paying for Home Health Care?

A relatively modest Medicare proposal put forward by President Obama in his 2014 budget may help to rekindle the debate about how we pay for long term care services in the coming years.  But where will we draw the line about our own responsibilities and those of the government?

This is because the President’s proposal is simple and easy to understand, and it will affect nearly all of us sooner or later.

He has asked for a $100 Medicare co-pay, starting in 2017, for five or more home care visits that are not preceded by a stay in an institution, according to a story this week in Kaiser Health News.  KHN added that “home care is one of the few areas in Medicare that does not have cost sharing.”

So should it?

While there is cost-sharing throughout most of the Medicare program – hospital deductibles, nursing home benefits, drug payments, and physician co-pays, for example – home health care has always been something of a special case.

A century ago, home care was pretty much all there was.

But as American medicine transformed itself during the first half of the 20^th century, home health care nearly disappeared.   According to Centers for Medicare and Medicaid (CMS) historical data, by 1960 the total amount we spent as a nation on home health care was only $57 million, barely a blip in national health care spending. 

CMS also notes that home health care spending still represents a very small share of national health care spending – around 2.7 percent.  In 2011, we spent $74 billion on home care – more than one thousand times what we spent on it fifty years earlier, but still not much in relative terms.  We spent more than ten times that, or $850 billion, on hospital care, and two times that, or $149 billion for nursing home and other residential care.

Hospital spending represents one third of our nation’s health care bill.  And nursing homes have been at the center of our long term care delivery system for at least forty years now.

But things have been quietly changing for Medicare recipients over the last thirty years.  The average inpatient length of stay in hospitals for people over the age of 65 was cut in half between 1980 and 2004.  Nursing homes picked up part of the slack, offering new short-term rehabilitation services in addition to long term care. 

But we gradually turned back to home care to meet many of our care needs.

By 2007, 1.5 million people were using home care health services, and not just for short-term recovery and rehabilitation.  The average length of stay in home care services was 315 days. 

And according to the Bureau of Labor Statistics, the home health care industry grew rapidly.  Over 839,000 people worked as home health aides in 2012.  This represented an industry growth rate of more than 400% over a quarter of a century.    

The problem isn’t the numbers.  It’s the trend.

An industry that represented a near zero share of our nation’s health care spending as recently as 1971 has tripled its share of our national health care bill since 1981.  It was one-sixth the level of nursing home spending in 1981.  Now it is half.  And that share will represent nearly $150 billion in spending by 2021 – almost 3,000 times what we spent on it in 1961.

That’s enough to get the attention of policy leaders, who don’t want to foot the bill by themselves. 

Some of us think they should not have to do so – we assume we may need long term care some day, and we’ve purchased long term care insurance to cover some of those down-the-road nursing and home care costs.  More of us seem to take the position that we will never need health care – that we will remain healthy and active up to the moment we die.

But the President’s proposal takes the middle ground.  It recognizes that most of us will need and want home health care some day, and that we will be willing to share the responsibility with our government to pay for this.

The President is not alone in seeking cost-sharing for home care.  Greater cost-sharing is a part of every Medicare reform proposal being floated today.  The only question is: where will we draw the line? 

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

Why Are We Afraid of Mental Health Screening?

Should all school children be screened for mental health?

The evidence suggests that if we do not screen them, then we will be continuing a persistent and historical pattern of neglecting the mental health needs of our children.  But why let evidence get in the way of fear?

Over the past several months, legislators in a number of states have considering mandating – or at least offering – mental health screening for all children, either in the schools or in pediatricians’ offices. 

But when the Connecticut Legislature had a public hearing on a mental health screening bill recently, opponents came out in force. 

One parent called mandatory screening an “unnecessary invasion.”  The Connecticut Civil Liberties Union argued that mental health screenings should be optional.  A treatment provider asserted that the problem wasn’t with a lack of assessment, but the lack of treatment options.

And in recent days, a Palm Beach Post writer in Florida joined the chorus when he claimed that mental health screening is less “straightforward” than vision and hearing screening in an editorial entitled “Florida Should Not Require Mental Health Screenings in Schools.”

The truth is that if we don’t at least screen, then we don’t know what it is we’re supposed to treat.  And this “head in the sand” approach is what has gotten us into trouble in the first place.

The extent of our neglect of our children’s mental health needs is staggering.  

In 1999, the U.S. Surgeon General estimated that 10 percent of children had mental illnesses serious enough to disrupt their home life or schooling.  That percentage is still cited today, but we have more recent data, too.

For example, the Substance Abuse and Mental Health Services Administration noted that in 2009 two million children between the ages of 12 and 17, or 8.1 percent of the population, had a major depressive episode.

In the same report, SAMHSA also disclosed that 2.9 million children that year, or 12.1 percent of the population, received at least some mental health services in a school setting.

But here’s where the neglect comes in.  Only 407,000 children in 2009 received special education services because of their mental illness – just a fraction of those who needed them.

And this neglect is getting worse.  According to the most recent data from the U.S. Department of Education, only 389,000 children were offered special education services in 2011 as a result of their mental illness.  To put this number in context, this was:

• The smallest number in 20 years;
• A drop of over 20 percent in just six years; and
• Only 8 tenths of one percent of the entire school-age population.

In other words, less than one in every ten children with a serious mental illness is even identified as emotionally disturbed by our special education system.

As for the other nine in ten, their time bombs just tick silently.

Perhaps this could be justified if the stakes were low.  But they are not.  We all know the results of neglect.  We see them every day in our homes and neighborhoods, and, most tragically, on the news.

And what is most frustrating is that the “controversial” screening that could save lives is both simple and non-invasive – and straightforward. 

More often than not, mental health screening consists of a few questions that can be answered and scored in minutes. 

Here is a link to a commonly-used tool, called the PHQ-9.

It asks nine questions about how a person has felt in the last two weeks, with one follow-up question at the end.  Has the person been having trouble falling asleep or staying asleep, or sleeping too much? Been feeling tired? Experienced a poor appetite or overeating? Had trouble concentrating?

These are hardly the kinds of questions that probe so deeply into the psyche of the individual as to scar or stigmatize them for life. 

But, ironically, when we refuse to ask these questions we do end up stigmatizing people for life – if not costing them their lives.

It may seem hard to believe that there could be any fuss about using such screening tools universally when you consider the alternative.  Or that the tools can reasonably accurately identify an emerging mental illness.  But they can, and do.  And the more we use them, the better off we will be.

So what are our schools afraid of?  And, more importantly, what are we all afraid of? 

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

From Twinkies To Tofu: The Ten Best Public Health Initiatives Ever

I never ate yogurt, avocadoes, or tofu until I was in my twenties.  When I first went to the dentist as an eight year old, I had twelve cavities.  And the Connecticut River smelled like raw sewage when I was a kid – because it was filled with raw sewage.

This is Public Health Week; the theme is “return on investment.”  The good news – spending on public health  (as a percentage of all health spending) has doubled in the last fifty years.  The bad news, this is still less than 3 percent of our national health budget.

Despite that meager investment, the return has been big.  Here are my top ten public health initiatives ever – or at least in my lifetime.

10. From Twinkies to Tofu.  Nutrition education has come a long way in the last fifty years. Twinkies, snowballs, chocolate cupcakes, and sugary cereals “fortified” with vitamins were staples of my youth.  We knew so little about nutrition in those days.  I never ate yogurt.  I never even heard of tofu.  And an avocado never touched my lips.  We may be heavier today than we were then, but thanks to public health professionals at least we know why. (Perhaps it’s the 701 sodas we consume every year – a 26 year low!)

9. HIV/AIDS Prevention.  I lost too many friends and classmates to AIDS in the 1980s, and we had no idea how to treat it for several years after it was first identified.  But once we cut through the noise created by people who worried that it came from mosquito bites, Haitians, and kitchen utensils, public health pros found effective prevention strategies that saved millions of lives while we waited for effective treatments.

8. Water Fluoridation.  Cavities were inevitable when I was young, and lost teeth were the price we paid later – in spite of brushing.  Then we fluoridated our water and prevented tooth decay.  Not only did the public health pros save teeth; they saved lives as we reduced heart disease linked to poor oral health, too. 

7. Smoking Bans in Public Places.  Thirty years ago, I was eating in a popular Italian restaurant.  The cigarette smoke was so thick that I could barely see clearly across the room.  The owner came over to say hello.  I asked him where his “no smoking” section was.  “Wherever you’re sitting,” he replied.  He was the Chairperson of the Connecticut Legislature’s Public Health Committee.  We’ve come a long way, baby.

6. Sewer Separation.  When I was young, toilets in my home town flushed waste into storm sewers that flowed directly into the river.  No wonder the water was brown.

5. Oral Polio Vaccine.  I remember getting my dose in the school cafeteria.  Immunization came of age in my lifetime, and we now we take it for granted that our children will never get many formerly life-threatening diseases – such as polio, measles, mumps, rubella, and even influenza.

4. Air Pollution Control.  My mother used to repeat the rhyme “red sky in morning, sailors take warning.  Red sky at night; sailors delight.”  Then red skies at night just meant ozone pollution.  While we have a long way to go, we can’t say that public health pros weren’t on top of the climate change issue almost from the beginning.

3. Bike paths and running trails.  When I ran my first road race thirty years ago, there were fifty people entered.   But when I ran my first marathon ten years ago, there were over ten thousand.  Exercise has gone mainstream in the last fifty years.  Don’t believe me? Compare the lack of muscle tone on the bodies of movie stars of the 1960s to what you see today.

2. The Rise and Fall of Plastics.  My wife Pam was reminiscing recently about when we used to see pictures of garbage floating down our rivers.  Everything became disposable about the time plastics arrived.  But then we began to redeem, recycle, and re-use, saving valuable landfill (and river) space.  Now cities like Austin have banned plastic bags entirely.  Why not?  Live simpler, and we often live healthier.

1. Getting the Lead Out.  When I was young, my brothers and I used to peel the lead paint off the side of our grandfather's house for fun.  We didn’t stop until he replaced the shingles with asbestos siding.  Oh, how we long for the everyday toxins of our youth.

And if only we could see this big a return on all of our investments in the future!  

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/