Tami Flu

After dropping non-health-insurance businesses, such as life insurance and reinsurance, years ago, the biggest health plans are rediversifying into the money management and banking businesses.

Employer-based health insurance does not appear to be at risk of losing its prime position with health plans, but plans are seeking the health savings account market, and many have started banks to capture it.

Though consumer-directed care has taken off more slowly than projected, the growth of high-deductible health plans paired with HSAs has quickened since 2005. There were about $9.4 billion in HSAs at the end of 2007, according to industry estimates.

"The health insurers would like to not lose that half of the health care wallet," said Charles Boorady, managing director and senior health care analyst for Citigroup, "and one way they're doing that is trying to make banks of their own."

WellPoint, UnitedHealth Group and the BlueCross BlueShield Assn. have FDIC-approved banks that hold HSA balances. But the banking-in-health-care movement is unlikely to end there, experts say.

In a report released in August 2007, Chicago-based Diamond Management & Technology Consultants estimated that the revenue from what its consultants refer to as the "health/wealth" market -- managing such interests as health debit cards -- could reach $40 billion over the next five years.

The authors estimated that $4.3 billion of that $40 billion could be made by companies that help people manage and invest HSAs, particularly as contribution limits rise. The key to profitability, the authors said, is to make money from "asset management," beyond maintenance and transaction fees.

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Proponents of home monitoring devices long have believed that widespread use of those systems can help solve some of the problems plaguing health care today. Now, some technology companies, medical centers, insurers and patients will be testing that theory.

Intel and the Cleveland Clinic announced in recent weeks that they are focusing less on the technology itself than on the ease of its use by the elderly, its role in the continuum of care, and the potential cost savings.

Technology developer Intel announced four separate pilot programs, in partnership with Aetna, SCAN Health Plans in Arizona, Erickson Retirement Communities and Advanced Warning Systems. The Cleveland Clinic is conducting a pilot with Microsoft HealthVault.

Home monitoring provides a way for patients to use electronic devices to collect their own health data, such as vitals or glucose levels. The devices can then be linked with a computer, allowing data to be transmitted to the health care team or to an accessible data repository.

Ray Askew, spokesman for Intel, said each of its pilot sites will focus on a specific chronic condition. Each partner will choose its own participants, with the pool likely to be made up mostly of elderly patients.

One of the biggest questions with home monitoring devices is whether the elderly, the population from which the most benefits could potentially be gained, will actually use the technology.

Askew said ease of use has been one of the key consumer research areas for Intel. Several modifications, such as limited functionality and large buttons, were made to make the systems easier to use.

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A survey released Dec. 4 by the Center for Studying Health System Change had findings similar to those of a Harris Interactive Poll released in June: A vast majority of Americans prefer word of mouth when choosing a new doctor or hospital, despite a drive to post doctor cost and quality information online.

The survey found 10.8% of patients look to online ratings sites to find a primary care physician, while 50.3% rely on friends or relatives, 38.1% on doctors or other health care personnel, and 34.7% on health plans.

For specialists, 6.8% of patients use online ratings sites, 68.5% seek referrals from their primary care physician, 19.9% rely on friends, 18% on another doctor and 10.5% on health plans. The Harris poll found 22% of patients looked at physician rating sites in 2007, and only 2% changed doctors as a result of what they found on a ratings site.

"The reality is most people have long relied on word of mouth to choose their physicians, and that is still the case," center spokeswoman Alwyn Cassil said.

Maribeth Shannon, director of the marketing and policy program for the California HealthCare Foundation, a proponent of online physician ratings sites, said information revealed by the center showed one possible reason why so few patients are investigating doctors online -- only a minority were in the market for a new doctor.

The center's Health Tracking Household Survey found that only 11% of patients looked for a new primary physician in 2007, 28% needed a new specialist and 16% underwent a medical procedure at a new facility. The national survey contained information on 13,500 adults and had a 43% response rate.

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Ian Hislop was interviewed by Radio 5 Live’s Simon Mayo on Friday. In a discussion about the Eye’s campaigning journalism Mayo brought up the Eye’s coverage of MMR vaccine. The Eye published a special edition about MMR in May of 2002 subtitled “The story so far: a comprehensive review of the MMR vaccination/autism controversy”. It was an appalling piece of scare-mongering journalism. Here are the views of David Elliman and Helen Bedford on the Private Eye publication at the time:

Perhaps not surprisingly the style is of a journalistic expos rather than a well argued scientific treatise, with Andrew Wakefield held up as a crusader for truth, opposing the mighty drug companies and Department of Health. Private Eye seems to have used the kind of lay, anecdotal information that you might read in What Doctors Don’t Tell You and the Informed Parent rather than what you would find in the BMJ or Lancet. Understandably, much space is given to the harrowing accounts of parents who believe that the triple vaccine caused their child’s autism. However, the overwhelming evidence suggesting no link between the vaccine and autism and bowel problems is either not mentioned or dismissed out of hand, while the suggestion of a link is given uncritical prominence.

For example, in telling the story of the evolution of Wakefield’s hypothesis the report fails to mention that at almost each stage independent researchers as well as the original investigators have been unable to replicate the findings. The scientists/researchers listed in the “Who’s who in the MMR story” is nowhere near complete (but then to publish the names of all those who continue to support the vaccine would leave little space for anything else) and reflects the Eye’s bias with seven of the nine doubting the safety of the vaccine. If one were to quantify the evidence for and against a link, the ratio would be in the other direction.

Having read that, have a listen to Ian Hislop’s admission that MMR vaccine is not related to MMR vaccine, and his utter failure to take responsibility for the actions of his publication over MMR vaccine. Simon Mayo’s quiet interview technique can be quite effective at times.

   Ian Hislop on Radio 5 Live 12/12/2008: Play Now | Play in Popup | Download

The Washington Post reports on an FDA decision on long-acting beta agonists (LABAs) in asthma:

The risks of two widely used asthma drugs outweigh their benefits for both children and adults, a U.S. Food and Drug Administration advisory panel said Thursday.

The health panel targeted GlaxoSmithKline’s Serevent [salmeterol] and Foradil [formoterol], made jointly by Novartis AG and Schering-Plough, for restrictions, but it excluded Advair [salmeterol and fluticasone], Glaxo’s biggest-selling drug in the class of medications known as long-acting beta-agonists. It also left alone a fourth such drug, AstraZeneca’s Symbicort [formoterol and budesonide].

The health experts did not say that the use of Serevent and Foradil should be abandoned altogether. Instead, they said the medications’ labeling should be reworded to urge doctors to use the drugs along with an inhaled corticosteroid — as guidelines already recommend.

There was some talk that FDA staff wanted LABAs removed from the market for under 18 year olds. The briefing documents the FDA advisory panel considered are freely available on the FDA site:

Overall, the meta-analysis showed that LABAs were associated with an increased risk of asthma-related events relative to non-LABA treatment as measured by the asthma composite endpoint consisting of asthma-related death, asthma-related intubation, and asthma-related hospitalization. Non-LABA treatment included ICSs [inhaled corticosteroids], short-acting betaagonists, other non-LABA treatments, placebo, or a combination of treatments. The risk difference estimate for the asthma composite endpoint of the LABA rate minus the non-LABA rate was 2.80 (95% CI: 1.11, 4.49) per 1000 subjects. This overall finding for the asthma composite endpoint was supported by both the asthma-related hospitalization and the asthma-related death components. However, findings for individual drugs and subgroups were driven by the asthma-related hospitalization component.

Three of the four drugs (Foradil, Serevent, Symbicort) had positive risk difference estimates for the asthma composite endpoint; however, only Serevent had a statistically significant estimate. The risk difference estimates for the asthma composite endpoint were positive both when (1) LABA without assigned ICS was compared to non-LABA treatment and (2) LABA with assigned ICS was compared to assigned ICS treatment. However, only comparison (1) was statistically significant [3.63 (95% CI: 1.51 – 5.75) per 1000 subjects], and comparison (2) had a small risk difference estimate [0.25 (95% CI: -1.69 – 2.18) per 1000 subjects].

So, the increased risk of asthma events is related to the use of LABAs when used without inhaled corticosteroids. When concern about LABAs came up a year ago, the NPC posted a useful blog post advising on the evidence and action to take:

Healthcare professionals should follow current CHM advice and national guidance on management of asthma. LABAs should be initiated (at step 3) only if inhaled corticosteroids at moderate doses are failing to control asthma symptoms adequately. Before initiating a new drug therapy practitioners should recheck compliance, inhaler technique and eliminate trigger factors. If LABAs are introduced this should be in context of a therapeutic trial.

Professionals should take particular note that LABAs should not be initiated in patients with rapidly deteriorating asthma: they are for “stable but poorly controlled” asthma. Practitioners should consider stepping down LABA use when good long term asthma control has been achieved.

It will be interesting to see if any of these views are revised in the light of the FDA data and the Advisory Panel descisions, but it is arguable that the above advice still stands and that the focus should be on inappropriate prescribing rather than the drugs themselves.