The Stories Behind the Headlines: Is This the Best We Can Do?

Health policy has often been in the news headlines this month.  

To cite three examples, CDC released a new report about causes of death.  CMS published data showing wide variations in hospital charges for common procedures.  And, in the context of a newly-reported Oregon Medicaid expansion study, states have been making decisions about Medicaid expansion.

Let's look at the mental health policy stories behind the headlines.

Suicide on the Rise

The CDC reported this month that as of 2009, there were more deaths from suicide in the United States than there were from motor vehicle accidents.

Suicide rates increased by over 28 percent among men and women aged 35-64 from 1999 to 2010.  While men were three times more likely to commit suicide, the rate increased more for women (32 percent) than for men (27 percent).

Suicide rates are highest in the west, but they are increasing in 39 states.

Men are most likely to commit suicide with firearms, women with poison.  The most rapidly growing cause is suffocation.

During the same period, results were down slightly among elders, and up slightly among youth.  CDC speculated that the bad economy could be affecting rates.  It also noted that baby boomers have had elevated suicide rates throughout their lives.

So what are we doing about this?  The recent Medicaid and Medicare debates suggest a whole lot less than we should be.

Oregon Study Links Medicaid Expansion to Reductions in Mental Illness

By now, everyone knows that the Florida legislature decided not to expand Medicaid to over 1 million residents.

Florida isn’t alone – it looks like elected officials in approximately half the states will turn down Medicaid expansion for at least this year, and forfeit billions of dollars that could be used for patient care.

Many expansion opponents latched onto a study published this month in the New England Journal of Medicine to support the case against expansion.  The study analyzed the results of an Oregon Medicaid expansion program over a two-year period.  It concluded that the Oregon expansion had no effect “on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions.”

Expansion proponents looked for a silver lining, arguing that the study also showed that Oregon’s expansion improved access to care and increased the use of preventive services.

But both seemed to overlook the study’s most definitive conclusion – diagnoses of depression went down by 30 percent among those covered by the Medicaid expansion. 

Mental Health America notes that depression has been estimated to cost $77 billion annually.  So how many billions could we save by cutting depression rates by 30 percent?

And why isn’t this garnering all the headlines?

New CMS Data Show Wide Variations in Payments for Psychosis Care

This past week, the Centers for Medicare and Medicaid Services (CMS) released data on charges for hospitals  throughout the country.  The release attracted plenty of attention, because there were wide variations in what different hospitals charged for the “same level of care.”

CMS wants high-charging hospitals to lower their charges.

Those charges, however, may not be the most important numbers in the data.  The real headline is in what Medicare actually pays for the “same level care” throughout the country.

If you suffer from psychosis, you’re better off being hospitalized in Maryland – where Medicare pays an average of $11,277 per discharge, twice as much as it does in a half dozen other states – than in any other place in the country.

The variation in payments in states – even within geographic regions – was astonishing.   I put a table with the numbers for all the states on my State Rankings page, but here are just a few examples.    Alabama hospitals were paid only $5,256 per discharge, while those in Florida were paid $7,006 and those in Georgia $6,605.  Connecticut hospitals were paid $8,239 (note: the overall number of discharges was very small for Connecticut), while those in Massachusetts were paid $7,494.  North Carolina hospitals were paid $6,188; those in Virginia were paid $5,851 and those in the District of Columbia were paid $9,444.  California and Oregon hospitals were paid $8,916 and $8,816, respectively, but Washington hospitals were paid only $6,504.

You can see information for all the states here.

When we look at the three reports together, they certainly beg at least this question.  Is this really the best we can do?

Paul Gionfriddo will be speaking at the breakfast meeting of the Middlesex (CT) County Coalition on Housing and Homelessness on Friday, May 17, at 8 a.m.  It is open to the public; RSVP to ann@anendinten.org. 

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

The People on the Plaza

On a recent bright and sunny Monday afternoon, I took the sixteen-minute BART ride from Oakland – where I was doing some work – into downtown San Francisco.  I went to several places where people who are homeless tend to congregate. 

What I saw made me wonder.  Do we realize that if we do nothing, up to half of the people who are chronically homeless are likely to die in the next ten years?

I exited the BART train at the Civic Center/UN Plaza station.  When I arrived above ground, I saw more than a hundred homeless people in the vicinity of the station.  They were sitting or resting on the plaza, pretty much keeping to themselves.

Scores of tourists, business people, and shoppers hurried about their business.  There was no interaction between the two groups.  It reminded me of the way old-time cartoons had the action layered on top of a static backdrop – a crowd bustling with activity set against the backdrop of stationary homeless people.

I witnessed something similar in at least three other settings that afternoon.

I walked into Buena Vista Park, a beautiful, wooded park on a hill along Haight Street with awesome, expansive views of San Francisco.  As I climbed its paths, I passed by several people out walking their dogs.  They barely noticed the homeless people sleeping or sitting on the grassy lawn nearby. 

In the nearby panhandle of Golden Gate Park, a few joggers and sunbathers also ignored the small groups of homeless people sitting together under the trees.

And at the Powell Street station later on that afternoon, hundreds of shoppers passed by scores of homeless people without paying them the least bit of attention.

At first, I didn’t see what was wrong with this picture.  I was impressed with the live-and-let-live spirit of the community, where no one hassled anyone else. 

But then I looked more closely.  The people passing through the plaza were so accustomed to the homeless people on the plaza that they were not moved – either to anger or to sympathy – by seeing them.

San Francisco has an estimated 24,000 people who are homeless.  Its governmental agencies and nonprofit community do far more for them than most. 

According to a recent article in the San Francisco Chronicle, the city has moved 8,000 people off the streets since 2004, and has 1,155 emergency shelter beds.  A new homeless health care clinic will open this summer with the capacity to accommodate 50,000 visits per year.  And because the homeless population is aging, 77 new apartments are opening for homeless seniors.

But that doesn’t mean that chronic homelessness isn’t a problem anymore.

The National Alliance to End Homelessness released a new report last month that documented some improvements in the prevalence rates of both overall homelessness and chronic homelessness in the United States over the past ten years. 

But the same report shows that the numbers of homeless people have remained steady during the last four years, in spite of an improving economy.  (Perhaps cutbacks in mental health funding are a reason.) One person in every five hundred is homeless. And out of every ten thousand veterans, 29 are homeless.

Here's something to think about.

The Chronicle article also noted that the mean age of the homeless population increased from 34 to 53 between 1990 and 2010, and that the life expectancy of a person on the streets is 64.  It is possible that chronic homelessness is decreasing because of better services.  But it is also possible that it is decreasing because chronically homeless people are dying off.  In the next ten years, half could be dead.

The NAEH report makes it clear that the problem of homelessness is not limited to warm weather and service-rich communities like San Francisco. 

In fact, Colorado, Oregon, Washington, Wyoming, and Alaska are among the eleven states with the highest rates of homelessness in the country. 

There is a clear connection between behavioral illnesses and chronic homelessness.  I plan to talk about this in a presentation I will be making at a breakfast open to the public sponsored by the Middlesex County Coalition on Housing and Homelessness in Haddam, Connecticut on Friday, May 17.

My goal in that talk will be simple – to remind people that no matter where you fall on the philosophical spectrum, doing nothing about homelessness is not an option. 

You may be able to walk right by the people on the plaza without them saying a word, but this doesn’t mean that they shouldn’t command your attention.

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

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/