Many Chronically Ill Patients Choose Needlessly Expensive Insurance Plans, Driving Up Medical Costs, According to Johns Hopkins University Researcher

Newswise, March 20, 2017 — Chronic illnesses account for 75 percent of health care expenditures in the United States, and while many cases could be treated with preventive care, a significant number of consumers choose more expensive “curative” options that needlessly drive up medical costs, according to a new study by a Johns Hopkins Carey Business School researcher.

The paper in Marketing Science by Carey Business School Associate Professor Jian Ni proposes a remedy that could guide chronic-illness patients to the appropriate level of care and thus reduce the costs to them and health insurers, helping to lower the nation’s ballooning health care bills.

Ni and his co-authors say their paper breaks new ground on this topic by mining a broader data set than was available to previous researchers, enabling a more detailed view of consumers’ health plan decisions over multiple years.

They had access to three years of detailed data from an unnamed health insurer that offered Preferred Provider Organization plans ― basic, medium, and comprehensive ― to customers through their employers.

Going from basic to medium to comprehensive, the annual premium increased, but the deductible, co-insurance rate (the percentage of expenses the consumer owes after paying the deductible), and out-of-pocket maximum decreased.

The researchers focused on the nearly 3,000 chronic-illness sufferers who bought individual care plans during the 2005-2007 period covered in the study.

Some 133 million Americans are afflicted with chronic maladies, the most common of which include heart disease, cancer, hypertension, respiratory diseases, diabetes, Alzheimer’s disease, and kidney disease.

Preventive care for such illnesses would include diagnostic tests and drugs that keep the patient’s condition from worsening. Curative care would include surgeries and drugs that, while expensive, provide a major boost to the patient’s health. 

In the study, Ni and his colleagues found that about 14 percent of the people who would have been a good match for a medium plan and preventive care ― that is, they were in moderate health, though they felt uncertain about their health status, and price wouldn’t likely be a factor in their purchasing decisions ― nonetheless chose the more costly comprehensive plans and curative care.

As Ni notes, this is a classic example of a “moral hazard,” when a risk taker is largely unaffected by the consequences of the action. In this instance, a health care consumer doesn’t mind choosing a more costly care plan, however unnecessary, because he knows that the insurer will pay for the bulk of it.

“Certainly some people with more serious conditions will benefit from a comprehensive plan and curative care, but the 14 percent in our study pose the kind of moral hazard that contributes to health care expenses in the U.S. that are higher than they probably should be, roughly a fifth of gross domestic product,” Ni, an expert on the impact of consumer behavior on firm strategies, said in an interview.

Giving customers better information could go a long way toward easing the problem, the paper suggests. With clearer instruction and guidance from their physicians and insurers, consumers could develop the habit of choosing plans that would more properly fit their health status. The moral hazard would be mitigated, and the costs to customers and insurers alike trimmed.

The paper, “A Dynamic Model of Health Insurance Choices and Health Care Consumption Decisions,” was derived from Ni’s doctoral dissertation. His co-authors are Professor Kannan Srinivasan of Carnegie Mellon University, Professor Baohong Sun of the Cheung Kong Graduate School of Business, and Associate Professor Nitin Mehta of the University of Toronto.

Hopkins Project Shows House Calls and Good Neighbors Can Benefit Patients and Hospitals

Four-year "J-CHiP" study helps hospitals operate more efficiently while helping patients in their homes...When people with chronic health problems couldn't get around town to their doctors' appointments, a four-year Johns Hopkins program brought the appointments to them

Newswise, January 3, 2017 — Johns Hopkins cardiologist and senior director for accountable care Scott Berkowitz, M.D., has published an extensive report of a four-year, $19 million Centers for Medicare and Medicaid Services grant in the journal Healthcare.

The grant, which wrapped up in late summer, was aimed at providing more efficient, less expensive care for people living with multiple chronic conditions in the Baltimore neighborhoods closest to The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center. Over the course of the grant, the Johns Hopkins Community Health Partnership (J-CHiP) provided East Baltimore residents care in community clinics, acute care hospitals, emergency departments, skilled nursing facilities and even people's homes.

J-CHiP had two components: one community-based and one acute-care based. The acute-care based program targeted the 40,000 adult patients admitted annually to The Johns Hopkins Hospital and the Johns Hopkins Bayview Medical Center. 

Those patients were screened for risks of hospital readmission. The community-based component scored 2,000 Medicare and 1,000 Medicaid patients on their risk of hospitalization.

The community-based program centered on community health workers — specially trained neighborhood residents — who helped identify “super users” of health care in the area and intervene. People who used the emergency department frequently, as well as those identified as high risk for hospital admission, were the program’s main targets.

Reducing hospital readmissions is a goal of government, payers and hospitals alike. Many government and private insurance payers are now refusing to pay for second hospital stays for the same condition. Thus, many hospitals are devising strategies to get patients more engaged in their own care, keeping them healthier and out of the hospital.

"The complex health and social needs of an urban community pose many challenges in the delivery of high-quality care," says Berkowitz, who led the study. "We've learned a lot over four years, and we look forward to learning even more, as the data rolls out in the months to come."

In the J-CHiP model, community health workers, paid by the grant, helped super users break down their barriers to paying regular visits to primary care providers. In addition to a community health worker, each super user was assigned a custom team of physicians, nurses, pharmacists and social workers. 

And finally, J-CHiP worked with skilled nursing facilities on standardizing transitions and keeping patients engaged and motivated.

Among Medicaid patients in the J-CHiP program, 38 percent listed transportation as the main barrier they faced to staying engaged with their own health care. In response, JCHiP provided bus tokens, cab vouchers or shuttle support to 550 patients.

Patients also faced barriers like unstable housing situations and an inability to pay for medicines or care. J-CHiP provided social workers, pharmacy assistance programs and pre-programmed mobile phones to patients who faced critical financial barriers.

Berkowitz says that J-CHiP aligned with Johns Hopkins Medicine goals for transforming care and improving population health. "We focused heavily on East Baltimore's health needs, as well as on innovation of care delivery across the settings where care takes place," he says.

In the report, Berkowitz cites Baltimore City Health Department statistics on life expectancy in the city. "The nearly 200,000 residents of East Baltimore, where life expectancy can be as many as 20 years shorter than nearby more affluent Baltimore neighborhoods, face many challenges to health and well-being," he says.

Berkowitz's article includes examples of J-CHiP team members helping patients overcome barriers to care. In one example, a patient with diabetes who made regular visits to her primary care doctor could no longer see well enough to read her insulin prescription. 

Embarrassed, the patient hid this fact from her doctor, who couldn't determine why her diabetes was so poorly managed. A community health worker visited the patient and saw the trouble she had measuring her insulin. 

After switching to a pre-measured pen system for insulin delivery, the patient also got an eye exam. After three months of her new regimen, both her blood sugar and her eyesight improved significantly.

The J-CHiP program was supported by grant number 1C1CMS331053-01-00 from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. The content of this press release is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

To read the full report, click here.

Researchers Add to Evidence That Common Bacterial Cause of Gum Disease May Drive Rheumatoid Arthritis

Newswise, December 26, 2016 — Investigators at Johns Hopkins report they have new evidence that a bacterium known to cause chronic inflammatory gum infections also triggers the inflammatory "autoimmune" response characteristic of chronic, joint-destroying rheumatoid arthritis (RA). The new findings have important implications for prevention and treatment of RA, say the researchers.

In a report on the work, published in the Dec. 14 edition of the journal Science Translational Medicine, the investigators say the common denominator they identified in periodontal disease (gum disease) and in many people with RA is Aggregatibacter actinomycetemcomitans.

An infection with A. actinomycetemcomitans appears to induce the production of citrullinated proteins, which are suspected of activating the immune system and driving the cascade of events leading to RA.

"This is like putting together the last few pieces of a complicated jigsaw puzzle that has been worked on for many years," says Felipe Andrade, M.D., Ph.D., the senior study investigator and associate professor of Medicine at the Johns Hopkins University School of Medicine, who also practices at Johns Hopkins Bayview Medical Center.

"This research may be the closest we've come to uncovering the root cause of RA," adds first author Maximilian Konig, M.D., a former Johns Hopkins University School of Medicine fellow now at Massachusetts General Hospital.

Medical investigators have observed a clinical association between periodontal disease and RA since the early 1900s, and over time, researchers have suspected that both diseases may be triggered by a common factor.

In the last decade, studies have focused on a bacterium known as Porphyromonas gingivalis, found in patients with gum disease. However, while major efforts are currently ongoing to demonstrate that this bacterium causes RA by inducing citrullinated proteins, all attempts by this research team have failed to corroborate such a link, says Andrade.

But his team has persisted on finding alternative bacterial drivers, he says, because of intriguing links between periodontal disease and RA.

For this study, the investigative team with expertise in periodontal microbiology, periodontal disease and RA began to search for a common denominator that may link both diseases.

Initial clues came from the study's analysis of periodontal samples, where they found that a similar process that had previously been observed in the joints of patients with RA was occurring in the gums of patients with periodontal disease. This common denominator is called hypercitrullination.

Andrade explains that citrullination happens naturally in everyone as a way to regulate the function of proteins.

But in people with RA, this process becomes overactive, resulting in the abnormal accumulation of citrullinated proteins. This drives the production of antibodies against these proteins that create inflammation and attack a person's own tissues, the hallmark of RA.

Among different bacteria associated with periodontal disease, the research team found that A. actinomycetemcomitans was the only pathogen able to induce hypercitrullination in neutrophils, an immune white blood cell highly enriched with the peptidylarginine deiminase (PAD) enzymes required for citrullination. Neutrophils are the most abundant inflammatory cells found in the joints and the gums of patients with RA and periodontal disease, say the researchers. These cells have been studied for many years as the major source of hypercitrullination in RA.Actinomycetemcomitans initiates hypercitrullination through the bacterial secretion of a toxin, leukotoxin A (LtxA), as a self-defense strategy to kill host immune cells. The toxin creates holes on the surface of neutrophils, allowing a flux of high amounts of calcium into the cell where concentrations are normally kept low.

Since the PAD enzymes are activated with calcium, the abrupt exposure to high amounts of calcium overactivates these enzymes, generating hypercitrullination.

The researchers previously found that a similar type of pore-forming protein that was produced to kill pathogens by host immune cells was driving hypercitrullination in the joints of patients with RA.

These findings point to a common mechanism that is poking holes on cells, which may be relevant to the initiation of RA when the disease is being established, says Andrade.

As part of its study, the team developed a test using the bacterium and LtxA to detect antibodies against A. actinomycetemcomitans in blood. Using 196 samples from a large study of patients with RA, the researchers found that almost half of the patients -- 92 out of 196 -- had evidence of infection by A. actinomycetemcomitans.

These data were similar to patients, with periodontal disease with approximately 60 percent positivity, but quite different in healthy controls, who only had 11 percent of people positive for A. actinomycetemcomitans. More strikingly, exposure to A. actinomycetemcomitans was a major determinant in the production of antibodies to citrullinated proteins in patients with genetic susceptibility to RA.

Andrade cautioned that more than 50 percent of the study participants who had RA had no evidence of infection with A. actinomycetemcomitans, which, he says, may indicate that other bacteria in the gut, lung or elsewhere could be using a similar mechanism to induce hypercitrullination.

Andrade further cautions that his team's study only looked at patients at a single point in time with established RA, and that to prove cause and effect of A. actinomycetemcomitans and RA, more research will be needed to track the potential role of the bacteria in the onset and evolution of the disease, which can span decades.

"If we know more about the evolution of both combined, perhaps we could prevent rather than just intervene."

An estimated 1.5 million people nationwide live with rheumatoid arthritis, according to the Centers for Disease Control and Prevention. Current treatments with steroids, immunotherapy drugs and physical therapy help some by reducing or slowing the crippling and painful joint deformities, but not in all patients. The exploration of alternative treatment options is necessary.

Additional Researchers from Johns Hopkins included Kevon Sampson and Antony Rosen, M.D.

This research was funded by the Jerome L. Greene Foundation, the Donald B. and Dorothy L. Stabler Foundation, Fundación Bechara, Rheumatology Research Foundation, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) under grant numbers R01AR069569 and AR050026-01, the National Institute of Dental and Craniofacial Research (NIDCR) under grant numbers DE021127-01 and R37 DE12354, and the Intramural Research Program of the NIDCR.