Entries in Riddle, Clive (299)


H1N1 Flu: Key Info, Web Resources and News Headlines

by Clive Riddle, July 29, 2009

So the health care community has been warned for some time to brace for a surge in swine flu this fall. As August approaches, what’s the latest? The following is a summary compiled of some key information, key web resources, and recent news headline:


CDC provides this summary in their latest situation update: “On June 11, 2009, the World Health Organization (WHO) signaled that a global pandemic of novel influenza A (H1N1) was underway by raising the worldwide pandemic alert level to Phase 6. This action was a reflection of the spread of the new H1N1 virus, not the severity of illness caused by the virus. At the time, more than 70 countries had reported cases of novel influenza A (H1N1) infection and there were ongoing community level outbreaks of novel H1N1 in multiple parts of the world.  Since the WHO declaration of a pandemic, the new H1N1 virus has continued to spread, with the number of countries reporting cases of novel H1N1 nearly doubling. The Southern Hemisphere’s regular influenza season has begun and countries there are reporting that the new H1N1 virus is spreading and causing illness along with regular seasonal influenza viruses. In the United States, significant novel H1N1 illness has continued into the summer, with localized and in some cases intense outbreaks occurring. The United States continues to report the largest number of novel H1N1 cases of any country worldwide, however, most people who have become ill have recovered without requiring medical treatment.”

According to the CDC Novel H1N1 Flu Situation Update as of July 24, 2009, the U.S. has experienced 43,771 cases involving 302 deaths. The top five states by number of cases are:  

  1. Wisconsin 6222 cases; 6 deaths
  2. Texas 5151 cases; 27 deaths
  3. Illinois 3404 cases; 17 deaths
  4. California 3161 cases; 52 deaths
  5. Florida 2915 cases;  23 deaths

For the week of July 12 -18 the CDC reported that:

· Widespread influenza activity was reported by seven states (California, Delaware, Georgia, Hawaii, Maine, Maryland, and New Jersey).

· Regional influenza activity was reported by Puerto Rico and 13 states (Arizona, Arkansas, Connecticut, Florida, Nevada, New York, North Carolina, Pennsylvania, Rhode Island, South Carolina, Virginia, Washington, and West Virginia).

· Local influenza activity was reported by the District of Columbia and 13 states (Alaska, Illinois, Massachusetts, Michigan, Minnesota, New Hampshire, New Mexico, Oklahoma, Oregon, Tennessee, Texas, Utah, and Wisconsin).

· Sporadic activity was reported by 17 states (Alabama, Colorado, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, North Dakota, Ohio, South Dakota, Vermont, and Wyoming).

The World Health Organization’s (WHO) latest update, as of July 24, 2009, states “in most countries the majority of pandemic (H1N1) 2009 cases are still occurring in younger people, with the median age reported to be 12 to 17 years (based on data from Canada, Chile, Japan, UK and the United States of America). Some reports suggest that persons requiring hospitalization and patients with fatal illness may be slightly older.... The development of new candidate vaccine viruses by the WHO network is continuing to improve yields (currently 25% to 50 % of the normal yields for seasonal influenza for some manufacturers). WHO will be able to revise its estimate of pandemic vaccine supply once it has the new yield information. Other important information will also be provided by results of ongoing and soon-to be-initiated vaccine clinical trials. These trials will give a better idea of the number of doses required for a person to be immunized, as well as of the quantity on active principle (antigen) needed in each vaccine dose. Manufacturers are expected to have vaccines for use around September. A number of companies are working on the pandemic vaccine production and have different timelines.”


Pandemic (H1N1) 2009

World Health Organization

Key Facts About Swine Influenza

Centers for Disease Control and Prevention

Novel H1N1 Flu (Swine Flu) and You

Centers for Disease Control and Prevention

 Novel H1N1 Flu Situation Update

Centers for Disease Control and Prevention

Interim Guidance on Antiviral Recommendations for Patients with Novel Influenza A (H1N1) Virus Infection and Their Close Contacts

Centers for Disease Control and Prevention

H1N1 Influenza A (Swine Flu) Alert Center



H1N1 Flu Spreads to Remote Corners of the World

Reuters Health Information, July 28, 2009

Pregnancy Likely to Be Swine Flu Shot Priority

Associated Press via Google, July 28, 2009

H1N1 Flu Shots Ready in Months, Winter a Risk: WHO

Reuters Health Information, July 27, 2009

China Presses Quarantine Against Flu

New York Times, July 27, 2009

Swine flu could hit up to 40% in U.S. this year and next without vaccine

Associated Press via USA TODAY, July 26, 2009

US: 160M doses of swine flu vaccine due in Oct.

AP via GoogleNews, July 23, 2009

First Trials of Swine Flu Vaccine Begin in Australia

Bloomberg News, July 22, 2009

Grants to States and Territories, July 2009

HHS Press Release, July 10, 2009


Checking out CMS’ Hospital Compare

 By Clive Riddle, July t6, 2009

Last week, CMS issued an announcement touting “important new information was added to the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare Web site that reports how frequently patients return to a hospital after being discharged, a possible indicator of how well the facility did the first time around” They noted around 20% of hospitalized Medicare beneficiaries experience a readmission within 30 days from discharge.

This prompted me to take the opportunity to check out Hospital Compare again, and see what was going on in that cyber neck of the woods. Here’s a few things I learned:

  • The tool is being used. Hospital Compare has been on-line since 2005. Last year the site 18 million+ page views, and is receiving around 1 million page views monthly during 2009.
  • Here’s how CMS describes the what information Hospital Compare provides: “The Hospital Compare Web site will show a hospital’s mortality or readmissions rate is ‘Better than,’ ‘No different from,’ or ‘Worse than’ the U.S. national rate...Hospital Compare also includes 10 measures that capture patient satisfaction with hospital care, 25 process of care measures, and two children’s asthma care measures. The site also features information about the number of selected elective hospital procedures provided to patients and what Medicare pays for those services.”
  • So what are you supposed to do with this information? CMS states that “Public reporting of these and other measures is intended to empower patients and their families with information they need to engage their local hospitals and physicians in active discussions about quality of care..” Charlene Frizzera, CMS Acting Administrator, tells us "Providing readmission rates by hospital will give consumers even better information with which to compare local providers. Readmission rates will help consumers identify those providers in the community who are furnishing high-value healthcare with the best results. CMS believes that all hospitals, regardless of their readmission and mortality rates, should use the data available in these free, detailed reports to find ways to continually improve the care they deliver.”
  • Of course, has lawyers on staff, and the hospital web site counsels us that we really shouldn’t “view any one process or outcome measure on Hospital Compare as a tool to ‘shop’ for a hospital” and that “consumers should gather information from multiple sources when choosing a hospital.”
  • If you really want to swim around in the hospital compare data, they do provide the option to download the entire database (9MB).
  • How old is the data, and how often is it updated? The collection period for the process of care quality measures is generally 12 months. Currently, the Hospital Compare quality measures are refreshed the third month of each quarter. The collection period for the mortality and readmission measures is 36 months. The risk-adjusted 30-day risk-adjusted mortality and readmission measures for heart attack, heart failure and pneumonia are produced from Medicare claims and enrollment data. The mortality and readmission quality measures will be refreshed once annually.
  • Downloading and then sifting through the actual database, I came across a table summarizing the national averages (as opposed to the hospital and state specific averages typically displayed in the online reports, or national data just for a specific item. Below are tables with the national HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey data and the national mortality readmission data.


HCAHPS Measures

HCAHPS Response Categories

Overall Survey %Response Rate

How often were the patients rooms and bathrooms kept clean?

Room was always clean


How often were the patients rooms and bathrooms kept clean?

Room was sometimes or never clean


How often were the patients rooms and bathrooms kept clean?

Room was usually clean


How often did nurses communicate well with patients?

Nurses always communicated well


How often did nurses communicate well with patients?

Nurses sometimes or never communicated well


How often did nurses communicate well with patients?

Nurses usually communicated well


How often did doctors communicate well with patients?

Doctors always communicated well


How often did doctors communicate well with patients?

Doctors sometimes or never communicated well


How often did doctors communicate well with patients?

Doctors usually communicated well


How often did patients receive help quickly from hospital staff?

Patients always received help as soon as they wanted


How often did patients receive help quickly from hospital staff?

Patients sometimes or never received help as soon as they wanted


How often did patients receive help quickly from hospital staff?

Patients usually received help as soon as they wanted


How often was patients pain well controlled?

Pain was always well controlled


How often was patients pain well controlled?

Pain was sometimes or never well controlled


How often was patients pain well controlled?

Pain was usually well controlled


How often did staff explain about medicines before giving them to patients?

Staff always explained


How often did staff explain about medicines before giving them to patients?

Staff sometimes or never explained


How often did staff explain about medicines before giving them to patients?

Staff usually explained


Were patients given information about what to do during their recovery at home?

No, staff did not give patients this information


Were patients given information about what to do during their recovery at home?

Yes, staff did give patients this information


How do patients rate the hospital overall?

Patients who gave a rating of 6 or lower (low)


How do patients rate the hospital overall?

Patients who gave a rating of 7 or 8 (medium)


How do patients rate the hospital overall?

Patients who gave a rating of 9 or 10 (high)


How often was the area around patients rooms kept quiet at night?

Always quiet at night


How often was the area around patients rooms kept quiet at night?

Sometimes or never quiet at night


How often was the area around patients rooms kept quiet at night?

Usually quiet at night


Would patients recommend the hospital to friends and family?

NO, patients would not recommend the hospital (they probably would not or definitely would not recommend it)


Would patients recommend the hospital to friends and family?

YES, patients would definitely recommend the hospital


Would patients recommend the hospital to friends and family?

YES, patients would probably recommend the hospital





Measure Name

National Mortality_Readm Rate

Heart Attack

Hospital 30-Day Death (Mortality) Rates for Heart Attack


Heart Attack

Hospital 30-Day Readmission Rates for Heart Attack


Heart Failure

Hospital 30-Day Death (Mortality) Rates for Heart Failure


Heart Failure

Hospital 30-Day Readmission Rates for Heart Failure



Hospital 30-Day Death (Mortality) Rates for Pneumonia



Hospital 30-Day Readmission Rates for Pneumonia




Medicare Drug Coverage and the Impact on Overall Health Care Spending

By Clive Riddle, July 8, 2009

An important paper reporting on results of an NIH funded study : “The Effect of Medicare Part D on Drug and Medical Spending”was posted online last week with the New England Journal of Medicine: [Volume 361:52-61 July 2, 2009 Number 1] and authored by Yuting Zhang, Ph.D., Julie M. Donohue, Ph.D., Judith R. Lave, Ph.D., Gerald O'Donnell, M.S., and Joseph P. Newhouse, Ph.D..

The pharma industry for decades has been a proponent that appropriate prescription coverage can have a positive impact on overall health care costs. Certainly Medicare policy advocates argued the point in the debate leading up to establishment of Medicare Part D prescription coverage earlier this decade. Now that time has passed, the opportunity has arisen to examine the actual data to address this issue.

The study examined over 35,000 Medicare members from Pennsylvania’s Highmark Blue Cross Blue Shield from 2004 through 2007. The study included a control group with employer based retiree drug coverage that did not change after Part D took effect, and had $10 to $20 copayments with no spending limits or coverage gaps. Three groups were also examined that had no or limited drug coverage before Part D, and then enrolled as in Part D plan as of January 2006. One group had no previous drug coverage, and the other two had previous drug benefits with quarterly spending limit caps.

The study found that the cost of introduction of Part D benefits for those with no or very limited prior coverage was approximately offset by savings in overall health care costs, but overall health care spending did increase for those with more generous prior coverage.

In comparison to the control group, after introduction of Part D, the average total monthly drug spending was $41 higher (74% increase) for enrollees with no previous drug coverage, $27 (27% increase) higher among those with a previous $150 quarterly cap, and $13 higher among those with a previous $350 quarterly cap (11% increase.) Furthermore, overall monthly medical expenditures (excluding drugs) were $33 lower in the group with no previous coverage, $46 lower in the group with a previous $150 quarterly cap, but $30 higher in the group with a previous $350 quarterly cap.

The study concluded that “The offsetting reduction in medical spending in the two groups with the most limited previous benefits was probably due to improved medication adherence among enrollees with chronic conditions.” The study also addressed the overall health care cost increase for the group with more generous prior coverage: “Why did medical spending rise in the group with a previous $350 quarterly cap (the most generous previous coverage among the three intervention groups), as compared with the no-cap group? The additional use of prescription drugs in all three groups probably included both overuse of some drugs and underuse of others, but the proportion of the increase that was overuse may have been highest in the group with the most generous previous coverage. Our finding that the use of oral antidiabetic drugs did not change significantly in this group is consistent with this hypothesis.”

The References section at the end of the report is well worth browsing, as links to various prior studies are provided. Beyond the References provided in the report, I found two other studies that proved to be of particular interest while researching this topic:

The AARP Public Policy Institute published “How Prescription Drug Use Affects Health Care Utilization and Spending by Older Americans: A Review of the Literature” by Cindy Parks Thomas, Ph.D., Brandeis University, Schneider Institute for Health Policy, in April 2008. Key conclusions from this 57 page report include: (1) “Prescription drug coverage can produce cost offsets from reductions in non-drug services, such as hospitalizations and emergency visits.”; (2) “Studies that incorporate increased longevity into spending projections suggest that cost offsets may diminish over time.”; and (3) “Strict benefit limits of all kinds decrease prescription drug use and increase use of other medical services, including acute and long-term care services.”

Baoping Shang, and Dana P. Goldman of the RAND Corporation; National Bureau of Economic Research (NBER) published results in 2007 from their study “Prescription Drug Coverage and Elderly Medicare Spending” (with preliminary results published in 2005) that examined Medicare Supplement (Medigap) enrollees with and without prescription coverage. They found that “Medigap prescription drug coverage increases drug spending by $170 or 22%, and reduces Medicare Part A spending by $350 or 13% (in 2000 dollars). Medigap prescription drug coverage reduces Medicare Part B spending, but the estimates are not statistically significant. Overall, a $1 increase in prescription drug spending is associated with a $2.06 reduction in Medicare spending.”


The Genormous Generic Market

By Clive Riddle, June 11, 2009


“Ginormous” is out. “Genormous” is in, at least if Pfizer is editing the Unabridged Dictionary of Pop Buzz Words, as they continue to go on record that they are pursuing generic growth. This week the Associated Press reported that Pfizer “expects to expand its offerings for generic pharmaceuticals by adding products to the business quoting Dave Simmons, Pfizer President of Established Products. A couple of weeks ago Pfizer licensing agreements with two Indian based companies was reported as a major signal of their strategy to seek growth through generics and emerging markets.


Continued growth in generics would seem a smart recession and health reform based strategy. But generic growth has been sustained through this and the prior decade through good times as well. Let’s have a look at a few of the factors driving these Genormous numbers: 

  • The Average price of generic vs. brand prescriptions: Brand: $119.51 ; Generic: $34.34 [Prescription Drug Trends, September 2008, Kaiser Family Foundation] 
  • Average Rx Copay by Tier: Generic Tier $10; Preferred Tier: $26; Non Preferred Tier: $46; Fourth Tier: $75 [Kaiser Family Foundation Employer Health Benefits 2008 Annual Survey] 
  • Generic Fill Rates: 65% of all prescriptions and 21% of drug sales [Prescription Drug Trends, September 2008, Kaiser Family Foundation] 
  • Generic Fill Rate by $ Differential between Generic/ Preferred Brand Copay: $ 0- 5: 47.6%; $ 6-10: 49.2%; $11-15: 51.6%; $16-20: 52.6%; $21+ : 55.0% [The American Journal of Managed Care, June 2007, “Copayment Differentials and Generic Utilization” ] 
  • Employer Strategies to Reduce Pharmacy Costs: #1 Mentioned response (75%) was "Promote greater use of generic drugs" (2nd highest response - 48%- was "Improve management of specialty drugs" [Mercer Survey] 
  • The 2009 Survey of Health Care Consumers found that 3 in 10 consumers switched medications in the past year, with 38% of them switching to save money [Deloitte Center for Health Solutions] 
  • IMS Health reports that "annual U.S. prescription sales growth of 1.3 percent in 2008, to $291 billion. Dispensed prescription volume in the U.S. grew at a 0.9 percent pace. Factors influencing the market’s slower growth in 2008 included higher demand for less-expensive generic drugs, lower new product sales, and reduced consumer demand due to the economic turndown." [IMS Annual U.S. Pharmaceutical Sales Report] 

Wasted Away in Medical Bankruptcyville: Jimmy Buffet meets Warren Buffet

by Clive Riddle, June 5, 2009

Just published this issue in the American Journal of Medicine, by David U. Himmelstein, MD et al, is: Medical Bankruptcy in the United States, 2007: Results of a National Study. Here’s what Harvard’s Doctor Himmelstein has to say about what this study means to you: “unless you're Warren Buffett, your family is just one serious illness away from bankruptcy.”

Now before you go file a legal change of name to Warren Buffet, you should know the paper’s authors are strong advocates of a particular position: a single payer health plan, and their conclusion is that health insurance in its present form will not protect you from medical bankruptcy, only Warren Buffet or a single payer plan will.

The headlines from the press releases regarding the study indicate medical bills cause 62.1% of all bankruptcies. That claim might be open to some interpretation, given 29% of debtors attributed medical bills as the reason for their bankruptcy. Here’s the table from the study that arrives at that figure:

  • 29%: Debtor said medical bills were reason for bankruptcy: 29%
  • Medical bills >$5000 or >10% of annual family income: 34.7%
  • Mortgaged home to pay medical bills 5.7%
  • Medical bill problems (any of above 3) 57.1%
  • Debtor or spouse lost >2 weeks of income due to illness or became completely disabled 38.2%
  • Debtor or spouse lost >2 weeks of income to care for ill family member: 6.8%
  •  Income loss due to illness (either of above 2): 40.3%
  • Debtor said medical problem of self or spouse was reason for bankruptcy: 32.1%
  • Debtor said medical problem of other family member was reason for bankruptcy: 10.8%
  • Respondents listing any of above 62.1%

But quibbling over the above that is not to take away from the seriousness of the findings they present, only to provide some disclosure to those unaware. So without digressing into an argument for or against a single payer health plan, certainly it hard to argue that various health insurance policies exist in the marketplace which leave patients seriously underinsured, and a number of these underinsured patients, in addition to the uninsured, found themselves in bankruptcy.

Thus the threat of medical bankruptcy does indeed loom over more than the uninsured population. In this recession and season of health reform, it is a very key issue. So here’s some of the other highlights from the study conducted by Doctor Himmelstein and friends from Harvard Medical School, Harvard Law School, and Ohio University and funded by the Robert Wood Johnson Foundation:

  •  Demographically: 60.3% of medical bankruptcies had attended college, 66.4% had owned a home and 20% included a military veteran or active duty soldier.
  • While many of the demographics are very similar, there are a few notable differences in the demographics of those experiencing medical bankruptcies vs. non-medical bankruptcies: Employment (75.5% medical vs. 85.0% non medical); market value of home ($141k vs. $159k); and a lpase in health coverage occuring sometime in the two years before bankruptcy (40% medical vs. 34% non medical)
  • Primary causes of medical bankruptcies: Hospital bills 48%; drug costs (19%); doctors' bills (15%) and insurance premiums (4%). Also, for 38% of cases, lost income due to illness was a factor.
  •  Out-of-pocket medical costs for the bankrupting illness averaged $17,943.
  • In 1981, using the same methodologies, medically-caused bankruptcies were 8% of total bankruptcies. In 2001, the figure was 46.2%
  • 92% of these medical debtors had medical debts over $5,000 or 10% of pretax family income
  • More than 75% of bankrupt families had some form of health insurance