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There’s room for improvement in diabetes and blood pressure care in employer sponsored health plans

Health and Benefits|Wellbeing
COVID 19 Coronavirus

By Jeff Levin-Scherz, MD | August 3, 2022

This week’s roundup looks at a recent data on the quality of care provided by employer sponsored health plans for those with chronic diseases, and the latest on polio, monkeypox and COVID-19.

Researchers from the University of Chicago funded by Morgan Health (a division of J.P. Morgan Chase) have collated data from four large government databases to assess potential disparities in medical care for people with private insurance. There are huge opportunities to improve.

Researchers used data from:

  • The National Health Interview Survey (2019)
  • The National Health and Nutrition Examination Survey (2017 – 2020)
  • The National Survey of Drug Use and Health (2019)
  • The 2020 vital statistics registry for childbirth

The analysis showed disparities, but also showed many areas where healthcare is not delivering good outcomes regardless of race.

For instance, Black people are about 30% more likely than the overall population to have hypertension. But the majority of all races who had diagnosed hypertension had inadequate blood pressure control (59%), and 43% of those with hypertension were not even diagnosed.

Hispanics were 38% more likely to have diabetes than the total population. But again the majority of all races with diagnosed diabetes (57%) did not have good blood sugar control, and 20% of diabetics were undiagnosed.

The data show that we clearly have too many people whose chronic diseases aren’t identified. Even after diagnosis, many people of all races with hypertension and diabetes remain undertreated. Furthermore, only one in eight Black people with diagnosed diabetes are under good blood sugar control.

This study also shows:

  • 43% of health insurance enrollees were obese
  • Cesarean sections were far more common in low-risk pregnant people of color (20% Black, 18% Asian, 17% Hispanic) than in white people (14%)
  • Lesbian, gay and bisexual enrollees were three times more likely to report psychologic distress than straight people

Implications for employers:

  • Although costs of family health insurance plans now exceed $21,000, people in the U.S. continue to receive poor outcomes from healthcare.
  • You can insist on meaningful quality reporting from health plans and encourage them to implement provider payment and/or performance guarantees to reward higher quality care.
  • Vendor reporting that includes race and other demographic variables can help identify the unmet needs of your participants.

First case of paralytic polio in the U.S. raises worries

The New York Department of Health has reported a case of paralytic polio in suburban New York in a young unvaccinated adult. Although early press reports noted that he had traveled out of the country, timing suggests he likely contracted the virus in the U.S. Over two-thirds of those who have polio are asymptomatic and under one in 200 have neurologic symptoms, so there are likely other undetected cases in the U.S.

Polio was a scourge in the 1950s. There were 21,000 cases of paralytic polio in 1952. Many families were reluctant to let their children out to play for fear that they would catch it. But after vaccines were created and licensed, this declined to just 61 cases in 1965. The last case of paralytic polio in the U.S. was in 2013 in a patient who was infected abroad. The last case transmitted in the U.S. was in 1979. A worldwide effort to eradicate polio has failed, as there continue to be ongoing transmission in Afghanistan and Pakistan.

There are two vaccines available for polio, an injection (inactivated virus) and an oral vaccine (weakened virus). The oral vaccine is easier to administer in developing countries as it requires no syringe or needle and can be administered by nonmedical personnel. The weakened virus can be spread to unvaccinated people, which means community-wide immunity can be achieved even though not everyone is vaccinated. But very rarely, the weakened vaccine virus can mutate and cause paralysis, which is why we have only used the inactivated vaccine in the U.S. since 2000.

An investigation into the New York case determined the virus is descended from a vaccine strain. Likewise, the poliovirus strain found in wastewater in London last month also was a vaccine strain. The New York Department of Health is offering polio vaccinations to children or adults who were not previously vaccinated to prevent future cases.

Implications for employers:

  • You should assure U.S. employees and participants that there is no chance of getting paralytic polio from the vaccine currently used in the U.S., and the U.S. vaccine effectively protects against paralytic polio from either “wild” poliovirus or circulating poliovirus descended from vaccines.
  • High rates of vaccination coverage protect the entire community from many infectious diseases, including polio, measles, mumps, rubella, human papillomavirus and chickenpox.
  • Childhood infectious diseases can cause substantial economic disruptions, including increasing time away from work.

Monkeypox cases continue to rise

The World Health Organization declared monkeypox a public health emergency. Cases continue to rise worldwide and in the U.S. (21,148 and 4,907, respectively, as of July 28).

A new study in the New England Journal of Medicine reviewed a series of 528 cases from 16 countries. The vast majority were adults (median age 38 years) who are gay or bisexual (98%), white (75%) and many were HIV-infected (41%). Monkeypox is transmissible in multiple ways, but this rise in cases is believed to be from close sexual contact. Infected individuals often have symptoms including fever and swollen lymph nodes as well as a characteristic rash, which often is fairly mild. Symptoms can last from two to four weeks, and people with no symptoms do not appear to transmit the virus.

Anyone who suspects that they have monkeypox should see a healthcare provider for an evaluation. If an employee is diagnosed with monkeypox, they need to isolate at home until cleared by a local public health authority. Individuals exposed to a known case should be informed and can receive a vaccine for post-exposure prophylaxis. Vaccines given within four days of the exposure often prevent infection, and those given within 14 days can prevent severe illness.

Those with a monkeypox exposure should monitor themselves for fever (over 100.4F), chills, swollen lymph nodes and a rash for 21 days. Those who are exposed but have no symptoms are not presumed infected/infectious and can be in the workplace.

Implications for employers:

  • You can develop protocols for those who are diagnosed with or exposed to monkeypox and provide educational information to supervisors and managers.
  • We should avoid stigma for this disease, which is currently mostly – but not only – found in men who have sex with men.
  • Sick leave helps encourage those who are not feeling well to avoid the workplace.
  • The CDC has guidelines for cleaning non-healthcare facilities after an employee has been found with an infection.

COVID-19 update

  • Protection for the immunocompromised
  • Evusheld is a monoclonal antibody which is highly effective at preventing COVID-19 infections in those with compromised immune systems. It requires two injections in a single visit and protection lasts for six months. The medication has full federal funding, so employer sponsored health plans would only pay for an administrative fee.

    Nonetheless, few who are eligible have received Evusheld. Seven million in the U.S. are eligible, and only 165,000 have received this medication. There are hundreds of thousands of doses sitting on pharmacy shelves, and these (along with vaccination) could save lives.

  • Vaccination protects against heart attacks and strokes after COVID-19
  • Reports of excess heart attacks and strokes in the year following COVID-19 infection are especially worrisome. Researchers reported in the Journal of the American Medical Association that South Koreans who were fully vaccinated had a 52% lower risk of heart attack and a 60% lower risk of stroke between 30 and 90 days after COVID-19 diagnosis compared to those who were unvaccinated. The researchers used a national COVID-19 registry and claims from national health insurance, so the sample size was large (about 168,000 who were fully vaccinated and 63,000 who had received no vaccination).

  • U.S. rates of vaccination of young children are low
  • A survey published this week by Kaiser Family Foundation shows that 43% of parents of children under age five say they do not intend to have their young children vaccinated. This is an increase from previous surveys and is consistent with reports showing very low uptake. Seven percent said that they already had their children under age five vaccinated, and 10% said they intended to have their children under age five vaccinated as soon as possible. Young children only rarely have severe illness from the coronavirus, but the vaccine has been shown to be quite safe. Increasing immunity among children could help disrupt transmission. Vaccinating children also can lead to less parental time away from work. My two grandchildren, ages three and six, are fully vaccinated.

  • COVID-19 hospitalizations and deaths have increased
  • The subvariant Omicron BA.5 now represents over 80% of cases in the U.S., and reported cases remain at a plateau of about 130,000 cases per day. Hospitalizations are over 43,000 (up 12% in the last two weeks) and there are almost 5,000 patients with COVID-19 in intensive care (up 13% in the last two weeks). Wastewater virus levels continue to climb. Almost half of counties (42%) report a high community level of infection and hospitalization, and over nine in 10 (93%) have a high level of community transmission. Walgreens reported that over a third of tests performed at its pharmacies were positive the week of July 25, 2022. This suggests that we should not expect a lull in COVID-19 cases this summer.

Author

Population Health Leader, Health and Benefits, North America

Jeff is a practicing physician and has led WTW’s clinical response to COVID-19. He has served in leadership roles in provider organizations and a health plan, and is an Assistant Professor at Harvard Chan School of Public Health.


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