Healthcare roundup: Missed cancer diagnoses, excess deaths in Black people, and medication costs

We know that cancer screening rates were down substantially in 2020, and I’ve seen anecdotal reports of higher rates of diagnosis of metastatic disease over the last two years. Now researchers have quantified how many cases of breast, lung and colorectal cancer were likely not diagnosed in 2020.

Researchers reported in the Journal of the American College of Surgeons that rates of diagnosis were down from predicted rates by almost 15% for breast cancer and about 18% for colorectal and lung cancer.

Cancer Diagnoses Down in 2020

Implications for employers:

• Screening rates are on the rise, but there is still room for employers to encourage age-appropriate screening. Recent new recommendations for breast cancer screening at age 40 will bring more attention to screening.
• Health plans often show preventive screening benchmarks that are their book of business rates. Employers can aim for (often) higher rates by using national HEDIS data or the Healthy People 2030 goals.
• We can expect higher medical costs in subsequent years since many will have their cancers diagnosed at a later stage.

Black people in the U.S. die earlier than white people, and the problem is getting worse

JAMA published a large national study of death certificates from 1999 to 2020 and found that non-Hispanic Black men and women die at rates substantially higher than white people. The difference in life expectancy for Black males decreased by almost half from 1999 to 2011 but started increasing even before the pandemic. The disparity is now back to the level it was at in 2000.

During this 21-year period, there were 1.63 million excess deaths among Black people, representing more than 80 million years of potential life lost. Excess deaths from heart disease and cancer were large components of total excess mortality.

A separate study by JAMA quantified the economic burden of health inequities for racial and ethnic minorities (including American Indian and Alaska Native, Asian, Black, Latino, and Native Hawaiian and other Pacific Islander populations), which was $421 billion to $451 billion in 2018.

Last month, KFF (formerly Kaiser Family Foundation) published data on the impact of the pandemic on life expectancy by race that show similar results. There was a decrease in life expectancy at birth across all races – this was greater for Black people (loss of four years) than white people (loss of 2.4 years).

This data can sometimes leave us numb. We must remember that disparities in life expectancy are deeply personal tragedies that affect entire families and communities.

Implications for employers:

• While many of the reasons for disparities require broad societal interventions, employers can play a substantial role by providing programs to better support:
  • Diagnosis and treatment for high blood pressure and cholesterol to decrease premature mortality from heart disease
  • Screening and subsequent treatment for cancers
• Employers can encourage carriers to improve provider access (offering programs to help patients find providers who are a good match) and increase the diversity of providers. Virtual care can increase the diversity of the pool of providers from which members can choose.
• Increased premature mortality means a smaller labor force and increased costs to replace workers who die earlier than would otherwise be expected.
• Employers can demand that quality reporting be segmented by race and ethnicity to draw attention to disparities – and expect carriers to develop plans to address these disparities. For example, Blue Cross Blue Shield of Massachusetts is doing this type of reporting.

Waiving out-of-pocket costs for basic medications lowered total cost of care

Many employers use value-based insurance design in their pharmacy benefit design, offering selected high-value medications without cost sharing (e.g., medication to treat diabetes, high cholesterol, high blood pressure and asthma). Canadian researchers went one step further: providing 128 commonly used medications without cost to patients to determine if free drugs lower the overall cost of medical care. These drugs are largely generic, inexpensive and cover a wide range of chronic and acute illnesses.

The results, published last month in JAMA Health Forum, show that those randomly assigned to free medications had statistically significant lower overall healthcare costs and fewer hospitalizations and emergency department visits.

This is great news. Most interventions like this are cost effective, offering better health for a reasonable price, but not typically cost saving. The authors previously published an analysis showing that those randomized to free drugs had higher rates of adherence to prescribed medication.

A few caveats: This study explicitly recruited adults who said that they had skipped medications because of cost. It was performed in Canada where many have no pharmacy insurance and both drug prices and out-of-pocket medical costs are far lower than in the U.S. Further, the researchers did not include the cost of medications when calculating savings. 

Implications for employers:

• This study supports value-based insurance design – demonstrating that increased adherence to medications which have no out-of-pocket costs can lower overall hospitalizations and emergency department visits.
• Medical savings in Canada are not directly applicable to potential medical savings in the U.S.
• Employers can work with their pharmacy benefit manager to design benefits that ensure member access to high-value, low-cost preventive medications (e.g., by ensuring the products bypass the deductible in high deductible health plans and/or assigning zero cost share for preventive medications).
• When WTW surveyed employers last year, 64% said they were taking steps to improve healthcare affordability, and 41% said they were seeking to add or enhance low- or no-cost coverage for certain benefits.

CDC issues new guidelines for clean indoor air

The CDC issued new guidelines for air exchanges and air filtration last month which could help decrease the spread of COVID-19 and other respiratory diseases. The American Society of Heat, Refrigeration and Air Conditioning Engineers (ASHRAE) also issued new draft standards that would require higher levels of air exchanges in schools, hospitals and workplaces.

The CDC guidelines are not enforceable regulations. Still, building operators now have clear guidance to aim for five complete air exchanges per hour, which is consistent with what public health experts recommend. The ASHRA draft standards will likely be finalized by summer and are often the basis of building codes.

This is excellent news. More air exchanges can prevent transmission of COVID-19, influenza, RSV and other respiratory viruses. Better filtration will also limit exposure to PM 2.5 particles (fine inhalable particles) from air pollution including wildfires, which increase the risk of heart and lung disease. During the recent wildfires in eastern Canada, New York City experienced an increase in emergency room visits for asthma, according to The New York Times.

Better quality indoor air also is associated with better ability to concentrate, which can improve productivity.

There is a cost to improving the quality of indoor air. Bringing in more outdoor air means conditioning it (heating in the winter and cooling in the summer), and higher efficiency filters make air handling units work harder. Nonetheless, many companies can make small adjustments to their existing air handling systems to improve indoor air quality.

I’ve been carrying around a carbon dioxide meter to assess whether there are enough air exchanges in small conference rooms. We all exhale carbon dioxide (CO2), so this is a good proxy for whether there are enough air exchanges.

Last week, I was in a business meeting with about eight others and the initial CO2 level was 600 (outdoor is 400, and up to 800 is fine, while over 1,000 means there is not enough air exchange.) Midway through the meeting I saw the meter edging up past 1,100. We opened the door and the CO2 level went down to under 700 within two minutes. Sometimes it takes very little to improve indoor air quality.

Some schools have installed CO2 monitors in classrooms to demonstrate their concern for clean indoor air. Here’s a link to the public-facing website where the Boston Public Schools disclose indoor air quality.

Implications for employers:

• Following current CDC guidelines, even in buildings where this is not a legal requirement, can reduce worker illness and improve productivity and happiness.
• Companies can install CO2 monitors in portions of the workplace that are high risk, such as small break rooms or crowded factory floors.
• Companies can communicate about their efforts to offer cleaner air to demonstrate their concern for employee wellbeing.
• WTW has a Workforce Vitality Practice, which consults for companies seeking to mitigate environmental risks in the workplace.

Author

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Jeff Levin-Scherz, MD

Population Health Leader, Health and Benefits, North America

Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. 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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