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The Pb funk

Low-level lead is phunking with your heart health, causing as many as 412,000 deaths a year in the U.S. from heart disease, according to a new study

Image courtesy of The Lancet

A study published by The Lancet identified low level lead exposure in adults as a key factor in mortality from heart disease in the U.S.

By Richard Asinof
Posted 3/19/18
A new study published by The Lancet identified low-level lead poisoning in adults as being a leading cause of deaths from heart disease in the U.S., raising the question whether high-cost clinical interventions are the best strategy for prevention of heart disease. And, the recently released OHIC study about the potential impact of the proposed merger between Care New England and Partners Healthcare on commercial insurance rates contains more guesswork than data analysis.
Why are confidential, un-attributed interviews with seven health insurance executives considered evidence-based analysis by OHIC? What are the cost comparisons between removing lead from the environment, including from housing, soil and drinking water, compared to paying for clinical interventions for heart disease in Rhode Island? Why has the House study commission on lead in drinking water in Rhode Island, approved in 2016 and 2017, never met? What kind of legislative support is there in Rhode Island to follow Vermont’s lead and develop an enhanced, universal primary care system for all residents? Will health equity zones and neighborhood health stations be included in the March 29 conversation around primary care delivery?
Recent reporting by ConvergenceRI has identified that EMS transports for impressions of alcohol intoxication in 2017 were one of the top reasons why patients are transported to hospitals.
In addition, recent data released by the R.I. Department of Health analyzing discharge data from Rhode Island hospitals found that in 2017, there were 18,582 visits by Rhode Island residents 12 years and older for acute alcohol-related intoxication, more than the combined total of marijuana-related [8,308], cocaine-related [3,180] and unintentional opioid overdose [1,417] visits.
The most recent TV ads for Bud Lite running during the NCAA basketball tournament tout the fact that kegs of that brand of beer are tapped every six seconds. Dilly, dilly, indeed.

PROVIDENCE – No one disputes that heart disease is still the number one killer of men and women, the underlying cause of death for some 800,000 Americans each year, accounting for a third of all deaths in the U.S., according to the American Heart Association.

In turn, the health insurance industry and the health care delivery system spend hundreds of billions a year in treatment for coronary heart disease, stroke, and high blood pressure. The annual cost of treating heart disease in the U.S. is estimated to be approximately $300 billion a year. Heart attacks [$11.5 billion] and coronary heart disease [$10.4 billion] were two of the 10 most expensive hospital discharge diagnoses a year, according to American Heart Association statistics, using 2013 data.

The usual suspects in the risk factors attributed to the high incidence of heart disease are: smoking, physical inactivity, nutrition, obesity, cholesterol, high blood pressure, and diabetes, with clinical treatments targeting care interventions around reducing these risk factors.

But a startling new study published on March 12 by The Lancet, “Low level lead exposure and mortality in U.S. adults: a population based cohort study,” found that approximately 412,000 deaths a year in the U.S. from heart disease could be attributable to low level lead exposure. [See link below to the study.]

The principal author of the study, Dr. Bruce Lanphear, professor of Health Science at Simon Fraser University in British Columbia, believes that low-level lead exposure is an important but largely overlooked key risk factor for heart disease mortality for adults in the U.S.

Translated, adults – and not just children – are life-long victims of low levels of lead poisoning, leading to their death from heart disease.

More importantly, based on the results of the study, Lanphear believes that a comprehensive strategy to prevent deaths from heart disease should include efforts to reduce lead exposure.

[Lanphear spoke last year in October of 2017 at Brown University. See the link below to the ConvergenceRI story, “Changing the way we think about disease.”]

The study by Lanphear published by The Lancet used data from 14,000 adults who were enrolled in the National Health and Nutrition between 1988 and 1994, who were followed up through Dec. 31, 2011.

The study participants had undergone a slew of medical tests, including quantifying the lead levels in their blood, and when relevant, linked up with records about their cause of death, according to reporting on the story by Vox.

The findings of the study reinforced the recent determination of the Centers for Disease Control and Prevention that there is no known safe blood lead level for children, which is measured in micrograms per deciliter of blood. The same holds true for adults, according to The Lancet study findings. [Researchers had previously believed that levels of 5 micrograms of lead per deciliter of blood were safe.]

“This is huge,” said Dr. Mona Hanna-Attisha, a pediatrician in Flint, Mich., whose research helped expose the water crisis there, as reported by Vox. “It’s time our policies and practices caught up with the science, and we truly invested in lead elimination not only for our children today but also for decades to come.” [See link to ConvergenceRI story below, “There are Flints everywhere.”]

Translated, perhaps the best, most cost-effective way to prevent heart disease, with its $300 billion a year costs to the health care delivery system, would be to eliminate lead exposure from the environment – from drinking water, from paint in older housing, from the soil.

Fiddling and diddling
In the midst of March Madness, to borrow an apt phrase from the late Johnny Most, the infamous Boston Celtics announcer, that he used to describe a basketball player who was dribbling with no apparent purpose, the R.I. General Assembly, and in particular, House Speaker Nicholas Mattiello, appear to be “fiddling and diddling” when it comes to addressing the threat of lead in drinking water in Rhode Island.

In 2016, and again in 2017, the R.I. House of Representatives enacted a legislative study commission to examine the problem of lead in drinking water in Rhode Island. The 2016 study commission never met. The 2017 study commission’s term expired on March 2, 2018, without ever having met once.

In attempting to explain away why the commission had never met, House spokesperson Larry Berman said: “Although a commission to continue the study of lead in drinking water was approved last year, the panel never met. The sponsor of the bill [2017-H6035] learned that the R.I. Department of Health has been reviewing this issue and the House is awaiting the department’s assessment until moving forward. I do not anticipate a commission working on the issue this session.”

Berman’s explanation, however, was contradicted by the R.I. Department of Health, whose spokesman, Joseph Wendelken, shared correspondence sent by the agency on May 1, 2017, to legislative leaders, including a baseline evaluation of lead in water in schools, in day care and in public water systems, three days before the study commission was enacted by the House.

Further, the agency asked to become a member of the study commission, endorsing the effort. [See link to ConvergenceRI story below, “There are Flints everywhere.”]

The new study published by The Lancet is not likely to be one of the items mentioned in the political roundup by Rhode Island Public Radio’s Ian Donnis or by WPRI’s Ted Nesi in his weekly “Nesi’s Notes,” nor is it likely to become a part of the conversation on “A Lively Experiment” around politics and the cost of health care.

Neither, for that matter, is the fiddling and diddling by the R.I House about the study commission on lead in drinking water in Rhode Island, which never met for two years, likely to become part of the conversation by political pundits.

Perhaps it should. Because the issue gets to the very heart of what is driving the escalation in health care costs in Rhode Island and in the nation: expensive clinical interventions for heart disease, the number-one cause of death for men and women, may never succeed without the ability to address what appears to be a key, primary, catalytic causal risk factor: low level lead exposure.

Translated, the efforts to address the rising costs of health care appear to be looking for answers [and lead] in all the wrong places.

The high cost of conjecture

The R.I. Office of the Health Insurance Commissioner, accompanied by some news media hoopla, particularly by WPRI’s Ted Nesi, recently released a study commissioned to look at the potential impact on commercial health insurance rates in Rhode Island by the proposed merger of Care New England and Partners Healthcare in Boston.

“This is big,” said Marie Ganim, the R.I. Health Insurance Commissioner, who told Nesi that the study conducted by Bailit Health was the first time her office had ordered a study on a specific transaction.

But a careful reading of the 26-page study finds it filled with what amounts to mostly anecdotal information, without specific attribution.

Bailit Health conducted just “seven interviews” with health insurers in Massachusetts, New Hampshire and Rhode Island. However, none of the insurance executives interviewed were directly identified, because Bailit promised that “their participation would be confidential and that their responses would not be attributed.”

The study reviewed data from the Massachusetts Health Policy Commission and the Massachusetts Center for Health Information and Analysis, but concluded that none of the Cost and Market Impact Reports by the Health Policy Commission related to Partners were “directly relevant to the proposed Care New England acquisition [emphasis added].” Further, insurers from Rhode Island who were interviewed by Bailit reported “relatively little patient migration to Partners facilities.”

The Bailit study relied in part on data from an out-of-date, six-year-old study conducted in 2012 funded by the R.I. Office of the Health Insurance Commissioner and the R.I. Executive Officer of Health and Human Services, comparing multi-payer hospital payment rates. [To put the dated nature of the 2012 study in perspective, the study was commissioned when Christopher Koller was the health insurance commissioner, Steven Costantino was secretary of R.I. EOHHS, and Lincoln Chafee was governor.] Bailit acknowledged the study and analysis “used data that are now several years old,” explaining that it used anecdotal information collected during the un-attributed interviews with Rhode Island insurance executives who “generally confirmed” that Care New England “continues to enjoy high rates relative to the rest of the Rhode Island hospital market.”

Further, as reported by Nesi, Care New England spokesman Jim Beardsworth downplayed the Bailit study, saying that it was conducted “in a vacuum without input from Care New England or Partners.”

Translated, the Bailit Health analysis of the proposed merger between Care New England and Partners Health Care is mostly dancing in the dark while reading the tea leaves, relying on confidential, un-attributed interviews with seven health insurance executives and out-of-date data analyses – without access to any of the actual current financial data.

In turn, that led to a kind of convoluted guessing game by Bailit, which listed six possible motivations about “why would Partners want to acquire Care New England,” and then attempted to provide educated guesses as analysis. How much did OHIC pay for this kind of guesswork?

Some nuggets within the study:

The commercial insurance executives interviewed were apparently divided in their opinion whether Rhode Island residents would travel to Boston for high-margin care. One interviewee said that Rhode Island residents are reluctant to travel “more than four miles” for care.

The state of Rhode Island “has more of a role than we might” in protecting against any rate increases sought by Partners following a merger, “because of the rate cap” under OHIC regulations, one interviewee said.

The positive impacts of value-based contracting with commercial insurers and the development of Care New England’s Integra accountable care organization [which includes both primary care and specialty practices] was deemed “ambiguous” by the Bailit study. [This conclusion seemed contrary to existing evidence often promoted by the three major commercial insurers in the Rhode Island market.]

Some important nuggets not to be found in the study:

The trend of declining market share for full commercial health insurance plans in Rhode Island regulated by OHIC, given the rapid adoption of self-insured plans by many large and now smaller companies, which are regulated under the federal ERISA statute.

The success achieved in moderating costs and increased savings by Care New England’s Integra ACO in 2016 for Medicare patients, and its potential increasing value in a merger with Partners.

Any discussion of the role that the increasing cost of drugs play in the overall rise in medical costs in Rhode Island, as reflected as a major factor in rising premiums.

What does primary care have to do with it?
On Thursday, March 29, from 7:30 a.m. to 9:30 a.m. at the Providence Marriott the Care Transformation Collaborative will host a panel discussion on “the state of primary care in Rhode Island,” featuring OHIC Commissioner Marie Ganim, Patrick Tigue, R.I. Medicaid director, Dr. Tom Bledsoe, University Medicine, and Matthew Ronan, COO at Thundermist Community Health Center, with Dr. Pano Yeracaris, the co-director of the Care Transformation Collaborative, serving as moderator.

The discussion is being targeted to health care leaders and lawmakers as being relevant to discussions about health care policies in the way that “advanced primary care is supporting an improved health care [delivery] system,” including workforce development and access to behavioral health.

In advance, here are some suggested questions from ConvergenceRI for the panelists:

How does the concept of Neighborhood Health Stations, such as the ones in Central Falls and Scituate, fit into the future of primary care?

Do the panelists support the recent developments in Vermont in creating an enhanced system of universal primary care?

How does the work of 10 health equity zones in Rhode Island fit into the equation of developing a community approach to health issues around social, health and economic disparities?

Is Rhode Island’s poor pay scale for primary care doctors a factor in the difficulty to recruit primary care physicians to the state?

How is the role of nurses valued within the current primary care delivery infrastructure? Do nurses share in shared savings from accountable care organizations and accountable entities?

Will primary care practices adopt lead screening for adults as part of the health screening for adults for cardiac care?

What is the waiting time to see a primary care physician, as distinguished from a nurse practitioner or a physician’s assistant? Is that being tracked? What are the policies about who gets to see a physician?

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