How health system reform affects patients

The Patient Protection and Affordable Care Act (H.R. 3590)—health system reform legislation signed into law by President Obama on March 23—contains a number of key provisions for you and your patients. Some provisions may have an immediate impact on your practice and patients, while others will not take effect for some time.

Given the new direction for the nation's health system, the AMA has developed Health System Reform Insight to help you understand the new law and how it will affect you, when certain provisions are scheduled to take effect, how you can be ready when the regulations go into effect and what your patients need to know. The first issue of the series explained how health system reform will affect physician practices. Today we focus on information for your patients. We encourage you to visit the AMA's health system reform Web site (PDF) and print copies to share with them.

How health system reform affects patients
H.R. 3590 has many significant benefits for patients—those who already have health insurance and those who don't. While some benefits take effect in 2010, many others will be phased in over several years to allow the health care system to absorb the changes ahead. Here's a snapshot of those benefits.

Patient benefits that take effect in 2010
For patients with private health insurance:

• Your insurer can no longer drop you from your plan if you get sick.
• Children ages 18 and younger can no longer be denied private insurance coverage if they have a pre-existing medical condition.
• For adults with pre-existing medical conditions who cannot obtain private insurance coverage, a temporary national "high-risk pool" will be established to provide coverage, with financial subsidies to make premiums more affordable, until all insurers are required to cover people with pre-existing conditions in 2014.
• Young adults up to age 26 can remain as a dependent on their parents' private health insurance plan.
• Your health insurance benefits can no longer run out because of a long or expensive illness because insurers can no longer impose lifetime financial limits on benefits.
• Preventive services for women, such as mammograms, and immunizations for children must be covered by insurers, with no co-payments or deductibles required.

In addition, Medicare patients who will hit the coverage gap known as the "doughnut hole" this year under the prescription drug benefit will receive a $250 rebate from Medicare.

Patient benefits that take effect during the next four years
In the private health insurance market:

• U.S. citizens and legal residents cannot be denied private health insurance coverage for any reason, beginning in 2014. All U.S. citizens and legal residents must obtain health insurance coverage or pay a minor tax penalty (although there are some exemptions). This is to ensure that everyone is in the insurance pool so no one can get a "free ride" by not having affordable coverage and then going to an emergency room for care.
• State-based health insurance exchanges will begin operating in 2014, where people who do not have access to employer-based insurance can shop and compare the benefits and costs of private health insurance plans. These exchanges will create insurance pools that will allow people to choose among affordable coverage options. All insurance companies in the exchange must provide at least a minimum benefit package, as well as additional coverage options beyond a basic plan.
• Federal subsidies through tax credits or vouchers will be provided in 2014 to people who cannot afford the full cost to help them purchase coverage through the exchanges.
• Beginning in 2011, states can require insurance companies to submit justification for premium increases and can impose penalties for excessive increases.

For patients enrolled in Medicare or Medicaid:

• You no longer will pay any cost-sharing for a number of preventive services, effective Jan. 1, 2011.
• If you are subject to the "doughnut hole" for your Medicare drug coverage, you will receive a 50 percent discount on those prescription drugs beginning Jan. 1, 2011.
• A series of pilot programs will be implemented during the next four years to help find new ways to improve quality and lower the cost of the care you receive from your doctors, hospitals and nursing homes in the Medicare and Medicaid programs.
• Medicaid coverage will be expanded in 2014 to all eligible children, pregnant women, parents and childless adults under age 65 who have incomes at or below 133 percent of the federal poverty level.

AAAAI: Test May Identify Asthma Patients Unresponsive to Steroids

By John Gever, Senior Editor, MedPage Today Published: March 05, 2010 Reviewed by Zalman S. Agus, MD; Emeritus Professor University of Pennsylvania School of Medicine and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner Earn CME/CE credit for reading medical news

NEW ORLEANS -- Asthma patients who will be unlikely to gain control of symptoms with inhaled corticosteroids might be identified with a blood test, a researcher suggested here. A plasma protein called uteroglobin appeared elevated enough in patients unresponsive to inhaled corticosteroids that a blood test might be feasible, reported Elena Goleva, PhD, of National Jewish Health in Denver. By identifying such patients before starting on these drugs -- the standard of care for patients with persistent asthma -- they might instead be treated with alternative controller medications such as omalizumab (Xolair) or montelukast (Singulair), Goleva suggested in a featured poster presentation at the American Academy of Allergy, Asthma & Immunology meeting. Goleva said about 15% to 20% of patients seen at her institution show poor responses to inhaled steroids. However, National Jewish Health is a national referral center, she pointed out, and the percentage would likely be smaller in an ordinary community practice. Action Points   Explain to interested patients that inhaled corticosteroids are the standard of care for long-term control of asthma symptoms and that most patients respond to them when used as directed. Explain that other medications are available for patients who fail to respond to these drugs after a fair trial. Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered preliminary until published in a peer-reviewed journal. She and her colleagues conducted a study in a total of 89 patients, 24 of whom were determined to be steroid-resistant. These 24 patients continued to show asthma symptoms despite treatment with inhaled corticosteroids. They also showed essentially no improvement in lung function (as measured by FEV1) following oral treatment with prednisone. In contrast, symptomatic patients believed to be responsive to steroids had a mean 39% increase in FEV1 with the prednisone burst. Previous research had suggested that uteroglobin, which is produced by Clara cells in the lung, was increased in patients with steroid-resistant asthma, but with insufficient detail to confirm that the protein could be a useful biomarker. Goleva and colleagues initially performed bronchoalveolar lavage in 20 patients, including 13 with steroid-resistant asthma and seven with asthma responding to the drugs. Mean levels of uteroglobin expression, as measured by mRNA for the uteroglobin gene in BAL fluid, was elevated about six-fold in the resistant patients (P<0.05). Actual levels of uteroglobin protein in the lavage fluid were roughly twice as high on average in the resistant patients (P<0.01), the researchers found. Moreover, they discovered that mean uteroglobin levels in plasma were about 50% higher in the resistant patients, prompting the researchers to perform blood tests on an additional 25 patients, including 11 with steroid-resistant disease. The findings were initially somewhat disappointing, Goleva explained. The means were still significantly different -- about 65 ng per μg of plasma protein in the resistant patients, compared with about 45 in the steroid-sensitive group, but there was considerable overlap between the individual results. For example, setting the cutoff at the lowest value in the steroid-resistant group would leave about three-quarters of the steroid-sensitive group above it as well. But Goleva said her team hypothesized that airway disease might allow uteroglobin in the lungs to "leak" into circulation in the steroid-sensitive group, inflating their plasma levels of the protein. If that were the case, they believed, lung proteins such as surfactant protein D and mucin-1 would also be elevated in the patients' plasma. When they tested for those proteins, they found that four patients with elevated plasma levels of those lung proteins also had high plasma levels of uteroglobin. With those four patients removed, there was clearer separation among the groups in their uteroglobin levels, although some overlap still remained, Goleva reported. Finally, the researchers performed an in vitro experiment on peripheral blood mononuclear cells from 44 asthmatic patients, without regard to whether they were steroid-resistant, to correlate plasma uteroglobin with steroid responsiveness. The latter was measured by the quantity of dexamethasone required to suppress lymphocyte proliferation and tumor necrosis factor production, both of which are associated with inflammatory activity. The researchers found strong correlations -- r coefficients of 0.35 and 0.46, respectively, both with P<0.05 -- between uteroglobin and steroid responsiveness in these cells. In sum, she said, it appears that uteroglobin could be a useful biomarker in guiding treatment selection. Stanley Szefler, MD, also of National Jewish Health, although not involved with the study, said the research held some promise but cautioned that most cases of "steroid resistance" seen in routine practice have nonbiologic causes -- especially lack of treatment compliance or inadequate dosing.