By the time you read this issue of Biomedical Business & Technology, election of the next president of the U.S. will likely be over, with the nation on track to make a variety of changes in its healthcare system.

Thus, you might consider over the next four years how those changes – large or not at all – match up with assessments of the two major candidates' plans issued in early October by the non-profit, bipartisan Commonwealth Fund.

Sens. John McCain and Barack Obama both have proposed health plans intended to reduce the growing number of the uninsured in the U.S. — standing at more than 46 million — and improve the quality of care. But the organization said in its analysis that the candidates' proposals would put the nation's health system on very different paths.

The analysis predicted that McCain's proposal in 10 years would reduce the number of people who are uninsured by 2 million, out of a projected 67 million, while Obama's would reduce the number by 34 million. And over the 10 years, McCain's plan would cost an estimated $1.3 trillion, while Obama's would cost $1.6 trillion.

The Commonwealth Fund said it based its analysis on estimates from the Tax Policy Center, a joint project of the Washington think tanks the Urban Institute and the Brookings Institution.

If implemented in 2009, McCain's proposal would reduce the number of uninsured by about 1.3 million that year, the organization said. However, that estimate does not include the effects of the state high-risk pools, Collins said. About 20 million people are expected to lose employer coverage under the McCain proposal and 21 million people would gain coverage through the individual market, she said.

It estimated that Obama's plan would reduce the number of uninsured by about 18.4 million in 2009, Collins said. McCain's proposal in 2009 would cost about $185 billion, while Obama's is estimated to cost $86 billion.

McCain's cost is more than twice as much as Obama's in the first year while covering 17 million fewer people because most of McCain's tax credits would likely be used by people who already have private health insurance, Collins noted.

McCain is proposing giving tax credits of $2,500 for individuals and $5,000 for families to encourage people to buy coverage in the individual insurance market. The tax credits would replace the current income tax exemption for employer-provided benefits.

"This would help some people who currently buy coverage in the individual market by giving them a tax benefit that does not now exist," said Sara Collins, the Commonwealth Fund's assistant VP and lead author of the report. However, she noted during a media briefing that employer premium contributions would become taxable income under the McCain proposal.

Obama would require that the public and private plans sold through the national insurance exchange have benefits and cost-sharing similar to that available to federal employees and members of Congress. Obama's proposal is very similar to Massachusetts' recent health reform law, which is now being implemented in the state and just received an increase in federal funding, Collins noted.

While McCain's plan would not require any American to have health insurance, Obama's seeks a requirement for coverage of all children.

Both candidates have offered strategies to improve the quality and efficiency of healthcare, such as expanding the use of information technology, evaluating the comparative effectiveness of medical treatment and changing the way providers are paid, Collins noted. But she argued that Obama's proposed national insurance exchange would provide an additional arena to pursue quality improvement strategies in a "systematic way."

But no matter who ultimately takes the White House, the current economic meltdown could result in both proposals going by the wayside, Davis lamented. "As the nation grapples with the financial crisis, we must recognize that investing in our healthcare system will pay future dividends in terms of a healthy work force and economically stable families," she told reporters. "In the event of a serious economic downturn, even more families will be at risk of losing their jobs and their health insurance coverage, leading to more medical debt and unmanaged health care bills and even more families going without the health care they need."

The plain truth about U.S. healthcare quality

Whoever he is, the next president of the U.S. is faced with abundant challenges, from economic instability to multiple foreign policy risks. Where will healthcare reform rank on the ensuing priority list of things to fix? Time will tell, but a new report by the National Committee for Quality Assurance (NCQA; Washington) reveals massive inconsistencies in the delivery and outcomes of healthcare in the U.S., further highlighting the need for a cure for the ailing system.

On the one hand, the quality of healthcare for millions of Americans — only those in private insurance plans — improved somewhat in 2007.

On the other, there are significant variations in performance which continue to leave many people receiving substandard care.

All of this in the shadow of ever-rising healthcare costs, insurance restrictions and millions of Americans without any coverage or care at all.

"There's a lot that we know right now about what constitutes basic quality care," NCQA spokesman Jeff Van Ness told BB&T in mid-October. "I'm not talking about the latest and greatest medical technology, just basic blocking and tackling. This report shows these basic tenants of high-quality care are being inconsistently delivered. The consistency can vary by where you live, by who pays for your care and even by what sort of plan you're in. The macro message: Our greatest challenge isn't making the next best medical technology. It's to more consistently apply the knowledge we have to provide better healthcare for all Americans."

The NCQA minces no words in reporting that, "Since 2000, the cost of coverage has more than doubled, yet the quality of care patients receive is often spotty and sometimes dangerous." But it also points out that transparency in reporting healthcare quality is improving. Without the performance measures, change will never occur.

"Today one in three Americans are enrolled in a health plan that is transparent regarding the measurement of the quality of its care and services," NCQA president Margaret O'Kane wrote in the report. "This increase in accountability was driven, in large part, by the addition of nearly 100 preferred provider organizations [PPOs] that reported quality data for the first time in 2008."

One reason for the increased transparency is that the NCQA updated its accreditation standards to require all plans to report audited Healthcare Effectiveness Data and Information Set (HEDIS) data as a condition of becoming accredited. HEDIS is the most widely adopted set of healthcare performance measures in the nation.

"It's about delivering the right care to the right patients at the right time," Van Ness said. "Many of our measures look directly at things that could be defined as patient satisfaction, some look at outcomes like whether blood pressure was controlled to an adequate measure or if you received a flu shot."

One area of notable improvement was the rate at which Medicare beneficiaries were kept on life-saving beta-blocker drugs six months after suffering a heart attack. The NCQA estimates that up to 30,000 lives have been saved since 1996 as a result. Similar gains have been seen in cholesterol management, blood pressure control and diabetes with HbA1c control.

The most significant declines are related to mental healthcare.

While commercial health plans showed improvements on 44 of 54 measures of healthcare quality, with 16 significant gains in areas such as blood pressure control, health plans serving Medicare beneficiaries posted gains on only 24 of 45 measures of care, and many of those improvements were quite small.

Additionally, there was little improvement in the quality of care provided to Medicaid beneficiaries. Among the 52 measures collected from Medicaid plans, only 26 showed any increase and most of those were very small. There was one exception: the delivery of childhood immunizations improved.

Geography also plays a major role in the quality of healthcare. Comparison of performance among plans in eight U.S. census regions shows people in accountable health plans in New England and the Mid-Atlantic states tend, on average, to receive better care than people in other parts of the country.

Rocky economy impacts healthcare patterns

The crisis of health, as a result of a financial crisis, might be increasingly personal, according to recent survey by health services company CIGNA (Philadelphia). The survey found that about one-third of respondents say the slumping U.S. economy has resulted in their changing the way they take care of themselves. Of those, 55% report taking better care of their health by exercising, eating healthier or getting regular check-ups and screenings, while 41% say they are taking worse care.

Among those who are taking worse care of themselves, more than one-third (35%) say they're not going to the doctor regularly or at all, while 17% say they're taking their medications less often or not at all, and 10% say they can't afford to eat properly or are eating less healthy foods.

Not surprisingly, Cigna used the results of the survey to encourage more effective use of "health plans. Charles Smith, MD, chief medical officer for CIGNA's health solutions organization, said, "With a faltering economy . . . it's more important than ever for people to understand the value their health plan offers and make the most of the benefits that may be available to them," And he recommended greater use of the preventive benefits offered by health plans.

In another report, a cardiologist has warned that the current economic atmosphere, if it results in increased stress in the workplace, could translate to increased heart ailments.

"Prolonged stress, both emotional and physical, impacts the overall cardiovascular status of our patients, particularly their blood pressure," said Keith Churchwell, MD, executive medical director of the Vanderbilt Heart and Vascular Institute (Nashville, Tennessee). He says that stress can lead to decreased heart rate variability and elevated blood pressure, and that stress hormones called catecholamines, including adrenaline, can have damaging effects on the heart muscle if exposed to elevated levels for a long time.

He cited a study in the European Heart Journal in January, by researchers at the University College (London), which found that civil servants under age 50 suffering chronic stress had a 68% higher risk of heart disease than those not stressed at work.

"It's almost always multifactorial," Churchwell said. "It's not just the stress, but also how people adapt to stress." Many people react to stress by eating poorly, stopping exercise, smoking, drinking and missing medications.

He said that Vanderbilt Heart and Vascular Clinic sees many people with chest pain, elevated blood pressure, and shortness of breath, those symptoms being "outward manifestations of the emotional currents going on in their work lives. They will either be dragged in by a family member who is worried about them or by a co-worker."

Study aims to assess impact of genetic screening

For $400 and a little saliva, a person can order an at-home test kit online to find out their genetic likelihood of developing Alzheimer's disease. Or, for a heftier price of $2,500, a consumer can order a similar at-home test kit to find out their potential risk of developing 20 or more common conditions, including heart attack, rheumatoid arthritis, and certain types of cancer.

But what happens after the consumer learns about their genetic likelihood of developing one of these health conditions? A consortium of healthcare, technology and research experts have launched a research study to find out the behavioral impact of personal genetic testing on people who choose to receive such screenings.

Sponsored by Scripps Translational Science Institute (STSI; San Diego), the study aims to find out if participating in personal genomic testing will improve health by motivating people to make positive lifestyle changes, such as exercising, eating healthy and quitting smoking, as well as decisions to seek further medical evaluation and preventive strategies. The study will offer genetic scans to up to 10,000 employees, family members and friends of the nonprofit Scripps Health (San Diego) system and will assess changes in participants' behaviors over a 20-year period.

Co-sponsors of the study include Navigenics (Redwood Shores, California), Affymetrix (Santa Clara, California), and Microsoft (Redmond, Washington). Study participants age 18 and older can receive a scan of their genome and a detailed analysis of their genetic risk for more than 20 health conditions that may be changed by lifestyle, including diabetes, obesity, heart attack and some forms of cancer.

Navigenics is one of a growing number of companies that are cashing in on consumers' genetic concerns. In April the company launched a service called Health Compass designed to give customers information about their chances of developing 18 or more common conditions, including Alzheimer's. The company's list of covered conditions has since grown to 23. The initial fee and first year of membership costs $2,500, with an ongoing membership rate of $250 a year, which includes updated medical information.

Elissa Levin, director of the genetic counseling program at Navigenics, told BB&T in June that the Health Compass scans through a person's entire genome and, based on scientific publications, identifies a certain marker or sets of markers associated with a disease.

The benefit of knowing such information, Navigenics says, is so that the consumer and their doctor can obtain earlier diagnosis, delay onset or prevent the conditions altogether. But critics of direct-to-consumer genetic testing say the market is largely unregulated and lacks the guarantee that these tests do what the companies selling them claim.

Task force revises colon cancer screening guides

In a change from its previous recommendation, the U.S. Preventive Services Task Force said last month that it now recommends that adults age 50 to 75 be screened for colorectal cancer using annual high-sensitivity fecal occult blood testing, sigmoidoscopy every five years with fecal occult testing between sigmoidoscopic exams, or colonoscopy every 10 years.

According to the task force, which is supported by the Agency for Healthcare Research and Quality (AHRQ; Rockville, Maryland), good evidence exists that using these methods save lives. The recommendation and the accompanying summary of evidence was posted in the Annals of Internal Medicine online and was scheduled to appear in the Nov. 4 print edition of the journal.

The task force recommends against routine colorectal cancer screening in adults between the ages of 76 and 85 because the benefits of regular screening were small compared with the risks. The task force also recommends that adults over the age of 85 not be screened at all because the harms of screening may be significant, and other conditions may be more likely to affect their health or well-being.