The Senate Can Tighten an Expensive Medicaid Loophole
The House version of the 'one big beautiful bill' started to clean up a financing scheme that lets states abuse the Medicaid program for extra money. The Senate version is poised to finish the job.
Forty-nine states use so-called healthcare provider taxes to siphon money from the federal Treasury, supposedly to fund health coverage for the poor. (Alaska is the lone exception.) Under Medicaid law, Washington matches a percentage of benefits paid out by states. Healthcare provider taxes let states collect federal matching dollars for money they didn't actually spend.
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Medscape
26 minutes ago
- Medscape
Dementia Risk May Follow a Geographic Pattern
TOPLINE: Dementia incidence varied significantly by US region in a new study, with the Southeast showing a 25% higher risk and the Northwest and Rocky Mountains each showing a 23% higher risk compared to the Mid-Atlantic. Investigators said the findings highlight the need for a geographically tailored approach to address dementia risk factors and diagnostic services. METHODOLOGY: Researchers conducted a cohort study using data from the US Veterans Health Administration for more than 1.2 million older adults without dementia (mean age, 73.9 years; 98%% men) from 1999 to 2021. The average follow-up was 12.6 years. Ten geographical regions across the US were defined using the CDC National Center for Chronic Disease Prevention and Health Promotion definition. The diagnosis of dementia was made using International Classification of Diseases, Ninth and Tenth Revision codes from inpatient and outpatient visits. TAKEAWAY: Dementia incidence rates per 1000 person-years were lowest in the Mid-Atlantic (11.2; 95% CI, 11.1-11.4) and highest in the Southeast (14.0; 95% CI, 13.8-14.2). After adjusting for demographics, compared with the Mid-Atlantic region, dementia incidence was highest in the Southeast (rate ratio [RR], 1.25), followed by the Northwest and Rocky Mountains (RR for both, 1.23), South (RR, 1.18), Southwest (RR, 1.13), and Midwest and South Atlantic (RR for both, 1.12). The Great Lakes and Northeast regions had < a 10% difference in incidence. Results remained consistent after adjusting for rurality and cardiovascular comorbidities, and after accounting for competing risk for death. IN PRACTICE: 'This study provides valuable insights into the regional variation in dementia incidence among US veterans in that we observed more than 20% greater incidence in several regions compared with the Mid-Atlantic region,' the investigators wrote. 'By identifying areas with the highest incidence rates, resources can be better allocated and targeted interventions designed to mitigate the impact of dementia on vulnerable populations,' they added. SOURCE: This study was led by Christina S. Dintica, PhD, University of California, San Francisco. It was published online on June 9 in JAMA Neurology. LIMITATIONS: This study population was limited to US veterans, limiting the generalizability of the findings. Education level was defined using educational attainment rates in the participants' zip codes rather than individual data. Additionally, because residential history was limited to a single location per participant, migration patterns could not be tracked. DISCLOSURES: This study was supported by grants from the Alzheimer's Association, the National Institute on Aging, and the Department of Defense. One author reported serving on data and safety monitoring boards for studies sponsored by the National Institutes of Health, as well as holding advisory board membership and receiving personal fees from industry. Full details are listed in the original article. The other four investigators reported no relevant financial conflicts. This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
Medscape
29 minutes ago
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Peer-Led Weight Loss Maintenance Proves Superior
Can a mentor/peer-led strategy surpass professionally led behavioral weight management sessions in helping patients with obesity maintain weight loss? If the findings of a recently published study are any indication, then the promise of keeping weight off after initial weight loss might be closer than ever. Obesity treatments (eg, bariatric surgery, lifestyle management, and medications like GLP-1s) have been shown in clinical trials and real-life settings to help patients with obesity lose anywhere from 10% to 60% of excess body weight, with added improvements in cardiovascular disease risk factors. Tricia M. Leahey, PhD But these gains are commonly fleeting, Tricia M. Leahey, PhD, lead study author, a professor in the Department of Allied Health Sciences, and director of the Institute for Collaboration on Health Intervention and Policy at the University of Connecticut in Storrs, Connecticut, told Medscape Medical News . 'Regardless of how people lose weight, they tend to regain the weight they lost. It starts quickly after initial treatment, and within 1-3 years, most have returned to their pretreatment weight,' she said. Biology plays a critical role. 'Because of biology — what we call metabolic adaptation to weight loss — the brain is always trying to push people back to their heaviest fat mass, unless they have tools like medicines or surgery,' said Gretchen Aames, PhD, clinical health psychologist and assistant professor of psychology in the Mayo Clinic College of Medicine in Jacksonville, Florida. 'I think that people underestimate the effort that it takes to keep the weight off,' she said. 'There's also psychology and behavior that's associated with weight management,' said Leahy, who added that continuous care strategies (ie, regular professional contact, skills training, and behavioral and social support sessions that are delivered biweekly and gradually tapered over time) can be costly. From Professional to Peer Support Leahy and her colleagues have conducted several studies examining the potential role that trained mentors (people who have previously faced and overcome a health situation) and 'peer dyads' (patient pairs initiating health behavior change matched to support one another) might play in helping individuals with obesity maintain initial weight loss. Their latest effort was a two-phase, proof-of-concept trial in which participants first received a 4-month online obesity treatment lifestyle intervention that was based on the National Diabetes Prevention Program (DPP). (DPP is a lifestyle change program designed to help prevent or delay diabetes in adults with prediabetes.) In phase 2, participants who achieved ≥ 5% weight loss were randomly assigned to an 18-month patient-provided weight maintenance program (n = 153) or to professionally delivered, 90-minute standard-of-care (SOC) sessions (n = 134) tapered over time. Participants' mean age was 53.6 years, and the majority (83.6%) were women. Patient-directed programs were delivered by two trained mentors who had previously lost ≥ 7% of body weight and kept it off for ≥ 1 year and who held 90-minute group sessions tapered over time. In the first seven sessions, the content was focused on peer training, empathic listening, and sandwich feedback (initiating feedback with a supportive comment, providing constructive suggestions or support, and ending with a supportive comment.) Peers were study participants who were randomly paired by gender and age range (18-30 years, 30-40 years); reciprocal support was composed of weekly progress reports and feedback exchanges delivered by text or email. 'We tried to match participants based on similarity and familiarity (ie, how much peers felt similar to or familiar with one another),' explained Leahey. 'We also did relationship development and induction activities (to create emotional closeness) and avoid conflict,' she said. Participants receiving the mentor/peer intervention were better able to maintain their weight loss compared with SOC participants (mean weight change at month 18: 0.77 [standard deviation, 0.46] kg vs 2.37 [standard deviation, 0.50] kg, respectively) throughout the trial. They also achieved significantly lower cardiovascular measures, namely diastolic blood pressure and resting heart rate, and engaged in significantly more physical activity. Are Mentor/Peer-Delivered Weight Maintenance Programs Ready for Prime Time? 'A lot of people don't have access to these maintenance interventions due to insurance access or availability of trained providers,' said Kathryn M. Ross, PhD, MPH, senior research scientist at Advocate Aurora Health Research Institute, Milwaukee, and author of the accompanying editorial. 'Looking into newer models that have more implementation potential, such as peer and mentor support, has a lot of potential.' Kathryn M. Ross, PhD, MPH 'But we don't know from one study if this is something that is ready to take country-wide in clinical practice,' she said. 'It's also unclear which components of the patient-delivered program are critical for successful implementation.' A key element is training. Leahey emphasized that the researchers continued to refine the training model study by study, eventually landing on factors like age, gender, and empathic listening and feedback strategies that encouraged compassion and cohesiveness. 'I have some patients doing this for me,' said Nida Latif, MD, a family practitioner and obesity specialist running a private practice in Westland, Michigan, and spokesperson for the Obesity Medicine Association, pointing to one in particular. 'She achieved a lot of success (she had bariatric surgery in her 30s and is now in her 60s; she has maintained a BMI of 27-28, from a BMI of 50), she reversed her diabetes and atrial fibrillation and is off all blood pressure medications,' said Latif. Though Latif said that the patient is a great advocate and has taken some of the burden off her shoulders in terms of time and resource utilization, she emphasized the need for professional oversight. 'Every so often, I have to harness her back. She's come so far that she's forgotten how difficult the change process is. I help her understand that it's a slow process. I identify struggles, the importance of helping patients change just one habit over a period of three to four weeks so they become more consistent,' said Latif. 'Even if it's someone who has had success, they need to adjust to whomever they're trying to help. And touch base with me every so often to discuss challenges.' Chronic Disease and Chronic Maintenance An important challenge to weight loss maintenance is the disease itself. Though a chronic illness, obesity is not always accepted as such by physicians or insurers, leaving patients to grapple with weight cycling on their own. Gretchen Aames, PhD 'If you have to leave your biases at the door,' said Aames. 'There are studies that show that the prevailing thought among primary care physicians and nurses is that weight loss is the patient's responsibility: Eat less, move more. Instead, they should take the time to figure out what their patients know, what they've tried, and things that are sustainable,' she said. 'Maybe they need a little bit of coaching and information and can run with it. Others will need more. We don't know enough yet who is the right person for the peer strategy or the critical components of this type of intervention that will help people.' For now, physicians might want to help patients build their own support networks to help them keep on track without having to try to set something up within an already time- and resource-crunched practice, said Ross. Locally run DPP programs (eg, by the Young Men's Christian Association or churches) are a good starting point. The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Leahey, Ross, Aames, and Latif reported no relevant financial relationships.
Medscape
an hour ago
- Medscape
Training Reduces Clinicians' Obesity Bias, Improves Practice
Many healthcare providers (HCPs) harbor bias against people with excess weight or obesity, and that stigmatization can negatively affect patient care. Now, an innovative two-endpoint continuing medical education (CME) initiative has shown that clinicians can change when brought face to face with their negative attitudes and less than optimal referral behaviors regarding patients with obesity. Amanda Velazquez, MD Reporting in the Journal of General Internal Medicine, researchers led by Amanda Velazquez, MD, of the Center for Weight Management and Metabolic Health and the Jim and Eleanor Randall Department of Surgery at Cedars-Sinai Medical Center in Los Angeles, found a 4-hour CME program, conducted in April 2021, significantly reduced HCPs' self-reported negative stereotypes compared with baseline. Self-reported empathy and confidence in caring for patients with obesity significantly increased immediately post intervention and endured at 4- and 12-month follow-up. Additionally, the 4-hour symposium led to objectively improved diagnosis and referral to obesity care for patients treated across different specialties. 'There is considerable gap in the education of healthcare professionals about obesity,' Velazquez told Medscape Medical News , adding that established data have confirmed the existence of anti-weight bias among HCPs. 'Our study was unique in that it had a broad target group and invited professionals across all specialties from plastic surgeons and Ob/Gyns to nurses and emergency medical technicians. Our goal was to move the needle toward greater comfort in referring their patients to appropriate obesity management.' She noted that excessive weight exacerbates many conditions treated outside of obesity medicine, such as psoriasis, cardiometabolic disease, and impaired fertility. The Intervention Conducted at a single site in the Kaiser Permanente Southern California healthcare system, the symposium invited a diverse population of 472 eligible HCPs. Weight Bias: Weight bias was assessed by a 16-item questionnaire originally developed for medical students by Robert F. K ushner and colleagues, designed to assess negative prejudicial beliefs about patients with obesity. This measure captured three types of weight bias: negative obesity stereotypes (eg, 'Individuals with obesity have themselves to blame'); empathy for patients (eg, 'People with obesity feel stigmatized by the medical profession'); and confidence in clinical interaction with patients with obesity (eg, 'I feel comfortable talking to people about their weight'). As a result of the program, negative obesity stereotypes among attendees, according to the post-program questionnaire, were significantly reduced over baseline levels (2.81 ± 0.47 vs 2.50 ± 0.46; P < .001), while both their empathy (3.33 ± 0.64 vs 3.47 ± 0.63; P = .006) and confidence (3.10 ± 0.86 vs 3.85 ± 0.79; P < .001) significantly increased. Practice Patterns: Behavioral outcomes of interest, according to electronic medical records, were participants' objective practice changes regarding obesity diagnosis and referrals to healthy lifestyle programs, obesity medicine, and bariatric surgery. Comparative analyses were done for 218 attendees and 89 nonparticipants. After adjustment for years in practice, race/ethnicity, gender, profession type, practice type, and panel size, HCPs who attended the program had significantly increased odds of obesity diagnosis and obesity-related referrals in the 12 months following the intervention vs those not attending. Specifically, compared with nonattendees, participants had increased odds of changes across several measures. Diagnosing obesity: odds ratio [OR], 1.60; (95% CI,1.54-1.66); referring patients to healthy lifestyle programs: OR, 1.27 (95% CI, 1.19-1.36); and referrals to an obesity medicine specialty clinic: OR, 1.87 (95% CI, 1.63-2.14). For patients with a BMI ≥ 35, the post-intervention OR for referral to bariatric surgery was 2.12 (95% CI, 1.70-2.67) in the 12 months following the intervention. The comparison group's odds either decreased or did not change. As to participation by profession type, physicians were the most likely to attend, with physicians from family medicine, internal medicine, and obstetrics/gynecology more likely to participate than those from orthopedics and ophthalmology. While Velazquez was not surprised by the level of anti-weight bias the symposium revealed, she was not prepared for the magnitude of objective change it effected in practice patterns. 'The increase in the number of referrals to obesity care was so overwhelming, we had to change the BMI eligibility criterion to handle the influx,' she said. With referrals to the obesity clinic doubling, the threshold for new referrals was raised from BMI ≥ 30 to BMI ≥ 35 to address the overwhelming demand. Leslie Heinberg, PhD Offering a nonparticipant's perspective on the intervention, Leslie Heinberg, PhD, a professor of medicine and vice chair for psychology in the Department of Psychiatry and Psychology at the Cleveland Clinic in Cleveland, called it 'an interesting and comprehensive study that goes beyond previous work in attitudinal change to look at change in actual practice behavior around obesity.' She was not surprised at the shift in attitude immediately after the symposium. 'We all know the right answers to give, but the change in attitudes persisted long after the intervention,' In her practice, patients often report experiencing weight stigma during interaction with their HCPs. 'But healthcare should be sensitive to patients across the entire weight spectrum.' Heinberg noted HCPs typically get little or no training in obesity issues, including the psychological aspects of this complex multifactorial condition. 'They might get one lecture during training, but 40% of the patients they treat will have obesity,' she said. Training is needed in how to talk to patients about excess weight. Her institution requires all new hires in any clinical capacity to have on-boarding training in obesity bias, with a yearly refresher course as well. Carolynn Francavilla, MD, an obesity medicine specialist and owner of Green Mountain Partners for Health in Lakewood, Colorado, also applauded the study. 'As someone who dedicates a significant amount of my time to developing CME and educating clinicians, I find it very encouraging that this study was able to demonstrate both reduced weight bias and improved referrals for care,' she told Medscape Medical News. 'While most physicians are now aware of treatment options, many do not understand the chronic nature of the disease and many still believe that willpower is enough to treat obesity.' The authors concluded that a focused CME intervention aimed at mitigating HCPs' weight bias and behavior can lead to improved diagnosis and referral to the full range of current options in obesity care. 'We're hoping to apply the intervention in other groups to see if it has the same positive impact on practice,' Velazquez said. 'But it will need some updating since the original interventions was conducted in 2021 before the explosion of GLP-1 therapy.' Future research should focus on integrating obesity pharmacotherapy into the CME content and further examining practice behaviors. 'In addition to a randomized trial of the intervention, future research should also assess longitudinal practice changes beyond 1 year, the authors wrote.
