• Healthcare Triage: Firearms and Suicide – Guns and Public Health Part 3

    We continue our special look at guns and public health in the United States. This week, we’re looking at how easily accessible firearms complicate the suicide rate in the United States. While people have always committed suicide, guns certainly make suicide attempts a lot more likely to succeed. Once again, there are things we can do to mitigate this.

    This series was produced with support from the NIHCM Foundation.

    Further reading:


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  • Preventing Teen Suicide: What the Evidence Shows

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

    Rates of teen suicide continue to rise, federal health officials reported this month, with rates for girls higher than at any point in the last 40 years. A rational response would be to engage in evidence-based measures to try to reverse this course. Too often, we assume that there’s nothing we can do.

    Sometimes, we even make things worse.

    Suicide rates were even higher in the 1990s. But from 2007 to 2015 rates rose from 10.8 to 14.2 per 100,000 male teenagers and from 2.4 to 5.1 per 100,000 female teenagers. In 2011, for the first time in more than 20 years, more teenagers died from suicide than homicide.

    But these trends have been known for years. Our response to them hasn’t adequately acknowledged their progression.

    There are evidence-based ways to prevent suicide. The World Health Organization has a guide for how media professionals should talk about the subject. They should avoid sensationalizing it or normalizing it. They should be careful not to repeat accounts of suicide or to provide explicit descriptions as to how suicide might be attempted or completed. They should word headlines carefully, and avoid video or photos of suicides or the victims.

    The Centers for Disease Control and Prevention has an evidence-based guide on how to prevent suicide as well. There are things the government can do, including strengthening economic supports, making sure families are more financially secure and have stable housing. The health care system needs to strengthen access to and delivery of mental health care, as well as improve our ability to identify and support teenagers at risk.

    There are things we as a society can do as well. We need to make things safer for teenagers, which includes reducing their access to the means they might likely use in a suicide attempt. Also important but more difficult, we need to promote connectedness and limit isolation. The best thing we can do for teens at risk is to prevent them from cutting themselves off from others.

    We have been failing to meet these goals too often when it comes to the media, guns and community.

    The most public discussion around suicide this year centered on the Netflix series “13 Reasons Why,” adapted from the book of the same title. Supporters of the series argued that the show brought attention to teen suicide, and that it prompted more discussions of the issue — which would be a good thing. Many experts were concerned that the series glamorized suicide, though. They were especially concerned because the producers chose to show the suicide in a long three-minute scene, where the protagonist slit her wrists in a bathtub. In the book, she overdoses on sleeping pills, and it takes place “offscreen.”

    Research shows that when the media focuses on the suicide of an entertainment or political celebrity, the copycat effect is much larger. This is even more true when the media focuses on the means by which the suicide occurred. Granted, there’s less of an effect when the suicide is fictional, but even then, it’s associated with more than a quadruple increase in a copycat effect.

    Researchers recently published a study that examined the series’s apparent effect on internet searches about suicide. “13 Reasons Why” generated more than 600,000 news reports. In the 19 days after its release, searches about suicide were about 19 percent higher than expected. As hoped, some searches for things like “suicide hotline,” “suicide prevention” and “teen suicide” went up. But so did searches for “commit suicide,” “how to commit suicide” and “how to kill yourself.” The long-term effects of this are unclear, but are certainly concerning enough to monitor.

    Our inability to address the issue of guns exacts a cost. There are about twice as many suicides annually using guns (more than 21,000 in 2014) as there are homicides using guns. Almost none of the guns used in suicides are assault weapons, and yet that seems to be the singular focus of many activists. In about 45 percent of suicides among those age 15 to 24, guns were used.

    Those who might counter that people who want to kill themselves would find other ways if we limited their access to guns ignore evidence about suicide. Research shows that most suicides are impulsive. Studies of people who came close to dying from suicide attempts, but lived, show that about one-quarter went from deciding to kill themselves to making the attempt in less than five minutes. Almost three-quarters of them took less than an hour.

    Having access to guns can make a big difference, because they are devastatingly efficient. Suicide attempts by gun succeed more than 85 percent of the time; attempts by overdose or poisoning succeed less than 2 percent of the time. Meta-analyses show that access to a firearm increases one’s odds of a successful suicide by more than a factor of three.

    While we can debate the relative merits of making it easier or harder to own a gun, it’s clear that guns should be kept out of the hands of children.

    Finally, we are allowing teenagers to become more withdrawn from others. The Monitoring the Future study has been looking at the behaviors, attitudes and values of American high school students for decades. I pulled data from their archives for 2007 through 2015, specifically looking at high school seniors. In 2007, only 25 percent of them reported going out on dates one or fewer times a month — three-quarters were more social than that. In 2015, the percentage of people reporting one date or fewer in a month had risen to 36 percent. In 2007, the percentage of people who reported going out for fun and recreation one or fewer times per week was 46 percent. By 2015, that had risen to 59 percent.

    In an article in The Atlantic, and in a new book, Jean Twenge argues that smartphones and social media have disconnected teenagers from society. Others fear the internet in general also may be doing the same or increasing the potential for bullying without immediate repercussions. I’m not sure we can lay as much of the blame on technology as they do, but all of these data make a strong argument that teenagers are more isolated and at higher risk than before.

    We need to talk about suicide in ways that help, not harm. We need to make sure young people have no access to guns. And we need to make sure they are connected enough to each other, to family, and to the health care system so that those at risk can be recognized and given the care they need. The rising toll shows we should not ignore this problem, or pretend that it’s just too hard.


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  • Coverage expansion and primary care access

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company) while I was on vacation.

    When you have a health problem, your first stop is probably to your primary care doctor. If you’ve found it harder to see your doctor in recent years, you could be tempted to blame the Affordable Care Act. As the health law sought to solve one problem, access to affordable health insurance, it risked creating another: too few primary care doctors to meet the surge in appointment requests from the newly insured.

    Studies published just before the 2014 coverage expansion predicted a demand for millions more annual primary care appointments, requiring thousands of new primary care providers just to keep up. But a more recent study suggests primary care appointment availability may not have suffered as much as expected.

    The study, published in April in JAMA Internal Medicine, found that across 10 states, primary care appointment availability for Medicaid enrollees increased since the Affordable Care Act’s coverage expansions went into effect. For privately insured patients, appointment availability held steady. All of the gains in access to care for Medicaid enrollees were concentrated in states that expanded Medicaid coverage. For instance, in Illinois 20 percent more primary care physicians accepted Medicaid after expansion than before it. Gains in Iowa and Pennsylvania were lower, but still substantial: 8 percent and 7 percent.

    Though these findings are consistent with other research, including a study of Medicaid expansion in Michigan, they are contrary to intuition. In places where coverage gains were larger — in Medicaid expansion states — primary care appointment availability grew more.

    “Given the duration of medical education, it’s not likely that thousands of new primary care practitioners entered the field in a few years to meet surging demand,” said the Penn health economist Daniel Polsky, the lead author on the study. There are other ways doctor’s offices can accommodate more patients, he added.

    One way is by booking appointment requests further out, extending waiting times. The study findings bear this out. Waiting times increased for both Medicaid and privately insured patients. For example, the proportion of privately insured patients having to wait at least 30 days for an appointment grew to 10.5 percent from 7.1 percent.

    The study assessed appointment availability and wait times, both before the 2014 coverage expansion and in 2016, using so-called secret shoppers. In this approach, people pretending to be patients with different characteristics — in this case with either Medicaid or private coverage — call doctor’s offices seeking appointments.

    Improvement in Medicaid enrollees’ ability to obtain appointments may come as a surprise. Of all insurance types, Medicaid is the least likely to be accepted by physicians because it tends to pay the lowest rates. But some provisions of the Affordable Care Act may have enhanced Medicaid enrollees’ ability to obtain primary care.

    The law increased Medicaid payments to primary care providers to Medicare levels in 2013 and 2014 with federal funding. Some states extended that enhanced payment level with state funding for subsequent years, but the study found higher rates of doctors’ acceptance of Medicaid even in states that didn’t do so.

    The Affordable Care Act also included funding that fueled expansion of federally qualified health centers, which provide health care to patients regardless of ability to pay. Because these centers operate in low-income areas that are more likely to have greater concentrations of Medicaid enrollees, this expansion may have improved their access to care.

    Other trends in medical practice might have aided in meeting growing appointment demand. “The practice and organization of medical care has been dynamic in recent years, and that could partly explain our results,” Mr. Polsky said. “For example, if patient panels are better managed by larger organizations, the trend towards consolidation could absorb some of the increased demand.”

    Although the exact explanation is uncertain, what is clear is that the primary care system has not been overwhelmed by coverage expansion. Waiting times have gone up, but the ability of Medicaid patients to get appointments has improved, with no degradation in that aspect for privately insured patients.


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  • Healthcare Triage: Homicide and Firearms – Guns and Public Health Part 2

    Let’s be clear. The biggest thing people worry about with guns in the US is homicide. There are lots of ways to look at the data, and most don’t make the US look very good. Prepare for a deep dive.

    This series was produced with support from the NIHCM Foundation.

    Further reading:


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  • Drugs that go through FDA’s expedited review might be better drugs

    A new paper in the latest issue of Health Affairs is worth a look. “Drugs Cleared Through The FDA’s Expedited Review Offer Greater Gains Than Drugs Approved By Conventional Process“:

    We investigated whether drugs approved by the Food and Drug Administration (FDA) through expedited review have offered larger health gains, compared to drugs approved through conventional review processes. We identified published estimates of additional health gains (measured in quality-adjusted life-years, or QALYs) associated with drugs approved in the period 1999–2012 through expedited (seventy-six drugs) versus conventional (fifty-nine) review processes.

    The FDA has a strict process for drug approval, requiring a number of phases of testing to establish safety and efficacy. It can, however, expedite this process when it thinks a drug may address an unmet clinical need. Of course, you want such a process to be fair and work. You want it to be focused on “better” and “more important” drugs. The 21st Century Cures Act moved even further. Some worry that loosening standards will lead to increased exposure to harm, especially if there isn’t proof that these drugs provide more benefits.

    Enter this study:

    We developed a data set of incremental QALY gains associated with drugs the FDA included in the expedited review programs and those the FDA did not include. We used drug-indication pairs as the unit of analysis. In other words, when incremental QALY data were available for a drug for multiple indications, each indication was included separately in the data set. We previously used this data set and a similar methodological approach to compare the incremental health gains associated with specialty and traditional drugs

    They then identified all new molecular entities approved by the FDA from 1999-2012, separating them into those that did and did not use the expedited process.

    They found that drugs that used at least one expedited review program (there are four) offered greater gains than those that did not (0.182 vs 0.003 QALYs). When they looked at the individual programs, there were differences in three of the four: priority review (0.175 vs 0.007 QALYs), accelerated approval (0.370 vs 0.031 QALYs), and fast track (0.254 vs 0.014 QALYs).

    There are limitations to this, of course. Not all drugs have QALY estimates, and those without can’t be studies. To be honest, I was surprised so many did. Clearly there are some other biases here as well – positive QALY outcomes are more likely to be published and pushed, especially by industry. QALY’s also aren’t perfect, but I’m not going to fault them for using an accepted standard.

    Bottom line: This is evidence that drugs in expedited programs seem to have larger QALY gains than those in the conventional process. Drugs in more programs have bigger gains. The FDA program appears to be working. That doesn’t mean we should stop looking and evaluating, but we should acknowledge the apparent success of the process.


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  • Healthcare Triage News: The Trump Administration Has Many Options to Undermine Obamacare

    While the Senate and the House haven’t been very effective in passing a repeal of Obamacare, the ACA’s provisions are still at risk. There’s a lot that Donald Trump’s administration can do (or not do) to undermine Obamacare’s provisions and marketplaces.


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  • Music therapy for austism spectrum disorder: it’s murkier than you might think

    Let’s start with the fact that there’s a good Cochrane review on music therapy for people with autism spectrum disorder. It included ten studies of 165 participants, all RCTs or controlled trials, that compared music therapy to placebo or standard care. Music therapy did well:

    The findings of this updated review provide evidence that music therapy may help children with ASD to improve their skills in primary outcome areas that constitute the core of the condition including social interaction, verbal communication, initiating behaviour, and social-emotional reciprocity. Music therapy may also help to enhance non-verbal communication skills within the therapy context. Furthermore, in secondary outcome areas, music therapy may contribute to increasing social adaptation skills in children with ASD and to promoting the quality of parent-child relationships.

    But these were small studies, and the outcomes didn’t overlap between them often, and some people still had questions.

    Enter the TIME-A RCT. Just published, it’s a randomized trial of 364 kids in 9 countries. It was assessor blinded, and it had reasonably strict entry criteria. It used a widely accepted primary outcome, the Autism Diagnostic Observation Schedule (ADOS). Outcomes were assessed at 2, 5, and 12 months.

    Everyone got “enhanced care”, which was usual care plus parent counseling. The intervention group also got improvisational music therapy, where trained therapists sang or played music with each child, to encourage affect sharing and joint attention.

    Most of the kids (86%) completed the primary end point of 5 months, and most completed the last end point (80%). Over the primary intervention period, kids got a median 19 sessions of music therapy in addition to other care.

    In the music therapy group, the ADOS social affect scores improved from 14.08 to 13.23. In the control group, they improved from 13.49 to 12.58. No difference. Of the 20 exploratory secondary outcomes, 17 showed no difference as well.

    You can scream “one trial!” and you’d be right. But this one trial was larger than all the other trials put together and then doubled. You can scream that it didn’t test every type of music intervention, and you’d be right. But it was pretty pragmatic and well thought out.

    Most of those previous trials were limited to one local area and one therapist. How generalizable were they? This was multicenter and multicountry.

    In 2017, there were about 7000 music therapists in the US. I’m sure they won’t like these results.

    The accompanying editorial is fair. It makes balanced arguments both for and against continued focus on musical therapy. I’m going to be honest and say that I fall into the “doesn’t seem to work” camp now. I say that because recognizing how common ASD is, and how important it is to intervene, I want to see time and money go to things that work, not where they might not.

    Regardless, whether we do more trials in this area, or abandon music therapy is up to the ASD research and patient communities. Supporters should be pushing for more research, though, not more money to therapies that lack a good evidence base.


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  • NEJM: Partial Medicaid Expansions Under the ACA

    Nick Bagley, Allan Joseph, and I have a new perspective piece up at the New England Journal of Medicine evaluating implications of Arkansas’s latest waiver application. Among other proposals, the state has requested to move to a “partial expansion” model, shifting the population with incomes between 100 and 138% FPL from Medicaid into the exchanges.

    Multiple states proposed partial (or phased-in) expansions before the ACA’s coverage provisions took effect, but the Obama administration rebuffed these efforts.

    Why were states interested in these partial expansions? Starting in 2020, states are responsible for covering 10% of the costs associated with the Medicaid expansion. Because of a drafting mistake, however, the ACA says that the 100-to-138 population can receive subsidies to purchase a private health plan on the exchanges — but only if they are ineligible for Medicaid. For those people, the federal government bears the entire cost of subsidizing private coverage, with no contribution from the states. As a result, the states save money for every beneficiary whom they can move from Medicaid into their exchanges.

    Though the justification against partial expansion was legal in nature—CMS contended at the time that the ACA “does not provide for” limited or phased-in expansions—the current administration might perceive broader flexibility.

    Now that repeal of the ACA’s Medicaid expansion seems unlikely, will the Trump administration allow partial expansions? Arkansas’s waiver request will force an answer to that question. Because Arkansas is already operating under a unique waiver that allows it to enroll Medicaid beneficiaries in exchange plans, partial expansion would have relatively muted effects in the state: it would just rejigger state–federal financing arrangements. Nonetheless, acceding to Arkansas’s request would set a precedent with extraordinary practical, budgetary, and political consequences.

    The budget-gimmicky nature of partial expansion is laid bare in the special case of Arkansas, which already enrolls its expansion population in exchange plans, using Medicaid dollars. Moving the enrollees more formally into the exchange primarily serves to remove state dollars from the funding equation. And in service of this goal, partial expansion imposes greater cost-sharing on beneficiaries while eliminating certain Medicaid-specific protections, like presumptive and retrospective eligibility. If the administration approves Arkansas’s request, they will be hard-pressed to reject similar waivers from other states, who will see the same budgetary appeal.

    You can read the whole thing here.

    Waivers are a matter of administrative discretion, but widely-implemented partial expansions could prove harder to unwind than other changes sought by states. Though they were beyond the scope of our piece, Arkansas’s waiver application—as well as applications from other states—would limit Medicaid enrollment in other ways, by imposing work requirements and strictly narrowing or eliminating presumptive and retrospective eligibility. Absent further congressional action, Medicaid waiver decisions will be among the most consequential health policy developments in the coming months.

    I would like to acknowledge and thank Dave Anderson of Duke University and the Balloon Juice blog, who helped me navigate 2017 premium data (from which I was able to extract cost-sharing information for plans with cost-sharing reductions). Also, for completeness: due to editorial constraints, we weren’t able to include a sixth citation for the analysis comparing exchange premiums in expansion and non-expansion states, which was published by ASPE in 2016. 

    Adrianna (@onceuponA)

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  • The Bad Food Bible – Preorder Now!

    I’ve mentioned it a number of times before, but let this post be the official notice: I have a new book being published on November 7. It grew out of some of my columns over at the Upshot about food (which also happen to be some of my most popular). From the description of the book:

    Advice about food can be confusing. Experts seem to only agree on one thing: some ingredients—often the most enjoyable ones—are bad for you, full stop. But as physician Aaron Carroll explains, if we stop consuming some of our most demonized foods, it may actually hurt us. Examining troves of research about dietary health, Carroll separates hard truths from sensationalized hype, showing that you can:

    • Eat meat several times a week: Its effects are negligible for most people, and arguably positive if you’re 65 or older.
    • Have a drink or two a day: In moderation, alcohol may protect against cardiovascular disease without much risk.
    • Enjoy a gluten-loaded bagel from time to time: It has less fat and sugar, fewer calories, and more fiber than a gluten-free one.
    • Eat more salt: If your blood pressure is normal, you may be getting too little sodium, not too much.

    Full of counterintuitive lessons about food we hate to love, The Bad Food Bible is for anyone seeking eating habits that are sensible, sustainable, and occasionally indulgent.

    You can preorder the book at any of the below:

    It goes without saying that I would love for you to buy it. Preorder it so you are assured to have it on the day of publication!


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  • Answering questions about Medicare Advantage

    Readers asked some questions about my most recent piece on Medicare Advantage. Here they are, with my answers.

    1. Isn’t it true that the government pays Medicare Advantage plans a lot less today than they did in 2010, the year of focus of the study you wrote about?

    Almost! According to government statistics, in 2010, Medicare Advantage plans received payments from the Medicare program equivalent to 113 percent of what it would cost a similar beneficiary to be covered by the traditional program. In 2017, that figure is 100 percent, but grows to 104 percent if you more accurately account for differences in the health of Medicare Advantage enrollees and traditional Medicare beneficiaries.

    2. If the government is now paying the same (or almost the same) for an enrollee in Medicare Advantage as for a traditional Medicare beneficiary, what’s the problem?

    Well, some believe that we should be taking advantage of market efficiency to save the government money, which was part of the original motivation for including private plan alternatives in Medicare. One key point of my piece was to compare what Medicare Advantage plans receive from the government to what it costs the plans to provide care, including marketing, administration, and profit as well. On that basis, in 2010, the plans received 8.5 percent more in government revenue than their costs. In 2017, that figure is 11 percent. What this means, as I wrote, is that Medicare Advantage plans are more efficient at managing care than the traditional program, but that taxpayers aren’t benefiting from that efficiency as much as they could be.

    3. Where does that extra money go?

    Medicare Advantage plans are supposed to use the additional revenue to enhance their benefits — either by providing coverage for things traditional Medicare does not cover (e.g., eyeglasses and hearing aids) or by reducing cost sharing. There is no doubt plans do this, as I wrote in my piece. And this is of tremendous benefit to enrollees, particularly lower income ones that cannot afford a supplemental plan to fill in the gaps in traditional Medicare.

    A post on the Health Affairs blog documents in greater detail the kinds of additional benefits Medicare Advantage plans provide, beyond what’s covered by traditional Medicare. Just over half get basic dental benefits, three-quarters get eye exam coverage, just under half get a hearing aid benefit, and about one-third get help paying for gym memberships. The vast majority of Medicare Advantage enrollees that get these benefits, and others, do so with no additional premium.

    But there is some doubt that plans provide additional benefits like these as efficiently as they could. Because the Medicare Advantage market is not as competitive as it might be, studies have shown that plans may pay more for benefits than they should, and enrollees receive less value from them than their costs. However, it’s also the case that the Affordable Care Act limits Medicare Advantage spending on things like marketing, management, and profit to 15 percent of revenue.

    4. Isn’t it true that sicker patients tend to leave Medicare Advantage?

    Yes. This is something I wrote about in another Upshot post. Because Medicare Advantage plans have networks, enrollees are not covered for just any doctor they wish. Medicare Advantage plans may also impose other restrictions on care, like requiring prior authorization for some services. For sicker patients, such practices impose a heavier burden, because they need more care and see more doctors. Some of those patients choose to leave Medicare Advantage and return to the traditional Medicare program, which has an open network and does not attempt to manage care.

    5. So, given all this, what is the value of Medicare Advantage?

    Medicare Advantage plans have been found to be of higher quality than traditional Medicare. They also reduce wasteful use of health care by managing care, something the traditional program doesn’t do at all. Finally, they fill in gaps in coverage and cost sharing of the traditional program. They’re able to do so when the traditional program is not because changing traditional Medicare would require legislation, and it’s hard to achieve political consensus on anything in health care these days.

    The bottom line is that Medicare Advantage plans offer choices that some beneficiaries value. They can deliver the Medicare benefit more efficiently and with higher quality. Yet, taxpayers do pay more to plans than they could, given plans’ own costs. Paying less might mean plans leave the market and that enrollees get less. There are always tradeoffs.


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