• Healthcare Triage: Marijuana

    I’ll be honest. I was a bit nervous about this one. But I stand by it:

    There’s just no way to talk about marijuana without someone completely misinterpreting what I say. Some of you are going to call me a fascist for saying anything bad about pot. Others are going to attack me for not coming down on it hard enough. But the truth of the matter is that many things that are far more dangerous than pot are totally legal in this country. That’s not my opinion, it’s what scientific studies show us. No one is saying marijuana is totally safe. But is it so bad for you that it should be illegal, even though it has benefits? Watch and decide. Happy weed day.

    For those of you who came here looking for references, here they are:

    Additionally, we do know about this study, which came out long after we taped. But as with a lot of research, it’s being totally misinterpreted by the media. Here’s a nice article where the author of the study says the same thing.


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  • Icosahedron prints

    Via Architecture of Doom:



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  • A reader’s response on Medicare Advantage payment rate changes

    Responding to my post on Medicare Advantage payment rate changes, Edwin Park wrote me with some important corrections, for which I am grateful:

    We don’t think it is quite correct to characterize the Administration as failing to uphold the scheduled payment cuts. The changes to the county benchmarks for 2015 required under the ACA as well as the required coding intensity adjustment for purposes of risk adjustment required under the ACA (as modified by the 2012 budget agreement) all took effect as scheduled.

    What the Administration did do was delay or modify fixes to make the risk adjustment system more accurate, which CMS periodically puts in place and would likely have considered and implemented with or without health reform (as they were not mandated by the ACA). Because Medicare Advantage plans tend to enroll healthier-than-average beneficiaries than those in traditional Medicare, a less accurate risk adjustment system doesn’t do as good a job of accounting for these health differences, so it will result in higher payments to Medicare Advantage plans in 2015 than would otherwise be the case.

    The three major changes from the February preliminary announcement to the final announcement were: delaying/reversing the transition to a new risk adjustment model, not prohibiting insurers’ use of home assessments to determine diagnoses for purposes of risk adjustment for another year — which CMS believes insurers are using to inappropriately increase risk scores — and modifying how to take into account the influx of healthier 65 year olds as a result of the retirement of the baby boom generation. (In our view, the preliminary announcement’s proposals to continue the transition to the new risk adjustment model and to prohibit the use of home assessments were sound policies and thus should be instituted as part of next year’s payment announcement for 2016. We are not sure about the merits of the third change related to accounting for the enrollment of baby boomers turning age 65; CMS is now instituting a non-linear adjustment and adding an additional base year.)

    These changes all had the effect of increasing the total payments plans would have otherwise received under the original preliminary announcement in February. While the Administration states that this would produce an overall payment increase of 0.4 percent compared to 2014, industry analysts claim there will still be a net reduction in payments in 2015. And it’s important to remember that much of the county benchmark reductions have already been phased in (the only county benchmarks still phasing in for 2015 were those in counties given a six year transition). We know that Medicare Advantage overpayments are being reduced as intended by the ACA, going from about 114 percent of traditional Medicare costs for comparable beneficiaries in traditional Medicare in 2009, on average, to 106 percent in 2014, according to MedPAC in its recent March 2014 report.

    This is probably why, as our blog post from last week notes, some leading Senate and House Republicans welcomed the Administration’s policy changes in the final payment announcement but then immediately demanded repeal or scaling back the ACA’s MA provisions as well.

    For all that, money is fungible. Though the ACA-mandated cuts are being implemented on schedule, it’s also true that they further motivate the industry to push back on Medicare Advantage cost cutting. There is an appearance that the changes CMS did make were to somewhat cushion that blow. But, I have to admit, the counterfactual is unknown. Maybe CMS would have made these changes anyway. 


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  • I think this study about milk is trolling me

    From PLOS ONE, “Chocolate Milk Consequences: A Pilot Study Evaluating the Consequences of Banning Chocolate Milk in School Cafeterias”:

    Objective: Currently, 68.3% of the milk available in schools is flavored, with chocolate being the most popular (61.6% of all milk). If chocolate milk is removed from a school cafeteria, what will happen to overall milk selection and consumption?

    Methods: In a before-after study in 11 Oregon elementary schools, flavored milk–which will be referred to as chocolate milk–was banned from the cafeteria. Milk sales, school enrollment, and data for daily participation in the National School Lunch Program (NSLP) were compared year to date.

    Results: Total daily milk sales declined by 9.9% (p<0.01). Although white milk increased by 161.2 cartons per day (p<0.001), 29.4% of this milk was thrown away. Eliminating chocolate milk was also associated with 6.8% fewer students eating school lunches, and although other factors were also involved, this is consistent with the notion of psychological reactance.

    Conclusions: Removing chocolate milk from school cafeterias may reduce calorie and sugar consumption, but it may also lead students to take less milk overall, drink less (waste more) of the white milk they do take, and no longer purchase school lunch. Food service managers need to carefully weigh the costs and benefits of eliminating chocolate milk and should consider alternative options that make white milk more convenient, attractive, and normal to choose.

    A bunch of schools eliminated chocolate milk from their cafeterias because it has extra sugar in it. When the schools did, the kids wound up buying less milk overall. The results of the study found that “removing chocolate milk from school cafeterias may reduce calorie and sugar consumption”. It also led students to “take less milk overall”.

    But this is presented as a BAD thing. They advise food service managers to consider whether it’s worth eliminating chocolate milk and to consider options that make white milk more “convenient” and “attractive”.

    WHY? The milk industrial complex strikes again…


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  • A reader’s response on Census survey changes

    Responding to Aaron’s post about changes to the Census’ survey methodology that will make it difficult to measure the impact of the ACA, Genevieve Kenney wrote me to remind us that there are many other good survey sources:

    I know you are thinking about what might be lost/gained as the CPS [Current Population Survey] adopts a new approach to measuring health insurance coverage. In considering what we’ll know from the federal surveys and how we’ll be able to assess the role that the ACA is playing in affecting coverage, I think it’s important to step back and consider the full array of federal surveys that will be available to provide information on how insurance coverage and related outcomes is changing over time. While the CPS was one source of information on how the expansion of dependent coverage to young adults under the ACA affected coverage, the NHIS [National Health Interview Survey] and the SIPP [Survey of Income and Program Participation] were also used to addressed that issue. Likewise, the ACS [American Community Survey], not the CPS was used to assess the coverage effects of the early Medicaid expansions under the ACA and the BRFSS [Behavioral Risk Factor Surveillance System] has been used to examine the impacts of a number of prior Medicaid expansions. While I would have preferred that Census introduce the change to the survey instrument using a split sample approach so that there would be a bridge from the past to the new regime, it will be a relief to move away from the messy measurement issues that were inherent in the CPS.

    We will have a lot more confidence that we have a handle on how coverage is changing and what is driving those changes if we observe the same patterns across different surveys.

    As I put it some email or other, the lights may have dimmed a little, but they have not gone out.



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  • We’re all a little wrong about Obamacare

    In a post I recommend you read in full (it’s not long), Ross Douthat puts a valid question on the table: by what metrics ought we judge Obamacare? He then goes through some possible enrollment, cost, and outcomes metrics that (some) supporters really did claim would be improved by the law. He ends with something of a proposition:

    I’ll lay down this marker for the future: If, in 2023, the uninsured rate is where the C.B.O. currently projects or lower, health inflation’s five-year average is running below the post-World War II norm, and the trend in the age-adjusted mortality rate shows a positive alteration starting right about now, I will write a post (or send out a Singularity-wide transmission, maybe) entitled “I Was Wrong About Obamacare.”

    It is fair to hold Obamacare supporters accountable for their claims. And I don’t think Douthat is wrong that the administration and its surrogates made the claims he lists. I just don’t, personally, think those were all reasonable claims to have been made. Many of them, and much of the debate, is far more politically salient than policy relevant. Correspondingly, my set of metrics for judging policy success would be (is) different.

    Enrollment. Douthat draws on CBO projections of enrollment and reductions in uninsured as benchmarks of success. There are two problems with this. First, CBO projections are not designed to be aspirational. To be sure, one can take them up as such—and the administration did so—but that was not wise, in my view.

    That leads to the second problem. Overall enrollment is a lousy benchmark, because it doesn’t tell you anything about the stability of the program at the level at which it matters: state-level markets. (I’ll get to reduction in uninsured below.) For state-level insurance markets to function, what’s needed is a mix risk that’s not too far off what insurers expected and for which they priced products. This is necessary for state-level market stability, which is a good policy metric. Related, one would like to see a “good” level of competition in exchanges, with more than a few insurers participating and dominating. My economist colleagues in industrial organization can devise myriad, decent metrics for this, none of which rely on a national, total enrollment figure.*

    The cost curve. Again, Douthat is right that claims were made about cost reductions. And, again, I think it was unwise to have made them, just as it’s unwise to claim that the recent downturn in health care cost growth can be attributed to Obamacare or will continue. Fundamentally, nobody knows how to, reliably and in a politically viable and sustainable way, reduce health care costs long-term. To its credit, the ACA is chock full of experiments in cost control that, in my view, are worth a try (as are others). But to confidently predict they will succeed is to be oblivious to the lessons of the history of health care in America.

    Health outcomes. Here, I think we can be more confident. I do expect insurance coverage to improve health, as the preponderance of credible evidence suggests it does. (I will have more to say about this next month.) In judging whether it does so, we should be careful to measure Obamacare’s effects relative to our best estimate of the counterfactual of no reform, not with a simple pre-post estimate, as Douthat suggests. Controlling for potentially confounding factors (e.g., economic change) is crucial. Moreover, some health outcome improvements, like mortality, may take years to manifest.

    But notice that even if Obamacare does not reduce mortality (as studies suggest it will), it’s important to also consider morbidity more generally, including mental health. Broadly, I’m very confident health insurance does and will improve health outcomes. What this means is that I would not declare failure if we, to my surprise, don’t find a mortality effect, so long as we find other, worthwhile health effects.

    Other good metrics. As I’ve written before, achieving “near” universal coverage is not a good metric. The ACA is simply not designed to do that, as the CBO has articulated (see the discussion on page 5 of their recent report). It cannot achieve anything like universal coverage without a massively bigger individual mandate penalty or equivalent inducement. Instead, I propose as a better metric achieving near universal access to affordable coverage of good quality. This is really what the ACA is about, despite the rhetoric. Notice that one can debate what “near universal,” “affordable,” and “good quality” mean. I’m not aware that the administration or other vocal proponents of Obamacare have established metrics along these lines; they should.

    But, thanks to the Supreme Court’s ruling that states can decline to expand Medicaid without losing all federal Medicaid funding, the ACA has already failed in this regard (or states have failed it). Access to affordable coverage is unavailable for below-federal poverty line residents of states not expanding Medicaid. This is a serious policy issue that deserves a lot more attention than whether or not more than 6 or 7 or 8 million people have enrolled in exchange plans to date.

    Another good metric is increase in financial protection (e.g., fewer bankruptcies) that coverage expansion might provide. We really ought to see some movement in this area.

    Finally, one must acknowledge that a lot rides on what future policymakers do. Will they redirect subsidy spending for other purposes, making insurance less affordable? Will they expand Medicaid or permit states more flexibility to do so? It’s not fair to view the ACA as static policy. It’s already changed, by virtue of administrative, judicial, and congressional action. Any big program will fail if it’s not nurtured, supported, and tweaked as required.

    Stepping back, fundamentally we know the ACA will fail in the sense that there’s obviously a lot more work to be done in improving the U.S. health system. Nobody should feel complacent because coverage became X% cheaper, on average or Y% of exchanges are stable with good levels of competition or morality rates fell by Z% over N years. It’s absolutely fair to ask proponents to define how to judge if the ACA is a step in the right direction, but even if it proves to be so, it’s not enough. It’s never enough. Even those who espouse benchmarks that the ACA or its tweaked successor surpasses would be wrong to claim “mission accomplished.”

    In that sense, we all may be at least a little wrong about Obamacare.

    * I’m dodging a complexity here. Market structure is, in fact, more complex than “state-level.” Plans can offer products on a county-by-county basis, so there’s really a patchwork of overlapping markets to consider, as one sees in Medicare Advantage.


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  • The crisis in medical research. And how to fix it.

    Recent US government budgets have harmed the National Institutes of Health. But the problems in the medical research system are deeper than just the current budget. If you care about medical research, read this article in the Proceedings of the National Academy of Sciences by Bruce Alberts, Marc Kirschner, Shirley Tilghman, and Harold Varmus.

    Alberts and his colleagues describe a hypercompetitive culture in science that undermines the process of discovery.

    Competition… has always been a part of the scientific enterprise, and it can have positive effects. However, hypercompetition for the resources and positions that are required to conduct science suppresses the creativity, cooperation, risk-taking, and original thinking required to make fundamental discoveries… biomedical scientists are spending far too much of their time writing and revising grant applications and far too little thinking about science and conducting experiments.

    You probably expect that the next sentence will be, “So give us more money.” But that’s not where they go.

    We believe that the root cause of the wide-spread malaise is a longstanding assumption that the biomedical research system in the United States will expand indefinitely at a substantial rate. We are now faced with the stark realization that this is not the case.

    Assuming that science will expand forever, senior scientists have trained far more junior scientists than the system can support, leading to hypercompetition.

    The mismatch between supply and demand can be partly laid at the feet of the discipline’s Malthusian traditions. The great majority of biomedical research is conducted by aspiring trainees: by graduate students and postdoctoral fellows. As a result, most successful biomedical scientists train far more scientists than [there are] relevant positions in academia, government, and the private sector.

    The overproduction of new scientists is driven by “perverse incentives”:

    Salaries paid by grants are subject to indirect cost reimbursement, creating a strong incentive for universities to enlarge their faculties by seeking as much faculty salary support as possible on government grants. This has led to an enormous growth in “soft money” positions, with stagnation in the ranks of faculty who have institutional support. The government is also indirectly paying for the new buildings to house these scientists by allowing debt service on new construction to be included in its calculations of indirect cost recovery.

    Alberts et al. have detailed suggestions for reform. They write

    (i) to advocate for predictable budgets for US funding agencies and for an altered composition of the research workforce, both with the aim of making the research environment sustainable; (ii) to rebalance the research portfolio by recognizing the inertia that favors large projects and by improving the peer review system so that more imaginative, long-term proposals are being funded and scientific careers can have a more stable course; and (iii) to encourage changes in governmental policies that now have the unintended consequence of promoting excessive, unsustainable growth of the US biomedical research enterprise.

    I cannot overstate how distinguished these authors are, both as researchers and institutional leaders in science. Alberts made discoveries in how chromosomes replicate during cell division, is the former editor of Science, and former President of the National Academy of Sciences. Kirschner made discoveries in developmental biology and is a University Professor at Harvard, where he served as chair of the departments of systems biology and developmental biology. Tilghman made discoveries in gene regulation and is the former President of Princeton. Varmus won the Nobel Prize for discovering retroviral oncogenes. He is the former director of the NIH, former President of the Memorial Sloan-Kettering Cancer Center, and the current director of the National Cancer Institute.

    Get it? It’s as if the Pope and three leading cardinals held a press conference predicting the collapse of the Catholic church. These people know what they are talking about and we need to listen.


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  • Curious about the exchange litigation? Here’s a podcast!

    For those of you following the exchange litigation—and if you care about the ACA’s successful implementation, you should be—I participated yesterday in a telephone discussion/debate about Halbig v. Sebelius with Jonathan Adler, one of the lawsuit’s architects. The Federalist Society graciously hosted the phone call and has made it available as a podcast. I encourage you to listen in!

    You can play the audio after the jump:


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  • This is why we can’t get the public to accept changes to screening mammograms

    In 2013, the Swiss Medical Board was asked to review the use of screening mammography. Two of the participants have penned a piece in the NEJM that’s just amazing. Here’s a bit (emphasis mine):

    First, we noticed that the ongoing debate was based on a series of reanalyses of the same, predominantly outdated trials. The first trial started more than 50 years ago in New York City and the last trial in 1991 in the United Kingdom. None of these trials were initiated in the era of modern breast-cancer treatment, which has dramatically improved the prognosis of women with breast cancer. Could the modest benefit of mammography screening in terms of breast-cancer mortality that was shown in trials initiated between 1963 and 1991 still be detected in a trial conducted today?

    Second, we were struck by how nonobvious it was that the benefits of mammography screening outweighed the harms. The relative risk reduction of approximately 20% in breast-cancer mortality associated with mammography that is currently described by most expert panels came at the price of a considerable diagnostic cascade, with repeat mammography, subsequent biopsies, and overdiagnosis of breast cancers — cancers that would never have become clinically apparent. The recently published extended follow-up of the Canadian National Breast Screening Study is likely to provide reliable estimates of the extent of overdiagnosis. After 25 years of follow-up, it found that 106 of 484 screen-detected cancers (21.9%) were overdiagnosed. This means that 106 of the 44,925 healthy women in the screening group were diagnosed with and treated for breast cancer unnecessarily, which resulted in needless surgical interventions, radiotherapy, chemotherapy, or some combination of these therapies. In addition, a Cochrane review of 10 trials involving more than 600,000 women showed there was no evidence suggesting an effect of mammography screening on overall mortality. In the best case, the small reduction in breast-cancer deaths was attenuated by deaths from other causes. In the worst case, the reduction was canceled out by deaths caused by coexisting conditions or by the harms of screening and associated overtreatment. Did the available evidence, taken together, indicate that mammography screening indeed benefits women?

    There’s only so many times you can say the same thing. It does not appear that universal screening reduces mortality. But what’s even more stunning is how much women misunderstand this fact:


    The bottom half of this pic shows the actual effect of mammography. If we take 1000 women age 50 and watch them for 10 years, and don’t screen them, 5 will die of breast cancer, 44 will die of other causes, and 951 will be fine. If we do screen them, then 4 women die of breast cancer, 44 or 45 die of other causes, and 951 or 952 are fine. This is why the effects seem to be negligible.

    But if you ask women to estimate how well mammography works, then you’re in for a whole different ballgame. They think that without screening, of those 1000 women, 160 are going to die from breast cancer in the next 10 years. They way, way, way overestimate the danger. They also overestimate the effectiveness of mammography. They think that it will halve the rate of death, so that only 80 of the 1000 women will die from breast cancer.

    Therein lies the problem. If you think that breast cancer is going to kill 16% of all 50-year-old women in the next 10 years and that mammography makes a huge difference in the mortality rate, then you’re going to demand a universal screening program. Hell, I’d demand it if that were the case. Until we can change the perception of the public to more closely match reality, and make them realize that the harms may outweigh the benefits, we’re going to get nowhere in trying to make changes.


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  • Stand Up! – April 16, 2014

    I am a frequent guest on Stand Up! with Pete Dominick, which airs on Sirius/XM radio, channel 104 from 6-9AM Eastern. It immediately replays on the channel, so those on the West Coast can listen at the same times.

    Today we talked about the CPS and various ACA updates.

    You can play the audio right here, after the jump…


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