• AcademyHealth: Physician shortages exist all over the world

    My latest post over at the AcademyHealth blog:

    The physician shortage, especially that of primary care physicians, is well documented in the United States. But even in specialties where there seem to be adequate numbers of doctors to service the citizens of the US, relative geographic shortages can occur. It turns out that this is not a problem specific to this country:

    Go read!


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  • What dental care can teach us about coverage expansions

    A simple prediction about the Affordable Care Act’s impact on health care access might go something like this: we have too few primary care providers and expanding coverage is going to cause a spike in demand that those providers can’t meet. Doctors will either refuse to see Medicaid patients or will do so at the expense of the privately insured, who will see longer wait times. Ergo facto, access will suffer. The outlook is bleak.

    Well, maybe. But a new NBER working paper from Tom Buchmueller, Sarah Miller, and Marko Vujicic serves as an important reminder: supply-side effects matter, too. That is, providers can change the way they practice to accommodate new demand, but the studies on provider behavior are much scarcer than demand-side (patient behavior) literature.

    Buchmueller et al examine how changes in Medicaid’s dental benefits—optional for states to provide for adults—influences dental practice. Dentistry might not seem like the most obvious place to search for lessons for the ACA, but it’s actually pretty excellent: dentistry is a form of preventive care and, like traditional primary care, there’s growing worry over a provider shortage. There’s also concern about low participation in the program due to low reimbursements; evidence suggests that access is improves when Medicaid covers dental, but only 39% of dentists in the sample reported serving Medicaid patients. Dentists often work with hygienists, much as a physician can work with nurse practitioners or physician assistants.

    So, what happened when states introduced dental benefits in adult Medicaid? Dentists didn’t just find a way to accommodate new demand—they did so while increasing their incomes by 7% on average.

    We find that when states expand Medicaid dental coverage for adults, there is an increase in the percentage of dentists that participate in the program and an increase in the supply of services to publicly insured patients, with no decrease in the number of visits for other patients. Dentists accomplish this mainly by making greater use of hygienists: following the expansion of public coverage, dentists employ a greater number of hygienists and hygienists provide about 5 additional visits per week. As a result, dentists’ income increases following the adoption of Medicaid adult dental benefits by approximately 7 percent. These effects are largest among dentists who practice in poor areas where Medicaid coverage is most prevalent. We also find that these coverage expansions cause wait times to increase modestly [less than a day, on average]. However, this effect varies significantly across states with different policies towards the provision of dental services by hygienists. The increased wait times are concentrated in states with relatively restrictive scope of practice laws. We find no significant increase in wait times in states that allow hygienists greater autonomy.

    This has pretty self-evident lessons for coverage expansion under the ACA. Just as dental hygienists were able to help meet new demand, researchers have highlighted that reorganizing how we deliver medical care—delegating more tasks to nurses, pharmacists, and other clinicians—could go a long way toward easing the PCP shortage. And like with dental hygienists, defining scope of practice falls squarely to the states, illustrated in the map below from Health Affairs.

    Maximizing access doesn’t rest exclusively on expanding the role of non-physician clinicians; innovations like retail clinics will also play a role. But this paper suggests that scope of practice will play an incredibly meaningful role in access and variation in access—and that there are actions that states can take to ease coverage expansion. You should go ahead and add that to the list of implementation issues that will play out at the state—not national—level.

    The paper is ungated, and well worth reading in full.

    Adrianna (@onceuponA)

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  • Stand Up! – April 23, 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 research, mammograms, vaccines, the ACA, and more.

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


    Read the rest of this entry »

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  • It’s getting even harder to justify not expanding Medicaid

    One of the reasons that many states have argued that they should refuse the Medicaid expansion is because they fear the “woodwork” effect. People who were previously eligible for Medicaid, and now want it, aren’t covered 100% by the federal government like those who are newly eligible. States have to pay for 25% – 50% of their Medicaid costs, which could get expensive.

    Of course, they could be on the hook for these payments even if they didn’t expand Medicaid, but most have ignored that point.

    Regardless, the CBO, in its latest revision, argued that fewer people are coming out of the woodwork than expected. This means that the projected state share of the Medicaid expansion is even lower than previously thought. Here’s a nice chart from the CBBP:


    That’s not even the whole story:

    CBO’s estimate of the impact of the Medicaid expansion and other health reform coverage provisions on state budgets is, as noted above, only a partial estimate — because it only reflects the impact on state expenditures for Medicaid and CHIP.  The CBO estimate does not reflect the substantial savings that states and localities taking the expansion will realize from no longer having to bear the costs for various health services they were providing to large numbers of people who were previously uninsured but now have Medicaid coverage.  The Urban Institute has estimated that if all states took the Medicaid expansion, states would save between $26 billion and $52 billion in this area from 2014 through 2019, while the Lewin Group has projected state and local savings of $101 billion.

    Plus, you know, millions of people will get health insurance. I’m just saying.


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  • Empowering the states to select essential health benefits.

    In the heat of the controversy surrounding the botched rollout of HealthCare.gov and the various ACA delays, it’s easy to forget one of the Obama administration’s most significant and controversial implementation decisions: the choice, back in 2011, to delegate to the states the power to pick what would count as “essential health benefits.”

    Helen Levy and I have a new article (blissfully ungated) in the Journal of Health Politics, Policy and Law that explores that decision. The source of the controversy is the vagueness of the ACA’s requirement that health plans sold in the individual and group markets must cover “essential health benefits.” Apart from an open-ended list of required coverage categories (like “hospitalization” and “prescription drugs”), the ACA doesn’t specify which benefits should count as essential.

    Instead, the ACA delegates to the Secretary of HHS the authority to adopt a more granular definition. That delegation put the Secretary in a tough spot. A narrow definition of essential health benefits would limit some treatment options, potentially ticking off both patients and providers. A broad definition, however, would drive up the cost of health plans, which could put insurance out of the reach of the very people the ACA was designed to help.

    So the Secretary delegated to the states the authority to choose what would count as “essential” within their borders. The decision was a “major surprise”—indeed, it was the first in a long string of implementation decisions to make front-page news. But punting to the states got the Secretary out of the delicate business of distinguishing essential from non-essential benefits.

    In the article, Levy and I ask two questions. First, was it legal for the Secretary to defer to the states on what counted as “essential health benefits”? Even today, the question is of some urgency. Someone who can’t secure exchange coverage in her state for a desired treatment might well have standing to sue. Such a plaintiff could build a plausible legal argument that deferring to the states runs contrary to a statute that, at a number of points, anticipates that the Secretary would adopt a national, uniform slate of essential health benefits. On balance, however, a close analysis of the ACA suggests that the Secretary’s choice—although it may have come close to the line—was lawful.

    Second, was it improper for the Secretary to use a spare, 13-page internet bulletin to announce the decision? Did using the bulletin allow her to avoid procedural hurdles—the obligation to give notice and take comments, White House oversight, and judicial review—that are meant to shape how HHS exercises its authority? Here, we conclude that the answer is no, and that the unorthodox process that HHS employed was more open to public scrutiny and institutional oversight than conventional rulemaking would have been.


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  • Only 1% of hepatitis C patients have received a life-saving, new and expensive drug

    Andrew Pollack reports:

    Record sales of a new hepatitis C drug pushed the first-quarter earnings of Gilead Sciences far beyond expectations, the company reported on Tuesday, but could also heighten concerns about the high cost of the drug, known as Sovaldi, and the ability of the health care system to pay for it.

    The $2.3 billion in sales of Sovaldi appears to have shattered the previous record for sales of a drug in its first full quarter on the market. It even appears to have already eclipsed the record for first-year sales, at least in the United States. [...]

    The drug, a pill taken once a day, has a higher cure rate, a shorter duration of treatment and fewer side effects than previous treatments.

    But Sovaldi, which has a list price of $1,000 per pill, or $84,000 for a typical course of treatment, has become a flash point in a debate over drug prices. [...]

    “If cost were not a factor, we would want to treat the entire population,” said Dr. Rena Fox, a professor of medicine at the University of California, San Francisco. She said it was frustrating that “we finally get this great treatment and then we withhold it.”

    Elsewhere in the piece we learn that of the 3-4 million Americans with hep C, at most 30,000 have used Sovaldi. Oh, but let us not ration!

    Prior TIE coverage of this drug here. H/t Bradley Flansbaum.



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  • A new study confirms that Obamacare will facilitate earlier retirements

    Nicholas Bagley and I previously covered job lock fairly extensively. (“Job lock” is the catch-all, labor market economist’s term for any situation that gives rise to workers working more or facing constraints in job mobility due to provision of work-related health insurance.) John Shoven and Sita Slavov have published the most recent work on the subject.

    We study the impact of retiree health coverage on the labor supply of public sector workers between the ages of 55 and 64. We find that retiree health coverage raises the probability of stopping full time work by 4.3 percentage points (around 38 percent) over two years among public sector workers aged 55-59, and by 6.7 percentage points (around 26 percent) over two years among public sector workers aged 60-64. In the younger age group, retiree health insurance mostly seems to facilitate transitions to part-time work rather than full retirement. However, in the older age group, it increases the probability of stopping work entirely by 4.3 percentage points (around 22 percent). [...]

    Given the growing evidence that retiree health programs lead to earlier retirement, it is interesting to note that the Affordable Care Act (ACA) of 2010 offers what amounts to universal retiree health. Under the ACA, all retirees under 65 can now purchase health coverage through the state-based exchanges, and those purchases will be subsidized for all whose income in retirement is below 400 percent of the official poverty standard. The research on retiree health programs, including this paper, suggests that the ACA may lead to earlier retirements, particularly for those in the private sector who currently do not have access to subsidized health insurance in retirement before age 65.

    Prior work already suggested as much, but now the evidence base that the ACA will facilitate earlier retirements is even stronger.


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  • Did WordPress remove the “keep linebreaks” paste option? (A bleg)


    WordPress just updated to version 3.9 and the only substantial change I noticed was how it handles pasting as text (no formatting) or from a Word document. I haven’t experimented with the latter, but the former seems broken. I’m annoyed, as best I can tell I’m the first person on the internet to flag this, and I want help.

    Before the update, when one clicked on the text paste button, one got a popup like the one shown below. In the upper right corner was a “keep linebreaks” checkbox. Toggle it off and click “insert” and your text drops into your draft post without any line breaks. That keep/remove line breaks functionality is gone in version 3.9, as far as I can tell. Am I wrong? How can I get it back without reverting to the prior WordPress version?


    Why does this matter? Well, removing line breaks is (was) super handy, particularly when cutting and pasting from a PDF document, which never has line breaks where you want them. It’s the difference between this:

    An example paste

    from a PDF document

    with line breaks that one

    would rather not have.

    and this

    An example paste from a PDF document with[out] line breaks that one would rather not have.

    Obviously it’s no big deal to delete three line breaks. But if you’re pasting in 20, 30, 50, 100 lines of text, one would rather avoid all that manual labor that a computer could (used to) do just fine.

    WordPress, what did you do? Why? Can anyone help? (Comments open for one week from date of this post.)

    Image credit: John Saddington

    UPDATE: Here’s an online tool that removes line breaks. There are others. Google “text editor remove line breaks” (no quotes) or similar and you’ll find them.


  • Economic booms and infectious disease

    We suggest that the workload is higher during economic booms and thus employees have to go to work despite being sick. In a theoretical model focusing on infectious diseases, we show that this will provoke infections of coworkers leading to overall higher sickness absence during economic upturns. Using state-level aggregated data from 112 German public health insurance funds (out of 145 in total), we find that sickness absence due to infectious diseases shows the largest procyclical pattern, as predicted by our theoretical model.

    That’s from the abstract of a new paper by Stefan Pichler, which I have not read in full. The findings point to another reason (among many others) why working-age individuals might see health improvements during recessions, and why health spending might be lower during them.


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  • You can read JAMA, or watch Healthcare Triage…

    First up is a small study on how physicians don’t do very well in interpreting test results. “Medicine’s Uncomfortable Relationship With Math Calculating Positive Predictive Value“:

    To make use of these skills, clinicians need access to accurate sensitivity and specificity measures for ordered tests. In addition, we support the use of software integrated into the electronic ordering system that can prevent common errors and point-of-care resources like smartphones that can aid in calculation and test interpretation. The increasing diversity of diagnostic options promises to empower physicians to improve care if medical education can deliver the statistical skills needed to accurately incorporate these options into clinical care.

    Or, you could watch this episode on test characteristics:

    Then there’s an editorial on the study. “Ensuring Correct Interpretation of Diagnostic Test Results“:

    In the meantime, before ordering any test, we must ask ourselves if it is even necessary. Assuming there are efficacious treatments for the disease being tested, what are our thresholds for “ruling out” disease on the low end and “ruling in” disease on the high end of probability, and then, what is the pretest probability of the disease? If your pretest probability falls between those thresholds, is the test accurate enough that a positive or negative test finding will result in a posttest probability that crosses these thresholds? If the test result is not going to change your clinical management, there is no reason for the patient to undergo testing in the first place.

    Or, you could watch this episode on Bayes’ Theorem:

    I swear, we didn’t plan this. It’s just a testament to how timely Healthcare triage is, I guess. :)


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