• Healthcare Triage News: Health Care Reform, and the Issues We Face

    As we approach the election this fall, it seems like the news media report on little else. Unfortunately, too little news coverage addresses health care reform. That’s wackadoo, because there is still so much to be done to improve the cost, quality, and access for patients within the US health care system.

    So let’s talk about the major health policy issues we in the US face. This is Healthcare Triage News.

    This episode was adapted from a post I wrote for the JAMA Forum. Links to further reading and sources can be found there.


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  • #5Things That Happened in Health Policy This Week

    5 Things That Happened in Health Policy This Week is produced by a mix of research assistants from the Healthcare Quality & Outcomes (HQO) Initiative at the Harvard T.H. Chan School of Public Health. In each edition we feature a variety of news articles, reports, and studies focused on U.S. health policy and health services research.

    If you’d like to stay up to date with weekly digests from the HQO team, you can subscribe here. (Note: this will not subscribe you to updates from The Incidental Economist.)


    Chicago may be on its way to require licensing of pharmaceutical sales reps, as an effort to fight opioid addiction, the Chicago Tribune reports. The city expects to introduce an ordinance in the next month requiring reps to track who they meet with, what drugs were promoted, samples provided, among other things. As part of the licensing process, reps would also receive training on prescription drug abuse.

    The big picture: Nationally, over 14,000 people are dying annually from prescription opioid overdose. Daily, emergency departments treat over 1,000 people for prescription opioid abuse. Last year, 403 people died from accidental opioid overdoses in Chicago. This places opioid overdose not far behind homicide as a cause of death in Chicago.

    So now what? If enacted, the ordinance would help better track the flow of prescription opioids within Chicago. The new data could help identify to what extent unethical marketing practices by drugmakers are influencing opioid prescription habits among physicians.

    What does this mean? If this measure is successfully implemented in Chicago, and new insights are drawn from the data, the ordinance could become an example for other states seeking new solutions to the opioid crisis. While some cities like Washington D.C. already have licensing requirements for pharmaceutical reps, Jesse Witten, a partner at the law farm Drinker Biddle & Reath notes that many drugmakers don’t do enough business in D.C. to make it worth the licensing fee of $175 per rep.


    A new perspective out this week in NEJM finds that two years after Oregon’s experimental Medicaid expansion, rates of ED utilization remain higher for those who received Medicaid coverage than for those who did not, and have not declined meaningfully since the first year of expansion.

    Reminder: A previous study of the Oregon Health Insurance Experiment found that while there was a decrease in depression diagnoses and reported rates of financial burden amongst those who received Medicaid coverage, there were no measurable changes in clinical outcomes, and ED utilization increased by 40%.

    So now what? Some experts thought that this increase in ED utilization could have come from pent up need and would decrease over time, but these new results from Finkelstein et al. show that increased utilization continued even two years into expansion.

    What does this mean? Supporters of insurance expansion often argue that increased access to healthcare will increase use of preventive care and primary care, thus altering utilization patterns and ultimately preventing hospitalizations and ED use, however this new data suggests otherwise. This could have implications for policymakers’ decisions around key provisions of the ACA, particularly Medicaid expansion.


    In attempts to prevent unintended pregnancies, states are providing Medicaid reimbursement to hospitals for the insertion of long-acting reversible contraception (LARC) in the delivery room, immediately after a woman gives birth. Kaiser Health News reports here.

    The big picture: So far, 20 states plus DC are promoting the option following urges from CMS this spring to adopt the reimbursement policy. However, lack of training for insertion of IUDs and general resources for making this a broadly adopted practice will be stumbling block.

    Who benefits? Immediate postpartum insertion of an IUD is cost-effective for low-income patients, who might not have access to this method of contraception otherwise. Further, since doctors advise spacing pregnancies at least 18 months apart, this practice not only would prevent unintended pregnancies, but might also help keep women healthier in future, planned pregnancies.

    Want more? Info on this from the American Congress of Obstetrics and Gynecology is here. An empirical study on how this practice has played out in Massachusetts is here.


    This piece in Marketplace reports back on the newly released Bureau of Labor Statistics, which confirms that prescription drug prices are historically high. In fact, prices are up 7 percent since last year, the biggest increase since 1992 (and since I was born).

    Catch me up. Unruly drug prices have been getting a lot of attention since Congress found out that EpiPen company Mylan has raised its prices. And before that, Gilead, producer of hepatitis C and HIV drugs, was in the hotspot.

    Tell me though…why? Yale economist Fiona Scott Morton suggested the 7 percent increase has to do with a new class of drugs – biologics — that are used to treat things such as autoimmune disease and cancers may be partly responsible for the $$$. On a more dramatic note, Dr. Walid Gellad at the University of Pittsburgh postulated that increasing prices are becoming scandalous because of a political shift and that “the end is coming” for high prices in this industry.

    Is that all? Nope. Valeant has increased their prices for a drug to treat lead poisoning by 2,700 percent in a single year. To make matters worse, this comes on the heels of lead poisoning in Flint, Michigan’s water supply.


    A new report released by the Department of Health and Human Services (HHS) focuses on rural health and health care, examining how rural hospitals perform in Value-Based Purchasing (VBP) and other delivery system reform initiatives. Modern Healthcare reports here.

    Some data: Last year only 34% of rural hospitals, in the VBP program were penalized compared to 49% of urban hospitals. However, over the same time period, 79% of rural hospitals were penalized due to the hospital readmissions-reduction program compared to 76% of urban hospitals.

    Some ideas: The report stated, “High levels of trust in providers may facilitate better patient experiences” in rural acute-care settings. The report also did not note any reason for difference in readmissions, but did identify that adults in rural areas on a whole have poorer health, more tobacco use, and more chronic conditions.

    The point: 59 million Americans living in rural settings, receive care and services from rural hospitals. Current payment incentives for mandatory hospital-based delivery system reform programs do not align perfectly with rural hospitals because of difference in payment structures and low patient volumes. Important to find a way to meet needs in rural settings when developing and implementing delivery system reform.

    Contributors: Stephanie Caty (@stephaniecaty), Yevgeniy Feyman (@YFeyman), Kim Reimold (@KimReimold), Zoe Lyon (@zoemarklyon), and Anthony Moccia (@Anthony_Moccia).

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  • Science and the Election: Media

    Last week I went to NYC to be part of a panel on “Science and the Election: Media” as part of a science-based town hall for the 2016 election held at the YouTube New York space and hosted by The Young Turks. The event was designed to try and fill what’s perceived to be a deficiency in our national public dialogue – science – in this election.

    While climate change is clearly a big topic, I think there are other fish to fry. I had a blast doing it. I hope you’ll enjoy it, too. Please watch and share!


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  • AcademyHealth: Medicare Advantage spillovers

    Because they may reduce traditional Medicare (TM) spending, Medicare Advantage (MA) plans may not be, on net, as costly as we think. In my latest AcademyHealth post I summarize all the studies of this subject I’m aware of.



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  • NEJM: Does the U.S. owe billions to insurers?

    Although it’s been eclipsed by the presidential election, the fight over the risk corridor lawsuits continues to simmer. Last Friday, the House of Representatives moved to file an amicus brief objecting to the administration’s willingness to open settlement negotiations:

    The law is clear that insurance companies operating on the health exchanges established pursuant to the [ACA] have no right to government handouts in excess of incoming funds under the Act’s risk corridors program. This is because the program was intended to be budget-neutral and self-funding—i.e., outgoing payments would be covered by incoming payments—and Congress has confirmed this intent, not once but twice, through annual appropriations legislation.

    I think the House is mistaken, and the New England Journal of Medicine has just published a piece of mine describing why:

    As the Government Accountability Office has explained, “the mere failure to appropriate sufficient funds is not enough” to change the scope of an entitlement. And that’s all the appropriations statutes are: “mere failure[s] to appropriate sufficient funds.” They do not purport to change what health plans are entitled to. So the promise that the ACA made has not been undone.

    [In addition], congressional Republicans maintain that the administration cannot settle the cases because Congress hasn’t appropriated the money to pay court judgments. Without an appropriation, they argue, the United States can’t make a payment even if a court orders that the money be paid. In other words, Congress is always free to refuse to honor its debts—and it has refused to honor these particular debts.

    The Republicans acknowledge that an existing, permanent appropriation known as the Judgment Fund normally allows the executive branch to settle lawsuits against the United States. By its terms, however, the Judgment Fund is available only when payment is “not otherwise provided for.” Drawing support from a memo compiled by the Congressional Research Service, they believe that they “otherwise provided for” risk-corridor payments when they partially funded the program.

    But in fact the Judgment Fund is not unavailable whenever Congress chooses to partially fund a program. It is unavailable only when Congress has designated an alternative source of funds to pay money judgments arising from a failure to fulfill the United States’ financial obligations. Because Congress has made no such designation here, the Judgment Fund appears to be available to settle the risk-corridor lawsuits.

    Go read the whole thing! (For more extensive coverage, see here.)


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  • Narrow networks: savings at what cost?

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company). It also appeared on page A3 of the 10 October 2016 print edition.

    You probably chafe a bit every time you learn that a certain doctor or hospital isn’t part of your insurance network. Narrowing the scope of your network helps insurers save money. They can drive hard bargains with doctors and hospitals to get lower prices and walk away from higher-priced ones.

    Increasingly, insurers are offering narrow network plans. Would you enroll in one? So long as quality doesn’t suffer, consumers should welcome the lower premiums they may offer.

    Researchers at the Leonard Davis Institute at Penn analyzed the relationship between network size and premiums for plans offered in the Affordable Care Act marketplaces. Plans with very narrow networks (covering care by less than 10 percent of physicians) charged 6.7 percent lower premiums than plans with much broader networks (covering care by up to 60 percent of physicians). This translates into an annual savings for an individual of between $212 and $339, depending on age and family size. For a young family of four, the savings could reach nearly $700 per year.

    “Marketplace consumers are looking for value,” said Daniel Polsky, the University of Pennsylvania health economist who led the study. “That level of savings could be a very good deal for consumers, but whether these plans provide value depends on how they are achieving those savings.”

    One way plans might save money could make it harder for patients to get care — so that they get less of it. Narrow network plans may do this if they don’t cover enough nearby providers, with the ones they do cover too busy to take new patients in a timely fashion. Clearly this would be especially problematic if appointments with one’s preferred primary care doctor are hard to obtain.

    Are today’s narrow network plans actually doing this? Until recently, we had no data to answer this question. But two studies published earlier this year — one focused on Massachusetts, the other on California — provide some insight.

    In 2012, the Massachusetts Group Insurance Commission, which provides health insurance to a lot of government employees in the state, offered most of them the chance to waive three months of employee premium contributions if they enrolled in new, narrow network plans. This premium holiday amounted to an average of $500 in savings to an enrollee. The new plans covered about half as many physicians and one-third fewer hospitals than prior, broad network plans.

    The deal was offered to the 100,000 or so state employees and their dependents, but not to the nearly 20,000 enrollees who are state municipality employees. That created the natural experiment we economists love. By comparing the experiences of the two groups, the economists Jonathan Gruber and Robin McKnight teased out the effect of narrow network plans on the 10 percent of enrollees induced by the premium holiday to enroll in one.

    Switchers spent a whopping 36 percent less on health care. Some of these savings can be attributed to narrow network enrollees who saw expensive specialists less. This could be because healthier enrollees who require fewer specialists were more attracted to the plans.

    But savings were not entirely driven by healthier people who switched to the plans. They were also achieved by more efficient use of the health system. Narrow network enrollees used the emergency department less, particularly for conditions treatable in office settings. The per-visit cost of outpatient care also fell for narrow network enrollees, which would be expected if the plans paid lower prices. The authors did not find evidence that patients in narrow network plans used lower-quality hospitals, consistent with other work that suggests networks can be narrowed without sacrificing quality.

    The savings were concentrated among enrollees who retained their primary care physician as they switched plans. And the distance that narrow network enrollees traveled for primary care visits — but not for specialists — fell. This suggests that plans that narrow their networks of costly specialists but maintain or increase their network of primary care doctors are on the right track. Not only can primary care doctors help patients select specialists and hospitals — and advise them when they’re necessary at all — but retaining primary care physician relationships is also important to many patients.

    That’s why the results of a recent study of new plans offered in California are especially troubling. Simon Haeder, a West Virginia University political scientist, and colleagues at the University of Wisconsin-Madison and the University of California, Irvine, found that access to primary care physicians was relatively poor for a sample of plans offered through California’s Affordable Care Act Marketplace in 2015. Most Obamacare marketplace plans in California, as well as in other states, are narrow network plans.

    Using a “secret shopper” approach, the study found that only about 30 percent of attempts for appointments with specific primary care doctors were successful. In this approach, an individual pretending to be a patient seeking an appointment called the offices of over 700 primary care doctors listed in marketplace plan directories.

    In about 15 percent of cases, the doctor did not accept the caller’s plan, despite being listed in its directory. In nearly 20 percent of cases, the directory included the wrong phone number or the number was busy in two calls on consecutive days. Ten percent of doctors called were not accepting new patients. And about 30 percent of doctors called were not primary care physicians, despite being listed as such in the directory.

    When callers were able to make an appointment, the average waiting time for a physical exam was about three weeks. In cases for which the caller pretended to have acute symptoms, the average time until an appointment was about one and a half weeks.

    “If patients struggle to obtain primary care appointments, narrow network plans may have a rocky future,” Mr. Haeder said. Consumers revolted against managed care in the 1990s, he notes, and they could very well revolt against poorly managed and loosely regulated narrow networks.


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  • Healthcare Triage: Medicaid has a Huge Return on Investment

    As we pass the 3-year anniversary of the opening of the insurance exchanges, most news seems to focus on the private insurance people can purchase there. In recent months, many have complained about private insurers exiting the exchanges, networks being narrowed, premiums rising, and competition dwindling out of existence.

    But it’s important to remember that many, if not most, of the newly insured are part of the Medicaid expansion. As of today, 19 states have still refused to participate in that program. Some cite reports and news that Medicaid offers poor quality and little choice of providers. But most seem to cite the cost of Medicaid, claiming that its growing cost will eventually bankrupt states.

    Such declarations only consider one side of the equation, though. In most ways, Medicaid offers an excellent return on investment. That’s the topic of this week’s Healthcare Triage.

    This episode was adapted from a column I wrote for the Upshot. Links to further reading and sources can be found there.


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  • Why is improvement in the quality of health care so slow?

    In JAMA Internal Medicine, David Levine, Jeffrey Linder, and Bruce Landon look at progress in improving quality of care in the US since 2002. They are not impressed.

    Objective. To measure changes in outpatient quality and patient experience in the United States from 2002 to 2013.

    Design, Setting, and Participants. We analyzed temporal trends from 2002 to 2013 using quality measures constructed from the Medical Expenditure Panel Survey (MEPS), a nationally representative annual survey of the US population… Participants were noninstitutionalized US adults 18 years or older (range, 20,679-26,509 individuals each year).

    Measures. Outpatient quality measures were compiled through a structured review of prior studies and measures endorsed by national organizations. Nine clinical quality composites (5 “underuse” composites, eg, recommended medical treatment; 4 “overuse” composites, eg, avoidance of inappropriate imaging) based on 39 quality measures; an overall patient experience rating; and 2 patient experience composites (physician communication and access) based on 6 measures.

    The authors acknowledge that there are limits to how well you can measure the quality of care with these methods. Nevertheless, if quality of care was improving quickly, that change should be reflected even in these imperfect measures. Was it?

    Change over time in (A) use of recommended care, (B) avoidance of non-recommended care, and (C) patient experience.

    Change over time in (A) use of recommended care, (B) avoidance of non-recommended care, and (C) patient experience.

    Results. From 2002 to 2013 (MEPS sample size, 20,679-26,509), 4 clinical quality composites improved: recommended medical treatment (from 36% to 42%; P < .01), recommended counseling (from 43% to 50%; P < .01), recommended cancer screening (from 73% to 75%; P < .01), and avoidance of inappropriate cancer screening (from 47% to 51%; P = .02). Two clinical quality composites worsened: avoidance of inappropriate medical treatments (from 92% to 89%) and avoidance of inappropriate antibiotic use (from 50% to 44%; P < .01 for both comparisons). Three clinical quality measures were unchanged: recommended diagnostic and preventive testing (76%), recommended diabetes care (68%), and inappropriate imaging avoidance (90%). The proportion of participants highly rating their care experience improved for overall care (from 72% to 77%), physician communication (from 55% to 63%), and access to care (from 48% to 58%; P < .01 for all comparisons).

    Levine et al. conclude:

    Despite more than a decade of efforts to improve the quality of health care in the United States, the quality of outpatient care delivered to adults has not consistently improved. There have been improvements in patient experience. Current deficits in care continue to pose serious hazards to the health of the American public in the form of missed care opportunities as well as waste and potential harm from overuse.

    So why has progress been so slow? In 2003, Elizabeth McGlynn and several colleagues published an important benchmark documenting quality problems in US health care. McGlynn, John Adams, and Eve Kerr have a commentary on Levine et al. in the same issue of JAMA Internal Medicine. They argue that

    Much of the work in quality improvement has focused on approaches that are driven by payers and policy makers. These have included measurement and public reporting, payment incentives, investments in electronic medical records, and developing virtual systems of care in select areas. None of these approaches by itself is likely to fundamentally alter the level of quality delivered throughout the nation. To do so requires significant work by health professionals on the front lines in collaboration with their patients. And those approaches require time, resources, and energy that are beyond what is available to many practices that are struggling to keep up with a rapidly changing world.

    I strongly agree that:

    • Measurement in and of itself does little,
    • Incentives won’t always change behaviour, particularly if the cost of change outweighs the value of the incentive, and
    • Quality improvement is accomplished by “health professionals on the front lines in collaboration with their patients”.

    But I don’t think these points quite capture why it’s so hard to improve medical quality. I see two reasons why we might have expected change to be faster. First, we expected change to be fast because we looked at dramatic improvements in quality achieved in other industries, such as automobile manufacturing.  Second, other nations deliver care that looks at least as good (or better) than US care, at significantly lower cost. This makes it seem like that there should be low-hanging fruit to harvest, that is, we should be able to make quick changes that move us to a higher quality of care without increasing cost.

    Change is hard, in my view, because the fruit is harder to pick than we thought. The fruit is hard to pick in part because delivering health care is not much like making a car.

    Manufacturing a Nissan. Notice all the people?

    Manufacturing a Nissan. Notice all the people?

    Auto manufacturing involves highly standardized and intensively automated workflows. Changing how work gets done may require a lot of capital investment. Nevertheless, a numerically-controlled lathe will change what it does when you reprogram it. And you don’t need to worry about the expectations of the steel that the lathe shapes. Medical work is much less standardized. No two patients are the same, biologically, psychologically, or in their social circumstances. Unlike steel, patients have agency that the care system should and must accommodate. All this makes caregiving a matter of craft skills, and care ‘algorithms’ are often more like suggestions. Above all, because they are craftsmen and craftswomen, and not robots, caregivers can be nudged, but they can’t be programmed.


    Logistic curve.

    The point is not that changing medical practice is impossible, but rather that it is hard and slow. There is a an old model in the theory of diffusion of innovations that argues that the adoption of a new idea or practice follows an S-shaped (logistic) curve. In the graph to the left, the vertical axis is the proportion of enterprises that use a new idea. Initially, and for a considerable time, adoption is slow, because early adopters have to work out the kinks, overcome poltical resistance to the new idea, and so on. When these problems get solved, change is easier, and adoption speeds up.

    My hope is that the problem is that improvement in the quality of health care is slow because we are still on the left hand side of the curve, and change will speed up in the future. Or, perhaps, we will eventually figure out how medical care can be automated.


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  • Stuff for Health Care Systems (PHMD2350)

    What is this post about? Look here.


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  • Bar graphs

    Via Anna Swartz:

    bar graph


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