• Why the Spike in Vaping Deaths and Illnesses?

    Electronic cigarettes, like Juul, have been in use in the United States for over a decade now, so what’s up with the sudden spike in e-cigarette related illnesses? Spoiler: We wish we knew more.

     

    @DrTiff_

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  • Which Health Policies Actually Work? We Rarely Find Out

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company) and on page A13 of the print edition on September 10, 2019.

    A few years ago, Oregon found itself in a position that you’d think would be more commonplace: It was able to evaluate the impact of a substantial, expensive health policy change.

    In a collaboration by the state and researchers, Medicaid coverage was randomly extended to some low-income adults and not to others, and researchers have been tracking the consequences ever since.

    Rigorous evaluations of health policy are exceedingly rare. The United States spends a tremendous amount on health care, but very little of it learning which health policies work and which don’t. In fact, less than 0.1 percent of total spending on American health care is devoted to evaluating them.

    As a result, there’s a lot less solid evidence to inform decision making on programs like Medicaid or Medicaid than you might think. There is a similar uncertainty over common medical treatments: Hundreds of thousands of clinical trials are conducted each year, yet half of treatments used in clinical practice lack sound evidence.

    As bad as this sounds, the evidence base for health policy is even thinner.

    A law signed this year, the Foundations for Evidence-Based Policymaking Act, could help. Intended to improve the collection of data about government programs, and the ability to access it, the law also requires agencies to develop a way to evaluate these and other programs.

    Evaluations of health policy have rarely been as rigorous as clinical trials. A small minority of policy evaluations have had randomized designs, which are widely regarded as the gold standard of evidence and commonplace in clinical science. Nearly 80 percent of studies of medical interventions are randomized trials, but only 18 percent of studies of U.S. health care policy are.

    Because randomized health policy studies are so rare, those that do occur are influential. The RAND health insurance experiment is the classic example. This 1970s experiment randomly assigned families to different levels of health care cost sharing. It found that those responsible for more of the cost of care use far less of it — and with no short-term adverse health outcomes (except for the poorest families with relatively sicker members).

    The results have influenced health care insurance design for decades. In large part, you can thank (or curse) this randomized study and its interpretation for your health care deductible and co-payments.

    More recently, the study based on random access to Oregon’s Medicaid program has been influential in the debate over Medicaid expansion. A state lottery — which provided the opportunity for Medicaid coverage to low-income adults — offered rich material for researchers. The findings that Medicaid increases access to care, diminishes financial hardship and reduces rates of depression have provided justification for program expansion. But its lack of statistically significant findings of improvements in other health outcomes has been pointed to by some as evidence that Medicaid is ineffective.

    @afrakt

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  • Some Unpleasant Facts about Research Priorities

    Sickle Cell Disease affects 100,00 Americans, and has been pretty well understood for a long time. So, why are there only two drugs available for the condition? Why are so few research dollars allocated to the problem? Well, the answers aren’t very nice.

     

    This video was adapted from a column written by Aaron Carroll for the Upshot. Links to sources can be found there.

    @DrTiff_

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  • Affordable Health Care is a Mirage

    This piece originally appeared in Public Health Post and is coauthored by Elsa Pearson (@epearsonbusph) and Austin Frakt (@afrakt). Research for this work was funded by the Laura and John Arnold Foundation.

    Health insurance is supposed to help us pay for expensive medical care, but what if the insurance itself becomes too expensive? What happens to our health?

    Private health insurance premiums are ever increasing. Premiums for a family plan grew 25% nationwide between 2012 and 2018, increasing much faster than wages.

    Higher premiums mean more people forgo insurance altogether. When individuals are uninsured, they use less health care—including preventative care—and even have higher chances of dying.

    It is possible to make progress on taming health care cost growth, which often makes its way into insurance premiums. In Massachusetts, employer-sponsored insurance premiums are the highest in the country, and they keep growing. Yet, compared to the rest of the nation, the state has done a good job improving access to care and addressing spending growth. Two major laws are responsible.

    Chapter 58—sometimes called RomneyCare—was passed in 2006 to expand access to affordable health insurance through state and federal subsidies. To address health care costs, Chapter 224 was passed six years later. Among other things, it established the Massachusetts Health Policy Commission, which sets health care cost growth goals and monitors the state’s progress.

    Both laws were successful; the state boasts the lowest uninsured rate in the country and an annual health care spending growth rate below the national average for most of this decade. Still, health insurance costs—especially for private plans—are persistently high.

    Premiums are only part of it. Out-of-pocket spending for private plans—deductibles, coinsurance, and copays—has also increased considerably nationwide.

    The individuals hit hardest by this cost growth are those stuck in a coverage gap, with incomes too high to qualify for Medicaid but too low to comfortably afford a private plan. Massachusetts residents below 300% of the federal poverty level and enrolled in employer sponsored insurance spend nearly a third of their entire income on health care.

    They are underinsured—they have insurance, but also deal with unaffordable out-of-pocket costs. In 2018, nearly 30% of insured adults in the United States were underinsured. Of that 30%, four in 10 admitted to delaying care because of cost.

    Just like being uninsured, being underinsured has consequences. People who have to pay more out-of-pocket tend to delay or skip care because of the added cost. A study in JAMA Pediatrics found that some parents of children with asthma rationed their children’s medications and even delayed appointments when out-of-pocket costs were high.

    Without change, health insurance will become even less affordable for more people over time, increasing the number who forgo coverage or care altogether. What could we do to fix this?

    For one, Massachusetts has set the state’s health care cost growth benchmark at the national rate of 3.1%. If the state can stay below this, it could help prevent health care costs from getting worse. Other states could follow suit and establish or maintain annual growth benchmarks of their own.

    But insurance is expensive now; what else could be done in Massachusetts and elsewhere?

    For those who purchase insurance on the exchange, many states have good and modestly priced options. In Massachusetts, individuals with exchange plans spend the least amount of their income on health care spending compared to those with any other type of insurance.

    For those with employer sponsored insurance, states could push employers to offer affordable insurance options. For example, Massachusetts could make permanent a law that penalizes employers who should offer affordable insurance but don’t. It’s set to sunset at the end of 2019, but allowing it to do so would be a step backwards, removing an incentive for employers to use their negotiating influence to reduce health care costs.

    High health insurance costs are built into our system by years of uncontrolled spending growth. States have made progress in addressing the issue, but, for many Americans, insurance is still unaffordable. With unaffordable insurance comes skipped coverage, delayed care, and worsening health. Future reform must close the insurance coverage gap in which so many Americans are still stuck.

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  • New Research On Plant-Based Diets and Mortality

    A new study out this month claims plant-based diets are associated with lower risk of not only cardiovascular disease and mortality but of all-cause mortality as well. Let’s see how the results stand up to scrutiny.

     

    @DrTiff_

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  • Why Doctors Still Offer Treatments That May Not Help

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company). It also appeared in the print edition on August 15, 2019.

    When your doctor gives you health advice, and your insurer pays for the recommended treatment, you probably presume it’s based on solid evidence. But a great deal of clinical practice that’s covered by private insurers and public programs isn’t.

    The British Medical Journal sifted through the evidence for thousands of medical treatments to assess which are beneficial and which aren’t. According to the analysis, there is evidence of some benefit for just over 40 percent of them. Only 3 percent are ineffective or harmful; a further 6 percent are unlikely to be helpful. But a whopping 50 percent are of unknown effectiveness. We haven’t done the studies.

    Sometimes uncertain and experimental treatments are warranted; patients may even welcome them. When there is no known cure for a fatal or severely debilitating health condition, trying something uncertain — as evidence is gathered — is a reasonable approach, provided the patient is informed and consents.

    “We have lots of effective treatments, many of which were originally experimental,” said Dr. Jason H. Wasfy, an assistant professor of medicine at Harvard Medical School and a cardiologist at Massachusetts General Hospital. “But not every experimental treatment ends up effective, and many aren’t better than existing alternatives. It’s important to collect and analyze the evidence so we can stop doing things that don’t work to minimize patient harm.”

    @afrakt

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  • Facts Don’t Really Change Minds

    GMOs. Vaccines. Death Panels. There are a lot of “beliefs” circulating about a wide variety of health policy issues. Luckily, these are all pretty well researched areas. Thanks to thorough investigations, we can conclude with certainty that vaccines are safe and effective, that GMOs are generally safe, and that the Affordable Care Act was not intended to execute any old people. But here’s a funny thing about these beliefs: giving the facts to people who are against these things doesn’t convince them to change their mind. Often, the people who hold to these ideas most stridently are the least knowledgeable about science, but BELIEVE they are the most knowledgeable about these subjects. Let’s talk about Dunning-Kruger and the paradox of incompetence.

     

    This video was adapted from a column Aaron wrote for the Upshot. Links to sources can be found there.

    @DrTiff_

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  • Planned Parenthood Withdraws from Title X Funding: What Does That Mean For Patients?

    Title X is a federally funded Family Planning Program that has been around since 1970 as part of the Public Health Service Act. Following new restrictions on healthcare providers in clinics receiving Title X funding, Planned Parenthood announced this week that it would withdraw from the federal program.

     

    @DrTiff_

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  • JAMA Forum: Price transparency

    The idea behind price transparency is that informed consumers can price shop for medical services that have widely varying prices, like elective surgeries or magnetic resonance imaging (MRI). The concept is very popular, both in the United States and abroad. Most recently, President Trump signed an executive order aimed at requiring hospitals to disclose what patients will “actually pay” for care. But evidence shows that transparency does little by itself. Some argue health care prices may actually go up in some cases. Giving consumers information alone does not mean they will actively use it to shop around for lower costs.

    That’s from my piece at JAMA Forum with Gilbert Benavidez. It’s mostly the sad tale of woe about how price transparency isn’t working out the way many hoped. But, there’s a glimmer of optimism at the end.

    For example, a recent article in the American Journal of Health Economics by Christopher Whaley, PhD, and colleagues at the University of California, Berkeley, examined pairing price transparency with reference pricing for Safeway employees. […]

    The study watched for employee health care behavior changes over 2 years, looking at laboratory and imaging test prices. After the first year, during which only price transparency tools were offered, the authors confirmed the findings of previous studies: health plan members rarely shopped.

    But when the reference pricing information was added in the second year things changed. Shopping picked up and prices decreased. Specifically, laboratory test prices dropped 27% and imaging test prices decreased 13%. The authors concluded that price tools will capture the attention of consumers only if the consumers have strong financial incentives to shop in the first place.

    It’s only one study. Clearly we need to see a lot more work on price transparency paired with reference pricing. Still, it’s the most promising thing in this area I’ve seen.

    Research for this piece was supported by the Laura and John Arnold Foundation.

    @afrakt

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  • Why Warning Pregnant Women Not to Drink Can Backfire

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company)

    In many areas of health policy, the best of intentions can lead to more harm than good. Such is the case with America’s approach to alcohol and pregnancy.

    The best evidence shows that punitive policies — such as equating drinking while pregnant as child abuse and threatening to involve child protective services — can dissuade women from getting prenatal care.

    Fetal alcohol spectrum disorders refer to a collection of problems in babies and children. These include low birth weight; impaired growth; and problems in the heart, kidneys and brain. Children can have developmental delays, communication difficulties, learning disabilities and lower I.Q. Some of these last a lifetime.

    It’s hard to know how many American children are affected. Studies done by the Centers for Disease Control and Prevention have estimated that between 2 and 15 infants per 10,000 born in the United States have fetal alcohol syndrome, the most severe form of the disorders.

    Some community-based studies that use the broader definition of the disorder have found more affected children, up to 5 percent.

    We know that infants of women who drink alcohol in pregnancy may develop these disorders. The problem is what we don’t know. We don’t know the level of alcohol exposure in utero that could cause a child to develop these disorders. We don’t know if the timing of the exposure matters. We don’t know why some women who drink little might have a child who is affected, while some can binge drink during pregnancy and have a child with no apparent problems.

    Because of this, most medical organizations, including the American Academy of Pediatrics and the C.D.C., recommend that women forgo alcohol during pregnancy. The only dose known to be “safe” is none, they say, and therefore women should not drink at all.

    Many women in the United States comply with this directive. But a significant number do not.

    study published in April found that 11.5 percent of women who are pregnant report drinking alcohol. Almost 4 percent report binge drinking — defined as four or more drinks on any occasion — in the last month. Given that women may be ashamed to acknowledge this, the true numbers may be higher.

    To combat this, 43 states have enacted policies. These can be affirmative measures, like giving pregnant women priority for substance-abuse treatment, or punitive ones, like defining drinking alcohol during pregnancy as child abuse or neglect.

    Proponents of such policies believe that they are making things better, especially for children. A recent study suggests they’re wrong.

    Researchers gathered birth certificate data for more than 155 million live births from 1972 to 2015. The researchers were interested in how many children were born at a low birth weight or prematurely. They compared the rates of these undesirable outcomes in times and places when alcohol-pregnancy policies did and did not exist. They controlled for a number of demographic and related factors, including those known to be associated with poorer birth outcomes, like poverty and cigarette smoking.

    They found that policies that defined alcohol use during pregnancy as child abuse or neglect were associated with an increase of more than 12,000 preterm births. The cost of these were more than $580 million in the first year of life. Policies mandating warning signs where alcohol was sold were associated with an increase of more than 7,000 babies born at low birth weight, at a cost of more than $150 million.

    A previous study looking at how these policies affected women’s drinking found mixed results. States with punitive policies had more drinking, not less. Over all, neither type of policy seemed to be associated with lower levels of drinking.

    It’s possible that states that already had more drinking might have put such policies in place in response to it. But the research methods used accounted for this and state-level data on drinking, and the prevalence of fetal alcohol spectrum disorders weren’t available when most of the policies were enacted, making it hard to believe that the relative levels of problems were what spurred policymakers to act.

    Dr. Sarah Roberts, an associate professor of obstetrics and gynecology at the University of California, San Francisco, is an author of this study and other related work. Doctors have long discussed potential dangers with patients, one on one, with many benefits, she noted. But policies that punish women for or publicly warn them about harms from alcohol or drug use during pregnancy may lead to further harms by scaring women into forgoing prenatal care, she said.

    Such policies may even convince them that talking with their physicians isn’t a good idea.

    “Qualitative research finds that pregnant women who use drugs avoid prenatal care out of fear that, if their providers find out about their drug use, they will be reported to child protective services and lose their children,” she said. “Our study found that child abuse/neglect policies led to decreased prenatal care use.”

    Other research confirms this hypothesis. Three years ago, researchers (including me) published the findings of a survey on legal requirements for drug testing in prenatal care. Although most women were tolerant of laws requiring screening of pregnant women, 21 percent reported they would be offended if their doctors asked them about drug use as part of prenatal care, and 14 percent said that mandatory testing would discourage prenatal care attendance.

    It’s that last bit that most concerns physicians. Avoiding medical care is not what we’d like to see happen.

    The goal of all of these policies is to improve the health not only of pregnant women, but also of the children they bear. Many people assume that if physicians simply provide more information — if women are just warned — things will improve. Without research, those assumptions are just unproven hopes.

    Dr. Roberts had two suggestions for what might work better. The first: Start over and go through a rigorous process of engaging with women who drink during pregnancy to find out — from them — what would help. Second, stop treating pregnancy as a special case when it comes to alcohol.

    “There is some evidence that general population alcohol policies — such as limiting where alcohol can be sold — are associated with improved birth outcomes,” Dr. Roberts said. “This makes sense as research shows that the biggest predictor of drinking during pregnancy is drinking before pregnancy. Women don’t start drinking during pregnancy; if they drink during pregnancy, it’s usually a continuation of the way and the amount they were drinking prior to pregnancy.”

    It might be better to spend time making sure that women are connected to the health care system in general, and that they enter pregnancy healthy — rather than focusing on the nine months of pregnancy, as if that were the only time that mattered.

    It’s easy to stigmatize women who drink during pregnancy, with words and with policy. The goal, though, is healthier mothers and infants. To achieve that, policymakers may need to stop stigmatizing and start over.

    @aaronecarroll

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