• The latest prostate cancer screening literature review

    Julia Hayes and Michael Barry published a new prostate cancer screening evidence review paper at JAMA. This is one of the (admittedly few) areas of clinical research I follow fairly closely. So, I feel some obligation to post about the paper. On the other hand, I’ve got some job lock posts and other work to attend to. So, I’ll make this brief.

    The literature review updates prior ones found here and here (possibly gated). Though it is primarily a review of studies of prostate cancer screening, it also briefly covers some recent treatment, adverse effects, and statistical (simulation) modeling literature.

    Here’s the abstract by Hayes and Barry:

    Importance: Prostate cancer screening with the prostate-specific antigen test remains controversial.

    Objective: To review evidence from randomized trials and related modeling studies examining the effect of PSA screening vs no screening on prostate cancer–specific mortality and to suggest an approach balancing potential benefits and harms.

    Evidence Acquisition: MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials were searched from January 1, 2010, to April 3, 2013, for PSA screening trials to update a previous systematic review. Another search was performed in EMBASE and MEDLINE to identify modeling studies extending the results of the 2 large randomized trials identified. The American Heart Association Evidence-Based Scoring System was used to rate level of evidence.

    Results: Two trials—the Prostate, Lung, Colorectal and Ovarian (PLCO) screening trial and the European Randomized Study of Screening for Prostate Cancer (ERSPC)—dominate the evidence regarding PSA screening. The former trial demonstrated an increase in cancer incidence in the screening group (relative risk [RR], 1.12; 95% CI, 1.07-1.17) but no cancer-specific mortality benefit to PSA screening after 13-year follow-up (RR, 1.09; 95% CI, 0.87-1.36). The ERSPC demonstrated an increase in cancer incidence with screening (RR, 1.63; 95% CI, 1.57-1.69) and an improvement in the risk of prostate cancer–specific death after 11 years (RR, 0.79; 95% CI, 0.68-0.91). The ERSPC documented that 37 additional men needed to receive a diagnosis through screening for every 1 fewer prostate cancer death after 11 years of follow-up among men aged 55 to 69 years (level B evidence for prostate cancer mortality reduction). Harms associated with screening include false-positive results and complications of biopsy and treatment. Modeling studies suggest that this high ratio of additional men receiving diagnoses to prostate cancer deaths prevented will decrease during a longer follow-up (level B evidence).

    Conclusions and Relevance: Available evidence favors clinician discussion of the pros and cons of PSA screening with average-risk men aged 55 to 69 years. Only men who express a definite preference for screening should have PSA testing. Other strategies to mitigate the potential harms of screening include considering biennial screening, a higher PSA threshold for biopsy, and conservative therapy for men receiving a new diagnosis of prostate cancer.

    I’ve already blogged about many of the studies and related papers referenced above and in the literature review, as well as some that are not. You’ll find it all under the prostate cancer tag.


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  • Job lock: Theory

    Links to all posts in the series to which this post belongs are in the introductory post

    On what basis does one have a reason to believe job lock exists? As Gruber and Madrian wrote,

    The very notion that health insurance is responsible for imperfections in the functioning of the U.S. labor market is somewhat curious. After all, health insurance is a voluntarily provided form of employee compensation. There is little discussion of the distortions to the labor market from cash wages. Why is health insurance different?

    As Gruber and Madrian show, in a perfectly competitive labor market in which employers can select which workers to whom they offer health insurance, employer-sponsored health insurance (ESI) does not impose any distortions on job mobility. Any firm wishing to hire a given worker either must offer that worker insurance or offer wages increased by precisely the cost of coverage for that specific worker. Since, in this simple model, employers can freely choose to whom they offer coverage, if an individual wishes to change jobs, she simply asks her new employer for health insurance—if she wants it—or the equivalent in wages of the cost of her coverage—if she prefers that. Since the cost is the same, it makes no difference to the employer.

    Perhaps you can already identify some of the ways in which the real world deviates from this simplified model. Gruber and Madrian run through them. First, for all practical purposes employers are constrained in their ability to offer health insurance to some workers and not others. For one thing, according to Gruber and Madrian, the IRS will not grant favorable tax treatment of ESI unless “most workers are offered an equivalent benefits package.” (More about this and other legal constraints in a future post in the series.) For another, it would be prohibitively costly for firms to assess the precise cost of coverage for each worker.

    Second, the labor market is not perfectly competitive. Firms face different prices for labor in part because they face different prices of coverage. In particular, large firms can obtain coverage more cheaply than small firms for several reasons (fixed administrative costs, lower risk due to the pooling of greater numbers of individuals). A consequence is that workers cannot obtain the same benefits across jobs, and they will attempt to match their preferences with employers that can accommodate them, a precondition for job lock.

    Gruber and Madrian consider a situation in which a worker holding a job at firm A, which offers health insurance that the worker finds valuable. Assume that the worker would be more productively employed at firm B. However, insurance costs at firm B are much higher than at A, perhaps because it is a smaller business. As a result, firm B doesn’t offer coverage. Even if it would like to hire the worker, firm B can’t just offer coverage to him alone, for reasons discussed above. Unless firm B can offer a wage such that the worker can purchase insurance on his own and still be as well off as the combination of wages and insurance from firm A, the worker will not switch jobs.

    Gruber and Madrian then raise an interesting possibility. Firm A, knowing that the worker values insurance and won’t switch to firm B on that basis, could reduce the worker’s wages. However, there has been no study to suggest that such worker-specific wage adjustment according to preference for insurance occurs. Moreover, it would probably be administratively difficult to administer such fine-tuned compensation packages. If we assume that firms rarely engaged in such fine-tuning of wages, then the forgoing provides a theoretical reason to expect job lock, at least with regard to job mobility.

    But what about labor force participation?

    Although we have framed the preceding discussion around the specific issue of job mobility, the same model developed above can be applied to labor supply decisions as well. In this case, the choice for the worker is not between one job and another, but between employment and nonemployment, where the health insurance availability across these two states may possibly differ. For example, consider an older worker thinking about whether to retire. Even if his value of leisure is greater than his marginal product of labor, a less healthy older worker may be unwilling to retire from a job that offers health insurance if health insurance when not employed is either not available or prohibitively expensive. This is a form of “lock.”

    Gruber and Madrian go on to discuss theoretical considerations pertaining to “welfare lock” (that potential workers may not enter the labor force in order to maintain means-tested welfare benefits) and job lock within the context of a secondary worker (e.g., with a spouse who may be the source of health insurance coverage). These are not that different from what has been discussed above. So, for brevity, I will omit them.

    So, the theory seems fairly clear that job lock can occur. The question is, is there evidence in support of that theory? That’s the subject of subsequent posts in this series, the next of which will be on Monday.


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  • Stand Up! – March 19, 2014

    Aaron is 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. But today, I joined Pete instead.

    My talk with Pete included discussions about exchange enrollment and its stability, the future of health GOP plans for health reform, and we took some calls.

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


    Read the rest of this entry »

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  • Job lock: Introduction

    Ask an economist about employer-sponsored health insurance (ESI) and it won’t be long until s/he tells you it distorts the labor market. To most health economists, “job lock,” the idea that workers work more or face constraints in job mobility due to provision of work-related health insurance, is a real and important phenomenon. It’s one reason why many advocate limiting or ending the exclusion of ESI from taxation, among other reforms.

    But why, you might ask, do some so firmly believe in job lock? What’s the conceptual or theoretical explanation? Where’s the evidence that it exists and is substantial? If it exists, what laws and regulations help keep it in place? Finally, how does the Affordable Care Act (ACA) begin to address it, if at all?

    We’ve touched on some of these questions and their answers on this blog over the years, but never addressed them in full. That’s about to end. In a series of posts and with some help from Nick Bagley and Daniel Liebman, I will tackle these questions. Daniel’s annotated literature review lists some sources that will inform the series. I will not exhaustively cover the papers he described, but will attempt to provide a representative overview. For this purpose, I will rely most heavily on the literature reviews contained in Gruber and Madrian (2002)Fairlie, Kapur, and Gates (2011)Bradley, Neumark, and Barkowski (2013), and GAO (2011). Nick’s forthcoming post will cover the legal landscape. He has also provided helpful feedback on early drafts of my posts.

    By way of overview, the nature of ESI can affect the labor market in two ways. It can affect labor force participation (LFP), by creating disincentives for retirement—particularly before the age of Medicare eligibility—and affect the decisions of secondary workers (e.g., the spouse of a family’s primary wage earner). It can also affect job choice and create disincentives for job mobility, including entrepreneurship.

    Gruber and Madrian wrote a job lock literature review in 2002, covering the literature on the subject that had developed through that year. Their review, divides the literature into studies of job choice and analyses of LFP for three types of adults: older adults (near retirees), prime-aged men/married women, and single mothers. The last group is largely considered in the context of Medicaid, and the studies are more properly viewed as analyses of “welfare lock” (nonparticipation in the labor force so as to maintain eligibility for means-tested benefits). Gruber and Madrian concluded that “there is a fairly consistent case to be made that health insurance matters quite a bit for decisions such as whether to retire or to change jobs.” A systematic literature review published in 2011 by the GAO concurs with Gruber and Madrian. It found that of the 31 studies reviewed, “29 presented evidence consistent with job-lock.”

    This introductory post will serve as an index to the series’ posts. All expected posts are listed below, and links will be added as they posts go live.

    1. Job lock: Introduction [this post]
    2. Job lock: Theory
    3. Job lock: Relevant laws and regulations
    4. Job lock: Labor force participation (retirement decisions)
    5. Job lock: Labor force participation (married couples)
    6. Job lock: Job mobility
    7. Job lock: Entrepreneurship lock
    8. Job lock: What the ACA does
    9. Job lock: Conclusion


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  • The best Times of my life

    Today’s announcement by David Leonhardt is personally significant for obvious reasons and another that is less so: there’s a special place in my heart for The New York Times.

    I grew up with The Times. It was on my family’s breakfast table. My dad kept some front pages with all caps, banner headlines like “KENNEDY IS KILLED BY SNIPER,” “MEN WALK ON MOON,” “NIXON RESIGNS,” “THE SHUTTLE EXPLODES,” “CLINTON IMPEACHED,” OBAMA: RACIAL BARRIER FALLS IN HEAVY TURNOUT,” and many more. A few, protected in plastic, hung in my childhood home. The others were in my dad’s files, which he showed me.

    At an early age, my dad taught me how to read The Times. That may sound silly to an adult, but there’s a structure to the paper that isn’t obvious to a child. He showed me how to find the sports section, figuring that’d be a good gateway to the newspaper reading habit. I followed the Yankees and the Knicks. I read my first box scores in The Times.

    Later, my dad showed me that there’s a news index in The Times where I could get a quick synopsis of the prior day’s events—those that were “fit to print,” of course! As I grew older, he encouraged me to read more of the paper. I recall his advice as something like, “Read the front page and the op-eds. Look at the index. Find something international to look at. Find something local. Not everything, just something. Enjoy the sports section. Devote a half hour to the paper every day.” That half an hour grew to an hour, sometimes more.

    When I was older still, my dad taught me basic, financial literacy by helping me invest in mutual funds. I tracked their progress in The Times‘ business section. Of course, there was the beloved Science Times, which I devoured every Tuesday.

    I learned Times trivia, like that there used to be a period printed after “The New York Times.” Boy did that seem dumb to me as a kid. It’s not a sentence! To my relief, The Times editors had agreed with me, and in the late-60s, the period was dropped. A decade or so later, the format changed from eight columns to six. (Other changes to The Times are documented here.)

    Periods change, The Times with it. I recall when “The Grey Lady” added color. It seemed sensible, but it looked wrong to me. Still does. I remember when the paper’s width narrowed. That still looks funny too.

    But, I don’t actually look at the paper, as paper, much these days. The Times is online. I read it on my iPad. I get other news electronically too, and in different ways, through blogs and via Twitter. The Times is well aware aware of changes in the media biz—more aware than I am! Its very existence depends on keeping up, after all.

    So, it has blogs and new ways of delivering news and information too. Its latest initiative, “The Upshot“, headed up by David Leonhardt, is under development. And I’m very proud that Aaron and I will be part of it. We have been invited to contribute several posts per month, joining other great scholars and journalists. (TIE will stay right here, and we’ll be here too.)

    I—we—could not be happier or more excited. The Times has long been in my life. Now I will be in its.


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  • AcademyHealth: The financial protection effects of health reform, evidence from Massachusetts

    Over on the AcademyHealth blog I summarize some new evidence on the financial protection effects of the Massachusetts health reform. There’s actually very little research on just this, so you definitely want to take a look.



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  • The Advisory Board’s health care crossword

    The back-story is here. Click on the image below for a full-sized PDF of the puzzle. Enjoy!



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  • Feedback from readers on high deductible health plans

    In response to the recent content on high deductible health plans, by email, a reader asked,

    I am wondering what you all may think about high deductible coupled with high value services that can be covered in full regardless of whether deductible had been met. Things like insulin for those diagnosed with diabetes, for example. To an outside, more casual observer it seems like the argument is often to have deductible or not and less about how we can use the deductible.

    Indeed, this has come up on TIE, and more than once. I discussed it when reviewing John Goodman’s book. This idea is also consistent with the value-based insurance design paradigm. We have a tag for that!

    Coincidentally, David Napoli (@Biff_Bruise) wrote me with this interesting, related implementation problem:

    If one takes a value-based design approach to the overall plan design—in an attempt to promote certain high(er) value care services and possible integration of several types of services—such a design has an immediate impact on the actuarial value. It raises it, and it often raises it enough that the plan no longer qualifies for the metal tier one was targeting.

    So, one is then left with the situation of having to alter the plan to bring it back to the target metal tier’s standard. The natural thought is to then make the less valued services more expensive to a plan subscriber. Such an approach will frequently (but not always) run afoul of “Reasonable modification” guidelines/regulations of states’ Division of Insurance (DOI), thus requiring an insurer to cancel the current plan for the up-coming year and file an entirely new plan—resulting in notable member abrasion in the process.

    So what’s left within the actuarial value calculator [see the second occurrence of "2015 actuarial value calculator" at the link] that can also pass muster with the DOI? Yep, the deductible and/or maximum out-of-pocket limit. Obviously this can also cause member abrasion, but it does not impact every subscriber as would a plan cancellation.

    So, value-based design, which has a lot of virtues, can itself lead to increasing deductibles, albeit with less cost sharing for high value services that balance out the actuarial value.


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  • JAMA Forum: The innovation vs consumer protection tug of war in health policy

    In the overheated political environment surrounding the Affordable Care Act (ACA), it’s easy to miss the fact that conservative and liberal health policy proposals exist along a coherent continuum: each strikes a different balance between the desires to promote innovation and protect consumers.

    Read the rest in my new post over on the JAMA Forum. It explains the entire health policy debate in 800 words.*

    * No, not really, but I think you’ll find it worth your time.


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  • Interpreting the latest prostate cancer study

    Last week in NEJMAnna Bill-Axelson and colleagues published the latest findings from the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4).

    METHODS: Between 1989 and 1999, we randomly assigned 695 men with early prostate cancer to watchful waiting or radical prostatectomy and followed them through the end of 2012. The primary end points in the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) were death from any cause, death from prostate cancer, and the risk of metastases. Secondary end points included the initiation of androgen-deprivation therapy.

    RESULTS: During 23.2 years of follow-up, 200 of 347 men in the surgery group and 247 of the 348 men in the watchful-waiting group died. Of the deaths, 63 in the surgery group and 99 in the watchful-waiting group were due to prostate cancer; the relative risk was 0.56 (95% confidence interval [CI], 0.41 to 0.77; P=0.001), and the absolute difference was 11.0 percentage points (95% CI, 4.5 to 17.5). The number needed to treat to prevent one death was 8. One man died after surgery in the radical-prostatectomy group. Androgen-deprivation therapy was used in fewer patients who underwent prostatectomy (a difference of 25.0 percentage points; 95% CI, 17.7 to 32.3). The benefit of surgery with respect to death from prostate cancer was largest in men younger than 65 years of age (relative risk, 0.45) and in those with intermediate-risk prostate cancer (relative risk, 0.38). However, radical prostatectomy was associated with a reduced risk of metastases among older men (relative risk, 0.68; P=0.04).

    CONCLUSIONS: Extended follow-up confirmed a substantial reduction in mortality after radical prostatectomy; the number needed to treat to prevent one death continued to decrease when the treatment was modified according to age at diagnosis and tumor risk. A large proportion of long-term survivors in the watchful-waiting group have not required any palliative treatment.

    About 23 years ago, the investigators randomly assigned Scandinavian men with early prostate cancer to receipt of surgery (prostatectomy) or no surgery (watchful-waiting). Those assigned to the surgery group were less likely to die after 23 years of follow-up. Being less likely to die doesn’t mean not dying. In fact, only one man in eight benefited from surgery in general and one man in four among those under 65.

    Even though some men didn’t benefit from surgery, it’s not easy to tell in advance who those men would be. This is typical in medicine: more people get treated than will benefit because we can’t precisely target treatment to only those we know will benefit. In fact, those surgery “number needed to treat” (NNT) figures of eight in general and four under 65 are quite low. Lots of widely accepted therapies have higher NNTs.

    So, is this a slam dunk for prostatectomy? Are the great debates about whether and how to treat prostate cancer over? Nope.

    There are a number of other considerations. First, treatment comes with other effects besides potential mortality reduction (side effects and complications that impact quality of life). As Richard Lehman noticed, surgery

    definitely decreases all-cause mortality, at the cost of a prevalence of erectile dysfunction of 84% in the radical-prostatectomy group at 12.4 years and 80% in the watchful waiting group; urinary leakage was reported in 41% and 11%, respectively.

    (More on quality of life outcomes from prostate cancer treatment here.)

    Second, the results of this study aren’t necessarily generalizable to a US population, as Richard Hoffman explained.

    PSA screening became widespread in the US in the early 1990s—a decade before the first SPCG-4 publication. Perversely, the American way was to expend considerable resources to promote screening efforts to find cancers…before knowing whether these cancers could be successfully treated. [So,] the SPCG-4 results are not readily translatable to US practice. Only 5% of the study cohort had cancers detected by screening PSA—the rest either had symptoms and/or a palpable tumor. In the US, a substantial proportion of men with PSA-detected cancers have microscopic disease—which may never cause problems during a man’s lifetime. The US Prostate Cancer Versus Observation Trial (PIVOT) also evaluated surgery vs. watchful waiting. However, PIVOT, which mostly enrolled men with PSA-detected cancers, found no benefit for surgery. Post-hoc analyses suggested that only the small proportion of men with higher-risk cancers (based on PSA and the microscopic appearance of the cancer) seemed to have a survival benefit. This suggests that most men with PSA-detected cancers—the great majority of whom undergo aggressive treatment–will experience only the potential harms of treatment without any expectation of experiencing a prostate-cancer survival benefit.

    (More on the PIVOT results here.)

    Finally, the SPCG-4 study only compares surgery with watchful waiting, not to various forms of radiation therapy as well. Though the results certainly add to our body of knowledge about the long-term benefits (and harms) of prostatectomy relative to watchful-waiting, they do not, by themselves, answer all the questions patients or practitioners might have. It’s essential that the findings be interpreted in the context of the wider body of evidence, and in light of their limitations.

    The prostate cancer screening and treatment debates will most certainly go on.


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