• The Health Policy Salon: Every third Friday of the month

    The Health Policy Salon is starting. If you’re in Boston, you might want to attend. Details follow.

    Who? Any health policy wonk, but the incomparable Emma Sandoe and I will attend for sure. (This is our idea.) We’ve heard from several others that they’ll be there, but I’m not putting them on the spot by naming names.

    What? A gathering to share ideas, coffee, breakfast (as desired)

    Where? A coffee shop in downtown Boston. Email for exact location. It won’t always be in the same place, maybe.

    When? Every third Friday of the month, typically. The first one is this Friday, September 19. Emma and I will attend from 7:15AM until at least 8:15AM, though anyone can come and go as they please. Future gatherings will be announced on TIE and Twitter with location details by email. So get on the email list.

    Why? To stimulate our thinking about issues pertaining to health policy and related research. Also to have fun.

    How? We will communicate with each other using our mouths, hands, facial expressions, and body language, and any other device, as needed, as one does in real life.

    Srsly? Yes.

    @afrakt

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  • *Five Days at Memorial*

    Hurricane Katrina hit New Orleans. Floodwaters rose in the Uptown streets surrounding Memorial Medical Center, where hundreds of people slowly realized that they were stranded. The power grid failed, toilets overflowed, stench-filled corridors went dark. Diesel generators gave partial electricity. Hospital staff members smashed windows to circulate air. Gunshots could be heard, echoing in the city. Two stabbing victims turned up at this hospital, which was on life support itself, and were treated.

    By Day 4 of the hurricane, the generators had conked out. Fifty-two patients in an intensive care wing lay in sweltering darkness; only a few were able to walk. The doctors and nurses, beyond exhaustion, wondered how many could survive.

    When evacuations were done, 45 patients had not made it out alive. The State of Louisiana began an investigation; forensic consultants determined that 23 corpses had elevated levels of morphine and other drugs, and decided that 20 were victims of homicide.

    That’s from Jason Berry’s review of Five Days at Memorial, by Sheri Fink. It sounds riveting, from the review. And it has its moments, to be sure. But, to me, the book is too long and confusing as, no doubt, were the events themselves.

    Later in the review Berry explains that the book is an extension of Fink’s Pulitzer Prize winning investigation. He called this a “literary gamble.” It’s great material for a gripping tale of ethically questionable decisions under challenging circumstances few could imagine in advance. It’s worth knowing and contemplating. But the gamble on this style, as a book, didn’t pay off. Some skimming and skipping may be warranted. Your mileage may vary.

    UPDATE: Bill Gardner’s take on the book is here.

    @afrakt

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  • The flow of pi

    Nice work by Cristian Ilies Vasile. Details of what this is at the link.

    flow-of-pi-cristian

    @afrakt

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  • AcademyHealth: Provider factors and regional variation

    Yesterday,  Louise Sheiner presented a paper at Brookings that challenges some of the the interpretations of Dartmouth research on geographic variation in health care. Her work suggests that patient, not provider, factors explain most of geographic (in her case, state) variation in spending. Coincidentally, I had already prepared a post reviewing work that comes to the opposite conclusion. It is not intended as a rebuttal to Sheiner’s work. You’ll find the post on the AcademyHealth blog.

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  • Methods: A short story

    As a basic primer, the methods tutorial in short story form by Martin Ravallion is a useful resource.

    This article provides an introduction to the concepts and methods of impact evaluation. The author provides an intuitive explanation in the context of a concrete application. The article takes the form of a short story about a fictional character’s on-the-job training in evaluation. Ms. Speedy Analyst is an economist in the Ministry of Finance in the fictional country of Labas. In the process of figuring out how to evaluate a human resource program targeted to the poor, Ms. Analyst learns the strengths and weaknesses of the main methods in ex post impact evaluation.

    Topics covered include: potential outcomes notation/framework, regression with and without a comparison group, propensity scores, difference-in-differences, and instrumental variables. A key omission is regression discontinuity. The suggested reading list is mercifully short. The paper is ungated.

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  • History of the $50k QALY threshold

    You’ll find it, and lots of other QALY details and limitations, in “Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold,” by Scott Grosse.

    The majority of investigators who used a $50,000 per QALY threshold beginning around 1996 were unclear as to the origin of the practice. Many used this value without citing a source for the practice. Still others cited sources that did not provide either theoretical or empirical support for thresholds of $50,000 per QALY or LY . [...]

    As Garber and Phelps stated, “The $50,000 criterion is arbitrary and owes more to being a round number than to a well-formulated justification for a specific dollar value”. This could account for the failure of subsequent studies to adjust the value for inflation or changing levels of income or healthcare budgets, a common criticism of the $50,000 per QALY value that applies to any fixed monetary threshold.

    Prior, recent, QALY threshold posts here and here. Searching TIE, I found a post defending QALYs from 2011 here. (Yes, it’s by me, but I had no memory of it.) Here’s a well-cited paper on willingness to pay for a QALY I’ve never blogged about (or don’t recall and can’t find evidence of) by Richard Hirth, Michael Chernew, and colleagues.

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  • Christina is an outlier

    Christina has a debilitating, severe case of Crohn’s disease, an extreme form of inflammatory bowel disease. Hers is a story of struggle, hope, near death, and life on the cutting edge of medical science.

    This is also personal. Christina is my sister-in-law, and her story is told by Jack, her husband, a health and science reporter with New Hampshire Public Radio.

    Listen here or below.

    @afrakt

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  • On Marketplace risk adjustment

    Below are links to three new papers on risk adjustment in the ACA Marketplaces. I have not read them in full, but intend to. This is an area I’ve found hard to get clarity on for some time. I hope these papers fill the void.

    1. Affordable Care Act Risk Adjustment: Overview, Context, and Challenges
    2. The HHS-HCC Risk Adjustment Model for Individual and Small Group Markets under the Affordable Care Act
    3. Risk Transfer Formula for Individual and Small Group Markets Under the Affordable Care Act

    At the links, you can download the papers. They’re ungated. (Your tax dollars at work.)

    @afrakt

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  • How much would you pay for a quality adjusted life year? — ctd.

    Previous coverage of this question here. In a recent NEJM Perspective, Peter Neumann, Joshua Cohen, and Milton Weinstein considered it.

    The $50,000-per-QALY ratio has murky origins. It is often attributed to the U.S. decision to mandate Medicare coverage for patients with end-stage renal disease (ESRD) in the 1970s: because the cost-effectiveness ratio for dialysis at the time was roughly $50,000 per QALY, the government’s decision arguably endorsed that cutoff point implicitly. However, the link to dialysis is inexact — and even something of an urban legend, given that the cost-effectiveness ratio for dialysis was probably more like $25,000 to $30,000 per QALY, the ESRD decision was controversial, and even at the time Medicare was covering some treatments costing more than $50,000 per QALY.

    Furthermore, the $50,000-per-QALY standard did not gain widespread use until the mid-1990s, long after the ESRD decision, and seems to stem more from a series of articles that proposed rough ranges ($20,000 to $100,000 per QALY) for defining cost-effective care. The field settled on $50,000 per QALY as an arbitrary but convenient round number, after several prominent cost-effectiveness analyses in the mid-1990s referenced that threshold and helped to congeal it into conventional wisdom. Researchers continue to cite the threshold regularly, although in recent years more have been referencing $100,000 per QALY. [...]

    Given the evidence suggesting that $50,000 per QALY is too low in the United States, it might best be thought of as an implied lower boundary. Instead, we would recommend that analysts use $50,000, $100,000, and $200,000 per QALY. If one had to select a single threshold outside the context of an explicit resource constraint or opportunity cost, we suggest using either $100,000 or $150,000.

    Not to detract from the piece at all, but just as a point of humor, I like the, “If you had to pick one, here are two” hedge.

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  • Deliberately bad designs

    Katerina Kamprani “has fun imagining the worst possible user experience with useless objects.” Here’s one of many at the link:

    the-uncomfortable-katerina-kamprani-9

    @afrakt

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