• Boston’s snow just went from amazing to unfathomable

    2015-02-15 07.15.54

    A view of my buried garage.

    Unless you’ve been living in a snow cave for a month, you’ve heard about Boston’s very (very, very, very) snowy winter, which is breaking all kinds of records. Last night and into today, we got another foot or so, on top of the six or so dumped over the past three weeks. The snow accumulations just went from amazing to unfathomable.

    I was already in awe of the snow before the latest dump. Snow banks towering over cars is one thing, but massively thick ones that reduce two lane roads to one are another. The standard line is that we have nowhere to put more snow. Even I’ve said as much, but it wasn’t really true at my house. I still had ready capacity … before today.

    I just came in from over four hours shoveling roofs, walkways and the driveway. (According to MyFitnessPal, I burned over 2,000 calories doing so. I’ll be eating a lot today.) And, that was aided by a Bobcat. I don’t know where it came from or who was driving, but it saved me several hours of work on the driveway. I only needed to scrape down to asphalt and clean the margins.

    2015-02-15 12.40.32-stairs label

    Snowscaped pile with makeshift stairs.

    That was hard enough. To make new capacity, I had to snowscape the big pile in front of my garage. I climbed up it on snowshoes to push snow off the top to make room for more.* To more easily deliver new snow to the top, I built some stairs by pounding in long two-by-fours.

    With this much snow, I had to cut some corners. I closed our front steps. Though we could still get down in an emergency, they’re no longer ready for regular traffic or deliveries.

    The snow is level with the bottom of some of our first floor windows. I can walk right up to the edge of our garage roof. The driveway is passable, but barely. The avalanches off our solar panels are thunderous. Keeping the hot water heater and furnace vents clear is a daily job. (On the plus side, though they don’t melt the snow directly beneath them, they do so a few feet out, making room to stuff in more snow.)

    More snow is in the forecast. I have only one more place to put it: inside the garage itself. I just might.2015-02-15 12.16.16

    * The pushed snow dumps into the neighbor’s driveway, but a portion they said they’re not going to use. Their second car buried there won’t move for months. (It’s also where I push garage roof snow.)


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  • Weak nutrition science and public health: hard to mix

    For the Washington Post, Peter Whoriskey reports:

    The nation’s top nutrition advisory panel has decided to drop its caution about eating cholesterol-laden food, a move that could undo almost 40 years of government warnings about its consumption. […]

    The finding follows an evolution of thinking among many nutritionists who now believe that, for healthy adults, eating foods high in cholesterol may not significantly affect the level of cholesterol in the blood or increase the risk of heart disease.

    According to my reading of Gary Taubes’ Good Calories, Bad Calories, this is, at long last, consistent with the available evidence. However, the Post article makes no mention of any consideration of the role of carbohydrates, which probably is causing Taubes’ head to explode. (If you don’t know, his read of the evidence is that it is far more consistent with the idea that first world diseases — diabetes and obesity among them — are due to overconsumption of carbs. Though he’s also quick to admit that the evidence about anything in nutrition is not as strong as it could or should be.)

    By the way, Good Calories, Bad Calories (GCBC), though a seemingly thorough tour of the history of nutrition and its (abysmal) evidence base, is not an easy read. It’s very long, repetitive, and doesn’t do a good job of helping the lay reader comprehend the physiological mechanisms, to the extent they’re known (or hypothesized). Your mileage may vary.

    I see that Taubes has written a more recent book, which my be better in these regards. Or, perhaps, one of his articles or those of others offers a more accessible treatment of the carbohydrate hypothesis, but I don’t know. You can email or tweet at me if you’ve seen something particularly good and relatively brief in this area.

    One of the most interesting bits of meta from GCBC is the idea that maximal promotion for public health purposes must gloss over scientific uncertainty. Articulate just a little bit of daylight between the science as known and the science as we’d like to believe and getting people to “do the right thing” becomes substantially harder. (Imagine, in today’s environment, articulating a single shred of uncertainty about vaccination, for instance. It’d be a disaster, as we’ve already seen from fraudulent claims of harm from vaccines.)

    This tension comes through in Whoriskey’s reporting: “the problem in nutrition stems from the arrogance that sometimes accompanies dietary advice.” That arrogance exists, in part, because expressing uncertainty can water down impact. When one believes that one is likely on the right side of science, even with the uncertainty (and even when one is wrong about it), if one wants people to change, one cannot be the least bit wishy-washy. “We kinda think perhaps cholesterol is [or carbs are] not so good, maybe” will get you nowhere, as accurate a reflection of the science as that may or may not be.

    Science is hard enough. Evidence-based public health with uncertain science is often even harder. If there’s a good way out, short of just keeping mum until the science is “sufficiently certain” (whatever that means), I’m not sure what it is.


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  • Roses are red … wine

    Via Courtney Birst:

    roses are red wine


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  • Health insurance and labor markets: a job lock update

    The December 2014 issue of the Journal of Health Economics had a special section on health insurance and public sector labor markets. TIE research assistant Garret Johnson worked up brief summaries of papers in that section, which you’ll find here. Below are some observations about job lock based on his summary. (Some prior TIE coverage of job lock is here.)

    Clark and Mitchell analyzed 6,650 respondents to the Health and Retirement Study survey to investigate the relationship between retiree health coverage among public sector employees and private household wealth accumulation. Those covered by retiree health plans reported less wealth accumulated than similar private sector workers without retiree coverage. Controlling for socioeconomic factors and pension funds, federal workers had $116,000 less wealth and state and local government workers had $35,000 less wealth, relative to workers without retiree health insurance.  (The former was statistically significant, the latter not, possibly due to small sample size.)

    It’s plausible that individuals anticipate their retirement health care needs and expenses and accumulate greater savings when they have less coverage for it. One way to accumulate greater savings is to work longer. So, this naturally leads to the idea of job lock: when one does not have retiree health care coverage, one works longer, both for the health insurance available as a worker and in order to accumulate greater savings for health care expenses upon retirement.

    Note that there are two other ways to get this result, however. First, workers without retiree health coverage stay in their jobs for the health benefits (job lock). A consequence of that is that they accumulate greater savings, but they do so without anticipating future health care expenses. It’s just a passive consequence. Second, organizations that aren’t funding retiree health benefits (a form of deferred compensation) may make up for the loss in compensation with higher wages or larger pension contributions, leading to greater savings. Clark and Mitchell controlled for this possibility, however.

    Fitzpatrick found such a job lock effect among Illinois Public School employees. Illinois introduced retiree health coverage (called THRIP) for teachers in 1980 and Fitzpatrick examined the effects on retirement age of doing so. Before THRIP, exit rate of teachers was highest at age 65 (probability of retirement: 0.51). After THRIP, the exit rate of teachers at 65 decreased 40%, (probability of retirement 0.29). Meanwhile, exit rate of teachers at age 55 jumped 81% (from probability of retirement of 0.054 to 0.098).

    These findings suggest that employees shift the timing of their retirement in response to the availability of pre-Medicare retiree health benefits. Again, this could be due to two effects: the availability of coverage without working and the less need to save up for future health care costs.

    Shoven and Slavov found something similar. They used Health and Retirement Study data to examine the effects of retiree health insurance on likelihood of retiring for public and private sector employees. They found that retiree health coverage is associated with a 4.3% increase over 2 years in probability of leaving full-time employment between ages 55-59 (largely shifting to part-time work) and a 6.7% increase over 2 years in probability of leaving full-time employment between ages 60-64 (largely leaving the labor force). Among private sector employees, the effects are smaller, 2.3% and 5.8%, respectively, but the difference between public and private employees is not statistically significant.

    None of this is surprising, and it’s consistent with prior work on job lock.


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  • Medicare’s new technology add-on payments

    I did not know this was a thing:

    In 2001 CMS created the new technology add-on payment program for new technologies that represent a “substantial clinical improvement” and are inadequately paid under the [standard diagnosis related group (DRG) payment] system. New technology add-on payments supplement hospital DRG reimbursement with temporary payments for high-cost technologies.

    That’s from John Hernandez, Susanne Machacz, and James Robinson in the most recent Health Affairs. This actually makes some sense:

    [C]linically beneficial innovations involve higher costs but produce clinical benefits that accrue over months or years. Many policy analysts have highlighted the need for adjustments to the [payment system] to remove financial disincentives to adopting innovations that increase costs.

    I know it’s a bit weird to favor cost-increasing technologies these days. But it shouldn’t be if the benefits are worth it (a big and important “if”). Moreover, this is not just a U.S. thing:

    Many other countries, including Germany, France, and Japan, have adopted new technology payment adjustments for their hospital payment systems.

    The authors summarize those, contrasting them to Medicare’s. I’m not getting into that here. Suffice it to say, the idea of paying more to hospitals was not taken lightly by Congress or the Center for Medicare & Medicaid Services (CMS).

    Congress and CMS struggled to balance the goals of innovation and efficiency when they pioneered Medicare’s technology payment mechanisms. They adopted criteria to limit the number of eligible technologies, the payment level at which they are reimbursed, and the duration of the supplemental payments. […] CMS was more concerned about overadoption than underadoption of expensive new technology.

    In part for that reason, reimbursement is set below cost:*

    Payments are set at the lesser of 50 percent of the estimated difference between the hospital’s estimated costs and the DRG payment amount and 50 percent of the new technology cost. This means that hospitals incur financial losses when adopting cost-increasing new technologies, even with the new technology add-on payment program. […] New technology payments are limited to three years after FDA approval and commercialization of the technology. […] Hospitals experienced losses for ten of ten technologies [eligible in 2012-2013].

    Use of these new technology payments has been relatively modest.

    Between 2001 and 2015, CMS approved nineteen of fifty-three applications for the new technology add-on payment program (fifteen devices and four drugs or biologics were approved). […] The program has resulted in $201.7 million in Medicare payments in fiscal years 2002–13. This is less than half of the amount anticipated by Congress and only 34 percent of the amount projected by CMS.

    The article concludes with some interesting points about new, value-based payments, which are not adjusted for new technology.

    [T]he direct financial incentive created by emerging value-based payments is for providers to avoid or delay the adoption of cost increasing devices, diagnostics, and drugs, regardless of long-term savings or improved clinical outcomes.

    That new payment methods shift incentives toward cost-saving technologies was a point made by Weisbrod in 1991. See also the prior paper on Medicare’s new technology add-on payment by Clyde et al. (2006).

    I would not claim that Medicare’s new technology add-on program is a sensible way to manage health care technology. I do not know enough about it to make such a claim. What it shows, though, is that there is some (albeit perhaps meager) attempt by Medicare to manage technology with payment adjustments, with its attendant incentives and disincentives. This is interesting.

    * One should always wonder if cost estimates are accurate or, possibly, inflated to game this system. I don’t have direct evidence on this, but it is not implausible.


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  • “Split benefit” health insurance

    This article tests a novel solution in health insurance policy design, called a “split benefit”, focusing on high-cost interventions for which the value is uncertain. Currently, insurance is provided as an “in-kind” benefit, which is paid directly to the provider; this creates a sunk cost, thereby biasing decisions toward consumption. In the split benefit model, the insurer can split the benefit between the beneficiary and the provider. The insurer pays the provider only if the patient consumes.

    For example, for an expensive (say, US$50,000) procedure that the physician prescribes and the insurer must cover, the insurer will pay to the patient a fraction of the charge for the treatment (say, US$5,000). Then, the patient will have the option of using that US$5,000 for the treatment, with the insurer matching by paying the US$45,000 to the provider as usual. Or, the patient could keep the US$5,000 for some other purpose, which can vary.

    The paper, by Christopher Robertson and colleagues, discusses variations and limitations, as well as a randomized, vignette-based survey about the concept. Note, as I emphasized above, the target for this design is care of uncertain value, not all care. Legal, ethical, and clinical implications of the idea are discussed here (a paper that I have not read).


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  • AcademyHealth: Whether it’s painkillers or heroin, we’re still in an opioid epidemic

    Recent studies suggest that policies and practices to curb misuse of opioid painkillers may have been effective, in a way. But they may have also encouraged a shift to heroin. More in my AcademyHealth post.


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  • Medical research, in charts

    A couple weeks ago, Bill posted about the JAMA paper on medical research. Below I share a few of the paper’s charts. Some you may want to click to enlarge.

    1. The U.S. invests a lot in cancer. (But, note, cancer is nowhere near the top in terms of total health care spending or spending growth.)fig 5-development

    2. AHRQ and health services industry research funding grew a lot between 2004 and 2011.

    fig 6-funding

    3. OK, biotech is big.

    fig 7-sectors

    4. Here comes China.

    fig 10-china

    5. Or maybe not so much China. (“Highly valuable patents are defined by the frequency they are cited by other inventors in subsequent patent applications.”)

    fig 12-not so much china

    6. We’re more bullish on biotech and health insurance than other areas of health care, including hospitals.

    fig 14-bullish

    7. Biotech venture capital is holding steady (positive spin). It’s not growing as quickly as it was before 2009 (negative spin). See also this recent Health Affairs piece by Sabin Russell.

    efig 3- venture biotech

    8a. Evidence of allocative inefficiency.

    efig 4 - burden of disease

    8b. Another look, via Chad Cotti:

    burden of disease


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  • Signage

    Via Ruth Jackson:

    sign not in use


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  • Thoughts provoked by Philip Klein’s *Overcoming Obamacare*

    Philip Klein’s Overcoming Obamacare provoked a few thoughts, some of which I list below. (See also Aaron’s post about the book.)

    • Separating possible conservative health reform ideas into Reform, Replace, and Restart schools of thought works (though imperfectly) as a policy exercise. I’m not sure it works politically. As Klein expressed, one can view “repeal and replace” as “reform” and vice versa.
    • The approach is imperfect because reform is multidimensional. Avik Roy’s proposal, which dominates the Reform School chapter, would preserve quite a bit of the ACA’s structure (relative to other approaches) but would not, over time, retain that of Medicare. On the other hand, a 2017 Project proposal, described in the Replace School chapter, would offer tax credits that vary by age, not income — quite a departure from the ACA’s approach. But, it would not change Medicare. Which is reform and which is replace? It depends what specific domain of policy you consider.
    • It’s likely that different politicians will find it advantageous to characterize the very same proposal in different ways, depending on their constituency. For instance, a Red state Republican may need to say that a plan repeals Obamacare (or else be out of a job upon next election). A Republican in a more moderate state, perhaps one with a large population relying on the ACA for coverage, may need to characterize it as retaining Obamacare but making some improvements. Any Democrat supporting a health policy change is likely to have to say the same. The actual proposal may not differ, but the characterization may need to. Can two apparently contradictory characterizations coexist politically? Or will some leverage one characterization to disrupt the message of the other? (Imagine someone attacking a Red state Republican as a fraud because the plan s/he says repeals Obamacare really does not, according to moderate Republicans in other states.)
    • I thought the discussions of which budget baseline, pre- or post-ACA, against which to measure health policy proposals was the most interesting dividing line. Anything measured against post-ACA can be viewed by some as caving to the budget preferences of the left. Anything building up from pre-ACA is, by definition a “repeal” approach, tend to be more radical (in the sense of deviating further from the ACA). I’m not sure how practical it is to budget as if the ACA didn’t happen, given the reality that we’ve been existing in a post-ACA world for five years (and will have been for over seven by the time any new reforms could be put in place).
    • Klein gets around to the real crux of the problem, which is bringing white paper proposals into the messy political fray and accommodating important stakeholders. Expect a great deal of turmoil and adjustment once a policy moves from the think tank conference table to the congressional committee room. What comes out may not look a great deal like what went in. My expectation is that it would move toward the Obamacare structure, not away from it. Why? Because Obamacare was shaped, in large part, by the same forces and stakeholders that will bear on anything that might come after it — hospitals, insurers, pharmaceutical manufactures, physicians and so on. And they have all become more, not less, invested. That’s not to say some change isn’t possible or desirable. It’s just to suggest that change as radical as some now promote is far less likely.
    • Governor Bobby Jindal’s idea that Republicans should be willing to take large political risks to reshape health policy strikes me as the wrong way to sell anything to politicians. Yes, Democrats did take political risks with the ACA, but I think they believed that they would turn into rewards as people came to understand, rely on, and like the law. That turned out not to play out as expected, but my point is that the push for health reform was not sold as a political risk, even if it was. To open with the idea that a party should plan on losing some seats over a legislative agenda — while noble and, perhaps, realistic — seems like a very tough sell.
    • As Klein notes, a lot could change in 2015. He is (and I am) thinking of King v. Burwell. If residents in more than half the states lose access to subsidies, that’s going to provide a lot more motivation for some kind of legislative action, but also a lot of opportunity for political grandstanding and obstruction. It’s also going to happen — if it happens — just as we’re entering the 2016 presidential campaign. I expect that will only make things messier and harder. But, recognize that things won’t change in many states, no matter the King v. Burwell outcome. Political actors from those states may not be as motivated for radical change as are those from states that lost access to subsidies. Why should Massachusetts, say, upset their apple cart to reshape health policy to Mississippi’s liking, for instance?

    Overcoming Obamacare is a very useful summary of conservative health policy thought. There’s plenty in it I don’t agree with and some things I do, but that’s not the point. If you want to understand how some conservatives would prefer move the country in health care, it’s a worthwhile read.

    Disclosure: Philip shared an advance copy of his book with me.


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