The Incidental Economist

A recent study looked into ketamine, noted animal sedative and party depressant, as a short-term treatment for severe, emergency room level depression. While it can help people who are suffering from suicidal ideation, it is a short term treatment. Also, approving the drug would mean more accessible (and more easily abused) ketamine.

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Elsa Pearson is a Policy Analyst with Boston University’s School of Public Health. She tweets at @epearsonbusph. Research for this piece was supported by the Laura and John Arnold Foundation.

In general, the research literature on administrative costs, which I summarized in a prior TIE post, assesses three broad categories: billing and insurance-related costs, hospital administrative costs, and physician practice administrative costs. But, there has been little comparison of administrative costs across insurance types…until now.

As promised in that post, below is a review of the recent Gottlieb, Shapiro, and Dunn Health Affairs article that fills that gap in the literature. Gottlieb et al. focus on the differences in billing complexity across insurers. They use billing complexity as an indicator of the burden of total health care administrative costs within the US system.

Methods

The authors used 2013-2015 claims data from the IQVIA Real-World Data Adjudicated Claims. IQVIA collects claims data for all the payers with whom a sample of physicians contract or bill, allowing researchers to study differences across payers for the same provider. Gottlieb et al. principally analyzed a sample of 68,000 physicians in the 2015 IQVIA data, though also looked at trends in some measures from 2013-2015. They considered five insurance types: fee-for-service (FFS) Medicare, Medicare Advantage, FFS Medicaid, Medicaid Managed Care, and private.

The authors characterized billing complexity in multiple ways. One set of measures pertains to how much of each claim was never paid: amount challenged and share challenged. Amount challenged was defined as the difference between what was actually paid for services and the full negotiated price. Share challenged was defined as the fraction of the negotiated price that was never paid. The authors understand that challenged claims are not equivalent to total administrative costs but believe they are a strong indication of national cost trends.

In addition to these measures of challenged claims, they used another four complexity measures: time to payment, number of interactions between physician and payer, claim denial, and nonpayment.

The authors use these measures to characterize billing complexity in the following sense: challenging and denying claims, as well as additional interactions between physician and payer, requires work (and resources) from both parties. Effectively, billing complexity means that additional resources are ultimately required for each dollar paid.

Comparisons of measures across insurance types were conducted using physician-specific fixed effects and adjusting for the logarithm of the allowed charge, the number of claims, each patient’s Charlson Comorbidity Index score, and each patient’s age. This limited the impact of differing patient populations.

Results

The analysis included 37.2 million office visits, totaling 44.5 million insurance claims. FFS Medicare and private insurance each accounted for almost 40% of the claim data and included more lengthy claims due to more complex clinic visits.

Overall, the authors found Medicaid, both FFS and Managed Care, to be the most complex insurer across all measures. Both types of Medicaid had the highest shares challenged (21% and 13%, respectively) as well as the longest times to payment. Medicaid claims were also denied three times as much as Medicare claims. (Of note, given lower overall potential payments, the monetary value of Medicaid shares challenged was comparable to other insurance types.)

The authors found billing complexity to be notable regardless of insurance type (for example, private insurers still had a share challenged of 6%) though the variation between insurers was substantial. Exhibit 2 shows this variation.

Finally, Gottlieb et al. extrapolated national estimates of contested claims. They calculated that the US health care sector handles up to $54 billion in challenged claims a year (though this estimate may be on the high end).

Limitations

As with any study, there are a few limitations. The authors note that the data are limited to only the physicians who participated in IQVIA’s collection process. Further still, the data do not adequately capture the breadth of insurance administration. For example, the data do not contain costs associated with prior authorizations, actuarial services, or marketing.

Impact

Since billing complexity varies across payers, reducing billing complexity is possible. (In other words, if FFS Medicare can have lower billing complexity than FFS Medicaid, perhaps there is room for improvement in FFS Medicaid billing practices.)

Reducing the administrative headache and wasted financial resources associated with billing practices may cause some providers to be more willing to accept patients with public insurance. Providers could also reclaim time and resources spent on administrative activities for patient care, increasing productivity.

The authors suggest a better understanding of administrative costs could also impact health policy, particularly antitrust policy and merger evaluation. Insurers and providers alike could weigh billing complexity when considering payment contracts, pursuing contracts based on administrative burden. Because of this, governing leadership could start to consider these types of nonmonetary aspects of insurer/provider relationships when assessing proposed mergers.

Gottlieb, Shapiro, and Dunn offer a fresh perspective on US health care administrative costs through their analysis of billing complexity. There seems to be some promise that billing complexity—and its associated costs—could be reduced across payers. In a health care system wrought with expense, it’s encouraging to see room for even small improvements.

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This piece is authored by Tonya Pavlenko, a Research Analyst at Center on Poverty and Social Policy (CPSP) at Columbia University.

In the last year I’ve sat across from several hundred expectant mothers who are living in poverty. I meet them in overcrowded apartments, drafty shelter rooms, or the public library if things are too unstable at home. Over the course of an hour I ask them a series of very personal questions about their health, their financial and employment history, their relationships, and hopes for their baby’s future. I’m there to gather data for an evaluation of a poverty intervention program called Room to Grow, a program that aims to give expectant mothers the supports they need to help them and their newborns thrive. The program couples parenting supports from clinical social workers with valuable material goods that make parenting easier – think diapers, clothes, books, strollers, and the like. This is the beginning of a randomized controlled trial where we will study the impacts of the intervention, comparing mothers and babies who receive services from Room to Grow and those who do not—with the goal of being able to measure the capacity of this intervention to alleviate the symptoms of poverty for some of New York City’s most vulnerable mothers.

When I first began studying poverty I started with a common assumption—that it’s a relatively stagnant condition. The poor remain poor and the cycle of poverty endlessly churns across new generations. While this situation is true for many, the assumption of a fixed poor population is too reductive. The latest research demonstrates the transience and reach of poverty: 46% of New Yorkers have experienced poverty for at least one year. In 2013, 9% of New Yorkers remained poor across two consecutive years, while equal numbers entered or exited a spell of poverty in just one of those years. The implication is clear: poverty is movable, and interventions can help people escape.

Though we typically think of things like job loss or a pay cut as precursors to poverty, a surprisingly common trigger is the birth of a new baby. Consider Cara Williams. At 23, she is engaged and pregnant with her first child. On my way to meet Cara I take two subway lines and a bus, then walk 20 minutes through the blustering cold—the apartment she shares with her brother and cousin is on the outskirts of Brooklyn. While I walk I realize that this is part of her commute every day; to make rent in a city with some of the most expensive housing, she has been pushed to the outskirts. Loose trash blows at my feet; I notice a frayed wire hanging down the side of her apartment building, the cord precariously caught in some rusted window guards. There’s a buzzer system, but it doesn’t work—the steel door requires a mere shove and I’m inside a lobby that reeks of urine and mildew. A few people shuffle past, they look weary; they know I don’t live here, but give a friendly nod and hold the elevator door.

Cara greets me—her belly swollen, eyes tired—and guides me to the bedroom she shares with her cousin. It’s cramped. Everything is always cramped; often poverty is clutter in the midst of scarcity. There are two twin mattresses, separated by a night stand that has a careful arrangement of peanut butter jars, ramen noodle cups, and prenatal vitamins. Tacked above her bed is a print out of a sonogram next to a photo of her fiancé.

After graduating from high school, she had been working at a department store and taking some classes towards an Associate’s degree. Things were going well, her supervisor liked her and hinted about an upcoming promotion to a management position. When her first bouts of extreme morning sickness hit, however, Cara was forced to take time off from work. Unable to keep any food down, she was either at home suffering from weakness and dehydration, or at work running to the bathroom. It did not take long for her secret to come out. Instead of congratulations, however, the news of her pregnancy quickly replaced the potential for a promotion with a pat on the back and the understanding that she would be gone soon, with no maternity benefits and no guarantee of employment after the birth of her baby.

Cara had planned to work up until the ninth month of her pregnancy so that she could save as much as she could for herself and her child.  Her doctor insisted, however, that she go on bedrest or risk a premature delivery. Like almost any expectant mother, Cara did what was best for her baby and followed the doctor’s orders. With each hour of bedrest, she noted the $11.50 less she’d have for diapers, books, and baby food.

With her food stamp benefit as her only income since leaving work, she now officially lives in poverty.  And what is particularly harrowing about the poverty that follows birth is that there is no shortage of scientific data on the profound impact of poverty on child health and development. Studies have linked poverty during birth and infancy to impeded cognitive development in childhood as well as lower educational attainment and lower earnings later in life. The physical manifestations of poverty are also rampant—poverty is associated with a myriad of health conditions, including: low birth weight, premature birth, higher rates of morbidity and mortality, and chronic illness.

I’ve come to see that what’s needed is not more research into the problem, but research into solutions; rigorous measurements and analyses on what works to lift impoverished families out of poverty and what can prevent the most vulnerable from entering into poverty in the first place. What can funders and policymakers get behind; what trails can America start to blaze with social innovation?

Assistance programs for vulnerable families almost exclusively separate monetary support from social support. For example, many hospitals and nonprofits will offer parenting and prenatal classes for underserved mothers, but then send their clients home without the needed resources to put the lessons into practice. You can teach an expectant mother that reading aloud to her baby is crucial for cognitive development, but that lesson does not address the fact that the food stamps she receives—her only income while she’s been laid off from her part-time job for being pregnant—do not pay for a stack of baby books; they barely even pay for the food she needs to survive. On the flipside, once-a-year income-support policies like the Child Tax Credit (CTC) and the Earned Income Tax Credit (EITC) offer sporadic cash to families without any social support to back it up. While families should have autonomy over their cash expenditures, social and therapeutic support can help parents take advantage of reduced financial distress in order to better advocate for themselves’ and their children’s needs.

Though the impact of tax credits and parenting programs for disadvantaged moms are well known, there is a major gap in understanding the short and long-term impacts of interventions that fuse financial support with parenting supports. This is why I find a program like Room to Grow so compelling. Mothers in the Room to Grow program form a relationship with a clinician—a social worker who meets with them every three months and stays in contact over the course of three years. During in-person visits, mothers like Cara work with their clinician to set goals, work through obstacles, and learn about their child’s needs and developmental milestones. At each visit, mothers also receive concrete material goods that help meet their needs for the particular phase of their baby’s development—over the course of 3 years, she receives $10,000 worth of in-kind support.

As I wrap up the interview with Cara, I ask her a final few questions about hopes she has for her baby’s future. She smiles: “I want him to know he is loved. And in life…I want him to achieve the things I just didn’t have a chance to,” she says. While the stories I hear are different, the answers to the last few questions rarely stray from these sentiments. I thank Cara and give her a hug before I leave. The next time I’ll talk to her is when her baby is 10 months old for the first round of study follow-up. By that time her son will be learning his first words and pulling himself up to stand; absent innovative programs like Room to Grow, it’s likely his first steps will be in the narrow space between two twin mattresses.

Under the direction of Chris Wimer and in partnership with Room to Grow, the Center on Poverty and Social Policy is currently conducting a randomized controlled trial of the Room to Grow program, an innovative poverty intervention that supports mothers and babies in the first three years of life. 

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The following originally appeared on The Upshot (copyright 2018, The New York Times Company). Research for this piece was supported by the Laura and John Arnold Foundation.

@afrakt

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Almost exactly two years ago, I experienced symptoms of sleep apnea. It lasted a couple nights, then disappeared until late December 2017. Naturally, I suspected nothing at the time, it being a one-off. In hindsight, it suggests my condition is not a few months old, but a couple of years.

It is indeed possible, according to the sleep expert in Calgary with whom I’ve corresponded. Sleep apnea can begin in mild, even intermittent form and gradually worsen over time, as one ages.

That’s a reasonable theory for my case. If true, it means my body has had a couple years to get good at responding to breathing difficulty during sleep. When my airway is blocked, it now rouses me, quite expertly, to consciousness if my sleep isn’t deep enough.

But, does it matter exactly how my airway is blocked? I don’t see why. My sleeping brain should react with the same panic.

Well, guess what? Provent therapy, which I’ve mentioned before works by restricting the airway on exhalation only. The point of this is to increase internal pressure that keeps the airway open. It does so with carefully crafted valves one applies to the nostrils with adhesive patches. They allow inhalation with little resistance, but exhalation is highly restricted. It’s ingenious, and there is evidence it can be effective for obstructive sleep apnea. See this systematic review and meta analysis.

The starter kit comes with two nights each of low and medium resistance patches, to help get used to the more extreme, therapeutic level patches. According to feedback from my wife, those worked pretty well for me. For the first time in years, I didn’t snore, she said. That’s by no means scientific evidence of reduction in apnea events, but it is consistent with it.

However, the standard, therapeutic level resistance is, to my taste, extremely restrictive. Except when I’m in deep (and, to date, Ambien-aided) sleep, my subconscious brain reacts the same way as to an apnea event. It wakes me up, and does so to consciousness more often than I’d like. Maybe one can get used to this. But it is darn hard to train one’s subconscious mind to relax and not panic during breathing restrictions.

Sleep hacking is hard … because you’re asleep!

So, it seems, at least until I get a more effective treatment (next week) I can choose my poison: wake up to apnea events (without Provent) or wake up to self-inflicted exhalation resistance (with Provent). Not much of a choice.

But there’s a third option. I can intentionally degrade Provent’s resistance by introducing some air gaps that partially bypass the device—basically trying to mimic the low-to-medium level resistance with the high resistance patches I have left. (I haven’t seen lower level resistance patches on the market. Anyway these things are expensive, so I’m not sure I’d buy them, having already invested in the starter kit that comes with ~30 pairs of standard resistance ones.)

Maybe I can find a balance between raising airway pressure enough to reduce apnea events, but not enough that my brain panics. I crudely experimented with this last night, but it was not a great test. More to come.

This is another way sleep hacking is hard. You can only experiment during the same type of sleep you’re having trouble with. That may only happen a few hours per night. There’s no way to speed up the cycle of innovation.

@afrakt

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Tracey Wilkinson (superstar faculty at IUSM) and I have a Viewpoint just out in JAMA Pediatrics:

Reproductive health advocacy has become more essential than ever before. Despite the United States having one of the highest rates of teen pregnancy among developed countries, general discomfort and unfamiliarity still persist among pediatricians regarding pregnancy and sexually transmitted infection prevention as well as provision of contraception. That attitude must change.

Go read it!!!

@aaronecarroll

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Have you bought into a low-carb or low-fat diet? Which one is the better answer for people who want to lose weight? It turns out, they both work about the same. A giant new study on nutrition is the subject of this week’s HCT.

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

@aaronecarroll

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As I mentioned in a previous post, I’m now the Web and Social Media Editor at JAMA Pediatrics. We’ve got a podcast where I discuss a paper from the journal. I do my best to pick good ones.

Please consider giving this a listen, and subscribe! Doing so makes it more likely that I’ll be able to keep doing this.

This week, I’m covering “Effectiveness of Universal Self-regulation–Based Interventions in Children and Adolescents: A Systematic Review and Meta-Analysis”:

This audio summary reviews a meta-analysis of clinical trials estimating the effects of interventions to improve self-regulation in children and adolescents on their health, academic, and social outcomes.

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I am trying to revive my yoga practice, with some success. I’m using the DownDog iPad app for home practice. I recommend it: it has good sequences, helpful instructions, and clear images to model the poses.

But I have a problem: Daily exposure to the instructor’s Yoga Voice is getting to me.

The Yoga Voice is the one that says that the instructor has Let Go Deeply and that they want you to give yourself double helpings of luscious Self-Care. The Yoga Voice is the cousin of the hated Poetry Voice:

After being introduced, a poet steps onstage and engages the audience with some light social speech. Maybe they talk about their forthcoming book, what they plan to read, how wonderfully warm it is for autumn here, how surprisingly cool for summer, how nice the people of this village and how prodigious the public works projects. During this banter the poet uses a slightly performative but mostly natural voice. It’s the voice they’d use to introduce you to their grandmother. Then they read the title of their first poem and launch into the first line. But now their voice is different. It’s as if at some point between the last breath of banter and the first breath of poem a fairy has twinkled by and dumped onto the poet’s tongue a bag of magical dust, which for some reason forces the poet to adopt a precious, lilting cadence, to end every other line on a down-note, and to introduce, pauses, within sentences, where pauses, need not go.

There’s likewise a Philosophy Voice, in which a bit of Oxbridge suddenly appears in the voice of a guy from Brooklyn, and many local dialects of Prayer Voices (tasting menu: try Canterbury, then Dallas, and finish with a bit of Salt Lake City).

To be fair, performative Voices serve real linguistic functions.

“I think [the Poetry Voice] frames [the poet’s performance] as poetry,” says Deborah Tannen, professor of linguistics at Georgetown University and author of You Just Don’t Understand. In linguistics, “framing” signals what you think you’re doing when you say something — your relationship to the words and to the people you’re saying them to.

So, yes, I am trying to be healthy, and it’s good to have a Voice reminding me that the practice is more than just another freaking chore, and maybe four days out of five the Yoga Voice is what I want to listen to.

However, there is a piece of me that just can’t stand being wholesome. I would be much better able to sustain a daily practice if I could occasionally select the same routine, with the same instructions, but delivered in a profoundly inappropriate voice.

On those days, my ideal Yoga Voice would be deadpan but lucidly drunk Christopher Hitchens telling me to push my top thighs back and stretch my heels down toward the floor.

But he’s no longer with us. So maybe seductive Melanie Griffith?

Or Enraged Lucy Liu at the meeting of the Yakuza in Kill Bill 1? Heath Ledger’s Joker is too obvious (but still, it would be awesomely wrong).

Of course, sometimes Yoga instructors provide counsel about the challenges of the ancient practice, the difficulties of converting healthy intentions into beneficial practice, and the moral duties of ahimsa. For these disquisitions, I would appreciate being able to listen to either one of these guys:

As Bertie remarked,

It was one of those cases where you approve the broad, general principle of an idea but can’t help being in a bit of a twitter at the prospect of putting it into practical effect. I explained this to Jeeves, and he said much the same thing had bothered Hamlet.
― P.G. Wodehouse, Jeeves in the Morning

The aforementioned voices would allow me to stay with Yoga without shirking my commitments to perversity and noncompliance. Your needs may be different. There may be men who do not bristle at Yoga’s wholesomeness but are uncomfortable entering such a strongly feminine environment. For them, here’s a Voice that is resolutely wholesome, yet ruggedly masculine:

However, this is the Yoga Voice I really want:

@Bill_Gardner

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I made it through the red tape more quickly than I expected and have been cleared by my insurer for a CPAP machine. The supplier will even come to my house. This is welcome news.

Here’s the bummer: the process took just long enough that I’m now up against a week’s vacation, and they probably can’t squeeze in delivery of the machine before I leave. I’m on the wait list just in case they get a cancellation. So, in all likelihood, I’ve got about 10 more days of sleep deprivation to endure, plus however much longer to adjust to the machine.

Still, this is far ahead of the schedule I expected, and I should count my blessings that therapy even exists. Oh, how people must have suffered before there was one.

This also means it won’t belong before I can bore you with actual data of apnea events per hour by day (the machines nowadays collect it and I’m pretty sure I can get it).

Other updates:

1. I tried extended release Ambien (6.5mg) two nights ago while traveling. Hotel sleep usually sucks, so I was hoping this would do the trick. I still woke to consciousness with many apnea events between 3AM and 6AM. WTF?!

2. A reader who used to work for “a leading health insurance company” said he did an analysis of CPAP coverage policy about a decade ago. He concluded, at the time, that it would be cheaper not to require a sleep study (which are very expensive) and to let doctors prescribe CPAP machines, then evaluate the data over the next few months. This is plausible because many people get sleep studies and CPAP machines and then stop using them, effectively wasting a lot of expense.

This study had no impact on coverage policy. Had it been in place, it’d have saved me about 10 weeks of delay.

Assuming the analysis is correct, why would an insurer leave money on the table? Some possibilities, all pure speculation: (a) Maybe it would have devastated sleep study labs and maybe they had some clout because they’re needed for other diagnoses. (b) Maybe the savings would be small relative to the headache of changing the policy. It’s not the low lying fruit. (b) Maybe the evidence supporting this idea is thin (it seems like it would be) and insurers don’t want to risk encouraging even a low level of diagnostic errors.

3. I started using the Provent therapy last night. Possibly coincidentally, I do not recall a single apnea event (I’m not claiming there weren’t any, just that I slept through them all). However, I wasn’t on a therapeutic level of Provent, just a training level. Even the training level creates some back pressure though, so maybe it can help a little (?). Confounding the results: (a) I was on Ambien, (b) I was extremely tired from my trip, having sleep poorly the night before (see #1), worked out for the first time in a month, given a talk, and met with tons of people at Ohio State University (tiring for an introvert).

I’ve got three more training nights of Provent before I’m on the real deal. I’ll get a handful of nights of experience with that before I get a CPAP machine — good opportunity to gather info about whether Provent would be helpful for traveling.

@afrakt

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