• Racial Disparities, Prescription Medications, and Promoting Equity

    Gilbert Benavidez is a Policy Analyst with Boston University’s School of Public Health. He tweets at  @GBinsolidarity

    Austin and I authored an article titled ‘Racial Disparities, Prescription Medications, and Promoting Equity’, which was published today at Public Health Post. The article is about promoting equity through pharmaceutical policy.

    We fleshed out the multi-layered issue of inequitable medicine access experienced by racial minorities by discussing cost, lack of insurance, and implicit bias in prescribing practices. In response, we gave four practical policy options that the field can pursue immediately, including continued expansion of Medicaid, promotion of the ACA, an evidence based approach to reducing implicit bias, and one way to reduce pharmacy costs.

    The multidimensional nature of health disparities and pharmaceutical law, policy, and practice requires multiple, synergistic approaches like those mentioned here, as a means to promote equitable access to necessary and effective medications for minorities.

    Read it here at Public Health Post.

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  • Healthcare Triage: Got a Bad Diagnosis? Talk to Someone Who Has Been Through It

    When someone gets a diagnosis, they should get lots of time with their doctors and nurses to talk and learn about the condition. This isn’t always possible. Sometimes, it can be useful to talk to patients who have also been through the same diagnosis. Peer health advice can provide helpful information, and important emotional support.

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


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  • The Large Hidden Costs of Medicare’s Prescription Drug Program

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company). It also appeared on page B3 of the print edition on August 14, 2018. Research for this piece was supported by the Laura and John Arnold Foundation.

    At a glance, Medicare’s prescription drug program — also called Medicare Part D — looks like the perfect example of a successful public-private partnership.

    Drug benefits are entirely provided by private insurance plans, with generous government subsidies. There are lots of plans to choose from. It’s a wildly popular voluntary program, with 73 percent of Medicare beneficiaries participating. Premiums have exhibited little to no growthsince the program’s inception in 2006.

    But the stability in the premiums belies much larger growth in the cost for taxpayers. In 2007, Part D cost taxpayers $46 billion. By 2016, the figure reached $79 billion, a 72 percent increase. It’s a surprising statistic for a program that is often praised for establishing a competitive insurance market that keeps costs low, and that is singled out as an example of the good that can come from strong competition in a private market.

    Much of this increase is a result of growing enrollment — it has doubled in the past decade to 43 million — and higher drug prices. But there is also a subtle way in which the program’s structure promotes cost growth.

    When enrollees’ drug costs are relatively low, plans pay a large share, typically about 75 percent. But when enrollees’ drug spending surpasses a certain catastrophic threshold — set at $5,000 in out-of-pocket spending in 2018 — 80 percent of drug costs shifts to a government program called reinsurance. This gives people in charge of private insurance plans an incentive to find ways to push enrollees into the catastrophic range, shifting the vast majority of drug costs off their books. For example, they could be less motivated to negotiate for lower drug prices for certain types of drugs if doing so would tend to keep more enrollees out of the catastrophic range.

    Reinsurance spending, which is not reflected in premiums, has been rising rapidly.

    “This harms the very competition that Part D was supposed to establish,” said Roger Feldman, an economist at the University of Minnesota. Consumers are naturally attracted to lower-premium plans, but choosing them increasingly shifts higher costs onto taxpayers if plans achieve those lower premiums in part by shifting more drug expenses onto the government’s books.

    Documenting this is a recent study by Mr. Feldman and Jeah Jung of Penn State University that was published in Health Services Research. The study found that the disconnect between premiums and reinsurance costs has increased over time. Additionally, insurance company plans exhibiting less of an effort to manage the use of high-cost drugs had higher reinsurance costs. This is consistent with incentives to encourage enrollees into the catastrophic range of spending.

    The Medicare Payment Advisory Commission has been warning about this problem for several years in its annual reports to Congress. According to MedPAC, between 2010 and 2015, the number of enrollees entering the catastrophic drug cost range grew 50 percent, from 2.4 million to 3.6 million, now accounting for 8 percent of enrollees.

    “It’s ironic for a program supposedly built on market principles,” said Mark Miller, a former MedPAC director. “You wouldn’t see this kind of thing in the commercial market.” For commercial market insurance products — such as those offered by employers or in the health insurance marketplaces — only about 1 percent of policyholders reach a catastrophic level of expenditures at which reinsurance kicks in. (Mr. Miller and I are co-authors of an editorial about Ms. Jung’s and Mr. Feldman’s study, which also appears in Health Services Research.)

    Reinsurance is the fastest-growing component of Medicare’s drug program, expanding at an 18 percent annual rate between 2007 and 2016. In 2007, it accounted for 17 percent of government spending for Part D. In 2016 it was 44 percent.

    The Affordable Care Act hastened this growth. The law requires pharmaceutical manufacturers to pay some of the cost of the drug benefit. (The Bipartisan Budget Act of 2018 further increased how much manufacturers must contribute.) For the purposes of reaching the catastrophic threshold and triggering reinsurance, these industry contributions count as out-of-pocket payments for enrollees, even though they are not.

    That means enrollees don’t have to spend as much as they otherwise would to trigger the reinsurance program. Although this is of great benefit to enrollees, it also pushes up taxpayer liability for the program.

    Changing the extent to which manufacturer’s contributions count as enrollee out-of-pocket spending is one potential reform of the program. Other solutions include increasing the liability of insurance company plans in the catastrophic range and decreasing the liability of taxpayers.

    This would have the effect of bringing premiums more in line with program spending. Doing so would “return Part D to the market-based program it was intended to be,” Ms. Jung said. As it stands, there is a substantial divide between what Part D was billed as and what it actually is.


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  • JAMA Forum: Given Their Potential for Harm, It’s Time to Focus on the Safety of Supplements

    Supplements, including vitamins, minerals, and herbal products, are a huge business in the United States. US consumers spend about $30 billion on them every year. Despite uncertain benefits and possible harm, their interest in supplement use, for children as well as adults, remains undeterred.

    My latest at the JAMA Forum. Go read it!


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  • Healthcare Triage: What Should Future Childhood Programs Look Like?

    In 2005, when the RAND Corporation wrote about early childhood interventions, they argued that the evidence to date showed those interventions improved outcomes and generated benefits that outweighed the costs. More than ten years later, the number of programs and studies has increased by a factor of five. There are more than three times as many benefit-cost analyses. We’ve given you a lot to think about in the last three weeks. But how do we use all this data to decide what to do in the future? That’s the topic of this week’s Healthcare Triage.

    Resources used in the making of this episode:


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  • Trump’s Sabotage of Obamacare Is Illegal

    So runs the headline of an op-ed that I co-authored with Abbe Gluck of Yale Law School in the New York Times. Here’s an excerpt:

    Never in modern American history has a president so transparently aimed to destroy a piece of major legislation. What makes Mr. Trump’s sabotage especially undemocratic is that Congress has repeatedly considered repealing the law — and repeatedly declined to do so. In addition, the Supreme Court has twice sustained the Affordable Care Act in the face of major legal challenges. Mr. Trump’s attempt to destroy the law any way he can is an unconstitutional usurpation of power.

    That is also the message of a lawsuit — the first of its kind — filed this month in federal court in Maryland. Brought by several plaintiffs including the cities of Chicago, Cincinnati and Columbus, the lawsuit recounts the “relentless and unlawful campaign to sabotage and, ultimately, to nullify” the Affordable Care Act. Taken individually, some of the Trump administration’s actions may be defensible. Taken together, they amount to a derogation of his constitutional duties.

    Whatever you think of the lawsuit—as we say in the op-ed, it’s not clear that “courts have the authority or the institutional competence to prevent violations of Article II’s requirement that the president ‘take care that the laws be faithfully executed'”—I’m glad that it’s drawn attention to the unconstitutionality of the president’s deliberate efforts to sabotage the ACA. We’ve become inured to so much over the past 18 months. We shouldn’t be complacent about this.


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  • Healthcare Triage News: The Trump Admin is Back to Sabotaging Obamacare

    Last week, we gave the Trump department of Health and Human Services some credit for approaching the administration Obamacare as honest brokers. This week, it’s back to sabotaging the ACA.


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  • Workplace Wellness Programs Don’t Work Well. Why Some Studies Show Otherwise.

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

    The gold standard of medical research, the randomized controlled trial, has been taking a bit of a beating lately.

    An entire issue of the journal Social Science and Medicine was recently devoted to it, with many articles pointing to shortcomings. Others have argued that randomized controlled trials often can’t address the questions that patients and physicians most want answered. I recently wrote about the limitations of the method in studying effectiveness, which is what we care about in real-world situations.

    But the randomized controlled trial remains a powerful tool. It’s still, perhaps, the best method for conducting explanatory research. In past articles, I have recounted numerous times when hypotheses from observational studies, those based solely on observations of particular groups, have failed to be confirmed by a controlled trial.

    Perhaps the greatest strength of the randomized controlled trial is in combating what’s known as selection bias. That occurs when groups being studied (intervention and control) are already significantly different after they are “selected” to be in the intervention or not. One of the most elegant examples of why we need such trials came recently in an examination of employer-sponsored wellness programs.

    These programs are usually offered by employers to make their employees healthier. They can offer screening for a variety of reversible conditions; access to weight-loss programs or gyms; encouragement and support; and sometimes even chronic disease management. Many of the analyses of these programs have shown positive results.

    Almost all of those analyses are observational, though. They look at programs in a company and compare people who participate with those who don’t. When those who participate do better, we tend to think that wellness programs are associated with better outcomes. Some of us start to believe they’re causing better outcomes.

    The most common concern with such studies is that those who participate are different from those who don’t in ways unrelated to the program itself. Maybe those people participating were already healthier. Maybe they were richer, or didn’t drink too much, or were younger. All of these things could bias the study in some way.

    The best of these observational studies try to control for these variables. Even so, we can never be sure that there aren’t unmeasured factors, known as confounders, that are changing the results.

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  • Healthcare Triage: Do Early Childhood Programs Pay Off?

    One of the reasons that life expectancy at birth has gone up so much in recent decades is because we’ve gotten better at taking care of childhood illnesses. When you prevent a child from dying, you add on, well, a lifetime of life. That makes a big difference in long-term statistics. There’s a similar effect when you make things better for a child. You can end up adding a lot of value.

    This also applies to early childhood interventions. If we do good for children, and the effects last a lifetime, we may be able to make a lot of the money that we spent investing pay off. Do early childhood interventions do that? We continue our deep dive into the RAND Corporation’s comprehensive report on early childhood programs in this episode of Healthcare Triage.

    Resources used in the making of this episode:


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  • Healthcare Triage News: ACA Risk Adjustment is out of Danger. For Now.

    A few weeks ago, we were critical of the Trump administration’s handling of ACA risk adjustment payments. We’re fair-minded types around here, so we though you should know that they’ve taken steps to fix it.

    This was adapted from a blog post Nick wrote recently.


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