• Healthcare Triage: Teen Suicide Rates Are Rising, but Prevention is Possible

    Rates of teen suicide are rising, and rates for girls are higher than any time in the last 40 years. There are a number of ways to address this problem, but why aren’t we using evidence-based approaches to the problem?

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


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  • Why aren’t men in medicine getting outed for sexual harassment?

    Many powerful men in journalism, entertainment, and politics are being exposed as sexual harassers. But we are not seeing a wave of similar events in medicine. Why not?

    • Because sexual harassment doesn’t happen in medicine? Hahahaha.
    • Because medicine has exceptionally strong secrecy norms? I have heard people say, “But he’s a doctor” (meaning, “one of us”) as if that were some kind of reason for keeping a scandal in-house.
    • Because journalism, entertainment, and politics are celebrity cultures? Perhaps complaints of harassment are lodged at similar rates in all industries, but we only learn about them when the perpetrator works in front of a camera.
    • Because the reputational costs to a news organization of having a harasser on-camera are a lot higher than the costs to a hospital of having a doctor who puts his hands on nurses? One gets fired, the other gets reprimanded.
    • Because the guild structure of medicine means that doctors are in a seller’s market for their labour? Actors, journalists, and politicians are easily replaced, whereas it is amazingly hard to hire a child psychiatrist, let alone a transplant surgeon. Doctors are therefore less likely to get fired for any cause.

    Or perhaps it is just a matter of time before the revolution comes to medicine.


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  • Mass shootings and the future: Update

    On October 1st, 2017, the most lethal mass shooting in American history occurred in Las Vegas, NV. What has happened and what hasn’t happened since Las Vegas?

    What has happened is that in the 50 days since Las Vegas there have been two more shootings that killed five or more people (San Antonio, TX, and Rancho Tehama, CA). If you sense that such shootings are becoming more frequent you are correct. The Figure below plots the number of days between successive mass shootings. The time between successive mass killings is decreasing. Alternatively, we can say that the frequency of mass shootings is steadily increasing.*

    Decreases in the number of days between successive mass shootings (5 or more deaths).

    What hasn’t happened is any regulation to control the technology that produced the extraordinary casualty rate in Las Vegas. The shooter was able to convert his automatic rifles into functional machine guns using legally available conversion kits (so-called “bump stocks”). These kits remain legal and there is no longer even public discussion of regulating them. There is no reason why a future mass killer cannot repeat the Las Vegas death toll.

    Perhaps the Las Vegas death toll is near the limit of what can be achieved with contemporary small arms. However, in my post on Las Vegas, I noted that

    the effectiveness of small arms will continue to improve. Current arms automate most of the loading of firearms, but foreseeable technology will also automate their aiming and facilitate their remote operation. If no limits are set on civilian access to continuously improving weapons technology, we should expect to see massacres with 100s of deaths.

    The Future of Life Institute has produced an 8-minute video that makes the same point. Please take a moment and watch it.

    This is science fiction, but it is near-future sci-fi in that it describes applications of currently available technology. The autonomous weapons in the video are likely illegal because they are explosive devices, which are regulated more strictly than firearms. However, if the drone’s charge propelled a metal disc — or if the drone simply carried a bullet in a short barrel — it’s not clear that the technology would be illegal.

    In my post, I argued that

    At some point, continued increases in the frequency and scale of mass shootings become incompatible with ordinary civic life.

    Unless we either prevent the development of autonomous weapons or somehow limit them exclusively to the military, they will be used by terrorists and other mass killers.

    *Similarly, the time between new records in the numbers killed during shootings also appears to be decreasing. Twenty-two people were killed in Killeen, TX, on October 16, 1991. Then 32 people were killed in Blacksburg, VA, on April 17, 2007 (15.5 years after Killeen). Then 37 people were killed in Newtown, CT, on December 14, 2012 (5.7 years after Blacksburg). Then 49 people were killed in Orlando, FL, on June 12, 2016 (3.5 years after Newtown). Then 58 in Las Vegas on October 1, 2017 (1.3 years after Orlando). It’s a short series, but it suggests that the Las Vegas total may be exceeded before the end of 2018.


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  • Healthcare Triage News: The ACA Insurance Exchanges Are Open! Go Get Insured!

    While Obamacare is has been under legislative threat all year, it’s still the law of the land, which means the exchanges are open for business for 2018. So if you don’t get insurance through your employer or Medicare or the VA, you should be shopping for your individual insurance coverage at the exchanges. So get to http://www.healthcare.gov, and get to shopping!


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  • The tradeoff here is both simple and brutal.

    “Republicans want to pay for a permanent corporate tax by taking insurance from millions of people. Is that who we are as a nation?”

    That’s the end of my latest op-ed in the Washington Post. Here’s the beginning.

    To finesse the tricky politics and brutal math of tax reform, Senate Republicans now say that they want to repeal the Affordable Care Act’s individual mandate. For Republicans, repeal would be a trifecta: a blow to Obamacare, a money-saver for the federal government and a way to finance a permanent cut to the corporate tax rate.

    Republicans are right about all of this. What they haven’t highlighted, however, are the tradeoffs: the estimated 13 million people who will lose insurance if the mandate is repealed. Is the country really better off if millions of people forgo medical care, and millions more go bankrupt, so that corporations can pay lower taxes? That’s not a rhetorical question. Those are the stakes of the game.

    It’s actually worse than my op-ed suggests. In a smart post, Bob Laszewski explains why eliminating the mandate while loosening the restrictions on short-term plans “would be devastating for those in the unsubsidized middle class who would not be able to afford coverage once they got sick.”


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  • Kept in the Dark About Doctors, but Having to Pick a Health Plan

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

    It’s open enrollment season, for Affordable Care Act marketplace plans, Medicare Advantage plans and many employer-sponsored plans as well. Lots of evidence suggests you should shop around, and shop carefully, though this is harder than it sounds.

    When you select a health care plan, you probably consider premiums, and maybe you check deductibles and other cost sharing. But you can’t easily scrutinize the plans’ networks and the quality of the doctors in them. That’s too bad, because you may be missing something important.

    Many health insurance options offered by employers or sold on the Obamacare marketplace come with narrower networks — covering treatment from a limited slate of doctors and hospitals. (Though there’s no official definition of a “narrow network,” many studies classify networks as narrow when they include less than about 30 percent of doctors or hospitals in the area.)

    Narrow network plans are cheaper, and insurers say they try to maintain quality as they narrow the choices they cover. Some appear to succeed, but some don’t, and that’s hard to fully assess before you sign up.

    It’s virtually impossible to thoroughly check the quality of doctors in each insurance plan. A typical plan, even a narrow one, may have a network of hundreds or thousands of physicians. It is a potentially simpler task just to know if you’re enrolling in a narrow or broad network plan. But in a study of Obamacare enrollees, for example, as many as 40 percent didn’t know this information, either.

    That confusion is understandable. A study of 2016 marketplace offerings in 13 states found that only two provided indications of network size. Eight of them, as well as HealthCare.gov, provided a way to look up whether a doctor was in a plan’s network, but only two could filter plans to show only those with providers a consumer selects.

    “To our surprise, we also found that few marketplaces could indicate which hospitals were in plans’ networks,” said Charlene Wong, a pediatrician and researcher at the Margolis Center for Health Policy at Duke University and lead author of the study. “In addition, none of these tools indicated network breadth by specialty.” This means that a “broad” network plan might actually be quite narrow for some specialists, without consumers knowing.

    A crop of new studies shows some of the specialties for which networks are likelier to be narrow, and suggests that what consumers don’t know might hurt them. Researchers at the University of Pennsylvania found that plans with more narrow networks systematically excluded oncologists affiliated with higher-quality cancer centers. In part, this is how the plans offer lower premiums, because higher-quality cancer centers may demand higher payments. But it’s pretty likely consumers don’t know that they may be trading quality for price.

    “Unless you already have cancer, it’s pretty unlikely you’ll check the quality of oncologists covered by health plans when making an enrollment decision,” said Daniel Polsky, a health economist with the University of Pennsylvania and a co-author of the study.

    Another study by Mr. Polsky and colleagues, published in Health Affairs, found that many marketplace plans offer relatively few choices of mental health care professionals. Even plans with wide primary care networks can have narrow mental health ones, the study found. Though only 39 percent of plans had very narrow networks of primary care physicians — covering less than 10 percent of those in their markets — 57 percent of plans had very narrow networks of psychiatrists.

    Marketplace plans also tend to be narrower for pediatric specialists than for adult specialists, according to other work by Dr. Wong and Mr. Polsky. And parents might have no idea until a child is ill.

    “A beneficiary needing more specialized care may only then discover the less attractive features of their health plan,” Mr. Polsky said. “The priority should be improved provider network transparency at the time a plan is purchased.”

    Scrutinizing the extent and quality of a plan is daunting. To find out which doctors are covered by a plan, you could consult its provider directory. But such directories are known to be error prone — listing physicians not in networks or failing to list those who are. Ideally, marketplaces would provide a sense of the breadth of a plan’s network. The marketplaces could directly provide metrics for how many doctors are covered, by specialty and by reasonable distance from your house, for example. First steps toward doing so have been planned but have yet to be widely adopted.

    Assessing hospital quality with online tools is also something consumers can do, but it takes effort, particularly if comparing networks of hospitals across plans. There are fewer ways to assess physician quality, but some sites like Yelp and RateMDs.com may be worth a look. None of these tools are integrated into websites that consumers use to shop for marketplace or Medicare Advantage plans, however.

    And these resources can’t overcome another challenge some people face — a lack of access to broad network plans. Health insurance markets are local, and a recent Health Affairs study found that Hispanic Americans, for example, live in areas with plans less likely to have very broad networks.

    What can be done? Insurers that wish to offer narrow network plans could be required to also offer broad network ones. This would provide a fuller menu of options to more consumers. Additionally, online marketplaces could start to provide much clearer indications of the extent and quality of doctors included in plans’ networks, not just over all but by specialty. Consumers still may not avail themselves of the information, but at least it would be more readily accessible.


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  • Uwe Reinhardt: Giant, mensch, knife twister

    The renowned Princeton University health economist Uwe Reinhardt died today. The email from his Dean at the Woodrow Wilson school said he passed peacefully and surrounded by family.

    Reactions on Twitter resonate with my own. They reflect Uwe’s contributions to and presence in health care policy and education — “insightful, “a treasure,” focused on the “moral underpinnings of policy,” “one of the nicest and funniest people in the field of health econ,” “a godfather of health policy and economics,” “a unique and disarmingly powerful voice in health policy,” a “world-class mensch,” “a gifted teacher and inspiring leader,” one of the “most acerbic speakers in Health Care over the last 20+ years. Never afraid to speak truth to power,” “engaging and understandable,” “a giant.”

    I once called him “the narrator of U.S. health care policy.” Any journalist who could get hold of him for a health care story was sure to get pure gold. His wit and precision were evident in his spoken and written word. His command of English was tremendous. His ability to explain to lay audiences, legendary. If you’re unfamiliar, go read anything he wrote for The New York Times Economix blog, where he posted regularly for years. He can teach. You will learn.

    Born and raised in Germany, he did it all in a second language. Of this, he reminded audiences regularly. The title of one of his presentations was, “Still Confused, After 40 Years in America!” Don’t believe it. Uwe was always the least confused person in the room.

    He opened many speeches with, “I’m just an immigrant so maybe I am missing something about the curious American health care system” (or similar). I heard it many times. It never got old, particularly because I knew what was coming next. Just after such an opening, he would reveal some peculiarity of the health system I had never noticed in the same way. And then he proceeded to show how it was illogical, in violation of basic concepts of economics, immoral, or hypocritical.

    He was a knife twister of the first class. Should you hold dearly an idea he targeted for systematic dismantling, you would squirm. If only I could write half as well or think one-third as clearly.

    He touched so many lives and careers, including my own.

    My first engagement with Uwe was in 2009, over one of his Economix posts. In the comments to that post, I asked him for an economics argument in favor of a public option. He was kind enough to respond at length directly to my inquiry in a follow-up Economix post. I was thrilled, even as I took a beating. I documented the encounter on this blog.

    Perhaps due to my repeated blog-based engagement with him — like a fly that just won’t go away — Uwe took some interest in what I was doing on TIE. He noticed my many posts on hospital cost shifting and suggested that an updated literature review should be published. I counter-offered that we do it together, and he accepted.

    I knew exactly what this meant. I was to write the first draft and he would serve as senior author and tell me how much more work it needed. Here’s where Uwe surprised me and earned my deepest respect. His response to my first draft was that it was so good he did not think it right that his name appear on it. Instead, I should publish it solo, with his support. This is good mentorship. It was my first solo-authored paper and is my most cited publication.

    I met Uwe in person only once, in Princeton in 2010. I was there to visit my parents and give a talk at the Woodrow Wilson School. Learning I’d be in town, he invited me to lunch. I thought it was just going to be the two of us, but he insisted I bring my parents too — his treat. (In advance of the lunch, with some help from YouTube, I practiced how to pronounce his name. It’s “oo-va” not “you-ee.”)

    Though I never saw him again in person, for years I encountered him over email. Usually our threads began with me asking a question or him sharing one of his lengthy emails to some other scholar or policymaker. (Oh, what a shame it is he didn’t post those emails for all to see. They were gems.) But frequently he would email out of the blue to inquire about my family. He took an interest in hearing what my children were up to and used that as an opportunity to remind me how different parenting or childhood was in his day.

    “Child rearing is so different nowadays,” he wrote me once. “When we were little, we left the house after lunch and came home for supper, roaming the country side in the meantime (and playing with live ammunition [left over from WW II]).” I have very few folders of saved emails, but this one and others of his I filed away, not to be deleted.

    Frequently, in the email back-and-forth that ensued he would type out some amazing story of past hijinks. Here’s one:

    Once, at a Duke University private sector conference, the entire brass of the AMA happened to be there. It was my turn at the podium and I could not resist the following stunt.

    The late James Sammons, then head of the AMA, had given interview in which he said Congress had carved Medicare to death like a turkey. I showed a slide of that quote which happened to have his picture next to it. I then showed data according to which between 1980 and 1988 constant-dollar Medicare spending on physician services per beneficiary rose 83%. Apologizing for this low number on behalf of taxpayers (the growth of 83% real allegedly did not permit physicians to give the elderly adequate care), I asked the AMA people: “What increase would have been adequate in your view?” So I counted out numbers (on a slide) like an auctioneer – 100%, 120% , …– but never got any takers. After +160% I left a blank spot and said: “Evidently 160% would not do it, so you give me the number. Is it 300%?” Icy silence. I then had a slide quoting country-music singer Conway Twitty or whoever it was from his song: “I need more of you (moolah) – more, anything less would not do.”

    I then I ended saying that Karen Davis and I, both then serving on the PPRC (now Medpac) would propose a budget for Medicare physician payment (the VPS), because the docs would not come to the table with a reasonable number.

    For a while I literally was banned at the AMA; but later I ended up on the JAMA board.

    With tales like this, I thought of him as the Richard Feynman of health policy — brilliant in his field but with an appetite for adventure and practical jokes. I encouraged him many times to write up stories like these in a book, interwoven with health policy analysis or history. Sadly, he never did. Though he took pride in his past escapades, perhaps he saw himself differently late in his career.

    “When I was younger I was more brash,” Uwe wrote me. “Now I’ve mellowed.”

    There are many giants in academia, and many in health care. But there are none I know like Uwe.


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  • Upshot extra: Narrow networks

    Since submitting my Upshot piece on narrow networks, which appears today, some new work on the topic has published.

    In sum, our results suggest that carriers with traditionally broad networks (national and Blues) are trending away from their use of narrow networks in this market; in contrast, carriers with experience in narrow networks (such as Medicaid, provider-based carriers, and some local/regional ones) are maintaining their use of narrow networks in their plan offerings. The data suggest signs that the carriers with a greater commitment to narrow network strategies in this market are those with more experience with these networks and perhaps those with stronger connections to the local markets they serve.

    That’s from the same team and Penn’s Leonard Davis Institute of Health Economics that has done tons of excellent work on networks among Marketplace plans. Read the rest of their issue brief here.


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  • A Link Between Alcohol and Cancer? It’s Not Nearly as Scary as It Seems

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company). It was also adapted from my new book, The Bad Food Bible: How and Why to Eat Sinfully, which is now available in stores!

    The headline had some of my friends in a panic.

    Citing evidence, the American Society of Clinical Oncology warned that even light drinking could increase the risk of cancer.

    Once again, we’ve been told that something we eat or drink is going to kill us. Once again, we’re provided an opportunity: A more nuanced discussion of risk — and how we communicate it — can leave us much happier, and perhaps healthier.

    Let’s begin with the fact that it’s easy to use studies to talk about cancer. Nothing illustrates this better than the classic 2013 study that examined research on 40 common ingredients selected from an ordinary cookbook. Researchers found 264 different studies touching on at least one of those ingredients. Their conclusion? Depending where you look, you can find evidence that says that nearly everything we eat is both associated with higher rates of cancer and lower rates of cancer.

    The gist of the oncology society announcement is that there is a reasonable amount of evidence finding an association between some cancers (specifically oropharyngeal and larynx cancer, esophageal cancer, hepatocellular carcinoma, breast cancer and colon cancer) and alcohol. It acknowledges that the greatest risks are with those who drink heavily, but it cautions that even modest drinking may increase the risk of cancer. In the United States, the announcement also notes, 3.5 percent of cancer deaths are attributable to alcohol.

    Of course, this means that 96.5 percent of cancer deaths are not attributable to alcohol. If we eliminate heavy drinking, which no one endorses as healthy and where the association is surest, that number climbs. If we also eliminate those who smoke — smoking is believed to intensify the relationship between alcohol and cancer — the number of cancer deaths not attributable to alcohol approaches 100 percent.

    Let’s stipulate that there may be a correlation between light or moderate drinking and some cancers. We still don’t know if the relationship is causal, but let’s accept that there’s at least an association. For breast cancer — which is the cancer that seems to be garnering the most headlines — light drinking was associated with a relative risk of 1.04 in the announcement. Relative risk refers to the percentage change in one’s absolute (overall) risk as a result of some change in behavior. (And 1.04 is a 4 percent change from 1.0, which represents a baseline of no difference in risk between an experimental group and a control group.)

    A 40-year-old woman has an absolute risk of 1.45 percent of developing breast cancer in the next 10 years. This announcement would argue that if she’s a light drinker, that risk would become 1.51 percent. This is an absolute risk increase of 0.06 percent. Using what’s known as the Number Needed to Harm, this could be interpreted such that if 1,667 40-year-old women became light drinkers, one additional person might develop breast cancer. The other 1,666 would see no difference.

    Of course, moderate or heavy drinking might increase the risks further. The absolute risks for that 40-year-old would go to 1.78 percent from 1.45 percent for the moderate drinker, and to 2.33 percent for the heavy drinker. Those numbers are still not that scary.

    But maybe any increase in risk is too much for you. That’s fine. If you’re one of those people, though, you have to acknowledge that you can’t look at any one cancer in a vacuum. A person can get almost any cancer.

    The large meta-analysis upon which this announcement was based looked at 23 types of cancer with respect to alcohol consumption. It found a harmful relationship between three of them and light drinking. But it also found protective relationships — meaning a decreased risk of cancer — between six of them and light drinking.

    I’m not arguing that you should engage in light drinking to avoid those six cancers. I’m merely pointing out that cherry-picking allows you to come to different conclusions. With respect to moderate drinking, there were harmful relationships with seven cancers and protective relationships with three. The announcement focused on the former, not the latter.

    2013 meta-analysis in the Annals of Oncology that looked at all cancers found that, over all, light drinking was protective; moderate drinking had no effect; and heavy drinking was detrimental.

    It’s even cherry-picking to focus only on cancer, though. A person can get any number of diseases, and this fact makes the dangers of light and moderate drinking even muddier.

    If you accept the methodology of case-control and cohort studies, from which many of the links between alcohol and cancer arise, you have to accept the results of similar studies of other diseases. For instance, a cohort study of about 6,000 people found that those who drank at least once a week had better cognitive function in middle age than those who didn’t. A 2004 systematic review found that moderate drinkers had lower rates of diabetes (up to 56 percent lower, although that’s a relative risk reduction).

    Randomized controlled trials of alcohol (they do exist) show that light to moderate drinking can lead to a reduction in risk factors for heart disease, diabetes and stroke. These protective factors may be greater than all the other negative risk factors (even cancer) that might be associated with light or moderate drinking. More women die in the United States of heart disease than cancer. So do more men.

    Moreover, dire warnings have consequences. I know far too many people who now throw up their hands at every news story because it seems as if “everything” causes cancer. These stories rarely acknowledge an alternative point of view. The absolute risks of light and moderate drinking are small, while many people derive pleasure from the occasional cocktail or glass of wine. It’s perfectly reasonable even if a risk exists — and the overall risk is debatable — to decide that the quality of life gained from that drink is greater than the potential harms it entails.

    This is true for many, many foods, not just alcohol.

    What can we do about this? We could make simple changes to have a better understanding of risk so that each new proclamation doesn’t send us into a tizzy:

    1) Consider the absolute risks. A 30 percent increase in risk sounds scary, but an increase from 1 percent to 1.3 percent absolute risk does not, though these are the same things. Likewise, we should be more concerned about a 5 percent risk increase to 21 percent from 20 percent than about a 30 percent increase to 1.3 percent from 1 percent.

    2) Don’t give too much weight to observational data. This is especially true when causal data are available.

    3) Don’t focus on any one disease while ignoring others. Something may be harmful regarding one disease while beneficial regarding another.

    4) Don’t cherry-pick. That is, don’t focus only on some studies, or only on some results. Review all the evidence for the most holistic picture possible.

    5) Acknowledge the harms, as well as the benefits, of recommendations. Consider both cost and joy.

    These rules may not make for exciting headlines. They may, however, lead to happier, and perhaps healthier, lives.


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  • Science and courts don’t mix well

    Pieter Cohen, Aaron, and I have a new piece at JAMA Internal Medicine on the toxic practice of suing researchers over their scientific results.

    In 2008, the manufacturer of a hip protector sued a Harvard researcher for commercial disparagement over a study published in JAMA demonstrating that the hip protector did not prevent fractures. In 2012, the chief executive officer of a pharmaceutical company sued a researcher who chaired his data monitoring committee after the researcher published an article in Annals of Internal Medicine explaining how the CEO mischaracterized study results. (The CEO was later convicted of wire fraud.) And, in 2013, a biomarker company sued a group of scientists and an academic journal, Clinical Chemistry, for publishing a study suggesting that the company’s assay was insufficiently sensitive. …

    When lawsuits target scientists, it does not matter that plaintiffs almost never win. It does not even matter if the case goes to trial. The goal is to intimidate. In the lawsuit over dietary supplements, for example, the head of the company who brought the suit openly admitted that he was “hoping that we were able to silence this guy,” as well as other researchers who might raise questions about the supplement industry. The most frivolous lawsuit can generate substantial legal costs, distract scientists from research, force the indiscriminate disclosure of laboratory notebooks and emails, and create unnecessary stress for colleagues and families.

    A few years back, Pieter was sued over a study in which he identified the presence of dangerous stimulants in some athletic and weight-loss supplements. Undeterred, he and his co-authors have now published another study with similar findings. We can’t afford to let private companies abuse the court system in a conscious effort to discourage this kind of important research.

    Go read the whole thing!


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