Effects of Physician-Directed Pharmaceutical Promotion on Prescription Behaviors: Longitudinal Evidence by Anusua Datta and Dhaval M. Dave (National Bureau of Economic Research)
Spending on prescription drugs (Rx) represents one of the fastest growing components of U.S. healthcare spending, and has coincided with an expansion of pharmaceutical promotional spending. Most (83%) of Rx promotion is directed at physicians in the form of visits by pharmaceutical representatives (known as detailing) and drug samples provided to physicians’ offices. Such promotion has come under increased public scrutiny, with critics contending that physician-directed promotion may play a role in raising healthcare costs and may unduly affect physicians’ prescribing habits towards more expensive, and possibly less cost-effective, drugs. In this study, we bring longitudinal evidence to bear upon the question of how detailing impacts physicians’ prescribing behaviors. Specifically, we examine prescriptions and promotion for a particular drug class based on a nationally-representative sample of 150,000 physicians spanning 24 months. The use of longitudinal physician-level data allows us to tackle some of the empirical concerns in the extant literature, virtually all of which has relied on aggregate national data. […] The estimates suggest that detailing has a significant and positive effect on the number of new scripts written for the detailed drug, with an elasticity magnitude of 0.06. This effect is substantially smaller than those in the literature based on aggregate information, suggesting that most of the observed relationship between physician-directed promotion and drug sales is driven by selection bias.
Why ask Why? Forward Causal Inference and Reverse Causal Questions by Andrew Gelman, Guido Imbens (National Bureau of Economic Research)
The statistical and econometrics literature on causality is more focused on “effects of causes” than on “causes of effects.” That is, in the standard approach it is natural to study the effect of a treatment, but it is not in general possible to define the causes of any particular outcome. This has led some researchers to dismiss the search for causes as “cocktail party chatter” that is outside the realm of science. We argue here that the search for causes can be understood within traditional statistical frameworks as a part of model checking and hypothesis generation. We argue that it can make sense to ask questions about the causes of effects, but the answers to these questions will be in terms of effects of causes.
Moral Hazard and Economies of Scope in Physician Ownership of Complementary Medical Services by Brian K. Chen, Paul J. Gertler, Chuh-Yuh Yang (National Bureau of Economic Research)
When physicians own complementary medical service facilities such as clinical laboratories and imaging centers, they gain financially by referring patients to these service entities. This situation creates an incentive for the physician to exploit the consumers’ trust by recommending more services than they would demand under full information. This moral hazard cost, however, may be offset by gains in economies of scope if the complementary services are integrated into the physician’s practice. We assess the extent of moral hazard and economies of scope using data from Taiwan, which introduced a “separating” policy, similar to the Stark Law in the US, that restricts physician ownership of pharmacies unless they are fully integrated into the physician’s practice. We find that physicians who own pharmacies prescribe 7.6% more drugs than those who do not own pharmacies. Overall, we find no evidence of economies of scope from integration in the treatment of patients with acute respiratory infections, diabetes, or hypertension. Overall the separating policy was ineffective at controlling drug costs as a large number of physicians choose to integrate pharmacies into their practices in order to become exempt from the policy.
Hospitals, Market Share, and Consolidation by David M. Cutler and Fiona Scott Morton (JAMA)
A large reduction in use of inpatient care combined with the incentives in the Affordable Care Act is leading to significant consolidation in the hospital industry. What was once a set of independent hospitals having arms-length relationships with physicians and clinicians who provide ambulatory care is becoming a small number of locally integrated health systems, generally built around large, prestigious academic medical centers. The typical region in the United States has 3 to 5 consolidated health systems, spanning a wide range of care settings, and a smaller fringe of health care centers outside those systems. Consolidated health systems have advantages and drawbacks. The advantages include the ability to coordinate care across different practitioners and sites of care. Offsetting this is the potential for higher prices resulting from greater market power. Market power increases because it is difficult for insurers to bargain successfully with one of only a few health systems. Antitrust authorities are examining these consolidated systems as they form, but broad conclusions are difficult to draw because typically the creation of a system will generate both benefit and harm and each set of facts will be different. Moreover, the remedies traditionally used (eg, blocking the transaction or requiring that the parties divest assets) by antitrust authorities in cases of net harm are limited. For this reason, local governments may want to introduce new policies that help ensure consumers gain protection in the event of consolidation, such as insurance products that charge consumers more for high-priced clinicians and health care centers, bundling payments to clinicians and health care organizations to eliminate the incentives of big institutions to simply provide more care, and establishing area-specific price or spending targets.
Increasing Demands for Quality Measurement by Robert J. Panzer and others. (JAMA)
Measurement of health care quality and patient safety is rapidly evolving, in response to long-term needs and more recent efforts to reform the US health system around “value.” Development and choice of quality measures is now guided by a national quality strategy and priorities, with a public-private partnership, the National Quality Forum, helping determine the most worthwhile measures for evaluating and rewarding quality and safety of patient care. Yet there remain a number of challenges, including diverse purposes for quality measurement, limited availability of true clinical measures leading to frequent reliance on claims data with its flaws in determining quality, fragmentation of measurement systems with redundancy and conflicting conclusions, few high-quality comprehensive measurement systems and registries, and rapid expansion of required measures with hundreds of measures straining resources. The proliferation of quality measures at the clinician, hospital, and insurer level has created challenges and logistical problems. Recommendations include raising the bar for qualtiy measurements to achieve transformational rather than incremental change in the US quality measurement system, promoting a logical set of measures for the various levels of the health system, leaving room for internal organizational improvement, harmonizing the various national and local quality measurement systems, anchoring on National Quality Forum additions and subtractions of measures to be applied, reducing reliance on and retiring claims-based measures as quickly as possible, promoting comprehensive measurement such as through registries with deep understanding of patient risk factors and outcomes, reducing attention to proprietary report cards, prompt but careful transition to measures from electronic health records, and allocation of sufficient resources to accomplish the goals of an efficient, properly focused measurement system.
The Toxic Politics of Health Care by Donald M. Berwick (JAMA)
It could be exciting. The ambitious nation that rallied to create the Marshall Plan, get to the moon first, and birth Medicare and Medicaid decides to move toward the health care it needs: universal, responsive, and affordable. But that task does not unite the nation; it rends it into political tatters. Health care reform could have been a moon shot, but instead it is a battlefield: red states against blue, north against south, coasts against the midland, and liberals, who trust in government, against conservatives, who don’t.
The Disruptive Innovation of Price Transparency in Health Care by Uwe E. Reinhardt (JAMA)
Until very recently, health care in the United States was delivered behind the secure walls of a fortress that kept information on the prices charged for health care and the quality of that care opaque from public view. Over time, enormous and ever-increasing amounts of money have disappeared behind the fortress walls. Much good undoubtedly was done for patients entering the castle in search of succor. But it has been nearly impossible for prospective patients thinking of entering the health care system to know what they or someone else will have to give up in return for whatever care they will receive from the inhabitants of the fortress.
Resolving the Tension Between Population Health and Individual Health Care by Harold C. Sox (JAMA)
Health care in the United States is far costlier than in any other country, yet its outcomes, while improving, are worsening relative to other countries in the Organisation for Economic Co-operation and Development (OECD). Perhaps the de facto organizing principle for US health care—approaching each patient strictly as an individual—is obsolete. The population health approach is an alternative. It aims to improve and maintain health across a defined population. A “defined population” can mean a clinician’s patients or a health plan’s enrollees, but the defined population for the population health approach includes everyone in the community.
The Media and Health Care Reform by Noam N. Levey (JAMA)
As implementation of the Affordable Care Act (ACA) moves ahead this fall, Americans remain startlingly uninformed about the landmark law and its prescriptions for the country’s health care system. Fewer than 4 in 10 adults in a recent national survey were familiar with the new insurance marketplaces at the center of the law. In any democracy, public misunderstanding on this scale is troubling. Still more disturbing, this misunderstanding has helped paralyze policymaking at a critical point for the nation and its ailing health system. Ideological claims and counterclaims, often based on erroneous information, have displaced informed discussion about the trade-offs and compromises necessary in any major legislative reform.
Unraveling the Physician Supply Dilemma by Richard A. Cooper (JAMA)
Over the past decade, physician shortages have worsened, patients’ frustrations have increased, and the profession has molded itself around these new realities. Some forecasters project that the shortages will further deepen, and many organizations and individuals are urging that residency training programs be expanded. But others argue that additional physicians would simply work in places where there are enough already, that additional physicians would induce the demand for unneeded care, that fewer physicians would be necessary if more were primary care physicians, and that any gaps in service could be filled by nurse practitioners and physician assistants. Although desired by many, the expansion of residencies faces a wall of opposition.
Consumers Gaining Ground in Health Care by James A. Guest, JD, Lynn Quincy (JAMA)
At long last public and private initiatives are on the verge of giving consumers more information and more fair opportunities when it comes to obtaining health insurance and health care, reducing the uneven care and dysfunctional financing that have long plagued the health care system in the United States. The Affordable Care Act (ACA) is recasting the marketplace for health insurance, allowing consumers who shop on their own to make more informed choices among a better selection of health plans. Health insurers must now play by a different set of rules. Consumers with preexisting conditions are no longer denied insurance. The products for sale are more standardized, and important loopholes such as misleading out-of-pocket maximums have been closed. Private plans can be compared on an apples-to-apples basis using a new Summary of Benefits and Coverage form that standardizes the way coverage is described no matter which company or organization is offering it.
Toward a New Social Compact for Health Research by Harvey V. Fineberg (JAMA)
Over the past 10 years, US public investment in health research has been erratic. This recent pattern reverses decades of increasing support, initiated by the conviction and persuasiveness of visionary leaders such as Mary Lasker and Sidney Farber and realized through the continued commitment of legislative champions of biomedical science. Between 1999 and 2003, congressional appropriators doubled the budget of the National Institutes of Health (NIH) from about $15 billion to nearly $30 billion. The nominal budget then remained flat for the next 5 years, until the American Recovery and Reinvestment Act (ARRA) injected another $10 billion over 2 years, 2009-2010, a financial pulse that has since dissipated.
Going to the Moon in Health Care: Medicine’s Big Hairy Audacious Goal (BHAG) by Ezekiel J. Emanuel (JAMA)
On September 12, 1962, during his famous speech at Rice University, President Kennedy made going to the moon a national goal. It galvanized the country. It led to NASA. It roused support for huge budgetary resources for scientific research and development, which yielded advanced rocket technology, light-emitting diodes, cochlear implants, freeze-dried food, and memory foam, among other inventions. It shifted the research of thousands of scientists and engineers toward space. And it generated tremendous public excitement.