• What are your questions? On what should I blog?

    Periodically, I ask these questions on Twitter. I thought I’d do it this way today. Fire away.

    @afrakt (via phone)

    • Love to hear your thoughts on the recent (recently in the news, that is) debates on risk and ethics in comparitive effectiveness research. Here’s today’s article from the Washington Post: http://www.washingtonpost.com/politics/2013/08/29/7ae65ca2-10e6-11e3-85b6-d27422650fd5_story.html.

      Another interesting article in today’s Post on a study of poverty’s impact on cognitive abilities: http://www.washingtonpost.com/national/health-science/poverty-strains-cognitive-abilities-opening-door-for-bad-decision-making-new-study-finds/2013/08/29/89990288-102b-11e3-8cdd-bcdc09410972_story.html

    • 1) The trend towards employed physicians seems like it should have significant effects on health care. In the past, we have had something of a divide between PCPs and specialists. Will this turn into a divide between docs who are employed by hospitals and those who are not? Wil this make it easier or more difficult to negotiate with hospitals?

      2) I am pretty sure you have seen the ACA as just the first step in reform. I think a lot of people have been playing defense on the ACA. Go on offense. What should we be looking to do next?

      3) The correct way to eat corn on the cob. Vertical or horizontal rows?


    • Frakt reminds me of Click and Clack (Car Talk for non-fans), two MIT grads. MIT grads working as auto mechanics always struck me unusual. About as unusual as an MIT Ph.D. in mathematics helping make health care policy. I’m a lawyer and work with physicians, which some call a “health care attorney” though it’s not what I call myself, If I’m a health care attorney, then Frakt must be a health care mathematician. See, it makes no sense. I’m a lawyer, Frakt is a mathematician. Simple. Which brings me to my question for Frakt: Would you attend medical school if offered a do-over? And would that make you a better health economist (I mean mathematician)?

      • This MIT comp. sci. grad is working as a translator (Japanese to English) and has an MA in Japanese literature (I prefer Ogai (an MD (!) whose stay in Germany left him upbeat on the future of medicine and science) to Soseki, whose stay in England left him depressed about human nature; we WASPs do that to people). Not odd at all. MIT grads are weird. Get used to it.

        • Here’s the Click and Clack (rhymes with Frakt) joke about how to distinguish MIT and Harvard grads. Young man with a cart full of items enters the 10 items or less line at a grocery store in Boston. The clerk says: “You must be a student at Harvard or MIT”. Young man responds: “How did you know?” Clerk says: “You either can’t count or you can’t read.”

    • Have you ever thought about what a US health care system dashboard might look like? What sorts of specific metrics would you choose to track, and why?

    • In today’s WSJ, ( http://on.wsj.com/16Wb2cI ) Christopher Weaver and Louise Radnofsky spotlight some alleged anomalies in ACA subsidies, claiming that some 62 year-olds will pay less for some plans than YAs with the same income. Seems to me they make much of a relatively minor quirk:

      “Insurers worry the subsidies could give customers like the Wengrows a bigger incentive to sign up for coverage than young people to offset their costs. For instance, a single 25-year-old whose earnings match the Wengrows’ $24,000, would spend $124 a month for the lowest-cost midlevel plan, while a single 62-year-old with the same income would pay $100.

      This disparity emerges from a complex quirk in how the subsidies are calculated, the Journal’s analysis shows. The law sets maximum amounts that people must pay before subsidies kick in at specific income levels. Because premiums are higher for older customers, the value of the subsidies is also much larger. Thus, when older people use subsidies to buy coverage that is cheaper than the benchmark plan used to determine subsidies, they can end up paying less than younger people who earn the same.”

      Curious what you think of a) the math and b) the emphasis. Article does not mention that underlying premiums for older adults can be up to 3x more than for YAs, or that YA incomes are on average much lower than older adults’, or that (I imagine) the underlying premium structure means that YAs at various income levels will pay less than older adults with the same income.

      Also, a sidebar points out that subsidies cut off abruptly, so if an older adult or couple crosses a red line, their premiums will jump. That is, of course, true — there is no gradual phase-out. On this one, I would point out that most people earning more than the subsidy-eligible max will get insurance from their employers — and the self-employed can generally jigger income to remain below the cap (e.g., buy a new laptop)…

    • Do wellness programs work? Is is acceptable for an employer to provide a discount to employees who participate? (The flip side is penalizing those who choose not to participate.)

    • My question which I am not sure is one question and can be answered easily but of course I may be missing the extensive knowledge you and your readers share.

      What are the metrics we should or need to look at to determine if as a country we are improving healthcare, outcomes, patient care, etc. Are there bits of data that show either improvement or decline? Not the large life expectancy or birth mortality. We have the vast majority of people using the Internet to learn about their health is that producing any change?

      Sorry if this is a bit muddied.

    • I’ve been wondering why there hasn’t been higher usage of health information exchanges. Why are health care providers preferring to shell out for EMRs offered by private companies that can only communicate fully with the company’s other clients? I’ve heard it said that providers are wary to make their patient data readily available by putting it on the exchange, but don’t they have to do this on the shared EMRs as well?

    • 1. Thoughts on this approach for estimating savings for pop health management in observational settings? http://www.ncbi.nlm.nih.gov/pubmed/22924661

      2. Following the successes of the “Nudge” unit in the UK, the US is looking to start a similar group in the Office of Science and Technology Policy headed by Maya Shankar to apply behavioral science to American policy. What are your thoughts on the application of behavioral economics to individual health decisions and health policy? What do we know, and what should this research focus on in the future?

    • Delta Airlines was in the news whinging about higher costs under Obamacare, and I missed seeing any rebuttals here, Wonkblog, etc. – any pointers or thoughts to counter the usual suspects’ rejoicing at this “evidence” of the ACA’s pernicious effects?

    • I would like to hear your thoughts on lowering the age for Medicare eligibility to 55. Most politicians probably recoil at the idea of adding more beneficiaries to Medicare fearing it would increase federal spending. However, it seems to me it would probably do the opposite. First, we would be adding a younger less expensive demographic cohort to Medicare, bringing down the average cost of the Medicare population as a whole and allowing premiums to fall. Even in Medicare now, the 65 – 69 year old cohort living in the community is much less expensive than more elderly seniors in long-term care or receiving long-term care assistance at home.

      Because the prices paid by Medicare are less than those paid by private insurance, costs for the US health care system overall would fall as well.

      Second, by lowering the age for Medicare eligibility to 55 we would be removing an older, more expensive demographic cohort from private insurance, again bringing down the average cost of the privately insured population as a whole and allowing premiums to fall. This would ease the price burden on the “young invincibles”, and increase their participation in the exchanges, expanding the risk pool and increasing the Exchanges chances of success.

    • Could you do a rundown of the various pay for performance initiatives? I work in health policy and still do not have a good handle on how PCMHs differ from ACOs, and how bundled payments fit into those, if at all.

      Unrelated, but I get confused reading articles about crazy hospital prices because they say the bill has thousands of lines in it, but I thought inpatient stays get a single DRG code? And how does the physician reimbursement system differ from that of the hospital/facility?

    • Indiana Governor Pence was on Morning Joe talking about Healthy Indiana program and it was being branded as an alternative to the ACA. Do you want to weigh in as a Hoosier?

    • 1) What are your thoughts on corporations exchanging full time positions for part time positions to avoid offering health care at all?
      2) How do you feel about companies no longer offering part-time employees health insurance to part-time employees (when they previously did albeit at an inflated cost to the employee). My company told their part-time employees that it was because the ACA would not allow them to offer this benefit to part-time employees. Is that factual?
      3) Do you feel the administration considered this scenario before the ACA was plemented?

    • Appropriate cost/QALY generally accepted as $50-80K. By who? Do right and left health economists agree?

      Should it have a yearly inflator (or deflator)?

      The future encompasses CER. We must agree on a framework.

    • Discuss CMS Innovation Center
      MedPac vs.IPAB
      Selling insurance across state line(no ACA in place presumably). I say really bad idea. What say you? (just curious on this)
      Fixes to reign in costs post ACA implementation (What is Mass. doing? and is it working?)
      Describe your ideal hybrid US healthcare system culling from systems around the world.
      List of your ideal fixes to ACA.
      What do you think of public financing of political campaigns?

    • The July 19, edition of the MMWR from the CDC reported “State-Specific Healthy Life Expectancy at Age 65 years — United States, 2007-2009.” The last data availble for state by state maternal mortality ratios (MMR) 2001-2005 can be divided into 5 groupings. The MMR mean for the best four states 2.5 (SD 0.91) and the worst 7 states was 19.50 (SD 1.18. For the two groupings, the total (men and women) longevity past 65 was 19.00 years (SD 0.37) for the best MMR states and 15.09 years (SD 1.41) among the worst MMR states. The longevity among the best MMR states (Maine, Vermont, Indiana and Alaska) 4 years longer than the worst MMR states (Louisiana, Maryland, New York, Mississippi, Oklahoma, Georgia and Michigan).

      • I neglected to add my question. I propose that the Maternal Mortality Ratio may be the best global measure for the accessibility of healthcare within a state. Are there other markers that might be considered as a measure of accessibility, as distinguished from its availability?

    • I would like to see you write a few posts on the ideas that knowledgeable people left and right mostly agree on. Ideas like better regulation i.e. letting NP’s and PA’s do more,like ending the tax differential between employee and individual health insurance plans, etc.

      I would also like to see you write about the states ability to drive up costs through bad regulation thus working against the Federal Gov. efforts to reduce costs.

    • In New York City, like many cities across the country, small community hospitals are closing. This has been highlighted in many articles including this article by KHN:
      The hospitals closures are due, I believe, to many factors including an excess of hospital beds, large number of relatively poor minority populations that the hospitals serve, and poor financial management. There are groups that believe the community hospitals should be subsidized and rescued so that people can get care in their communities, while others who believe that consolidation into larger, busier hospitals will result in more specialized, higher quality care. This problem is being argued across the country, so it is an important issue bigger than New York. Can you please comment on the evidence for and against letting community hospitals close to lower overall costs and improve quality of care.
      Thank you,