Tag Archives: health

The quintessential challenge of our time

“…the quintessential challenge of our time: the ascendance of belief over fact, outrage over thoughtful debate, and the accessibility of an endless supply of “information” that confirms our preexisting beliefs, whatever they may be. In a sociopolitical climate in which disgust often substitutes for disagreement, many people recognize the futility of using evidence to establish common ground, but few seem to know what to do about it.”

 

From Lisa Rosenbaum, M.D. Understanding the Planned Parenthood Divide — Albert Lasker and Women’s Health

New England Journal of Medicine, November 1, 2017DOI: 10.1056/NEJMp1713518

#stupideconomics and Healthcare Triage on the AHCA

Two interesting links related to the recent Republican health care proposal called the AHCA.

The first is a serious but also humorous Forbes article by my BU colleague Larry Kotlikoff in his series about Stupid Economics, this one targeting Tom Price and the AHCA bill. (A 3-minute read.)

Tom Price’s Liver And ‘The Coverage They Want’

The second is an excellent Youtube summary of the CBO forecasts (called “scoring”) of the effects of the AHCA by pediatrician Aaron Carroll.

Healthcare Triage: Results Are In! Congressional Budget Office Scores the American Health Care Act

Posted: 17 Mar 2017 06:09 AM PDT  Text of the report here.

(Broadcast is eight minutes.)

Facts about Tom Price, HHS nominee

Health economists and every concerned citizen should disseminate the facts in this NEJM article about Donald Trump’s nominee of Tom Price to be the next secretary of HHS.
Coauthor Richard Frank is also a BU Ph.D. alum!

Randy Ellis

 

Care for the Vulnerable vs. Cash for the Powerful — Trump’s Pick for HHS

Sherry A. Glied, Ph.D., and Richard G. Frank, Ph.D.

New England Journal of Medicine

December 21, 2016DOI: 10.1056/NEJMp1615714

http://www.nejm.org/doi/full/10.1056/NEJMp1615714#t=article

 

Since there is no abstract, here are the first two paragraphs.

Representative Tom Price of Georgia, an orthopedic surgeon, will be President-elect Donald Trump’s nominee for secretary of health and human services (HHS). In the 63-year history of the HHS Department and its predecessor, the Department of Health, Education, and Welfare, only two previous secretaries have been physicians. Otis Bowen, President Ronald Reagan’s second HHS secretary, engineered the first major expansion of Medicare, championed comparative effectiveness research and, with Surgeon General C. Everett Koop, led the fight against HIV–AIDS.1 Louis Sullivan, HHS secretary under President George H.W. Bush, focused his attention on care for vulnerable populations, campaigned against tobacco use, led the development of federally sponsored clinical guidelines,2 and introduced President Bush’s health insurance plan, which incorporated income-related tax credits3 and a system of risk adjustment. In their work at HHS, both men, serving in Republican administrations, drew on a long tradition of physicians as advocates for the most vulnerable, defenders of public health, and enthusiastic proponents of scientific approaches to clinical care.

Tom Price represents a different tradition. Ostensibly, he emphasizes the importance of making our health care system “more responsive and affordable to meet the needs of America’s patients and those who care for them.”4 But as compared with his predecessors’ actions, Price’s record demonstrates less concern for the sick, the poor, and the health of the public and much greater concern for the economic well-being of their physician caregivers.

Since the NEJM full article  requires a subscription, here is a summary what they document:

Price has sponsored legislation that

  • supports making armor-piercing bullets more accessible
  • opposes regulations on cigars
  • Repeals and replaces the ACA (see details below)

Voted  

  • Against the Affordable Care Act (ACA)
  • Against regulating tobacco as a drug
  • Against the Domenici–Wellstone Mental Health Parity and Addiction Equity Act
  • Against funding for combating AIDS, malaria, and tuberculosis
  • Against expansion of the State Children’s Health Insurance Program
  • In favor of allowing hospitals to turn away Medicaid and Medicare patients seeking nonemergency care if they could not afford copayments
  • Against reauthorization of the Violence Against Women Act
  • Against legislation prohibiting job discrimination against lesbian, gay, bisexual, and transgender (LGBT) people
  • Against enforcement of laws against anti-LGBT hate crimes.
  • Against expanding the NIH budget
  • Against the recently enacted 21st Century Cures Act

Price stated views:

  • Favors converting Medicare to a premium-support system
  • Favors changing the structure of Medicaid to a block grant program
  • Favors amending the Constitution to outlaw same-sex marriage
  • Opposes stem-cell research
  • Inconsistent in supporting investments in biomedical science.

His proposal for repealing and replacing the ACA is H.R. 2300, the Empowering Patients First Act,5 which would

  • Eliminate the ACA’s Medicaid expansion and
  • Replace ACA subsidies with flat tax credits based on age, not income
  • Be regressive, with larger subsidies for high than low incomes.
  • Credits would pay only about one third of the premium of a low-cost plan
  • Credits proposed are smaller than those proposed by President Bush in 1992, and will not be sufficient to get most people to buy health insurance
  • Eliminate the guaranteed-issue and community-rating requirements in the ACA, with ineffective substitutes.
  • Withdraw almost all the ACA’s federal consumer-protection regulations, including limits on insurer profits and requirements that plans cover essential health benefits.
  • Allow the sale of health insurance across state lines, effectively eliminating all state regulation of health insurance plans
  • Fund his plan by capping the tax exclusion for employer-sponsored health insurance at $8,000 per individual or $20,000 per family, caps that are lower than the unpopular Cadillac tax in the ACA, which Price himself has voted to repeal, and hence is unlikely to ever be approved
  • Directly advance physicians’ economic interests by permitting them to bill Medicare patients for amounts above those covered by the Medicare fee schedule and allowing them to join together and negotiate with insurance carriers without violating antitrust statutes.
  • Oppose strategies for value-based purchasing and guideline development,
  • Oppose the use of bundled payments for lower-extremity joint replacements and
  • Propose that physician specialty societies hold veto power over the release of comparative effectiveness findings.

Consider what you can do to make sure that these facts are widely known. Perhaps ask your legislators which of these views they support.

Obama’s JAMA article is a must read for all professionals

There is a very important  article in this week’s JAMA – Internal Medicine, written by Barach Obama.

It highlights the effects of the ACA/Obamacare.  It is free on-line.

United States Health Care Reform: Progress to Date and Next Steps

http://jama.jamanetwork.com/article.aspx?articleid=2533698

If you are short on time, then the following link to just the figures provides many of the key results.

http://jama.jamanetwork.com/article.aspx?articleid=2533698

To me the highlights of the article are that it documents:

The decline in the uninsured (no surprise, but well presented) now down to 9.1 percent from over 16
Declines in teen smoking from 19.5% to 10.8% due to the Tobacco Control Act of 2009 (Wow)
Much slower rates of decline in the uninsured in states that refused the Medicaid expansion (no surprise)
The decline in the underinsured among privately insured as measured by the near disappeance of unlimited exposure (new to me)
Lower rates of individual debt sent to a collection agency (great to see)
Negative rates of real cost growth in Medicare and Medicaid since 2010, with drastically lower growth in privately Insured
Constant share of out of pocket spending as a fraction of total spending among the employer based insurance
(new to me, he cites increases in deductibles offset by decreases in copays and coinsurance.)
Forecast Medicare spending in 2019 is now 20% LOWER than when he took office.
Decline in Medicare 30 day, all hospital readmission rates as well as improvements in other measures.
This information is important to understand to counter the repeated false claims that Obamacare is a failure, or has increased health care spending, or is bankrupting the government, all of which are shown to be false in the evidence presented here.

Here is the link again.

http://jama.jamanetwork.com/article.aspx?articleid=2533698

Obamacare reality: It is working

At a time in the US when all of the Republicans presidential candidates are declaring Obamacare a failure which needs to be undone, it is worth noting the REALITY that it is succeeding in its primary purpose of covering more American with health insurance. It does not mandate insurance coverage, but the subsidies and tax penalties for not having insurance are motivating more people to get insurance. 20 million more people now have health insurance than did before. (Click on graphs for a clearer image.)

 20 Million Gained Health Insurance From Obamacare, President Says
The Huffington Post

Uninsured rate Gallop-HealthwaysEven though cost containment was not its primary goal, Obamacare is also reducing, not increasing, costs of health care.
Since many people don’t trust the government, here are some private sector slides.
PriceWaterhouseCoopers, an actuary firm not known for being political, forecasts that health expenditure
cost growth in 2016 will continue to slow down.

http://www.pwc.com/us/en/health-industries/behind-the-numbers/assets/pwc-hri-medical-cost-trend-chart-pack-2016.pdf

Here are my two favorite slides from their chart pack. Note the changes since 2010.

pwc trends gdpand nhe

My view is that the above figure is misleading, since the decline in rates of growth did not start in 1961, but still the slow growth since 2010 is clearly evident.

 

spending growth rate PWC 2016

Obamacare is working. We just don’t have enough leaders and media telling us this.

 

Note: I sent this blog to my BUHealth email list.

Let me know if you would like to be added as a BUHealthFriends subscriber by emailing ellisrp at bu.edu

Important Reposting on Placebo surgery from TIE

I am forwarding this excellent TIE post since every health researcher and indeed every consumer should realize how serious the lack of evidence is on many common surgical procedures. Here are some quotes organized in a succinct way.

“2002… arthroscopic surgery for osteoarthritis of the knee … Those who had the actual procedures did no better than those who had the sham surgery. ” (We still spend $3 billion a year on this procedure)
“2005… percutaneous laser myocardial revascularization, …  didn’t improve angina better than a placebo”
“2003, 2009, 2009… vertebroplasty — treating back pain by injecting bone cement into fractured vertebrae … worked no better than faking the procedure.”
“2013 … arthroscopic procedures for tears of the meniscus cartilage in the knee… performed no better than sham surgery” (We do about 700,000 of them with direct costs of about $4 billion.)
“[2014] … systematic review of migraine prophylaxis [prevention], while 22 percent of patients had a positive response to placebo medications and 38 percent had a positive response to placebo acupuncture, 58 percent had a positive response to placebo surgery.
“2014… 53 randomized controlled trials that included placebo surgery as one option. In more than half of them … the effect of sham surgery was equivalent to that of the actual procedure.”

If you are getting surgery done, do your own research on it and ask questions!

 

——– Original Message ——–

Subject: “The Placebo Effect Doesn’t Apply Just to Pills” plus 1 more
Date: Thu, 9 Oct 2014 11:13:06 +0000
From: The Incidental Economist <tie@theincidentaleconomist.com>
To: <ellisrp@bu.edu>

“The Placebo Effect Doesn’t Apply Just to Pills” plus 1 more


The Placebo Effect Doesn’t Apply Just to PillsPosted: 09 Oct 2014 04:00 AM PDT

The following originally appeared on The Upshot (copyright 2014, The New York Times Company).

For a drug to be approved by the Food and Drug Administration, it must prove itself better than a placebo, or fake drug. This is because of the “placebo effect,” in which patients often improve just because they think they are being treated with something. If we can’t compare a new drug with a placebo, we can’t be sure that the benefit seen from it is anything more than wishful thinking.

But when it comes to medical devices and surgery, the requirements aren’t the same. Placebos aren’t required. That is probably a mistake.

At the turn of this century, arthroscopic surgery for osteoarthritis of the knee was common. Basically, surgeons would clean out the knee usingarthroscopic devices. Another common procedure was lavage, in which a needle would inject saline into the knee to irrigate it. The thought was that these procedures would remove fragments of cartilage and calcium phosphate crystals that were causing inflammation. A number of studieshad shown that people who had these procedures improved more than people who did not.

However, a growing number of people were concerned that this was really no more than a placebo effect. And in 2002, a study was published thatproved it.

A total of 180 patients who had osteoarthritis of the knee were randomly assigned (with their consent) to one of three groups. The first had a standard arthroscopic procedure, and the second had lavage. The third, however, had sham surgery. They had an incision, and a procedure was faked so that they didn’t know that they actually had nothing done. Then the incision was closed.

The results were stunning. Those who had the actual procedures did no better than those who had the sham surgery. They all improved the same amount. The results were all in people’s heads.

Many who heard about the results were angry that this study occurred. They thought it was unethical that people received an incision, and most likely a scar, for no benefit. But, of course, the same was actually true for people who had arthroscopy or lavage: They received no benefit either. Moreover, the results did not make the procedure scarce. Years later, more than a half-million Americans still underwent arthroscopic surgery for osteoarthritis of the knee. They or their insurers spent about $3 billion that year on a procedure that was no better than a placebo.

Sham procedures for research aren’t new. As far back as 1959, the medical literature was reporting on small studies that showed that procedures like internal mammary artery ligation, a surgical procedure used to treat angina, were no better than a fake incision.

In 2005, a study was published in the Journal of the American College of Cardiology proving that percutaneous laser myocardial revascularization, in which a laser is threaded through blood vessels to cut tiny channels in the heart muscle, didn’t improve angina better than a placebo either. We continue to work backward and use placebo-controlled research to try to persuade people not to do procedures, rather than use it to prove conclusively that they work in the first place.

A study published in 2003, without a sham placebo control, showed that vertebroplasty — treating back pain by injecting bone cement into fractured vertebrae — worked better than no procedure at all. From 2001 through 2005, the number of Medicare beneficiaries who underwent vertebroplasty each year almost doubled, from 45 to 87 per 100,000. Some of them had the procedure performed more than once because they failed to achieve relief. In 2009, not one but two placebo-controlled studies were published proving that vertebroplasty for osteoporotic vertebral fractures worked no better than faking the procedure.

Over time, after the 2002 study showing that arthroscopic surgery didn’t work for osteoarthritis of the knee, the number of arthroscopic procedures performed for this condition did begin to go down. But at the same time, the number of arthroscopic procedures for tears of the meniscus cartilage in the knee began to go up fast. Soon, about 700,000 of them were being performed each year, with direct costs of about $4 billion. Less than a year ago, many were shocked when arthroscopic surgery for meniscal tearsperformed no better than sham surgery. This procedure was the most common orthopedic procedure performed in the United States.

The ethical issues aren’t easily dismissed. Theoretically, a sugar pill carries no risk, and a sham procedure does. This is especially true if the procedure requires anesthesia. The surgeon must go out of his or her way to fool the patient. Many would have difficulty doing that.

But we continue to ignore the real potential that many of our surgical procedures and medical devices aren’t doing much good — and might even be doing harm, since real surgery has been shown to pose more risks than sham surgery.

Rita Redberg, in a recent New England Journal of Medicine Perspectives article on sham controls in medical device trials, noted that in a recentsystematic review of migraine prophylaxis, while 22 percent of patients had a positive response to placebo medications and 38 percent had a positive response to placebo acupuncture, 58 percent had a positive response to placebo surgery. The placebo effect of procedures is not to be ignored.

Earlier this year, researchers published a systematic review of placebo controls in surgery. They searched the medical literature from its inception all the way through 2013. In all that time, they could find only 53 randomized controlled trials that included placebo surgery as one option. In more than half of them, though, the effect of sham surgery was equivalent to that of the actual procedure. The authors noted, though, that with the exception to the studies on osteoarthritis of the knee and internal mammary artery ligation noted above, “most of the trials did not result in a major change in practice.”

We have known about the dangers of ignoring the need for placebo controls in research on surgical procedures for some time. When the few studies that are performed are published, we ignore the results and their implications. Too often, this is costing us many, many billions of dollars a year, and potentially harming patients, for no apparent gain.

@aaronecarroll

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Placebo historyPosted: 09 Oct 2014 03:00 AM PDT

Here are my highlights from “Placebos and placebo effects in medicine: historical overview,” by Anton de Craen and colleagues. All are direct quotes.

  • In 1807 Thomas Jefferson, recording what he called the pious fraud, observed that ‘one of the most successful physicians I have ever known has assured me that he used more bread pills, drops of colored water, and powders of hickory ashes, than of all other medicines put together’. About a hundred years later, Richard Cabot, of Harvard Medical School, described how he ‘was brought up, as I suppose every physician is, to use placebo, bread pills, water subcutaneously, and other devices’.
  • The word placebo (Latin, ‘I shall please’) was first used in the 14th century. In that period, it referred to hired mourners at funerals. These individuals often began their wailings with Placebo Domino in regione vivorum, the ninth verse of psalm cxiv, which in the Latin Vulgate translation means ‘I shall please the Lord in the land of the living’. Here, the word placebo carries the connotation of depreciation and substitution, because professional mourners were often stand-ins for members of the family of the deceased.
  • In 1801, John Haygarth reported the results of what may have been the first placebo-controlled trial. A common remedy for many diseases at that time was to apply metallic rods, known as Perkins tractors, to the body. These rods were supposed to relieve symptoms through the electromagnetic influence of the metal. Haygarth treated five with imitation tractors made of wood and patients found that four gained relief. He used the metal tractors on the same five patients the following day and obtained identical results: four of five subjects reported relief.
  • In the 1785 New Medical Dictionary, placebo is described as ‘a commonplace method or medicine’. In 1811, the revised Quincy’s Lexicon-Medicum as ‘an epithet given to any medicine adapted defines placebo more to please than to benefit the patient’.
  • In the 1930s, several important papers were published with regard to the introduction of placebos in clinical research. [… Two] papers assessed the value of drugs used in the treatment of angina pectoris in cross-over experiments and deceptively administered placebos to the ‘no-treatment’ comparison group. […] In both trials the drugs were judged to exert no specific action that might be useful in the treatment of angina. Gold and colleagues tried to explain why inert interventions might work: their points included ‘confidence aroused in a treatment’, the ‘encouragement afforded a new and ‘a of medical by procedure’ change advisor’.
  • Placebo was a fraud and deception that had the ‘moral effect of a remedy given specially for the disease’, but placebos did not affect the natural course of disease; they were a priori excluded from having such an impact. Placebos were therapeutic duds to manage patients, or, as in the Flint investigation, a camouflage behind which to watch nature take its course.
  • In 1938, the word placebo was first applied in reference to the treatment given to concurrent controls in a trial.
  • The efficacy of cold vaccines was evaluated in several placebo-controlled trials. […] The conclusion [of one] reads ‘one of the most significant aspects of this study is the great reduction in the number of colds which the members of the control groups reported during the experimental period. In fact these results were as good as many of those reported in uncontrolled studies which recommended the use of cold vaccines’. The placebo effect was born.

@afrakt

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Explaining these two graphs should merit a Nobel prize

Reposting from The Incidental Economist Blog

What happened to US life expectancy?

Posted: 07 Jan 2014 03:00 AM PST

Here’s another chart from the JAMA study “The Anatomy of Health Care in the United States”:

life expectancy at birth

Why did the US fall behind the OECD median in the mid-1980s for men and the early 1990s for women? Note, the answer need not point to the health system. But, if it does, it’s not the first chart to show things going awry with it around that time. Before I quote the authors’ answer, here’s a related chart from the paper:

ypll

The chart shows years of potential life lost in the US as a multiple of the OECD median and over time. Values greater than 1 are bad (for the US). There are plenty of those. A value of exactly 1 would mean the US is at the OECD median. Below one would indicate we’re doing better. There’s not many of those.

It’d be somewhat comforting if the US at least showed improvement over time. But, by and large, it does not. For many conditions, you can see the US pulling away from the OECD countries beginning in/around 1980 or 1990, as was the case for life expectancy shown above. Why?

The authors’ answer:

Possible causes of this departure from international norms were highlighted in a 2013 Institute of Medicine report and have been ascribed to many factors, only some of which are attributed to medical care financing or delivery. These include differences in cultural norms that affect healthy behaviors (gun ownership, unprotected sex, drug use, seat belts), obesity, and risk of trauma. Others are directly or indirectly attributable to differences in care, such as delays in treatment due to lack of insurance and fragmentation of care between different physicians and hospitals. Some have also suggested that unfavorable US performance is explained by higher risk of iatrogenic disease, drug toxicity, hospital-acquired infection, and a cultural preference to “do more,” with a bias toward new technology, for which risks are understated and benefits are unknown. However, the breadth and consistency of the US underperformance across disease categories suggests that the United States pays a penalty for its extreme fragmentation, financial incentives that favor procedures over comprehensive longitudinal care, and absence of organizational strategy at the individual system level. [Link added.]

This is deeply unsatisfying, though it may be the best explanation available. Nevertheless, the sentence in bold is purely speculative. One must admit that it is plausible that fragmentation, incentives for procedures, and lack of organizational strategy could play a role in poor health outcomes in the US — they certainly don’t help — but the authors have also ticked off other factors. Which, if any, dominate? It’s completely unclear.

Apart from the explanation or lack thereof, I also wonder how much welfare has been lost relative to the counterfactual that the US kept pace with the OECD in life expectancy and health spending. It’s got to be enormous unless there are offsetting gains in areas of life other than longevity and physical well-being. For example, if lifestyle is a major contributing factor, perhaps doing and eating what we want (to the extent we’re making choices) is more valuable than lower mortality and morbidity. (I doubt it, but that’s my speculation/opinion.)

(I’ve raised some questions in this post. Feel free to email me with answers, if you have any.)

@afrakt

Playing video games does not predict voilent behavoir in children

(Reposted from The Incidental Economist) This November 2013 UK study confirms what other studies have shown, which is that playing video games does not predict psychosocial adjustment problems in young children. Even watching 3 hours of TV per day in the UK has no meaningful association.

I also reposted my favorite graph about videos and gun violence from an earlier TIE posting.

Perhaps the 50th anniversary of  JFK’s death, done with a $20 mail order rifle, is yet another good time to refocus on gun control.

Happy Thanksgiving!

Randy

The dangers of TV and video games
Posted: 25 Nov 2013 06:01 AM PST
From Archives of Diseases of Childhood, “
Do television and electronic games predict children’s psychosocial adjustment? Longitudinal research using the UK Millennium Cohort Study
“:

BACKGROUND: Screen entertainment for young children has been associated with several aspects of psychosocial adjustment. Most research is from North America and focuses on television. Few longitudinal studies have compared the effects of TV and electronic games, or have investigated gender differences.

PURPOSE: To explore how time watching TV and playing electronic games at age 5 years each predicts change in psychosocial adjustment in a representative sample of 7 year-olds from the UK.

METHODS: Typical daily hours viewing television and playing electronic games at age 5 years were reported by mothers of 11 014 children from the UK Millennium Cohort Study. Conduct problems, emotional symptoms, peer relationship problems, hyperactivity/inattention and prosocial behaviour were reported by mothers using the Strengths and Difficulties Questionnaire. Change in adjustment from age 5 years to 7 years was regressed on screen exposures; adjusting for family characteristics and functioning, and child characteristics.

RESULTS: Watching TV for 3 h or more at 5 years predicted a 0.13 point increase (95% CI 0.03 to 0.24) in conduct problems by 7 years, compared with watching for under an hour, but playing electronic games was not associated with conduct problems. No associations were found between either type of screen time and emotional symptoms, hyperactivity/inattention, peer relationship problems or prosocial behaviour. There was no evidence of gender differences in the effect of screen time.

CONCLUSIONS: TV but not electronic games predicted a small increase in conduct problems. Screen time did not predict other aspects of psychosocial adjustment. Further work is required to establish causal mechanisms.

Since we’re never going to have an RCT of TV or video games, these kinds of prospective cohort studies are important. In this one, they followed more than 11,000 children in the UK. They found that watching TV for three hours or more (a day!) at 5 years associated with a higher chance of having a conduct disorder at 7 years versus kids who watched less than an hour a day. How much of a difference? A 0.13 point increase in conduct problems. That corresponds, according to the article, to “0.09 of a SD [standard deviation] increase in age 7 years conduct score. Do you understand now? I don’t either.Anyway, the authors said it was a “small increase in conduct problems”.Video games? No effect.Yes, these are young kids, and it’s unlikely that they have been playing much GTA 5 or Battlefield 4. So I’ll look forward to more data. But that this point, it’s hard to point to a large study like this and find a smoking gun. Figuratively or literally.More on this topic here and here.@aaronecarrollShare

This is my favorite graph on this topic. From here

http://theincidentaleconomist.com/wordpress/wp-content/uploads/2012/12/video-game-chart-no-trendline.jpg

Two great reposts from TIE/JAMA

This repost from The Incidental Economist (TIE) is one of the best summaries of US Health Care I have seen. I also appended the Uwe posting at the bottom.

(The JAMA Authors are Hamilton Moses III, MD; David H. M. Matheson, MBA, JD; E. Ray Dorsey, MD, MBA; Benjamin P. George, MPH; David Sadoff, BA; Satoshi Yoshimura, PhD

The JAMA Article, which has an abundance of tables, references and graphs, will be on my MA and Ph.D. reading lists.

Anyone interested in keeping up with current US health policy from an economists point of view should subscribe to TIE, although it can be distracting, frustrating, and time consuming.

Randy

Study:The Anatomy of Health Care in the United States

Posted: 13 Nov 2013 03:55 AM PST

From JAMA. I reformatted the abstract, and broke it up into paragraphs to make it easier to read:

Health care in the United States includes a vast array of complex interrelationships among those who receive, provide, and finance care. In this article, publicly available data were used to identify trends in health care, principally from 1980 to 2011, in the source and use of funds (“economic anatomy”), the people receiving and organizations providing care, and the resulting value created and health outcomes.

In 2011, US health care employed 15.7% of the workforce, with expenditures of $2.7 trillion, doubling since 1980 as a percentage of US gross domestic product (GDP) to 17.9%. Yearly growth has decreased since 1970, especially since 2002, but, at 3% per year, exceeds any other industry and GDP overall.

Government funding increased from 31.1% in 1980 to 42.3% in 2011. Despite the increases in resources devoted to health care, multiple health metrics, including life expectancy at birth and survival with many diseases, shows the United States trailing peer nations. The findings from this analysis contradict several common assumptions. Since 2000,

  1. price (especially of hospital charges [+4.2%/y], professional services [3.6%/y], drugs and devices [+4.0%/y], and administrative costs [+5.6%/y]), not demand for services or aging of the population, produced 91% of cost increases;
  2. personal out-of-pocket spending on insurance premiums and co-payments have declined from 23% to 11%; and
  3. chronic illnesses account for 84% of costs overall among the entire population, not only of the elderly.

Three factors have produced the most change:

  1. consolidation, with fewer general hospitals and more single-specialty hospitals and physician groups, producing financial concentration in health systems, insurers, pharmacies, and benefit managers;
  2. information technology, in which investment has occurred but value is elusive; and
  3. the patient as consumer, whereby influence is sought outside traditional channels, using social media, informal networks, new public sources of information, and self-management software.

These forces create tension among patient aims for choice, personal care, and attention; physician aims for professionalism and autonomy; and public and private payer aims for aggregate economic value across large populations. Measurements of cost and outcome (applied to groups) are supplanting individuals’ preferences. Clinicians increasingly are expected to substitute social and economic goals for the needs of a single patient. These contradictory forces are difficult to reconcile, creating risk of growing instability and political tensions. A national conversation, guided by the best data and information, aimed at explicit understanding of choices, tradeoffs, and expectations, using broader definitions of health and value, is needed.

My frustration? That anyone treats any of this as news. At some point we need to stop diagnosing the problem and start doing something about it.

The whole thing is worth a read. But none of it will be news for regular visitors to TIE. Why isn’t everyone reading this blog already?!?!?!

@aaronecarroll

Quote: Uwe (Need I say more?)

Posted: 13 Nov 2013 04:00 AM PST

[T]he often advanced idea that American patients should have “more skin in the game” through higher cost sharing, inducing them to shop around for cost-effective health care, so far has been about as sensible as blindfolding shoppers entering a department store in the hope that inside they can and will then shop smartly for the merchandise they seek. So far the application of this idea in practice has been as silly as it has been cruel. […]

In their almost united opposition to government, US physicians and health care organizations have always paid lip service to the virtue of market, possibly without fully understanding what market actually means outside a safe fortress that keeps prices and quality of services opaque from potential buyers. Reference pricing for health care coupled with full transparency of those prices is one manifestation of raw market forces at work.

Uwe Reinhardt, The Journal of the American Medical Association. I thank Karan Chhabra for the prod.

@afrakt

AHRF/ARF 2012-13 data is available free

AHRF=Area Health Resource File (Formerly ARF)

2012-2013 ARHF can now be downloaded at no cost.

The 2012-2013 ARF data files and documentation can now be downloaded. Click the link below to learn how to download ARF documentation and data.

http://arf.hrsa.gov/

“The Area Health Resources Files (AHRF)—a family of health data resource
products—draw from an extensive county-level database assembled annually from
over 50 sources. The AHRF products include county and state ASCII files, an MS Access
database, an AHRF Mapping Tool and Health Resources Comparison Tools (HRCT). These
products are made available at no cost by HRSA/BHPR/NCHWA to inform health resources
planning, analysis and decision making..”

“The new AHRF Mapping Tool enables users to compare the availability of healthcare providers as well as environmental factors impacting health at the county and state levels.”

Early Exchange Bids from NY are VERY LOW

This news is sufficiently important that I am posting sections of several articles and summaries.

From July 16, 2013 New York Times:

Health Plan Cost for New Yorkers

Set to Fall 50%

By and
Published: July 16, 2013

Individuals buying health insurance on their own will see their premiums tumble next year in New York State as changes under the federal health care law take effect, Gov. Andrew M. Cuomo announced on Wednesday.

Read Full article here. Particularly view the graphic.

http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/health_insurance_and_managed_care/index.html?inline=nyt-classifier

Comments from today:

New York Times

9) Obamacare is the Right’s Worst Nightmare
from New York Times by Paul Krugman

News from New York: it looks as if insurance premiums on the individual market are going to plunge thanks to Obamacare. This shouldn’t come as a surprise; in fact, the New York experience perfectly illustrates why Obamacare had to look the way it does. And it also illustrates why conservatives should be terrified about this legislation, as it takes effect. Americans may have had a lot of misgivings in advance, thanks to vast, deliberately spread misinformation. But I agree with Matt Yglesias – unless the GOP finds even more ways to sabotage the plan, this thing is going to work, it’s going to be extremely popular, and it’s going to wreak havoc with conservative ideology.

Wall Street Journal

10) Big Labor Wakes Up to ObamaCare
from Wall Street Journal by Editorial Board

Every revolution devours its children, but it’s still surprising to see some of ObamaCare’s keenest boosters deny paternity so soon after the birth. Witness the emotional volte-face from three top union leaders, warning that the program will “shatter not only our hard-earned health benefits, but destroy the foundation of the 40-hour workweek that is the backbone of the American middle class.”

 

11) ObamaCare’s Coalition Begins to Fracture
from Wall Street Journal by Karl Rove

The three union leaders also complained their nonprofit insurance plans are still subject to ObamaCare’s new 2%-3% tax on each insurance policy. They want their members exempted from the tax every other family with health insurance must pay. Who knew labor leaders were such staunch tax opponents? It will not help Democratic enthusiasm in the 2014 midterm elections if ObamaCare causes (a) more workers to lose their union-provided insurance and (b) their hours and paychecks to be cut. In addition, Democratic candidates could be seriously damaged if the three labor bosses follow through on their letter’s threat to stop helping elect Democrats if the law isn’t changed.

2) Obama to Tout Americans Already Benefiting from Health Law
from USA Today by Aamer Madhani

President Obama will use a speech at the White House on Thursday to tout how a provision in his signature health care law is forcing health insurance providers to return money to consumers. With his administration facing deadlines to establish health care exchanges in all 50 states by Oct. 1 and GOP lawmakers continuing to call for a repeal of the law, the president is looking to trumpet the law by highlighting one of the most tangible ways Americans are benefiting from it even as his administration struggles to fully implement it. With that objective in mind, Obama will hone in on what is known as the medical loss ratio provision of the health care law in his speech. The provision requires insurers to refund customers when they spend less than 80% of premiums they collect on medical care. This year the provision will result in 8.5 million Americans receiving $500 million in rebates later this summer, according to the Department of Health and Human Services. The agency estimates that the average rebate is about $100 per family.

Washington Post

8) Obama’s Last Campaign: Inside the White House Plan to Sell Obamacare
from Washington Post by Ezra Klein and Sarah Kliff

The focus on young, minority voters. The heavy reliance on microtargeting. The enthusiasm about nontraditional communications channels. The analytics-rich modeling. It sounds like the Obama campaign. And administration officials don’t shy away from the comparison. But the effort will have to go far beyond engineering turnout among key demographics. The administration needs to build more insurance marketplaces than they ever expected, and create an unprecedented IT infrastructure that lets the federal government’s computers seamlessly talk to the (often ancient) systems used in state Medicaid offices. They need to fend off repeal efforts from congressional Republicans – like Wednesday’s vote to delay the individual mandate – and somehow work with red-state bureaucracies that want to see Obamacare fail. And they can’t escape the fact that the law, three years after passage, remains stubbornly unpopular.

31 charts to destroy your faith in humanity

This humorous web site from the Washington Post’s WonkBlog is worth a look. It will only take a couple of minutes.

31 charts that are informative but illustrates how one can put a negative spin on anything.

http://www.washingtonpost.com/blogs/wonkblog/wp/2013/05/24/these-31-charts-will-destroy-your-faith-in-humanity/

Here is the original post that it is spoofing.

http://www.businessinsider.com/charts-that-will-restore-your-faith-in-humanity-2013-5

NEJM Study Says Eat Olive Oil and Nuts

There has been a lot of news recently about a NEJM randomized trial  Spanish study of diets that shows  statistically significant benefits of two Mediterranean diets, one providing free olive oil, the other providing free nuts (mostly walnuts), along with other diet recommendations.Scientists randomly assigned 7,447 men and women in Spain over age 55 who were overweight, were smokers, or had diabetes or other risk factors for heart disease to follow the Mediterranean diet or a low-fat diet as the control group. Here is the key paragraph from the NY Times.

“One group assigned to a Mediterranean diet was given extra-virgin olive oil each week and was instructed to use at least 4 four tablespoons a day. The other group got a combination of walnuts, almonds and hazelnuts and was instructed to eat about an ounce of the mix each day. An ounce of walnuts, for example, is about a quarter cup — a generous handful.”

The articles in the Times and Post have emphasized that it was the Mediterranean diet, but the following important blog from Dr. Aaron Carroll, highlights that it very likely that the effects were solely due to increased olive oil and nuts, since the three groups do not differ meaningfully in their consumption of other foods (red meat, fish, vegetables, fruit, grains, red wine, etc.).  Hence instead of saying “Go Mediterranean”, it should have said “Eat Olive Oil and Nuts” to reduce heart and stroke risks.

See table linked in this blog.

Now we’re all going Mediterranean?

Now we’re all going Mediterranean?

More work should be done in this area.

Here is the full cite and abstract from the NEJM.

Primary Prevention of Cardiovascular Disease with a Mediterranean Diet

Ramón Estruch, M.D., Ph.D., Emilio Ros, M.D., Ph.D., Jordi Salas-Salvadó, M.D., Ph.D., Maria-Isabel Covas, D.Pharm., Ph.D., Dolores Corella, D.Pharm., Ph.D., Fernando Arós, M.D., Ph.D., Enrique Gómez-Gracia, M.D., Ph.D., Valentina Ruiz-Gutiérrez, Ph.D., Miquel Fiol, M.D., Ph.D., José Lapetra, M.D., Ph.D., Rosa Maria Lamuela-Raventos, D.Pharm., Ph.D., Lluís Serra-Majem, M.D., Ph.D., Xavier Pintó, M.D., Ph.D., Josep Basora, M.D., Ph.D., Miguel Angel Muñoz, M.D., Ph.D., José V. Sorlí, M.D., Ph.D., José Alfredo Martínez, D.Pharm, M.D., Ph.D., and Miguel Angel Martínez-González, M.D., Ph.D. for the PREDIMED Study Investigators

February 25, 2013DOI: 10.1056/NEJMoa1200303

http://www.nejm.org/doi/full/10.1056/NEJMoa1200303?query=featured_home#t=article

Abstract: The traditional Mediterranean diet is characterized by a high intake of olive oil, fruit, nuts, vegetables, and cereals; a moderate intake of fish and poultry; a low intake of dairy products, red meat, processed meats, and sweets; and wine in moderation, consumed with meals. In observational cohort studies and a secondary prevention trial (the Lyon Diet Heart Study), increasing adherence to the Mediterranean diet has been consistently beneficial with respect to cardiovascular risk. A systematic review ranked the Mediterranean diet as the most likely dietary model to provide protection against coronary heart disease. Small clinical trials have uncovered plausible biologic mechanisms to explain the salutary effects of this food pattern. We designed a randomized trial to test the efficacy of two Mediterranean diets (one supplemented with extra-virgin olive oil and another with nuts), as compared with a control diet (advice on a low-fat diet), on primary cardiovascular prevention.

Steve Brill Interview on the Daily Show

Steve Brill, who just wrote a 36 page article for Time Magazine, conducted an informative interview on the daily show on Thursday, Feb 21, 2013. Here is the link to the unedited version. It is in three parts, and lasts about 12 minutes (including some ads). Worth watching if you have time.

http://www.thedailyshow.com/watch/thu-february-21-2013/exclusive—steven-brill-extended-interview-pt–1

Myths, Presumptions, and Facts about Obesity

There is a very interesting article about obesity in this week’s New England Journal of Medicine. I recommend it highly to anyone interested in the topic.

K. Casazza and Others | N Engl J Med 2013;368:446-454

To tempt you to look at the full article, here is the list of what the team considers myths.

___________________________

Myths

Small sustained changes in energy intake or expenditure will produce large, long-term weight changes

Setting realistic goals in obesity treatment is important because otherwise patients will become frustrated and lose less weight

Large, rapid weight loss is associated with poorer long-term weight outcomes than is slow, gradual weight loss

Assessing the stage of change or diet readiness is important in helping patients who seek weight-loss treatment

Physical-education classes in their current format play an important role in preventing or reducing childhood obesity

Breast-feeding is protective against obesity

A bout of sexual activity burns 100 to 300 kcal for each person involved

____________________________

Read the article to learn about “presumptions” and “facts”.

Commonwealth Fund Report on Health Care Cost Control

The Commonwealth Fund has just come out with a new report outlining a strategy for containing health care costs in the US. It seems rather optimistic to me. Here is the opening two paragraphs and link.

Confronting Costs: Stabilizing U.S. Health Spending While Moving Toward a High Performance Health Care System, Authored by The Commonwealth Fund Commission on a High Performance Health System
January 10, 2013

Michael Chernew (Harvard) is the only economist on the Commission, which is mostly MDs and MBAs.

“Overview

The Commonwealth Fund Commission on a High Performance Health System, to hold increases in national health expenditures to no more than long-term economic growth, recommends a set of synergistic provider payment reforms, consumer incentives, and systemwide reforms to confront costs while improving health system performance. This approach could slow spending by a cumulative $2 trillion by 2023—if begun now with public and private payers acting in concert. Payment reforms would: provide incentives to innovate and participate in accountable care systems; strengthen primary care and patient-centered teams; and spread reforms across Medicare, Medicaid, and private insurers. With better consumer information and incentives to choose wisely and lower provider administrative costs, incentives would be further aligned to improve population health at more affordable cost. Savings could be substantial for families, businesses, and government at all levels and would more than offset the costs of repealing scheduled Medicare cuts in physician fees.” from The Commonwealth Fund Report

The heart of their analysis is in the technical report by Actuarial Research Corp.

Jim Mays, Dan Waldo, Rebecca Socarras, and Monica Brenner “Technical Report: Modeling the Impact of Health Care Payment, Financing, and System Reforms” Actuarial Research Corporation, January 10, 2013

The areas they simulate are revealed in the table of content headings. Nice recent references.

Introduction ……………………………………………………………………………………………………………………………….. 1
I. Improved Provider Payment ………………………………………………………………………………………………….. 4
II. Primary Care: Medical Homes ………………………………………………………………………………………………… 7
III. High-Cost Care Management Teams …………………………………………………………………………………….. 13
IV. Bundled Payments ……………………………………………………………………………………………………………… 16
V. Modified Payment Policy for Medicare Advantage …………………………………………………………………. 22
VI. Medicare Essential Benefits Plan ………………………………………………………………………………………….. 26
VII. Private Insurance: Tightened Medical Loss Ratio Rules ……………………………………………………………. 30
VIII. Reduced Administrative Costs and Regulatory Burden ……………………………………………………………. 32
IX. Combined Estimates …………………………………………………………………………………………………………… 35
X. Setting Spending Targets …………………………………………………………………………………………………….. 37
Appendix A. Creating the “Current Policy” Baseline ……………………………………………………………………….. 40

 

17-Month Extension of OPT for Econometrics etc.

UPDATE: On May 11, 2012, the U.S. Department of Homeland Security added several fields of study to the list of CIP codes that now qualify for the 17-month extension of initial 12 months of Optional Practical Training (OPT). The new list of  majors – and their corresponding CIP codes – that qualify for the extension (updated in May 2012) include:

45.0603 Econometrics and Quantitative Economics
51.2007 Pharmacoeconomics/Pharmaceutical Economics

For more info visit:
http://www.bu.edu/isso/students/current/f1/employment/off-campus/17MonthExt.html

The list of fields included is shown here.
http://www.ice.gov/doclib/sevis/pdf/stem-list.pdf

Unfortunately the BU Economics program majors do not fit exactly into these areas, so this extension does NOT immediately apply to BU graduates. BU ISSO is working on it though. I apologize that my earlier post was more encouraging.

2012 Handbook of Health Economics, on ScienceDirect

2012 Handbook of Health Economics (Pauly, McGuire and Barros) is free on-line. Here is the link to the pdf files.

Excellent literature reviews and new insights. I purchased the hard cover version, but this is wonderfully accessible.

http://www.sciencedirect.com/science/handbooks/15740064

Many research universities, including BU have access to ScienceDirect.

It is unusual for Elsevier to post its new material for free access in this way.

Enjoy.

US Physician office visits declined 17% from 2009-2011

Being insured is no guarantee unemployed will seek care

Research suggests they may be unable to cover co-pays and deductibles, or fear they cannot afford the expenses that result.

By Victoria Stagg Elliott, amednews staff. Posted Feb. 7, 2012.

Unemployed people who have private health insurance are less likely to put off care because of cost than those without insurance or on public plans. But they are much more likely than the employed to stay away from the doctor’s office.

“Even if you have insurance, you typically have to pay 20% or more of the price, and when you become unemployed, you become more cautious about spending money,” said Randall Ellis, PhD, professor of economics at Boston University and president of the American Society of Health Economists. “You put off preventive visits, and if you have the flu, you choose not to go in for treatment.”

About 29.3% of the unemployed had private insurance, according to a data brief issued Jan. 24 by the Centers for Disease Control and Prevention’s National Center for Health Statistics analyzing adults 18-64 who participated in the National Health Interview Survey for 2009-2010 (www.cdc.gov/nchs/data/databriefs/db83.htm).

Full article is here.

http://www.ama-assn.org/amednews/2012/02/06/bisd0207.htm

Puzzling fact is that outpatient office visits declined by 17%:

“Outpatient office visits declined 17% among patients with private insurance — from 156 million in the second quarter of 2009 to 129 million in the second quarter of 2011.”

(Ibid)

Yet  total private insurance spending on physicians remained almost unchanged.

2009 2010 Change
Total $408.3 billion $415.8 billion 1.8%
Private insurance $209.0 billion $209.4 billion 0.2%

Source: National Health Expenditure Data, Centers for Medicare & Medicaid Services Office of the Actuary, January (www.cms.gov/nationalhealthexpenddata/01_overview.asp)

Also see: http://www.ama-assn.org/amednews/2012/01/23/gvl10123.htm

Could be worth exploring…