Category Archives: BUHealth

Our Daily US Gun Killings

This repost is from the Daily Kos.

http://www.dailykos.com/story/2013/04/01/1198534/-Another-day-in-the-Gun-Crazy-U-S-A

While Sandy Hook murders and the Marathon Bombing get a lot national attention, it is the daily tragedy of gun shootings and killings that should be of greatest concern. The Daily Kos simply compiled lists of all of the daily reports of murders for a week ending April 1 on the above web site.  Here is the April 1 media summary, the Monday after Easter.

April 1, 2013 edition (Monday)

 

Northwest Miami-Dade, Fla. — A 4-year-old girl died after being struck by a bullet while sitting in a parked car at a residence along with several other children about 6:10 p.m. Saturday. Police believe one of the children might have accidentally fired the gun.

Kansas City, Mo. — A 14-year-old boy, a middle school student, was shot and killed on a street when someone fired at him from a passing car about 3 p.m. Saturday. A 15-year-old boy who was with the victim was not injured.

Indianapolis, Ind. — A man cleaning his gun was killed about 3:30 p.m. Saturday when the weapon accidentally discharged.

Philadelphia, Penn. — A 27-year-old woman was accidentally shot and killed by her 28-year-old boyfriend about 7:45 p.m. Saturday. The boyfriend says he was arguing with a neighbor, possibly an uncle, when the neighbor threatened him with a hammer. Fearing for his safety, the boyfriend took out a gun, but then tripped and accidentally pulled the trigger, shooting the woman in the neck.

Cleveland Heights, Calif. — A 25-year-old woman was apparently accidentally shot and killed outside a restaurant by a security guard about 3 a.m. Saturday. Police say the victim and three other women were involved in an altercation with the guard inside the restaurant. As he was escorting them off the property, he was knocked to the ground and his weapon discharged, hitting the victim.

Harrisburg, N.C. — A 50-year-old man shot and killed two of his neighbors — a 64-year-old man and a 42-year-old man — in the backyard of one of their homes on a cul-de-sac. He then used the gun to kill himself after a several-hours-long standoff with police. The shooting was related to a dispute of some sort.

Ashtabula, Ohio — A 52-year-old man was shot and killed outside a church by his 25-year-old son shortly after Easter services ended about 1:15 p.m. Sunday.

Hartford, Conn. — A 22-year-old man was shot to death behind a building about 9:20 p.m. Sunday. He was hit once in the head.

Forney, Tex. — A 63-year-old man and his 65-year-old wife were found shot to death at their home Saturday night. The man was the district attorney for the county and police believe the victims were targeted.

North Harris County, Tex. — A 25-year-old man was fatally shot outside a house about 11:30 p.m. Saturday night.

Los Angeles, Calif. — About 11:10 p.m. yesterday, a man and woman encountered two gunmen after they went outside their home to investigate a car-alarm that was going off. A confrontation resulted and it ended up in the house where the man, 50 years old, was shot twice in the chest. He died a short time later. Police report that the gunmen and the victim might have known each other.

Washington, D.C. — A 33-year-old man was shot and killed about 2:10 a.m. Saturday outside an apartment complex. He had been shot in the chest.

Melbourne, Fla. — A sales manager at an auto dealership was shot and killed during an apparent road-rage incident while test-driving a vehicle for a trade-in. During the test drive, the manager stopped to make a right-hand turn and was rear-ended by another car. The driver of that car, a 64-year-old man, then shot the victim, killing him.

Oakland, Calif. — A 31-year-old man was fatally shot while sitting inside a car around 10 a.m. yesterday. The gunman fled in a vehicle.

Oakland, Calif. — A man was fatally shot while on a street about 4:10 p.m. yesterday.

Oakland, Calif. — A man was fatally shot while on a street about 8:10 p.m. yesterday.

Jacksonville, Fla. — A 32-year-old man was fatally shot Sunday morning after getting into a disagreement with a 20-year-old man. Police are looking for the suspect.

Brooklyn, N.Y. — A 37-year-old livery-cab driver on his way to pick up a fare was killed about 12:45 a.m. today after being shot in the face and crashing his minivan.

Bronx, N.Y. — A 28-year-old man was shot in the throat and killed about 12:15 a.m. yesterday inside an apartment building.

Las Vegas, Nev. — A 43-year-old man is a suspect in the shooting deaths of his mother and father. The son claimed he found the couple fatally shot inside their home about 9 p.m. Friday. Police initially thought it was a case of murder-suicide, but now believe the son killed them.

St. Louis, Mo. — When someone in a passing car shot at a group of people, one of the bullets struck a 4-year-old girl in the shoulder as she walked with her mother up the steps of a home. Police arrested a 23-year-old man in connection with the incident.

South Pittsburgh, Tenn. — About 6:30 p.m. Thursday, a 13-year-old was struck in the shoulder by a bullet when his father tested his gun by firing it from his back porch into thick woods. The father didn’t know his son was in the woods; he thought the boy was inside the house. The victim was listed in good condition.

Madison County, Ga. — A 17-year old boy watching TV in a living room accidentally shot himself in the hand while trying to unload a pistol on Saturday.

Port Deposit, Md. — A 20-year-old man accidentally shot himself in the torso when he tripped and fell while walking back to his house after target shooting Saturday about 2:30 p.m. No word on his condition.

Chicago, Ill. — Someone in a moving car opened fire on a 21-year-old man sitting on a porch about 7:30 p.m. yesterday. The victim was struck in the abdomen and was listed in serious condition.

Chicago, Ill. — A 26-year-old man was shot in the hip and knee while leaving a store about 9:15 p.m. yesterday. He was listed in critical condition.

Chicago, Ill. — A 29-year-old man walking down a street was shot in the leg about 9:50 p.m. when someone fired shots at him from a passing car. He was listed in stable condition.

Stamford, Conn. –About 7 p.m. Thursday, a 26-year-old man accidentally shot himself in the leg at his residence while cleaning his semi-automatic gun after returning from a firing range. No word on his condition.

Milwaukee, Wis. — About 9:15 p.m. Saturday, a 17-year-old male was shot by someone during an altercation over a female acquaintance. No word on his condition.

New Orleans, La. — A man was shot in the foot about 7 p.m. yesterday. No word on his condition.

Oakland, Calif. — Someone was shot about 7 p.m. yesterday. No word on the victim’s condition.

Jacksonville, Fla. — A man was shot in the upper torso about 9 p.m. yesterday. He was expected to survive.

Washington, D.C. — A 16-year-old boy was shot and wounded while on a street about 12:40 a.m. today when someone in a car fired at him. His injuries were reported as non life-threatening.

Jacksonville, Fla. — A man sitting in front of a house with two or three friends was shot twice in the leg about 5 p.m. Saturday when a car pulled up and someone in the car opened fire. The victim was reported to have non life-threatening injuries.

Oregon City, Ore. — After a 22-year-old woman parked her car about 10:20 p.m. Sunday, a male stranger approached from behind and grabbed her hair and then began dragging her backward. The assailant fled when she pulled out a handgun and pointed it at him.

Today’s sources: Akron Beacon Journal, cecildaily.com, Chicago Tribune, Denver Post, Hartford Courant, Houston Chronicle, KABC-TV Los Angeles, KCTV-TV Kansas City, madisonjournaltoday.com, Milwaukee Journal-Sentinel, Oakland Tribune, The Oregonian, Orlando Sentinel, stamfordpatch.com, Times-Picayune, Washington Post, WCAU-TV Philadelphia, WISH-TV Indianapolis, WRCB-TV Chattanooga, WSOC-TV Charlotte, WTLV-TV Jacksonville

http://www.dailykos.com/story/2013/04/01/1198534/-Another-day-in-the-Gun-Crazy-U-S-A

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.

Useful reference for serious SAS programmers

I often do bootstrap and simulations in my research, and for some background research, I found the following excellent short article on how to use SAS to do efficient replications/bootstrapping/jackknifing.

Paper 183-2007
Don't Be Loopy: Re-Sampling and Simulation the SAS® Way
David L. Cassell, Design Pathways, Corvallis, OR

http://www2.sas.com/proceedings/forum2007/183-2007.pdf

Here is an elegant example that shows how to do 1000 replications of the Kurtosis of X. Note that proc univariate could be replaced with anything. Discussion of proc append and critique of alternative programs is also useful.

(I will note that it starts by creating a sample that is 1000 times as large as the original, but still, it is very fast given what is being done.)

proc surveyselect data=YourData out=outboot /* 1 */
seed=30459584 /* 2 */
method=urs /* 3 */
samprate=1 /* 4 */
outhits /* 5 */
rep=1000; /* 6 */
run;
proc univariate data=outboot /* consider noprint option here to reduce output */;
var x;
by Replicate; /* 7 */
output out=outall kurtosis=curt;
run;
proc univariate data=outall;
var curt;
output out=final pctlpts=2.5, 97.5 pctlpre=ci;
run;

Wennberg, Staiger et al on Observational Intensity Bias

This very interesting paper by John Wennberg, Doug Staiger et al develops a new approach for calibrating risk adjustment models so as to not over adjust for the higher intensity of coding that results when there are more visits. In short, in markets where doctors do more visits, they will also tend to code more diagnoses. Their approach takes into account both visits and diagnoses to improve model fit. There are many further questions one could ask, but this is destined to be an influential paper.

http://www.bmj.com/highwire/filestream/632298/field_highwire_article_pdf/0/bmj.f549

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".

2007-2020 MarketScan Data at Boston University

Boston University is now in its third year of licensing use to the MarketScan Commercial Claims and Encounters databases. This data is available for free to Boston University faculty, staff, and students for unfunded research, but researchers are required to request funding for any externally funded research projects. Interested researchers should contact Randy Ellis, who is data manager for the data.

The Truvan Analytics MarketScan Commercial Claims Databases provide individual-level clinical utilization, expenditures, and enrollment across inpatient, outpatient, prescription drug, and carve-out services from a selection of large employers and health plans. The MarketScan Databases link paid claims and encounter data to detailed patient information across sites and types of providers, and over time. The annual medical databases include private sector health data from approximately 100 payers. Historically, more than 500 million claim records are available in the MarketScan Databases. These data represent the medical experience of insured employees and their dependents for active employees, early retirees, COBRA continues and Medicare-eligible retirees with employer-provided Medicare Supplemental plans.

While the information about the individuals is rather limited (age, gender, employment status, industry, MSA, enrollment information, plan type), the information about their utilization of medical care is incredibly detailed. Some of the most useful variables are: Out-of-pocket payment (sub-divided into deductible, coinsurance, and copayments) and total payment by service rather than by admission, detailed diagnosis and procedure codes, service codes, precise dates of visits and admissions, provider-type, and facility information. The data also included detailed information on prescription drug claims including information for identifying the specific (down to the dose) drug purchased, the amount purchased, and the date of refills.

This vast amount of information allows researchers to construct general variables such as the financial risk of an enrollee (in terms of an age-gender and diagnosis-based risk score), an enrollee’s annual out-of-pocket expenses, geographic variation in spending, geographic variation in the use of a particular procedure or drug down to the state and MSA-level (State and county and 3-digit zip code-level in 2007-2010 data). It also allows researchers to construct more detailed individual-level variables such as cancer diagnosis and subsequent chemotherapy use, ER admission and subsequent readmissions, individual preferences for brand vs. generic pharmaceuticals, etc.

There are separate tables for enrollee information (individual-level), outpatient claims (service-level), inpatient services (service-level), inpatient admissions (admission-level; aggregated version of inpatient services), prescription drug claims (prescription/refill-level), and facility information (facility-level). All of these tables can be linked using a unique enrollee ID. The unique enrollee IDs are constant across years, allowing researchers to follow individuals over time as long as they remain insured by the same payer.

The information in these tables comes directly from the payers (employers and insurance plans). Truven Analytics then cleans and verifies the data from each payer, de-identifies the data it, and combines it to form the final dataset. Because the data come from the payers, and the payers are paying Truven Analytics to provide them with accurate information and analysis about the claims, the incentives are aligned to provide accurate data.

The data includes an electronic copy of the Red Book list of all pharmaceuticals marketed in the US, along with information about each of the 350,000+ NDC (National Drug Code) values. Significant detail about the data is available in the accompanying data description and data quality appendices.

The versions we have use a six month claims “runout”, which is to say that claims for 2011 services are accepted through the June 30, 2012.

The following table includes additional year-specific information about the data files:

Year Number of Individuals Size of all files Geographic Detail
2007 35,305,924 203 GB MSA, 3-digit zip code & county
2008 41,275,020 251 GB MSA, 3-digit zip code & county
2009 39,970,145 263 GB MSA, 3-digit zip code & county
2010 45,239,752 281 GB MSA, 3-digit zip code & county
2011 52,194,324 321 GB MSA and state ONLY
Total 213,985,165 1.319 TB

 

Letter calls for gun injury research

Colleague Austin Frakt forwarded to me the link to an open letter to VP Joseph Biden and members of the Gun Violence Commission.

http://crimelab.uchicago.edu/sites/crimelab.uchicago.edu/files/uploads/Biden%20Commission%20letter_20130110_final.pdf

The letter is signed by over 100 well-known health professionals, policymakers and economists.

The letter addresses the fact that both teh CDC and the NIH agencies are currently prohibited from funding research on the health effects of guns.

Anyone serious about wanting to understand how to control gun violence should support the letter's two recommendations:

RECOMMENDATION ONE: We call for the removal of the current barriers to firearm-related
research, policy formation, evaluation and enforcement efforts.

RECOMMENDATION TWO: We call on the federal government to make direct investments in
unbiased scientific research and data infrastructure.

The following table in the letter tells the story clearly.

9 Branas, C., Wiebe, D., Schwab, C. & Richmond, T. (2005) Getting past the "f" word in federally funded public health research, Injury Prevention 11(3): 191.
10 http://projectreporter.nih.gov/reporter.cfm
11 Calculated updated numbers for 2002 -2012 for cholera and rabies using average case occurrences per year

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

 

US Cardiovascular Diseases Rates are Improving But…

I browsed to the following overview of US research on Heart, Lung, and Blood diseases in the US. This report documents the dramatic improvements in cardiovascular health in the US, which they estimate costs the US about $300 billion or about $1000 per American in 2008 (Direct of treatment and indirect costs from premature mortality).  This makes the US look good, until they compare this trend to trends in other countries, which are almost all better, and have also had large decreases in mortality from 2000 to 2008. We currently spend $3 billion per year on research on Heart, Lung and Blood diseases ($10 per American per year). Below are three figures all from this one report.

http://www.nhlbi.nih.gov/about/factbook/FactBook2011.pdf

 

 

 

 

 

1994 assault weapons ban may have saved 6000 lives per year

Although not a statistical statement, there is a noticeable association between when the 1994-2004 assault weapon ban was in place and the observed decline in gun-related deaths. That ban also contained other provisions that will have affected availability of guns.

A decline of more than 6000 gun-related deaths per year appears to be  associated  with that legislation before it expired. See linked picture.

 

Another articles on this issue also has compelling graphs. The title of the paper could be its abstract..

S Chapman, P Alpers, K Agho, M Jones. 2006. Australia’s 1996 gun law reforms: faster falls in firearm
deaths, firearm suicides, and a decade without mass shootings.
Injury Prevention 2006;12:365–372. doi: 10.1136/ip.2006.013714

 

Two Great Articles in the December JEL

Journal of Economic Literature, December 2012

Two great articles.

Racial Discrimination in the Labor Market: Theory and Empirics

Kevin Lang and Jee-Yeon K. Lehmann

We review theories of race discrimination in the labor market. Taste-based models can generate wage and unemployment duration differentials when combined with either random or directed search even when strong prejudice is not widespread, but no existing model explains the unemployment rate differential. Models of statistical discrimination based on differential observability of productivity across races can explain the pattern and magnitudes of wage differentials but do not address employment and unemployment. At their current state of development, models of statistical discrimination based on rational stereotypes have little empirical content. It is plausible that models combining elements of the search models with statistical discrimination could fit the data. We suggest possible avenues to be pursued and comment briefly on the implication of existing theory for public policy. (JEL J15, J31, J64, J71)
Wonderful synthesis from Kevin and Lehmann, a recent BU Ph.D. alum.

Full-Text Access | Supplementary Materials 

Psychologists at the Gate: A Review of Daniel Kahneman's Thinking, Fast and Slow

Andrei Shleifer

The publication of Daniel Kahneman's book, Thinking, Fast and Slow, is a major intellectual event. The book summarizes, but also integrates, the research that Kahneman has done over the past forty years, beginning with his path-breaking work with the late Amos Tversky. The broad theme of this research is that human beings are intuitive thinkers and that human intuition is imperfect, with the result that judgments and choices often deviate substantially from the predictions of normative statistical and economic models. In this review, I discuss some broad ideas and themes of the book, describe some economic applications, and suggest future directions for research that the book points to, especially in decision theory. (JEL A12, D03, D80, D87) 

Nice short summary of key themes from the extraordinary Kahneman book.

Full-Text Access | Supplementary Materials

HCC risk adjustment formulas for ACA Exchanges

HHS announced the new risk adjustment formulas proposed for the ACA Health Insurance Exchanges on December 7, 2012.
Here is the citation and direct link.
Department of Health and Human Services. HHS Benefit and Payment Parameters for 2014, and Medical Loss Ratio. 2012 [Dec 7 2012]. Available from: http://www.gpo.gov/fdsys/pkg/FR-2012-12-07/pdf/2012-29184.pdf
Focus only on the first 33 pages for teh Risk adjustment system.
Summary:
This proposed regulations provides details on the risk adjustment formula that is proposed for the Federal and STate Health insurance exchanges. At its heart is an HCC model similar to the Medicare 100 condition HCC model. Innovations are that it has separate models for four metal levels (bronze, silver, gold, platinum), it uses a concurrent rather than prospective framework, it has separate models for infants, children and adults. It was estimated at RTI using Truven Health Analytics 2010 MarketScan® data, which we also have licensed at Boston University for research use. The rules are a painful 373 pages long. Focus on pages 1-33 for an overview of the RA approach.
Other NPRM (=Notice of Proposed Rule Making) for regulations of the ACA are the following.
EHB/AV (Essential Health Benefits/Actuarial Value) NPRM:
Summary: http://www.healthcare.gov/news/factsheets/2012/11/ehb11202012a.html
Citation: US National Archives and Records Administration. 2012. Code of Federal Regulations. Title 45. Patient Protection and Affordable Care Act; Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation; Proposed Rule. [Available at: http://www.regulations.gov/#!documentDetail;D=CMS-2012-0142-0001]

Discussion: The rule discusses accreditation of health plans in a federally-facilitated or state-federal partnership exchange. States that plans offered inside and outside of the exchange must offer a core package of benefits including the following: Ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative services, lab services, preventive and wellness services and chronic disease management, and pediatric services.

The rule also specifies options for each state's "benchmark" plan. Plans must offer coverage greater than or equal to that offered by the benchmark plan.

The rule also specifies that HHS will provide an AV calculator to help issuers determine health plan ACs. The calculator uses a nationally representative sample. Starting in 2015, HHS will accept state-specific datasets to use with the calculator. The rule proposes a 2% AV window around the AV specified by for each metal group.

Market Reform NPRM:
Rule: http://www.regulations.gov/#!documentDetail;D=CMS-2012-0141-0001
 

Citation: US National Archives and Records Administration. 2012. Code of Federal Regulations. Title 45. Patient Protection and Affordable Care Act; Health Insurance Market Rules; Rate Review; Proposed Rule. [Available at: http://www.regulations.gov/#!documentDetail;D=CMS-2012-0141-0001]

Discussion: This rule focuses on reforms to the health insurance market. It includes guaranteed issue, premium regulation (rate bands, rate restrictions), single statewide risk pool, etc. The rule also proposes regulation changes to streamline data collection.

MPFS (Medicare Physician Fee Schedule) Rule:
Citation: US National Archives and Records Administration. 2012. Code of Federal Regulations. Title 42. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to-Face Encounters, Elimination of the Requirement for Termination of Non- Random Prepayment Complex Medical Review and Other Revisions to Part B for CY 2013. [Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-11-16/pdf/2012-26900.pdf]
More rules and regulations are presented here.
I thank without implicating Tim Layton (BU RA extraordinaire) for organizing this information for me.

US Affordable Care Act and Risk Adjustment

Although there is no accompanying paper, I thought it might be useful to post the PowerPoint slides that I have used in several recent talks about the US since there is an enormous interest in a relatively concise summary of the features of the ACA.

Since my area of particular interest is risk adjustment, there are a number of slides on that topic.

Since Massachusetts is an important early demonstration, I included three slides on Massachusetts.

There are three versions posted: the PowerPoint slides, a pdf version, and a pdf version as a handout (four slides per page).

Powerpoint pdf Handout

 

 

 

A SURVEY OF AMERICA’S PHYSICIANS: PRACTICE PATTERNS AND PERSPECTIVES

An Examination of the Professional Morale, Practice Patterns, Career Plans, and Healthcare Perspectives of Today’s Physicians, Aggregated by Age, Gender, Primary Care/Specialists, and Practice Owners/Employees

Survey conducted on behalf of The Physicians Foundation by Merritt Hawkins | Completed September, 2012. Copyright 2012, The Physicians Foundation

I found this physician survey very useful for statistics about age, hours, patient visits per day, specialty, practice size, attitudes, health reform, ACOs, PCMH and more.

The results reflect selection bias and has an older set of respondents than all MDs, but is still interesting.

http://www.physiciansfoundation.org/uploads/default/Physicians_Foundation_2012_Biennial_Survey.pdf

US physician hours and visits still down 17% in 2012.

Edward Davies
BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6863 (Published 10 October 2012)
 

Cite this as: BMJ 2012;345:e6863
"Between 2008 and 2012, the average number of hours physicians worked fell from 57 hours a week to 53, and doctors saw 16.6% fewer patients. The research, based on a survey of 13 575 physicians across the US, estimates that if these patterns continue 44 250 full time equivalent (FTE) physicians will be lost from the workforce in the next four years. 

More than half of physicians (52%) have limited the access of Medicare patients to their practices or are planning to do so, while one out of four physicians (26%) have already closed their practices altogether to Medicaid patients, the survey shows. Physicians cited rising operating costs, time constraints, and diminishing reimbursement as the primary reasons why they are unable to accept additional Medicare and Medicaid patients."

The survey was fielded online from late March to early June 2012 by Merritt Hawkins for the Physicians Foundation

 

What I Wish Obama Had Said

Alternative Debate Speech Text that President Obama Could Have Used at the First Presidential Debate on October 3, 2012[i]

Randall P. Ellis

Boston University, Department of Economics

October 6, 2012

On Taxes

We have heard a lot of talk from the Republicans about the importance of lowering taxes on people earning more than $250,000 which the Republicans like to call the "job creators." Republicans especially like to link being wealthy with being a small business owners. But let me tell you something else. Small business owners for the most part reinvest their earnings back in their own company, and earn relatively modest incomes. IRS returns show that 97 percent of small business owners earn less than $250,000 per year[ii] , and hence will not be hurt by increasing individual income taxes on the wealthy. Let me repeat that: 97 percent of small business owners earn less than $250,000 per year. It is the overpaid senior executives of large businesses who largely earn more than $250,000, not the small business owners. The Republicans are eager to protect these big guys, the ones funding the Republican campaigns, with tax cuts that favor the wealthy. Less than two percent of all households earn more than $250,000 per year[iii], and they are doing just fine. I want to focus our tax reforms and government investments on helping the other 98 percent of households.

On Social Security

I am glad you asked about Social Security, which is working well: I have no plans to make any changes to this wildly popular program. All Americans earning a paycheck are required to contribute to support this program through a social security payroll tax, which is a type of income tax. The Social Security system provides income to elderly people when they retire, even if they have not been so clever, organized or motivated to save enough for their own retirement. Social Security is a social insurance program, since people who live longer take out more money than people who are less unfortunate and die while young. Social Security also redistributes money a little bit from people who earn more to people who earn less. For example a parent who works hard raising a family still gets some social security even if their spouse dies, or they are divorced, and even if the parent never receives a pay check. Despite it being social insurance and redistribution, Social Security is wildly popular. My republican opponents think social insurance is socialism, and even call it Socialist Security because it is a form of redistribution, which they have made out to be a political no-no to mention. But there it is, a wildly popular, income redistribution program that we should all embrace.

As all of you know who have watched the revealing secret video taken of Mitt Romney speaking to a select group of large donors, Governor Romney discounts this sizable income tax as being unimportant even though it represents more than 35 percent of our federal revenue.[iv] He considers the elderly retired, students working part time while earning a degree, and anyone earning less than about $15,000 for single head of households or about $30,000 for families as being dependents, not worthy of his concern, because they pay no income taxes.  I couldn’t disagree with him more. Social payroll taxes, paid by hardworking citizens generate more than four times the federal revenue as all corporate taxes.[v]

On reducing the national deficit:

I would like to respond to Governor Romney's correct statement that there are three ways of cutting the national debt: Raising taxes, cutting government expenses, and growing the economy. On the third one, growing the economy, every economist, every politician, and every citizen I have ever met will agree that the third one is the best of the three.  It is American apple pie. But it doesn't mean anything for Gov. Romney to claim that he will do a better job at growing the economy. In fact, if you look back over the last fifty years, the economy, jobs and the stock market have all grown faster under Democratic presidents than Republican ones. Go check out the facts.[vi] And this is especially true under the disastrous leadership of the previous Republican president, George W. Bush who caused the greatest recession in eighty years with his tax cuts and unfunded spending policies.

The only specific, substantive policies that Gov. Romney has proposed for promoting growth is to cut taxes, particularly on the wealthiest Americans. And that is the same policy that was tried and failed by George W. Bush and the Republicans who tied or had a majority in both Houses of Congress for six of the eight years that President Bush was in office[vii], notably at the time that Congress voted for two unfunded wars and the first of the two enormous Bush tax cuts.

Former president Bill Clinton said it well when he highlighted that republicans, not democrats have a worse record of increasing our national debt. Ronald Reagan nearly tripled the national debt under his presidency, while George W. Bush nearly doubled the national debt.[viii] President Clinton was the only president in the postwar period to hand his successor a budget surplus when he left office. Democrats, not Republicans, are more effective at cutting the national debt.

I am sad that because of the two unfunded wars, the Bush tax cuts, and increased spending necessitated by this Great Recession, the National Debt has also increased greatly during my term. It is not what I wanted. But a reasonable American will agree that I was handed an economy in such serious agony by my predecessor that it would have been irresponsible not to have continued and in many cases increased government spending and tax cuts so as to get us out of this recession.

As our economy improves, I promise to work hard toward implementing elements of the bipartisan recommendations of the 2010 Bowls-Simpson commission, which reflected a balanced reduction in spending together with selective increases in taxes.   In contrast to my willingness to support a balanced approach to deficit reduction that includes both tax increases and in spending reductions, Gov. Romney has stated that he will be unwilling to agree to a deficit reduction even if it involves less than $1 of tax increases for every $10 in spending reductions[ix]. That is not going to solve our budget deficit problem.

On ObamaCare

I thank the former Governor for giving me credit for creating the Affordable Care Act, also known as ObamaCare, since a different candidate would perhaps take pride in something that he himself helped create in Massachusetts. Contrary to what he says, I worked hard to try to get Republican support for this health reform bill, using Romney’s own successful health reform approach from Massachusetts, and embracing concepts from the conservative Heritage Foundation and from Republicans who supported the idea of setting up private exchanges when President Clinton tried to do health reform. Unfortunately the Republicans in congress could no longer support their own approach once it was embraced by me and the Democrats, so we had to move forward without their voting support. It is dishonest to say that I did not try to reach across the aisle and try to get bipartisan support.

Even though some features of ObamaCare remain controversial, the features of ObamaCare that have already been implemented are enormously popular. Let me describe a few of its features that are already in place.

ObamaCare allows all young people to remain on their parent's health insurance policy up until age 26, which resulted in immediate coverage for over 2 million young people in 2010.[x] This feature is enormously popular.

ObamaCare prohibits health insurance plans from dropping coverage for anyone just because they became sick. This feature is enormously popular.

Obama prohibits health insurance plans from denying coverage to any family just because they have a child with a serious or expensive preexisting health condition. This feature is enormously popular.

ObamaCare helps reduce the donut hole gap in Medicare's prescription drug coverage, whereby Medicare enrollees have to pay 100 percent of their prescription drug costs once annual drug spending exceeds $2800.[xi] This reduces prescription drug costs by an average of $250 in 2012. This benefit is enormously popular among the elderly.

ObamaCare creates a reinsurance pool for uninsured retirees aged 55 to 64, which is very popular with this highly vulnerable group.

ObamaCare creates a high risk pool to help insurance companies be more willing to insure people with expensive preexisting conditions.[xii] Very few insurers have taken up this program, suggesting that insuring people with expensive preexisting conditions is less expensive than they sometimes lead us to believe.

ObamaCare forces insurance companies to give rebates to enrollees whenever claims costs are less than 80 or 85% of premium revenues. This very popular program has already forced plans to pay back more than a billion dollars to commercially insured enrollees in 2012. It is likely that even plans not paying rebates have been motivated to not raise premiums as much as they would of, and hence this is likely one reason why health insurance premiums have grown so slowly in the past two years.

So from my point of view, Obamacare is already proven to be highly popular among the Americans already benefiting, which includes most of our elderly, our young adults, people with sick children, and everyone at risk of high cost illnesses. You should ask yourself whether you think these changes I just mentioned are something you yourself support, and keep an open mind about your support for the changes yet to come in future years.

Closing remarks

We have heard a lot of new statements from Gov. Romney tonight, as he tries to “reboot” his image. But Americans should not be voting based on the marketing image that the Republican Party has chosen to broadcast in the final months of this long campaign. Instead they should base their voting on facts. The fact is that Gov. Romney has gone out of his way to align himself with a relatively extreme group of Republicans, exemplified by his choice of a vice presidential partner, that represents a radical change in how our society and government operates. Today’s Republican Party is not the party of Ronald Reagan, it is now the Republican Party of Negativity.

Today’s Republican Party of Negativity is assaulting women’s rights, trying to undo women’s access to birth control, right to humane treatment when raped, or right to equal pay.

Today’s Republican Party of Negativity is in denial that global warming is largely caused by the actions of humans and will have disastrous consequences if we don’t begin to take notice and do something about it.

Today’s Republican Party of Negativity is repeatedly voting to obstruct legislation in the Senate. The Senate leadership said this bluntly shortly after I was elected, and has proceeded to filibuster and delay legislation repeatedly. The democratic majority has had to invoke cloture, which is a vote to try to end a filibuster hundreds of times during my term, an intentional Republican strategy.

Today’s Republican Party of Negativity wastes its time voting 33 times to repeal  ObamaCare in the House even when it knows the legislation has no chance of making it through the Senate or being signed by me.

Today’s Republican Party of Negativity repeatedly asserts that ObamaCare reflects a government takeover of health care, while even any fool can look at Massachusetts reforms on which it is based and see that ObamaCare does precisely the opposite, building upon private health care provision, private insurance plans and individual consumer choice  of health plan options.

Today’s Republican Party of Negativity needlessly held our country hostage by refusing to raise the US debt ceiling, even after many of the same Republican senators  voted 17 times to raise the debt ceiling under Ronald Reagan, and voted seven times to raise the debt ceiling under George W Bush.

Today’s Republican Party of Negativity and new chief spokesman Governor Romney says that they care about everybody, but their own votes, their own private speeches, and the words of their corporate sponsors tell us the truth.

I urge you to vote for me, Barack Obama and for others in the Democratic party this November, and show today’s Republican Party of Negativity that theirs is not the direction that our country should go in.

God Bless America.


[i] http://www.youtube.com/politics?feature=etp-pv-ype-b54f6ff011

[iv] http://www.youtube.com/watch?v=Ge03Sys8SdA, http://www.youtube.com/watch?v=rBj0joyCeag&feature=relmfu

[v] http://www.taxpolicycenter.org/briefing-book/background/numbers/revenue.cfm

[viii] http://treasurydirect.gov/govt/reports/pd/histdebt/histdebt_histo4.htm