Last week LDI hosted a day-long conference on Medicare for All & Beyond. Our goal was to participate in one of today’s most pressing conversations in health care—how to expand health insurance to the 28 million people in the United States who are currently uninsured. We welcomed close to 300 people from across the spectrum to participate in this conversation, to consider the critical questions underlying today’s debate, and to look in depth at the challenges we face in expanding insurance coverage in our country. The conference gave us all plenty to mull over.
In a new paper in JAMA Network Open, our team looked at the potential effects of Medicaid work requirements on Medicaid participation among those not actually subject to these requirements. We estimate that these “spillover effects” – which thus far have not been part of the conversation on work requirements – could be quite large. How we arrived at this answer is worth a bit of explanation.
Accountable care organizations (ACOs) figure prominently in Medicare’s shift “from volume to value.” Providers in ACOs assume financial accountability for overall quality and costs for a defined patient population, and they earn shared savings for containing spending below a defined benchmark. To date, most ACOs have focused on primary care, outpatient services, and care management for patients with chronic medical conditions, such as diabetes and heart failure. This strategy has yielded some savings, but many ACOs may be missing a critical source of savings: surgical procedures.
The novel coronavirus, true to its name, continues to display properties that are surprising once discovered. The official data from the Centers for Disease Control and Prevention on reported cases and deaths appeared to indicate that it is much more lethal than other viral infections (like the flu). In Pennsylvania we have had about 1,600 deaths out of 40,000 cases, or a death rate of 4% (slightly less than the overall national rate but above that in rural states). However, new research using antibody tests that detect whether the test taker had an infection have consistently shown much higher rates of prevalence than indicated by identified cases.
In a newly-published article in Gastroenterology, my colleagues and I present a dramatic chart showing decreases in cirrhosis hospitalizations attributable to the COVID-19 pandemic. This study is one of the first to quantify nationwide shifts in the way health care is being delivered during the pandemic.
As the current COVID-19 pandemic demonstrates, nurses have a critical role in the coordination, delivery, and evaluation of care. Studies show, however, that nursing care is often “missed,” meaning that it is delayed, partially completed, or not completed at all. In a recent study at Penn Nursing's Center for Health Outcomes and Policy Research, my colleagues Eileen Lake, Douglas Sloane, and I investigated how changes in the hospital work environment and nurse staffing over time affect missed nursing care.
In a new study published in JAMA Oncology, my colleagues and I find that behavioral nudges can promote high-value, evidence-based prescribing of specialty drugs in cancer care. For patients with breast, lung, and prostate cancer with bone metastases, clinicians face a decision between two therapies of comparable effectiveness but dramatically different cost. Guidelines endorse the use of either zoledronate or denosumab, bone-modifying agents that protect against skeletal complications. But zoledronate costs as little as $215 a year while denosumab costs as much as $26,000 a year.
Amid a surging Covid-19 pandemic that has overwhelmed hospitals, several states — including California, New York, New Jersey, Pennsylvania, and Washington— have told nursing homes that they must accept Covid-19-positive patients when they are discharged from the hospital. This decision drew immediate pushback from nursing home officials, who care for an extremely vulnerable population. They say an influx of patients with Covid-19 would put their other residents and staff at risk for infection and that they lack the tools — such as adequate staffing and the ability to isolate patients — to care for patients with active Covid-19 infection.
Because much of the decline in economic activity is driven by a lack of consumer demand and businesses' hesitation to open their doors, rather than the shelter-in-place policies, economic revival will only occur once we can ensure public safety through rigorous public health measures that slow the virus to a halt – or a vaccine. Only public health will return the United States to normal economics.
Back in February, when COVID-19 didn’t prevent us from gathering in a room with 300 people, Penn LDI’s conference, Medicare for All and Beyond dug into some of the major sticking points around health care reform. We capped off the day with a discussion on political feasibility, in which an expert panel shared their insights on public opinion and the viability of various reform proposals. Since that time, Americans are living through a generation-defining pandemic, a public health threat that most would have found unimaginable only a few months ago. What is politically feasible now may be very different from what our panel discussed in February. Could a pandemic usher in dramatic health care reform in the United States? We reconnected (virtually) with our panel to hear their latest thoughts. Several themes emerged from these conversations:
During the COVID-19 pandemic, the vast majority of clinical research visits have stopped, with the recognition that any in-person contact adds risk that, for the time being, outweighs any research without direct benefit. Researchers have adopted this new normal, often under the premise that this too shall pass. Soon enough, when going to the grocery store becomes a mundane errand instead of a momentous event preceded by days of planning, our work lives – including research – will resume as well. But is that true?
Overuse of medical care—the provision of services that can do more harm than good—remains a key driver of waste in our health care system. While most work on this topic has focused on individual overused services, we think it is valuable to conceptualize overuse as a systemic phenomenon, defined as the general tendency of an organization or region to overuse medical services. It turns out that regions and organizations have persistent patterns of overuse, and we’re beginning to understand why.
These days, it feels like every article is a COVID-19 article. In the last month alone, LDI Senior Fellows have outlined the unique challenges of delivering post-acute care during a pandemic (solution: more intensive care at home), described the rapid rollout of a robust telemedicine system at Penn (“three weeks to build an army”), and even evaluated the effects of the lockdown in Wuhan, China (it worked). But LDI Associate Fellows, who comprise clinical fellows, postdocs, and PhD students, many of whom work on the frontlines, have also added to the COVID-19 commentary, bringing the unique experience of being a trainee amidst a global pandemic.