Featured Post
January 22, 2019
Late last year, the Centers for Disease Control and Prevention (CDC) announced that more than 70,000 people died from drug overdoses in 2017, a 9.6% increase from 2016. Deaths continue to soar, even as states and health systems implement policies to curb the overprescribing of opioids that led to the epidemic in the first place. It’s hard not to be discouraged by these numbers and our failure to reduce overdose deaths. To fully appreciate the shifting dynamics of the opioid crisis, we need to understand both the nature of the policies we are implementing as well as their likely short- and long-term effects.
The ugly truth is that health care is often inefficient, costly, and does not meet the needs of its principal constituent—the patient. This realization has led many physicians and health systems to enthusiastically turn to a new model for delivering primary care, the patient-centered medical home. The patient-centered medical home is a simple idea. It reorganizes care around the needs of the patient, emphasizing coordinated, accessible, and efficient care. In short, it reimagines the health care delivery system in the best image of itself.
Becoming a medical home has been a rather straightforward (though at times costly) process for most primary care practices. According to the NCQA, the organization that certifies most medical homes in this country, practices must invest in infrastructure to support this new delivery model—by using patient registries to easily identify patients who might benefit from coordinated care, increasing doctors’ accessibility for their patients through extended hours, same-day appointments, or secure messaging, and making other changes to the structure of delivery to support the goals of the medical home. Physician practices often make these changes in exchange for increased payments, which may also be tied to metrics to ensure that high-quality care is delivered.
The idea seems too good to not work. Yet the evidence to date is disappointing. Studies often find that when practices adopt the patient-centered medical home there is little change in the quality or costs of care.
(Cross-posted on The Field Clinic blog at philly.com)
Last week, Gov. Corbett submitted his Medicaid expansion proposal to the federal government. By most accounts, this proposal, which entails work-search requirements, premium payments, and changes to existing benefits, faces significant obstacles to federal approval. Even if approved, Medicaid coverage for nearly 300,000 uninsured people will not begin until January 1, 2015 at the earliest.
Why didn’t Pennsylvania choose to expand Medicaid on January 1 of this year, as 26 states have done? According to Gov. Corbett, the current program (one of the costliest in the country) is too bloated and too inefficient to simply expand. “We need to reform the entire Medicaid system that already exists before we do this other,” he said.
By 2015, guns are projected to surpass car accidents as the leading cause of death among Americans aged 15 to 24. Despite these high rates of firearms-related morbidity — via homicide, suicide, and accidental death — researching gun violence in relation to public health has been a challenge.
The Center for Public Health Initiatives hosted a talk on February 25 titled, “Toward a Public Health Research Agenda for Firearms-Related Violence,” which focused on the many impediments to gun research and the pressing need for more data. The event featured talks from Dr. Susan Sorenson of Penn and Dr. Alan Leshner of the American Association for the Advancement of Science, both of whom served on an Institute of Medicine committee last year dedicated to creating a research agenda linking gun violence and public health.
There’s an excellent group of articles in the LDIHealthEconomist by my colleagues who attended the recent AcademyHealth National Health Policy Conference. Together, they chronicle much of the excitement and frustration of this era of health care reform, and reflect next steps in the policy agenda to improve health and health care. All are worth reading, but until you find the time, here are some brief highlights and excerpts.
The group reads like a Who’s Who of economists from across the political spectrum, and includes Nobel Laureates Peter Diamond and Eric Maskin along with LDI Senior Fellows Dan Polsky, Mark Pauly, and Ezekiel Emanuel. They have signed on to an amicus brief in the appeal of Halbig v. Sebelius, which challenges the availability of premium subsidies under the Affordable Care Act (ACA) through federal exchanges in the 36 states that did not establish their own insurance exchanges. Nick Bagley, in The Incidental Economist, has written an excellent summary of the legal findings in the original ruling.
The appellants argue that Congress meant to limit subsidies to people obtaining coverage on state-based insurance exchanges only. So what do 48 economists have to say in this legal brief? They answer something well within the range of their expertise: whether Congress intended the negative economic consequences that would flow from this narrow interpretation of the statute.
The Congressional Budget Office recently released a report predicting that full implementation of the subsidized health insurance packages that are part of the Affordable Care Act (ACA) will reduce the number of Americans who are employed by several millions. This will happen, the report is careful to note, because the availability and form of subsidized insurance coverage will make continuing to work (or working more) less financially rewarding than in the absence of the law. That is, it will not reduce “job opportunities” but rather the incentives people have to take those jobs. This effect will be especially strong on low to moderate income older persons who continued to work (rather than retire) because of the availability of health insurance as part of their total compensation for work. With more generously subsidized insurance available on the exchange even before they turn 65 (and subsidies that are larger than for younger workers), they will be more likely to choose to stop working.
The findings should be no surprise to anyone who knows a little intuitive economics (and most of us do, whether we took a course or not). As designers of the ACA understood and as the CBO points out, in exchanges “subsidies decline with rising income (and increase as income falls) thus making work less attractive. As a result, some people will choose not to work or to work less.”
Here we're highlighting some of the original research published by LDI Senior Fellows in the last month. We feature articles by Andrea Apter, Karin Rhodes, Dan Polsky, Judith Long, Catherine Maclean, and Barbara Reigel. The articles include:
"No Other Choice": Reasons for Emergency Department Utilization Among Urban Adults With Acute Asthma
Challenges to Regulatory Decentralization: Lessons from State Health Technology Regulation
Preventive Cancer Screening Practices in HIV-Positive Patients
An Application of Unconditional Quantile Regression to Cigarette Taxes
Electronically Monitored Medication Adherence Predicts Hospitalization in Heart Failure Patients
Read More for summaries of this excellent work! And if you'd like to be considered for this list next month, please send published or in-process articles to Janet Weiner, LDI Blog editor.
(cross-posted with the Scattergood Foundation)
A recent article in The Milbank Quarterly found that certain measurable personality traits are associated with the use of high-cost health care services, such as emergency room visits and nursing home stays, among high-risk Medicare beneficiaries. Such a finding opens up the possibility that personality profiles can be used to customize interventions to ensure appropriate and cost-effective care.
The study used the “Big Five,” one of the most well-known and widely studied personality taxonomies. It captures five broad domains of personality: agreeableness, openness to experience, extraversion, neuroticism, and conscientiousness. In concept, these traits could, or should, be linked to measures of behavioral health as well.
Recent news articles tell two different stories about children's mental health. The first documents an alarming proliferation of mental health diagnoses accompanied by a steady increase in the number of children treated with stimulant medications, such as Ritalin and Adderall. The second, which surfaced in the wake of the 2012 Newtown shooting, documents a broken treatment system, where families with children in dire need wait weeks -- or months -- to find the right treatments, often at great financial burden to the family.
At first blush, it seems difficult to reconcile the Newtown stories with a world of rampant over-treatment. But both narratives reveal important truths that can help advocates and policymakers lay the groundwork for mental health system reform.
(cross-posted on the Field Clinic Blog at philly.com)
It’s tempting to get lost in the politics of Gov. Corbett’s proposed plan to expand Medicaid (see here for scathing commentary, here for gentler one) or the wonky “weeds” of the plan itself (see here for excellent analysis).
A few months ago, I spoke with LDI Senior Fellow Lawton R. Burns about a newly-published study in JAMA entitled, "Changes in Health Care Spending and Quality for Medicare Beneficiaries Associated With a Commercial ACO Contract." Burns challenged the findings by arguing that the contract under study was more like the HMOs of the 1990s than an ACO of today. That post, “Still Looking for That Unicorn: Latest ACO Study 'Misleading'” is here.
J. Michael McWilliams, the lead author of the JAMA study, responded to this critique, and here we publish his comments in their entirety. We include a response from Burns as well. This exchange highlights an even larger issue—whether “ACO” is becoming an umbrella term encompassing varying degrees of risk-sharing and network “openness.” Going forward, it will be important to define and test the salient characteristics of the specific model presented as ACO, or ACO-like. We think this is a valuable debate, and welcome other contributions (use comments section).
Sometimes there is more to political posturing than meets the eye. Last week, Governor Tom Corbett of Pennsylvania requested a waiver from the Centers for Medicaid and Medicare Services to permanently ensure that children in families between 100% and 133% of the poverty line remain in the state’s children’s health insurance plan (CHIP) rather than transition to the state’s Medicaid program as was mandated in the Affordable Care Act (ACA). This was not the first time that Governor Corbett had requested a waiver from the feds, and it is clear that he is mounting a “Custer’s last stand” around his state’s CHIP program.