Featured Post
July 16, 2019
There’s something unusual happening on patients’ 20th day in skilled nursing facilities (SNFs). In a JAMA Interal Medicine study, Paula Chatterjee, Norma Coe, Rachel Werner, and colleagues found that more people were discharged on day 20 of their SNF benefit period than days 19 or 21, which reflects how Medicare pays for postacute care at a SNF. While the findings raise more questions than answers, they do demonstrate a higher discharge rate among vulnerable patients when Medicare stops paying on day 20.
The recent debate about the ethics of a health system’s decision to refuse to hire new workers who smoke was understandably couched in the framework of ethics. But hiring a worker—buying labor—is an economic transaction that occurs in a market, and so it may be useful to discuss the economic framework as well.
The very narrow framework presented was of a firm (a hospital, in this case) hiring a given number of workers in a labor market where more workers are willing to work at the wage-benefit package it offers than it needs to hire. Thus the ethical issue is framed as whether it is fair to “give” one of the jobs in short supply to a non-smoker rather than a smoker. But wages and demand for labor are determined in markets, both for labor and for products or services. Considering these market level effects, I argue that that some of the framing of the ethical problem is factually dubious and that the conclusions about fairness may need to be modified.
Dan Polsky, PhD, MPP
Professor, Health Care Management and Medicine
A new National Bureau of Economic Research (NBER) working paper by Afendulis, Chernew, and Kessler says yes. If this working paper holds up to peer review, these findings will offer an important endorsement of the Medicare Advantage program. The paper attributes large and striking reductions in all hospitalizations (22%), hospitalizations for ambulatory sensitive conditions (18%), and mortality (15%) to Medicare Advantage as illustrated in the graph below. The authors argue that their results provide evidence that private Medicare Advantage plans are more efficient than traditional Medicare. But, I will provide an alternative explanation and an important caution after reviewing their approach.
What is clever about the paper is that they have devised an analytical method that successfully avoids the criticism that better outcomes among Medicare Advantage beneficiaries could be attributed to healthier enrollees.
In March, the American Board of Internal Medicine (ABIM) Foundation released the second wave of its groundbreaking campaign to identify and reduce low-value care, that is, common tests and procedures that are frequently overused or misused. This campaign, "Choosing Wisely," challenged medical professional societies to come up with the "Five Things Physicians and Patients Should Question." All told, 26 medical specialty societies have identified more than 130 tests and procedures; another 14 societies will release their lists later this year.
The participation of so many specialty groups is virtually unprecedented in its scope and unanimity. The ABIM Foundation has also partnered with Consumer Reports to develop companion materials for patients and the public. The goal is to encourage "physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm."