Featured Post
February 26, 2020
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.
Newly-published studies by Senior Fellows Mark Neuman, Jeffrey Silber, Rachel Werner, and colleagues have direct implications for the management of hip fractures, which afflict more than 300,000 older adults each year.
The first study, published earlier this week in JAMA Internal Medicine, focuses on outcomes in a particularly vulnerable and understudied population: long-term residents of nursing homes, who are at twice the risk of sustaining a hip fracture as community dwellers.
The second study, published yesterday in JAMA, compares surgical outcomes in hip fracture patients receiving general anesthesia vs. regional (i.e., spinal or epidural) anesthesia. This is an extremely well-done retrospective cohort analysis of more than 56,000 hip fracture patients over 50 in New York State hospitals over a seven-year period. It features an innovative “near-far” instrumental variable match that paired patients who lived at different distances from hospitals that specialized in regional or general anesthesia.
Cross-posted with the Field Clinic blog
The Obama administration has given employers a reprieve from the mandate that they offer their workers insurance at low employee premiums or pay a penalty. As things now stand, enforcement is postponed until 2016. But should the mandate ever come back?
Even strong supporters of the Affordable Care Act are divided. David Blumenthal of the Commonwealth Fund thinks the mandate on employers is needed to compel them to honor their “shared responsibility” to pay their workers’ premiums. Tim Jost, a professor at Washington and Lee University and a leading backer and interpreter of the complex ACA rules, thinks the mandate has too many adverse side effects and should be “repealed and replaced” by something else. Commonsense Americans may wonder why, if we can get by without the employer mandate for next two years, we ever need it.
Cross-posted with the Field Clinic blog
We help several groups of Americans to obtain health insurance through a series of separate programs. Medicare helps seniors. Medicaid helps people in families with low incomes. And now the Affordable Care Act provides subsidies to many with low and moderate incomes for purchasing coverage in private insurance exchanges. (Middle and upper income people receive a massive subsidy for purchasing group insurance through the tax exclusion of premiums that, in my opinion, defies rational explanation.)
We see each of these groups as deserving help from higher income taxpayers, but we treat them in very different ways. In the exchanges, subsidy recipients in most states enjoy a wide range of insurance plan choices that vary both in the extent of required out-of-pocket payments and in the limitations imposed on provider networks. The subsidies remain the same regardless of whether one chooses a generous plan with a high premium or a plan with a lower premium that includes high deductibles and strict limits to network doctors and hospitals. Consumers have a wide range of choices but with a floor in the form of minimum mandated benefits.
Cross-posted with The Field Clinic Blog
Could so called “narrow networks” be good for your health? As insurers look to hold down premiums one strategy they are using is to limit the number of choices patients have for doctors and hospitals. Cost is lower because insurers can negotiate lower prices and direct patients to doctors that deliver lower cost care. Last week at the Field Clinic, Dr. Drew Harris blogged that maybe this more limited choice might be good for patients. By limiting choice, patients would be more likely to see doctors that better coordinate their care. Better coordination would hopefully lead to better quality and better health.
Senbagam Virudachalam MD, MSHP
Aside from being a means of enjoyment, expression and culture, food is a crucial element of health. It's generally known that food prepared in a family's kitchen is healthier than food prepared outside the home. But do American families do it enough?
Research by a team led by Senbagam Virudachalam suggests that "cooking" means different things to different people. For many, just finding time to cook is a major challenge; for others, money gets in the way of nutrition. More data is needed to understand why people do or do not cook at home in order to design effective, sustainable, and scalable strategies to improve the nation's cooking habits.
Lest we forget that guidelines are (and should be) living, breathing documents, LDI Senior Fellows Mark Neuman and Sandy Schwartz provide an excellent reminder in a new study in JAMA that reviews the “durability” of recommendations across serial versions of the same cardiology guidelines.
In a review of 11 American Heart Association/American College of Cardiology guidelines issued from 1998-2007, and revised from 2006-2013, the authors find that 80% of 619 index recommendations stayed the same, 9% were downgraded or reversed, and 11% were omitted from subsequent versions.
It’s not easy to make the case that health care innovation can come from within…from the physicians and nurses on the front lines of patient care. Clinically-trained, path-driven, and time-starved, these clinicians may not appear to be the best source of disruptive change in health care. But in a perspective in today’s New England Journal of Medicine, David Asch and colleagues at the Penn Center for Health Care Innovation make a powerful case that “clinicians have the requisite drive, experience, and context to be productive innovators.”
It seems that nurses are getting a lot of bad press in England lately, coming under fire recently for being “uncaring.” In an article published in Nursing Standard, Linda Aiken of Penn’s School of Nursing contends that this erosion of public trust is the result of high workloads and low investment in nursing education, rather than any attitudes held by English nurses.
Aiken should know. She led a large study of effective nursing practice known as the Registered Nurses Forecasting (RN4CAST) study, in which she could compare nurses’ reports on conditions of practice in NHS hospitals with nurses’ experiences in 11 other European countries. English nurses reported much higher levels of burnout, less adequate staffing and resources, and much poorer work environments than their European colleagues.
How do we get people and organizations to change, especially when what they are currently doing adds little value, is very costly, is perhaps outmoded, and may, at worst, be dangerous? This is the question Benjamin Roman and David Asch raise in their new Annals of Internal Medicine piece on “Faded Promises”. As difficult as it is to get new treatments in medicine adopted, they argue, it is more difficult to get physicians to stop old treatments they have come to believe in, even when there is compelling evidence that those treatments don’t work particularly well.
What Roman and Asch describe is a perfect example of what I call the exnovation conundrum, and although it may be evident in medicine, this phenomenon is universal. And here is the conundrum. Often as not, when something new is introduced, that which it is designed to replace is not, in fact, replaced.