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.
In the journal Childhood Obesity, there’s a great interview with Philadelphia health officials about the city’s progress in reducing childhood obesity rates and in the racial/ethnic disparity in those rates. Deputy Mayor and Health Commissioner Don Schwarz and Giridhar Mallya, Director of Policy and Planning for the Department of Public Health, describe a broad initiative over the past 15 years that is notable for its success in a resource-poor environment.
What’s most striking about the Philadelphia experience is the cooperation among City departments and agencies that do not have the word “Health” in their name.
Last week’s article by Jon Skinner in the MIT Technology Review, "The Costly Paradox of Health-Care Technology" was an excellent synopsis of the unique and bizarre relationship between technology and the marketplace that exists in American medicine. Unlike almost any other sector of the economy, in health care new technology drives up costs while often providing little or no benefit.
Skinner compares this phenomenon to the costs and benefits of technology improvements in cars, pointing out that modern vehicles are markedly better than 25 years ago, yet are cheaper in real terms. I use a similar example with my students -- the personal computer I used during my early college years cost $5,000 in today's dollars, but now I can buy a computer for $1,000 that is, quite literally, thousands of times better.
The news from the latest ACO study in JAMA seemed good; not only could ACOs save money in commercially insured patients in Massachusetts, the savings were "contagious," spreading to non-ACO Medicare patients seen by the same providers. The Washington Post reported that "ACOs may actually be the unicorns we've been waiting for, spreading their cost-saving magic throughout the health system."
I spoke with LDI Senior Fellow Lawton R. Burns, Professor and Chair of the Health Care Management Department at Wharton, about the news. He says that unicorn is a mirage and the study report is misleading.
Life expectancy has been in the news lately. Over the summer, The New York Times summarized a new report from the CDC analyzing racial difference in life expectancy between U.S blacks and whites; last month, the OECD released comparative data between the U.S. and OECD countries. The U.S., which now ranks 51st in the world in life expectancy, was about at par with other OECD countries in the early 1990s, especially for females, but the other countries have created a big gap since.
The data tells us the relative contribution of certain demographics to the life expectancy gap, but don’t tell us why. And a recent Institute of Medicine report noted that the disparities in life expectancy within the U.S. are even larger than the cross-national differences, and may help explain why the U.S. compares so unfavorably with peer nations.
"How'm I doin?" Ed Koch, longtime mayor of New York City, would ask his constituency. "Am I doin’ all right?" Koch understood the importance of taking stock, assessing progress, and changing directions if need be.
The need for increasing the ethnic and racial diversity of our health services research workforce is unquestioned. A 2007 study documented a lack of diversity among health services researchers, a particularly important issue given the increasing diversity of the population. Many initiatives sprung up, including LDI’s Summer Undergraduate Minority Research (SUMR) program
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."