Looking for our new site?

Health Policy

Pay More, Get Less

  • By
  • Joshua Freedman,
  • New America Foundation
April 30, 2014
The American middle class faces an uncertain future. Staring headlong into a difficult – and changing – world economy that has yet to fully recover from the Great Recession, many middle class families are trapped between low, stagnant wages and an increasingly expensive set of social and economic supports.

Productivity Measurement in the United States Health System

  • By
  • Joe Colucci,
  • New America Foundation
  • and Rick McKellar, Harvard Medical School, and Michael Chernew, Harvard Medical School
October 2, 2013

Improving productivity in health care is, unquestionably, among the most important challenges facing policy makers and health care systems. Advances in medicine have greatly improved lives over the last century and ideally will continue to do so in the future. However, medical care also consumes a rapidly increasing proportion of society’s time and resources. That trend has continued to the point that growth in health care spending is considered a drag on the remainder of the economy.

Productivity and the Health Care Workforce

  • By
  • Shannon Brownlee,
  • Joe Colucci,
  • New America Foundation
  • and Thom Walsh, Dartmouth Center for Health Care Delivery Science
October 2, 2013

"Do I Have Any Business Being a Doctor?" at Zocalo

May 20, 2013
Publication Image

Our former intern, Catherine Jameson, has just written a fantastic post for Zocalo Public Square on her decision to become a doctor. It's a remarkably human story, and she demonstrates exactly the kind of compassion that doctors need to have for their patients in order to keep the medical system in check.

Go read it!

What a week!

May 2, 2013
Publication Image

Medicaid in Oregon

 

First, the big one: yesterday afternoon kicked off a flurry of discussion - some of it rather heated - about the most recent paper (ungated version) to come out of Oregon’s Medicaid program. In case you’ve forgotten: a few years ago, Oregon had money to expand Medicaid enrollment - but they didn’t have enough to cover everyone who was eligible. So the state created a list of around 90,000 people, and enrolled 10,000 - giving people the opportunity to apply through a random lottery. That created an incredible research opportunity - the randomized design allows researchers to really see the effect of Medicaid enrollment on people’s health, and hopefully put to bed the nonsense idea that Medicaid is bad for people’s health.


The new publication is mildly disappointing in that regard - but the reaction to it has been way overblown. While the first study (which we wrote about in 2011) showed clear improvements in self-reported health, this paper is the first to report actual clinical data from the experiment. It did not find that Medicaid decreased average blood pressure, cholesterol levels, or HbA1c (glycated hemoglobin, a measure of blood sugar used as a diagnostic criterion for diabetes). The Medicaid group was far more likely to be formally diagnosed with and in treatment for diabetes. They also had much lower rates of depression (9% absolute risk reduction, meaning roughly one in eleven people was no longer depressed), and drastically lower rates of catastrophic medical spending.


As we noted, the results on cholesterol, blood pressure, and blood sugar are somewhat disappointing. But it’s crucial to put those measures in context. As usual, Aaron Carroll and Austin Frakt of The Incidental Economist have done incredible work pointing out the limits of the study, and the ways that it’s been over-interpreted. You should absolutely readtheirposts. They’ve also been active on Twitter, where Aaron has pointed out that the study may not have beenlarge enough to detect important effects on those variables, even if they were there, and that it’s not easy to reduce HB even when that’s what a study is specifically intended to do! We won’t spoil all of their points, but they’re excellent. Go read the post, and direct your friends to it.


As a final note on the Medicaid experiment, we’d like to point out that (while we appreciate the solid methodology) this is not the kind of study health care needs most. There is ample evidence that people benefit from insurance, both financially and medically. But our ability to benefit from access to medical care is currently limited by the massive flaws in the delivery system. Providing insurance to low-income people is great, but its value is drastically reduced when we’re spending a lot of that money on screening tests that cause overdiagnosis, unwanted elective surgeries, and expensive drugs that are no better than existing options. Eliminating the waste from the system is crucial to making universal coverage sustainable and affordable; we need RCTs of programs that focus on eliminating overtreatment and improving how we care for patients.


Elsewhere in the news...


This week, The New York Times Magazine featured a piece by Peggy Orenstein entitled,“Our Feel-Good War on Breast Cancer.”  The article couldn’t be more timely, as research on overdiagnosis continues to highlight the downsides of widespread screening. It’s a nuanced discussion of Orenstein’s personal experience with breast cancer, and the “survivor” culture surrounding the disease.  Definitely worth a read!


The Fountain of Youth

Last weekend, Ezra Klein posted a great example of how politics, money, and bureaucracy influence the kind of health care we receive. Health Quality Partners (HQP), created by Medicare with funds allocated by the 1997 Balanced Budget Act, provides seniors with a home visit from a nurse on either a monthly or weekly basis. The program was an incredible success, lowering spending on enrollees’ health care by 22%, improving their quality of life, and reducing their hospitalizations by 33%. But even though it’s been labeled “The Fountain of Youth,” HQP’s funding is due to expire in June of this year and it’s unlikely that a similar program will take its place.  Even more unfortunate is that HQP’s success won’t be used to inform future programs.  Instead, Medicare is creating a new generation of programs meant to shift from a fee-for-service system to a pay-for-quality system, arguing that the results of HQP were limited by its small size and that to scale-up the program would be less cost-effective than to change the payment structure that governs the entire program.  Perhaps this analysis is valid, but the situation highlights the difficulty of reshaping an existing healthcare system in which so many have a stake.  

 

"We torture people before they die.”

Jonathan Rauch profiles Dr. Angelo Volandes, creator of a series of videos showing patients the reality of aggressive end-of-life treatment, in this month’s Atlantic magazine.  For the last several years, Volandes has been working on a series of videos showing patients what it's like to receive intense medical treatments like CPR, feeding tubes, and being placed on a ventilator, and helping them understand what benefits they can actually gain from medical treatment - and what they can't.  When patients see those videos, the reality of aggressive end-of-life care hits home - and they're much less likely to choose aggressive, expensive, and often futile treatments.

 

Volandes's work highlights the importance of talking about death with patients and their families, and illustrates how much of end-of-life care is actually unwanted care. His videos help doctors and patients have what Volandes refers to as “The Conversation,” a necessary but often avoided discussion about the imminence of death and the need for a patient and his or her family to decide how far they want to push the boundaries of life-saving medicine. It's good to see docs like Volandes stepping up and pushing their profession toward having more honest, productive conversations about end-of-life care. We'll all die better - and live better - for it.


California End-of-Life Care

Unfortunately, patients don't always get what they want. In fact, many dying patients are subjected to far more intense treatment than they would have chosen. The new report "End-of-Life Care in California: You Don't Always get What You Want," by Senior Fellow Shannon Brownlee, highlights those discrepancies.  Most people say they would prefer to die at home - yet huge fractions end up dying in a hospital. Hospice has been shown to have positive effects on quality of life without reducing lifespans, yet adoption of hospice remains slow.

The report also highlights the huge geographical variations in how much treatment dying people receive. In nearly every category, California lags behind other parts of the country. In many cases, Southern California particularly sticks out as a hotbed of intense treatment. Patients in that area should pay particularly close attention to this report - it has important implications for what their last few months might look like, and what we might do to make the medical system serve their needs better.

For more on the CHCF atlas, and how it connects to Rauch's story, see our post on In the Tank.

Are Work Hour Restrictions Putting Patients at Risk of Medical Errors?

April 11, 2013
Publication Image

In July of 2011, as that year’s class of freshly-minted physicians began its journey through residency, the American College of Graduate Medical Education (ACGME) instituted a 16-hour limit on shift length for first year residents (interns) with the goal of improving intern well-being and patient safety.  The guidelines also indicated that shifts should be separated by at least eight hours of “off” time.  This change followed the 2003 ACGME guidelines, which limited resident work weeks to no more than eighty hours.

While limiting shift length seems like it should be a bedraggled intern’s dream come true, research coming from the University of Michigan suggests otherwise. According to a recent study published in JAMA, interns working under the 2011 limitations are not sleeping more, are just as depressed, and in general, reported no improvement in well-being compared to interns who served before the 2011 changes.

But here’s what’s more disturbing: under the new hours regime, far more interns said they were concerned about having made a serious medical error.

In the survey, 19.9% of interns who served during 2009-2010 reported being concerned about having made a serious medical error.  That number increased to  23.3% in 2011, after the most recent ACGME limitations were implemented.

In response to the initial report out of the University of Michigan, Dr. Lara Goitein and Dr. Kenneth Ludmerer suggest potential explanations for why the 2011 changes failed to improve intern well-being.  They note that work compression (expecting interns to do the same amount of work in a shorter amount of time), more frequent patient hand-offs, and the  inability to follow patients through critical times in their hospital care may all prevent interns from reaping the intended benefits of the 2011 guidelines.   

Limiting shift length may not be the answer to improving patient and intern well-being.  Drs. Goitein and Ludmerer argue that decreasing workloads - not just limiting consecutive hours worked - will improve productivity, patient outcomes, and clinician well being.  Goitein and Ludmerer note studies in which decreased intern and resident workloads have shown improved resident satisfaction, increased time spent on education, and a decrease in duty hour violations.  While hospitals typically depend heavily on their residents for relatively cheap labor, Goitein and Ludmerer point out that decreasing resident workload results in shorter lengths of stay, fewer 30-day readmissions, and fewer admissions to the ICU.

But why the increased concern about medical errors? While the increase is troubling, it’s worth pointing out that “more interns are worried about having made a serious error” doesn’t necessarily mean “more interns are making serious errors.” The very fact that these hour limits exist reflects a change in the culture of medical education. The ACGME and other groups are becoming much more aware of the harms caused by medical errors. In that kind of climate, it’s possible that interns are simply more aware of mistakes that their predecessors had been making all along.

Unfortunately, because of its design, all this study can do is open the question. Without better data, from registries or public reporting of medical errors, it’s hard to tell the difference between a destructive change (reduced shift length makes interns so rushed that they make more mistakes) and a welcome one (changing medical culture makes interns more aware of their own fallibility, so they can learn from mistakes and avoid repeating them).

We'd like to thank Adriana McIntyre and Karan Chhabra for drawing our attention to this article. Check out their writing at Project Millennial.

BBC: Overuse of Hysterectomies in India

February 7, 2013
Publication Image

A BBC report from earlier this weeks makes it very clear: overuse of elective medical procedures is not just an American problem, or even just a developed-world problem. The report tells the story of women in a number of rural villages in India, where hundreds of women have been convinced, cajoled, and frightened into having hysterectomies they almost certainly didn't need.

The story suggests that the procedures are probably being done to make money for unscrupulous local doctors. The docs work in India's private medical system, but the public insurance program for the poor allows patients to see private physicians when they can't acces the public healthcare system. According to the story, the doctors often tell patients they have cancer and need an immediate hysterectomy--sometimes without even performing a biopsy, and without offering other, less invasive forms of cancer treatment. Unnecessary operations make money for the physician, but they're a huge financial burden for patients--and although the article didn't mention it, unnecessary treatments also expose patientsto needless risk of serious complications and death.

The Indian government is starting to react to the apparent epidemic of overuse. But in addition to fixing perverse financial incentives, it's important to consider the role informed and empowered patients can play in ensuring unnecessary treatments don't happen. The article notes that women find it hard to refuse a surgery that the doctor says they need right away. One young woman said she wasn't even able to discuss the surgery with her husband first. Fixing that rushed and insensitive process is crucial. Patients in rural India have just as much right to make their own decisions as patients in rural Indiana--and fortunately, there are effective tools to help them make those decisions. Even if the public medical system can't yet reach all parts of rural India, it might be possible for the government to make sure shared decision making and decision aids are available--that could save money, and help patients avoid unnecessary treatment.

 

UPDATE: Dr. Mohammad Zakaria Pezeshki, Associate Professor in the Department of Community Medicine at Tabriz Medical School in Tabriz, Iran, saw this post & responded with some good thoughts of his own. He points out that it's crucial to have decision aids in patient-accessible languages, and that opportunities to inform and engage patients are not limited to shared decision making. Check out the post and the rest of his blog, Earth Citizens' Health!

The Sidebar: Dispatch from Syria and Spy Doctors

January 17, 2013
Barak Barfi reports on the real state of the Syrian Civil War after returning from a recent trip to the country, and Charles Kenny explains why mixing public health campaigns with covert operations is disastrous. Elizabeth Weingarten hosts.

Ideas for a Smarter SNAP

January 4, 2013
Publication Image

The first article in last week's Journal of the American Medical Association, coauthored by Health Policy Senior Fellow Susan Blumenthal, presents a compelling argument that the SNAP program (formerly food stamps) is contributing to the growing obesity problem, particularly among low-income children. If we want to keep people healthier in the long run--and better control our healthcare spending at the same time--it's worth thinking about ways to help SNAP beneficiaries stay a healthier size.

The problem is pretty simple. Federal food assistance programs have been very successful in reducing the number of Americans who don't get enough calories to live, but SNAP--the largest one--doesn't include any mechanism for targeting spending toward foods that provide high-quality energy and plentiful nutrients, so a lot of the money ends up getting spent on soda and other junk food. Those foods appear to contribute to obesity, which can later lead to diabetes and a host of other medical conditions.

That challenge prompted Blumenthal to lead a group that created a report, SNAP to Health, laying out some policy changes that could help reduce obesity among the SNAP population and improve our health in the future. The report is long, but worth a look--check it out! Also check out the JAMA piece here.

Please, stop talking about "health care costs."

January 2, 2013
Publication Image

"Health care costs"  are a constant companion of budget wonks, showing up in every discussion of long-term fiscal policy and discussions of healthcare reform going back decades. But in an Atlantic piece from the end of the year, coauthored with Thom Walsh of the Dartmouth Center for Healthcare Delivery Science, we argue that talking about "costs" ignores our increasing utilization of healthcare services,  misrepresenting the real nature of our spending problem and obscuring solutions:

"...the more worrisome reason for rising spending is the quantity of high technology specialty services we undergo. We get more high tech imaging studies, more days in the ICU, more robotic surgeries than we did 40 years ago, or even 14 years ago. Sometimes that high-tech medicine leads to better outcomes, but a lot of the time it does not -- it just means we spend more. 

Given this increasing use of high-tech services, it should be easy to see why the "rising healthcare costs" frame is misleading: if we're using more and more services each year, it's hardly reasonable to blame rising costs of production. [...]

 The real problem, then, isn't merely that we're spending a larger and larger percentage of our income on healthcare -- it's that we are spending indiscriminately. Yet when healthcare spending rhetorically becomes healthcare costs, it implies that overconsumption of useless, overpriced services is not part of the problem."

Read the full piece at The Atlantic.

Syndicate content