Rather Wealthy Than Healthy?

A couple of weeks ago, I came across an article in the New York Times that described an experimental program designed to increase patient adherence to prescription regimens by, get this, paying them to take their pills like they are supposed to. Be glad you weren’t sitting across from me when I read this, because I would have shot coffee out of my mouth in your general direction at a high rate of speed. It’s not that providing rewards to incentivize certain behaviors is a crazy idea, it’s that for so many patients improved health is not a powerful enough incentive, but cold, hard cash apparently is.

Now, from a policy perspective, this seemingly backwards approach actually makes some sense: a small payment is enough to get people to take their medications with regularity, and that avoids the expense of worse health conditions down the road that occur when the medication isn’t taken as directed. In fact, the article puts that cost at upwards of $100 billion annually. In essence, then, if you can eliminate that $100 billion expense by paying people a total of $1 billion annually in incentive payments, you realize a net savings of $99 billion. Sounds good, doesn’t it?

But putting the numbers aside for a moment, I have some real issues with this. Why should someone who doesn’t take their medication as directed stand to get paid for that, while someone who is faithful in following their doctor’s orders gets nothing but better health? After all, why wouldn’t I just try to convince people that I hate taking my medicine, get into one of these programs, and then resume taking my medication regularly and cashing the checks? I think this is exactly what people will do, and that would spell the end of what is really a very unjust solution to a vexing problem.

I’m also really bothered by the fact that people are willing to do something for money that they aren’t willing to do for improvements in their health. Is suffering with an illness really so trivial as to be overcome by the possibility of winning $10? I think that further inquiry into the psychology of this is warranted, because it seems to be practical evidence that much of what the field of decision sciences considers to be the monetary value of a year of good quality life may be quite over-inflated.

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Alcohol Consumption and Body Weight

Terms like the “Freshman 15” and “Beer Belly” seem to make it pretty clear: drinking alcohol–especially in excess–leads to weight gain. It certainly makes sense. After all, consuming too much of anything containing calories is likely to lead to you ingesting more calories than you expend, with the inevitable result of no longer fitting comfortably in what used to be your favorite jeans. When you take into account the fact that a gram of alcohol contains 7 calories (compared to 9 calories for a gram of fat and just 4 calories for a gram of protein or carbohydrates), drinking a beer falls somewhere between drinking a regular soda and chugging a glass of drawn butter.

Yes, alcohol contains a lot of calories, but it’s also more complex than that. Because it’s not often something you do while say, playing sports yourself, but rather while you’re watching others play sports on TV, alcohol consumption can actually exacerbate a sedentary lifestyle. And it usually makes you want to eat less healthy foods, which compounds the weight gain problem–especially because the way the body process alcohol interferes with other metabolic processes: because alcohol is toxic, the body works to eliminate it first, and sticks that steak and baked potato away as fat until it can get to it later. The case seems pretty airtight, doesn’t it? Drink too much, weigh too much, end of story.

Well, according to a study by Michael French, Edward Norton, Hai Fang, and Johanna Maclean it isn’t exactly true. The results of their study, which appear in the latest issue of Health Economics, indicate that while an increase in the frequency of alcohol consumption is associated with a statistically significant increase in Body Mass Index (BMI) for men, the effect is so small as to be of no practical significance. An increase in the number of drinks consumed per episode also had a statistically significant positive association with BMI, but again, the effect was practically quite small. In other words, drinking might make you a little heavier, but it doesn’t appear to be the driving factor in major weight gain for a man. However, the study authors suggest that persons who consume alcohol may compensate for this in other ways, like diet and exercise, that would offset the caloric intake from drinking and explain why BMI doesn’t jump with increased alcohol consumption. The authors also find that the small, but significant effects they observed in men do not exist in women. No explanation was provided for this null finding.

Of course, I don’t think that this study should be used to justify drinking to excess. Obviously, the law of conservation of energy dictates that if you don’t change other aspects of your diet or exercise routine, drinking more will cause you to gain weight. And even if you do compensate in other areas to avoid gaining weight, the fact remains that alcohol is harmful to the body when consumed in large quantities for long periods of time. As with most things in life, moderation appears to be the key. But, with the obesity epidemic continually cited as one of America’s worst and growing (pun intended) health problems, studies like this one are useful in identifying contributory factors. If I had the resources to field a large survey, I’d like to do a similar study using self-reported fast food consumption to predict changes in BMI. I’ll bet that would show some pretty large effects. In fact, if we modeled those who routinely ordered at the counter separately from those who use the “drive-thru” we’d be able to control for people who are likely to exhibit compensatory behaviors like exercise and those who are just growing fatter so quickly that you can almost hear them as they do it.

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Proof that State Governments Don’t Care About their Residents?

George Washington University professor Leighton Ku has an article in the latest issue of Health Affairs that takes a look at the expansion of Medicaid that is scheduled to roll out under the new health reform law. The paradigm shift that has occurred, Ku notes, is that we have finally moved away from the notion–at least in the health policy world–of the “deserving” versus the “undeserving” poor. You see, it used to be that to qualify for Medicaid coverage, you not only had to be low income, but you also had to belong to one of a defined number of eligibility groups, like children or pregnant women. If you didn’t belong to one of these “deserving” groups, you didn’t qualify for Medicaid no matter how poor you were.

The health reform law changes that. When it is fully implemented, Medicaid will no longer require categorical eligibility, but will truly become a program for the country’s poorest citizens. Our nation’s health insurance safety net will finally catch all low-income people, rather than having large holes shaped to let childless adults and parents fall through untouched. That’s a great thing.

What’s not a great thing is that governmental opposition to health reform comes from states whose residents would stand to benefit from it the most. Ku puts it this way:

“Another problem is opposition to the federal legislation by some states’ political leaders. As of mid-May 2010, twenty-one states have engaged in lawsuits to block the new law as being unconstitutional. Paradoxically, the opposition in these states appears to run contrary to the economic and health insurance interests of their residents. On average, 39 percent of the Medicaid-eligible adults in the twenty-one “opposing states” were uninsured, compared to 26 percent in the rest of the nation. Because opposing states have relatively more eligible-but-uninsured adults, their residents have much more to gain from the Medicaid expansions, and these states would draw down far more federal funding.”

Why would states not want what is clearly best for their residents? Because they worry about what it means for the state budget. You see, unlike the federal government which can run a deficit, states are required to balance their budgets annually, and entitlement programs like Medicaid are a perennial thorn in their side. But the Medicaid expansion is financed almost entirely by the federal government, so what are the states so worried about? Well, as Ku explains, it seems that many states are worried that currently eligible, but non-enrolled individuals will suddenly decide to enroll because of the high visibility of the health reform efforts. Such individuals would not fall under the federally-funded expansion, and the states are guarding their checkbooks. Now, I suppose that one could argue that a state maintaining its budget is a move to protect its residents, but the question then becomes, at what cost?

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RepubliCare: Three Decades of Broken Promises

With Congressional elections looming this November, the political posturing continues. One of the primary strategies of the right? Capitalize on people’s frustration over health reform’s passage. Fresh from Minority Leader Boehner’s office comes the report “ObamaCare: Three Months of Broken Promises.” The report attempts to lay out various claims made by Obama, Democratic members of Congress, and others that have not come to pass–in three months. Where, oh where, to begin?

First of all, how about the fact that having not yet fulfilled a promise is not the equivalent of breaking a promise? Sure, at some point the two become pretty synonymous, but let’s get realistic here–it takes time to implement new laws, which brings me to my second point. Three months?!?! Does anyone–from American citizens to members of Congress–truly believe that a major overhaul of the U.S. health care system could be achieved in three months? If so, I’d suggest that those persons lack an appreciation for the complexities involved in steering the Titanic around the iceberg. Health care represents roughly one-fifth of the entire national economy. It can’t be stopped on a dime or fixed overnight. This process is going to take a considerable amount of time. In fact, as Exhibit A, I’d point to the Medicare Part D program proudly passed by a Republican Congress during the Bush Administration, which is still having its kinks ironed out several years later.

And, finally, how handy for the GOP to take the strategy of “what have you done for me lately?” when they haven’t managed to do much of anything to improve our health care system during their time in power. If they want to write up and disseminate a report like “ObamaCare: Three Months of Broken Promises” then they had better hope that no one writes its counterpart: “RepubliCare: Three Decades of Broken Promises.” Believe me, there’s plenty of fodder to include in that report–and if you want to level criticisms after three months, that’s fine, just be prepared to explain how it’s taken you forty times as long to accomplish far less.

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Health Wonk Review: Research Edition

The Annual Research Meeting for AcademyHealth kicks off this weekend in Boston–starting with interest group meetings on Saturday and continuing with the presentation of a variety of workshops, presentations, and round table discussions through Tuesday. It’s a great chance for members of the health policy and health services research communities to get together and learn from each other by sharing their work. In that spirit, I present the Research Edition of the Health Wonk Review–a chance for you to learn from the best recent work of the health policy bloggers. (As an aside, I’ll be in town for the AcademyHealth meeting, and encourage you to get in touch with me if you’ll be there too and would like to meet up.)

Why is research so important? Well, obviously, both sides in the fight over health reform used research–of some kind–to support their respective positions. More than that, however, research is going to prove incredibly important going forward as health reform is implemented and evaluated. After all, if we don’t evaluate it, how will we know if it’s working as intended and how will we know what further changes need to be made?

While a lot of health policy and health services research is currently underway, it’s a bit too soon to evaluate health reform, or is it? In what is essentially qualitative research, Henry Stern of The InsureBlog does a nice bit of investigative reporting into insurance company nHealth’s claim that they are being forced to go out of business as a consequence of “ObamaCare.” Stern, a self-proclaimed opponent of the reform law, wishes this were true, but finds that nHealth’s claim is likely dubious. Although, if not, he says, we will continue to see more such closures in short order.

John Goodman, President of the National Center for Policy Analysis, chimes in as well with some pretty grim predictions about the implications of health reform. According to Goodman, “ObamaCare” will break most of its promises, including the all-important “If you like your coverage you can keep it.” It’s important to keep in mind, however, that both of these posts are reporting on forecasts–they’re prospective rather than retrospective–so their predictions may or may not be borne out.

Still, it’s an election year, seniors tend to vote in greater numbers than other groups, and they are none-too-pleased about the prospects of cuts to the Medicare program, writes Austin Frakt of The Incidental Economist. So, to recap, government involvement in health reform could be quite bad–especially if it places limits on health insurance financed by the federal government. Paradoxes make for great research.

Anyway, accepting that this health reform is less than perfect, one has to wonder how bad “ObamaCare” will really be if it mirrors other forms of “socialized medicine” like the Veterans Administration health system. This is an example of extrapolating the findings from one setting in order to generalize and make predictions about the outcomes in another area. Over at Managed Care Matters, Joe Paduda covers this topic by looking at a recent report from the Congressional Budget Office that finds that the VA health system has done a wonderful job of controlling costs while providing exceptionally high quality care. In fact, it makes private insurance look downright bad. So, maybe a single-payer system might be a good thing. Maybe this explains the Colorado Health Insurance Insider’s post from Louise that presents the case that Barbara Bush believes health insurance to be a right. A Republican believes health insurance is a right? Is this pseudoscience or are we witnessing a paradigm shift?

But enough about health insurers, what about health care providers? Well, for starters, Rich Elmore at Healthcare Technology News cites the results of a national Gallup poll of physicians that puts the cost of practicing defensive medicine at 26% of total health care costs–between $650 billion and $800 billion. Now, there are methodological concerns with relying too heavily on self-reported data from physicians whose responses may suffer from things like recall bias, but there’s also something to be said for asking physicians themselves about how they practice medicine. Even if they are over-reporting their numbers by half, we could still save nearly $400 billion by finding a way to eliminate the practice of defensive medicine.

Next, Richard Fogoros (aka DrRich) of the Covert Rationing Blog takes a fascinating look at physician-industry relationships and advocates for them and the benefits they can yield, despite the potential for conflicts of interest to arise and the threats they pose.

Bringing it all together–insurers, providers, and patients–Jaan Sidorov of the Disease Management Care Blog checks out a press release from Blue Cross Blue Shield of Michigan and scrutinizes the possible–repeat possible–likelihood that the Patient Centered Medical Home could reduce insurance claims expense. While the PCMH has yet to show credible savings outside of Medicaid or integrated delivery systems, the potential promise of the model has led to its inclusion in the new health reform law. The jury is still out, but based on BCBSM, maybe there is a reason to be optimistic about the PCMH.

There is certainly a need for a better integrated delivery system. At “health AGEnda”–the blog of the John A. Hartford Foundation–Chris Langston looks at the issue of transitioning older adults from the hospital to other settings like home health care and rehabilitation facilities as well as who is providing patients’ care in the hospital and asks if we’re “Fumbling the handoff?” The interesting thing here, in my opinion, is that people seem very “anti-hospitalist.” Langston highlights this to point out the need for more interdisciplinary teams in medicine, and while I agree, I also see it as underscoring the need for more consumer involvement in the health care system. And that’s exactly what the Health Care Renewal Blog’s Roy Poses advocates in his post “Finding Out About Healthcare Bureaucracy the Hard Way.”

All of these changes could be facilitated by the implementation of health IT, but overcoming the status quo will require a significant investment of time, money, and energy. At the Healthcare Talent Transformation blog, Peggy Salvatore writes about the intersection of health reform, health IT, and reimbursement cuts–making it clear that health IT is the future of health care, but also underscoring that its advent will be a painful transition for many who are already feeling the pinch.

One of the biggest questions in all of this is: Will the Patient Protection and Affordable Care Act actually be able to bend the cost curve? The June issue of Health Affairs tackles this and other aspects of health reform, and Chris Fleming presents a nice synopsis on the Health Affairs Blog. Another big question is how health reform will encourage more comparative effectiveness studies. This is about which treatment works better–but it also has the potential to open the door to cost-savings if we decide to stop covering certain treatments based on cost-effectiveness analysis. David Williams of the Health Business Blog takes a look at some of the barriers to comparative effectiveness research through the unique lens of a JAMA study of two nearly equivalent drugs: Avastin and Lucentis.

And what do we do when some of the elements of health reform inevitably don’t work out? Well, we could start by looking at how they do things elsewhere, and thinking about which elements we might be able to borrow. For that, we can look to a recent series exploring a variety of international health care systems posted by Jason Shafrin at The Health Economist. Jason covers the usual suspects (e.g., France and Canada) as well as some interesting and often overlooked countries (e.g., Japan and Rwanda).

Not everyone who submitted for this edition had a research-related post to offer, but they deserved to be included nonetheless. In a two-part post, Jon Coppelman of Workers’ Comp Insider tells the sorry tale of New York’s self-insured trusts for workers comp (part 2 here), a case of joint and several liability run amuck.

Next Up: Health Wonk Review takes a well-deserved break for summer vacation and comes back on July 22nd, with an edition hosted by Julie Ferguson at the Worker’s Comp Insider.

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A Shift Towards Transparency to Avoid Conflicts of Interest

When you don’t like what the experts have to say, the best thing to do is discredit their results. But that can be difficult–especially if you’re not an expert yourself. In that case, the most effective plan of attack is to discredit the experts themselves, by leveling accusations that their work is biased by conflicts of interest. That’s one of the primary reasons, I believe, that some brilliant people like Jonathan Gruber and Uwe Reinhardt have been called out for not disclosing certain financial relationships that at least present the appearance of a conflict. I’ve written about Gruber and Reinhardt before if you want the details.

As I’ve also said before, I don’t necessarily think that the work of either of these individuals has been unduly influenced by these undisclosed relationships, but that’s not really the point. The goal should be to disarm your opponents by volunteering the information yourself. It’s when you don’t that it leaves the door open for them to say “Well, so-and-so might have said ‘X’, but did you know that they were paid some money by a corporation who also thinks ‘X’ at some point in time?”

So, much to my delight, as I was reading the latest entry from Uwe Reinhardt on the New York Times’ Economix blog, I saw this disclaimer at the bottom of the post:

“Professor Reinhardt serves on the board of Amerigroup Inc., a Medicaid managed-care company that does not operate in the small-group market, but in a market regulated by the states, with premiums negotiated with the state governments that pay those premiums.”

Now, this disclosure certainly doesn’t represent every board Reinhardt sits on or every venture he’s involved with. Rather, it focuses on a specific potential conflict. The blog post was about insurance and small businesses, and this gets right to the point by saying, “Yes, I serve on the board of a health insurance company,” but “No, that company does not have anything to do with the small-group market about which I am writing this post.” This is the type of transparency that the health policy and health services research community–and indeed all those in any scientific community–should strive for. It is relevant, succinct, and enhances Reinhardt’s credibility rather than leaving him vulnerable to accusations of bias from those who disagree with his views. And for that, I applaud him.

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Why Health Reform Finally Passed

The June 2010 issue of Health Affairs is all about health reform–how and why it happened and where we go from here. Rest assured that I’ll be relying on this to provide content for my blog posts for a while. The first article I have to mention was written by the chair of my dissertation committee, Jon Oberlander. You should read the article for yourself, but here’s my synopsis.

Oberlander’s commentary asks and answers the question: “Given the long history of failed health reforms in the United States, why did health reform finally pass this time?” Sure, Obama enjoyed majorities in both the House and the Senate, but those majorities were not novel–in fact, as Oberlander points out, both FDR and Lyndon Johnson enjoyed much larger majorities when Social Security and Medicare were enacted. As a result, Obama–along with Speaker Pelosi and Majority Leader Reid–had to walk a very fine line, negotiating with moderates, but not going so far as to alienate progressives, lest the coalition of votes needed to pass the legislation should disband.

There was the usual problem: People dislike the notion of government involvement in their lives, especially in something as personal as health care, where people tend to embrace the status quo and reject “socialized medicine.” There was also a new contextual problem: The U.S. economy was experiencing the worst recession since the Great Depression. An expansion of “non-essential” government spending could be targeted by opponents as unwise during such a time. And then Sen. Kennedy passed away and Scott Brown won the election in Massachusetts, and it looked like the whole effort was unraveling. So, again, why, with the deck seemingly stacked so high against it, did health reform pass?

Oberlander gives several explanations. First, he says, it has to do with Obama’s decision to prioritize health reform from the start and to remain committed to that priority even when its outcome appeared uncertain or even in doubt. He also acknowledges the commitment of Pelosi and Reid in securing the votes in their respective bodies. Second, Oberlander suggests, the Obama administration learned from the failures of the Clinton administration’s attempt at health reform. Clinton’s White House designed the reform bill in great detail and would have fundamentally changed the structure for purchasing health insurance in this country. By contrast, Obama let Congress draft the legislation, and emphasized the need to build on what works–keeping employer based coverage at the core of the system. Third, the committees in Congress worked together to draft the reform legislation, which helped to avoid early dissension between the various committees which could have prevented a bill from ever reaching the floor. Fourth, the Obama administration engaged and negotiated with a variety of health care stakeholders. As Oberlander puts it “If You Can’t Beat Interest Groups, Co-Opt Them.” Since the health care industry has the most to gain or lose in health reform, getting them involved and neutralizing their opposition was perhaps the biggest factor in the success of reform.

In the end, the effort was successful, although the reform legislation was–and is–seen by many as less than ideal. Oberlander himself suggests that “For health reform in the United States, this is….probably as good as it gets.”

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ER Wait Times On Display

The increasingly rapid pace of life we all enjoy thanks to the seemingly endless stream of technology has at least one notable side effect: growing impatience. “We want what we want and we want it now!” has never been a more true mantra. It seems, however, that as long as we are informed about the wait, we are able to find a little bit more patience within ourselves.

For instance, anyone who’s been to Walt Disney World in the last decade knows that they have signs up around the park telling you how long you can expect to wait to ride a particular ride. I’m not sure what they may do these days–it’s been a while since I was last in Orlando–but I do know that they used to have signs that weren’t updated. That is, there would be a hand-painted sign reading something along the lines of “Your expected wait from this point in line is 30 minutes.” Now, one of the clever psychological  tricks was that your wait was never expected to be 30 minutes from that point. The sign instilled in you the expectation that it would take 30 minutes, so that when it only took 22, you’d find yourself pleasantly surprised.

We also have the “estimated hold time” that we are updated about when we call a customer service department, the arrival and departure boards at train stations and airports, and–at least in my neck of the woods–the “real-time” signs at bus stops that tell you when each of the next buses on a particular route will be arriving at your stop. This last example has been particularly helpful in my opinion, helping me know when to head to the bus stop, when to take one bus rather than another, and when to just walk to my destination because it will probably be quicker.

But there are other areas of life where wait times aren’t really announced. For example, if you go out to eat at a restaurant, you might be told “Your food should be out shortly,” but that’s not the same thing as saying “Your food will be table side in 3 minutes.” Similarly, though they are mentioned as a drawback of a “socialized” health care system, and even studied by health services researchers, wait times to receive health care are not reported to the patients who seek them. As a result, you are likely to have heard a story from a friend or family member who spent 8 to 10 hours in the emergency room just to get seen. Often times, the person has gone in for something that doesn’t warrant treatment in the emergency room–an urgent care center might be just fine, or the person could even wait until the next day to call their regular physician–but they stay in the ER and grow impatient and resentful. If they knew how long it would take, maybe they would opt to leave and seek care elsewhere, or maybe they would at least find themselves more patient with an understanding of how long they were going to be there. It’s the unknown that causes us humans such frustration.

Well, it turns out that some emergency rooms are announcing their wait time estimates to patients online, over the phone, and by text message. Obviously that leaves the non-tech-savvy in the dark, but it’s a step in the right direction. The next logical question is how this practice will affect patient satisfaction. My hunch is that patients who visit ERs who are transparent about their current wait times will be more satisfied than patients who, being uninformed, feel like they are left endlessly waiting for their turn to see the doctor. We have the technology, after all, we might as well use it.

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Health Care Through a Recession

There are a lot of things about our health care system in the United States that need to be fixed. Passing health reform was a start, but it still leaves a lot to be desired. One of the remaining problems, as I see it, is a continued reliance on an employer-based system. Ideally I’d like a single-payer system, or at least a public option. In fact, I think I really prefer a strong public option over single-payer–I see tremendous potential through competition–and right now we lack that competition. But more to the point, there are some tremendous drawbacks to employer-sponsored coverage.

For instance, if you really need your health insurance, you may be afraid to leave or change jobs, a phenomenon known as “job lock.” You also wind up getting compensated in the form of benefits you aren’t easily able to quantify while rarely seeing your paycheck increase at all (especially if you account for annual inflation). But the worst thing–the thing you absolutely have the least control over–is that with an employer-based system, you can lose your coverage if your employer decides to stop providing benefits, and you will lose your coverage (save COBRA) if you happen to lose your job. Fun fact? Both of those scenarios are much more likely when the country goes through an economic recession.

But according to a recent study of the near-universal coverage system in Massachusetts, published in Health Affairs, a public option can lead to such a problem being avoided. The study finds that Massachusetts has gone through the recession just like every other state–seeing large increases in unemployment, state budget problems, and the like–but has been quite different in one key respect: Unlike other states, the uninsurance rate in Massachusetts did not increase during the recession. That’s remarkable evidence in support of severing insurance coverage from employment–perhaps not entirely, but at least in part. In other words, it should be a one-way street of necessity: You should be able to get insurance through your employer, but you should have affordable options for maintaining coverage in the absence of an employer-based option.

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Transportation and Health

A couple of years ago, I wrote up a review of the literature on the lack of transportation as a barrier to health care access, which many people in the United States face. There’s another side to the intersection of transportation and health, however, and that’s that our transportation infrastructure and policies go a long way in shaping our health. In addition to access to transportation being an important determinant of access to care, the modes of transportation we use have health consequences. For example, heavy reliance on personal automobiles can contribute to obesity–we walk less and drive more–and negatively effects the environment–from the air we breathe to other consequences of the greenhouse effect and global warming–not to mention that people die in car accidents.

It would be best if people walked or biked more often, but our community infrastructure isn’t designed with this in mind. Actually, where I live in North Carolina, we are way above the national average in terms of things like bike paths and trails–and I routinely see more people out and about here than anywhere else I’ve lived.

But back to the original point–our transportation modes can take a toll on our society’s health. And now there’s a report from the American Public Health Association, “The Hidden Health Costs of Transportation,” that quantifies that toll and puts its cost in the billions of dollars. It’s pretty remarkable. Maybe we need to rethink how we get around.

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