I would urge THCB-ers to read Reframing Healthcare by Dr. Zeev Neuwirth. While much of the territory he covers will be familiar to those of us with an interest in healthcare reform (meaning just about everyone reading this blog), Chapter 5 breaks new ground in the field of primary care.
Primary care is perhaps the sorest spot in healthcare, the
sorest of industries. Primary care providers (PCPs) are underpaid,
dissatisfied, and in short supply. (The supply issue could be solved in part if
employers didn’t pay employees
bonuses to get useless annual checkups or fine them if they don’t, of
They are also expected to stay up to date on a myriad of
topics, but lack the time in which to do that and typically don’t get
compensated for it. Plus, there are a million other “asks” that have nothing to
do with seeing actual patients.
For instance, I’ve gone back and forth three times with my
PCP as she tries to get Optum to cover 60 5-milligram zolpidems (Ambien)
instead of 30 10-milligram pills. (I already cut the 5 mg. pills in half. Not
fair or good medicine to ask patients to try to slice those tiny 10 mg pills
into quarters. And not sure why Optum would incentivize patients to take more
of this habit-forming medicine instead of less.)
This can’t be fun for her. No wonder PCPs burn out and leave
the practice faster than other specialties. What some of my physician
colleagues call the “joy of practice” is simply not there.
Soeren Mattke (as mentioned in the last installment) and I were quite relentless in trying, quixotically, to get Professor Baicker to explain her results. Its popularity could have landed her many profitable speaking and consulting gigs, but she evinced no interest in cashing in, or even in defending her position. Indeed, the four times she spoke publicly on the topic, she didn’t do herself, or her legions of sycophants in the wellness industry, any favors. In each interview, she distanced herself more and more from her previous conclusion. Here are her four takeaways from her own study “proving” wellness has precisely a 3.27-to-1 ROI:
Individually or in total, these comments sounded an awful lot like retractions, but she (and her co-author and instigator, David Cutler) claimed those comments didn’t constitute retractions. Whatever they were, she wasn’t exactly doubling down on this 3.27-to-1 conclusion.
Let’s climb into the WABAC Machine (and, yes, that’s the way it’s spelled) and set the dial for 2008.
Then-candidate Barack Obama, campaigning on the promise of universal health coverage, enlisted Harvard professor David Cutler as his key adviser on that topic. Business lobbying associations were not thrilled about their members having to cover all their full-time employees and incorrectly assumed, then as now, that the major drivers of healthcare cost were employees smoking, overeating, and not exercising. Prof. Cutler suggested, quite correctly, that one way to assuage that concern would be to allow employers to spend less money covering employees with those three health habits.
Fast-forward to 2009, when it appeared that — with enough concessions to enough vested interests — the Affordable Care Act (ACA) could become a reality. Business lobbying groups were, then as now, powerful entities. Using Prof. Cutler’s suggestion, they were pacified by allowing businesses to tie up to 30% of total premium dollars to employee health (in practice, largely employee weight). Generally, the business lobbying groups engineered this withhold in the shadows. It wasn’t until 2015 that one of those business groups, the Business Roundtable, publicly admitted that the 30% withholdwas the main reason they bought into the ACA.
Medical Homes Fail Yet Another “Natural Experiment”
Three “natural experiments,” three failures. Such is the fate of patient-centered medical homes (PCMH), a well-intentioned but unsuccessful innovation now kept afloat by the interaction of promoter study design sleight-of-hand with customer innumeracy.
By way of review, a natural experiment is an experiment in which the design is outside the control of investigators, yet mimics an experiment. The first two natural experiments below involve applying the intervention across entire states. The third involves a stimulus-response experiment in one specific community.
Statewide Natural Experiments: North Carolina and Vermont
In North Carolina, a statewide Medicaid PCMH was implemented years ago and steadily expanded until most Medicaid recipients belonged to one. There was no reduction in relevant event rates (for ambulatory care-sensitive admissions) and costs increased. While the overall Medicaid budgets were routinely exceeded and that should have caused legislators to realize that something in their PCMH was amiss, Milliman fabricated data to pretend the PCMH program was a success. Milliman got caught making up data (and ignoring other data that quite definitively invalidated its conclusion, and changed their story 180 degrees, a tacit admission that they lied. And shortly thereafter (at least “shortly” by the standards of state government), North Carolina announced that it is abandoning this failed experiment.
Suppose there were: (1) a widely held but false perception that gays had lower productivity and higher healthcare costs than straights; (2) false literature that companies with gay conversion programs outperformed the stock market; and (3) a mandate that companies disclose to shareholders the percentage of gays they employ.
Obviously, many corporate CEOs would stop hiring gays, de facto require gay conversion among current employees, and fire gays who failed the program, in order to maximize stock price and hence their own net worth.
Preposterous? Of course, but if Johnson & Johnson (J&J), Vitality Group and a few pharmaceutical companies get their way, this exact same scenario will befall overweight employees. Indeed, two-thirds of this dystopian scenario is already in place:
The Wall Street Journal just reported that Genetic Testing May Be Coming to Your Office Soon. This is all well and good, assuming employees would want their health insurer’s buddies collecting their DNA for no good reason, handling it, selling it, and possibly losing it. This is not us talking. This is what the testing company itself says on their website. You can read all about it here.
Instead we will focus on the fact that this scheme simply doesn’t save money – according to the main proponents of this dystopian scheme, Aetna and its buddies at the ironically named Newtopia. Anticipating the day (yesterday) that this would become front-page news, we have already showed how Aetna’s study accidentally showed the opposite of what it intended to show. This is that proof.
“Where in the Affordable Care Act (ACA) does it mandate that every health insurance policy must include a free annual checkup?”
I posed this question to Al Lewis and Vik Khanna in the comments of their recent post entitled: The High Cost of Free Checkups, where they argue against the Affordable Care Act (ACA) provision that requires “free checkups for everyone.” They cite a recent New York Times Op-ed authored by ACA co-architect, Dr. Ezekiel Emanuel, that essentially debunks the link between annual checkups and overall health outcomes. For Lewis and Khanna the solution is simple, we need to “remove the ACA provision that makes annual checkups automatically immune from deductibles and copays.” But for me there’s an enormous problem with their argument: The ACA doesn’t actually have any such provision.
After raising the issue in the comments section of the post, Mr. Lewis responded informing me that: “It’s definitely there” and “You’ll have to find it on your own, though — I unfortunately have to get back to my day job.” What Mr. Lewis doesn’t consider with his quick dismissal, is that I have already looked. I’ve combed through the law and other policy guidance, rules and regs; searching for any mention of this required annual wellness exam, physical, visit, or any other linguistic derivative. It doesn’t exist.
So what gives? Lewis and Khanna aren’t the only ones who’ve mentioned this “free” Obamacare benefit. Even when researching this piece I had to engage in a lengthy discussion with a friend who is a healthcare policy advisor, unexpectedly defending my position. This claim has to be coming from somewhere, surely people smarter than me have gotten it right?
“Gentlemen. Great post. Like you, I am disappointed that researchers of the caliber of Kate Baicker and David Cutler do not respond to the mounting debate about their paper. They should defend or disown their work rather than hope that the debate goes away.
In my mind, their paper is a product typical of high-end academic research. Two brilliant professors spot a gap in the evidence on a hot policy topic and decide to go after it. But the actual work gets done by a graduate student in his cubicle without windows or guidance, and then hastily published.
Then the problem arises that the paper becomes hugely influential and people start having a closer look. For our paper on the PepsiCo program, we reviewed in detail the seven publications that Baicker and colleagues called “high quality evidence”. We found that five of those analyzed programs that operated over 20 years ago and most of them had severe methodologic flaws. (John P. Caloyeras, Hangsheng Liu, Ellen Exum, Megan Broderick and Soeren Mattke. Managing Manifest Diseases, But Not Health Risks, Saved PepsiCo Money Over Seven Years. Health Affairs, 33, no.1 (2014):124-131)
Unfortunately, many defenders of the industry continue to take the Baicker paper at face value, while closely scrutinizing or ignoring more nuanced and scientifically sound findings.
There are certainly many points of contention and areas for continued discussion on this topic. It turns out that Lewis et al. and I agree on many things, and there are other areas where we see things differently.Continue reading…