Tag: Health Affairs

A Baby Step Backwards

Sep 26, 2024

Bringing the Tools of Accountable Care to Maternity Care is a Great Idea – But This Sure Ain’t It

By VICTORIA ADEWALE & J.D. KLEINKE

How desperate are we to find some kind of good news about the sorry state of maternity care in America? To find out, look no further than the current cover of no less venerable a health policy journal than Health Affairs.

With the headline “Medicaid ACO Improves Maternity Care” jumping off the cover of its September issue, we were expecting great things from the article “Massachusetts Medicaid ACO Program May Have Improved Care Quality for Pregnant and Postpartum Enrollees” (Megan B. Cole, et al.). The headline certainly promises some rare good news for all of us working to fix the national embarrassment that is maternity care in the US in general, and the maternal mortality crisis in particular.

But alas, the article itself is one more reminder that process improvements are not outcomes improvements. It is also a classic case of earnest researchers’ tendency to torture retrospective data — because it happens to be available for study — into something that might be useful. While it would be easy to dismiss out of hand the listless findings of this study of data-convenience, the danger here is they may well provide yet more ammunition for skeptical payers not to pay for more care that numerous studies have shown patients desperately need.

The authors make a valiant effort with an elegant study design to glean what they can from the “natural experiment” of analyzing pre- and post-natal care delivered to pregnant patients before and after the implementation of Accountable Care Organizations in Massachusetts. But as another old saw goes: when you have a hammer, everything looks like a nail; and patient enrollment in a primary care ACO, as with this dataset, hardly counts as an independent variable with much power to predict the care utilization and outcomes of maternity care for covered enrollees.

It is well established in the literature – not to mention an accepted truism among providers and patients – that when most women become pregnant, the bulk of their care shifts from the primary care setting to obstetrician/gynecologists (OB/GYNs) and certified nurse-midwives (CNMs). Many researchers and clinicians believe that much of this shift occurs even before a confirmed pregnancy, as a consequence of fertility challenges and pregnancy planning.

The authors did find that pregnant patients newly enrolled in ACOs had a small increase in the number of pre- and post-natal visits.

ACO Turnover is High. Doctors Have Few Patients, and Those Patients are Unusually Healthy

May 22, 2017• 4

By KIP SULLIVAN, JD

ACOs suffer astonishingly high turnover rates among their doctors and patients; their patients are unusually healthy; and those unusually healthy ACO patients constitute about 5 percent of each ACO doctor’s panel of patients. These facts appear in three recent reports: CMS’s final evaluation of the Pioneer ACO program, and two papers published in Health Affairs by John Hsu et al.

Each of these facts – high turnover, healthier patients, and few ACO patients in each physician’s panel – poses problems that cannot be solved without a substantial redefinition of the ACO. How are doctors supposed to influence the health and cost of patients they see only sporadically or not at all? How are ACO doctors supposed to lower costs if their sickest and most costly patients are not in the ACO? How are ACOs supposed to alter physician behavior when their physicians see fewer than 100 ACO patients out of a typical panel of 1,500 to 2,000 patients?

Will the Real Professor Katherine Baicker Please Stand Up?

Dec 31, 2014• 16

By AL LEWIS and VIK KHANNA

Harvard Professor Katherine Baicker is arguably most acclaimed health policy researcher at arguably the most acclaimed (and not even arguably, the best-endowed) school of public health in the country. Her seminal account of the effect of Medicaid coverage on utilization and health status is a classic. As luck would have it, in 2008 Oregon used a lottery to ration available Medicaid slots. A lottery controls for motivation and as such eliminates participant-non-participant bias, since everyone who enters the lottery wants to participate. That meant only one major variable was in play, which was enrollment in Medicaid or not.

Chance favors the well-prepared, and Professor Baicker jumped on this research windfall. She found that providing Medicaid–and thereby facilitating access to basic preventive medical care–for the previously uninsured did not improve physical health status, but did increase diagnoses and utilization. Because of the soundness of the methodology, the conclusion were unassailable – more access to medical care does not improve outcomes or optimize utilization, which is a proxy for spending. (We ourselves reached a similar conclusion based on a similar analysis on North Carolina Medicaid’s medical home model.)

Yet Professor Baicker herself used exactly the opposite methodology to reach the exact opposite conclusion for workplace wellness. And that’s where the identity crisis begins.

She and two colleagues published a meta-analysis in 2010 of participant-vs-non-participant workplace wellness programs. Somehow—despite her affinity for Oregon’s lottery control—she found this opposite methodology to be acceptable. She concluded that workplace wellness generated a very specific two significant-digit 3.27-to-1 ROI from health care claims reduction alone, with another 2.37-to-1 from absenteeism reduction. The title of the article–now celebrating its fifth anniversary as the only work by a well-credentialed author in a prestigious journal ever published in support of wellness ROI—was equally unambiguous: Workplace Wellness Can Generate Savings.

PepsiCo’s Wellness Program Falls Flat

Jan 6, 2014• 41

By Al Lewis and Vik Khanna

For those of us who actually think wellness outcomes should be evidence-based, a landmark study was released today: the first evidence provided by a major organization voluntarily (as opposed to being outed by us, like British Petroleum and Nebraska) that wellness doesn’t work. January’s Health Affairs features a case study of PepsiCo, authored by RAND Wellness Referee Soeren Mattke and others, in which a major wellness program was shown to fall far short of breaking even.

The specific highlights of the PepsiCo study are as follows:

Disease management alone was highly impactful, with an ROI of almost 4-to-1;
Wellness alone was a money sink, with each dollar invested returning only $0.48 in savings;
The wellness savings were attributed to an alleged reduction in absenteeism, as self-reported by participants. There was no measurable reduction in health spending due to wellness.

Even though the wellness ROI was far underwater, we suspect that the ROI was nonetheless dramatically overstated, for several reasons. First, the authors acknowledge underestimating the likely costs of these programs, focusing only on the vendor fees without considering lost work time, program staff expense and false positives. Second, no matter how hard one tries to “match” participants with non-participants (the wellness industry’s most utilized measurement scheme), it simply isn’t possible to compare mindsets of the two groups. We learned from one of Health Fitness Corporation’s many missteps that participants always outperform non-participants, simply because they are more motivated. Third, the absenteeism reductions were self-reported, by participants.

Finally, PepsiCo’s human resources department, having made the mistake of accepting Mercer’s advice to implement one of these programs, was already taking some political risk by acknowledging failure. Had they incorporated the adverse morale impact, lost productivity due to workers fretting about false positives, Mercer fees and staff costs, participant bias, and self-reporting bias, the ROI could easily have turned negative (meaning the program would have been a loser even if the vendor had given it away) and the HR staff could have been taking serious career risk.

Wellness Programs Aren’t Working. Three Ideas That Could Help.

Apr 1, 2013• 29

By MIKE MIESEN

You’d be forgiven if, after reading last month’s Health Affairs, you came to the conclusion that all manner of wellness programs simply will not work; in it, a spate of articles documented myriad failures to make patients healthier, save money, or both.

Which is a shame, because – let’s face it – we need wellness programs to work and, in theory, they should. So I’d rather we figure out how to make wellness work. It seems that a combination of behavioral economics, technology, and networking theory provide a framework for creating, implementing, and sustaining programs to do just that.

Let’s define what we’re talking about. “Wellness program” is an umbrella term for a wide variety of initiatives – from paying for smoking cessation, to smartphone apps to track how much you walk or how well you comply with your plan of care, and everything in between. The term is almost too broad to be useful, but let’s go with it for now.

When we say “Wellness programs don’t work,” the word work does a lot of, well, work. If a wellness program makes people healthier but doesn’t save lives, is it “working”? What if it saves money but doesn’t make people healthier?

Health Care Shibboleth

Mar 24, 2013• 29

By Frank de Libero

“We spend far more on health care than other peer countries yet have worse outcomes. Why is U.S. health care so expensive?” I’m sure you’ve encountered similar statements, maybe even expressed it yourself. It occurs often, including by knowledgeable people and health-related institutions. However, it’s a fallacy because it confuses health care with population health.

Health care is a proper subset of population health. For example, longevity is determined by more than just health care. Using a specific recent estimate (Appendix Exhibit A6 – gated), an average 20-year old U.S. white male who did not graduate high school will live 10.5 fewer years than a similar man with a college degree. That’s over ten years of life related to educational attainment. Sure, there are many reasons for the difference, and health care or the lack of it is only one of them.

Engaged Patients Translate to Better Outcomes and Costs

Feb 10, 2013• 10

By JUDITH HIBBARD and JESSICA GREENE

The expansion of health insurance coverage may be the most visible aspect of health reform, but other elements will ultimately have a significant impact on how we all experience health care. One pivotal change is how health care organizations are paid. New payment approaches will reward providers based on whether services actually improve patients’ health and keep costs down versus simply incentivizing them to provide more care.

One of the more consequential changes will be a greater focus on helping patients to be more involved in their care. There is ample evidence that the behaviors people engage in and the health care choices they make have a very clear effect on both health and costs, positively and negatively. The most innovative health care delivery systems recognize this and see their patients as assets who can help them achieve the goals of better health at lower costs. From this point of view, “investing” in patients and helping them to be more effective partners in care makes good sense.

Our study, reported in the February issue of Health Affairs, highlights this role that patients play in determining health-related outcomes. We found that patients who were more knowledgeable, skilled and confident about managing their day-to-day health and health care (also known as “patient activation,” measured by the Patient Activation Measure) had health care costs that were 8 percent lower in the base year and 21 percent lower in the next year compared to patients who lacked this type of confidence and skill. These savings held true even after adjusting for patient differences, such as demographic factors and the severity of illnesses.

Even among patients with the same chronic illness, those who were more “activated” had lower overall health care costs than patients who were less so. Among asthma patients, the least activated patients had costs that were 21 percent higher than the most activated patients. With high blood pressure, the cost differential was 14 percent.

You Get What You Pay For

Jun 18, 2012• 15

By David Dranove

Two recent research papers remind us that it may be difficult to cut U.S. healthcare spending without harming quality. The first, written by a research team led by University of Chicago economist Tomas Philipson, appears in the latest issue of Health Affairs and has deservedly garnered a fair bit of media attention. The authors examine cancer spending and survival times for patients in the United States and ten European countries during the period 1983-1999 (later data were not available.) Their data confirm what we already know about health spending; the average cost of treating a cancer patient was about $15,000 higher in the United States. But the data also show that the typical U.S. cancer patient lives nearly two years longer; most of the difference is attributable to prostate and breast cancer patients. The gain appears to be due to greater longevity rather than early diagnosis. Using generally accepted measures of the value of a life, they conclude that the benefits of additional health spending outweigh the costs by a factor of 4:1 or higher. The latter calculation does not consider QALYs (quality adjusted life years) and so may be overstated. The authors acknowledge that other nations may do a better job of cancer prevention, so that their overall approach to cancer may be superior to that in the U.S., but they can find no evidence of this one way or another.

Philipson’s study suggests that U.S. healthcare consumers may get a substantial bang for their higher bucks. Maybe the U.S. system is not so inefficient after all. What about efficiency within the U.S. system? Some providers are far more expensive than others. Is the higher cost worth it? A new study by a team led by MIT economist Joseph Doyle, and released as an NBER Working Paper, suggests that you may get what you pay for within the United States. Doyle and his colleagues ask whether higher cost hospitals in the United States achieve better outcomes than lower cost hospitals. It is not easy to answer this question, because higher cost hospitals may admit more severely ill patients. This results in a statistical problem known as selection bias that is difficult to eliminate with available severity measures.

Paying an Arm and a Leg for a Month of Life?

Apr 19, 2012• 110

By Peter Ubel

Imagine for a moment that you are an oncologist caring for a 53-year-old man with metastatic cancer, a person whose tumor has spread to lung and liver.

With standard chemotherapy, this man can expect to live around 12 months. That standard treatment isn’t all that expensive in today’s terms, only $25,000 and his insurance company will pick up the entire tab since he is already maxed out on his yearly deductible and co-pays.

But wait! Before prescribing the standard treatment, you find out there is a new chemotherapy on the market, one that costs $75,000 (in other words, fifty thousand dollars more than usual care) and has no more side effects than that standard treatment.

How much longer would patients like this have to live, on average, for you to feel that this new chemotherapy is warranted?

That’s not an easy question to answer. But it’s not an impossible one either. Clearly if the treatment would provide only, say, 1 day of additional survival on average, that would not amount to $50,000 well spent. Just as clearly, if this man could expect 10 years of additional life, no one would deny him this new treatment.

So when, between 1 day and 10 years, does it become a tough call whether to prescribe this new treatment?

The Nonprofit Question

Mar 14, 2012• 4

By David Dranove

I am getting caught up on the news after a couple of weeks away and two stories caught my attention. The first is the ongoing debate about the tax exempt status of Illinois nonprofit hospitals, which has received extensive coverage in the Chicago Tribune. Nonprofits avoid paying most state taxes, notably property taxes. For some nonprofit, the tax exemption could be worth tens of millions of dollars annually.

The question before the state is what they should expect of nonprofits in exchange for tax exemption. The current law requires nonprofits to provide “community benefits” commensurate with their tax savings. The state and the Illinois Hospital Association have been unable to find mutually acceptable language to replace this vague standard. The most draconian approach limits community benefits to charity care. At the other extreme, the IHA (and the Chicago Tribune) largely back a proposal by the Civic Federation that defines community benefits broadly to include losses incurred on Medicare, Medicare, bad debt, and community outreach programs.

A few years ago, I advised the state Attorney General’s office on this issue. I argued for the following conceptual approach: In exchange for tax exemption, nonprofit hospitals should be required to perform a commensurate level of “charitable acts,” which I defined as services and programs for which the hospital expects to lose money. Alternatively, charitable acts are those that investor-owned hospitals would not undertake.