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.
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…
Middle Age is where your broad mind and your narrow waist begin to change places.” – John Crossman
I never really took a regular medication for a condition before I was in my forties. My mother did not believe in pills. She was one part Christian Scientist and two parts Inuit Darwinist subscribing to the notion that sick children, like old people, should be just set outside the igloo at night and if they were still alive in the morning, they were allowed to rejoin the family. Illness and chronic conditions were things that plagued other people, like old man Norton who lived across the street. At 85, he suffered from heart failure and diabetes and it seemed like every other week they were lopping off one of his appendages as a sort of burnt offering to his disease. It was a preview of a movie I hoped to never see.
As a kid, you averted your eyes from the vagaries of aging, not so much out of denial but out of some misguided sense that old age only happened to other people. Deep down, you knew it would be waiting for you, like that German Shepherd that sometimes chased you on your bike. On sunny afternoons, I occasionally glimpsed Mr. Norton and he would wave to me from his wheel chair – all two arms, one foot and a half leg. It freaked me out and I made a pact that I would never succumb to old age.
By now readers of this and many other outlets know that conventional workplace wellness doesn’t work. Period. It’s not that there is no evidence for it. It’s far more compelling: all the evidence is against it. The so-called “evidence” in favor of it is easily disproven as being the result of gross incompetence and/or dishonesty. And occasionally, as in the American Journal of Health Promotion, investigators in this field manage to disprove their own savings claims without intending to, “face invalidity” as it might be termed. This is not an isolated event: analytic self-immolation happens so often that Surviving Workplace Wellness even has a line about it: “In wellness, you don’t have to challenge the data to invalidate it. You merely have to read the data. It will invalidate itself.”
Just before Thanksgiving, both Health Affairs (with our blog post which, given the events we are about to describe, seems almost prescient) and the often-misquoted authorof multiple RAND studies (in a comment to that post) weighed in with the same conclusion, as described in the headline: “Workplace Wellness Produces No Savings.”
The article, Health Affairs most widely read posting of November and one of the most widely read of the year, was described to me as the wellness equivalent of the 1912 Armory Show, as being the seminal event that immediately changed the field forever. No longer could anyone claim with a straight face that “pry, poke, prod and punish” wellness programs saved money, or were even beneficial for employee health.
Within one business day of this posting, Reuters’ Sharon Begley reports that on Tuesday, December 2, the Business Roundtable’s (BRT’s) CEO is having a sit-down meeting with President Obama to demand exactly the opposite of what all the evidence shows: more flexibility and less enforcement to do wellness as the ACA empowers them to. In particular, they want the Administration to call off the EEOC watchdogs, who have recently attacked Honeywell and others for forcing its employees into medical exams that appear to violate the Americans with Disabilities Act.
The BRT’s goal is to allow companies to punish unhealthy workers to the limits of the Affordable Care Act’s wellness provision. (Recall from our earlier postings that the ACA wellness provision itself was modeled after the Safeway wellness program, which Safeway later admitted did not even exist during the period for which the company claim it saved money.) In essence, the BRT leadership wants to make their employees love wellness whether they like it or not.
Two months ago Al wrote a column titled: Are Obamacare Wellness Programs Soon to be Outlawed? Truthfully that headline was picked for its sky-is-falling value, in an attempt to generalize one Equal Employment Opportunity Commission (EEOC) lawsuit against one wacky wellness program to an EEOC risk for wellness programs everywhere.
As luck would have it, the sky has now fallen — right on the head of Honeywell…and the EEOC is indicating more lawsuits are to come. The scary part here: Unlike the wacky wellness program above, Honeywell was in compliance with the Affordable Care Act (ACA), but compliance with the ACA doesn’t seem to get you a free pass on the EEOC’s own “business necessity” requirement, plucked from the Americans with Disabilities Act (ADA), which they enforce.
Essentially the Honeywell lawsuit means no company doing invasive biometric screenings and mandating doctor visits or measuring health outcomes on individuals, and that has a significant financial forfeiture attached to it, is immune to prosecution, even if they are in compliance with ACA.Continue reading…
Making Sense of Blue Button, Meaningful Use, and What’s Going on in Washington …
At the recent Health 2.0 Conference in Santa Clara, co-chair Matt Holt expressed frustration about the difficulty of getting copies of his young daughter’s medical records. His experience catalyzed a heated discussion about individuals’ electronic access to their own health information. Many people are confused about or unaware of their legal rights, the policies that support those rights, and the potential implications of digital access to health data by individuals. The Health 2.0 conference crowd included 2000 entrepreneurs, consumer technology companies, patient advocates, and other potentially “disruptive” forces in healthcare, in addition to more traditional health system players.
Why is this topic so important? Until now, most people haven’t accessed their own health records, whether electronically or in paper, and I believe that making it easier to do so will help tip the scales toward more meaningful consumer/patient engagement in healthcare and in health. Access by individuals and their families to their own health records can empower them to coordinate care among multiple healthcare providers, find and address dangerous factual errors, and take advantage of a growing ecosystem of apps and tools for improving health-related behaviors, saving money on health services, and getting more convenient, personalized care.
A shorthand phrase for this kind of personal empowerment through access to digital health data is “Blue Button,” which is also the name of a public-private initiative in which hundreds of leading healthcare organizations across the US participate. The Blue Button Initiative is bolstered by the electronic access to health information requirements for patients in the “Meaningful Use” EHR Incentive Program, which is administered by CMS (the Centers for Medicare & Medicaid Services) with companion standards and certification requirements set by ONC (the Office of the National Coordinator for Health Information Technology).Continue reading…
Crowdsourcing is engaging a lot of news organizations today. While some journalists are nervous about crowdsourcing — “Yikes, we’d rather talk than listen, and what if they tell us something we don’t want to hear? Or something that we know isn’t true?” — we here at clearhealthcosts.com love crowdsourcing. We find, as journalists, that our communities are smart, energized, truthful and engaged, and happy to join hands in thinking, reporting and helping us make something that’s bigger than the sum of its parts. We learn great things by listening, so … now we’re going to to an experiment crowdsourcing coverage for our blog.
Our current project crowdsourcing health care prices in California, with KQED public radio in San Francisco and KPCC/Southern California public radio in Los Angeles, has been a great success, as was our previous project with WNYC public radio, and we’re looking forward to launching similar projects with other partners.Continue reading…
The use of marijuana is associated with a marked increase in the risk of being involved in severe trauma particularly motor vehicle collisions. In 2009, for instance, marijuana use was a contributing factor in more than 460,000 emergency department visits in the United States.
But we also know that cannabis is potentially neuroprotective. Previous studies have found that tetrahydrocannabinol (THC), the active ingredient in marijuana, may have beneficial effects in certain types of neurodegenerative processes, like Alzheimer’s and Huntington’s disease. In addition, previous studies indicate THC may protect the brain in animal models of neurologic injury. However, clinical trials of a synthetic THC derivative were not ultimately associated with an increase in survival in patients with traumatic brain injury. Since overall findings were mixed, we hypothesized that use of the “native” form of THC could be associated with an increase in survival in patients with traumatic brain injury.
The search for an antidote to the ills of our ailing healthcare system inevitably bumps up against the pervasive mindset that more is better. Each year we develop and prescribe more drugs, more tests, more technology. Yet, despite these investments, more treatment doesn’t always result in better outcomes. Procedures can be invasive or have unintended consequences, medications can have side effects, and tests can be unnecessary. But what is the alternative? As we look to improve quality and reduce cost, less can actually be more.
Results of recent research indicate that there is much to tap into beyond reliance on drugs and other interventions when helping patients heal. For example:
The doctor’s connection with a patient can improve clinical outcomes
In a treatment experiment where the only variable was the quality of the clinician’s engagement with the patient, those in the “higher engagement” group reported much greater relief. 1
Seeing a treatment administered increases effectiveness
Morphine injected directly by syringe has greater pain-killing effects than when added, out of view, to a patient’s IV.
Sugar pills can work as well as “real” medicine 2
In a study concerning migraine, patients reported as much relief after taking a dummy pill labeled as a proven medication as patients who took the proven medication that was labeled as a dummy pill. 3
These occurrences tend to be aggregated under the rubric of the “placebo effect.” Once pigeonholed as a nuisance factor in clinical drug trials, the placebo effect is now the subject of a promising list of studies and experiments in the fields of neurophysiology, psychology, neuroscience, molecular biology, and genetics.
I am a public health professional, educated at the vaunted Johns Hopkins University Bloomberg School of Hygiene and Public Health. I like guns, and I believe the Second Amendment clearly secures the rights of individuals to own firearms.
You read that correctly. I am a public health professional.
And I like guns.
This make me a heretic in American public health, where embracing firearms and the rights of gun owners is a gross violation of orthodoxy.
As a society, our focus on guns and not gun users derives from the shock of mass killings, such as those in Newtown, CT, Aurora, CO, Virginia Tech, and Norway, which has some of the strictest gun control laws on the planet. Mass killings, however tragic, get distorted by saturation media hysterics and 24-hour political grandstanding. What gun opponents refuse to discuss is the precipitous fall in violent crime and deaths by firearms over the past 20 years, and how it coincides with an equally dramatic increase of guns in circulation in the US.
While that isn’t cause and effect, the association is certainly curious.
In 2013, the Institute of Medicine, at the behest of the Centers for Disease Control, produced a report on firearms violence that has been ignored by the mainstream media. The upshot: defensive use of firearms occurs much more frequently than is recognized, “can be an important crime deterrent,” and unauthorized possession (read: by someone other than the lawful owner) of a firearm is a crucial driver of firearms violence.
That report went away for political reasons. Translation. Nobody wanted to talk about it because it raised more questions than it answered.