Joe Colucci: All Related Content

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.

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.

No fiscal policy event is complete without the plaintive cry that health care costs are out of control. The phrase has become a form of rhetorical boilerplate that is often used to imply that policy makers are helpless in the face of market forces, and that the only way to reduce "costs" is either cutting benefits or rationing.

Last week's Health Wonk Review is worth checking out--it has posts on a whole slew of topics, ranging from implementation of the ACA to Medicare readmissions penalties, and more. It's also stocked with Chanukah facts! Check it out here.

One of the particularly important posts covers a surprising JAMA paper looking at patients who had online access to their medical records and other information online. Contrary to the popular narrative that patients who have access to their information and can manage their medical needs will consume less healthcare, utilization among patients using the online system went up. The study is far from a complete analysis of the effects of better IT on healthcare spending, but it does pose serious problems for people who believe electronic medical records and giving patients better access to their information will make a serious difference in the healthcare system.

Last night, CBS's 60 Minutes aired a segment reporting on the allegations that for-profit hospital chain Health Management Associates (HMA) has committed widespread Medicare fraud, including by pressuring ER docs to admit at least 20% of their patients (and at least 50% of patients over 65!), and by using a computer system that automatically ordered tests before patients even saw a doctor. The company has denied the accusations, but they are under investigation by the Justice Department.

Obviously, if HMA was breaking the law, it should be investigated and punished. But it's important to note that similar questionable admissions happen all the time, at hospitals across the country, without any deliberate Medicare fraud. Supply-sensitive admissions are a huge and expensive problem that the 60 Minutes story didn't address. It doesn't matter to a patient who ends up getting an infection if they were admitted explicitly to make more money, or "just in case" and because there was a bed available. Preventing fraud is yet another reason we need much better evidence on when being admitted to the hospital is helpful, and when it just puts patients in harm's way.

CBS based the report on conversation with a large number of former HMA employees, as well as on some documents that apparently show the pressure from inside the organization. We've asked to see the documents, and will update this post to reflect anything we hear about that request from CBS.

Watch the full segment here!

We've just closed out a month where everything from the White House to professional football players' cleats turned pink to raise awareness of breast cancer. Every year during October, there's a constant focus on raising money for breast cancer research, and on reminding women to get screened. The mantra is always, "Early detection saves lives."

As we've written before, it's an article of faith for many patient advocates and medical organizations that cancer screening is an unadulterated good. But a new study in the Lancet on breast cancer screening provides yet more evidence that while mammography can save lives, screening also causes serious harms. They find that for every woman whose life is saved, three other women will be overdiagnosed and face unnecessary treatment. That doesn't even count the harm caused by false positives on screening mammograms, which lead to unnecessary stress as well as biopsies and other tests. It's worth noting that the population in the Lancet study includes women over 50, in line with the US Preventive Services Task Force's recommendations. Expanding screening to women under 50 means that fewer of the women screened will have harmful cancers, so the harm of overdiagnosis is more likely to outweigh benefits from catching cancer early.

To go along with the Lancet study, the New England Journal of Medicine has a new Perspective piece by Drs. Steve Woloshin, Lisa Schwartz, William Black, and Barnett Kramer. They make a forceful argument against one-sided pro-screening campaigns that present the benefits of screening, while ignoring the harms. The piece is linked to a great slide show with some of the most egregious pro-screening advertizements.

Overtreatment has hit the popular press in a big way over the last couple of weeks. We haven't been able to highlight every article as it's come out, so here they are all in one place. Take some time this afternoon & catch up!

"The Cost of Assuming Doctors Know Best" - In The Atlantic, Shannon Brownlee & I outline the shared decision making program implemented at Group Health Cooperative in Washington State, and argue that it should be a strong signal to hospitals across the country to start their own SDM programs.

"Unnecessary care: are doctors in denial and is profit driven healthcare to blame?" - Jeanne Lenzer discusses the Avoiding Avoidable Care conference, previews our efforts to eliminate overtreatment, and poses the inevitable question: what has to change about payment structures for medicine to put the patient first?

"Is the USA’s problem ours too?" - Margaret McCartney assesses the risk of overtreatment in a truly government-run healthcare system, and finds that the UK faces many of the same challenges that the American healthcare system does, including rampant overuse & poor reaction to evidence.

"Patient power needs to be built on strong intellectual foundations" - Former NHS head Nigel Crisp argues that "the balance of power in health systems needs to be shifted so that people are enabled to live the life that they want rather than having to fit in with professional and commercial views."

Video: The harms of overtreatment - The video supplement to Jeanne Lenzer's article includes interviews with Shannon Brownlee, Dr. Vikas Saini of the Lown Institute, and the story of Michael Skolnik and the harms of overtreatment.

"The Epidemic of Excess Medical Treatment" - Dr. Marty Makary, Johns Hopkins surgeon and author of Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care, describes the numerous reversals of medical advice to come out in recent years and the massive scale of overtreatment in the US.

Dr. Marty Makary on the Diane Rehm Show - Dr. Makary is the sole guest for a full hour of excellent discussion on one of public radio's best interview programs.

"Psychiatrist Contends the Field Is ‘Committing Professional Suicide'" - Maia Szalavitz describes tje problems with the relationship between psychiatry and the pharmaceutical industry--a relationship that's getting so close and so corrupting that one psychiatrist says his fellows are “committing professional suicide.”

"How Hospitals Can Stop Killing So Many Patients" - On her Forbes column, Kare Anderson lays out some things that patients can do to avoid being harmed by the inefficiencies and patterns of overuse in American hospitals.

Health Wonk Review, October Surprise Edition - Finally, this week's Health Wonk Review has a whole slew of other posts worth reading. Check it out!

“The habit of assuming the doctor knows best has created a system where huge numbers of patients aren’t getting the treatment they would have chosen if they were fully informed,” write the article’s authors, Shannon Brownlee and Joe Colucci of the New American Foundation.

Original article

Tara Parker-Pope, Well columnist for the New York Times website, highlighted overtreatment as a serious problem in a blog post yesterday. The post describes several people's direct experiences with unnecessary testing and treatment, and does a good job conveying the physical, emotional, and financial harm that comes from a disorganized system prone to overtreatment.

Overtreatment is a human issue, and reducing the personal harm it causes is at least as important as controlling healthcare spending growth. But healthcare spending is a crucial political issue, so it was smart to put the post on the Times's current campaign issues channel, The Agenda. Tackling overtreatment will be a defining issue of the next few years--either because we make crucial progress toward eliminating overse and reducing total medical spending, or because the next President ignores the problem while we continue on the ruinous path of letting healthcare strangle the rest of our economy.

Given the importance of the issue, though, I wish the post had looked a little bit closer at the policy issues involved. Most importantly, the post doesn't address the causes of overtreatment, including the financial incentives faced by clinicians and hospitals, lack of research on what treatments are effective, and physicians' failure to communicate to patients about their treatment options. The thing is, there are huge differences in policy between the two tickets on those issues. Since the post appeared on The Agenda, it could have done a lot more to point out those differences--like the fact that the ACA moves Medicare away from paying for the volume of services and toward rewarding higher-quality, more cost-effective care, or that it funds patient-centered outcomes research to determine which treatments actually work. On the other hand, Romney's running mate, Paul Ryan, recently parroted the absurd idea that IPAB is a "death panel," even though it is specifically prohibited from rationing care. That kind of rhetoric is hard to square with the notion that a Romney/Ryan administration would be willing to take any political risk to push back against unnecessary care.

Finally, on a related note, Dr. Aaron Carroll of The Incidental Economist has pulled together an incredibly useful set of politically difficult truths about reducing healthcare spending, in a set of posts titled "Why is this so hard to understand?" All of them are important and worth reading:

Part 1: When Medicare spending goes up, seniors’ premium costs go up.

Part 2: You can be for reducing Medicare spending, or you can be for increasing Medicare spending, but you can’t be for both.

Part 3: If you spend more on Medicare, someone has to pay for it.

Part 4: Don’t argue that reducing government involvement is the way to reduce spending.

Hosted this week by Dr. Jaan Sidorov at the Disease Management Care Blog, it's "A Brainy Health Wonk Review on Health Reform, the Affordable Care Act and Lots More!" Go check it out.

Health Wonk Review will be back on September 13th, hosted by Louise Norris of the Colorado Health Insurance Insider Blog.

Austin Frakt tweeted a news release from AcademyHealth this afternoon that brought painful flashbacks to the health policy world.

The House Appropriations Committee has released its proposed 2013 budget for the Departments of Labor, Health and Human Services and Education, in which it "terminates" the Agency for Healthcare Research and Quality (AHRQ). The budget proposal also cuts $150 million from PCORI's funding source, and prohibits any federal agency covered by the committee's jurisdiction from performing patient-centered outcomes research with other funds.

The proposal is, quite simply, insane. It's a direct attack on the only federal agency that produces research on the health care sector and the delivery system--research that is crucial to any effort to reduce unnecessary care, improve patient safety, and curb the increase in healthcare spending.

This budget marks a return to the bad old days, when Congress stood up against science and killed the Agency for Health Care Policy and Research. It's not clear whether this is just dangerous political posturing that will die on the House floor or in the Senate, or if it's dangerous political posturing that might actually pass, but either way we'll be watching the story and keeping you posted. In the meantime, The Incidental Economist is collecting stories about AHRQ funding of valuable (or not-so-valuable) projects.

This program has received funding from AHRQ in the past, including funding for the Avoiding Avoidable Care meeting. That funding has not colored our perspective on this--we would be ardent supporters of the Agency and of evidence-based medicine regardless.