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Jonathan Gruber went from unknown to infamous in the last few weeks, a result of disparaging comments he made about the Affordable Care Act (aka Obamacare) and even more disparaging ones he made about the American people. According to Gruber, the Obama administration counted on “the stupidity of the American voter” to pass the bill. In fact, the Obama team’s “lack of transparency” was deliberate, because they believed the law would not have passed if people fully understood it.
Under the sharp glare of our politicized media, Gruber’s comments have led to predictable disputes about what the comments really meant, and whether he accurately described the Obama administration and, of course, about who-the-heck Gruber is. He is described as an “architect” of the law on the right. On the left, he is portrayed as “did you say ‘Gruden’? ‘Goober?’ Sorry never heard of him.”
I’m not here to analyze Gruber’s infamous remarks. Instead, I am here to remark upon what Gruber has not said about Obamacare.
The food stamp program helps over 40 million Americans pay for groceries. Unlike other forms of economic assistance, this program, called SNAP (the Supplemental Nutrition Assistance Program), only pays for food, thereby constraining how recipients make use of the aid. But are food stamps constrained enough?
Experts estimate that SNAP recipients consume almost twice as many calories from sugar-sweetened beverages, like Pepsi and Coke, than they do from vegetables and fruits. These dismal statistics have caused some experts to use food stamps to nudge people toward healthier behavior.
But how best to nudge? And what might such nudging accomplish? (To read the rest of the post and leave comments, please visit Forbes.)
It is well known that Medicare expenditures threaten the financial solvency of the U.S. government. And it is pretty well agreed upon that some of our Medicare spending goes towards wasteful medical care.
A study in JAMA Internal Medicine provides a sneak peek at answers to these important questions. The research, led by Aaron Schwartz , a graduate student at Harvard, focused on interventions that medical experts deem to provide little or no health benefit. For example, the Choosing Wisely campaign, promoted by medical societies, has concluded that testing people’s lung function prior to low and intermediate-risk surgeries does not improve surgical outcomes. Similarly, the United States Preventive Services Task Force has concluded that colon cancer screenings yield more harms than benefits for elderly patients.
The researchers explored how often Medicare beneficiaries received unnecessary services like this, a list of 26 tests or procedures that medical experts have deemed to be unnecessary. The worse culprit, financially speaking, was stenting (propping open) coronary arteries for people with stable heart disease, which by one of their estimates leads to almost $3 billion per year of wasted Medicare spending. Close behind was another cardiology procedure, stress testing for patients with stable heart disease, which triggered over $2 billion of unnecessary spending. Toss in $200 million per year for unnecessary back imaging, another $200 million for unnecessary imaging tests to evaluate headaches, and the researchers uncovered over $8 billion of Medicare waste, for just these 26 interventions. (To read the rest of the article and leave comments, please visit Forbes.)
Here is the opening of a recent media story, reporting on a noble attempt researchers made to promote colon cancer screening by telling people when their genetic risk of such cancer was elevated:
People at average-risk for colorectal cancer (CRC) who underwent genetic and environmental risk assessment (GERA) to evaluate their risk for CRC were no more likely to undergo CRC screening than those people who did not receive this individualized assessment, results of a study showed.
Additionally, among those people who underwent GERA, those told that they were at elevated risk for CRC were no more likely to undergo screening than those told to be at average risk .
Along with Jennifer Blumenthal-Barby and Amy Lynn McGuire, I wrote an editorial accompanying the research report, which was published in the prestigious Annals of Internal Medicine. Check out the media story if you are interested.
In collaboration with Peggy Liu and Jim Bettman, I’ve had fun doing some research on just how hard it is for people to guess how many calories they are consuming, at restaurants like Chipotle where everyone puts different ingredients on their burrito. Here is the beginning of an absolutely excellent journalist’s take on the topic:
Maricelle Ramirez is a foot soldier in America’s battle against obesity. For three years, Ramirez has politely offered Boston area patrons of McDonald’s, Kentucky Fried Chicken, Burger King, Dunkin’ Donuts, Wendy’s and Subway a $2 gift card in exchange for their estimates of the amount of calories in their fast-food feasts.
“I’ve met all types of people,” Ramirez says, recalling the surprise of encountering a nutritionist who was on her way out of McDonald’s after chowing down on a burger and fries. “She explained that she was just enjoying a meal because she had a craving for something indulgent, but she provided a very careful nutritional analysis of what she was eating”….(click here to read her full article)
For decades now, policymakers have been trying to slow down the growth of healthcare costs. For much of this time, a large part of that effort was directed at hospital spending. American hospitals are extremely expensive, and take care of patients with the most severe illnesses. So if we’re going to control costs, it seems to be the place to start.
But when you squeeze the healthcare balloon one location, it will surely expand in another. When Medicare began paying hospitals through a prospective system, called DRGs, hospitals realized the days of the blank check were over. So they started rushing people out of the hospital quickly, for outpatient follow-up. When third-party payers put pressure on hospitals to reduce how much they charge for expensive procedures, providers began offering such procedures in “outpatient surgery centers.” (To read the rest of the article and leave comments, please visit Forbes.)
Clearly we in the United States are not taking the obesity epidemic as seriously as the Russian government. We debate whether it is appropriate for the government to require restaurants to inform their customers about how many calories they are consuming. Whereas in Moscow, sit at a park bench, and it will tell you how much you weigh!
There’s all kinds of problems with this “nudge,” of course, starting with the fact that this woman has an overstuffed purse joining her atop the bench. But you have to give the Russians credit for trying to change the culture of obesity.
An article in the New England Journal of Medicine in June (no one accused me of being a timely blogger!) shows that academic medical centers often provide poorly-reimbursed services that other healthcare institutions avoid. Where more general hospitals might avoid having psychiatric emergencies available, 90% of academic medical centers offer such services:
Whereas only 4% of nonacademic institutions offer pediatric intensive care, over half of academic medical centers do. In fact, academic medical centers have historically provided almost 40% of all charity care in the U.S. (To read the rest of this blog and leave comments, please visit Forbes.)
There was a very nice piece in the Washington Post recently, exploring the relationship between life satisfaction and the minimum wage. They summarize their findings in the following figure:
I suggest you read the piece, to see what they make of this connection. Importantly, they explicitly mentioned that correlation does not prove causation. Unfortunately they only throw that tidbit in at the very end of the piece, after they’ve convinced most readers that the connection is real. In addition, I have to say that scatterplots like these don’t look like strong causal relationships until people impose lines on them, estimating the best fit from linear regression. I wonder if anybody has done research, on whether the insertion of such lines in these pictures strengthens people’s beliefs about the power of the connection between the phenomena being measured.
That nitpicking aside, I think this is a provocative bit of work, that we need to keep in mind when deciding what to do about the minimum wage in the U.S. The well-being of the population matters, and deserves a role in policy decisions.
Such a no-brainer: If patients who receive care at Hospital A are more likely to get readmitted to the hospital 10, 20 or 30 days after discharge than patients in Hospital B, then Hospital A must be doing something wrong. Perhaps clinicians at that hospital are less adept at diagnosing and managing patients’ problems. Perhaps the follow-up care at Hospital A is less organized, leaving patients’ problems to spin back out of control. Maybe that hospital’s electronic medical record system is fragmented, making it harder for outpatient clinicians to figure out what happened to their patients when they were in the hospital. Whatever the reason for this shoddy care, we shouldn’t stand by and let it happen. Right?
That has certainly been the view in the Medicare office lately, with the Centers for Medicare and Medicaid services (or CMS) reducing payments to hospitals that have excessive 30-day readmission rates. CMS is trying to use its financial clout to motivate healthcare providers to provide higher quality care. The readmission policy is one of many reimbursement changes built into the Affordable Care Act (aka Obamacare).
But it is a policy that probably needs revision. Evidence is continuing to accumulate that the readmission policy will unduly harm hospitals that care for low income patients. (To read the rest of this post and leave comments, please visit Forbes.)