Unbiased Analysis of Today's Healthcare Issues

Health Wonk Review is up

Written By: Jason Shafrin - Feb• 12•16

Steve Anderson has a freshly posted Money Changes Everything Edition of Health Wonk Review at medicareresources.org blog.

Changes in the MSSP program

Written By: Jason Shafrin - Feb• 10•16

Medicare’s ACO program–the Medicare Shared Savings Plan (MSSP)–has recently been revised.  AJMC reports that Patrick Conway, MD, MSc, deputy administrator for innovation and quality and chief medical officer at CMS, describes the proposed changes to the Medicare Shared Savings Program and how they will assist accountable care organizations transitioning to tracks with more risks.

Does more spending improve patient outcomes?

Written By: Jason Shafrin - Feb• 09•16

The answer to this question is not so clear cut.  Comparing outcome for patients living in Beverly Hills and those in South Los Angeles may be different not only due to health care spending but also due to the patient socioeconomic factors that affect health outcomes.  To get around this econometric challenge, an interesting paper by Doyle, Graves and Gruber (2015) use the randomness of ambulances to examine how increased spending affects outcomes.

This paper uses the effective random assignment of patients to ambulance companies to generate comparisons across similar patients treated at different hospitals. We find that assignment to hospitals whose patients receive large amounts of care over the three months following a health emergency do not have meaningfully better survival outcomes compared to hospitals whose patients receive less. Outcomes are related to different types of treatment intensity, however: patients assigned to hospitals with high levels of inpatient spending are more likely to survive to one year, while those assigned to hospitals with high levels of outpatient spending are less likely to do so. This adverse effect of outpatient spending is predominately driven by spending at skilled nursing facilities (SNF) following hospitalization.

Thus, people should not look at an additional dollar of healthcare as always inherently  good or bad.  In many cases, these funds are improve health outcomes–such as increased hospital spending.  However, there are some cases–SNFs in this paper–where higher spending does not improve outcomes.  Thus, whenever you hear a policymaker say that additional health care spending is either good or bad, a key follow-up is: what type of spending and for which patients?  The answer to that more specific question is the key to identifying where U.S. society should invest the health care dollars it spends.

What is the FDA doing about opioids?

Written By: Jason Shafrin - Feb• 09•16

The FDA is planning to put additional scrutiny on the use and approval of opioids in order to prevent opioid abuse and addiction.  Here is their plan:

  • Re-examine the risk-benefit paradigm for opioids and ensure that the agency considers their wider public health effects
  • Convene an expert advisory committee before approving any new drug application for an opioid that does not have abuse-deterrent properties;
  • Assemble and consult with the Pediatric Advisory Committee regarding a framework for pediatric opioid labeling before any new labeling is approved;
  • Develop changes to immediate-release opioid labeling, including additional warnings and safety information that incorporate elements similar to the extended-release/long-acting (ER/LA) opioid analgesics labeling that is currently required;
  • Update Risk Evaluation and Mitigation Strategy requirements for opioids after considering advisory committee recommendations and review of existing requirements;
  • Expand access to, and encourage the development of, abuse-deterrent formulations of opioid products;
  • Improve access to naloxone and medication-assisted treatment options for patients with  opioid use disorders; and
  • Support better pain management options, including alternative treatments.

The value of surrogate endpoints for predicting real-world survival across five cancer types

Written By: Jason Shafrin - Feb• 07•16

You can find one of my recent papers measuring how well survival measures from clinical trials (i.e., overall survival, progression free survival, time to progression) translate into real-world survival outcomes in Current Medical Research and Opinion here.  The abstract is below.


Objective It is unclear how well different outcome measures in randomized controlled trials (RCTs) perform in predicting real-world cancer survival. We assess the ability of RCT overall survival (OS) and surrogate endpoints – progression-free survival (PFS) and time to progression (TTP) – to predict real-world OS across five cancers.

Methods We identified 20 treatments and 31 indications for breast, colorectal, lung, ovarian, and pancreatic cancer that had a phase III RCT reporting median OS and median PFS or TTP. Median real-world OS was determined using a Kaplan–Meier estimator applied to patients in the Surveillance and Epidemiology End Results (SEER)-Medicare database (1991–2010). Performance of RCT OS and PFS/TTP in predicting real-world OS was measured using t-tests, median absolute prediction error, and R2 from linear regressions.

Results Among 72,600 SEER-Medicare patients similar to RCT participants, median survival was 5.9 months for trial surrogates, 14.1 months for trial OS, and 13.4 months for real-world OS. For this sample, regression models using clinical trial OS and trial surrogates as independent variables predicted real-world OS significantly better than models using surrogates alone (P = 0.026). Among all real-world patients using sample treatments (N = 309,182), however, adding trial OS did not improve predictive power over predictions based on surrogates alone (P = 0.194). Results were qualitatively similar using median absolute prediction error and R2 metrics.

Conclusions Among the five tumor types investigated, trial OS and surrogates were each independently valuable in predicting real-world OS outcomes for patients similar to trial participants. In broader real-world populations, however, trial OS added little incremental value over surrogates alone.

Friday Links

Written By: Jason Shafrin - Feb• 05•16

On management and regulation…

Written By: Jason Shafrin - Feb• 03•16

Guide the people by law, subdue them by punishment; they may shun crime, but will be void of shame. Guide them by example, subdue them by courtesy; they will learn shame, and come to be good.


HT: John Kay’s Other People’s Money: The Real Business of Finance.

Who pays for the elderly’s medical care in the U.S.?

Written By: Jason Shafrin - Feb• 01•16

In the U.S., the answer is largely the government.  An NBER paper by Mariacristina De Nardi, Eric French, John Bailey Jones, and Jeremy McCauley provide some helpful statistics using data from 1996 to 2010 waves of the Medicare Current Beneficiary Survey (MCBS).

The government pays for two-thirds of health care spending by the elderly, with Medicare accounting for 55 percent, Medicaid for 10 percent, and other government programs for 3 percent…Nearly 20 percent of the medical spending of the elderly is financed out-of-pocket, while 13 percent is covered by private insurance.

However, wealthier individuals have a higher share of their cost covered by private insurance and out-of-pocket sources:

By income, those in the bottom income quintile spend about $5,000 more per year than those in the top quintile. Again, nursing home expenditures are key — excluding these, those in the bottom quintile spend only $1,000 more per year. The financing of health care varies also dramatically by income. In the bottom quintile, Medicare pays $9,500 a year and Medicaid $3,900, while private insurance covers just $900 and out-of-pocket spending is $2,500. In the top quintile, Medicare pays $6,300 and Medicaid only $300, while private insurance pays $2,400 and out-of-pocket spending is $3,000.

You would not be surprised to learn that the highest cost patients make up a disproportionate share of overall costs:

Medical spending by the elderly is highly concentrated. Individuals in the top 5 percent of the distribution of total expenditures spend about $98,000 per year, nearly seven times the overall average of $14,000 and accounting for 35 percent of all medical spending. Out-of-pocket expenditures are even more skewed, with almost half of expenditures made by the top 5 percent of spenders. As the authors note, “even with public and private insurance, out-of-pocket medical expenditure risk is significant.”

Further, high (and low) health care spending is relatively persistent over time.

Those in the top quintile of spending in one year, for example, have a 54 percent chance of being in the top quintile in the next year and a 48 percent chance of being in the top quintile in two years. The chances that an individual in the lowest quintile of spending will remain a low spender one or two years later are 62 and 58 percent, respectively.


Canada’s single payer system doesn’t cover drugs?

Written By: Jason Shafrin - Jan• 31•16

Yes it is true.  Wang et al. (2015) report:

Unlike physician and hospital services, which are universal in Canada, coverage for prescription drugs dispensed outside hospitals falls outside the Canada Health Act and provincial governments only provide public drug programs for some population groups,primarily seniors and social assistance recipients…Canada is still the only country that does not provide universal coverage for prescription drugs among all developed countries with universal health care system.

Outpatient prescription drug coverage, however, does vary over time and by region.  Before 1997, Quebec only covered prescription drug costs for the elderly and patients with certain illnesses.  Only the low-income elderly had prescription drug costs fully covered by the provincial government.   Beginning in 1997, Quebec required all residents to have drug insurance.

The public prescription drug insurance plan, administered by the Régie de l’assurance maladie du Québec (RAMQ), covers all Quebecers who are not eligible for a private plan. All persons under age 65 eligible for a private plan are required to join that plan and ensure coverage for their spouse and children

Using data from the longitudinal household component of the National Population Health Survey (NPHS), the authors measure trends in prescription drug insurance, use of prescription drugs, medical costs, and health status measured by health utility index (HUI3) and self-assessed health status.  They use a difference-in-difference strategy comparing changes in these outcomes in Quebec compared to other Canadian provinces.

Using this approach, the authors find that:

We find that the introduction of the mandatory drug program substantially increased drug coverage among the general population…[and]…also increased medication use andGP visits. No statistically significant effects were found for specialist visits and hospitalization…Furthermore, effects on drug and GP utilization for the previously uninsured are concentrated at the extensive margin, indicating that the reform improved access to these services for them. Subgroup analysis by presence of chronic condition reveals that the reform had a much large effect on the probability of GP visit for those with chronic conditions. Most importantly, results of quantile regressions show that the reform had differential health impacts. People with worse health outcomes experienced a large improvement in their health status.


Health Work Review celebrates its 10 year anniversary!

Written By: Jason Shafrin - Jan• 29•16

Joe Paduda has a freshly posted Health Wonk Review – The Tenth Anniversary Edition! at Managed Care Matters.

Health Wonk Review – The Tenth Anniversary Edition!