Unbiased Analysis of Today's Healthcare Issues

The association between observed mobility and quality of life in the near elderly

Written By: Jason Shafrin - Aug• 21•17

In a recent paper with Jeff Sullivan, Dana P. Goldman, and Thomas M. Gill in PLOS One, we try to answer this question. The paper’s abstract is below.



Chronic diseases associated with aging, such as arthritis, frequently cause reduced mobility, pain and diminished quality of life. To date, research on the association between mobility and quality of life has primarily focused in the elderly; hence, much less is known about this association in the near elderly. This cross-sectional study aimed to assess the association between mobility and quality of life measures in the near elderly.


A prospective observational study of persons aged 50–69 years was conducted. The primary endpoint was quality of life measured by EQ-5D-5L, and the primary explanatory variable was observed mobility assessed using the 6-minute walk distance (6MWD). We applied regression models controlling for demographic, health status and other factors to evaluate the association between 6MWD and EQ-5D-5L.


Of the 183 participants analyzed in the study, 37% were male and the average age was 59.8 years. After adjusting for differences in demographic characteristics and health status, EQ-5D-5L-based utility values were 0.046 points (p<0.001), or 5.2% (95% CI: 2.7% to 7.8%), higher on average for individuals with 100 meters longer 6MWD. Holding constant the mobility-specific component of EQ-5D-5L, we still found that walking an additional 100 meters was associated with an EQ-5D-5L utility value that was 0.029 points (p<0.001), or 3.5% (95% CI: 1.7% to 5.5%), higher than the average participant. Among persons with arthritis, the association between 6MWD and EQ-5D-5L was slightly stronger.


Near elderly persons with better mobility had higher quality of life. Diseases that decrease mobility, such as arthritis, are likely to have a significant impact on quality of life.


What do patients think about price shopping?

Written By: Jason Shafrin - Aug• 20•17

Initiatives such as high-deductible health plans (HDHPs) aim to transfer risk form insurers to patients. The rationale behind this risk transfer is that when patients are in control of more funds, there will be less moral hazard and patients will use health care resources more efficiently. That is the theory, but does it bear out in reality? A paper by Mehrotra et al. (2017) aims to answer this question. Using a survey of almost 3,000 non-elderly adults in the U.S., they find that:

The majority of respondents believed that price shopping for care is important and did not believe that higher-cost providers were of higher quality. Common barriers to shopping included difficulty obtaining price information and a desire not to disrupt existing provider relationships.

It will be interesting to see whether social norms around price shopping change if HDHPs continue to grab more market share.  In addition, patients often have limited information on provider quality, and because they often rely on these same physicians for referrals based on quality, price shopping may be counter-productive in the long-run if it decreases the chance that your current physician gives you a high quality referral.  However, tools that provide patients with information on provider prices did not have a measurable effect on health care spending.


Written By: Jason Shafrin - Aug• 17•17

The market works!

Written By: Jason Shafrin - Aug• 16•17

In 2011, CMS created a demonstration to have competitive bidding for durable medical equipment (DME).   Prior to the implementation of this program, CMS used an administrative fee schedule, similar to how physicians are currently reimbursed.  How did this market-based solution fare?  A paper by Newman, Barrette, and McGraves-Lloyd (2017) answers this question.

We compared prices from Round 1 of the Medicare competitive bidding program, which were established for the periods 2011–13 and 2014–16, to prices paid by national commercial insurers for the same types of items in 2011–14. Our results suggest that the initial years of the program produced prices comparable to those obtained, on average, by large commercial insurers—sophisticated purchasers that presumably were able to negotiate prices with suppliers of durable medical equipment and similar items.


Philipson to join CEA

Written By: Jason Shafrin - Aug• 15•17

The WSJ reports:

President Donald Trump named Tomas Philipson, an economist at the University of Chicago who has specialized in health-care policy, to the three-member Council of Economic Advisers on Monday.

More information is in this White House press release.  Dr. Philipson is one of the founders of my current employer, Precision Health Economics.   I wish Tomas the best of luck in his new endeavor.

Off-label use of cancer drugs

Written By: Jason Shafrin - Aug• 15•17

When each drug is approved by the FDA, the drug is not approved to treat all patients.  Each drug receives an “indication” which basically represents the types of patients the drug can treat.  Giving the treatment to patients with said indication is known as “on label” prescribing.

Drugs developed to treat one disease may sometimes be used “off label” to treat another disease.  In cancer treatment, for instance, in cases where there may be no effective treatments for a patient’s tumor, other cancer treatments may be used “off label” to treat this patient. It is often unclear whether “off label” drug use is inappropriate or not.

Smieliauskas et al. (2017) looks at off-label cancer drug use is a recent study by:

…we identified 41% of utilization of infused chemotherapies as being off‐label, including 29% of use deemed as appropriate off‐label use and 17% of utilization characterized as inappropriate off‐label administration under reference compendia over the 1999–2007 timeframe. We observed an overall declining trend from 1999 to 2007 for all three measures of off‐label use: overall, appropriate, and inappropriate use.

The authors define inappropriate off-label drug use as any use outside of those recommended by drug compendia, such as the National Comprehensive Cancer Network (NCCN).  The authors rely on a crude measure as some off-label uses may be helpful to patients if physicians have private information not available to health insurers or recorded in claims data that may make the off label treatment decision reasonable.

The authors also investigate whether state laws that mandate insurers to cover cancer treatments for off-label indications recommended by drug compendia.  They find:

…no discernible effect of the implementation of state laws to mandate coverage of off‐label use of cancer drugs on utilization in eight states that were late adopters of these mandates…Overall, these results suggest null to small effects on off-label utilization of the state laws passed during the time window of our analysis.

The authors are surprised by this small effect, but it could be the case that most private insurers already cover off-label use of cancer drug therapies included in these drug compendia.


Too many trials, not enough patients

Written By: Jason Shafrin - Aug• 13•17

As research in new cancer treatments has grown, scientists may have run into a serious roadblock: there many not be enough patients to fill the needed clinical trials.  As the New York Times reports:

There are too many experimental cancer drugs in too many clinical trials, and not enough patients to test them on. The logjam is caused partly by companies hoping to rush profitable new cancer drugs to market, and partly by the nature of these therapies, which can be spectacularly effective but only in select patients…

As a result, there are more than 1,000 immunotherapy trials underway, and the number keeps growing. “It’s hard to imagine we can support more than 1,000 studies,” said Dr. Daniel Chen, a vice president at Genentech, a biotechnology company.

In a commentary in the journal Nature, he and Ira Mellman, also a vice president at the company, wrote that the proliferating trials “have outstripped our progress in understanding the basic underlying science.”

“I think there is a lot of exuberant rush to market,” said Dr. Peter Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center. “And we are squandering our most precious resource — patients.”

While the limited supply of cancer patients available for clinical trials is a serious scientific problem, cancer patients should be excited that there is a significant investment in research and development to find cures for these same cancer patients.


Understanding The Value Of Innovations In Medicine

Written By: Jason Shafrin - Aug• 10•17

Health Affairs is holding an interesting event in September on “Understanding The Value Of Innovations In Medicine” at the National Press Club. They describe the event as follows:

Value” is at the center of discussions of payment and policy, but value has different definitions and meanings reflecting the diversity of stakeholders in the healthcare system. As part of our ongoing efforts to foster discussion about this important concept in health policy, on September 13 Health Affairs will sponsor a forum for policymakers to examine various frameworks for formally defining and measuring value and discuss the public policy issues and strategies attendant to their use.

You can see the full list of speakers, and RSVP for the event (or webcast) here.

The Stethoscope

Written By: Jason Shafrin - Aug• 10•17

The site 99% Invisible has an interesting post on the invention of the stethoscope had how it transformed medicine.

René Laennec actually felt that patient’s accounts of their own disease were still important, but the quest for objective information about disease was underway, and the stethoscope was just the beginning. Now we have X-rays, CT scanners and MRI and PET scans. All of these devices are basically trading upon the same paradigm that the stethoscope created: that doctors should be able to detect abnormalities inside the body to reach a diagnosis, regardless of how the patient is feeling.

At the same time, new diagnostic innovations are basically making the stethoscope part of the physician costume rather than a needed diagnostic.

Powerful imaging technologies like ultrasound have made the stethoscope exam less critical to the diagnostic process. Medical students aren’t as good as using stethoscopes as they used to be, and across the board doctors today rely less on the stethoscope to make diagnoses. The rise of portable ultrasound has some doctors arguing that we don’t need the stethoscope anymore… “It’s become almost a ritual more than an actual tool in terms of making diagnosis.”

Interesting throughout.

Should we put an end to Medicare Advantage?

Written By: Jason Shafrin - Aug• 09•17

Austin Frakt of the Incidental Economist argues convincingly–and I agree with him–that the answer is no.

Medicare Advantage plans have been found to be of higher quality than traditional Medicare. They also reduce wasteful use of health care by managing care, something the traditional program doesn’t do at all. Finally, they fill in gaps in coverage and cost sharing of the traditional program. They’re able to do so when the traditional program is not because changing traditional Medicare would require legislation, and it’s hard to achieve political consensus on anything in health care these days.

The bottom line is that Medicare Advantage plans offer choices that some beneficiaries value. They can deliver the Medicare benefit more efficiently and with higher quality. Yet, taxpayers do pay more to plans than they could, given plans’ own costs. Paying less might mean plans leave the market and that enrollees get less. There are always tradeoffs.

A longer piece on Medicare Advantage is published by Frakt in the New York Times.   Frakt’s article focuses mostly on the the current state of Medicare Advantage but does not fully capture the value of choice.

To consider the reason why choice is important, think about the decision to buy a car.  Let’s say that the Toyota Camry is the car that provides the best value for dollar.  Should we mandate that all people buy a Camry?  The answer is no.  Some people may prefer the less practical, but higher performance and higher cost Ferrari; others may prefer lower cost used cars.  In addition to the value of choice, having a private market for health insurance allows Medicare fee-for-service to compare its performance against private insurers.  If patients believe the quality of care they receive will decrease over time, they can shift to Medicare Advantage plans.  This choice value is difficult to quantify in a given year, but over time having options will likely lead to improved quality of care and insurance packages that better target patient demand.