Unbiased Analysis of Today's Healthcare Issues

Obamacare in Mississippi

Written By: Jason Shafrin - Jun• 03•15

An interesting article from Politico shows that Mississippi was instituting a program—known as One Mississippi—that would allow small businesses employees to come together to purchase insurance at lower rates. It was seen as a conservative politically as it helped those who were working to access healthcare. This is exactly what one of the provisions of the Affordable Care Act did.   However, support for “Obamacare” was low.

But the Affordable Care Act had descended on Mississippi like so many prior federal edicts: as an invasion from the North that fractured along racial lines, stoking long-held grievances against the federal government…There is a stark racial disconnect between the Tea Party’s ascendant politics—and its almost exclusively white leadership—and the state’s black voters, who vote overwhelmingly Democratic. Whites dominate Mississippi’s elected elite, despite the fact that Mississippi is home to a higher percentage of African-Americans—37 percent—than any other state.

When ACA did come to Mississippi, the options weren’t particularly attractive for residents.

Still, when the federal website, HealthCare.gov, made its disastrous debut on October 1, just four counties had two insurers competing for business; the rest had only a single choice…By December 2013, the scope of Mississippi’s disaster had a number: A grand total of 802 people in the state had signed up for Obamacare.

$15 minimum wage and health insurance

Written By: Jason Shafrin - Jun• 01•15

Typically most workers want more money.  In the case of one man, however, an increase in the minimum wage may force him to work less.

At $15 an hour, his annual income would become too high to qualify for CountyCare under the current income limit. So any salary gains could be wiped out by the price of his medications and supplies, including two kinds of insulin at $403 a month and drugs to control high cholesterol and blood pressure that add an extra $330 a month…

At $15, he figures he’d need to reduce his total work hours to ensure his new income didn’t disqualify him from his current benefits.

Although giving health insurance benefits to the poor improves equality in the nation, taking away these benefits using a means test creates a perverse incentive to work less. Clearly, government benefits need to be structure to incentivize people to work more, not less.

ASCO Poster

Written By: Jason Shafrin - May• 31•15

Tomorrow I will be presenting a poster on “How well do surrogate endpoints and overall survival endpoints in clinical trials predict real-world survival?”at the American Society of Clinical Oncology (ASCO) conference.  Below is the poster information if anyone wants to stop by.  You can download the poster HERE.

  • Session Title: Poster Session: Health Services Research and Quality of Care
  • Session Date, Time, Location: 6/01/15, 1:15-4:45; McCormick Place: S Hall A
  • Abstract ID: 6574
  • Abstract Title: How well do surrogate endpoints and overall survival endpoints in clinical trials predict real-world survival?
  • Poster Board #: 131

Patient adherence to antipsychotic medications

Written By: Jason Shafrin - May• 31•15

Patients with schizophrenia often require medication—such as antipsychotics—to control the symptoms of their disease. However, adherence to these medications has been poor. Valenstein et al. (2004) estimate that 40% of patients are non-compliant with therapy [i.e., mediation possession ratio (MPR)<0.8].

Why are schizophrenia patients likely to be non-complient to antipsychotic therapy?

One key reason is side effects. Extrapyramidal symptoms, postural hypotension, sedation, anticholinergic side effects and weight gain are all common side effects. Additionally, patients may become non-adherent if their copays are significant. Others may not have insight into their disease and may believe that the medications are unnecessary.

Who is likely to be non-compliant?

A study by Higashi et al. (2013) found that patients who lacked insight into their disease, and who were substance abusers were less likely to be adherent. Unsurprisingly, patients who have been adherent to their medications in the past are more likely to be adherent to their medications in the future. Patients who believe ex ante that the medication was unlikely to be effective were less likely to be adherent.   In fact, Gibson et al. (2013) found that 54% reported intentional non-adherence and 29% of patients who were non-adherent were “satisfied with being so.” As some of the antipsychotics produce lethargy, patients may miss does when they want an energy boost. One patient stated “I had a meeting at work the next day so skipped my evening dose.”

A study by Valenstein et al. (2004) found that patients who are younger or African American are less likely to be compliant. Higashi et al. (2013), however, notes that other studies do not show any relationship between sociodemographic factors and adherence. Further, patients who receive a high dose therapy may be non-compliant. The causation between non-adherence and high dose therapy is unclear. Non-adherence may increase the likelihood of a high dose; if patients are non-adherent, therapy will be ineffective and physicians may try to address this lack of effectiveness by increasing the dose. Alternatively, increasing the dose may increase side effects that may lead patients to discontinue therapy. Patients on atypical antipsychotics may have better adherence. Valenstein et al. (2004) found that overall adherence rates were similar between patients who use conventional and atypical therapies; however, patients who use atypicals may represent more serious cases. The authors found that patients who switch from conventional antipsychotics to atypicals improve adherence whereas those who switch from atypicals to conventional antipsychotics experience a decrease in adherence.

Do patients report adherence information to doctors accurately?

Sometimes yes, sometimes no. Gibson (2013) reports that one patient stated “I told the Dr the symptoms but wasn’t honest about what medication I was taking less of.” Some patients don’t report non-adherence for fear they will be taken off the medication or they feel ashamed.

Weekend Links

Written By: Jason Shafrin - May• 29•15

Fish and Economics

Written By: Jason Shafrin - May• 28•15

Form a paper in Nature:

Noë, a primate behavioural ecologist now at the Hubert Curien Multidisciplinary Institute in Strasbourg, France, had come up with a biological market-based theory of cooperation. It proposed that animals cooperate to trade a specific commodity — such as food — for a service that would promote their survival, such as protection from a predator.

‘Cleaner’ fish, such as the brightly striped wrasse, will nibble parasites off the skin of ‘client’ fish in small coral territories known as cleaning stations…

While racking up evidence for the market theory, Bshary also observed a range of other social behaviours that had never been seen before in fish. He saw that unsatisfied clients sometimes punish cheating cleaners by chasing them around, and that this punishment makes these fish less likely to cheat. He saw cleaners ingratiating themselves with certain clients: they gave preference to visiting fish such as groupers, rather than the smaller, local fish that did not have the option of going elsewhere. He found that the cleaners cheated less when they were being watched by other potential clients — a sign that they were buffing their reputations. And he saw reconciliation: if cleaners behaved badly, they then massaged the backs of offended clients with their pelvic fins.

As Tyler Cowen says, Markets in everything.

Medicaid Expansions and Crowd Out

Written By: Jason Shafrin - May• 26•15

Most previous research into Medicaid expansions focus on extending coverage to pregnant women or children. However, a recent Section 1115 waiver allows for researcher to examine what happens when Medicaid coverage is extended to a larger share of adults. This is exactly what a paper by Atherly et al. (2015) examines:

…prior to ACA adults generally have not been eligible for Medicaid. One exception is the Health Insurance Flexibility and Accountability (HIFA) initiative, which extended Medicaid coverage to a variety of typically ineligible populations and explicitly allowed the inclusion of childless adults, offering new opportunities to explore crowd-out…HIFA targeted individuals with incomes below 200 percent of the federal poverty level

Did HIFA give insurance to the uninsured or were people switching from commercial plans to HIFA? Based on a survey of almost 800 individuals, the authors find that:

Most HIFA enrollees (91 percent) reported being uninsured prior to participation
in HIFA. Of those who were uninsured, most reported having been
uninsured for an extended time…Prior to joining HIFA programs, a large share of enrollees had been without health insurance for more than a year (59 percent in NM and 69 percent in OR) or had never had health insurance (16 percent in NM and 9 percent in OR).


What are “conditions specific to military service”?

Written By: Jason Shafrin - May• 25•15

Just before Memorial Day, a Maryland congressman recently proposed shrinking the scope of services the VA provides to veterans.   How would he do this? He proposes a model:

…where the VA is not the place of general health care for the veterans, but the place of highly-specialized care where skilled professionals are particularly well-equipped to deal with issues that veterans have based on their service. But then for routine care, the veterans might prefer to just access the general health care system,” Rep. John Delaney (D-Md.) said on the Federal Drive with Tom Temin.

The question is, what is a military-related condition. PTSD is clearly linked to medical service, but what about depression. Many people have major depressive disorder who are not in the military and it is unclear whether or not this would be covered. Further, for a patient with mental health issues and other conditions (e.g., diabetes, cardiovascular disease), would they need to work with two different health systems to treat their different diseases? Where would the line be drawn.

Health care is moving towards more integrated care. While allowing for specialization does clearly offer some benefits, the logistics for implementing this type of programming would be challenging to say the least and could place more burden on veterans to navigate a more complex web of health insurance coverage.

End of week links + HWR

Written By: Jason Shafrin - May• 21•15

…plus a pre-Memorial Day Edition of Health Wonk Review at Workers Comp Insider.


The Placebo Blocker

Written By: Jason Shafrin - May• 20•15

Courtesy of xkcd.