- How high are adverse events rates?
- Do MTM work?
- Immigration status and the ACA.
- Factors NICE considers when making health technology appraisals.
- How expanding Medicaid affects the use of inpatient & ER sevices.
What is digital health? Although a single definition is hard to fine, digital health uses data collected from patients to improve care. Mobile health, the use of electronic medical records, the “quantified self” movement and various forms of health information technology all count as digital health.
Is digital health just a fad or will it revolutionize health care? If you look where the money is going, a good bet is on the latter. WonkBlog reports:
Companies in the Big Data and analytics space are the biggest fundraisers this year, with 77 deals totaling $1.17 billion, according to StartUp Health. That’s followed by companies that help navigate the health-care system (40 deals, $794 million) and practice management (26 deals, $598 million).
This isn’t just a San Francisco phenomenon either, though that city leads the country in digital health funding this year (62 deals, raising $948 million). It’s followed by New York ($584 million, 33 deals) and the D.C./Maryland area ($536 million, 14 deals).
The question seems now whether or not digital health will be the wave of the future, but rather exactly how it will affect the care provided to patients in the US and around the world.
Typical hours when illness strikes is 24 hours a day, 7 days per week. In the US, typical physician hours are 9-5, Monday through Friday.
Although this is changing (CVS Minute Clinics have Saturday and Sunday hours), it is still difficult for individuals who are work and are ill to see a doctor without taking time off for work.
In England, however, this may no longer be an issue. The UK’s National Health Service is planning a pilot program where patients will have access to primary care physicians 7 days per week. Pharmafile reports:
Cameron says: “People need to be able to see their GP at a time that suits them and their family. That’s why we will ensure everyone can see a GP seven days a week by 2020. We will also support thousands more GP practices to stay open longer – giving millions of patient’s better access to their doctor.”
The plans are part of a new GP contract to be announced later today. In April the government launched a £50m pilot scheme where practices in nine key areas of England were able to bid for money in order to open from 8am to 8pm seven days a week, in addition to offering Skype consultations.
Despite these plans, fewer physicians in the UK are going into primary care. Thus, will the UK have the staff to fulfill these promises? Will it have the budget since these doctors likely would require salary increases to work nights and weekends?
Politico.com has an interesting series of articles titled Obamacare 2.0, which examines different perspectives on how to improve the Affordable Care Act. One common theme in about half the articles is that the ACA does not do enough to cut healthcare spending.
The rise in healthcare spending over the past few decades has been significant. In 1995, 13.6% of the economy went to healthcare. By 2012, this figure had climbed to 17.9%. The CBO projects that federal spending on Medicare, Medicaid, CHIP and health insurance exchange subsidies will rise by 85% between 2014 and 2024. Further, 22% of the federal budget goes to Medicare, Medicaid and CHIP, and this figure will only rise as the baby boomers retire.
Those who focus on cost control have a valid point which cannot be discounted, especially as it relates to the fiscal solvency of the federal government.
On the other hand, consider where else you would want to spend your money besides healthcare. In 1995, per capita GDP in the US was $28,782. By 2012, this figure had risen to $51,755. In other words, each person saw an increase of $22,973 in income on average. Of this increased income, $5,353 went to healthcare and $17,620 went to non-healthcare items.
Ignoring issues of the unequal distribution of income, one might think that by 1995 the US had sufficient income to cover the basic needs (e.g., clothing, food, housing) for all its citizens. If this is the case, then how would you rather spend your money? Nicer cars? Bigger houses? Better education? Certainly. However, many believe that healthcare is a luxury good and that as society’s income increases, society and individuals become more willing to pay a larger share of their income towards healthcare. Life is short and one cannot enjoy and of the aforementioned luxuries if you are not alive and healthy.
To put the increase in health spending another way, in essence, society got a 3.5% raise every year between 1995 and 2012 and we decided to spend 23 cents of every dollar of that raise on health care and 77 percent of the raise on everything else.
That doesn’t sound like too crazy a breakdown to me.
How do reimbursement rates affect quality? One school of thought holds that decreased reimbursement decreases quality in the short-run and decreases innovation in the long-run. Another school of thought believes that there is so much inefficiency in the health care system, that reducing reimbursement rates will have no affect on quality. Which answer is correct?
A study by Wu and Shen (2014) aims to answer this question by examining the long-run impact on quality of the reimbursement rate reductions from the Balanced Budget Act of 1997 (BBA). Why is the BBA so important?
With the exception of the Prospective Payment System (PPS), the BBA is the only legislation that reduced Medicare inpatient payments in nominal terms, rather than just slowing down the growth rate. Second, BBA payment cuts could have a long-lasting effect on hospitals because the legislation not only reduced diagnosis-related group (DRG) payment levels between 1998 and 2002 but also permanently altered the formula for special add-on payments [i.e., DSH and IME payments]…Third, Medicare BBA reductions occurred after a sustained period of declining inpatient admissions and lengths of stay, as well as aggressive payment negotiations from managed care plans (Wu 2009) that limited hospital ability to cost shift to private payers.
Using MedPAR data between 1995 and 2005, the author uses a DDD design. They compare “…the relative change in mortality trends between large- and small-cut hospitals before and after the BBA.” They find that:
…the BBA generated long-term financial pressure to hospitals that extended beyond the BBA implementation period. While there is a general declining trend in AMI mortality rate, Medicare patients treated at hospitals facing a large degree of such fi nancial pressure experienced smaller improvement in mortality outcomes relative to patients treated in small-cut hospital, not in the short run, but in the longer run post-BBA period. The elasticity of the effect, while small ( 0.2), is constant and consistently observed from 7-day to 1-year post hospitalization…hospitals responded to BBA cuts by reducing operating costs per bed immediately after the BBA took effect, and such effort involved a reduction in staffing, particularly among registered nurses.
How can you compare how similar two rankings are. For instance, US News and Consumer Reports may both rate hospitals. If they have identical ratings, then they are obviously the same. However, what if the rankings differ for 2 hospitals? For 4 hospitals? How can one quantify the similar of rankings?
One method for doing so is Kendall’s W (or Kendall’s coefficient of concordance). Kendall’s W is a not parametric measure of how similar two or more rankings are. Whereas the Spearman rank correlation measures the similarity of any two sets of rankings, Kendall’s W can be used to measure similarity for more than two raters.
A common heuristic for judging Kendall’s W is the following:
Do demonstrate how to use Kendall’s W, I look at last year’s college basketball rankings. I choose the top 5 teams according to the AP poll and see how other polls (RPI and Ken Pomeroy’s rating) would rank these same teams. You can see the calculations of Kendall’s W for this example HERE.
How do policymakers increase the speed of healthcare innovation in the US? A 2014 report by RAND gives five proposals which I list below with my own commentary.
In summary, I believe the RAND propositions will have a small effect on innovation. Reducing barriers to entry by speeding up FDA review and increasing basic science fund would clearly improve innovation. Creating prizes, buying out patients, or creating a government investment fund would likely work in selected cases, but they will not have a major impact on innovation.