Unbiased Analysis of Today's Healthcare Issues

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.


Depression Among the Elderly & Medicare Part D

Written By: Jason Shafrin - May• 19•15

How did the enactment of Medicare Part D affect the mental health of the elderly? This is the question Ayyagari and Shane attempt to answer in their recent JHE paper.

The authors use data from the Health and Retirement Study (HRS) between 2010 and 2010 to measure changes in depressive symptoms among patients aged 60-70. The key endpoint of interest is an abridged version of the Center for Epidemiologic Studies (CESD) scale. HRS has detailed measures of mental health, demographic, and socioeconomic variables, it does not include detailed information on prescription drug use or spending. To address this shortcoming, the authors also use the Medical Expenditure Panel Survey (MEPS).

In the baseline specification, the authors use a difference-in-difference approach to measure difference CESD levels between 65-70 years olds and 60-64 year olds before and after 2006 (when Medicare Part D was implemented). The authors also use an IV approach. The measure whether or not the individual had prescription drug coverage and use whether the person was age ≥65 after 2006 as an instrument for prescription drug coverage.

The authors found the found that depressive symptoms among the elderly decreased significantly after the introduction of Medicare Part D.

Using our preferred specification, we find that Medicare Part D resulted in a 14.8% decline in depressive symptoms and a 21.2% decline in the likelihood of experiencing 3 or more depressive symptoms…our estimates are comparable to estimates from prior studies on the relationship between insurance coverage and mental health.

Increasing insurance coverage does increase premiums, but it also improves access to care and–at least in the case of mental health–dramatically improves patient outcomes.


ACA and Commercial Underwriting

Written By: Jason Shafrin - May• 18•15

The ACA (aka Oabamacare) has a “guaranteed issue” provision that requires insurers to offer coverage to all individuals who apply.  The ACA also prohibits insurers from taking into account patients’ pre-existing conditions when setting premiums and mandates the coverage of certain services, such as preventive services and an annual check-up.

This sounds like a great idea.  Everyone can get insurance; sick people don’t cost more; and everyone gets lots of benefits.

However, this poses a significant challenge for insurers. InsureBlog writes:

“The guaranteed-issue aspect of the ACA essentially negates underwriting,” Stark said, referring to Obamacare rules requiring health insurers to allow anyone to enroll, even if they’re already sick. “Health insurance companies have struggled with plan pricing for the past few years because they now must sell to anyone, regardless of preexisting conditions.

Thus, insurers must set premiums based on the average cost of insuring a large group of people without knowing the composition of people who make up their group of enrollees. An alternative to the ACA–from the Best of Both Worlds proposal–would allow insurers to set premiums that reflect their true health care costs. To ensure premiums are affordable, this proposal proposes subsidies to the poor, especially the sick poor.

Although the ACA does lower premiums for the sickest individuals, moving away from market prices is likely to have problematic long-run consequences.

Links to start the week

Written By: Jason Shafrin - May• 17•15