Unbiased Analysis of Today's Healthcare Issues

The Standard Gamble

Written By: Jason Shafrin - Dec• 22•14

One concept often used in healthcare is the quality-adjusted life years (QALY).  The concept is fairly simple.  It assumes that people value one year of life in perfect health at 1; people who die have a value of a life year of 0.  One year of life where you have 50% health is then valued at 0.5.

The question is, how do you determine what share of a life year different health states are.  What share of a life year do I value if I break my arm?  What if I am paralyzed?

One approach to quantifying the value of different health states is through a standard gamble.  Hammitt et al. (2012) describes how this is calculated. The standard gamble gives people two option. One option is living for t years in health state h.  For instance, one could live for 5 years with a broken arm. In the second option, the patient has a probability p of living t’ years in perfect health (i.e., h=1) or immediate death (i.e., t”=0).

The goal of the standard gamble is to determine the value of p.  If a patient prefers to live for 10 years with a broken arm compared to 5 years in perfect health, but would prefer to live 5 years in perfect health to 9 years and 11 months with a broken arm, then, the value of is 0.5.  In essence, 0.5 years of perfect health is equivalent to 1 year with a broken arm.  Thus, the value of a QALY with a broken arm (in my simple and very unrealistic example) is 0.5.


How did Obamacare affect Medicaid enrollment?

Written By: Jason Shafrin - Dec• 21•14

The Affordable Care Act (ACA) contained the provision requiring States to significantly expand Medicaid eligibility. The Supreme Court, however, ruled that states had the option of implementing this provision.  Thus, the change in Medicaid eligibility and subsequent enrollment varied significantly across states based largely on whether or not they were an expansion state.  A recent PwC study finds that Nevada, Oregon and Colorado had the largest percentage increase (all >50%), but three states Alaska, Missouri, and Georgia actually experienced decreases in Medicaid enrollment.


Overall, 3/50 states experienced a decrease in enrollemnt, 4/50 states experienced no change, and 43/50 experienced an increase in Medicaid enrollment since 2013. In fact, 27/50 states experienced an increase in Medicaid enrollment of 10% of more.

Public Employee Health Insurance Data Sources

Written By: Jason Shafrin - Dec• 18•14

What data sources are available to measure active and retired public employees health insurance?  A study by Morrill (2014) outline several data sources that identify federal, state, and local government employees to answer this question.  The following tables are excepted from her article.




Health Wonk Review Holiday Edition

Written By: Jason Shafrin - Dec• 18•14

The always insightful Julie Ferguson of Workers’ Comp Insider hosts a holiday  edition of the Health Wonk Review.  Check it out.

Insurance does not equal health care

Written By: Jason Shafrin - Dec• 15•14

One part of the Affordable Care Act extended Medicaid benefits to millions of Americans.  One problem, however, is that patients with Medicaid insurance often have trouble finding doctors who will treat them.  The New York Times reports:

Large numbers of doctors who are listed as serving Medicaid patients are not available to treat them, federal investigators said in a new report.

“Half of providers could not offer appointments to enrollees,” the investigators said in the report, which will be issued on Tuesday.

Many of the doctors were not accepting new Medicaid patients or could not be found at their last known addresses, according to the report from the inspector general of the Department of Health and Human Services. The study raises questions about access to care for people gaining Medicaid coverage under the Affordable Care Act…

“For example,” the report said, “a number of obstetricians had wait times of more than one month, and one had wait times of more than two months for an enrollee who was eight weeks pregnant. Such lengthy wait times could result in a pregnant enrollee receiving no prenatal care in the first trimester of pregnancy.”

Just having insurance is not enough. The insurance must be sufficient that physicians are actually willing to treat the patient.

Friday Links

Written By: Jason Shafrin - Dec• 11•14

Cavalcade of Risk #223

Written By: Jason Shafrin - Dec• 10•14

Bob Wilson of Workers’ Comp Insider presents this week’s rockin’ and rhymin’ risky roundup of risk-related posts. Clever *and* informative – that’s what I call win-win.

Germs and Quality Improvement

Written By: Jason Shafrin - Dec• 10•14

Medicare has stopped paying for care related to surgical site infections. Further, it fines hospitals whenever too many patients need to be readmitted within 30 days of discharge. How is this affecting care at the physician and patient level? As Karen Sibert writes, some odd things are happening:

An edict just came down in one big-city hospital that all scrub tops must be tucked into scrub pants. The “Association of periOperative Registered Nurses” (AORN) apparently thinks that this is more hygienic because stray skin cells may be less likely to escape, though there is no data proving that surgical infection rates will decrease as a result…One OR supervisor stopped an experienced nurse and told to tuck in her scrub top while she was running to get supplies for an emergency aortic repair, raising (in my mind at least) a question of misplaced priorities.

Improving quality of care and reducing infections is important. Achieving this goal using evidence-based, practical rules, however, is equally important.

Top Health Industries Issues for 2015

Written By: Jason Shafrin - Dec• 09•14

What are the top health industry issues for 2015?  A PwC report believes the following 10 issues should top the list:

HRI’s top 10 issues for the health industry in the year ahead:

  1. Do-it-yourself healthcare. U.S. physicians and consumers are ready to embrace a dramatic expansion of the high-tech, personal medical kit. Wearable technology, smartphone-linked devices and mobile apps will become increasingly valuable in care delivery.
  2. Making the leap from mobile app to medical device. A proliferation of approved and portable medical devices in patients’ homes, and on their phones, makes diagnosis and treatment more convenient, redoubling the need for strong information security systems.
  3. Balancing privacy and convenience. Privacy will lose ground to convenience in 2015 as patients adopt digital tools and services that gather and analyze health information.
  4. High-cost patients spark cost-saving innovations. The soaring cost of care for Medicare and Medicaid “dual eligibles,” aging boomers and patients with co-morbidities will foster creative care delivery and management systems.
  5. Putting a price on positive outcomes. With high-priced new products and specialty drugs slated to hit the market in 2015 increasing demand for new evidence and definitions of positive health outcomes are expected.
  6. Open everything to everyone. New transparency initiatives targeting clinical trial data, real-world patient outcomes and financial relationships between physicians and pharmaceutical companies will improve patient care and open new opportunities.
  7. Getting to know the newly insured. 2015 will be a revelatory year for the U.S. health sector as a portrait of the newly-insured emerges, fostering better care management programs and shifting marketing strategies.
  8. Physician extenders see an expanded role in patient care. Physician “extenders” are becoming the first line of care for many patients, as doctors delegate tasks, monitor patients digitally and enter into risk-based payment models.
  9. Redefining health and well-being for the millennial generation. As the economy rebounds and baby boomers retire, employers and insurers look for fresh ways to engage, retain and attract the next generation of health consumers.
  10. Partner to win. In 2015, joint ventures, open collaboration platforms and non-traditional partnerships will push healthcare companies out of the comfort zone toward new competitive strategies.

Do quality rankings matter?

Written By: Jason Shafrin - Dec• 07•14

There have many policy initiatives to measure and improve quality of care.  For instances, NCQA’s HEDIS measure are the most widely used quality measures among commercial insurers.  Since employers generally choose insurance plans for employees (or at least select the menu of insurance options for employees), one would expect that employers would look for high quality, low-cost plans when evaluating their plan choice.  Employers may value “quality” but likely do not do so in an objective fashion.  A recent report from RWJ finds:

  • Six in 10 employers offering insurance think plan quality ratings are important, but 9 in 10 are unfamiliar with objective quality metrics.
  • When selecting health plans, employers’ top consideration is their own bottom line, but the cost to their employees is also important.

Unsurprisingly, cost to employers is the key factor when choosing an insurance plan.  Employers themselves may engage in improving the health of their employees, but these activities typically do not draw much attention.

  • Although half of employers (50 percent) offer some sort of wellness program to their employees, fewer (24 percent) have any promotion strategy for those programs.