Health Care Policy


Next Steps for Federal Health Reform

Incoming Harvard Kennedy School dean shares recommendations at Seidman lecture


Unless those who object to the Affordable Care Act are willing to put forth an alternative with comparable information about its effects on spending and access to care, then the huge amount of time that has been devoted to the ACA debate should be used for more constructive policymaking.

This was the theme at the 15th annual Seidman Lecture at Harvard Medical School on Nov. 2, delivered by the next dean of the Harvard John F. Kennedy School of Government, Douglas Elmendorf.

“We have a lot to do, and we should get going,” Elmendorf said.

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Elmendorf drew upon his vast experience to share his analysis of the Affordable Care Act and his recommendations for next steps for federal health care policy. In addition to heading the Congressional Budget Office from January 2009 until March of this year, Elmendorf spent much of his prior professional career at the Federal Reserve Board, the Council of Economic Advisers and the Treasury Department

Elmendorf is currently serving as a visiting fellow at the Brookings Institution. He was named to head the Harvard Kennedy School in June and will assume that role in January 2016.

The audience for the Seidman Lecture included leading scholars in health policy from HMS, the Harvard T.H. Chan School of Public Health, the Harvard Kennedy School and the Harvard Faculty of Arts and Sciences, as well as physicians and leaders from Harvard-affiliated and other Boston area hospitals.

“The incoming dean was able to weave together judgments related to value and critical analysis in his review of the ACA,” said Barbara McNeil, Ridley Watts Professor of Health Care Policy and head of the HMS Department of Health Care Policy, in an interview after the event.  “HMS was pleased to be the first school at Harvard to introduce him to this distinguished community.”

Assessing the state of federal policy

“In my view, the system of rules and subsidies established by the ACA is the right system in its fundamental elements, although we could discuss the pros and cons of specific changes within that system,” Elmendorf said.

His view was based on two judgments. “The first is a value judgment—I think we should bear the cost of achieving nearly universal health insurance in this country,” he said, “and the second is an analytic judgment—there are no alternatives to the ACA framework that would achieve that goal at significantly lower cost.”

Elmendorf made recommendations for changes to federal health care policy that he said could potentially further reduce spending and improve the value of care, including incentives to limit the use of unduly expansive health insurance, payment reforms for Medicare, and efforts to make markets for health care and health insurance more competitive. 

“This was a remarkably clear, comprehensive assessment of where the American health care system is—the challenges it faces and how it might address those challenges,” said Michael Chernew, Leonard D. Schaeffer Professor of Health Care Policy at HMS, in an interview after the event.

In 2000, on the occasion of his 50th reunion from Harvard Law School, Marshall J. Seidman provided endowment support to the Harvard Medical School Department of Health Care Policy to support research related to health care costs and quality and to host an annual meeting by a leading policy maker on issues related to costs and quality of health care with a particular emphasis on activities that are most likely to impact on federal and state approaches to these problems. The department has sponsored the lectures yearly since 2001.


Does Defensive Medicine ‘Work’?

Higher-spending doctors face fewer lawsuits

Higher-spending physicians face fewer malpractice claims, a study led by researchers at Harvard Medical School has found.

Nearly three-quarters of physicians report practicing defensive medicine, which is broadly defined as the ordering of tests, procedures, physician consultations and other medical services solely to reduce risk of malpractice claims. Defensive medicine is estimated to cost the U.S. as much as $50 billion annually.

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Despite its ubiquity among physicians, whether or not higher spending by physicians actually reduces malpractice claims is unknown. One view is that better communication and early apologies for errors can reduce a physician’s liability. However, greater spending by physicians could also either reduce errors or signal to patients, attorneys and courts that despite an error, a physician was exhaustive in his or her care.

The research was led by Anupam Jena, associate professor of health care policy at Harvard Medical School and an internist at Massachusetts General Hospital. The findings, published in the BMJ, combined data on 18,352,391 hospital admissions in Florida during 2000-2009 with data on the malpractice histories of the 24,637 physicians who treated patients during those hospitalizations. Overall, 4,342 malpractice claims were filed against physicians (2.8 percent per physician-year), with malpractice claims rates ranging from 1.6 percent per physician-year in pediatrics to 4.1 percent per physician-year in general surgery and obstetrics and gynecology.

Jena and colleagues at the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California and at Stanford University found that in six out of seven specialties, higher-spending physicians faced fewer malpractice claims, accounting for differences in patient case-mix across physicians. 

For example, among internal medicine physicians, those in the bottom 20 percent of hospital spending (approximately $19,000 per hospitalization) faced a 1.5 percent probability of being involved in an alleged malpractice incident the following year, compared to 0.3 percent in the top spending quintile (approximately $39,000 per hospital admission).

Similar findings were seen in C-section rates among obstetricians. High C-section rates are commonly considered a signal of defensive practice, and obstetricians who performed relatively more C-sections were less likely to face a malpractice claim.

“It has remarkably been unknown whether defensive medicine ‘works’ or whether the majority of U.S. physicians could be incorrect in believing that greater spending is associated with reducing malpractice liability,” said Jena.

Prior work by Jena and co-author Seth Seabury, a Fellow at the Schaeffer Center and associate professor of clinical emergency medicine at the Keck School of Medicine at USC, has found that the typical physician spends nearly 11 percent of their career with an open malpractice claim and that in high-risk specialties, the lifetime risk of being sued is nearly 100 percent.

“The threat of malpractice is a very salient risk for most practicing physicians, particularly in high-risk specialties,” Seabury said. “If physicians perceive that higher spending can protect them from malpractice claims, then they are likely to practice defensively even if they feel that the additional spending is unnecessary or offers no clinical benefits to patients.”

An important limitation of the study is that it could not conclude exactly why greater spending by physicians was associated with fewer malpractice claims. Moreover, whether higher levels of spending were defensively motivated by malpractice concerns is still unknown.

“Although not conclusive, our study provides initial evidence on why efforts to reduce health care spending among physicians may meet sluggish opposition. Physicians may perceive a potential tradeoff between lowering spending and increasing risk of malpractice,” Jena said. “Broader health care reform efforts should recognize the role that physician perceptions about malpractice play in resource utilization decisions.”

The study was funded by an Early Independence Award 1DP50D017897-01 from the National Institutes of Health.



Paying for Health Care with Time

Hidden aspect of health care falls disproportionately on the disadvantaged

In 2010, people in America spent 1.1 billion hours seeking health care for themselves or for loved ones. That time was worth $52 billion.

“That’s about the same as all of the time worked in a year by the entire working population of the city of Dallas,” said Ateev Mehrotra, associate professor of health care policy and medicine at Harvard Medical School.

Mehrotra is a lead author of two studies published this fall that measure the amount of time patients spend seeking care; calculate the total time costs to society; and analyze the difference in time burden by race, ethnicity and socioeconomic status.

How much is the time spent obtaining health care worth, and who pays the most? Video: Hannah Semigran.

Writing in the American Journal of Managed Care, the researchers reported that the average total visit time for a person seeking care for themselves, a child or another adult was 121 minutes. That total includes 37 minutes of travel time and 84 minutes in the clinic. Of those 84 minutes, people spent only 20 minutes with physicians; they spent the rest of the time waiting, interacting with nonphysician staff, or completing paperwork or billing.

Economists calculate the value of time spent doing an activity—known as opportunity cost—based on the income that an individual would earn working the same amount of time. The researchers calculated that the average opportunity cost per visit was $43, compared to an average out-of-pocket cost per visit of $32.

“We also found that this time burden fell disproportionately on the disadvantaged,” said Kristin Ray, assistant professor of pediatrics at University of Pittsburgh School of Medicine.

Writing in JAMA Internal Medicine, the researchers reported that, while all groups spent the same 20 minutes face-to-face with physicians, blacks and Hispanics spent approximately 25 percent longer when seeking health care than whites, due to increased travel, wait and administrative times. Lower-income groups and the unemployed also spent more time seeking care than their better-off counterparts.

“Typically, when we talk about how much we spend on health care, we focus on what is paid to doctors and hospitals through co-pays and insurance payments,” said Mehrotra, who is also a physician and HMS professor medicine at Beth Israel Deaconess Medical Center. “This work helps us put a dollar amount on the significant time it costs people to seek health care.”

The researchers said that it is important to consider time costs when evaluating innovative treatment and care delivery models designed to create higher value, more patient-centered care and to reduce health care disparities. They noted that many initiatives currently underway might offer considerable benefits in reducing the time-cost burden of health care. These initiatives include streamlining office visits; incorporating clinics into schools, community centers, and places of work; and using new models of care delivery, such as telemedicine visits, e-visits and other Internet-powered medicine.

The researchers combined data from several sources to calculate time spent in transit, at the clinic and with clinicians face-to-face. One key resource was the American Time Use Survey, which ties detailed reporting about how respondents spend their day in a given 24-hour period with demographic and income information.

These studies were supported in part by grants from the California HealthCare Foundation, the Health Resources and Services Administration National Research Service Award for Primary Medical Care, the Agency for Healthcare Research and Quality, and the National Institutes of Health.


Equity Gap

Women face challenges becoming full professors at U.S. medical schools

Women physicians are substantially less likely to be full professors than men of similar age, experience, specialty and research productivity.

With recent increases in the number of women attending medical school, women now comprise nearly half of all new physicians. But the proportion of women at the rank of full professor at U.S. medical schools has not changed since 1980, despite efforts to increase equity, according to a new research study led by Anupam Jena, associate professor of health care policy at Harvard Medical School. The results are published today in JAMA.

“Many people have opinions about why women in medicine are less likely to be promoted than men,” said Jena, who is also a physician at Massachusetts General Hospital. “We're trying to separate fact from conjecture by using detailed data.”

Taking advantage of a database from Doximity, a commercial social networking service for physicians containing professional data from more than a million doctors and more than 90,000 U.S. medical school faculty members, the researchers were able to analyze data from state licensing boards, Pub Med and other sources, which was compiled by the company and verified by registered users.

Many theories exist to explain the persistent gap between male and female promotions, Jena said, including suggestions that women are promoted less often because they take time off from their careers during childbearing, that they choose specialties that offer fewer opportunities for promotion, or that they are less productive because, on average, they make different work-life choices than men.

It is also thought that the pre-existing shortage of senior women faculty members may make it hard for young women trainees to find mentors. These and other factors, the thinking goes, might make women less productive than men, and therefore, less likely to be promoted in a system that rewards research productivity.

Jena and colleagues wanted to see what the numbers said.

First, they found that there were some significant differences in productivity. Women averaged fewer total publications than men (on average, 11.6 publications for women vs. 24.8 publications for men) and fewer papers on which they were the first or last author (5.9 first or last authorships for women vs. 13.7 for men). They were also less likely to have NIH grants (6.8 vs. 10.3) or to have led large clinical trials (6.4 percent vs. 8.8 percent).  But most of these differences stemmed from the fact that female faculty were younger, on average, than male faculty.

When the researchers looked at women and men with identical age, experience and research productivity, they found that women were nearly 13 percent less likely to be full professors than their male peers.

Answering the question of equal pay for equal work is challenging across professions, Jena noted, because it can be difficult to find big data sources with good measures of productivity. Since research productivity is the major currency of success in academic medicine, the number of papers, grants and clinical trials serve as an objective measure to compare the output of individuals of different sexes.

“What we see here is that women and men doing equal work are not being equally rewarded,” Jena said. “If the goal is to achieve equity, or to give incentives for the best researchers to stay in academic medicine, we need to work on closing that gap.”

Listen to JAMA's author interview with Anupam Jena.

This research was funded by the Office of the Director, National Institutes of Health (NIH Early Independence Award, 1DP5OD017897-01).


Rating Readmissions

Hospitals penalized for serving vulnerable populations

To encourage hospitals to improve quality of care, Medicare penalizes those with higher than expected rates of readmission within 30 days of discharge.

The logic behind the penalties is that if patients receive high quality care, including proper discharge planning, they should be less likely to end up back in the hospital.

This seems straightforward, but it turns out that the social and clinical characteristics of a hospital's patient population that are not included in Medicare’s calculation explain nearly half of the difference in readmission rates between the best — and the worst — performing hospitals, according to the results of a study published in JAMA Internal Medicine.

Using the standard Medicare formula—which adjusts only for patient age, sex and certain diagnoses—the best-performing hospitals had 4.4 percent fewer readmissions than the worst-performing hospitals.

Researchers from Harvard Medical School’s Department of Health Care Policy found that including a more comprehensive set of patient characteristics—including clinical variables such as self-reported health, cognition and functional status, as well as sociodemographic variables such as race and ethnicity, income and educational attainment — cut the difference nearly in half, to 2.3 percent.

In 2014, Medicare levied penalties totaling $428 million on 2,600 hospitals with higher than expected readmission rates. The fines were concentrated among hospitals that serve disadvantaged communities.

The researchers wanted to find out if that was because these hospitals do a worse job of treating their patients or because the people who use the hospital have a higher risk of readmission due to their socioeconomic and clinical status.

“The readmissions reduction program is designed to penalize hospitals for poor quality of care, but our findings suggest that hospitals are penalized to a large extent based on the patients that they serve,” said J. Michael McWilliams, HMS associate professor of health care policy and medicine, a practicing internist at Brigham and Women’s Hospital and senior author of the study.

Using nationally representative survey data and linked Medicare claims, the researchers assessed 29 characteristics not included in standard adjustments as potential predictors of 30-day readmission.

They found that the distribution of many of those characteristics differed substantially between hospitals with higher vs. lower readmission rates reported by Medicare.

They then compared the difference in readmission rates between these hospitals before and after adjusting for the more comprehensive patient profile.

“By extension, our findings suggest that the hospitals treating the sickest, most vulnerable patients are being deprived of resources that they could use to take better care of their communities,” said Michael Barnett, research fellow in medicine at HMS and Brigham and Women’s and lead author of the study.

Barnett, McWilliams and co-author John Hsu, HMS associate professor of health care policy and medicine at Massachusetts General Hospital noted that there are a number of potential solutions that would serve the goal of reducing readmissions and improving quality of care without exacerbating disparities by penalizing hospitals that treat sicker patients.

“Efforts to improve quality do not have to be at cross purposes with the goal of eliminating disparities,” McWilliams noted.

Risk adjustment, for example, could be more comprehensive. The authors cite recent legislation that calls for investigation of the effects of adjustment for more clinical and social characteristics on how providers perform on quality measures. 

Because detailed information on patients is difficult to collect, however, programs like the Hospital Readmissions Reduction Program may need to be redesigned to achieve their goals while minimizing unintended consequences.

For example, inadequately adjusted comparisons against national averages could be replaced with incentives for hospitals to improve over their baseline performance.

Alternatively, payment models that place the full spectrum of care under a global budget could allow providers greater discretion in identifying and reducing avoidable events such as readmissions.

“Hospital readmissions are complex and can result from any number of factors, like poor health literacy or lack of access to transportation,” Barnett said. “Therefore, it’s crucial to have a comprehensive picture of patients’ social and clinical context when assessing hospital quality.”

This study was supported by grants from the National Institute on Aging (P01AG032952) and Health Resources and Services Administration (HRSA) (T32-HP10251).


Checking Up on Symptom Checkers

Web-based diagnostic and triage tools often get it wrong, but sometimes they can help guide seriously ill patients to needed care

Hundreds of millions of times every year many of us turn to a new kind of online software called symptom checkers to try to self-diagnose our symptoms and to get advice on whether we should seek further medical care or just rest at home until we feel better.

But how good is the information we receive?

The first wide-scale study of the accuracy of general-purpose symptom checkers found that while the online programs are often wrong, they are roughly equivalent to telephone triage lines commonly used at primary care practices—and they are better than general Internet-search self-diagnosis and triage. The study, led by researchers at Harvard Medical School, is published in the BMJ.

“These tools may be useful in patients who are trying to decide whether they should get to a doctor quickly, but in may cases, users should be cautious and not take the information they receive from online symptom checkers as gospel,” said senior author Ateev Mehrotra, associate professor of health care policy and medicine at HMS and Beth Israel Deaconess Medical Center.

Symptom checkers are hosted by medical schools (including Harvard Medical School), hospital systems, insurance companies and government agencies (including the United Kingdom’s National Health Service). This type of software asks users to list their symptoms, using methods such as multiple choice checklists and free text entry.  Once a program has collected the information, the computer returns a list of potential illnesses that might cause the listed symptoms and suggests whether the patient should seek care immediately, visit a doctor in the next few days or use self-care methods, such as resting at home.

How well do symptom trackers work? Video by Hannah Semigran.

To test the symptom checkers, the researchers created standardized lists of symptoms from 45 clinical vignettes that are used to teach and test medical students and then inputted those symptoms into 23 different symptom checkers. Overall, the software algorithms that the researchers studied listed the correct diagnosis first in 34 percent of cases. The correct diagnosis was included in the top 3 diagnoses in the list in 51 percent of cases and in the top 20 in 58 percent.

In many cases, getting the exact diagnosis may not be as important as getting the correct advice about whether—or how quickly—to go to the doctor.

“It’s not nearly as important for a patient with fever, headache, stiff neck and confusion to know whether they have meningitis or encephalitis as it is for them to know that they should get to an ER quickly,” Mehrotra said.

Overall the 23 symptom checkers provided correct triage advice in 58 percent of cases with the checkers performing much better in more critical cases, correctly recommending emergency care in 80 percent of urgent cases.  In comparison, other studies have found that Internet search engines for urgent symptoms only led to content that suggested emergency medical treatment 64 percent of the time.

The symptom checkers that were evaluated tended to be overly cautious, encouraging users to seek care for situations where staying at home might be reasonable. The researchers noted that this tendency toward overly cautious advice encouraged people to seek unnecessary care—an outcome that health care reform seeks to minimize in order to reduce costs.

The researchers found that there was a great deal of variation between checkers, but none were without limitations; for example, checkers with the most accurate diagnoses (Isabel, iTriage, Mayo Clinic, and Symcat) were not on the list of the programs that did the best job of recommending the appropriate level of care for a given case (, Steps2Care and Symptify).

Symptom checkers are part of a larger trend of both patients and practitioners using online platforms for a range of health care tasks, such as patient-doctor chat sessions and algorithmic tools used to aid the diagnosis and triage of patients, the researchers said.

“The tools are not likely to go away,” said first author Hannah Semigran, HMS research assistant in health care policy. “With symptom trackers, we’re looking at the first generation of a new technology. It’s important to continue to track their performance to see if they can reach their full potential in helping patients get the right care.”

Other authors on the study were Courtney Gidengil, HMS instructor in pediatrics at Boston Children’s Hospital and a physician scientist at the RAND Corporation, and Jeffrey Linder, HMS associate professor of medicine and a physician and researcher at Brigham and Women’s Hospital.

Harvard Medical School’s Family Health Guide is used as the basis for one of the symptom checkers evaluated. None of the study authors is involved with the HMS-related symptom checker.

This study was funded by the U.S. National Institutes of Health (National Institute of Allergy and Infectious Diseases grant #R21 AI097759-01).


Out of Breath and Out of Pocket

After ozone-protecting inhaler ban, asthma patients pay nearly twice as much more per year for inhalers.

In 2008 the FDA banned a class of asthma inhalers that contained ozone-depleting propellants.  These banned inhalers were available in both generic and branded versions, and the ban left people with asthma-only branded inhalers only one option: inhalers utilizing a recently-developed propellant technology.

A new study has found that the out of pocket costs of the average asthma patient with private insurance in the country nearly doubled following the FDA ban.

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The research, led by Anupam Jena, assistant professor of health care policy and medicine at Harvard Medical School and an internist at Massachusetts General Hospital, measures the financial and health impact of the ban, which critics said would have a minimal environmental benefit. The findings were  published online today in JAMA Internal Medicine.

“The goal of reducing the use of ozone-depleting chemicals is obviously an important one, but we wanted to see how patients with asthma were affected by this policy,” Jena said. 

More than 25 million people in the U.S. rely on inhalers for short-acting relief of asthma symptoms.

Policy Change Effects

Jena and colleagues at the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California and the Division of Health Policy and Management, at the University of Minnesota School of Public Health in Minneapolis, wanted to know what the financial and health impacts of the policy change were.

The researchers found that branded inhalers cost patients from $5 to $75 more than generic inhalers, depending on insurance plan and type of inhaler used.

Across more than 140,000 asthma patients in 77 different health plans, the researchers found an average increase of $10 per inhaler prescription, or nearly double what patients with asthma paid out of pocket prior to the FDA ban.

While they saw a slight decline in overall inhaler use, they found no increase in hospitalizations and no decline in the use of maintenance drugs to control asthma. 

An important limitation of the study is that it does not include patients without insurance, who might face more serious challenges with the new, more expensive inhalers, said study co-author Pinar Karaca-Mandic, associate professor in the Division of Health Policy and Management, at the University of Minnesota School of Public Health.

Ozone Depletion

The rule change was allowed under the U.S. Clean Air Act, which prohibits the use of nonessential technology that uses ozone-depleting chemicals.

Ozone depletion causes serious risks for humans, including an increased danger of skin cancer.

For years, the FDA allowed CFC-inhalers as medically necessary, but announced plans to phase them out in 2008 when new inhalers using a different propellant became available.

The ban has been controversial both because of concerns about increased costs for essential medication and because of skepticism about the relative value to the environment of banning CFC-propelled inhalers.

While damage to the ozone layer has significant, dangerous consequences, the share of emitted CFCs that come from inhalers was less than one-thousandth of total emissions, according to a 2011 Mother Jones article that cited estimates suggesting that the ban will likely have a “minimal” effect. The article also noted that the new inhalers use a propellant that is a known powerful greenhouse gas.

“Economics gives researchers and policymakers a set of tools that allow us to bring evidence to bear on complex policy decisions,” Jena said.

“In this case, patients with asthma have essentially subsidized environmental efforts to improve the ozone, by paying higher prices for their medications. To tackle tough problems like this we need to know the costs and benefits of all the policies being considered. Our study provides an important piece to that puzzle,” he said.

Anupam Jena, assistant professor of health care policy, is an economist/physician who studies a broad range of issues relating to healthcare, including medical malpractice and the economics of medial innovation. This video is part of a series in which researchers explain the importance of their work. Video: Rick Groleau

The study was funded by Health Early Independence Award 1DP50D017897-01 from the National Institutes of Health, by grants 5P01AG033559 and 5K01AG036740 from the National Institute on Aging, and by a University of Minnesota Academic Health Center Faculty Development Grant.


Win Some, Lose Some

Uneven impact found for those with serious mental illness in transition from Medicaid to Medicare Part D

When Medicare Prescription Drug Coverage started in 2006, many experts voiced concerns about disabled patients with serious mental illness making the transition from Medicaid to Medicare. 

A new study by Harvard Medical School researchers at the Harvard Pilgrim Health Care Institute is one of the first to examine the impact of the transition in mentally ill populations.  It found that effects on the use of essential and sometimes lifesaving drugs for these patients varied greatly by state.  Mentally ill patients transitioning from Medicaid to Medicare Part D in states with strict limits on coverage benefited from the change, while those transitioning from states with more generous coverage had less satisfactory outcomes.  The results were published online in JAMA Psychiatry on Jan. 14.

The study performed time-series analysis for patients spanning 2004 – 2007, comparing states that capped monthly prescription fills to states with no prescription limits.  Researchers considered Medicaid and Medicare claims for 9,229 patients who lived in the community, were under 65 years old, disabled, enrolled in both Medicaid and Medicare, and who had schizophrenia or bipolar disorder.

The study found the effects of transitioning from Medicaid to Medicare Part D depended on where patients lived.  Transition to Part D in states with limited drug coverage reduced the number of cases of untreated mental illness, which can result in hospitalization and suicide. By contrast, antipsychotic treatments decreased after implementation of Medicare Part D for patients living in states with more generous drug coverage, probably because the new Medicare drug plans also used cost controls that inhibit medication use.   Given that most states in the US are in this latter category, with relatively generous Medicaid drug coverage, the authors also found significant and worrisome reductions in antipsychotic use nation-wide.

“To the best of our knowledge, this is the first study of Medicare Part D to examine barriers to mental health treatment for the vulnerable under-65 population with severe mental illness,” said Jeanne Madden, first author of the paper and HMS instructor in population medicine at Harvard Pilgrim Health Care Institute. “It highlights the impact of different state Medicaid policies regarding prescription coverage.  It also suggests the potential harmful effects of cost shifting strategies sometimes used in Medicare prescription coverage for these patients.”

Senior author Steve Soumerai, HMS professor of population medicine at Harvard Pilgrim Health Care Institute, added, “Now the Affordable Care Act is changing insurance for prescription drugs very rapidly.  A lot of people have gained health insurance recently, but harmful prescription caps and very high deductibles for needed drugs are widely used.  We need to look at whether barriers to treatment, such as the high cost sharing allowed under the ACA, might put vulnerable patients at risk of poor health and institutionalization.”




Program Pilots New Approach to Improve Aging Care

Partnership will help determine how home care can improve senior health and reduce costs

Researchers from Harvard Medical School’s Department of Health Care Policy have launched a joint partnership with ClearCare, a company that provides a software platform for home care agencies, and Right at Home, a senior home care franchise. The program, titled “The Intervention in Home Care to Improve Outcomes,” or simply “In Home,” will test a brand-new, large-scale randomized intervention aimed at preventing hospitalizations, improving health outcomes and lowering Medicare spending among private-pay home care recipients.

“To date, almost no one has looked on a large-scale basis at how the private-pay home care population utilizes health care,” said David Grabowski, professor of health care policy at Harvard Medical School. “In this program, we will have access to a large population of private-paying home care recipients via our partnership with Right at Home. We will also have the ability to identify detailed changes in care-recipient condition and hospitalizations over time via our partnership with ClearCare.” Grabowski will manage the project.

The study is one of the inaugural projects under the newly established Healthcare Markets and Regulation Lab at Harvard Medical School, supported in part by the Laura and John Arnold Foundation.

The program consists of two components: early identification of changes in a patient’s condition and monitoring (or helping to manage) these changes in the home.

If these changes remain undetected and unmanaged, they frequently escalate into costly hospitalizations. Under this new program, acute changes in a patient’s physical or cognitive status are observed and reported via a caregiver checklist. Any changes in status are communicated in real-time to a care manager who reviews the reported change in condition and decides on the appropriate course of action. By identifying avoidable conditions in their early stages, determining the appropriate escalation and then helping to manage the condition in the home, the In Home program can achieve the win-win of improving outcomes while lowering health care spending for the home care population.

“Through these partnerships, for the first time ever, we will be able to determine whether home care technology coupled with a simple intervention strategy can reduce hospitalizations, improve overall health and reduce costs,” said Grabowski.

“We are experiencing a massive demographic shift, with more older people than younger for the first time in human history,” said Geoff Nudd, CEO of ClearCare. “This fact, in combination with expensive treatments driving the health care cost crisis, is prompting a general examination of how preventative, nonmedical care might be the answer to the problem. This program will provide us with invaluable insight into how the power of home care can improve lives.”

“According to the U.S. Department of Health and Human Services, roughly 28 percent — or 11.8 million — American seniors now live alone,” stated Allen Hager, founder of Right at Home. “While this fact illustrates that there is, indeed, a real need for home help for seniors, what’s even more critical is that it prompts us to gain a deeper understanding, and validation, of how this help can support a better quality of life.”

The In Home Program should be of particular interest to provider groups and health plans. These groups are increasingly working together to decrease hospitalizations, reduce the overall expense to health networks and ultimately lower costs for the care recipient. Until now, these providers and plans have not typically reimbursed for home care services, which are mostly paid for privately by the care recipient, because the impact of these services has not been formally examined at scale. The findings of the In-Home Program could further reinforce aging at home as not only the choice of most seniors but also as a model of aging that simultaneously lowers health care spending while maximizing quality of life.


Startling Benefit of Cardiology Meetings

Lower mortality rates found during national scientific meetings 

High-risk patients with certain acute heart conditions are more likely to survive than other similar patients if they are admitted to the hospital during national cardiology meetings, when many cardiologists are away from their regular practices.

Sixty percent of patients with cardiac arrest who were admitted to a teaching hospital during the days when cardiologists were at scientific meetings died within 30 days, compared to 70 percent of patients who were admitted on non-meeting days.

“That’s a tremendous reduction in mortality, better than most of the medical interventions that exist to treat these conditions,” said study senior author Anupam Jena, assistant professor of health care policy at HMS, internist at Massachusetts General Hospital and faculty research fellow at the National Bureau of Economic Research.  There is substantial ambiguity in how medical care is practiced, particularly for these complex patients, he said. “This study may help illuminate some of those gray areas and suggest ways we can provide better care for those high-risk patients.”

The results of the study were published Dec. 22 in JAMA Internal Medicine.

Video: Rick Groleau and Jake Miller

Along with collaborators at the National Institutes of Health, the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California, Los Angeles, and the RAND Corporation, Jena compared similar populations of patients treated at teaching and nonteaching hospitals during American Heart Association and American College of Cardiology meetings and on matched dates immediately surrounding those meetings. They looked at survival rates of high-risk and low-risk patients with heart failure, heart attack and cardiac arrest.

While survival rates at teaching hospitals went up during meetings for high-risk heart failure and for cardiac arrest, there was no difference in mortality between meeting and non-meeting dates for patients with high-risk heart attack or for low-risk patients with any of the conditions studied. There was also no change in mortality rates for any patients for any of the conditions in nonteaching hospitals.

“We don’t have the full set of answers about what works best in these cases, but the evidence suggests that a less is more approach might be best for higher-risk patients with these conditions,” Jena said.

The researchers found that certain intensive procedures were performed less often on the high-risk patients in the study during meeting dates than outside meeting dates.

One explanation for these findings, the researchers said, is that physicians who don’t attend the conferences take a more conservative approach for high-risk patients; another is that the physicians who stayed behind were reluctant to perform intensive procedures on another physician’s patients while that doctor was out of town. Survival rates might be higher because, for high-risk patients with cardiovascular disease, the harms of intensive procedures may unexpectedly outweigh the benefits.

High-risk patients are typically older people with complicated medical histories and clinical profiles that make them especially vulnerable to the illnesses studied and, perhaps, to some of the more intensive methods used to treat these conditions.

Little is known scientifically about the benefit of many interventions for high-risk patients: A 50-year-old overweight smoker having a heart attack is a classic candidate for certain intensive interventions, such as coronary artery stenting, based on the effectiveness of those procedures in clinical trials conducted on other similar patients. More complex, higher risk cases might not benefit from or tolerate the same interventions in the same way.

Clinical trials teach us a great deal about how to treat a certain subset of patients, most often low- to moderate-risk patients, Jena said. Many trials do not enlist the highest risk patients, and it may be incorrect for physicians to assume that patients of all risk levels should be treated the same.

“Our study provides some evidence that treating high-risk patients the same as lower-risk patients may be bad medicine,” Jena said.

The researchers speculated that differences in survival rates were detected only among patients treated at teaching hospitals because of the higher concentration of physicians from a teaching hospital who would be likely to attend a scientific meeting. Detailed information about the demographics of attendees at the meetings was not available for the study.

The study was inspired by prior research showing that patients hospitalized on weekends and late at night have worse outcomes than those who become ill during regular office hours, due to lower overall staffing levels during off hours. What might happen, the researchers asked, when overall staffing levels remained the same but the number of physicians dropped?

Every year, thousands of physicians attend scientific meetings. The researchers chose to study cardiology because cardiac conditions are often acute, with sudden onset, and a patient’s treatment cannot be easily rescheduled to accommodate a physician’s travel schedule. The researchers said they expected to find that patient outcomes were worse when physicians were out of town and so were surprised by the results of the study.

This research was funded by the Office of the Director, National Institutes of Health (NIH Early Independence Award, grant 1DP5OD017897-01 and the National Institute on Aging (grant 5P01AG033559).