Health Care Policy

News

Mental Health on the Line

Use of telemedicine for mental health in rural areas on the rise but uneven

Newly published research by Harvard Medical School and the RAND Corporation reveals a dramatic growth in the use of telemedicine for the diagnosis and treatment of mental health disorders in rural areas, but strikingly uneven distribution of services across states.

The results, published in the May issue of Health Affairs, stem from analysis of telemedicine use among Medicare beneficiaries nationwide over 10 years.

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The study shows an average 45 percent jump per year in telemedicine visits between 2004 and 2014, among rural patients, with striking variation across states. Four states had no such visits in 2014, while in nine states, there were more than 25 telemedicine visits per 100 patients with serious mental illness. 

The reasons for the dramatically uneven distribution remain unclear, but the study investigators say state laws that regulate the provision and reimbursement of telemedicine services for mental health appear to play some role.

“Our results highlight the growing importance of telemedicine in the treatment of mental health disorders in rural settings where access to mental health care is often problematic,” said study lead investigator Ateev Mehrotra, associate professor in the Department of Health Care Policy at Harvard Medical School.

Additionally, the researchers pointed out, overall use of telemedicine services across all rural patients with mental health disorders remains extremely low—at 1.5 percent.

Telemedicine has been touted as a way to eliminate barriers to treatment for patients who would normally have no access to specialists. In the area of mental health, the researchers say, telemedicine seems particularly promising as a way to close the access gaps by providing remote video conferencing. Compared with other conditions, mental health disorders may be particularly well suited for telemedicine services as patients often do not need a physical exam.

There is an ongoing debate in Congress about the value of expanding telemedicine coverage for Medicare beneficiaries. Given that Medicare coverage standards often set the tone for services covered under commercial health plans, expanding access to telemedicine for Medicare patients could translate to expanding coverage for privately insured patients as well.
The Congressional Budget Office has called for more research in this area as they deliberate on passing federal legislation to loosen restrictions for telemedicine services.

Some medical groups, including the Department of Veterans Affairs, have widely implemented telemedicine services, but Medicare has much more stringent criteria on which services can be reimbursed and a requirement that mandates that the patient and clinician must live in the same state.

In their analysis, the investigators tracked telemedicine visits among Medicare beneficiaries with mental illness over 10 years.

The number of telemedicine visits increased from 2,365 in 2004 to 87,120 in 2014. An average of 5 out of 100 rural beneficiaries with a mental health condition had a telemedicine visit, and the number was even higher—12 out of 100—for patients with serious mental illnesses, such as bipolar disorder or schizophrenia. The latter group makes up a mere 3 percent of rural Medicare beneficiaries, yet it accounted for more than a third of these telemedicine visits.

The investigators underscore the need to balance under-use with over-use and caution that further research is needed to delineate ways to ensure responsible use of telemedicine for mental health.

"This work provides us with crucial information as we move forward to understand whether the rapid rise in mental telehealth actually translates into better patient outcomes,” said co-investigator Sherri Rose, associate professor of health care policy at Harvard Medical School.

This research was funded by an unrestricted gift to Harvard Medical School by Melvin Hall and CHSi Corporation.

Co-investigators included Haiden Huskamp, Jeffrey Souza, Bruce Landon, MD, Anupam Jena and Alisa Busch, of Harvard Medical School, and Lori Uscher-Pines, of the RAND Corporation.

News

The Coming Sea Change for Health Care

HMS economists discuss the ACA and what might come next

If what’s past is prologue, the history of the U.S. Affordable Care Act suggests that ongoing efforts at national health care and health insurance reform will continue to be tempestuous.

At a recent Talk@12, two leading researchers on health care cost and quality from the HMS Department of Health Care Policy outlined the intended workings of the ACA, highlighted a few of the many political and legal challenges to the original law and set the scene for current efforts underway on Capitol Hill to repeal, replace or reconfigure the law.

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Joseph Newhouse, the John D. MacArthur Professor of Health Policy and Management at Harvard University, and Michael Chernew, the Leonard D. Schaeffer Professor of Health Care Policy at HMS, were joined on campus by students, faculty and staff from across the HMS community. Their talk was also livestreamed to thousands who logged on in 40 countries, including Algeria, Australia, Italy, Romania and Morocco.

Moderator Gina Vild, associate dean for communications and external relations at HMS, invited Chernew and Newhouse to talk through the complexities and controversies around health care reform. Following brief presentations, Chernew and Newhouse took questions from the audience in the auditorium and from livestream viewers via Twitter.

“Imagine that we have a big bag of money that has to pay for all the health care for everyone,” Chernew said. “That money has to come from somewhere.”

In the United States, health care is funded by the people, either through taxes, insurance premiums, or fees paid for care at the doctor’s office or the hospital, said Chernew, who is also the director of the Healthcare Markets and Regulation (HMR) Lab in the HMS Department of Health Care Policy.

“The fundamental debate we’re having now is about best mix of these forms of payment,” Chernew said.

Should healthy people pay more to offset costs for the chronically ill? Should the wealthy pay more for the care of the poor? Should the young pay more to subsidize and support the old? These tradeoffs are at the heart of the philosophical and political questions that fuel the debate around health care reform, Chernew said.

Newhouse described the ACA’s attempt to find the right payment mix, which included the proposed expansion of Medicaid to any American earning less than 138 percent of the poverty level, new marketplaces for small groups of employees and individuals, subsidies to make purchasing insurance more affordable for low-income earners and tax penalties to discourage people who choose not to purchase insurance.

Ongoing opposition

The ACA faced stiff opposition from the time it became a law, with a series of lawsuits by state governors and by Congress challenging various provisions of the legislation. In one case, the Supreme Court overturned rules in the ACA that would have mandated that states expand Medicaid, allowing states to opt out.  

This ruling, and the subsequent decision of 19 states plus the District of Columbia to opt out were the main reason the estimates for the number of people who would be covered by the ACA were so low, said Newhouse, who is also director of the Harvard Interfaculty Initiative in Health Policy.

Because the ACA was designed to work as a complete package, changes in one aspect of the law have had cascading effects on other aspects. For example, when states chose not to expand Medicaid, the people who ended up purchasing insurance through the individual and small group marketplaces were more likely to be chronically ill than insurers had predicted, which destabilized those markets, Newhouse said. 

Chernew noted that recent Republican proposals for replacing the ACA favor a move toward individuals paying more of their share of the costs, either through higher premiums, higher deductibles or higher fees at the doctor’s office.

This could mean charging people who are chronically ill more than their healthy peers, or raising premiums for older Americans. The reason proponents say this is necessary, Chernew said, is that asking individuals to pay more encourages the fiscal discipline needed to curb spending growth, even though it may cause inequity and suffering.

Many paths to change

Though legislative efforts to repeal or replace the Affordable Care Act seem to have stalled, speakers noted that there were many administrative ways to impact the effectiveness of ACA without action from Congress.

“Simply because they can’t get a bill through Congress doesn’t mean that the ACA will work the way it was intended to,” Chernew said.

A pending lawsuit by the U.S. House of Representatives challenging the legality of the subsidies that help make insurance more affordable for low-income earners could end the use of those subsidies, making it impossible for many low-income individuals to afford marketplace insurance and returning them to the ranks of the uninsured.

While the Obama administration was appealing a lower-court decision that the subsidies were not allowed, the Trump administration could drop the appeal and end the subsidies.

The political fallout from these maneuvers is hard to predict, the speakers said.

For some opponents of federal health care reform efforts, Newhouse noted, the key question is who has the right to decide what’s best for the citizens of the United States.

“One of the fault lines that runs through American history is the role of states versus the role of the federal government,” Newhouse said. “Should voters in Massachusetts have the prerogative to tell the people of Texas that Texans have to take better care of their poor people?”

Seeking new solutions

In addition to the ongoing debate about federalism, there is growing recognition that the best way to find solutions to the complex problems of delivering the best, most efficient health care to the most Americans is not through top-down mandates, but through diverse innovation and experimentation at the point of care.

One of the provisions of the ACA was the creation of the Centers for Medicare and Medicaid Services Innovation Center, which encouraged provider groups to find their own ways of improving care. Instead of telling physician practices how to do a better job of coordinating care for chronically ill patients with multiple illnesses, the new program offered incentives for groups that found their own ways of improving care and saving money.

“We’re at the beginning of that process.” Chernew said, noting that many questions remain unanswered.

What do we do to control the growth of spending? Is investing in preventive care a good way to bring down overall costs? Would single payer be more efficient than a system mediated by insurance companies, or do we need more freedom in the market so competition can drive down costs? Which kind of patients benefit most from coordinated care? Is it worth investing in better information technology? And how are we going to pay for all this?

In order for the next plan to succeed in the long term, policymakers, physicians and citizens will have to answer these questions.  

For now, health care spending continues to grow faster than the economy.

“It’s pretty simple math,” Chernew said. “If health care spending continues to grow faster than GDP, eventually there isn’t enough money to pay for health care and all the other things that we want.”

 

 

News

Marathon Risk for Non-Runners

Having a heart attack near a major race makes for grim survival odds

Lead researcher Anupam Jena discusses the findings. Video: Rick Groleau

People who suffer heart attacks or cardiac arrests in the vicinity of an ongoing major marathon are more likely to die within a month due to delays in transportation to nearby hospitals, according to newly published research from Harvard Medical School.

The delays, the researchers say, likely stem from widespread street closures during major races that can hamper transportation in an emergency.

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Writing in the April 13 issue of the New England Journal of Medicine, the study authors call for citywide strategies that ensure unhampered access for medical crews in a certain radius of major races and other large public gatherings, such as sporting events or parades.

Previous studies have examined death rates among marathon runners to assess the risk of endurance training, but this is believed to be the first study to analyze the impact of such races on those living nearby due to causes that have nothing to do with the physical exertion of running a marathon.

“We have traditionally focused medical preparedness and emergency care availability to address the needs of race runners, but our study suggests that effects of a marathon may spread well beyond the course of the event and affect those who live or happen to be nearby,” said the study’s senior author, Anupam Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School.

The investigators examined 10 years’ worth of patient records analyzing death rates among older Americans, 65 years of age and over, within 30 days of having a heart attack or a cardiac arrest near a major marathon across 11 U.S. cities. Researchers compared death rates among patients hospitalized on the day of the race with those hospitalized five weeks prior or five weeks after the race. Additionally, the researchers divided patients by ZIP code, comparing death rates among those living near the marathon and those living in ZIP codes well outside of the event’s radius and unaffected by street closures.

Patients admitted to a hospital on race day were nearly 15 percent more likely to die within a month of suffering a heart attack or cardiac arrest compared with those admitted on a nonmarathon day or in a hospital outside of the marathon’s ZIP code(s).

That spike translated into a nearly 4 percent difference in the number of deaths. In other words, the researchers say, for every 100 patients with heart attack or cardiac arrest, three to four more people died within a month in the group admitted to a hospital on race day if they happened to go to a hospital near the race course.

The research also showed that ambulance transport was delayed by an average of 4.4 minutes on marathon days, 32 percent longer travel time compared with transports not delayed by marathons. Additionally, nearly a quarter of patients in the study got themselves to the hospital without an ambulance. While there is no record of the amount of  time private transportation took, the authors suspected that many such trips would have been slow on marathon days.

While the study findings do not establish cause and effect between street closures and greater mortality, the researchers point out that many studies have shown that even very small delays in getting care could make the difference between life and death.

“When it comes to treating people in the throes of a heart attack, minutes do matter. Heart muscle dies quickly during a heart attack, so current guidelines call for rapid intervention, preferably within an hour or so of diagnosing a heart attack, to salvage cardiac muscle function,” said Jena, who is also a physician at Massachusetts General Hospital.

As runners speed through the streets of the nation’s most popular marathons, traffic around race routes slows to a crawl. Marathon organizers make every effort to ensure safe and smooth passage for runners, but large public gatherings—such as major sporting events, parades or Independence Day fireworks—can cause major traffic snags.

So, the HMS researchers wondered what kind of unintended consequences these sprawling, 26.2-mile events might have on the health of people who live near the race course.

The findings suggest that between three and four preventable deaths likely occur each year among older residents who suffer heart attacks and cardiac arrests during marathons across the eleven cities studied.

“Marathons and other large, popular civic events are an important part of the fabric of life in our big cities, and they bring people a lot of pride and joy,” Jena said. “But the organizers of these events need to take these risks to heart when they are planning their events, and find better ways to make sure that the race’s neighbors are able to receive the lifesaving care that they need quickly.”

The races included in the analysis took place between 2002 and 2012 in Boston, Chicago, Honolulu, Houston, Los Angeles, Minneapolis, New York City, Orlando, Philadelphia, Seattle and Washington, D.C.

To rule out other possible explanations for the spike in mortality, the researchers checked to see whether patients were sent to different hospitals, whether they traveled longer distances, whether out of town spectators or race participants skewed the mix of patients, whether people waited until their conditions were more severe before calling for an ambulance, or whether staffing levels or the type of treatment used on marathon days were different from usual, and they found no evidence to support any of these possibilities.

The researchers say that their findings suggest that citywide strategies for emergency medical preparedness need to do more to account for the risks to nonparticipants whose emergency medical care may be delayed.

“When cities host big marathons, or when people participate in races, they don't think that there might be a chance that a person not taking part in the race could die because of the event,” Jena said. “These findings don’t mean we shouldn't have large public events, but hopefully our research will shine some light on the problem and suggest ways that planners can better provide for the health and safety of the people who live nearby.”

N. Clay Mann, professor in the Department of Pediatrics at the University of Utah School of Medicine and director for research at the Intermountain Injury Control Research Center; Leia N. Wedlund, a student at Harvard University; and Andrew Olenski, a research assistant in the HMS Department of Health Care Policy, were co-authors of this study. 

This research was supported with funding from the Office of the Director, National Institutes of Health (NIH Early Independence Award, Grant 1DP5OD017897-01).

News

Location Matters

Patients at hospital-based primary practices more likely to get unnecessary tests and services 

Patients with common conditions such as back pain, headaches and upper respiratory infections are more likely to receive tests and services of uncertain or little diagnostic or therapeutic benefit—so-called low-value care—when they seek treatment in primary care clinics located at hospitals rather than at community-based primary care clinics, according to a nationwide study led by researchers at Harvard Medical School and the David Geffen School of Medicine at UCLA.

The key factor driving this disparity appears to be clinic location rather than clinic ownership, the research showed. Indeed, aside from referring patients to specialists slightly more often, hospital-owned community clinics delivered care otherwise similar to physician-owned community clinics.

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The study findings, published April 10 in JAMA Internal Medicine, found an overreliance on referrals to specialists, CT scans, MRIs and X-rays in patients treated at hospital-based primary care practices, raising concerns about the value of hospital-based primary care, the research team said.

Overtesting and unnecessary referrals are serious concerns because past research shows that up to one-third of medical care may be wasteful or unnecessary. Unnecessary care can not only fuel higher overall treatment costs and spending but also lead to additional invasive and potentially harmful procedures and, in the case of CT scans and X-ray testing, expose patients to unnecessary radiation, the researchers say.

Insights from the study could help hospital-based practices develop strategies that limit the use of tests and procedures that provide little value for patients while driving up health care costs.

“Hospital-based practices need to be aware of their tendency to overuse certain tests and services of questionable therapeutic value for patients with uncomplicated conditions,” said study senior author Bruce Landon, an HMS professor of health care policy and of medicine at Beth Israel Deaconess Medical Center, where he practices general internal medicine. “That knowledge can help both frontline clinicians and hospital leaderships find ways to eliminate or at least reduce such unnecessary services.”

The researchers say their findings suggest that more immediate access to specialists and the proximity and convenience of imaging services in hospitals may drive physicians in such settings to overuse them.

“An estimated 10 to 30 percent of health care spending in the United States stems from services that provide low-value care,” said first author John Mafi, an assistant professor of medicine in the Division of General Internal Medicine and Health Services Research at the David Geffen School of Medicine at UCLA. “Reducing the use of such services can not only help curb health care costs—and redirect such resources in more meaningful way—but also protect patients from the potentially harmful effects associated with such services.”

Common examples of low-value care include prescribing antibiotics for a patient with the common cold or other viral upper respiratory infection not affected by antibiotics, or sending a patient with uncomplicated back pain or headache for an MRI or a CT scan.

In their analysis, the team compared patient records obtained from two national databases, comprising more than 31,000 patient visits over a 17-year period during which patients sought treatment in hospital-based primary care clinics or community-based clinics for upper respiratory infections, back pain and headaches.

In order to better identify patients for whom the services were likely of low value, the researchers excluded those with more complex symptoms suggestive of a more serious disorder as well as people with underlying disorders and chronic conditions.

Antibiotic prescription rates were similar in community- and hospital-based clinics.

However, hospital-treated patients were referred more often for MRIs and CT scans (8 percent, compared with 6 percent) than community-treated patients, more often for X-ray testing (13 percent, compared with 9 percent) and more often for an evaluation by a specialist (19 percent, compared with 7.6 percent).

Additionally, the patients most likely to receive unnecessary tests and services were those visiting hospital-based primary care clinics but seeing someone other than their usual primary care physician. The finding, the researchers say, highlights the importance of continuity of care and suggests that when patients bounce from physician to physician they may be more likely to be overtested or overtreated.

“Not seeing your regular primary care physician—what we call discontinuity of care—might be a weak spot where low value care can creep in,” Landon said. “The more we know about what situations are most likely to lead to patients’ receiving low-value care, the more we can do to prevent it.”

Co-authors on the study include Christina Wee, HMS associate professor of medicine at Beth Israel Deaconess Medical Center, and Roger Davis, associate professor of medicine (biostatistics) at Beth Israel Deaconess and associate professor of biostatistics at the Harvard T.H. Chan School of Public Health.

This research was supported with funding from the National Institutes of Health (Midcareer Mentorship Award K24DK087932 and Harvard Catalyst National Institutes of Health Award UL1 TR001102).

News

Under Scrutiny

Hospital patients less likely to die when accreditation surveys are underway

Patients treated at hospitals during unannounced accreditation inspections appear to have a slightly lower risk of dying within 30 days of admission, compared with patients treated in the few weeks before or after such surveys take place, according to a study led by researchers at Harvard Medical School and the Harvard T.H. Chan School of Public Health.  

Notably, the research team said, the effect does not seem to be directly related to any of the factors that inspectors focus on, such as hospital-acquired infections or other aspects of patient safety. Rather, the authors said, overall heightened awareness and increased vigilance by clinicians, as a result of intense observation, may explain the effect. The study findings are published March 20 in JAMA Internal Medicine.

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While the differences in mortality risk were small and dissipated soon after the survey visits were over, according to the researchers, even minuscule drops in mortality can have serious aggregate effects on the U.S. population. The trend underscores an opportunity to further minimize preventable harm and boost patient safety efforts across U.S. hospitals, the researchers wrote in the paper.

“As physicians, we have the health and safety of our patients first and foremost in our minds and in all of our efforts,” said study senior author Anupam Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School. “It is critical to understand how clinical decisions get made and what can make them better.”

Medical error is a significant cause of preventable death in U.S. hospitals. To ensure compliance and help hospitals identify gaps in their patient safety and quality of care protocols, the hospital-accrediting body known as the Joint Commission performs unannounced on-site inspections as a core part of their surveillance process.

They happen without warning once every 18 to 36 months across all U.S. hospitals. Teams of inspectors descend on the hospital, observing how rigorously clinicians follow patient safety and care procedures, ranging from hand-washing and medication management to clinical note keeping and myriad other routine and unexpected procedures involved in patient care. Low-performing hospitals face penalties, loss of accreditation and, in extreme cases, even closure.

To measure the impact of hospital inspections on patient outcomes, the researchers analyzed records from Medicare patient admissions at 1,984 surveyed hospitals from 2008 to 2012. The researchers focused on inspection weeks and compared patient outcomes to the three weeks before and the three weeks after the inspection took place.

The researchers found that across all hospitals, patients treated during an inspection week had a 1.5 percent lower risk of dying, on average, within 30 days of admission than patients treated in the three weeks before or after an inspection. 

The decrease was more pronounced at major teaching hospitals, where patients admitted during survey weeks had a nearly 6 percent lower chance of dying in the month following admission than patients admitted in the weeks before or after a survey. The researchers found that the steeper drop in mortality risk at teaching hospitals may stem from these institutions’ having more resources and clinical staff and from the intense preparation they have traditionally invested in accreditation performance.

While the cause of the effect remains unclear, the researchers speculate that improvements may stem from the basic human impulse to perform better when being watched and evaluated. In other words, they wrote, the effect may stem from heightened clinician vigilance during periods of intense observation.


Challenging Common Knowledge: An HMS Labcast Episode with Anupam Jena

Jena  talks about finding research questions in unusual places, what happens when a result contradicts “common knowledge,” what’s fun and challenging about his work, and learning when to let a project go.


“Our results suggest that heightened focus and attention during periods of intense observation may influence clinical decision making and downstream patient outcomes,” Jena said.

The researchers note that the findings require further analysis to tease out precisely what changes in behavior fueled the decline in mortality.

“Interruptions in clinical care occur frequently. Efforts to minimize distractions and increase clinician focus and attention could have measurable impact on patients,” Jena said.

Finding a way to harness that reaction and the behavioral shifts it precipitates could give patient safety efforts a healthy boost, the researchers said.

“We’ve all seen how traffic slows when drivers see a police officer ahead of them on the road,” said the study’s lead author Michael Barnett, assistant professor of health policy and management at the Harvard Chan School and an HMS instructor of medicine at Brigham and Women’s Hospital. “We believe the same dynamic may be at play here, and physicians and staff find ways to step up the overall quality of care when they know they are being observed.”

While the team found significant decreases in 30-day mortality risk among patients admitted during the inspection week, they didn’t find any evidence that patients were doing better because staff were more focused on the specific things that the inspectors were scrutinizing. For example, there was no difference in the levels of hospital- acquired infections, which might be attributed to changes in hand-washing practices or in other infection-prevention measures while inspectors were present. There were no differences in other patient-safety indicators such as the number of preventable pressure ulcers or the number of nonfatal cardiac arrests. Analysis of the differences between preventable postsurgical complications revealed a small reduction during inspection weeks.

"It's an enormous fire drill for hospitals when the inspectors arrive,” said Jena, who is also a physician at Massachusetts General Hospital. “It was entirely possible that the distraction of a Joint Commission visit could lead to worse patient outcomes, but we found the opposite.”

This research was supported with funding from the Office of the Director, National Institutes of Health (NIH Early Independence Award, Grant 1DP5OD017897-01) and the Health Resources and Services Administration (T32-HP10251).

Disclosures:

Jena received consulting fees unrelated to this research from Pfizer, Inc., Hill Room Services, Inc., Bristol-Myers Squibb, Novartis Pharmaceuticals, Vertex Pharmaceuticals and Precision Health Economics.

News

Get What We Pay For?

For hospitalized patients, spending more on care doesn’t buy better health

Hospitalized patients treated by physicians who order more or more expensive tests and procedures are just as likely to be readmitted or to die as patients treated by doctors who order fewer or less expensive tests, according to research led by Harvard Medical School and the Harvard T.H. Chan School of Public Health.

The study, published in JAMA Internal Medicine on March 13, is believed to be the first to examine the impact of individual physicians’ spending patterns on patient outcomes.

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“If you spend more money on a car or a TV, you tend to get a nicer car or a better TV,” said study senior author Anupam B. Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School. “Our findings show that’s not the case when it comes to medical care. Spending more doesn’t always mean you get better health.”

Research on variation in spending and outcomes between geographic regions and between hospitals has produced mixed results, but most evidence suggests that greater spending does not reliably translate into better outcomes.

What has been missing from the picture, the authors said, is how individual physician spending within the same hospital translates into patient health. That insight, the researchers added, is a key piece of the puzzle because individual doctors make most of the clinical decisions that drive spending and affect outcomes. 

“Before now, most of the research and efforts aimed at cutting spending and improving the value of care have been aimed at hospitals, health systems and groups of doctors,” said the lead author Yusuke Tsugawa, a research associate at the Harvard T.H. Chan School of Public Health. “The differences between hospitals and regions are important, but they’re only part of the puzzle. Our findings show how important it is to consider the differences between individual doctors in any effort to improve health care.”

The researchers analyzed outcomes among Medicare fee-for-service patients aged 65 years and older who were hospitalized for a nonelective medical condition and treated by an internist between 2011 and 2014.

Health care spending varied more across individual physicians within a single hospital than across hospitals, even after accounting for differences between hospitals and patient populations, the data showed.

Overall, 8.4 percent of the total variation in health care spending could be explained by differences between individual physicians, compared to 7 percent explained by differences between hospitals.

Next, researchers examined the link between physician spending and patient outcomes.

When they compared lower- and higher-spending physicians, the researchers found no difference in 30-day patient mortality, nor did they see a difference in readmissions, two factors regarded as key measures of quality of care.

Jena, who is also a physician at Massachusetts General Hospital, cautioned that it’s too soon to say whether the results mean that higher-spending physicians could simply spend less with no ill effects for patients.

“Say you have two painters. One usually takes two hours to paint a room, and one takes six hours. You can ask the slow painter to hurry up, but you might end up with a room that’s sloppily painted, or with one of the walls the wrong color,” Jena said. “That’s obviously a situation we want to avoid in health care.”

It could be that some doctors don’t fully consider the costs associated with the tests and procedures they order, Jena said, and so policymakers or insurers could create incentives to curb some of the more wasteful spending. On the other hand, Jena said, some doctors might just be less efficient than others and may need additional resources to arrive at a proper diagnosis or an effective treatment. Whatever the causes of the variation, Jena added, these findings underscore the impact of decisions made by individual doctors on health care spending.

This research was supported with funding from the Office of the Director, National Institutes of Health (NIH Early Independence Award, Grant 1DP5OD017897-01) and by the Social Science Research Council and St. Luke’s International University (Tokyo, Japan).


Challenging Common Knowledge: An HMS Labcast Episode with Anupam Jena

Jena  talks about finding research questions in unusual places, what happens when a result contradicts “common knowledge,” what’s fun and challenging about his work, and learning when to let a project go.


News

Habit Forming

Physicians’ opioid prescribing patterns linked to patients’ risk for long-term drug use 

Emergency room patients treated by physicians who prescribe opioids more often are at greater risk for long-term opioid use even after a single prescription than those who see less-frequent prescribers, according to the findings of a study from Harvard Medical School and Harvard T.H. Chan School of Public Health.

The research, believed to be the first to measure variation in provider prescribing practices and their impact on long-term opioid use, will be published Feb. 16 in the New England Journal of Medicine.

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Long-term opioid use increases the danger of misuse, addiction and even overdose, fueling what public health experts have called a national epidemic of opioid overuse. In 2015, more than 15,000 people in the United States died from an overdose involving prescription opioids, according to the Centers for Disease Control and Prevention.
 
The findings, the researchers add, underscore an acute need to educate clinicians on judicious prescribing practices and reduce wide variation in prescribing patterns for similar patients.

“These are sobering results,” said lead study author Michael Barnett, assistant professor of health policy and management at the Harvard Chan School and an HMS instructor of medicine at Brigham and Women’s Hospital. “Our analysis suggests that one out of every 48 people newly prescribed an opioid will become a long-term user. That’s a big risk for such a common therapy.”
 
Specifically, the study found that patients who saw frequent, or so-called high-intensity, opioid prescribers were three times as likely to receive a prescription for opioids as patients seen by infrequent, or low-intensity, prescribers in the same hospital.
 
Individuals treated by the most frequent prescribers were 30 percent more likely to become long-term opioid users—defined as receiving six months worth of pills in the 12 months following the initial encounter—and were also more likely to have an adverse outcome related to the drugs, such as a fall, a fracture, respiratory failure or constipation.
 
The study also showed that patients treated by low-frequency prescribers were no more likely to return to the hospital overall or with the same complaints—findings that suggest these people were not under-treated for their symptoms.
 
“Who treats you matters. Our findings lend support to the narrative that we often hear—a patient happened to be prescribed an opioid by a dentist or in the emergency room and unwittingly became a long-term user,” said study author Anupam Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at HMS and an HMS associate professor of medicine and physician at Massachusetts General Hospital. “A physician who prescribes an opioid needs to be conscious that there is a significant risk that the patient could continue to be on an opioid for the long term, even from a single, short, initial prescription.”
 
In their analysis, the researchers compared opioid use during 12 months following an initial emergency department encounter among more than 375,000 Medicare beneficiaries treated by more than 14,000 physicians between 2008 and 2011.
 
Although the physicians saw patients with similar complaints, they treated them differently. On the low end of the spectrum, one quarter of providers gave opioid prescriptions to just 7 percent of the patients they saw. At the other extreme, the top quarter of prescribers gave opioids to 24 percent of their patients.
 
"That’s an enormous amount of variation just from walking through a door and getting assigned to one doctor instead of another," said Barnett.
 
This research was funded by National Institutes of Health Director’s Early Independence Award number 1DP5OD017897-01.

Challenging Common Knowledge: An HMS Labcast Episode with Anupam Jena

Jena  talks about finding research questions in unusual places, what happens when a result contradicts “common knowledge,” what’s fun and challenging about his work, and learning when to let a project go.


News

See Change

Hospital readmission rates decrease with Affordable Care Act penalties

The Affordable Care Act instituted financial penalties against hospitals with high rates of readmissions for Medicare patients with certain health conditions. A new analysis led by researchers at Harvard Medical School, Beth Israel Deaconess Medical Center, Harvard T.H. Chan School of Public Health and Massachusetts General Hospital has found that the penalties levied under the law’s Hospital Readmissions Reduction Program were associated with reduced readmissions rates, and that the poorest performing hospitals achieved the greatest reductions.

The research appears online in Annals of Internal Medicine on Dec. 27.

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The Hospital Readmissions Reduction Program was enacted into law in 2010 and implemented in 2012 in response to the high numbers of patients who were readmitted within 30 days of their initial discharge from the hospital after treatment for several common conditions—including heart failure, pneumonia and acute myocardial infarction (heart attack).

While some readmissions may be unavoidable, there was evidence of wide variation in hospitals’ readmission rates before the ACA, suggesting that patients admitted to certain hospitals were more likely to experience readmissions compared to other hospitals.

“Paying hospitals not just for what they do, but for how well they do—that’s still a relatively new way of reimbursing hospitals, and it looks to be effective,” — Robert Yeh

“Hospital readmissions represent a significant portion of potentially preventable medical expenditures, and they can take a physical and emotional toll on patients and their families,” said co-senior author Robert Yeh, HMS associate professor of medicine and director of the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess.

“The Affordable Care Act sought to introduce financial incentives to motivate hospitals, especially the poorest performing ones, to reduce their readmission rates, and only the data could tell us if and how well it worked,” Yeh said. 

“We know that the national hospital readmissions rate has been declining since passage of the Affordable Care Act, and our team wanted to assess whether this improvement was driven by the best-performing hospitals alone or if all groups improved,” said first author Jason Wasfy, instructor in medicine at HMS and director of quality and analytics at the Mass General Corrigan Minehan Heart Center.

The researchers examined Medicare fee-for-service hospitalization data from more than 2,800 hospitals across the country between 2000 and 2013. Based on 30-day readmission rates after initial hospitalization for acute myocardial infarction, congestive heart failure or pneumonia, the researchers categorized hospitals into one of four groups based on the penalties they had incurred under the Hospital Readmission Reduction Program: highest performance (0% penalty), average performance (greater than 0% but less than 0.5% penalty), low performance (equal to or greater than 0.5% but less than 0.99% penalty), and lowest performance (equal to or greater than 0.99% penalty). 

"We analyzed data from more than 15 million Medicare discharges,” said co-senior author Francesca Dominici, professor of biostatistics and senior associate dean for research at the Harvard Chan School.

“We implemented Bayesian hierarchical models to estimate readmission rates for each hospital, accounting for differences in each hospital’s patient population. We then used pre-post analysis methods to assess whether there were accelerated reductions in readmission rates within each group after the passage of the reform. It turned out that all groups of hospitals improved to some degree. Notably, we found that it was the hospitals that were the lowest performers before passage of the Affordable Care Act that went on to improve the most after being penalized financially,” Dominici said.

“For every 10,000 patients discharged per year, the worst performing hospitals—which were penalized the most—avoided 95 readmissions they would have had if they’d continued along their current trajectory before the implementation of the law,” added Dominici.

“It’s a testament to the fact that hospitals do respond to financial penalties, in particular when these penalties are also tied to publicly reported performance goals,” she said.

“Paying hospitals not just for what they do, but for how well they do—that’s still a relatively new way of reimbursing hospitals, and it looks to be effective,” Yeh added.

This work was funded, in part, by grants from the National Institutes of Health (P01 CA 134294, R01 GM111339, R01 ES024332 and K23 HL 118138-01) as well as support from the Mass General Cardiology Division’s Hassenfeld Scholars Program.

Adapted from a Beth Israel Deaconess news release.

News

Price Point

Patients who choose doctors with low office visit prices save hundreds of dollars per year on overall health care costs

Patients who choose primary care doctors with low office visit prices can rack up considerable savings on overall health care costs according to new research from Harvard Medical School.

The report, published Dec. 5 in the December issue of the journal Health Affairs, suggests that office visit costs may be a reliable indicator of what a patient will pay for a wide range of services and procedures.

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The analysis shows that a relatively small difference in office visit price—$26—translated into hundreds of dollars in savings over the course of a year. The study found that when patients received care from primary care doctors with lower-than-average office visit prices, they spent, on average, $690 less per year, compared with patients who saw higher-priced physicians.

The savings, the researchers note, were not driven by fewer services or less care. Indeed, there was no significant difference in the kind and amount of services received by the two groups of patients. Rather, patients whose physicians charged lower prices for office visits also paid less for almost every other outpatient service they received.

In the past decade, patients have had to pay more for health care, due to higher deductibles.  Many states and private insurers now offer price transparency tools in the hope that access to such information could help people make better-informed decisions on how much they will pay per visit or for a given procedure. 

Would picking a provider based on low-priced office visits translate into overall savings including procedures and other follow-up care? The study suggests so.

“Because of the tremendous growth in high-deductible health plans, Americans are being forced to think about prices when they choose where to get care,” said study lead author Ateev Mehrotra, associate professor of health care policy at Harvard Medical School and a hospitalist at Beth Israel Deaconess Medical Center. “Our data suggest that looking at the price of your doctor’s office visit is a good place to start. Choosing a lower-priced primary care doctor could save someone a lot of money.”

Using the 2010 Ingenix insurance database, which contains data from 27 national employers, the researchers grouped primary care doctors into high, average and low price tiers based on the cost of an office visit. From there, they examined the spending of those doctors’ patients, looking at how many services such as drugs and emergency care visits patients used and how much the services cost.

Other investigators on the research included Peter Huckfeldt, assistant professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health; Amelia Haviland, Anna Loomis McCandless Professor of Statistics and Public Policy at the H. John Heinz III College of Public Policy and Management at Carnegie Mellon University; Laura Gascue, programmer and quantitative analyst at the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California, Los Angeles; and Neeraj Sood, professor of public policy at the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California.         

The work was funded by the Common Fund of the National Institutes of Health (Grant No. R01 AG043850-01).

News

Measuring the Marketplace

Lessons from the California ACA Exchange

Premiums for marketplace plans in the Affordable Care Act will increase by an average of 25 percent nationwide from 2016 to 2017, new reports from the federal government say.

Opponents of the politically contested health care reform law, sometimes referred to as Obamacare, have reacted by saying that the latest increases are proof that the ACA is a failure.

But some states are saying that the law has proven successful.

Peter Lee, executive director of Covered California, the California ACA insurance marketplace, said that states that have taken advantage of all of the tools provided by the ACA, such as California, have been able to make great progress in providing affordable care for consumers.

Lee was the featured speaker at this year’s 16th Annual Marshall J. Seidman Lecture on Oct. 25.

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 “We keep hearing a lot about the exchanges failing,” Joseph Newhouse, HMS professor of health care policy, said. “But our speaker may be able to tell you, ‘It ain’t necessarily so.’”

California has had the best performance in the health exchanges of any state on many measures.

“We're at a pretty good time to pause and look at how the ACA and the exchanges are doing,” Lee said. “With any large-scale policy, at five or six years in you need to pause and do a tune-up.”

From 2013 to 2015 the share of California residents without health insurance fell from 17 percent to 8.1 percent, according to federal calculations.

Covered California’s data show that most people who have left their plans either entered an employer-provided plan or became eligible for Medicaid, with very few leaving to become uninsured.

One reason that California has had such success is that the state started with the healthiest mix of residents of any state. The state government also wholeheartedly embraced the provisions of the ACA, Lee said.

Step one was to increase participation in Medicare, Lee said. This move served both to increase the portion of the population with health care coverage and to decrease the number of unhealthy people in the population who would be eligible for exchange-based individual insurance.

Covered California also actively sought to market and sell its insurance plans, which allowed the program to reach healthier consumers who might not have sought out insurance on their own, Lee said.

“Many of the exchanges that are struggling are in states that have been politically hostile to the ACA," Lee said.

In states that did not increase Medicare participation or invest in marketing the exchange plans, Lee said, many of the consumers who sought to purchase plans were already in poor health and therefore expensive to cover.

On average, exchange plan premiums in California will rise 13 percent in the new year, compared to states like Arizona, where rates will more than double, Lee said.

In contrast to some states, where insurers have lost money and struggled to set sustainable prices, leaving both consumers and health plans unhappy, Lee noted that insurers are eager to participate in the California exchange because they can sell products that make a profit.

Covered California is using that as leverage to require improved benefits for consumers and to prune low-quality and high-cost hospitals and provider groups from insurers’ networks, Lee said.

“We can push changes in the delivery system to improve the quality of care," he added.

Noting that much of the research that guided the design and implementation of the ACA came from HMS and colleagues throughout Harvard University, Lee said that researchers have an important role to play in evaluating the reform effort and guiding improvements in the future.

“Credit and blame lies on your doorstep,” Lee said, challenging researchers in the audience to “help the new Congress and the new president build on what we've got, which is actually working pretty well." 

In 2000, on the occasion of the 50th reunion of his Harvard Law School class, 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 policymaker on issues related to costs and quality of health care with a particular emphasis on activities that are most likely to impact federal and state approaches to these problems. The department has sponsored the lectures yearly since 2001.

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