I’ve been writing a lot about suicide in kids lately, first at The Upshot and then over at The Incidental Economist. We even did a Healthcare Triage that touched on new data. But a recent study and editorial in JAMA Pediatrics, “Widening Rural-Urban Disparities in Youth Suicides, United States, 1996-2010,” is worth another look:

Importance  Little is known about recent trends in rural-urban disparities in youth suicide, particularly sex- and method-specific changes. Documenting the extent of these disparities is critical for the development of policies and programs aimed at eliminating geographic disparities.

Objective  To examine trends in US suicide mortality for adolescents and young adults across the rural-urban continuum.

Design, Setting, and Participants  Longitudinal trends in suicide rates by rural and urban areas between January 1, 1996, and December 31, 2010, were analyzed using county-level national mortality data linked to a rural-urban continuum measure that classified all 3141 counties in the United States into distinct groups based on population size and adjacency to metropolitan areas. The population included all suicide decedents aged 10 to 24 years.

Main Outcomes and Measures  Rates of suicide per 100?000 persons.

Over the 15 years of this study, almost 66,600 youths died by suicide. The most startling finding (at least to me) was that the suicide rate in rural areas was almost twice that of urban areas. This held true for both males and females. Further, even after controlling for both individual and geographic variables, the gap between urban and rural suicide rates has been increasing.

Suicides by suffocation/hanging have been increasing (as noted in the TIE post). Firearm rates have gone down. However, the rates of both of these types of suicide were higher in rural areas, and the disparities have been worsening.

But trends only tell part of the story. More than half of all suicides committed during the study were by firearm. An accompanying editorial by JAMA Pediatrics editor Fred Rivara* makes a compelling argument that we’ve been ignoring suicide in our national debate on guns for too long.

First, he cites CDC data. In 2012, there were 33,363 deaths by firearms in the United States. But only 12,093 of these deaths were by homicide. About 62% of deaths by firearms, or 20,666 of them, were suicides. Guns are used far more often in suicides than homicides. He then cites research showing that access to guns can make an impulsive suicide attempt far more likely to succeed. Almost half of patients who have survived a suicide attempt report that the time between thinking about suicide and attempting is was 10 minutes or less.

People, especially kids, aren’t always planning suicide. It’s a spur of the moment decision. And having access to a gun can make things far worse. Guns work. Suicide attempts with a gun succeed more than 85% of the time; suicide attempts with poison or overdoses succeed less than 2% of the time. Meta-analyses show that there is a significant association between having access to a firearm and a higher chance of a suicide succeeding.

If someone wants to commit suicide, they can find a way, with out without access to a gun. That’s very true. But certainly some could be prevented. Moreover, given the impulsivity of suicide attempts by youth, it’s also possible that reducing access of youth to guns even without restricting the sale and ownership of guns by legal adults might make a difference–for example by increasing safe, locked storage apart from ammunition.

Rivara makes three recommendations as to how physicians can help:

  1. In health supervision visits, inquire in a nonjudgmental tone whether firearms are present in the home. If the patient is depressed or has other signs of mental illness, the physician should make greater efforts to inquire about firearms in the home.

  2. If firearms are present, forgo one’s personal philosophical beliefs about firearm ownership and concentrate on the pragmatic matter of safe storage.

  3. Participate in community efforts to promote safe storage of firearms. The success of community campaigns is enhanced by the authoritative voices of police officers who are enlisted as spokespersons on gun safety.

Many have long advocated for these. Yet, recent efforts have made it illegal for physicians to even ask about guns at all in some areas of the country. I think that’s a mistake, as I argued here at The Upshot. We need to continue in our efforts at harm reduction, and continue to work towards making suicide rarer among youth in the United States.


*Full disclosure: The pediatric health services research world is small. Fred is a longtime mentor and friend (I trained with him in Seattle), and I serve on the editorial board of JAMA Pediatrics.



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A paper published last year by Stryjewski et al. found that Massachusetts health reform was not associated with health improvements for patients with certain chronic conditions. A different paper, published earlier in the year by Sommers et al., found that Massachusetts health reform was associated with reductions in mortality.* How could both findings be true?

The answer: Different samples yield different results. Often such a glib response would be a cop out. But here it isn’t. Let’s look carefully at the samples to see why.

I summarized the sample for the Sommers study in my editorial.

[F]indings [are] based on county-level data from the Centers for Disease Control and Prevention and other sources. These data permit a much larger sample (270 000 adults gaining coverage) than work relying on smaller natural experiments; they also allow a longer follow-up. These reasons may have accounted for the investigators’ finding of a statistically significant reduction in all-cause mortality (2.9%) associated with reform in Massachusetts counties compared with propensity score–selected control counties in other states.

The key here is that the sample included data from all Massachusetts counties, comparing them to matched counties from other states. Hold that in your head as we consider the sample in the Stryjewski study. Quoting the paper:

We examined uninsured and insured patients seen in the Partners HealthCare network, the largest delivery system in Massachusetts. It includes Massachusetts General Hospital (MGH), Brigham and Women’s Hospital (BWH), their outpatient departments, and their 20 outpatient community health centers and satellite locations. [...] At Partners, patients with no insurance had their hospital and outpatient services billed to the uncompensated care pool and were not required to make copayments. Physicians waived their portion of the total care charges for uncompensated care pool patients on a pro bono basis. Uninsured patients were required to pay a $1–$3 monthly copayment for prescription drugs, but a voucher to waive payments was available.

There are two things to note. (1) The study compared “uninsured” to insured patients from before and after health reform in Massachusetts. But, in this sample, “uninsured” patients weren’t that uninsured. They had their care billed to an uncompensated care pool, without copayments! (2) Moreover, the sample is drawn from patients seen at Partners and who had received blood sugar and cholesterol tests. So they were already getting some care for the specific conditions in question before the reform took effect. This is very different from a sample of genuinely uninsured patients not seen by health care providers. Such individuals would have been represented in the data used by Sommers.

To use a technical term, there’s an ascertainment bias in the Stryjewski study. The investigators could only measure characteristics of an “uninsured” (but not really) population that received care. Given the nature of “uninsurance” among those in the sample, that care may have been about as comprehensive as that of insured patients. If the groups basically look the same in that regard, one shouldn’t expect to find a contrast.

This is about all I need to know to explain a big reason why the study authors didn’t observe any improvement for the chronically ill populations it studied (those with high cholesterol, diabetes, or hypertension). The authors turn to the study limitations in their discussion:

Generalizability of our findings to other states should be considered carefully. Compared with Massachusetts, other states might not have as generous a compensated care pool, might not have baseline rates of uninsured patients as low, and might not have as high a concentration of health providers. It is possible that patients with more severe access limitations in other states would have improved outcomes after receiving insurance. On the other hand, it is also possible that other states will have fewer resources for enrolling, subsidizing, or treating uninsured patients after health reform, so that outcomes could be worse compared to those we detected. [...]

[The study design] limits generalizability of our findings to uninsured patients who have contact with the health care system.

Having said all that, what the Stryjewski et al. does tell us is that, for the population studied, the (potentially) chronic care coordination functions of insurance did not seem to make a difference. Maybe those functions weren’t in place or maybe they didn’t work. This is not an insubstantial finding. Chronic disease management is precisely where we should be targeting our efforts to improve health and reduce spending. If insurers aren’t playing a role, why do we have them?

This post begins with links to many others about it.

Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs and an associate professor at Boston University’s School of Medicine and School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs or Boston University.


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There’s little disagreement that health care providers are consolidating. I do not detect a similar degree of agreement about the consequences.

Hospitals and other providers tend to justify consolidation on the grounds that it will improve quality and reduce costs. For years, health policy experts viewed such claims skeptically.

Last summer, Thomas Tsai and Ashish Jha reminded us that there is little evidence that consolidated hospitals improve quality. Quality improvement comes not from size, but from leadership, they wrote. Indeed, work by Jha, and other work by K. John McConnell and others suggests that hospitals boards, CEOs, and other levels of management can play key roles in quality improvement. Moreover, hospitals facing greater competitive pressure have better management practices. In a broad review of the evidence, Martin Gaynor and Robert Town found that, in general, when hospitals consolidate prices go up and quality suffers.

More recent work, published in JAMA, suggests that when they consolidate, “health care organizations and perhaps physicians benefit, in the form of higher prices,” [click to continue…]


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A lot of time, and a lot of ink, has been spent talking about access and Medicaid. Many who oppose the expansion of the program will point to the fact that sometimes evidence shows that fewer doctors accept Medicaid insurance than other types of coverage. There’s some truth there. Medicaid does often reimburse at a lower rate than other insurance coverage, and sometimes doctors don’t want to accept those lower rates. But there’s more to the story.

The recent Medicaid expansion, however, has provided us with the opportunity to explore how children are able to find doctors when on Medicaid and CHIP, especially as Medicaid raised its reimbursement rates as part of Medicare parity. Sandra Decker explored much of this in a recent manuscript, “Acceptance of New Medicaid Patients by Primary Care Physicians and Experiences with Physician Availability among Children on Medicaid or the Children’s Health Insurance Program“:

Objective. To estimate the relationship between physicians’ acceptance of new Medicaid patients and access to health care.

Data Sources. The National Ambulatory Medical Care Survey (NAMCS) Electronic Health Records Survey and the National Health Interview Survey (NHIS) 2011/2012.

Study Design. Linear probability models estimated the relationship between measures of experiences with physician availability among children on Medicaid or the Children’s Health Insurance Program (CHIP) from the NHIS and state-level estimates of the percent of primary care physicians accepting new Medicaid patients from the NAMCS, controlling for other factors.

More children who lived in states where fewer than 60% of primary care providers accepted new Medicaid patients had trouble finding a doctor or difficulty finding someone to see their child (2.9%) than in states where 75% or more of primary care physicians did (1.1%). No such differences existed for those with private insurance. More children in the <60% states didn’t get care in the last year because waits in the office were too long (8.6%) than in the 75%+ states (4.0%), too. The disparities, and the difficulties, were worse for children who had a significant health condition or developmental disability. Almost 16% of kids with significant health conditions or developmental delay experienced a clinic not accepting their insurance in states with less than 60% of primary care docs accepting new Medicaid patients, versus only 3.5% of such kids having this issue in states with at least 75% of primary care docs accepting new Medicaid patients.

One of the nice aspects of the ACA, though, was that it raised reimbursement to more Medicare like levels. This study tried to see if that might make a difference. The answer is a qualified “yes”. The data show that in states where the Medicaid to Medicare primary care fee ratio was under 50%, about 10% of kids with a health condition or developmental delay experienced a doctor’s office or clinic not take their insurance, verses less than 4% of such children having that experience in states with a fee ratio of 75% or more. About 9% of kids like this didn’t get care in the last year because the wait in the office was too long in states with fee ratios less than 50% versus only 4% of kids experiencing this issue in states with a fee ratio of 75% or more.

In other words, when more docs accept Medicaid, fewer kids experience issues with access. When Medicaid reimburses more, fewer kids experience issues with access.

None of this is terribly surprising. Nor is it hard to understand. But it provides a nice data point to bring up when people want to cut Medicaid or make it spend less. The reason it’s so cheap, relative to other types of insurance, is that it does often pay less. However, I’m often struck by how often people who complain about how Medicaid has access issues are also the same people who want to see us spend less on Medicaid. The way to improve access is to spend more. When Medicaid looks more like Medicare, kids have a much easier time.

Of course all this may be moot. The Medicaid fee raises weren’t a permanent part of the ACA. They will expire soon, unless action is taken by Congress.


[Editor’s Note: For more insights on the research and data questions policymakers have about Medicaid, please see AcademyHealth’s recently released Listening Project report: Improving the Evidence Base for Medicaid Policymaking.]


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Placebos raise ethical quandaries, as highlighted by a PLOS ONE study published last summer. At their heart is the notion that placebos only work if patients are deceived as to what they really are (inert). However, another PLOS ONE study suggests that this may not be so.

To elicit views on physicians’ use of placebos, Felicity Bishop, Lizzi Aizlewood, and Alison Adams conducted eleven focus groups, collectively including 58 people residing in England (18 men, 40 women, 19-80 years old). Discussions centered on vignettes presented by the investigators in which placebos were variously prescribed to patients with either a serious or mild condition (terminal cancer or a cold) and with or without deception. The ensuing discussions raised the core ethical tension: should doctors tell the full truth about what placebos are when prescribing them (if at all), or is it OK for them to deceive patients in an attempt to maximize (positive) placebo effects?

This ethical tension rests on two beliefs: (1) To many, “placebo” means “ineffective.” And, (2) there is some benefit merely from thinking one is receiving an effective treatment, in the mere expectation of an effect. Therefore, should a physician disclose that she is prescribing a placebo to a patient holding these beliefs, they act to cancel each other out. One can’t think one is receiving an effective treatment if one is also told that one is receiving a “placebo,” synonymous with “ineffective.” (An exception arises if one disbelieves one’s physician, but that is probably rare among patients who actively seek treatment.)

The idea that the placebo effect can only be harnessed by physicians who deceive patients is an uncomfortable principle to endorse. Who wants to be deceived? On the other hand, there are circumstances in which employing the placebo effect is the best a physician can do to help a patient feel better (i.e., no other therapy would be more effective). Who doesn’t want to feel better?

Not surprisingly, people are torn between wanting to feel better (the consequentialist view) and wanting to preserve control over their care (respecting autonomy). Quotes from the focus groups highlight this tension:


“The point is do I get better? I don’t really care how it happens, to be honest.”

Respecting autonomy:

“I would be furious, I have to say, if I did go to the GP and wanted – needed medication and [...] then find afterwards that it had been a placebo, without my permission, I would want to sue, I would be so angry.”

A few situations dodge the consequentialist-autonomy dilemma. First, when placebos were viewed as ineffective, their use was judged unacceptable by focus group participants. Deception for snake oil and quackery is not OK. Second, some participants thought placebos were a less acceptable use of public and personal resources for minor conditions, like colds, that would resolve on their own. Third, offering placebos to children was viewed as more uniformly appropriate. It was acknowledged that parents do this all the time, with “magic kisses,” and the like. Finally, with informed consent, use of placebos in clinical trials was also felt to be appropriate.

Discussion also turned to the possibility of placebo prescribing without deception.

Some focus groups suggested that careful use of language might resolve the dilemma: if doctors are vague or tentative in how they describe placebos then they might be able to use them to elicit placebo effects without directly lying to patients. In other words, some participants suggested that careful wording (or ‘‘fudging’’ the truth) could be a way of avoiding ‘‘blatant’’ lies and thus rendering placebo-prescribing acceptable.

Could this, or even more straight-forward disclosure, ever work? A study by Ted Kaptchuk and colleagues suggest it’s possible. They conducted a three-week randomized controlled trial (RCT) comparing an open-label (no deception) placebo (N=31) to no-treatment controls (N=39) for patients with irritable bowel syndrome (IBS). The placebo nature of the “treatment” group was disclosed to patients by explaining that it was inactive (an inert substance) like a sugar pill. Further, patients were told that the placebo effect is powerful, that the body can respond to it, a positive attitude helps, and faithfully taking the placebo is critical.

Results after 21 days are summarized in the following figure. In brief, the investigators found statistically significant and clinically meaningful improvements in various measures of IBS symptoms in the open-label placebo group, relative to the no-treatment controls. (A separate study on depression also found encouraging but limited improvements from an open-label placebo.)

IBS placebo

What is unclear from this study is whether the placebo effect would have been even larger if it was closed-label (relying on deceit). However, the authors noted that their open-label placebo response was larger than typical closed-label placebo responses in other IBS studies.

Including use of medications for conditions for which they cannot help (e.g., antibiotics for viral infections), placebos are frequently prescribed. And prior work has found that patients, by and large, don’t mind, without much detail on how they think though the ethical dilemmas. The American Medical Association’s code of medical ethics advises that placebos be used only if a patient provides informed consent. This could put too much emphasis on autonomy if it completely ruins the placebo effect, under the presumption it relies on deceit.

But at least two studies, noted above, suggest we can have our autonomy and our placebo effect too. This is not enough work to convince me that’s generally true, but it’s an interesting possibility.

Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs and an associate professor at Boston University’s School of Medicine and School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs or Boston University.


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NHPC Day 1: At a Glance

by Lindsey Horan on February 9, 2015

The National Health Policy Conference, this year celebrating its 15th anniversary, covers the issues that will define the policy and practice agenda in 2015. Monday’s dynamic sessions revealed the intricacies and complexities of what Congress and the administration face in the year to come, but left panelists and attendees feeling optimistic about the role health services research and health services researchers could play in the policy debate.

Here, you will find a quick recap of some of the day’s sessions from AcademyHealth staff:

Administration’s Plenary on Health Policy Priorities: “The Reward is Worth the Work”

William Corr, Deputy Secretary of the United States Department of Health and Human Services, kicked off the 2015 National Health Policy Conference (NHPC), noting that it’s a historic time to work in the health care field. The transformation, he said, is due in large part to health services researchers, who are helping to create a foundation of research and knowledge for the administration to build upon and pave the path for advancement. Deputy Secretary Corr spent much of his session highlighting the progress made by the administration and states to move millions of Americans into health care coverage, while also noting there is still more work to be done:

“For the sake of our health, our wallets and our economy, we need to go further…We have a responsibility to lead.” He told attendees that the United States isn’t going to be able to fix the health care system unless we make it better and smarter, something in which individuals of all political parties and ideologies have a stake [and something we at AcademyHealth would say requires the contributions of health services research]. “We all have a stake in more access to quality, affordable health care,” said Corr, adding that there was a deep commitment to building on the current health care momentum and writing the next chapter.

Plenary: State Health Policy

With the second open enrollment period closing on February 16, states continue to experiment with new innovations to expand coverage and improve access, quality and cost. This session, moderated by Dan Crippen of the National Governors Association featured Rita Landgraf, Delaware Department of Health and Social Services; Nico Gomez, Oklahoma Health Care Authority; and Brian Neale, Office of the Governor, Indiana.

Speakers discussed varying initiatives to address state-specific challenges and expand coverage in Delaware, Oklahoma, and Indiana, and they agreed that there is a great opportunity for states to use innovations to improve coverage and access. Speakers also agreed on the need to bring all of the players to the table to discuss coverage, payment, and care delivery issues and to create a lean operation and avoid duplication of effort. Nico Gomez stated “…we need to use opportunities to bring everyone to the table to make changes.” 

Another important goal of state strategy that speakers discussed is empowering consumers. Landgraf giving consumers an ownership in health care so that they understand the value of health insurance and access. 

This session highlighted the important role that states have in creating innovations to address changes and expansions brought on by the Affordable Care Act and the idea that states should work together to share ideas, challenges, and solutions. Brian Neale summarized the approach by saying, “When states have the opportunity to work with one another to create best practices, everyone wins.” 

By leveraging multiple state resources, population health, the workforce, payers, employers, technology and more, participants believe that states can achieve success in expanding coverage and achieving the triple aim. Landgraf encouraged attendees to “look innovatively and leverage across the spectrum.”

Late Breaking Session: U.S. Health System Preparedness: Lessons from Ebola & Other Threats

Dr. Nicole Lurie, the Assistant Secretary of Preparedness at the U.S. Department of Health and Human Services moderated a panel on the recent Ebola outbreak and the state of the nation’s public health infrastructure. Dr. Lurie commented on the interconnectedness of the world and the crucial dependence on the efficiency and efficacy of the public health and health care system in order to combat public health threats. 

The recent outbreak exposed healthcare gaps in preparedness procedures and day-to-day infection control processes and begs the question, “what are the roles and responsibilities of the public health and health care system in confronting threats?” Dr. Michael Stoto of Georgetown University compared the Ebola response in New York and Dallas. He asserted that, while systemic breakdowns occurred in Dallas, New York City prepared its institutions, and was able to effectively treat an Ebola case and quarantine individuals who were exposed. 

Dr. Bryce Gartland, Emory University, provided remarks on the importance of adequate funding in order to sustain an appropriate state of readiness Additionally, the importance of communicating risk appropriately is key to the success of systemic response. 

Dr. Jeff Levi, Trust for America’s Health, tied the perspectives together by illustrating that policymakers ramp up resources after adverse events, which eventually dwindle, weakening the necessary infrastructure— including the public health workforce; response training and resources; and the ability of the healthcare system to treat. 

The ACA Punch List: Top 5 Things that Congress Needs to Fix in the ACA

The sentiment coming out of this Monday session is that the Affordable Care Act (ACA) is complicated—and panelists may argue even that is an understatement. Despite varying political ideologies and affiliations, panelists Joseph Antos, Sabrina Corlette, Jon Kingsdale, and Judith Solomon did have a common thread: a deep understanding of the health care system and how the ACA can affect it, noted moderator Timothy Jost.

Although there was some overlap between some panelists—one overlay being the dire need for the legislation’s simplification—viewpoints varied on which components were most important and in need of fixing. These ranged from eliminating surcharge rates based on tobacco use and providing plans with greater health incentives to cover more primary and chronic disease management pre-deductible (Sabrina Corlette, who focused solely on private market reform) to fixing the “family affordability glitch” (Judith Solomon) to computing different tax credits and eliminating extra plans “that serve to confuse” (Jon Kingsdale) to fixing the subsidies and eliminating the mandates (Joe Antos). Ultimately, Jost said, “Repealing the ACA is no more possible than removing the interstate highway system;” at this point, the question is how to amend it, and panelists gave members of  the audience much to think about in that respect. 

Lunch Plenary: Separating the Buzz from the Boon in Population Health

Elizabeth Bradley of Yale University and co-author of The American Health Care Paradox kicked off the luncheon plenary with a discussion on health care spending in the United States as compared to Scandinavian countries, and provided recommendations on what we can do to address the paradox. 

Bradley compared the ratio of health care spending to social services spending in the United States and in the OECD countries: from 2000-2009, for every one dollar spent on health care, the United States spends about 90 cents. For every one dollar spent on health care, OECD countries spend two dollars on social services. 

Countries with higher ratios of social to health spending have statistically better health outcomes. The difference, she suggested, can be attributed to history: in the United States, health care and social service sectors grew up from independently from one another and where as health care grew into a marketable commodity, social services were conceived of being “for the poor.” In Europe, the two sectors were knit together from the beginning.

To address this paradox, Dr. Bradley stressed the importance of debunking the popular American myth that health equals health care. By driving a culture shift on what drives health, separating health from health care, and incentivizing collaboration, we can begin to unravel the paradox of the U.S. health care system.

She highlighted the success of small, individual, champion-led programs, which led to improved outcomes for their populations and encouraged the mobilization of collaboration for health nationally. In addition, she called for common metrics for health care and social providers to measure public spending in order to report on results. 

Following her presentation, Dr. Bradley participated in a panel discussion with Chris Koller, Milbank Memorial Fund and Alan Weil, Health Affairs. Koller emphasized the importance of primary care in improving population health and bridging the gap between health and social services. Weil emphasized the need for new tools and pathways to build capacity for health care organizations to do community-based, population health work. 

Expanding the “Ownership” of the Social Determinants of Health

This session discussed the evolving nature of partnerships and new perspectives on the return on investment (ROI) for non-health sector investments in improving the social determinants of health, and the trans-disciplinary research required to continue to build the evidence base for action.

Dr. Ana Diez Roux, Drexel University, presented rationale for building the evidence base in order to understand the implications of social determinants of health. Dr. Diez Roux urged the audience to consider what place-based factors explain why individual characteristics related to health are spatially patterned.

Building on theme of “place matters,” Amy Gillman, Local Initiatives Support Corporation, presented the community development movementdriving investments to low-income communities to improve the quality of life for all residents. For example, in the Eastern North neighborhood of Philadelphia, an investment in several local programs e.g. a credit union, lead to a 12% reduction in poverty.

Dr. Eduardo Sanchez, American Heart Association, discussed the “upstream promotion of health” to improve the cardiovascular health of individuals, with critical attention to how an individual’s location affects their ability to establish heart-healthy behaviors.  Dr. Sanchez elucidated that low education level and racial segregation contribute as equally, if not more, as tobacco use to poor heart health.

Dr. Alonzo Plough, Robert Wood Johnson Foundation, moderated the session and lead with a call to action to all stakeholders to enable every member of society to make healthy choices through greater resource equity, in order to build a culture of health.  

HSR Impact Award Presentation

Day one of the NHPC ended with the presentation of the HSR Impact Award, an annual award presented to health services research that has made a clear impact on health policy and practice. This year’s award was presented to Jonathan P. Weiner, Dr. P.H., of The Johns Hopkins Bloomberg School of Public Health by Helen Burstin, chief scientific officer of The National Quality Forum, on behalf of his and his colleagues’ groundbreaking work on The Johns Hopkins ACG Case-Mix System.

This model has gained international acceptance as a standardized risk adjustment tool for health services and outcomes research. AcademyHealth congratulates Dr. Weiner and his colleagues on this well-deserved achievement.

Private Sector Health Care Transformation Plenary

Today’s final plenary examined how exactly private-sector payers, provider systems, and recent or new entrants into health care are reshaping the way care is delivered and financed.

Jeffrey Kang from Walgreens Co. discussed how his organization is responding to consumer needs through providing convenience, simplicity, and affordability. According to Kang, providing these characteristics lead to both a simple transactional relationship with a consumer and engagement in other health care channels such as digital health and chronic condition care services.

Innovative technology and technological assistance for both providers and consumers was a reoccurring theme during the plenary. David Notari of Innovation Health stated the importance of providing consumers with the tools necessary to compare prices and make firm decisions in the health care market place, an important factor in achieving better health, higher quality and lower costs. Aparna Higgins, AHIP, further built on this theme by explaining that giving providers data on patients is critical to helping them better manage their practices as well as exchanging health information through access to online portals.

This session was moderated by Susan Dentzer from the Robert Wood Johnson Foundation. 

Adjunct Meetings and Day Two 

This evening’s adjunct meetings include:

  • Student Networking Event
    6:30-8:30 p.m. | President’s Sports Bar & Grill | Renaissance Washington, D.C. Downtown Hotel
  • Disparities Interest Group Networking Happy Hour
    7:00-8:30 p.m. | Penn Quarter | Renaissance Washington, D.C. Downtown Hotel

Tomorrow morning’s adjunct meetings include:

We will update this post with links to presentations as they become available. In the meantime, we hope you enjoy your second day of the NHPC. Be sure to follow us and add to the conversation on Twitter @AcademyHealth, #nhpc15.


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Paying for quality, not quantity is getting to be almost cliche. Recently, the Obama administration doubled down, however, announcing ambitious targets for Medicare payments to be “tied to” quality in the future. Unfortunately, the evidence behind such programs working continues to elude us. This week, two studies were published in JAMA that add to my skepticism. The first, “Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries“:

Importance  The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) provides feedback to hospitals on risk-adjusted outcomes. It is not known if participation in the program improves outcomes and reduces costs relative to nonparticipating hospitals.

Objective  To evaluate the association of enrollment and participation in the ACS NSQIP with outcomes and Medicare payments compared with control hospitals that did not participate in the program.

Design, Setting, and Participants  Quasi-experimental study using national Medicare data (2003-2012) for a total of 1?226?479 patients undergoing general and vascular surgery at 263 hospitals participating in ACS NSQIP and 526 nonparticipating hospitals. A difference-in-differences analytic approach was used to evaluate whether participation in ACS NSQIP was associated with improved outcomes and reduced Medicare payments compared with nonparticipating hospitals that were otherwise similar. Control hospitals were selected using propensity score matching (2 control hospitals for each ACS NSQIP hospital).

Main Outcomes and Measures  Thirty-day mortality, serious complications (eg, pneumonia, myocardial infarction, or acute renal failure and a length of stay >75th percentile), reoperation, and readmission within 30 days. Hospital costs were assessed using price-standardized Medicare payments during hospitalization and 30 days after discharge.

Researchers looked at a decade of data for hundreds of hospitals which did (and did not) participate in the American College of Surgeons National Surgical Quality Improvement Program. Specifically, they looked at whether 30-day mortality, complications, and readmission changed in participating hospitals. They looked at costs as well.

After controlling for patient factors and secular trends, they found no differences at all in outcomes before enrollment, and 1, 2, and 3 years after enrollment. No difference in 30-day mortality (4.5% before, 4.3% after. No difference in complications (11.0% before, 11.1% after). No difference in readmissions (12.8% before, 13.3% after). Mean total Medicare payments didn’t change either.

Some surgical outcomes did improve over the study, but these occurred in all hospitals, even those not in the program. It appears that the quality-based feedback didn’t make a difference.

The second study, “Association of Hospital Participation in a Surgical Outcomes Monitoring Program With Inpatient Complications and Mortality“:

Importance  Programs that analyze and report rates of surgical complications are an increasing focus of quality improvement efforts. The most comprehensive tool currently used for outcomes monitoring in the United States is the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP).

Objective  To compare surgical outcomes experienced by patients treated at hospitals that did vs did not participate in the NSQIP.

Design, Setting, and Participants  Data from the University HealthSystem Consortium from January 2009 to July 2013 were used to identify elective hospitalizations representing a broad spectrum of elective general/vascular operations in the United States. Data on hospital participation in the NSQIP were obtained through review of semiannual reports published by the ACS. Hospitalizations at any hospital that discontinued or initiated participation in the NSQIP during the study period were excluded after the date on which that hospital’s status changed. A difference-in-differences approach was used to model the association between hospital-based participation in NSQIP and changes in rates of postoperative outcomes over time.

Exposure  Hospital participation in the NSQIP.

Main Outcomes and Measures  Risk-adjusted rates of any complications, serious complications, and mortality during a hospitalization for elective general/vascular surgery.

This study looked at surgical outcomes at hospitals also participating, and not participating, in this program. Specifically, they looked at elective surgery to look at rates of complications and mortality from 2009 to 2013. More than 100 hospitals took part, with more than 345,000 hospitalizations. The most common procedures were hernia repairs, bariatric surgery, mastectomy, and cholecystectomy. After controlling for other factors, once again there were no differences between hospitals in the quality programs and those out of them with respect to complications, serious complications, or mortality.

From the accompanying editorial:

The most likely explanation for the findings of these 2 studies is that end-results information, although necessary for improvement, is not sufficient, and that the skills necessary to make effective changes in processes and cultures do not yet pervade US hospitals, to say the least. Both research groups speculate about that as a reason for their results. As Osborne et al suggest, “Changing physician practice requires complex, sustained, multifaceted interventions, and most hospitals may not have the expertise or resources to launch these effective quality improvement interventions.”

I agree. I’ve said so before, and I’ll say it again. I think the problem with our quality metrics is that we use the ones that are easy to measure, not the ones that “matter”. Getting information is also just the first step. Using it to change behavior and practice requires infrastructure, time, and money. We routinely underestimate how much more than just “data” is necessary. As long as we continue to do so, I fear many of the announcements we see about “paying for quality, not quantity” will amount to sound and fury.



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The Ebola epidemic is a stark reminder that the United States needs a multi-pronged strategy to ensure vigilance and capacity to respond to all health threats. A late-breaking session, “U.S. Health System Preparedness: Lessons from Ebola & Other Threats” has been added to the 2015 National Health Policy Conference agenda for February 9 at 11:00 a.m. ET. The session will be moderated by Dr. Nicole Lurie, Assistant Secretary of Preparedness and Response, U.S. Department of Health and Human Services. On site registration is still available.

On November 3, 2014 the Institute of Medicine in partnership with the National Academy of Science convened experts and stakeholders for Research Priorities to Inform Public Health and Medical Practice for Domestic Ebola Virus Disease (EVD): A Workshop. AcademyHealth research assistant Danielle Robbio prepared the following reaction to the event.


The recent epidemic of Ebola has thrust public health preparedness back into the spotlight. The disease has spread rapidly and dangerously across West Africa (Guiena, Liberia, Sierra Leone, Nigeria and Senegal) and cases have been confirmed in the United States. As media attention and scrutiny dies down, the opportunity exists to examine the three core functions of public health (i.e., assessment, policy development, and assurance). The field of health services research, and its sub-discipline, public health services and systems research (PHSR), is positioned to address the systems-level challenges posed by this unique threat. PHSR investigates the public health system’s organizational structure, financing, and processes, and could point to strategies for addressing the spread and treatment of a transnational disease, as well as chronic threats to America’s health.

The 2014 IOM workshop  convened experts from all arenas—virologists, wildlife specialists, public health officials and physicians—in order to identify research priorities to prevent further spread and future outbreaks. (Read the full brief here.) In kicking off the event, Dr. Lurie noted “We do believe that it’s possible to help to foster research during a response to inform practice and also to ensure that guidance in the future is based on the most current and best available science and to make sure that data are gathered before they are lost.”

(For more on the importance of studying real-time events, and methodological considerations for researching public health emergency preparedness system capacities, see:Getting from What to Why: Using Qualitative Methods in Public Health Systems Research)

Ultimately, this outbreak has sparked a nationwide re-examination of the unique role of governmental public health. How will the public health system respond to a transnational disease outbreak? How should it respond? And, more broadly, how should the public health infrastructure adapt to meet new population health challenges?

Given this increased scrutiny, the field of PHSR has the opportunity to revisit the three core functions of public health and address the systems issues raised in the workshop i.e., impact of Ebola on healthcare settings and procedures, household and mass transit risks, and vulnerabilities in the health care safety net. PHSR provides evidence that practitioners need to answer these questions, evaluate successes, identify best practices, and most important, learn from failures.


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Use and abuse of opioid medications and attendant problems have grown tremendously since the late 1990s or so, fueling a quadrupling of deaths from opioid pain relievers between 1999 and 2010. Well aware of the growing problem, state governments and federal agencies have attempted a range of remedies. A recent, NEJM-published study by Richard Dart and colleagues offers evidence that they may have helped, in a way, but may have also encouraged a shift from painkiller use to heroin.

Attempts to address the opioid painkiller abuse epidemic are numerous. Some examples include:

Many other state laws regulating access to and dispensing of opioid painkillers are found at this CDC page.

Perhaps the increased attention to the opioid problem is penetrating clinical practice. Catherine Hwang and colleagues published results in JAMA Internal Medicine of a survey of 420 primary care physicians, examining their attitudes and perceptions of use and abuse of prescription drugs. The vast majority (85-90%) reported that drug abuse is a “big” or “moderate” problem and that opioids are over-prescribed. Yet, nearly half said they were prescribing them less than one year ago.

Richard Dart and colleagues used the collection of data sources that comprise the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System to assess use and abuse of opioid painkillers from January 2002 through December 2013. They also obtained measures of heroin use from the National Poison Data System and the National Survey on Drug Use and Health, prescription volume from IMS Health, and population data from the 2000 and 2010 U.S. Census.

The authors found that prescriptions of opioid painkillers grew from 47 million in first quarter of 2006 to 62 million in the fourth quarter of 2012. However, since then, prescriptions dispensed has trended downward to 60 million in the final quarter of 2014. Provided this recent downward trend of prescriptions written isn’t adversely affecting those for whom use for pain would be appropriate, this is good news. Overuse may still exist, but its growth may have abated.

opioid prescriptions

One notable exception to the trend suggested in the chart above is from the College Survey Program. The authors’ analysis of that data set found that the rate of nonmedical opioid painkiller use increased from 0.14 per 100,000 college students in 2008 to 0.35 by the end of 2013.

As prescriptions for opioid painkillers have leveled off, heroin use has increased. For example, data from the National Poison Data System show that the rate of heroin use accelerated in late 2010. At the same time, abuse of extended-release OxyContin decreased. Other data sources included in the RADARS are consistent with these findings, with the notable exception of the College Survey Program.

abuse rate

It is possible that those who would have otherwise abused OxyContin switched to heroin. But it’s also possible some of them used other opioid painkillers not shown in the chart above. However, death rate evidence suggests a more systemic substitution of heroin for opioid painkillers since 2010. Opioid painkiller deaths increased from 2002-2006, plateaued, and then decreased from 2009-2013. In contrast, heroin deaths were flat until 2010, and then increased.

The forgoing evidence suggests that policy interventions may have had their intended impact, though we can’t prove that. The authors wrote, for instance, that “studies show that the introduction of a less desirable formulation of oxycodone can rapidly decrease demand for that formulation.” At the same time, they may have encouraged substitution of heroin for opioid painkillers, which certainly is not their intent. “[I]t seems likely that the reformulation of extended-release oxycodone in 2010 has contributed to the increase in reported heroin use,” the authors wrote.

Whether it’s heroin or painkillers, we’re still in the midst of an opioid epidemic. Policy interventions may be helping, but the myriad sources for opioids, as well as accommodations for appropriate use, complicates efforts to address the problems they create.

Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs and an associate professor at Boston University’s School of Medicine and School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs or Boston University.


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The Common Rule is undoubtedly one of the most significant governing documents in research today, with jurisdiction over human research subjects and Institutional Review Boards, or IRBs. Human subjects research protections and relating policies are critical to the public good, and have the potential to dramatically impact the conduct of research. As such, they are of the utmost importance to AcademyHealth and its members. In late 2014, two different comment opportunities surfaced that had the potential to affect human subjects research, and AcademyHealth had a responsibility to respond on behalf of the field.

Disclosing Reasonably Foreseeable Risks in Research Evaluating Standards of Care

In October, the Office for Human Research Protections (OHRP) announced the invitation of public comments on its Draft Guidance on Disclosing Reasonably Foreseeable Risks in Research Evaluating Standards of Care. Within the draft guidance, OHRP specifically addressed what risks to subjects are presented by research evaluating standards of care, and which of these risks are reasonably foreseeable and should be disclosed to prospective research subjects as part of their informed consent.

As written, AcademyHealth felt the guidelines would have a negative effect—both on the ability to develop critically needed knowledge and on the likelihood of patients enrolling in studies that would provide them with more information on risks and benefits than they currently receive as part of routine care. There is important work being done to clarify public attitudes on consent in this type of research, and if OHRP were to implement this draft, the participation of those patients representative of the intended target population could be jeopardized.

The full set of comments can be found here.

Use of a Single Institutional Review Board for Multi-Site Research

In December the National Institutes of Health (NIH) released a request for comments on the Draft NIH Policy on the Use of a Single Institutional Review Board for Multi-Site Research.

AcademyHealth believes the proposed revision from NIH will speed the initiation of studies by reducing administrative burdens to scientific innovation and progress while simultaneously assuring the rigorous and potentially enhanced protection of human subjects.

The full set of comments can be found here.

AcademyHealth continues to monitor for comment opportunities that would advance our field, promote the interests of our members, and ultimately contribute to the improvement of health and health care. Continue to monitor our work through the AcademyHealth blog and on the advocacy portion of our website.


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