Aaron E. Carroll's Blog, page 18

Climate Change and Health: Heat, Rain, Storms, and Fires

Climate change is causing weather events that are a direct threat to human life. We’re not gonna lie, this is an anxiety-provoking topic, as is much of the conversation surrounding climate change. Increased heat, changing precipitation patterns, and increased wildfires all have a host of health impacts for individuals and populations. Let’s talk about it.

 



The post Climate Change and Health: Heat, Rain, Storms, and Fires first appeared on The Incidental Economist.

Fraud and Dysfunction in American Healthcare: The 2022 Shkreli Awards

The 2022 Shkreli Awards have been released! Each year, the Lown Institute passes out awards as a way of reporting on dysfunction in the US health care system. Dysfunction in healthcare is one of our foundational pillars here at Healthcare Triage, and these awards highlight some of the worst examples.

 



The post Fraud and Dysfunction in American Healthcare: The 2022 Shkreli Awards first appeared on The Incidental Economist.

Lessons Learned From Studying Healthcare Abroad

In this episode, Dr. Aaron Carroll talks with Julie Manning Magid, executive associate dean of the IU Kelley School of Business in Indianapolis, and Nir Menachemi, executive associate dean of the IU Richard M. Fairbanks School of Public Health, about the Kelley School’s global health course in its Physician MBA Program. Students recently had the opportunity to immerse themselves in the health care systems of the United Kingdom and France. Menachemi and Magin discussed the fascinating differences between health care systems and the cultures around them in different countries and the United States, as well as what American doctors can learn from these immersive international experiences.

 

Transcript: bit.ly/3ZrRImf

This Healthcare Triage podcast episode is co-sponsored by Indiana University School of Medicine, whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research, and patient care, and the Indiana Clinical and Translational Sciences Institute, a three way partnership among Indiana University, Purdue University and the University of Notre Dame, striving to make Indiana a healthier state by empowering research through pilot funding, research education and training. More information on the Indiana CTSI can be found by visiting IndianaCTSI.org.

The post Lessons Learned From Studying Healthcare Abroad first appeared on The Incidental Economist.

Safer Schools Means Better Mental Health Outcomes for LGBTQ+ Students

Schools are becoming less safe for LGBTQ+ youth and students are facing more mental health challenges as a result. My piece, recently published in Public Health Post, explores what can be done to stop increases in interpersonal and structural discrimination at school.

I suggest a mix of local interventions and broader policies to support the wellbeing of LGBTQ+ students. Local interventions likely to help include using school psychologists/social workers to promote anti-bullying, cultural competency, and inclusive curriculums. If passed, federal policies, such as the Safe Schools Improvement Act and the Equality Act, would ban LGBTQ+ discrimination in schools.  

Read the full article here.

The post Safer Schools Means Better Mental Health Outcomes for LGBTQ+ Students first appeared on The Incidental Economist.

Reforming Federal Laws that Slow Marijuana Research

Marijuana is classified as a Schedule I drug, making it difficult for researchers to study, and difficult to understand how it may help or harm our health. A recently passed bill is aimed at making marijuana research easier to conduct, and we’re here to talk about the pluses and the shortfalls of the bill’s final version.

 



The post Reforming Federal Laws that Slow Marijuana Research first appeared on The Incidental Economist.

Climate Change Is Already Impacting Our Health

Massive storms, flooding, extreme heat, droughts, air pollution, increased rates of disease, changes to our food and water… global warming, and the changes to climate that come with it, are increasing human health risks. Our physical and mental health both stand to suffer, and some populations are more vulnerable than others. What are the specific health issues, what can we do to address them, and most importantly – is there any hope? We hope to answer these questions and more in a handful of episodes on Climate Change and Health. This year, we’re going to be taking a look at how Climate Change can impact health.

 



The post Climate Change Is Already Impacting Our Health first appeared on The Incidental Economist.

Hospitals in Texas serving some of the most vulnerable populations are expected to do more with less

Hospitals have the opportunity to play a significant role in addressing inequities in the communities they serve. This is particularly true in Texas, a state that exhibits some of the starkest disparities in health care coverage and access and other socioeconomic outcomes. But Texas hospitals serving some of the most vulnerable groups may be less capable of investing in the unmet needs of their patient populations, due to limited resources.

Hospitals serve as anchor institutions: they remain in place, even as conditions around them change, and have long-term, deeply-rooted investments in the communities they serve. This positions hospitals to understand and address the factors in the community that shape people’s health — the conditions in which people are born, grow, live and work — in addition to serving patients’ direct health needs.

Unequal access to employment, housing, education and social integration and support systems can deepen health inequities. For example, people who are chronically homeless experience higher morbidity and increased mortality. And beyond facing poorer health, unstable housing, such as moving frequently or falling behind on rent, can result in disruptions to employment and the receipt of social service benefits, among other adverse outcomes.

By leveraging their central role in their communities, hospitals can play an important role in intervening in some of these upstream challenges. For example, hospitals can connect patients with resources outside of the health system, like housing advocacy organizations and employment agencies.

In Texas, the need for this type of engagement is particularly acute.

Texans face more problems related to social and economic factors than people elsewhere in the nation. Among the 50 states, Texas ranks sixth in food insecurity and seventh in income inequality. The state has also invested significantly less in its  social safety net programs. For example, despite overwhelming public support for expansion, Texas is among the 11 states that have not expanded their Medicaid programs. About one in five residents lack health insurance — the highest uninsured rate in the country. Nearly three in ten people in the state report having no usual source of medical care, and almost half report affordability challenges.

Hospitals in Texas — especially those serving some of the state’s most vulnerable populations — could play a particularly important role in addressing these pressing needs. But a recent study from our Harvard research team suggests that they may not be equipped to do so.

In our study, we took a look at what hospitals serving people with more need (like rural hospitals, critical access hospitals, and safety-net hospitals) are doing to address community drivers of health. We found that, across the country, these hospitals aren’t playing as big of a role as one would expect. They aren’t asking patients about whether they experience problems like housing and food insecurity any more than hospitals expected to serve less vulnerable patients (like urban hospitals, non-critical access hospitals, and non-safety net hospitals). They also aren’t implementing more programs or interventions targeting social needs; in some cases, they’re actually doing less. These hospitals also have fewer partnerships with community organizations that focus on these areas compared to hospitals not specifically serving vulnerable populations.

Texas is no better than average on these measures; what’s happening in the state largely mirrors what’s happening at the national level. And, on one of the measures we looked at (number of community partnerships), Texas is actually worse than average when compared to the rest of the country.

Addressing what makes us healthy should be a priority for all hospitals, especially in Texas. But hospitals serving patients with greater need oftentimes lack funding to even provide sufficient medical care to meet the needs of their communities. More attention has been devoted to easing financial pressure on hospitals at the federal level; pandemic relief legislation has provided enhanced financial support for hospitals, with an eye towards hospitals that provide care to underserved groups.

But more needs to be done at the state level. Last year, the Texas House passed a bill to establish an Office of Health Equity. Among other things, this office would’ve studied health outcomes in rural and underserved parts of the state; this work could’ve helped policymakers identify regions with higher need. This bill died in the Senate, taking a back seat to other issues.  But just because attention waned doesn’t mean the need hasn’t. Allocating resources to high-need hospitals should be a priority for the state; increased funding would significantly help these hospitals address their patients’ needs. The state’s inattention to the factors that give rise to poor health is a missed opportunity.

Research for this piece was supported by the Episcopal Health Foundation.

The post Hospitals in Texas serving some of the most vulnerable populations are expected to do more with less first appeared on The Incidental Economist.

Narrow Networks and the Quality of Care in Medicare Advantage

In my last blog post, I explored whether Medicare Advantage (MA) networks vary by plan-type within contract. Although networks are regulated at the contract level, differences in plans’ characteristics and cost-sharing may create some variations in plan networks under the same parent contract (e.g. if one contract has both an HMO plan and HMO-POS plan). Given the potential variations in plans’ networks, it is important to think about why networks matter in the first place.

Network breadth is just one of many factors that MA beneficiaries might consider when choosing a plan that is right for them. Generally, networks allow insurers to govern which providers beneficiaries can see and at what cost. This influences beneficiaries’ choice of and timely access to primary care and specialty providers.

Typically, broader networks with larger selections of physicians and specialists that patients can see without prior authorization have higher monthly premiums. Conversely, plans with narrow networks—which Kaiser Family Foundation (KFF) defines as having fewer than 30% of physicians in network—have significantly less expensive premiums, on average ($54 vs. $4 per month for HMOs & $100 vs. $28 per month for PPOs).

While it’s clear that beneficiaries face a tradeoff between network breadth and their costs, what are they getting in terms of quality of care when they buy into a broader or narrower network plan? Current literature indicates that there is an association between network narrowness and quality, but maybe not in the way one would expect. Several studies using 2019 Vericred Provider Directory Data (now Ideon) presented evidence that narrow MA networks had better performance on plan quality metrics compared to non-narrow network plans, as measured by Center for Medicare and Medicaid Services’ (CMS) Star Ratings. For MA plans, star ratings are scored on up to 38 measures, capturing information on plan’s care coordination, access-related measures, chronic disease management, screenings and other preventive care metrics, etc.

Sen and colleagues found that approximately 30% of MA beneficiaries were enrolled in narrow network plans in 2019. Among those narrow network plans, over 50% of plans had star ratings of 4.5 or higher out of a total of 5 stars; whereas only 9.2% of non-narrow plans exhibited star ratings of 4.5 or higher. The work of Meyers et al. also found similar results demonstrating that the highest rated MA contracts were associated with having the narrowest primary care networks. In both studies, the authors used a more restrictive definition of “narrow network” than KFF, with narrowness defined as having less than 25% of available providers in a geographic service area, in-network.

Collectively, these findings may suggest that narrowing networks have the potential to act as a policy lever in lowering health care costs without compromising the quality of care. One explanation would be that plans with narrow networks are incentivized to selectively contract with high-performing, quality physicians and provider groups under the Star Rating program, given the bonuses associated with high star-ratings. Additionally, Urban Institute’s interviews with MA plans in 2018 found plans expressing that narrow networks allowed them to more actively control spending and cost-savings through coverage restrictions that lower utilization, deterring unnecessary low-value, high-cost services.

However, this does not mean we should entirely rule out concerns over narrowness. We need to consider the impact that narrowness may have on beneficiaries’ access to care, racial and ethnic disparities, and beneficiaries in need of mental and behavioral health providers (which we know are sparse and frequently excluded from MA networks).

Moreover, as CMS works towards developing a centralized, nationwide provider directory, it will be important for them to provide beneficiaries with accurate and transparent information on plans’ networks and the quality of physicians included. While we should continue studying network narrowness and its effects, we must also recognize that for most consumers, knowing the extent of a plan’s network may not be that informative. As the studies above show, beneficiaries in narrow network plans seem quite satisfied with the quality of care received.

As CMS calls for public input on creating this centralized directory, it may not be necessary to request explicit information on how broad or narrow a provider’s network may be. Instead, provider metrics of timely access, quality, and cost might the most relevant pieces of information to assist beneficiaries when selecting a plan. To fully help beneficiaries realize access, however, more work will be needed from CMS. Even with a centralized directory, issues concerning “ghost providers” remain an issue, as observed in the Medicaid Managed Care program, and regulatory audits and enforcement of network adequacy standards will be needed to ensure that providers listed “in-network” are accepting of MA patients and not just those who are commercially insured.

Research for this piece was supported by Arnold Ventures.

The post Narrow Networks and the Quality of Care in Medicare Advantage first appeared on The Incidental Economist.

A Fentanyl Vaccine Shows Promise

Fentanyl is many times more potent than heroin or morphine, and is responsible for a lot of overdose deaths. Recent news reports have covered a potential fentanyl vaccine – how does that work, and how far are we from human trials?

 



The post A Fentanyl Vaccine Shows Promise first appeared on The Incidental Economist.

Noise is more than a nuisance

I recently moved into a city’s downtown from the suburbs and was immediately greeted with noise. I started thinking about the impacts of noise pollution on health, both mental and physical, and what I learned is that it isn’t good.

I wrote about this recently in The Valley Breeze, a Rhode Island newspaper:

First declared a public health hazard in 1968, the cacophony around us is growing. There is no “on/off switch” for our ears either, so we can’t mitigate our own exposure…This trend isn’t without consequence. Not only does noise pollution reduce our quality of life but it also hurts our health.

Read the full article here.

Research for this piece was supported by Arnold Ventures.

The post Noise is more than a nuisance first appeared on The Incidental Economist.