Aaron E. Carroll's Blog, page 32

The Association Between Continuity of Marketplace Coverage During Pregnancy and Receipt of Prenatal Care

Elsa Pearson, MPH, is the policy director of the Partnered Evidence-based Policy Resource Center at VA Boston. She tweets at @epearsonbusph.

Pregnancy is a significant life event, one that typically leads to substantially more interaction with the health care system than average. In the United States (US), pregnant people usually have about one health care visit per month of pregnancy, during which they receive a myriad of services. However, access to high quality prenatal care — and enough of it — is often limited by one’s health insurance coverage.

When the Affordable Care Act was enacted, it established the individual Marketplaces from which those who are ineligible for Medicaid, Medicare, and/or employer-sponsored insurance can purchase coverage. However, pregnancy is not considered a qualifying life event, so an individual cannot just sign up for coverage once they find out they’re pregnant; they must wait until the next open enrollment period or the birth of their child, whichever comes first. Thus, they may be stuck without coverage during pregnancy. This can have a significant impact on access to appropriate prenatal care.

New Research

A recent study in Health Affairs looked at Marketplace enrollment patterns for pregnant people and the impact of Marketplace insurance coverage on their health and care utilization.

The authors are Sarah Gordon and Melissa Garrido from Boston University School of Public Health (BUSPH) Health, Law, Policy, and Management Department (HLPM) and VA Boston Healthcare System; Charlotte Alger from BUSPH HLPM; and Eugene Declercq from BUSPH Community Health Sciences Department.

The authors used data from the Pregnancy Risk Surveillance and Monitoring System (PRAMS) from 2016 to 2018. Developed by the Centers for Disease Control and Prevention, PRAMS is a self-reported survey within 40 states and New York City and is representative of 83 percent of all US births. State health departments pull a representative sample of recent births from birth certificate registries and reach out via mail and telephone to the selected mothers. The survey asks respondents about health status and behaviors, health care use, and insurance coverage.

With these data, they studied two questions. First, they assessed how likely pregnant people were to be enrolled in Marketplace insurance coverage preconception, during pregnancy, and/or postpartum. Sample size for this question was 6491 and the authors used simple descriptive analysis techniques.

Second, they studied how Marketplace enrollment impacted individuals’ receipt of prenatal care, such as the number of prenatal visits, receipt of care within the first trimester, and receipt of specific health care services like flu shots and screenings for intimate partner violence and depression. The sample size for this question was 3443, limited to individuals who reported Marketplace coverage during pregnancy. The authors used logistic regression models and inverse probability of treatment weights to conduct these analyses.

Findings

For enrollment, the authors found that about one third of respondents had continual Marketplace coverage, from preconception to postpartum. Of those who were only enrolled in the Marketplace preconception, over 70 percent reported Medicaid coverage during pregnancy. Of those who were only enrolled in the Marketplace postpartum, almost 50 percent reported Medicaid coverage and one third reported employer-sponsored insurance coverage during pregnancy.

For impact of enrollment during pregnancy, the authors compared those with continuous coverage (preconception to postpartum) to those who only enrolled in the Marketplace during pregnancy. Those with continuous Marketplace coverage were more likely to have “adequate” or “more than adequate” prenatal care use. (The authors defined these classifications using the Adequacy of Prenatal Care Utilization Index which measures timing and quantity of care.) Those with continuous coverage were also more likely to initiate prenatal care in the first trimester, though over 80 percent of respondents in both groups did so. The authors did not find any significant differences in the likelihood of receipt of particular prenatal services, such as flu shots or social/mental health screenings.

Limitations

There were several limitations to this study due to the nature of the PRAMS data set. For example, PRAMS is self-reported, subject to both recall bias and response bias. Plus, the survey is not conducted in all states and, thus, assumptions must be made about generalizability. Lastly, PRAMS simply includes a finite set of questions; this is certainly understandable but does limit researchers’ analyses.

Discussion

With the connection between insurance coverage and access to care clear, several notable policy questions arise from this study. Classifying pregnancy as a qualifying life event is perhaps the most obvious. As mentioned previously, pregnancy is not a qualifying life event, though the birth of a child is. (Only two states have implemented policies to the contrary.) Allowing an individual to sign up for health insurance coverage once pregnant, rather than waiting until birth or the next open enrollment period, could improve access to prenatal care and even improve maternal and child health outcomes.

Another related policy implication is determining what type of insurance is ideal for pregnant individuals. The authors found that individuals without Marketplace coverage often have other types of coverage, at least temporarily. What type of insurance is best or most cost-effective for pregnant people — and the benefits of coverage continuity regardless of type — could be studied further.

The study did not touch on the quality of prenatal care but that is also worth discussion. In the US, pregnant people tend to receive far more prenatal care than other countries but that doesn’t mean the quality is better, nor do maternal health outcomes suggest that’s true. In fact, the US’ maternal health outcomes are some of the worst in the industrial world.

Pregnancy is full of changes, expenses, and challenges. Determining how Marketplace insurance coverage — which has been around for a decade — access to care, and maternal and child health outcomes all interact from preconception to postpartum warrants more study.

The post The Association Between Continuity of Marketplace Coverage During Pregnancy and Receipt of Prenatal Care first appeared on The Incidental Economist.

Would Medicare for All Increase Your Wages?

Medicare for All, which would extend health coverage to all Americans, has been a hot topic of debate in recent years. Researchers have looked into the many ways that a switch to Medicare for All might change our lives, and one of those areas of change might be wages. Employer provided healthcare is baked into our current system of healthcare, and there are a lot of studies that look at how employer paid premiums can depress wages, and how our paychecks might shift in a M4A-type situation.

 

This video was adapted from a column Austin wrote for the Upshot. Links to sources can be found there.

The post Would Medicare for All Increase Your Wages? first appeared on The Incidental Economist.

If Economists Chose the Health Care System

Health economists study the economic determinants of health. They also analyze how health care resources are utilized and allocated, and how health care policies and quality of care can be improved. In this episode, we discuss what exactly a healthcare system would look like if these professionals were calling all the shots.

This video was adapted from a column Austin wrote for the Upshot. Links to sources can be found there.

The post If Economists Chose the Health Care System first appeared on The Incidental Economist.

Parasites & Monster Legends on The Healthcare Triage Podcast

If you’ve contracted toxoplasmosis from your cat, you may be more likely to take risks. So why not take the plunge and listen to this podcast?

As Halloween approaches, Bill Sullivan, PhD, joins the Healthcare Triage podcast to share his research on the “zombifying” parasite toxoplasma gondii, and the science behind monster legends like vampires, werewolves and zombies.

 

 

Healthcare Triage podcasts are hosted by Aaron Carroll, MD. The podcast is sponsored by the IU School of Medicine and the Indiana Clinical and Translational Sciences Institute (CTSI).

Available wherever you get your podcasts! Including iTunes

The post Parasites & Monster Legends on The Healthcare Triage Podcast first appeared on The Incidental Economist.

Do you want one of the best jobs in the world?

Are you an accomplished pediatrics researcher, well-established in her or his career, who has considerable experience leading researchers and research teams and executing programmatic initiatives? Do you have a commitment to policy-relevant research, and are you energized by the possibilities of cultivating and sustaining productive relationships with faculty and staff, external research collaborators, funders, operational partners, and other key stakeholders? Do you have an interest in pediatric health services, informatics, patient-centered outcomes research, comparative effectiveness research, and translational research, including organizing and financing of care, clinical evaluation and outcomes research, monitoring and accountability, clinical decision making, populations and communities, artificial intelligence, data science and analytics and provider and consumer behavior?

Would you like the best job in the world?

Ok, clearly, I’m biased, but here in the Department of Pediatrics, at Indiana University School of Medicine, we’re looking for someone with vision, thought leadership, intellectual curiosity, integrity, excellence, and research expertise to start as the Associate Director for two key divisions – Children’s Health Services Research and the Center for Pediatric and Adolescent Comparative Effectiveness Research – help merge them, and then take over as Director.

My first job was in CHSR, and I later founded and became Director of PACER. The current director of CHSR (Sarah Wiehe) and I want to do a planned transition/merger of these very successful groups, helping to hand over leadership to the new AD->D while we step back and focus on new roles (Sarah co-runs our CTSI, and in addition to other jobs, I’m now Chief Health Officer for IU).

I can’t stress enough that you’d be taking over two groups that are extremely successful in their own rights. The merged group will be a powerhouse. The Department of Pediatrics couldn’t be in better shape. This position, and the center, would be extremely well resourced and set up for success.

Here is the official job posting. We are looking for someone in the Associate/Full Professor range, and although it should go without saying, I’ll say it anyway:

As the nation’s largest medical school, IUSM is committed to being an institution that not only reflects the diversity of the learners we teach and the patient populations we serve, but also pursues the values of diversity, equity, and inclusion that inform academic excellence. We desire candidates who enhance our representational diversity, as well as those whose work contributes to equitable and inclusive learning and working environments for our students, staff, and faculty. IUSM strives to take an anti-racist stance, regularly evaluating and updating its policies, procedures, and practices to confer equitable opportunities for contribution and advancement for all members of our community. We invite individuals who will join us in our mission to advance racial equity to transform health and wellbeing for all throughout the state of Indiana.

When I moved to Indiana 18 years ago, I had never lived in the midwest. I thought I’d be here five years and leave. I’m still here – many years later – largely because this is just the absolute best place to work. This job will be one of the best there. You’d be foolish not to consider it!

Questions? Email or DM me!

@aaronecarroll

The post Do you want one of the best jobs in the world? first appeared on The Incidental Economist.

The Pitfalls of Cost Sharing in Healthcare

Cost-sharing is the practice of making individuals responsible for part of their health insurance costs beyond the monthly premiums they pay for health insurance – think things like deductibles and copayments. The practice is meant to inspire more thoughtful choices among consumers when it comes to healthcare decisions. However, the choices it inspires can often be more harmful than good.

 

This video was adapted from a column Aaron wrote for the Upshot. Links to sources can be found there.

The post The Pitfalls of Cost Sharing in Healthcare first appeared on The Incidental Economist.

HSR Special Issue Call for Abstracts: Age-Friendly Health Systems

Health Services Research (HSR) and The John A. Hartford Foundation are partnering to publish a Special Issue on Age-Friendly Health Systems. Abstract proposals are due November 22, 2021.

A key challenge facing health systems in the United States and around the world is how to best design services to provide care to a growing population of older adults that is heterogenous in health and function. The spectrum for this population will range from healthy and fit persons to others with serious illness and disability including a small number with high healthcare needs and who incur high costs. Across this spectrum, many of these individuals will be among the most vulnerable to the effects of inequality, climate change and emerging infectious diseases, as we have recently witnessed. Our healthcare systems are not always designed to address these vulnerabilities. As such, they are at increased risk for complications including delirium, medication-related adverse events, falls and complications associated with reduced mobility.

To address these issues, The John A. Hartford Foundation, Institute for Healthcare Improvement, American Hospital Association, and the Catholic Health Association have collaborated on an initiative to improve the safety and effectiveness of care for older adults. The Age-Friendly Health Systems (AFHS) movement builds on existing evidence-based models of geriatric care and integrates with a wider ecosystem of age-friendly public health, public policy, cities, and states.

The goal of the AFHS initiative is to aim for all care with older adults to be age-friendly care. Its work is intended to improve the experience of care for older adults, reduce health care-related harms, improve satisfaction with care, reduce costs, address health disparities, gaps, and inequities in care, and optimize value for patients, families, caregivers, healthcare providers, payers and health systems.

Therefore, the goal of this Special Issue is to highlight cutting-edge work that showcases the potential to learn from those involved in understanding, designing, implementing and studying age-friendly programs and policies.

Find more information about the issue and how to submit an abstract here.

The post HSR Special Issue Call for Abstracts: Age-Friendly Health Systems first appeared on The Incidental Economist.

Regulating Contagion

Last semester, I developed a new class at the University of Michigan called Regulating Contagion: Pandemics and Disease in U.S. Legal History (syllabus here). Drawing partly on a seminar I co-taught back in 2015, and partly on work as special counsel to Governor Whitmer on her COVID-19 response, the class advanced three big ideas.

First: COVID-19 is not an anomaly. Contagion has shaped American history and law from the moment of first contact, when smallpox and other novel diseases ravaged Native American tribes and cleared the way for their dispossession. The relative vulnerabilities of American and British troops to malaria and smallpox were strategically crucial in the Revolutionary War; yellow fever paved the way both for the Louisiana Purchase and aggressive exercises of maritime quarantine; and the threat of cholera led to the creation of the country’s first modern public health agency in New York City. Plague, variola minor, typhoid, flu (both the Spanish flu and the 1976 swine flu), malaria, AIDS, and SARS all left indelible marks in American law. And all of the debates we’re having over COVID-19—about the tension between individual liberty and collective responsibility, the allocation of authority between state and federal governments, and the harms that disease disproportionately visits on marginalized groups—have historical antecedents.

Second: A study of contagious disease in the United States challenges the pervasive narrative that the nineteenth-century state was weak and that Americans have always been—and will always be—suspicious of state authority. Confronted with extraordinary threats to life, Americans time and again moved aggressively to restrict travel, quarantine vessels, compel vaccinations, isolate the sick, tear down infected buildings, and curtail social interactions. We tend to overlook those measures, both because historical memory is short and because public health law first took shape in states and municipalities, which receive much less attention from legal scholars than the federal government. But we are the heirs of an interventionist state, not a recessive one.

Third: Contagious disease offers an unusually good vantage point from which to study American legal development and in particular the evolution of public health law. From an initial focus on coercive measures designed to prevent person-to-person spread, the nineteenth century witnessed a shift toward sanitary interventions that aimed to create better conditions for health. Contrary to popular imagination, the courts have generally upheld aggressive public health actions, including those that have severe and sometimes troubling implications for personal liberty. Over time, the federal government has gradually accrued more authority to control disease, especially in connection with travel and with the approval of drugs and vaccines, while leaving most day-to-day responsibility with the states. Etc.

The class was immense fun to teach and I think/hope the students got a lot out of it. Somewhat unexpectedly, I came around to the view that it was a valuable addition to the law school curriculum and would be worth teaching even if we were not in the midst of a global pandemic.

In case anyone else is hoping to teach a similar course, the syllabus is here, with many thanks to the historians, lawyers, and science journalists—including Bill Novak, John Witt, Howard Markel, Elizabeth Fenn, Polly Price, Charles Mann, and David Quammen—whose work helped the students and me to wrap our hands around the topic. Please drop me a line, too, if you’d like class notes or slides or just to talk the class through.

@nicholas_bagley

The post Regulating Contagion first appeared on The Incidental Economist.

Effectiveness of a Ketogenic Diet and Virtual Coaching Intervention for Patients with Diabetes

The health and wellness industry is big business. In 2017, estimated global expenditures totaled $4.5 trillion, $702 billion of which were spent on “healthy eating, nutrition, and weight loss.” In the United States alone, the diet and weight loss market is valued at $78 billion annually. This investment simultaneously reveals two truths — Americans want to lose weight and Americans need to lose weight.

The harmful effects of being overweight or obese are well-documented and many. One potential consequence is Type 2 diabetes (T2D). In 2018, nearly 33 million Americans had T2D, and diabetes was the seventh leading cause of death. The economic impact of diabetes is similarly grim — a quarter of all health care expenditures go to diabetes-related costs.

Conventional wisdom holds that the primary intervention for managing diabetes is to achieve and maintain a healthy weight through diet and exercise. One diet that has gained traction in recent years and, in response, has spawned numerous weight loss products and services, is the ketogenic (keto) diet. Keto diets emphasize the severe restriction of carbohydrates and increased consumption of fats for the purpose of initiating ketosis, a metabolic state in which the body burns fat as its primary energy source.

Historically, keto diets have been used to manage a variety of health conditions, most notably epilepsy. More recently, there has been burgeoning interest in whether keto diets may be beneficial to other chronic diseases, in particular diabetes, including at the Department of Veterans Affairs (VA). The prevalence of diabetes within the Veteran population is disproportionately high compared to the general population (25% vs. 9%, respectively) and VA has long been a pioneer in diabetes research. Further inquiry is undoubtedly needed – diet research is notoriously difficult to conduct and existing research into keto diets is relatively limited, especially long-term studies.

New Research

In a recent study published in Diabetes, Obesity and Metabolism, a research team from VA and Boston University School of Public Health (BUSPH) evaluated the effectiveness of a keto diet and virtual coaching intervention on treating diabetes.

(Affiliations of the authors for this study include Kiersten L. Strombotne, PhD, Nambi J. Ndugga, MPH, Steven D. Pizer, PhD, and Austin B. Frakt, PhD, of VA Boston Healthcare System (VABHS) and BUSPH, Department of Health Law, Policy & Management; Jessica Lum, MA, VABHS; Paul R. Conlin, MD, VABHS and Harvard Medical School, and Anne E. Utech, PhD, Veterans Health Administration.)

This evaluation was developed in response to a Virta Health virtual diabetes coaching intervention pilot within VA. Virta Health, a private sector digital health company based in San Francisco, provides a diabetes intervention that emphasizes strict adherence to a ketogenic diet, health data monitoring, and personalized coaching. Beginning in April 2019, a sample of VA patients (n=454) were given access to this pilot program, cost free, on a first-come-first-served basis. To be included, participants were required to be actively enrolled in VA medical benefits, have a diabetes diagnosis, and be prescribed at least one diabetes medication. An additional 867 patients expressed interest in participating but were instead placed on a waitlist due to capacity constraints. The aim of the evaluation was to ascertain what impact the intervention had on metabolic health and regulation, diabetes-related health care utilization, and the use and costs associated with prescription drugs.

The authors employed a difference-in-differences approach that allows for a pre- and post-intervention comparison between the treatment group (those in the Virta program) and the control group (those on the treatment waitlist). The authors measured changes in observational data for the following outcomes: HbA1c, body mass index, blood pressure, emergency department encounters, outpatient visits, hospitalizations, insulin prescriptions, medication prescriptions, and costs associated with prescription medication. Outcome data were collected at five months post-intervention and the two groups were compared in parallel.

Findings

When comparing the treatment group to those in the control group, the authors’ analyses recorded several improved outcomes. First, participants in the treatment group saw significant improvements in both their HbA1c and body mass index during the study period. Significant reductions were also observed relative to insulin and medication prescriptions. On average, the decrease in monthly prescription use resulted in average savings of $34.54 per patient. The analysis also found a small reduction in monthly outpatient visits but no significant changes in emergency department encounters or hospitalizations.

This study was not without its limitations. One is that, although the waitlist control group allowed the researchers to control for similarities in motivation, the study was not randomized. The study design also limited the authors’ ability to monitor the two groups. Specifically, it was not possible to know how closely individuals in the treatment group followed the treatment protocol or whether individuals in the control group attempted or sustained dietary changes because these data were not captured in VA electronic health records. Therefore, it was unclear whether the improvements were attributable to adherence to the diet, personalized coaching, individual motivation, or a combination of these factors. Lastly, given that the study only looked at five months post-intervention, the authors were unsure whether the improved outcomes would be sustained over time.

Conclusion

Casting aside all other reasons to shed a few pounds, diabetes alone demonstrates that there is both a clinical and economic imperative to promote sustained weight loss. The favorable results of this study suggest that a ketogenic diet may be a useful part of a treatment regimen for diabetes. However, there is not enough evidence to say that a keto diet by itself leads to improved outcomes. Other studies of virtual diabetes interventions have found comparable effects, regardless of diet type. Additional research is needed to understand the extent that other factors (e.g., intensive coaching, patient motivation) contribute to improved outcomes.

Further, the popularization of keto diets is not without its controversy. For starters, keto may not be right for every person, and may in fact be harmful for patients with certain clinical profiles. Medical professionals caution that keto diets should be undertaken in consultation with a treating physician. Given the rising profile of keto diets and the increasing market penetration of keto-related products and services, further evaluation and research as to its efficacy and risks is needed.

The post Effectiveness of a Ketogenic Diet and Virtual Coaching Intervention for Patients with Diabetes first appeared on The Incidental Economist.

Cancer Journal: Thanksgiving

Cancer is a transformative experience. You ask, “Transformative how?” and I can’t answer in one post. But I can start by catching you up on my story.

Me. With cancer.

I was diagnosed with throat cancer in July of 2020. Thirty-five sessions of radiotherapy followed. Soon after, though, the pain surrounding my tumour began to increase. Several scans and a surgical biopsy confirmed that the cancer was resurgent. Treatment-resistant throat cancer is deadly. My surgeon told me that I had a life expectancy in months, not years. He saw no further treatment options. He wanted to discuss — and I respect his honesty — when and how I wanted to die.

Were there options elsewhere? Dave Fuller, a head and neck cancer specialist at the M. D. Anderson Cancer Center in Houston (MDACC), thought that they might be able to treat me. MDACC has proton beams and surgical robots, technologies that Canada does not use because they do not believe that they are cost-effective. Fuller promised nothing; they needed to see me. It wasn’t clear that MDACC could help me because my tumour was probably inoperable, and it had already shrugged off a lot of radiation. Nevertheless, talking to MDACC seemed to be the only choice on offer.

So at the beginning of May, days after getting my prognosis, my wife and I began driving to Houston. We wedged our dog’s bed into our Toyota Highlander amidst some luggage and put her in it. I was overcome when we left Ottawa. I had committed to Canada and loved the life we had made there. I didn’t expect to see our house again. We didn’t have a place to live or more than a sketch of a plan for getting treatment. And we didn’t have much time. One of us drove while the other worked the phone.

Mika and her bed.

We drove first to Pittsburgh to meet our children. It’s where we raised them, and four of our five have moved back. The border had just reopened, and we had not seen them since the beginning of the pandemic. The closed border also meant that I hadn’t seen them since before my diagnosis. Lots of Zoom and FaceTime, but that goes only so far.

But when we arrived in Pittsburgh, such plans as we had unravelled. Cancer is expensive, and you have to get ‘financial clearance’ before a U.S. hospital agrees to treat you. To get clearance, you need insurance that the hospital accepts. I’m a U.S. citizen, and I had signed up for Medicare when I turned 65. Well, sort of. I had a Medicare card, but I didn’t have the correct letters on it. I had checked the wrong boxes and only had Medicare A, which covers hospital care. Most cancer care is outpatient, and Medicare A will not cover it. The Medicare problem was fixable… but not until July 2022. By then, I would almost certainly be dead. The upshot was that I couldn’t pass financial clearance at MDACC. Or Memorial Sloan Kettering, the Dana Farber, or any of the glittering U.S. cancer centers.

We spent a week with our kids. Then we started driving home. We didn’t talk much about it, but we were going home so I could die in Canada, where end-of-life care would not drain our estate.

And then our luck turned. My friend at MDACC had asked, “Why aren’t you getting treated at the Princess Margaret Hospital (PMH) ?” Princess Who? I didn’t know that the PMH in Toronto is Canada’s leading cancer centre. As we drove north, we made calls to get a consultation there. An appointment came through just as we were passing through Toronto. That meeting connected us to a new medical oncologist in Ottawa. We drove home. We didn’t have a solution yet, but a door had opened that might lead to treatment.

OK, but what treatment? The past year has been a crash course in cancer treatment. Guided by my good friend David States, my wife and I had been reading the immunotherapy literature. Kathi, a physician, found pembrolizumab (trade name, Keytruda), a recent monoclonal antibody. Pembrolizumab, however, wasn’t approved in Ontario for my cancer. It’s easy to understand why: it did nothing for about 80% of recurrent head and neck cancer patients. But what did we have to lose? We paid $9700 Canadian for an initial dose. (One. Dose.) I was able to get on Merck’s compassionate care program for the following two doses. My oncologist appealed the decision not to treat me, and the Ontario Health Insurance Program agreed to pay for it.

And, hallelujah, the stuff seems to be working. A recent CT scan indicated that there had been substantial tumour shrinkage. I appear to be one of the lucky 1 in 5. Will the drug cure me? Unlikely. More likely: I will have a few years until the tumour evolves another way to defeat my immune system. Then the tumour will begin to grow again, and that will be that.

I don’t care. Contrary to expectation, we’re back in our house in Ottawa. This weekend was Canadian Thanksgiving. This is my bourbon-maple turkey, which I served with roasted Brussels sprouts with pearl onions and pancetta, and curried cranberry-apricot sauce. I am wholeheartedly grateful for having more time. I’m tired; cancer has burned the chaff in my life, stripped it to the bones. But I am thankful even for that. I have an intense desire to love as deeply as possible. And to write.

If you know someone who has cancer, consider sending them a link to this post.To read the Cancer Journal from the start, please begin here.A table of contents for the Cancer Journal is here.To get the Cancer Journal in email, subscribe here.

@Bill_Gardner

The post Cancer Journal: Thanksgiving first appeared on The Incidental Economist.