Aaron E. Carroll's Blog, page 4

Health Services Research ownership change

As announced on LinkedIn, the December 2024 issue of Health Services Research (HSR)

marks the last one published by the American Hospital Association’s Health Research and Educational Trust (HRET). Starting in January 2025, HSR will be owned by Wiley, continuing its legacy within the Wiley publishing family.

Historical addendum: HRET has owned HSR since its inception 60 years ago.

The post Health Services Research ownership change first appeared on The Incidental Economist.

Reducing FTEs Increases Costs: The Impact of Increasing VA ED Providers on Community Care ED Use

Emergency department (ED) capacity management has far-reaching implications for health and health system functionality. Overcrowded EDs can delay care, increase patient mortality, and lead to patient dissatisfaction.

Meanwhile, underutilized EDs can lead to waste, particularly in a health system already short on providers. In response, some health systems reduce ED capacity as a cost-containment strategy. While the Department of Veteran Affairs (VA) has not adopted this practice, there has been a significant shift towards Veterans utilizing non-VA community ED care, carrying the risk that Veterans leave the VA system altogether. This has led to ballooning financial costs for the VA, and comes with potentially negative impacts on Veteran health.

New Research

A recent paper by the Partnered Evidence-based Policy Resource Center (PEPReC) evaluated the impact of VA ED physician capacity on Veteran utilization of community care (CC) EDs. Specifically, the authors assessed whether increased VA ED physician capacity would shift demand away from CC EDs and ultimately brings Veteran back in-house for care.

Study Methods and Limitations
The authors used VA Corporate Data Warehouse data from over 100 VA EDs between 2014 and 2019, enriching the data with socioeconomic indicators from the American Community Survey and Area Health Resources Files. The independent variable was ED physician capacity, measured  using the number of hours spent on patient encounters during an 8-hour clinic-day, while CC ED claims was the outcome variable​.

The study used an instrumental variables approach. The two instruments were the proportion of weekday federal holidays and emergency clinician full-time equivalents. The models adjusted for Veteran demographics, insurance coverage, socioeconomic factors, and ED wait times. Sensitivity analyses confirmed the findings were robust, and the instrumental variables were validated for relevance and strength.

Worth noting, the evaluation was limited by reliance on claims data and how ED capacity was assessed by the VA. The findings lacked differentiation between Veteran ED and urgent care usage and cannot speak to how specific resources were allocated in clinics (e.g. number of facility beds). Lastly, the study period ended in 2019 and does not encapsulate significant operational changes post-2020. Overall, the evaluation findings may not be generalizable beyond the VA system. ​

Findings
The study found that increasing VA ED physician capacity reduced the use of CC ED services. When the authors used the proportion of weekday federal holidays as an instrument, they found that adding one eight-hour clinician shift per 10,000 enrollees reduced CC ED claims by 61 claims per month per 10,000 enrollees. When they used emergency clinician full-time equivalents as the instrument, they found that adding one eight-hour clinician shift per 10,000 enrollees led to a reduction of 48 claims per month per 10,000 enrollees.

Said another way, using the holiday-based model, every 1% increase in VA ED capacity led to a 1.42% decline in CC ED claims. Similarly, using the emergency clinician full-time equivalents model, a 1% capacity increase led to a 1.13% decrease in CC ED claims.

Importantly, VA facilities with the lowest ED capacity had significantly higher CC ED claims. Conversely, VA facilities with the highest ED capacity had the lowest CC ED claims. In short, this means that adding an 8-hour clinic day to facilities with the lowest ED capacity had the most impact on Veteran CC ED use.

Conclusion
These findings confirmed that enhancing VA ED capacity could meaningfully curb CC ED reliance. Similarly, keeping more ED care in-house has potential to increase use of other VA services, as many ED encounters require follow up care. As policymakers consider various options to address VA challenges, expanding VA ED capacity provides a proven method to help reintegrate Veterans into the VA system.

The post Reducing FTEs Increases Costs: The Impact of Increasing VA ED Providers on Community Care ED Use first appeared on The Incidental Economist.

Gaming the system: how drug manufacturers use patents to stifle innovation and harm consumers

The patent system is supposed to encourage innovation, but some drug manufacturers are using it to stifle it instead.

Drug development is a long and expensive process, even for drugs that never make it to market (and most don’t). For the products that do, patents give manufacturers a market monopoly for a certain number of years, ensuring no biosimilars or generics are sold. These monopolies are considered foundational to drug innovation, being extremely lucrative and designed to reward companies who risk resources developing new drugs.

There’s evidence, however, that some drug manufacturers game the system by extending these exclusive windows of profit. Over the last twenty years, a few common tactics have emerged.

One is patent thickets, which create a dense network of overlapping patents for one drug and crowd out the market. Without making any actual changes, manufacturers patent different parts of a drug at different times, extending the overall life of their intellectual property. For instance, Humira has more than and about 90 percent of them were filed after the drug was already on the market, serving as a huge monopolistic barrier to competition.

Another tactic is evergreening, a delay strategy that involves making minor modifications to some aspect of an existing drug, and then patenting those changes. The manufacturer’s timeframe of exclusive control is now extended well beyond the original patent window. This is a popular approach, with a recent paper finding that for all patents approved between 2005 and 2015, more than three quarters of them were for existing drugs.

Finally, product hopping is a tactic where manufacturers slightly alter a drug and then switch their consumer base to the new version before competitors have a chance to create a generic for the original version. Thankfully, the Federal Trade Commission (FTC) and courts have cracked down on this over the last few years, so the prevalence of future product hopping is uncertain.

While drug manufacturers reap the rewards with these strategies, significant costs crop up for patients.

The most obvious is actual health care costs. Taken together, these tactics heavily delay generic (or biosimilar) entry, forcing patients to use more expensive brand name drugs. This is huge, as generics have reduced health care costs by trillions over the past decade.

Taxpayers also pay. First and foremost, they foot the bill for government agencies to investigate drug manufacturer patent abuses. Second, their taxes partially subsidize drug development costs – with some conflicting, but far reaching, impacts. Coupled with some of the highest prices in the world for prescription medications, taxpayers don’t just “pay twice” for drugs, they pay three, four, or five times.

Meanwhile, the more hidden cost is lost innovation.

For one, patent gaming deters generic drug development. Even the biggest companies feel this, with Boehringer Ingelheim laying off staff after failing to bring a Humira generic to market due to Humira’s patent thicket.

Additionally, patent gaming contributes to a  hostile environment for smaller biotech startups trying to enter the market. New companies face huge barriers when they’re starting out, and generic creation offers a way to generate revenue while they hope to develop the “next blockbuster.” Patent hurdles exacerbate those challenges, an unwelcome reality as biotech bankruptcies hit a 10-year peak last year.

Luckily, the government is increasingly aware of these issues and beginning to address them.

In the last year, the FTC challenged the validity of over 400 patents on weight loss drugs, inhalers, and other medical devices. The Food and Drug Administration and the United States Patent Office are also collaborating to streamline patent review and dispute processes.

Progress is slow though. The FTC’s patent challenges last year had limited success: Just 30% of challenges received legal responses, and only a handful of patents were removed. But the work is ramping up, and federal offices are laying the groundwork for stronger patent action in the future.

Legislatively, Congress is considering a law that would create stricter criteria for patent extensions that would result in deeper scrutiny of minor drug modifications. This would help federal agencies reduce patent gaming by denying patents that don’t offer the public meaningful innovation.

Congress could also increase payments for more cost-effective drugs to incentivize innovation. For instance, the funding emphasis could be placed on developing drugs that cure or prevent disease rather than indefinitely treat patients. Success here would save patients and insurers from having to pay the financial and medical costs of lifelong medication maintenance.

In short, the goal of future policy to tackle patent abuses should be to expand competition, increase the value of innovation, and lower drug costs. The government already has the tools to do those things. Encouraging innovation over profit-driven patent manipulation will lead to a more sustainable and equitable health care system.

Research for this piece was supported by Arnold Ventures.

The post Gaming the system: how drug manufacturers use patents to stifle innovation and harm consumers first appeared on The Incidental Economist.

Palliative Care and Hospice

For many of us, a time will come at the end of our lives when we need a specific kind of care to maintain as much quality of life as possible, and to die with dignity. Hospice and palliative care are the topics of this week’s Healthcare Triage.

 



The post Palliative Care and Hospice first appeared on The Incidental Economist.

Physician Salary and Time to Fill at the Veterans Health Administration

Across the United States, health systems face a physician shortage, exacerbated by both an aging patient population and an aging physician workforce. On top of these stressors, lingering workforce challenges remain from the COVID-19 pandemic.

The physician shortage impacts the Veterans Health Administration (VHA), too. In addition to the aforementioned stressors, VHA also contends with salary limitations, strict regulatory processes, and other constraints. As a result, VHA is always working to “hire faster and more competitively” with the ultimate goal of improving access to care for the Veterans it serves.

To further investigate VHA physician hiring, the Partnered Evidence-based Policy Resource Center (PEPReC) evaluated the relationship between physician base salary and the amount of time required to fill open positions. PEPReC evaluators found that base salary matters when it comes to hiring quickly. Detailed results can be found in a new PEPReC policy brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

The post Physician Salary and Time to Fill at the Veterans Health Administration first appeared on The Incidental Economist.

PACT Act: Year Two in Review

The PACT Act of 2022 was enacted to extend Department of Veterans Affairs health care and benefits to more Veterans and survivors, especially those with conditions resulting from exposure to hazardous conditions during active military service (i.e., military toxic exposures).

In 2023, policy analysts at the Partnered Evidence-based Policy Resource Center (PEPReC) summarized the impact of the law after the first year of implementation. Now, in 2024, they wrote a follow up policy brief to compare implementation in Year Two. New implementation successes were observed, alongside continued challenges from the previous year. Read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

 

The post PACT Act: Year Two in Review first appeared on The Incidental Economist.

Understanding Veteran Access to Care by Modeling Underservedness

Measuring access to health care has been traditionally done with waiting times, that is, how long a patient waits between requesting an appointment and actually seeing their provider. The Veterans Health Administration (VHA) acknowledged the limitations of this metric and aimed to better grasp what timely access to quality care really looks like for Veterans with the passage of the MISSION Act of 2018. In particular, Section 401 of the law required VHA to develop a measure of underservedness that would holistically assess access at every Department of Veterans Affairs Medical Center (VAMC). 

New Research 

In partnership with VHA’s Office of Integrated Veteran Care (formally, the Office of Veterans Access to Care), the Partnered Evidence‐based Policy Resource Center (PEPReC) responded to the MISSION Act’s mandate to measure and mitigate underservedness at each VAMC. PEPReC outlines this new evidence-based approach to modeling access to care in a commentary published in Health Services Research. In it, PEPReC explains how to identify underserved VAMCs by using the econometric principles of supply and demand. 

PEPReC defines underservedness as an imbalance between the supply of VHA care and the expected Veteran demand for VHA care. In the first year after the law’s passage, PEPReC developed a statistical model to measure underservedness in primary care. (PEPReC has similar methodology ready for implementation in specialty care as well but those models have not yet gone live.)  

Model and Variables 

The model is centered around new patient waiting times, but takes a step further by considering the various factors that can impact waiting times. These variables and their relationships to waiting times are explained by being assigned numerical weights. Some increase waiting times while others decrease waiting times; some impact waiting times a lot and others not so much. A larger weight indicates more influence over waiting times.  

The model includes 21 variables to comprehensively capture VHA supply of care and Veteran demand for VHA care. For example, on the supply side, PEPReC includes clinic capacity and clinic efficiency, measures of staffing and productivity, respectively. On the demand side, PEPReC includes the household median income in the area surrounding the VAMC, the percent of Veterans who also have private insurance, Veterans’ Nosos risk scores (a measure of how sick they are), and the percent of Veterans who are 65 or older. 

Scores and Facility Rankings 

The model estimates the relationship between the variables listed above and raw waiting time data and creates an underserved score for each VAMC. The higher a VAMC’s score, the more underserved they are. In other words, the higher a VAMC’s score, the more they may struggle to provide timely access to quality care for their Veterans. 

After running the model and producing underserved scores each year, VAMCs are ranked relative to each other.  

Impact 

The underserved scores for all VAMCs are shared with the Office of Integrated Veteran Care. From there, the VAMCs with the highest scores are notified of their underserved status and are required to submit action plans explaining how they plan to mitigate underservedness in the coming year. The most underserved VAMCs and their action plans are shared with Congress via an annual congressionally mandated report.   

Each year, the model is refined and the underserved scores are recalculated.  

Importantly, this novel approach to measuring access to care can be used beyond the MISSION Act. The model and scores allow VHA to systematically identify and address imbalances in the supply of and demand for VHA care through evidence‐based policy making and equitable resource allocation. For example, VHA can used the scores to guide mental health clinic operations forecasting, budget forecasting, and local clinic management.  

The approach can also be used by other health systems, too, helping Veterans and non-Veterans alike access the quality care they need. 

Understanding and managing access to care for any population is tricky, and the MISSION 401 models are just one way to tackle that complexity. 

The post Understanding Veteran Access to Care by Modeling Underservedness first appeared on The Incidental Economist.

Our Organ Donation System Is Broken. Here’s What We Need to Do to Fix It.

Despite a record-breaking number of transplants in the United States (US) in 2023, the country’s organ donation system is broken.

Organ donation in the US is far more efficient now than it was before the transnational network was put in place in the 1980s, but operational issues and negligence plague the system. The product of light regulation and little consequence, these grave operational errors mean life or death for patients waiting for an organ or tissue transplant. But there are better ways to hold the operational entities that run the network accountable. The question is: Will we finally flex our regulatory muscle?

Read the full piece here BU Today by Katherine O’Malley.

The post Our Organ Donation System Is Broken. Here’s What We Need to Do to Fix It. first appeared on The Incidental Economist.

Heat-related illnesses are preventable. Here’s how.

Heat-related illnesses are becoming more common — and deadly — across the United States, yet they’re entirely preventable.  

With rising temperatures and inconsistent regulations, it’s critical to address heat vulnerability through proactive, community-based strategies. Our new piece recently published in The Health Care Blog describes the need for stronger policy interventions, such as workplace protections, urban planning adjustments, and public health outreach, especially for high-risk communities. There’s a lot that can be done to keep people safer as climate change continues to make heat a leading health threat.  

Read the full article here. 

The post Heat-related illnesses are preventable. Here’s how. first appeared on The Incidental Economist.

Tampon Tim | Menstruation, Public Schools, and Political Nicknames

Like it or not, political mudslinging gets heavy around election time, and people come up with all flavors of insults. These aren’t always representative of a person’s actual character or actions, and we think that’s especially true for one we’ve heard this year. Today we’re talking about menstruation and period poverty, and why the derisive nickname “Tampon Tim” isn’t actually an insult at all.

 



The post first appeared on The Incidental Economist.