Primary care physicians in the United States are increasingly joining multispecialty group practices, such as the Palo Alto Medical Foundation and Stanford Health Care.
Stanford Health Policy’s Loren Baker and Kate Bundorf analyzed how a physician’s single practice vs. a multispecialty practice (MSP) affects health-care spending and use.
Focusing on Medicare beneficiaries who changed their primary care physician due to a geographic move, they compared changes in practice patterns before and after the move between patients who switch practice types and those who do not.
With their co-author Anne B. Royalty of Indiana University-Purdue University Indianapolis, they found that changing from a single to a multispecialty primary care group practice decreases annual Medicare-financed, per-capita expenditures by about $1,600, or a 28% reduction.
“The effect is driven primarily by changes in hospital expenditures and is concentrated among patient with two or more chronic conditions, suggesting that MSP improves care delivery by reducing hospitalizations among relatively sick patients,” they wrote in their working paper published by the National Bureau of Economic Research.
“The results imply that, while research has shown the potential for physician consolidation to increase prices in some settings, large multispecialty groups also have the potential to lower costs.”
Physician training has long been notorious for marathon shifts, sleepless nights on call, and holidays worked. But that began to change in 2003, when the medical profession placed restrictions on work hours during residency. However, experts wondered, can we train residents in fewer hours and still make good doctors?
A new study in the BMJ says yes. The researchers, led by Dr. Anupam Jena, a professor of health care policy and medicine at Harvard Medical School, and Stanford Health Policy's Jay Bhattacharya, looked at the performance of internal medicine doctors in their first year of unsupervised medical practice after completing their training.
They compared the outcomes for patients of two groups of physicians: those trained before 2003, when the typical work week was 100 hours; and those trained later under the new rules, which capped weekly hours at a mere 80, with no individual shift exceeding 30 hours. For the three quality measures examined — mortality within 30 days of being hospitalized, readmissions, and hospital services used (a measure of efficiency) — they found no differences between the groups.
Read More from this article published in STAT News.
Mariam Noorulhuda has seen health disparities up close in the developing world, particularly in Afghanistan, where she interned at a hospital in Kabul last summer.
“There was a shortage of trained health-care professionals, especially women, poor facility conditions, and insecurity,” she said. “Our hospital was minutes away from multiple bombings.”
Noorulhuda is a rising senior and one of six Stanford undergraduates chosen for the inaugural class of Stanford Health Policy Undergraduate Research Fellows. From a variety of disciplines, they will spend this summer partnered with SHP faculty to work on research projects. The students were chosen for their desire to blend health policy with their own undergraduate studies.
Noorulhuda’s Story
Mariam Noorulhuda
Noorulhuda’s family first fled Afghanistan during the Soviet invasion in 1979. They made it to a refugee camp in neighboring Pakistan, where an infant brother died for lack of health care. They returned to Kabul after the Soviets left in 1991, but the country fell back into civil war.
That is when she lost another brother, as health-care infrastructure was demolished after much of the capital was destroyed in bombings. When the Taliban targeted her father for his resistance efforts, they fled again and were granted asylum in the United States in 1997. Though raised in the Bay Area, many family members remain in Afghanistan.
“Much of my family has been affected by the brutal impact that war has on health — not entirely through bombs and bullets per say — but through indirect effects like displacement and virtually nonexistent health systems,” said Noorulhuda, a history major with a minor in human rights.
She will work with SHP’s Eran Bendavid, an infectious diseases physician and associate professor of medicine who focuses on the impact of health policies and outcomes in developing countries. He is the fellowship coordinator for this inaugural summer program.
Impact of Health Policy
"There is a growing recognition that health policy impacts just about every facet of human experience and well-being, and we see students picking up on that earlier and earlier,” said Bendavid. “The scholarship at SHP — from the effects of gun ownership or armed conflict to quality of care and guideline development — is an exceptional environment for gaining experience and a deep-dive into health policy research."
The fellowships were made possible with generous support from Stanford political scientist Scott Sagan, and his wife Sujitpan Bao Lamsam, vice chairman of Kasikornbank in Thailand. Sagan is a senior fellow at the Center for International Security and Cooperation who focuses on nuclear strategy, the ethics of war and the safety of hazardous technology.
“One of the great strengths of Stanford is the opportunity for undergraduates to get deeply involved in faculty research projects,” said Sagan, whose daughter Charlotte Sagan (BA, `15) was a research assistant in health policy while at Stanford. “We wanted to help create such opportunities for future students.”
Tiffany Liu
Tiffany Liu just finished her freshman year and has yet to declare her major, though she’s thinking symbolic systems, the study of human-computer interaction.
“Both fields incorporate so many diverging perspectives and methods in order to solve salient issues,” said Liu, who will work with Jason Wang, an associate professor of pediatrics who looks at the use of innovative technology to improve quality of care and health outcomes.
“I’m eager to engage in health policy research through a mix of technical and non-technical methods — we can process and analyze data in so many more interesting ways using computers, and yet we can’t ever lose the humanistic aspect of health initiatives,” Liu said.
Nikhil Shankar, also a rising senior, is an economics major. He jumped at the health policy fellowships because he believes applied economics can have “real-world impact.”
He will be working with SHP’s Grant Miller, a senior fellow at the Freeman Spogli Institute for International Studies and director of the Stanford King Center on Global Development. They will examine the impact of population policy on child health outcomes by gender in China.
Nikhil Shankar
“Effective health policy, informed by sound research, plays a vital role in ensuring that every child has the capabilities needed to achieve their potential,” Shankar said. “I hope to be a small part of the global community of researchers, policymakers and advocates working to ensure equitable and affordable health care for all.”
Health-care inequality driven by factors beyond the control of individuals is something that troubles Andrea Banuet, a human biology major and another a rising senior.
“Factors such as socioeconomic status, age, ethnic and racial backgrounds should not determine the type of care an individual can attain — but the really sad reality is that in many parts of our country, it does.”
She believes that policy informed by research has the power to combat institutional biases and promote change in health-care accessibility. She will be working Kathryn M. McDonald, executive director of CHP/PCOR, an expert on health-care quality and patient safety.
Conrad Milhaupt is another rising senior with a double major in economics and public policy.
“I have a passion for the intersection of economics, politics and policy, with a particular focus on health and environmental policy,” said Milhaupt, who will work with SHP’s Jay Bhattacharya, a professor of medicine and economics.
Milhaupt took Bhattacharya’s health economics class in his sophomore year and became intrigued by the discrepancies in costs for health services with only marginal differences in outcomes. He is particularly interested in health care in rural America and ways that changes to our public-private insurance mix may improve access to care and help manage costs.
“Ultimately, I am driven to study this topic by my belief that health care is a human right and that health is an integral aspect of every individual’s life,” he said.
Conrad Milhaupt
Calvin Tolbert, with funding from the Office of the Vice Provost for Teaching and Learning, will work with Eric Sun, an economist and assistant professor of anesthesiology who researches consolidation in physician markets and the economics of pain treatments.
Tolbert is a rising junior majoring in economics and classics, with a minor in mathematics.
“The thing that initially drew me to economics was the fact that it was both math-intensive and pertinent to public policy, which is a keen interest of mine,” he said.
He will be working on a project that looks at physician compensation across countries and the wide gap in costs and access to medical care and drugs.
“This is an area that first caught my eye, when I read accounts of medical tourism in the news, including both people from developing countries who come to America for serious procedures and Americans who visit other countries to receive treatment due to the expense of medical care in this country.”
The United States has more people with new HIV diagnoses each year than any high-income nation. There is this widespread misconception out there that we’ve got it under control; that the drug cocktails are so effective that HIV is no longer a leading threat.
“Unfortunately, HIV remains a major public health problem in the U.S.,” said Stanford Health Policy’s Douglas K. Owens. He is chair of the U.S. Preventive Services Task Force, which issued two influential recommendations Tuesday for the prevention and treatment of HIV.
“Each year, almost 40,000 people acquire HIV, he said. “It’s not acceptable and requires our urgent attention.”
Owens, the Henry J. Kaiser, Jr., professor at Stanford Medicine, said an estimated 1.1 million people are currently living with HIV in this country — and more than 700,000 people have died of AIDS since the first cases were reported in 1981. Of the 38,281 new diagnoses of HIV reported in 2017, 81% were among men and 19% among women.
“There are highly effective preventive interventions that can help us toward the goal of ending the HIV epidemic in the U.S.,” said Owens, who is also an investigator at VA Palo Alto Health Care System “However, we know not enough people receive these interventions.”
The task force recommends clinicians screen everyone aged 15 to 65 and all pregnant women for HIV and offer pre-exposure prophylaxis (PrEP) — a pill that helps prevent HIV — to people at high risk of contracting the potentially fatal infection.
It released its recommendations with a series of articles and editorials in the Journal of the American Medical Association (JAMA), calling for dramatic action to end the AIDS epidemic in the United States once and for all.
The task force is an independent, volunteer panel of national experts in prevention and evidence-based medicine who work to improve the health of all Americans by making recommendations. They typically give letter grades to its recommendations, and this time issued its highest grade, an A.
The draft recommendations were made last year and then put out for review and public comment. The recommendations made Tuesday are final.
The benefit of this endorsement could be substantial, according to one of the accompanying editorials in JAMA, because under the Affordable Care Act, Grade A and B recommendations made by the USPSTF should be covered by private insurance without patient cost-sharing.
“How this recommendation will be implemented is of critical importance because cost is a major barrier for people both to start and to stay on PrEP,” wrote Diane V. Havlir, MD, and Susan P. Buchbinder, MD, in their editorial. At present, they wrote, the average monthly retail cost for PrEP without insurance is nearly $2,000.
The task force members concluded “with high certainty” that while there are some small harms associated with PreP, the magnitude of benefit with oral tenofovir disoproxil fumarate-based therapy to reduce the risk of HIV infection in people at high risk is substantial.
“Clinicians can make a real difference toward reducing the burden of HIV in the United States, Owens said in the task force statement. “HIV screening and HIV prevention work to reduce new HIV infections and ultimately save lives.”
Fewer than half of all adults have ever been tested for HIV in the U.S. and many of those requiring more frequent testing are not receiving it. The task force emphasized that clinicians should make testing routine and ensure patients are given an environment that is free of judgment during discussions of sexual health.
Screening is the only way to know if a person has been infected with HIV because, after initial flu-like symptoms, HIV does not cause any signs of symptoms for several years. So the task force recommends HIV screening for everyone between of 15 and 65 and for pregnant women.
In addition to screening, people need to prevent getting HIV by using condoms during sex, the task force said, for those who inject drugs, using clean needles and syringes.
People at high risk for HIV have an additional strategy for prevention in taking PrEP, the task force said in its statement. “For people at high risk of getting HIV, the benefits of PrEP far outweigh the harms, which can include kidney problems and nausea.”
Medicare made $70 billion in payments to physicians in 2017 for care they provided to the 44 million Americans covered by the federal health-care program.
Who decides how much a physician should be reimbursed from Medicare for their services?
Medicare has depended on a committee convened by the American Medical Association known as the Relative Value Scale Update Committee (RUC) since 1992. The RUC has been called the most important health care committee you’ve never heard of.
The RUC has 31 members, most of whom come from the major specialty societies, such as the American Academy of Orthopedic Surgeons and American Association of Neurological Surgeons. By estimating the time and effort physicians take to perform thousands of different services, the RUC assigns “values” to each service that determine how much physicians are paid for delivering it.
The RUC has come under heavy criticism in health policy circles for its influential role in setting payment levels. But its performance and methods have never been closely studied.
So Stanford researchers David C. Chan and David Studdert — both core faculty members at Stanford Health Policy — set out to evaluate how well the RUC was doing. The researchers analyzed one critical ingredient of the valuation process: how long services take to perform. They compared the RUC’s estimates of the duration of 293 common operations to “benchmark” times for the same operations, obtained from actual surgical cases recorded in a large national database.
The study, published in The New England Journal of Medicine, found substantial discrepancies between the RUC’s time estimates and the benchmark times. But Chan and Studdert also found that the RUC did not show a systematic bias; times were as likely to be overestimated as they were to be underestimated.
The research team, which also included Johnny Huynh, a PhD student in economics at UCLA, then characterized inaccuracies, quantified their effect on physician revenue, and examined whether re-review by the RUC corrected them.
“The inaccuracy of the RUC’s estimates for some procedures times was quite large,” said Chan, a faculty fellow at the Stanford Institute for Economic Policy Research and staff physician at the Veterans Affairs Palo Alto Health Care System. “The best way we could think of to indicate how large was to convert them into clinical revenue, and see how the inaccuracies affected different specialties.”
The study estimated that orthopedic surgeons and urologists received higher payments than they would have if benchmark times had been used — $160 million and $40 million more, respectively, in Medicare reimbursements over a five year period. Whereas cardiothoracic surgeons, neurosurgeons and vascular surgeons received lower payments — $130 million, $60 million, and $30 million less, respectively — during the same period.
Yet the researchers did not find evidence that inaccuracies stemmed from systematic bias.
“There was already an awareness that the RUC was missing the mark on some of its time estimates. Our study reinforces that inaccuracy story,” said Studdert, a professor of medicine and law. “But the prevailing view is that RUC uses times that are systematically longer than the truth, and we just don’t see that.”
The study concludes nonetheless that reform is still needed, because the time discrepancies are large and have substantial effects on payment allocations. It points to two policy reforms that have the potential to improve the accuracy of service valuations by the RUC:
Use larger and more reliable sources of data for the time estimates;
Enhance the real-time accuracy of the valuations by monitoring such data sources for substantial changes in the duration of procedures and using this information to prioritize procedures for re-review.
“I believe that the RUC has moved in this direction recently, and I suspect that there would be a fairly general agreement that the process could be improved by going further and using more and better data,” Chan said.
The researchers now intend to turn their sights on another aspect of physician payment policy: the perception that the RUC methods lead to underpayment of primary care physicians.
“The biggest criticism of the RUC over the years is the allegation that it systematically undervalues the work of primary care physicians, relative to surgeons,” Studdert said. “Now that we have developed method for benchmarking the RUC’s accuracy, we’d like to redeploy it on this primary care versus surgical care issue.”
Drug companies and medical device manufacturers have long cultivated ties with physicians and hospitals in an effort to promote their wares. This has led to some suspicion that patients may end up with prescriptions for drugs they don’t need or devices they don’t want.
So the federal Centers for Medicare & Medicaid Services established the Open Payments database — required under the Affordable Care Act — which allows patients to discover whether their physicians or hospitals have any financial ties with drug or device companies.
It is designed to give the public a more transparent health-care system, though as the website notes, all information on the Open Payments database is open to personal interpretation.
"Transparency has become a very vogue strategy in U.S. health policy,” said Stanford Health Policy’s Michelle Mello. “Information disclosure requirements are being used to do everything from curbing overeating to helping patients decide where to have their heart surgery.”
Mello, a professor of health research and policy at the School of Medicine and professor of law at Stanford Law School, and her colleagues wanted to understand whether the Open Payments system is achieving its goal of helping patients make more informed decisions.
In a new study published by JAMA Network Open, the researchers found an unintended consequence of the public disclosure system: It may have diminished trust in even those physicians who never received payments from drug or medical device firms.
Lack of Public Trust
The authors’ survey of 3,500 respondents found that public disclosure of payments was associated with a 2.7% decline in trust in one’s own physician regardless of whether the respondents knew their physicians had received payments. In fact, the authors note, fewer than 5% of U.S. adults report knowing about their physicians’ industry payments or using the Open Payment website.
“Doctors might consider that unfair because people reported diminished trust even though most of them had no idea whether their doctor took industry payments or not,” Mello said. “About two-thirds of physicians receive industry payments, so what we’re seeing is a kind of spillover reputational damage to the one-third who don’t.”
Mello said she and her co-authors — Genevieve P. Kanter of the University of Pennsylvania, Daniel Carpenter of Harvard University and Lisa Lehmann of the National Center for Ethics in Health Care in the Veterans Health Administration — were surprised by their findings.
“Why would trust go down if few people are using the Open Payments data?” Mello asked. “We think that the large amount of media publicity about the Open Payments law — which has described drug companies’ financial influence as pervasive and highlighted extreme cases of physicians taking very large payments — may have changed how people think about the trustworthiness of the medical profession as a whole.”
Pharmaceutical companies for decades have engaged physicians through a variety of kinds of financial relationships. Grants for company-sponsored research constitute the largest expenditure, but consulting fees, honoraria for giving lectures, providing meals, covering travel expenses, and giving small gifts are also common activities. Physicians may also have investment interests in drug and device companies.
“However, the nature of these relationships and the magnitude of the dollars flowing from companies to physicians have largely been opaque to the public,” the authors wrote.
The Policy Implications
Trust is a crucial element of the physician-patient relationship affecting many aspects of patient behavior and sentiment that ultimately affect health, the authors said. For example, trust in one’s physician is associated with “whether patients follow treatment recommendations, how well they self-manage chronic conditions, and whether they seek preventive care.” Further, the authors wrote, “Trust in the medical profession may affect the public’s views of scientific authority and medical research, which may influence patient adherence and health-promoting behaviors,” they wrote.
The researchers suggested institutional policies should be implemented by hospitals and physicians to help patients understand what these payments represent. Some kinds of payments, such as an honorariumfor serving as a paid speaker for a drug company, are more concerning than, say, research grants. But many patients may not be able to distinguish between the two.
“Pharma-free physicians might consider advertising that status to current and prospective patients, or health plans could include a marker for that on their `Find a Physician’ websites,” Mello said.
Finally, she said, patients should look up their doctor and if they see any payments they find concerning, ask their doctors about them.
“Seeing whether the payments pass the `red-faced test’ in these conversations should be illuminating,” Mello said.
The IHEA awarded the 27th annual Arrow Award to Alsan, a core faculty member at Stanford Health Policy, a senior fellow at FSI and SIEPR, and co-author Wanamaker of the University of Tennessee for their paper, “Tuskegee and the Health of Black Men” published in the Quarterly Journal of Economics.
The infamous Tuskegee study began in 1932 when the U.S. Public Health Service began following approximately 600 African-American men, some of whom had syphilis, for the stated purpose of understanding the natural history of the disease. The government willingly withheld treatment even after penicillin became an established magic bullet for treating the illness.
The medical doctors and staff of the CDC followed the men for four decades, until ultimately the study was halted in 1972 when it was brought to the attention of the media by law student Peter Buxtun.
As noted in this story about the research, Alsan and Wanamaker found that the public disclosure of the study in 1972 was associated with an increase in medical mistrust and mortality among African-American men in the immediate aftermath of the revelation.
“The award is an immense honor for both Marianne and me. First, it sheds light on the importance of history for understanding health disparities. Second, it reaffirms the “expected behavior of the physician” that Professor Arrow eloquently described in his seminal 1963 paper on the distinctive features of the market for medical care and the externalities associated with deviating from those expectations.”
African-American men today have the worst health outcomes of all major ethnic, racial and demographic groups in the United States. Life expectancy for black men at age 45 is three years less than their white male peers, and five years less than for black women.
When their working paper was first published by the National Bureau of Economic Research, it became part of the national discussion about the lasting impact of the Tuskegee study.
“The story that Alsan and Wanamaker uncovered is even deeper than the direct effects of the Tuskegee Study,” wrote Vann R. Newkirk II in The Atlantic. “Their research helps validate the anecdotal experiences of physicians, historians, and public health workers in black communities and gives new power to them.”
Researchers at Stanford University released findings of a study examining what happens to physicians who experience multiple malpractice claims. Where do physicians with poor malpractice liability records go? Where do they practice? Who would hire them? Stanford professors David Studdert and Michelle Mello, both core faculty members at Stanford Health Policy, wanted to know.
The answers to these questions are described in a new study released March 27 in the New England Journal of Medicine. After reviewing more than a decade’s worth of data from nearly half a million physicians, Studdert and Mello found that physicians who were sued repeatedly were no more likely to relocate their clinical practices than colleagues who had no claims. However, they were more likely to either cease practice or, if they continued to practice, to shift to smaller practice groups or solo practice.
“There is an emerging awareness that a small group of ‘frequent flyers’ accounts for an impressively large share of all malpractice lawsuits,” said Studdert, the lead researcher and professor at both Stanford Law School and Stanford University School of Medicine. “This study confirms that, and begins to shed light on the professional trajectories of these physicians.”
In a 2016 study, also published in the New England Journal of Medicine, Studdert and Mello examined demographic characteristics of claim-prone physicians. “When we presented that work, people kept asking us questions about this group that we couldn’t answer, like who would ever hire or insure them,” Studdert said. “Now we have a better idea.”
A small group with many lawsuits
The research team reviewed data from 480,894 physicians who had 68,956 claims paid against them between 2003 and 2015. The researchers estimated that 2 percent of practicing physicians had two or more paid malpractice claims. Those physicians account for nearly 40 percent of all paid claims, confirming results from their earlier study.
“Our main goal was to follow these multi-claim practitioners over time as they accumulated claims and see where they went and what kind of changes they made to their practices,” said Mello, professor of law and professor of health research and medicine at Stanford and a co-author of the study. “One surprising result was that they were no more likely to relocate than their colleagues.”
In the late 1980s, widespread concerns that physicians with poor liability records were moving interstate to put their reputations behind them led Congress to establish the National Practitioner Data Bank. When a malpractice claim is paid on behalf of a health practitioner, or the practitioner is subjected to certain forms of disciplinary action, the information must be reported to the Data Bank. Employers, such as hospitals, are then required to check the Data Bank.
“Given the policy history here, it was gratifying to find that physicians prone to malpractice claims were not flight risks,” Mello said, noting that it is clearly harder for physicians with bad records to escape their past than it once was.
They don’t move, but many go solo
The study also found that claim-prone physicians were more likely than their peers to quit practicing. Nonetheless, more than 90 percent of physicians who racked up five or more paid claims continued to practice medicine.
The study also showed that claim-prone physicians were much more likely than their peers to shift into smaller practice settings. For example, physicians with five or more claims were more than twice as likely as physicians with no claims to switch to solo practice.
“Compared to practicing in large group practices or hospitals, physicians in small or solo practices are subject to less oversight from administrators and peers,” Mello said. “Quality problems with solo practitioner may be more difficult to detect and report. From a patient safety standpoint, this is the study’s most troubling finding. Frankly, solo practice is the last place we want practitioners who pose patient safety risks to be working.”
While a single malpractice claim is a weak signal that there’s a quality problem, when there are repeated paid claims over a relatively short period of time, that sends an important signal about patient safety risk, Studdert said.
“We think the study’s main message is that regulators and the companies that provide physicians with liability insurance should be paying closer attention to this signal,” Studdert said. “I wouldn’t want my family members to be treated by a physician who had paid out six malpractice claims in the past few years. Who would?”
Additional authors on the study include Matthew J. Spittal from the Melbourne School of Population and Global Health, University of Melbourne; Yifan Zhang from Stanford’s Center for Health Policy; and Derek S. Wilkinson and Harnam Singh from the Health Resources and Services Administration in the U.S. Department of Health and Human Services.
The study was supported by a grant from SUMIT Insurance, a company that is wholly owned by Stanford Hospital and Clinics and Lucile Packard Children’s Hospital, and a Future Fellowship to Spittal from the Australian Research Council.
Stanford Health Policy’s Douglas K. Owens was named chair of the U.S. Preventive Services Tasks Force, an independent panel of national experts in prevention and evidence-based medicine that makes health-care recommendations to Congress and the American public.
Owens, the Henry J. Kaiser, Jr. Professor at Stanford University and a general internist at the VA Palo Alto Health Care System, is also a professor of medicine, health research and policy, and management science and engineering at Stanford. He is the director of the Center for Health Policy in the Freeman Spogli Institute for International Studies, where he is also a senior fellow, and the Center for Primary Care and Outcomes Research in the Department of Medicine.
“The goal of the Task Force is to help people live longer and healthier lives,” said Owens. “We aim to bring the best science about prevention to our guideline recommendations on more than 70 preventive services, including screening, behavioral counseling and preventive medications."
Owens noted that the Task Force guidelines — unbiased, independent assessments of the benefits and harms of preventive services — impact virtually every primary care patient in the country. From statins, mammograms and cervical cancer screening, to depression, HIV screening or cardiovascular disease, the 16 volunteer members of the Task Force weigh all the medical evidence to determine the safest course of action from adolescence to old age.
A guideline this January about perinatal depression, for example, was highlighted in this New York Times article. Depression hits one-in-seven women during and after giving birth, prompting the Task Force to recommend that clinicians refer at-risk women to counseling, specifically cognitive behavioral or interpersonal therapy.
“I am delighted to congratulate Dr. Owens on his appointment as chair of the Task Force,” said Susan J. Curry, a distinguished professor in the Department of Health Management and Policy at the University of Iowa. “Over the years, he has brought invaluable expertise in evidence synthesis, clinical decision-making and modeling — all critical to the methods we use to develop evidence-based recommendations.”
Some other recent recommendations by the Task Force include that men aged 55 to 69 talk to their doctors about prostate cancer screenings; patients at high risk of HIVshould take a daily preventive drug; and that adults aged 50 to 75 be screened for colon cancer.
Each year, the Task Force makes a report to Congressthat identifies critical evidence gaps in research related to clinical prevention services. It recommends priority areas that deserve further explanations, all of which are made public on the Task Force website for public comment.
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Douglas K. Owens teaching a class, Analysis of Costs, Risks, and Benefits of Health Care.
Americans know that choosing a health insurance plan can tough. And once you’re retired and possibly on a limited or fixed income, it can become downright brutal.
Stanford Health Policy’s M. Kate Bundorf and Maria Polyakova and their colleagues set out to develop an online decision-support tool to test whether machine-based expert recommendations would influence choice among Medicare Part D enrollees — and make it easier.
“The use of technology seems like a natural way to address the challenges of choosing among plans,” they write in their study published in Health Affairs.
Medicare beneficiaries have been choosing among Medicare Advantage and Part D prescription drug plans for years, and more recently the Affordable Care Act established health insurance marketplaces for those who are younger than 65.
All that choice is supposed to create incentives for plans to offer a variety of low-cost, high-quality products that allow people to choose the plan that best meets their needs.
But sometimes too many good choices can lead to bad outcomes.
“Health insurance is a complex financial product with complicated cost-sharing rules, and the implications of different benefit designs for out-of-pocket spending and health care use vary across consumers depending on their needs,” wrote Bundorf, chief of the Department of Health Research and Policy and an associate professor of medicine at Stanford Medicine.
Another researcher in the study was Albert Chan, chief of digital patient experience and an investigator at Sutter Health, in Palo Alto, as well as an adjunct professor at the Stanford Center for Biomedical Informatics Research. Ming Tai-Seale, a professor of family medicine and public health at University of California San Diego, was also a principal investigator of the study.
Choosing Health Plan is Complicated
“Consistent with these challenges, researchers have documented that many consumers, both young and old, do not understand the characteristics of their plans,” they wrote in the March issue of Health Affairs, which is holding a public briefing on patients-as-consumers at the National Press Club on March 5th. Bundorf will present their research at the briefing in Washington, D.C., which will be streamed live and will be posted here once it has aired.
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“(Patients) often make decisions that may signal inaccurate evaluation of the costs and benefits of coverage — such as staying in their plan when better options are available, not enrolling in the plan that provides the best coverage for their drugs, or enrolling in plans that are objectively inferior to other available choices,” the authors wrote.
The Centers for Medicare and Medicaid Services (CMS) offers a tool to help beneficiaries choose among plans, but older adults — even those with high levels of formal education — find it difficult to use.
So, the research team developed a decision-support software tool called CHOICE to assist Medicare beneficiaries in choosing a Part D prescription plan. The software automatically imported the user’s list of current drugs from their electronic medical records (allowing users to adjust the list if desired); the algorithm would then crunch the numbers to come up with three recommended plans which were likely to be the least expensive for the user.
The team then conducted a randomized trial of this software tool among 1,185 patients of the Palo Alto Medical Foundation (PAMF), a large health-care provider in Northern California. Fifty-four percent of those patients were women, 65 percent were white, and 54 percent were married. Living in the Bay Area, their income and education levels were fairly high: They lived in areas in which the median income is $106,808 and 54 percent of the population has a college degree or more education.
While not representative of the general population of seniors in the United States, the researchers emphasized that it was important to conduct this study among these potential users, who are more likely to respond positively to an interaction with a computer. If these users didn’t find this software helpful or user friendly, it would not likely be a useful tool to roll out across the country as a whole.
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The study participants received access to one of two versions of the CHOICE tool: expert recommendations or individual analysis. Both versions automatically imported information on patients’ prescription drugs from their electronic health records and combined it with information on plan benefit design to provide individually customized information on users’ likely spending on both premiums and prescription drugs in each of the stand-alone Part D plans available in their area. The version of CHOICE that offered expert recommendations combined this information with an explicit recommendation on which plans were best for the user.
Willing and Able
The researchers found that providing an online tool not only increased older adults’ satisfaction with the process of choosing a prescription drug plan, but they also spent more time choosing that plan.
“The most significant finding of our trial is that individually customized information alone didn’t seem to be enough,” Bundorf, who is also a senior fellow at the Stanford Institute for Economic Policy Research (SIEPR), said in an interview. “The tool we developed was most effective when individually customized information paired with a clear-cut algorithmic expert recommendation that highlighted three plans that the computer thought were the best for the user based on total spending for prescription drugs.”
She said she was surprised to see that people spent more time choosing a plan and were more satisfied with the process when they had access to the CHOICE tool.
“Prior to our trial, I thought people might spend less time choosing a plan when they had access to expert recommendations because it would make the process easier,” Bundorf said. “But taken together, these results suggest that people are more engaged in decision-making when they have access to a patient-centered tool.”
Polyakova, who is also a faculty fellow at SIEPR, said a key takeaway from the trial is that people who are likely to use sophisticated tools are already more likely be more sophisticated shoppers of health care and prescription plans.
Mariam Noorulhuda
Tiffany Liu
Nikhil Shankar
Conrad Milhaupt
“The thing that initially drew me to economics was the fact that it was both math-intensive and pertinent to public policy, which is a keen interest of mine,” he said.
