All research in progress seminars are off-the-record. Any information about methodology and/or results are embargoed until publication.

Abstract:

Nearly half of total health care expenditures in the Veterans Affairs (VA) system are generated by 5% of its patients. These patients generally have complex health and health care needs, including multiple chronic conditions, comorbid mental health conditions, and social stressors, all of which contribute to high rates of hospitalization, urgent care visits, and outpatient encounters. In recent years, a number of intensive primary care models have emerged outside the VA that focus on health systems’ high-risk, high-cost patients. Early evaluations suggest that these models have the potential to improve quality of care and enhance patients’ care experience, while simultaneously keeping utilization in check and using resources more wisely. However, there are few rigorous evaluations of these programs, and studies of their applicability inside the VA are lacking. In 2013, the Palo Alto VA launched a quality improvement (QI) program for high-risk, high-cost patients to augment the VA’s patient centered medical home (Patient Aligned Care Team, or PACT) with Intensive management (ImPACT). ImPACT’s multidisciplinary team offers patients enhanced access, chronic disease management, support during health deteriorations, and social work and recreation therapy. Although ImPACT was designed as a QI program, Palo Alto VA leadership chose to enroll a random sample of eligible patients, providing an opportunity for a randomized controlled evaluation. We will describe this unique QI/research partnership, as well as early findings from the ImPACT pilot study, and discuss implications for future services for high-risk, high-cost patients within the VA system.

All research in progress seminars are off-the-record. Any information about methodology and/or results are embargoed until publication.

Abstract:

Background: As part of efforts to move away from FFS payment, Medicare established the Accountable Care Organization (ACO) initiative.  ACOs are provider based organizations that can share savings with Medicare if spending falls below a financial benchmark and are rewarded if they meet quality metrics.  There are now over 400 ACOs.

Methods: In a difference-in-differences analysis of Medicare, we assess the impact of ACOs on spending, patient satisfaction, and quality.  

Results: Adjusted Medicare spending and spending trends were similar in the ACO and control groups during the pre-contract period.  In 2012, total adjusted per-beneficiary spending differentially changed in the Pioneer ACO group (−$29.2/quarter; P=0.01), consistent with a 1.2% savings.  Savings were significantly greater for ACOs with baseline spending above the local average (P=0.048) and those serving high-spending areas (P=0.04).  Savings were unrelated to financial integration between hospitals and physician groups and significant among ACOs that exited the program. Quality in the Pioneers either improved or was similar.  Patient experiences (in Pioneers and Shared Savings ACOs) were either statistically similar or better that traditional FFS, with the improvements in areas that ACOs can more readily impact and for patients they are likely to target.

Conclusion:  Early results from the ACO program suggest ACOs can achieve savings without lowering quality or patient satisfaction.

In collaboration with Kimberly Singer Babiarz, Paul Ma, and Shige Song

All research in progress seminars are off-the-record. Any information about methodology and/or results are embargoed until publication.

Abstract:

During the 1970s, the total fertility rate in rural China fell more than 50% from 6.4 in 1970 to about 3 in 1980, one of the most dramatic fertility declines ever observed. This decline coincides with an intense, widespread fertility control campaign called the ‘Later, Longer, Fewer’ campaign, which aggressively promoted later marriage, longer birth intervals and fewer children prior to the 'One Child Policy' (by when fertility rates were already very low).  In this work in progress, we use a novel dataset combining previously unused data on the province-level initiation of early fertility control policies in combination with detailed birth history data on more than 1.5 million births to study the policy’s effect on fertility.  Importantly, we also study behavioral sex selection under the policy, which is coincident with the rise of sex imbalance at young ages in the Chinese population. Specifically, we study three distinct mechanisms of sex selection: (1) male-biased fertility stopping rules, (2) prenatal sex selection (sex-specific abortion, abandonment, or infanticide), and (3) differential neglect during childhood.

All research in progress seminars are off-the-record. Any information about methodology and/or results are embargoed until publication.

Mark McClellan, MD, PhD, is a senior fellow and director of the Health Care Innovation and Value Initiative at the Brookings Institution. Within Brookings, his work focuses on promoting quality and value in patient - centered health care.  Dr. McClellan is a former administrator of the Centers for Medicare & Medicaid Services (CMS) and former commissioner of the U.S. Food and Drug Administration (FDA), where he developed and implemented major reforms in health policy. He previously served as a member of the President’s Council of Economic Advisers and senior director for health care policy at the White House, and was an associate professor of economics and medicine at Stanford University.

All research in progress seminars are off-the-record. Any information about methodology and/or results are embargoed until publication.

Older scientists are often seen as less open to new ideas than younger scientists. We put this assertion to an empirical test. Using a measure of new ideas derived from the text of nearly all biomedical scientific articles, we compare the tendency of younger and older researchers to try out new ideas in their work. Our main finding is that, in biomedicine, papers published by younger researchers are more likely to build on new ideas. Collaboration with a more experienced researcher matters as well. Papers with a young first author and a more experienced last author are more likely to try out new ideas than papers published by other team configurations. Given the crucial role that the trying out of new ideas plays in the advancement of science, our results buttress the importance of funding scientific work by young researchers.

All research in progress seminars are off-the-record. Any information about methodology and/or results are embargoed until publication.

Abstract:

Multi-criteria decision analysis enables the user to explicitly consider multiple attributes of a decision, including qualitative factors.  This technique was first developed by management scientists and has been endorsed by the European Medicines Agency.  It has the potential to transcend some of the limitations of traditional cost-effectiveness analysis.  We worked together on an Institute of Medicine committee that produced SMART Vaccines (Strategic Multi-Attribute Ranking Tool for Vaccines) -- a pioneering decision-support software tool to help prioritize new vaccines for development.  In this talk, we will describe the MCDA method, demonstrate its application in SMART Vaccines, and discuss work in progress using MCDA in influenza vaccination policy and cancer genomic screening.