Health Policy

Productivity Measurement in the United States Health System

  • By
  • Joe Colucci,
  • New America Foundation
  • and Rick McKellar, Harvard Medical School, and Michael Chernew, Harvard Medical School
October 2, 2013

Improving productivity in health care is, unquestionably, among the most important challenges facing policy makers and health care systems. Advances in medicine have greatly improved lives over the last century and ideally will continue to do so in the future. However, medical care also consumes a rapidly increasing proportion of society’s time and resources. That trend has continued to the point that growth in health care spending is considered a drag on the remainder of the economy.

Productivity and the Health Care Workforce

  • By
  • Shannon Brownlee,
  • Joe Colucci,
  • New America Foundation
  • and Thom Walsh, Dartmouth Center for Health Care Delivery Science
October 2, 2013

Beyond the Low Wage Social Contract

  • By
  • Joshua Freedman,
  • Michael Lind,
  • New America Foundation
September 10, 2013

The issue of low wages has moved to the center of American public debate recently, thanks to protests against the low pay of fast food workers, the large share of poorly-paying and part-time jobs that have been created in the aftermath of the Great Recession, and proposals by President Obama and others to raise the minimum wage. But while the debate may be recent, today’s low wages are neither new nor surprising. On the contrary, they are the result of decades of public policy.

"Do I Have Any Business Being a Doctor?" at Zocalo

May 20, 2013
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Our former intern, Catherine Jameson, has just written a fantastic post for Zocalo Public Square on her decision to become a doctor. It's a remarkably human story, and she demonstrates exactly the kind of compassion that doctors need to have for their patients in order to keep the medical system in check.

Go read it!

What a week!

May 2, 2013
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Medicaid in Oregon


First, the big one: yesterday afternoon kicked off a flurry of discussion - some of it rather heated - about the most recent paper (ungated version) to come out of Oregon’s Medicaid program. In case you’ve forgotten: a few years ago, Oregon had money to expand Medicaid enrollment - but they didn’t have enough to cover everyone who was eligible. So the state created a list of around 90,000 people, and enrolled 10,000 - giving people the opportunity to apply through a random lottery. That created an incredible research opportunity - the randomized design allows researchers to really see the effect of Medicaid enrollment on people’s health, and hopefully put to bed the nonsense idea that Medicaid is bad for people’s health.

The new publication is mildly disappointing in that regard - but the reaction to it has been way overblown. While the first study (which we wrote about in 2011) showed clear improvements in self-reported health, this paper is the first to report actual clinical data from the experiment. It did not find that Medicaid decreased average blood pressure, cholesterol levels, or HbA1c (glycated hemoglobin, a measure of blood sugar used as a diagnostic criterion for diabetes). The Medicaid group was far more likely to be formally diagnosed with and in treatment for diabetes. They also had much lower rates of depression (9% absolute risk reduction, meaning roughly one in eleven people was no longer depressed), and drastically lower rates of catastrophic medical spending.

As we noted, the results on cholesterol, blood pressure, and blood sugar are somewhat disappointing. But it’s crucial to put those measures in context. As usual, Aaron Carroll and Austin Frakt of The Incidental Economist have done incredible work pointing out the limits of the study, and the ways that it’s been over-interpreted. You should absolutely readtheirposts. They’ve also been active on Twitter, where Aaron has pointed out that the study may not have beenlarge enough to detect important effects on those variables, even if they were there, and that it’s not easy to reduce HB even when that’s what a study is specifically intended to do! We won’t spoil all of their points, but they’re excellent. Go read the post, and direct your friends to it.

As a final note on the Medicaid experiment, we’d like to point out that (while we appreciate the solid methodology) this is not the kind of study health care needs most. There is ample evidence that people benefit from insurance, both financially and medically. But our ability to benefit from access to medical care is currently limited by the massive flaws in the delivery system. Providing insurance to low-income people is great, but its value is drastically reduced when we’re spending a lot of that money on screening tests that cause overdiagnosis, unwanted elective surgeries, and expensive drugs that are no better than existing options. Eliminating the waste from the system is crucial to making universal coverage sustainable and affordable; we need RCTs of programs that focus on eliminating overtreatment and improving how we care for patients.

Elsewhere in the news...

This week, The New York Times Magazine featured a piece by Peggy Orenstein entitled,“Our Feel-Good War on Breast Cancer.”  The article couldn’t be more timely, as research on overdiagnosis continues to highlight the downsides of widespread screening. It’s a nuanced discussion of Orenstein’s personal experience with breast cancer, and the “survivor” culture surrounding the disease.  Definitely worth a read!

The Fountain of Youth

Last weekend, Ezra Klein posted a great example of how politics, money, and bureaucracy influence the kind of health care we receive. Health Quality Partners (HQP), created by Medicare with funds allocated by the 1997 Balanced Budget Act, provides seniors with a home visit from a nurse on either a monthly or weekly basis. The program was an incredible success, lowering spending on enrollees’ health care by 22%, improving their quality of life, and reducing their hospitalizations by 33%. But even though it’s been labeled “The Fountain of Youth,” HQP’s funding is due to expire in June of this year and it’s unlikely that a similar program will take its place.  Even more unfortunate is that HQP’s success won’t be used to inform future programs.  Instead, Medicare is creating a new generation of programs meant to shift from a fee-for-service system to a pay-for-quality system, arguing that the results of HQP were limited by its small size and that to scale-up the program would be less cost-effective than to change the payment structure that governs the entire program.  Perhaps this analysis is valid, but the situation highlights the difficulty of reshaping an existing healthcare system in which so many have a stake.  


"We torture people before they die.”

Jonathan Rauch profiles Dr. Angelo Volandes, creator of a series of videos showing patients the reality of aggressive end-of-life treatment, in this month’s Atlantic magazine.  For the last several years, Volandes has been working on a series of videos showing patients what it's like to receive intense medical treatments like CPR, feeding tubes, and being placed on a ventilator, and helping them understand what benefits they can actually gain from medical treatment - and what they can't.  When patients see those videos, the reality of aggressive end-of-life care hits home - and they're much less likely to choose aggressive, expensive, and often futile treatments.


Volandes's work highlights the importance of talking about death with patients and their families, and illustrates how much of end-of-life care is actually unwanted care. His videos help doctors and patients have what Volandes refers to as “The Conversation,” a necessary but often avoided discussion about the imminence of death and the need for a patient and his or her family to decide how far they want to push the boundaries of life-saving medicine. It's good to see docs like Volandes stepping up and pushing their profession toward having more honest, productive conversations about end-of-life care. We'll all die better - and live better - for it.

California End-of-Life Care

Unfortunately, patients don't always get what they want. In fact, many dying patients are subjected to far more intense treatment than they would have chosen. The new report "End-of-Life Care in California: You Don't Always get What You Want," by Senior Fellow Shannon Brownlee, highlights those discrepancies.  Most people say they would prefer to die at home - yet huge fractions end up dying in a hospital. Hospice has been shown to have positive effects on quality of life without reducing lifespans, yet adoption of hospice remains slow.

The report also highlights the huge geographical variations in how much treatment dying people receive. In nearly every category, California lags behind other parts of the country. In many cases, Southern California particularly sticks out as a hotbed of intense treatment. Patients in that area should pay particularly close attention to this report - it has important implications for what their last few months might look like, and what we might do to make the medical system serve their needs better.

For more on the CHCF atlas, and how it connects to Rauch's story, see our post on In the Tank.

Medicaid Is Asset Building?

May 2, 2013

A new study came out this week evaluating the impact Medicaid coverage has on participants' health, financial lives, and general well-being. Sarah Kliff describes the study design:

The research uses data from Oregon, where the state held a lottery among low-income adults in 2008 for a limited Medicaid expansion. Of the 90,000 people who applied, 10,000 ultimately gained coverage. The lottery gave researchers a unique opportunity to conduct the first randomized experiment on Medicaid coverage, by studying those who gained insurance through the lottery and comparing them against a similar group of adults who did not.

The randomization of the study is an important feature: other studies have struggled to control for the differences in people who seek out Medicaid coverage and those who do not (but may be eligible). As Joe Colucci from New America's Health Policy team explains, "That created an incredible research opportunity - the randomized design allows researchers to really see the effect of Medicaid enrollment on people’s health, and hopefully put to bed the nonsense idea that Medicaid is bad for people’s health."

The study looked at what impact Medicaid coverage has on people's physical health, as measured by things like blood pressure, cholesterol levels and other "easy to obtain" indicators. In the two year study period, the researchers found "few short-term physical health gains," which came as a surprise and disappointment to some and as fodder for others to decry the program as ineffective. (The results on the physical health side are complicated and mixed, but I would refer you to Kevin Drum's analysis for more on some of the statistical issues at play. A question posed Aaron Carroll and Austin Frakt is also relevant here: "How many people saying that are ready to give up insurance for themselves or their family?") 

From an asset-building perspective, the really amazing finding from the study is on the impact Medicaid coverage had on participants' financial security. Jonathan Cohn explains:

The big news is that Medicaid virtually wiped out crippling medical expenses among the poor: The percentage of people who faced catastrophic out-of-pocket medical expenditures (that is, greater than 30 percent of annual income) declined from 5.5 percent to about 1 percent. In addition, the people on Medicaid were about half as likely to experience other forms of financial strain—like borrowing money or delaying payments on other bills because of medical expenses.

I bolded parts of that because I really want to emphasize what a striking impact having health insurance had on people's financial situations. On top of the benefits to low-income people's financial security, the study also reported "significant improvements in mental health outcomes, with rates of depression falling by 30 percent."

Are Work Hour Restrictions Putting Patients at Risk of Medical Errors?

April 11, 2013
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In July of 2011, as that year’s class of freshly-minted physicians began its journey through residency, the American College of Graduate Medical Education (ACGME) instituted a 16-hour limit on shift length for first year residents (interns) with the goal of improving intern well-being and patient safety.  The guidelines also indicated that shifts should be separated by at least eight hours of “off” time.  This change followed the 2003 ACGME guidelines, which limited resident work weeks to no more than eighty hours.

While limiting shift length seems like it should be a bedraggled intern’s dream come true, research coming from the University of Michigan suggests otherwise. According to a recent study published in JAMA, interns working under the 2011 limitations are not sleeping more, are just as depressed, and in general, reported no improvement in well-being compared to interns who served before the 2011 changes.

But here’s what’s more disturbing: under the new hours regime, far more interns said they were concerned about having made a serious medical error.

In the survey, 19.9% of interns who served during 2009-2010 reported being concerned about having made a serious medical error.  That number increased to  23.3% in 2011, after the most recent ACGME limitations were implemented.

In response to the initial report out of the University of Michigan, Dr. Lara Goitein and Dr. Kenneth Ludmerer suggest potential explanations for why the 2011 changes failed to improve intern well-being.  They note that work compression (expecting interns to do the same amount of work in a shorter amount of time), more frequent patient hand-offs, and the  inability to follow patients through critical times in their hospital care may all prevent interns from reaping the intended benefits of the 2011 guidelines.   

Limiting shift length may not be the answer to improving patient and intern well-being.  Drs. Goitein and Ludmerer argue that decreasing workloads - not just limiting consecutive hours worked - will improve productivity, patient outcomes, and clinician well being.  Goitein and Ludmerer note studies in which decreased intern and resident workloads have shown improved resident satisfaction, increased time spent on education, and a decrease in duty hour violations.  While hospitals typically depend heavily on their residents for relatively cheap labor, Goitein and Ludmerer point out that decreasing resident workload results in shorter lengths of stay, fewer 30-day readmissions, and fewer admissions to the ICU.

But why the increased concern about medical errors? While the increase is troubling, it’s worth pointing out that “more interns are worried about having made a serious error” doesn’t necessarily mean “more interns are making serious errors.” The very fact that these hour limits exist reflects a change in the culture of medical education. The ACGME and other groups are becoming much more aware of the harms caused by medical errors. In that kind of climate, it’s possible that interns are simply more aware of mistakes that their predecessors had been making all along.

Unfortunately, because of its design, all this study can do is open the question. Without better data, from registries or public reporting of medical errors, it’s hard to tell the difference between a destructive change (reduced shift length makes interns so rushed that they make more mistakes) and a welcome one (changing medical culture makes interns more aware of their own fallibility, so they can learn from mistakes and avoid repeating them).

We'd like to thank Adriana McIntyre and Karan Chhabra for drawing our attention to this article. Check out their writing at Project Millennial.

Quick Hit: Canadian Doctor Connects the Dots on Income and Health

March 20, 2013
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Meet Gary Bloch, a family practice doctor living and working in Toronto, Canada. Dr. Bloch takes the time with each patient he sees to remind them to fill out their tax returns, knowing that many will see a refund and be able to claim various tax credits. As he explains in this piece for The Globe and Mail, "The link between health and income is solid and consistent – almost every major health condition, including heart disease, cancer, diabetes, and mental illness, occurs more often and has worse outcomes among people who live at lower income. As people improve their income, their health improves. It follows that improving my patients’ income should improve their health."

The connection between income and health is both clear and simple: if patients collect the refunds and tax credits they are eligible for, they will boost their income and be much better able to meet their immediate health care needs and stay healthy in the long term.

As I've written about in the past, health problems compound financial ones and vice versa. I would guess that by initiating these conversations about income and tax filing with patients, Dr. Bloch is learning a great deal about possibly the largest sources of stress in his patients' lives, is better able to understand any financial limitations patients' may have in following his medical directives, and is gaining the trust of his patients.

Guest Post: How Nonprofit Hospital Wealth Can Build Assets for Low-Income Communities

March 8, 2013
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Editor's note: This blog post was authored by David Zuckerman, Research Associate with The Democracy Collaborative at the University of Maryland. 

Study after study tell us that socioeconomic factors contribute more greatly to overall health than lack of access to healthcare. And few statistics are more powerful than the fact the zip code you live in is a better determinant of your life expectancy than your genetic code. When eight-and-a-half miles can result in a difference in life expectancy of more than 20 years, the local hospital’s quality of care is not at fault. Instead, the culprit is the lack of community wealth in the poorest neighborhoods.

To achieve their mission of promoting health, hospitals would do well to focus not just on providing acute-care services in the low-income communities they serve, but on building wealth in those communities. Policymakers, community organizers, and public health advocates should recognize the tremendous opportunity to leverage nonprofit hospitals’ reported revenues of more than $650 billion and assets of $875 billion (as of August 2012) to transform neighborhoods and build assets for residents.

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