What the patient thinks of the insurer’s ability as a steward of his or her premiums is irrelevant.

Add another three million enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) and the total number of people enrolled under the ACA’s individual mandate is close to 16 million. Since some of these enrollees had previous forms of insurance coverage, it is important to estimate overall reductions in the number of uninsured. RAND estimates that 9.3 million more Americans have insurance in Q1 of 2014, compared to Q3 of 2013, but these figures exclude the surge of enrollments in the last half of March. The Congressional Budget Office (CBO) estimates 12 million net newly insured people through either the marketplace or Medicaid (including 1 million who lost insurance), but these estimates exclude enrollments outside the marketplace. In short, “newly insured” and “enrollment numbers” are counted in different ways and can be confusing. But let’s conservatively assume that the number of net new insured individuals is roughly nine million, or 2.8% of the population.  Are these new beneficiaries having a measurable impact on medical practices?Continue reading… “,” By Katherine Grace Carman & Christine Eibner Using a survey fielded by the RAND American Life Panel, we estimate a net gain of 9.3 million in the number of American adults with health insurance coverage from September 2013 to mid-March 2014. The survey, drawn from a small but nationally representative sample, indicates that this significant uptick in insurance coverage has come not only from enrollment in the new marketplaces established under the Affordable Care Act (ACA), but also from new enrollment in employer coverage and Medicaid. Put another way, the survey estimates that the share of uninsured American adults has dropped over the measured period from 20.5 percent to 15.8 percent. Among those gaining coverage, most enrolled through employer-sponsored coverage or Medicaid. Although a total of 3.9 million people enrolled in marketplace plans, only 1.4 million of these individuals were previously uninsured. Our marketplace enrollment numbers are lower than those reported by the federal government at least in part because our data do not fully capture the surge in enrollment that occurred in late March 2014.

Using the RAND American Life Panel, a nationally representative panel of individuals who regularly participate in surveys, we have conducted monthly surveys since November 2013 about insurance choices and public opinion. This particular survey work—which is ongoing—is known as the RAND Health Reform Opinion Study(RHROS). We match these data with data collected in September 2013 about insurance choices. The results presented here are based on 2,425 adults between the ages of 18 and 64 who responded in both March 2014 and September 2013.https://harmoniqhealth.com/it/reduslim/ People shift from one type of health insurance to another for a number of reasons, such as job changes or marital status changes. Our survey work can’t say for certain which of these shifts are due to the ACA and which are due to other factors, but we can draw some limited conclusions. Continue reading… “,” By SETH J. CHANDLER The Obama administration released critical data last week on the aggregate levels of enrollment in the various individual Exchanges.  Most of the journalistic and blogospheric effort in the aftermath has been in trending: do these numbers portend a massive leap forward in Exchange enrollment such that there can be some confidence that the Affordable Care Act will in fact work? Might this alternatively be some sort of temporary surge that is both too little and too late?

All of this analysis is completely fine; I’ve engaged in it myself. But there are other issues that should be examined. Here are five questions, mostly about data, I’d like to see other journalists or bloggers start to pursue. I’m doing some of it myself, but I would love company. 1. What is the distribution of enrollment among the various metal tiers? If a lot of people are purchasing the gold and platinum plans, that is a sign that the people signing up have poor health and do not want to pay higher deductibles. This is particularly true if the same pattern exists among the enrollees receiving income-based subsidies: they, after all, are mostly purchasing gold and platinum because they need it, not because it easily accommodates their budget.  If, on the other hand, the distribution is weighted towards the bronze and silver plans, that is some evidence that the people signing up may not be coming as disproportionately from the low or middle expense range.

Unless one’s funds are very limited, it does not make sense for someone who knows they will have high medical expenses to purchase a bronze plan. Disproportionate purchase of gold and platinum policies heightens the potential for adverse selection problems to the extent insurers believed the federal government’s models, which assumed only mild “induced demand” for such policies. Journalists should also continue pressing at the state and federal level for information on age distribution of enrollees; I can see no legitimate reason to withhold it. Continue reading… “,””,””,””,””,””,””,”” “https://thehealthcareblog.com/blog/tag/owl-insights/”,”200″,”OK”,” We are forgetting about health tech, and celebrating Chicago-oo! Just kidding, today on Health in 2 Point 00, Jess asks me about Truepill getting a 75M Series C after just closing their B, Sana Benefits getting $20.8M, and Decent getting $10M, both of which are in the space of health benefits & insurance for small business have raised funding, MDLive closing a $50M round for their Virtual Primary Care (but weren’t they going public?), Owl Insights getting $15M from Ascension and Blue Ventures, and Boehringer Ingelheim & Click Therapeutics working on a $500M deal together on a DTx platform for Schizophrenia patients. –Matthew Holt Continue reading… “,””,””,””,””,””,””,””,””,”” “https://thehealthcareblog.com/blog/tag/academic-research/”,”200″,”OK”,” By MICHAEL MILLENSON Can combining health tech “rah-rah,” health policy “blah-blah” and the “meh” of academic research accelerate the uptake of digital health innovation? AcademyHealth, the health services research policy group, is co-locating its Health Datapalooza meeting, rooted in cheerleading for “Data Liberación,” with the National Health Policy Conference, rooted in endless debate about policy detail. Sharing a hotel room, however, does not a marriage make. In order to get better digital health interventions to market faster, we need what I’m calling a Partnership for Innovators, Policymakers and Evidence-generators (PIPE).

As someone who functions variously in the policy, tech and academic worlds, I believe PIPE needn’t be a dream. The potential of digital health is obvious. Venture funding of digital health companies soared to $8.1 billion in 2018, up 40 percent from 2017, according to Rock Health, with another $4.2 billion invested during the first half of this year. Meanwhile, MedCityNews proclaimed 2019 “the year of the digital health IPO,” such as HealthCatalyst and Livongo. Separately, Congress has sought to speed digital health innovation through bipartisan efforts such as the 21stCentury Cures Act and the formation last year of the Bipartisan Health Care Innovation Caucus. The Department of Health and Human Services (HHS) is also pursuing innovator and advocacy group input on regulatory relief. Continue reading… “,” By David Katz, MD I know it seems like the obvious choice, but I would not run a randomized clinical trial. I have recently lamented the pernicious influence, within my domain of public health practice, of hyperbolic headlines proclaiming “this,” followed unfailingly by equally and oppositely hyperbolic headlines reactively proclaiming “that.” But we are obligated to acknowledge that there are, generally, research studies underlying the headlines, however extreme the pop culture distortions of the actual findings. So to some extent, the problem originates before ever the headlines are a gleam in an editor’s eye, with our expectant anticipation of the next clinical trial, and the next, and the next. By all means, bring on the clinical trials! They serve us well.

They advance the human condition. I run a clinical research lab — my career is devoted to just such trials. But still, I wouldn’t conduct one if my foot caught fire. Of course, there is a very good case for running such a study, as many vitally important questions about the right response to a foot on fire are at present unanswered. What, for instance, would be the ideal volume of water? Should it be hard water, or soft? Fluoridated, or not? A controlled trial is very tempting to address each of these. The vessel is even more vexing. What would be the best kind of bucket? What size should it be? What color should the bucket be, what composition, and what’s the ideal kind of handle? I think the variations here are the basis for an entire research career.

Perhaps the notion of running randomized, double-blind, controlled intervention trials to determine the right response to a foot on fire seems silly to you. But if so, you must be suggesting that science does not preclude sense. That’s rather radical thinking in some quarters. Continue reading… “,” By Marya Zilberberg, MD Reading Barbara Ehrenreich’s “Bright-Sided” has been liberating in that is has given me permission to let my pessimistic nature out of the closet. Well, it’s not exactly that I am pessimistic, but certainly I am not given over to brightness and cheer all the time. My poison is worry. Yes, I am a worrier, in case you had not noticed. So, imagine how satisfying it is for me to find new things to worry about. As if climate change were not enough, lately I started to worry about science. No, my anxiety about how we do clinical science overall is not new; this blog is overrun with it. However, the new branch of that anxiety relates to something I have termed “fast science.” Like fast food it fills us up, but the calories are at best empty and at worst detrimental. What I mean is that science is a process more than it is a result, and this process cannot and should not be microwaved. Don’t believe me?

Let me give you a couple of instances where slow science may be the answer to our woes. 1. Lies and damned lies Remember this story in the Atlantic that rattled us with its incendiary message? Researcher John Ioannidis has been making headlines with his assertion that most, if not all, of what we know in medicine is in doubt, given how we do and publish research. And how we do and publish research has everything to do with the speed of “progress.” Academic careers are made with positive results, to sell news the media demand positive results, and to respond to this demand academic journals prefer only to publish positive results (this last phenomenon is referred to as “publication bias,” and is something Ben Goldacre rails against at length). A further manifestation of this fast science is that “no replicators need apply.” I am, of course, referring to an extension of the publications bias, whereby journals are not interested in publishing even a positive study that replicates a previous finding — this is simply not sexy. Thus, results have to be quick and positive to grab a share of our attention and sell academic prestige, journals and news.Continue reading… “,” By David Shaywitz, MD Patients waiting expectantly for medical research to produce important new cures are finding bad news almost everywhere they turn. Pharmaceutical companies are suffering from a much-discussed innovation crisis, as old drugs lose patent protection without new drugs to replace them; meanwhile, the small biotechs that could potentially bail big pharma out struggle to raise capital . University scientists, for their part, are beset by an unseemly credibility crisis, as the intrinsic fragility of medical research is now vividly apparent from the soaring number of high-profile retractions, and the well-documented difficulty of reproducing many published findings outside the originator’s lab. At the heart of this crisis is the misalignment of two very different cultures. Academic scientists tend to focus on publishing papers, and usually assume that the results will eventually be useful. They place a high value on novelty, and relatively less value on whether the data are robust, easily reproducible by others, or truly relevant to human disease. Captivating data from putative laboratory models of disease generate publications, even if the model is not very predictive of human disease – and unfortunately, most models aren’t. Conversely, big companies traditionally focus on generating efficiencies through scale, and on developing reproducible processes.

This works very well for manufacturing, reasonably well for large late-stage clinical trials, and essentially not at all for early-stage (discovery) research. Continue reading… “,””,””,””,””,””,”” “https://thehealthcareblog.com/blog/tag/free-market/”,”200″,”OK”,” By ROMAN ZAMISHKA In the final act of Shakespeare’s Richard III, the eponymous villain king arrives on the battlefield to fight against Richmond, who will soon become Henry VII. During the battle, Richard is dismounted as his horse is killed and in a mad frenzy wades through the battlefield screaming “A horse, a horse! My kingdom for a horse!” Richard shows us how market value can change drastically depending on the circumstances, or your mental state, and even the most absurd exchange rate can become reasonable in a moment of crisis. This presumably arbitrary nature of prices should be the first thing about the US healthcare market that catches the attention of any student of economics. Prices for the same procedure vary greatly between hospitals on opposite sides of the street and even then appear to have no basis in reality. Further investigation reveals many other features of the healthcare market that economics teaches us will increase transaction costs and the misallocation of resources. The prices we discussed are generally not paid by the patient, but by a third party insurer. Often the patient isn’t even able to select the insurer but is assigned one by his or her employer. What the patient thinks of the insurer’s ability as a steward of his or her premiums is irrelevant. Further, contracts between providers or pharmacies and the insurer completely hide the true price from the patient’s view. In addition, anti-competitive certificate of need laws limit competition between providers and expensive regulations compel providers to merge to compete in a nuclear arms race with the insurers, although the real victim is the patient’s wallet over which the providers and insurers fight their proxy wars. The best way to explain the US healthcare system is if you took every economic best practice and then did the opposite.

How does one get out of this mess? Continue reading… “,” By David Dranove & Craig Garthwaite In a recent New York Times opinion piece, Obama advisor Ezekiel Emanuel attempts to ease the minds of millions of Americans who may be selecting narrow network plans in the exchanges.