Maybe we do need Hospital Compare after all

A few weeks ago, I reviewed a study that showed that maybe we don’t need Hospital Compare any more.  The study found that there was significant overlap between crowdsourced ratings of hospital quality and those on Hospital Compare.  However, will the quality of crowd-sourced reviews decline over time?

This may be the case if reputation management software is increasingly being used by the health care providers being rated.  CBC reports:

Did that doctor pay to hide some bad reviews on RateMDs, the online physician rating system? You wouldn’t know.

Nor would you know if a doctor hired a reputation management service to boost the volume of positive reviews.

Online reputation management is an emerging industry with companies offering a variety of services to professionals who find themselves ranked on rating sites with no ability to opt out and with no control over the anonymous comments that can affect their reputation.

With the increasing use of reputation management tools, independent third party reviews of health care quality may become increasingly valuable to patients in choosing their physician or hospital.

Maybe we do need Hospital Compare after all posted first on http://dentistfortworth.blogspot.com

A Concerning Gap in Cybersecurity for Medical Technology

Notwithstanding mass adoption of antivirus protection and firewalls among healthcare providers, there remains a security gap for biomedical technologies, according to a report from Zingbox.

This concerning finding was confirmed in recent observations from Gartner, which wrote in a market trends report that, “generally, medical devices are not replaced for at least ten years, with many running old software that has not been updated or patched.”

Zingbox learned that most healthcare executives say they’re confident in their ability to protect connected medical devices: 79% of health IT professionals say they have real-time information about which connected devices are vulnerable to cyber-attacks, 87% are confident that the devices are protected from an attack, and 69% say their traditional security approaches for computers are adequate to secure connected medical devices.

However, there’s a disconnect between these sanguine perceptions about cybersecurity versus the actual solutions in place, Zingbox found.

Zingbox surveyed over 400 U.S.-based healthcare IT leaders for the survey in October 2018.

Health Populi’s Hot Points:  Unisys published their 2018 Security Index, finding growing global insecurity concerns among consumers about the internet, identity theft and bankcard fraud — ahead of terrorism, natural disaster and epidemic threats.

It’s important to note that 79% of consumers support the idea of medical devices and sensors that immediately transmit significant changes to peoples’ doctors, as the bar chart from Unisys’s consumer survey data illustrates. But at the same time, Unisys VP and global head of Life Sciences and Healthcare Jeff Livingstone noted in the Index report that, “We’re seeing in life sciences and healthcare that criminals are moving away from financial fraud and bankcard fraud, and more toward identity theft related to healthcare personal data. It’s become very lucrative for criminals to mine healthcare identifies on the black market.”

To deal with this growing challenge, this week the U.S. Department of Health and Human Services launched the Health Sector Cybersecurity Coordination Center. October is National Cybersecurity Awareness Month (who knew?) and this Center demonstrates DHHS’s commitment to keeping U.S. healthcare secure from cyber-attacks.

There were over 400 major healthcare breaches reported between 2017 and 2018, accessing sensitive medical data, targeting patient medical equipment, and seeking to extort financial gain.

In the promising and growing Internet of Things landscape for healthcare providers and patients, more medical “things” will be connected to the internet for remote health monitoring, patient care, and diagnostics. The more connected nodes in healthcare, the more temptations and opportunities for cyber-attackers to attack. Being honest and mindful about these threats is step one; step two is shoring up the security for each of them, and across the healthcare enterprise.

Consumers and clinicians would be wary of using medical devices known to be hacked, shown in the last graphic from a recent PwC study.

Without security strategies and assurances, patients-as-consumers would be less likely to want to share their healthcare data with providers and researchers, and patient care and cures will be the poorer for that. Furthermore, the enterprise itself could lose patient-customers, wary of using a specific hospital facility whose equipment was hacked. Risk management for cybersecurity in healthcare touches finance, quality and reputation alike.

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How Food and Data Can Support Consumers and Healthy Living: Listening at Groceryshop

Eat food, not too much, mostly plants, Michael Pollan advised us on the cover of his breakthrough book on nutrition in America, In Defense of Food.  In Las Vegas, it’s not too easy life according to Pollan.

We’re at a fork in the road when it comes to food, retail grocery shopping, and health, which is an intersection I’m increasingly working in these days. The Groceryshop conference is further informing my understanding of the landscape of the technology that’s enabling the consumer’s ability to curate, purchase, and receive the food they want to satisfy hunger and health.

I frequently go to Las Vegas for CES (each January, the world’s largest consumer electronics meet-up) and HIMSS (the annual health IT conference). This year, Groceryshop launched at the ARIA in Vegas, featuring the latest in retail technology especially focused on how retailers organize, distribute, market, sell and increasingly deliver food directly-to-consumers.

I’ve got my trend weaving lens on the conference, seeking out consumer-facing trends for food@retail that can support people in their daily quest for healthy living and disease management.

Groceryshop has convened over 2,000 stakeholders in the industry, from enterprise-wide technology solution providers that are managing very Big Data (with AI behind it), to niche vendors building way-finding tech that can help shoppers through Big Box stores to locate products in the center of the store.

Here are three key themes supporting the food-for-health mission featured at Groceryshop 2018…

• The health-and-wellness consumer is truly mainstream when it comes to grocery shopping. Folks from Soylent, The Future Market, Freshly and others addressed how to reach health-conscious consumers
• Grocery shopping is part of peoples’ lifestyles, and consumers are shopping with health and personal missions in mind.
• That mission for good food extends to food safety and supply chain transparency, with Microsoft, RxBar, and Walmart discussing this at the meeting.

Health Populi’s Hot Points: The larger context for Groceryshop through my lens as a health economist is that people are seeking health from their personal places and life goals — whether patients, younger consumers, caregivers, or fitness fanatics. Important discussions at Groceryshop that translate to health were hyper-personalization, streamlining time-and-space, cost and value. These all feature highly in health consumers’ priorities as well as the collective consumer grocery store shopping ethos.

The challenge of healthcare costs is also on my mind this week as the Milken Institute published their annual report on America’s Obesity Crisis, measuring the health and economic costs of excess weight in the U.S.

The total costs of obesity and overweight exceeded $1.7 trillion in 2016, the Milken team calculated, with the highest tallies attributable to Hypertension, Type 2 Diabetes, Osteoarthritis, Chronic Back Pain, and Alzheimer’s and Vascular Dementia.

Together, these top five cost categories accounted for $1.5 trillion of the total, the vast majority of costs; hypertension comprised over one-fourth of the total costs, and T2D, nearly 20% of the total costs of obesity and overweight conditions.

The Milken report coins this situation as a “Crisis” in the report’s title not to be catastrophizing, but to call out the economic challenge to the nation that excess weight among U.S. health citizens carry (literally).

The $1.7 trillion total cost of chronic diseases due to obesity and overweight equals 9.3% of the U.S. gross domestic product (GDP).

Simply put, America’s state of overweight represents nearly 10% of the national economy.

When we discuss the state of healthcare costs in America and how to reform the health system, the state of our food system, public transportation, education (literacy and fitness), are all components of public policy that must be addressed beyond how we finance health”care.”

The underlying technologies that we see emerging at Groceryshop 2018 can help. Consider…

• The ability to distribute fresh and healthy food via Ocado and Amazon to people living in food deserts.
• Kraft’s recipe-curation that could be customized based on health and medical goals (inspired by the third graphic here from the Kraft presentation at Grocershop). Nina Barton, President-Global Growth at Kraft Heinz, talked about the company’s role as a “strategic curator of food” on behalf of the consumer.
• ThriveMarket’s, Kroger’s, Albertson’s, and other grocers’ commitments to health and wellness throughout the bricks-and-mortar store.
• The growth of omnichannel touchpoints for health consumers where people could bundle healthy grocery carts in convenient, personalized ways.

The private sector players, from food manufacturers to technology developers and retailers, are organizing for health and wellness. I continue to appreciate this as I work cross-silo across these companies.

Will public sector policymakers respond to bolster America’s social determinants of health, baking health and wellness into all policies?

I’m speaking this Saturday 3rd November at the Ninth Annual Obesity Conference in Philadelphia on the topic of consumers going mobile and digital for health. Digital technologies are empowering consumers to be healthier grocery shoppers both both self-health care and for managing chronic conditions like heart disease and diabetes. The most engaged health consumers have begun to take advantage of these technologies, and a supply-side of healthier food products. But this hopeful health-future is clearly not yet evenly distributed, as we soberly consider the Milken Institute data.

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90% of health plans think the use of alternative payment models will increase in the coming years

A recent report from the Health Care Payment Learning and Action Network (HCP LAN) examines how providers are getting paid in the U.S. today.  Traditionally, health care providers (e.g., physicians, hospitals) were paid via fee-for-service (FFS).  Fee-for-service means that every time a provider does a service, they get paid.  This is truly largely regardless of quality and whether or not the service was actually needed.

Alternative payment models (APM) aim to change this.  APMs increase reimbursement for high quality care and also for providers that save money for the system.  The problem with APMs are: (i) quality is difficult to measure and providers may shift effort from unmeasured to measured dimensions of quality, and (ii) providers may start to under-provide care to patients who need it.

Defining an APM

The HCP LAN defines four categories of APMs in a previous report.

• Category 1: Pure FFS payment (not really an APM).
• Category 2: FFS linked to quality or value such as payment for foundational initiative or infrastructure (e.g., HITECH payments for EMR implementation, pay-for-reporting, or pay-for-performance.
• Category 3: APMs built on FFS structure.  Examples include APMs with shared savings, and APMs with shared savings and downside risk (e.g., Medicare Shared Savings Program)
• Category 4: Population-based payments such as condition-specific population-based payments, comprehensive population based payments (e.g., global budgets), or integrated finance and delivery systems where the insurer owns the providers (e.g., Kaiser Permanente model).

Share of spending captured by APMs

Regardless of your thoughts on FFS payment and APMs, there has been significant growth in the later.  HCP LAN surveyed health plans and states to asked them to provide data on the share of dollars paid to providers during the previous calendar year that were for APMs.  actual dollars paid to providers during the previous calendar year (CY) or the most recent 12- month period for which the data was available.  Responses were received from 61 health plans, three Medicaid states, and Medicare’s fee-for-service arm.  The results of the survey found the following:

• Category 1: 41% in pure FFS in 2017, down from 43% in 2016
• Category 2: 25% of health care dollars in FFS with quality metrics, down from 28% in 2016Category 2
• Category 3/4: 34% in some type of APM in 2017, up from 29% of health care dollars in 2016

APMs were most common in Medicare Advantage (49.5%) and Medicare FFS (38.3%) but less common in commercial (28.3%) or Medicaid programs (25.0%). Further, 90% of respondents thought the use of APMs will increase in the future.

90% of health plans think the use of alternative payment models will increase in the coming years posted first on http://dentistfortworth.blogspot.com

Healthcare Costs Stress Out U.S. Voters One Week Ahead of 2018 Mid-Term Elections

With seven days until voters go to the polls for what some call the most momentous U.S. election in decades, most Americans say that healthcare costs are a major stress, second only to money.

So warns the Sixth Annual Nationwide TCHS Consumers Healthcare Survey, with the tagline: “Stressed Out: Americans and Healthcare.”

Perhaps this is why healthcare has become a top voting issue for the 2018 mid-term elections that will be held on November 6 one week from today.

The first chart illustrates that healthcare costs, the economy, and family responsibilities all closely cluster as sources of stress for a majority of Americans in this poll, which was conducted among 3,604 working-age U.S. adults in August 2018.

One-half of people age 18 to 64 have received a surprise medical bill they thought would be covered by insurance, and one-third say that the ability to pay for care they need is the most pressing issue in American healthcare.

Nearly two-thirds of Americans 18-64 have a chronic condition, and 35% of people are worried about losing coverage due to their pre-existing condition if healthcare policy changes.

Thus, most Americans are concerned about potential changes to current healthcare policy, Transamerica found.

Health Populi’s Hot Points:  The vast majority of the most seriously ill patients in the U.S. have health insurance (91%), but even with coverage one-third have serious problems paying hospital bills, and 29% have difficulty affording prescription drugs. This was found in a joint study published by from The Commonwealth Fund, the Harvard T.H. Chan School of Public Health, and the New York Times published earlier this month. It’s titled Being Seriously Ill in America Today. 

Among seriously ill Americans, one-fourth were denied some type of treatment they needed because of the type of insurance they had, or because they didn’t have coverage at all.

Among the seriously ill population that is working age (18-64 years of age), 42% have used up all or most of their savings, 40% were contacted by a collection agency, and 29% cannot pay for basic necessities such as food, heat, or housing.

The second graphic quotes patients’ comments to the survey; let’s focus on the statement with the bold words, “too darn expensive.” The quote reads, in full, “I was diagnosed with asthma-exacerbated pneumonia, and I came very close to dying. And the reason why I got that bad was because I stopped taking my asthma medication, because it was too darn expensive.”

In this patient’s case, she/he could not afford to pay for their prescribed medicine due to cost, and so their illness got worse — resulting in their having to be readmitted to hospital, and costing the U.S. healthcare system even more due to complications.

We know from recent polling that most Americans across political party identification believe that people with pre-existing conditions should be ensure access to health insurance, and not be charged more for that coverage. This comment could have come from a Democrat, an Independent, or a Republican. Healthcare costs do not discriminate this way; however, the sicker in America tend to use up their financial resources, even when people are covered by health insurance, due to the prices of medicines and medical supplies, and out-of-pocket costs that the sicker and frailer health citizens bear in the U.S.

As we approach November 6, American voters in 2018 appear to be very health-cost-pragmatic.

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Book Review: Overcharged

In the book Overcharged, authors Charles Silver and David Hyman identify a number of problems with the current health care system.  Third party payment under a fee-for-service system means that providers have an incentive to provide more rather than less care.  Further, because the people receiving the services (patients) are not the ones who are footing most of the bill (employers/insurers/government), fraud is common.  The authors spend the first 270 pages or so detailing how overuse and fraud occur in this third party payment system.  The authors do a good job of documenting the size of the problem using peer-reviewed research and anecdotes, but to be honest one could have cut this section down by half and the reader would have understood the key points.

Identifying problems in the current health care system is easy to do; the more important question, however, is what is the solution?

Silver and Hyman first advocate for high-deductible health plans (HDHPs).  The benefit of HDHPs is that they lower premiums.  HDHPs are also supposed to make consumers shop for more high value care.  The downside of course is that more of the risk for adverse health events is shifted to patients.  While HDHPs are promising in theory, in practice, patient’s do very modest amounts of price comparisons and cost savings are likely to be low. Further, the highest cost to the system are patients who will have already hit their out-of-pocket maximum, so HDHPs don’t help there.  The authors do argue that a modest increase in HDHPs may not be as effective as large scale take-up of HDHP as supply sides are more likely to occur in a general vs. partial equilibrium setting.  By 2018, however, 26% of all workers are were enrolled in a health plan with a deductible of $2000 or more; among individuals in small firms this figure is 42%.

The authors also advocate for the use of non-traditional health care providers such as CVS’ Minute Clinics and Costco.  While these options may provide more convenient, more efficient services for standard well visits, check-ups and minor problems, more serious (and costly illnesses) in the near term at least likely will still be treated at physician offices and hospitals.

Another proposed solution is to have patients travel abroad for care, where cost are less expensive.  This approach works for expensive surgical interventions as long as the quality of care is maintained.  Also, if the patient is too sick, travel may not be feasible.  Further, recuperating away from a network of family and friends is problematic.  Again, this solution is likely confined to relatively low-risk surgical interventions.

The authors also advocate for prizes for pharmaceuticals.  While a good idea in theory, in practice these are often problematic. If you offer a prize for a cure for cancer, what happens if a drug cures 90% of cases?  Do they get the prize or not?  Also, some pharmaceuticals will treat conditions for which prizes are not available. I discuss the prizes vs. patents conundrum in more detail here.  The Netflix pricing model for pharmaceuticals is one approach that is between the prize/patent approach.

In short, the policies argued for here likely will be helpful to bring the market to health care.  These measures, however, work best for people who are moderately ill and are able to price shot in their HDHP, use outpatient retail clinics and potentially travel abroad for care.  The cost of paying for innovative new treatments, and caring for more severely ill patients with multiple comorbidities, however, is a more complex issue and one that is likely not adequately addressed in this book.

Source:

• Silver, Charles, and David A. Hyman. Overcharged: Why Americans Pay Too Much for Health Care. Cato Institute, 2018.

Book Review: Overcharged posted first on http://dentistfortworth.blogspot.com

Curious Questions You’ll Love Knowing The Answers To

We understand that, more than once, you’ve thought of lots of questions to ask the dentist in the weeks or days leading up to your appointment. But when you actually get in the chair, you either forget questions or worry that your questions are silly and unnecessary, and forego asking them altogether. 

 

Don’t let fear stop you from asking questions—trust us, we’ve heard it all, and enjoy answering every curiosity you have! If we don’t know the answer off the top of our head, we’ll be happy to research anything you want to know and get back to you right away. If you are someone that suffers from “chair amnesia” and all your questions seem to disappear, consider writing them down or sending us an email prior to your appointment. We understand the amount of stuff running through your head on a daily basis, so don’t worry about showing up with a note pad or sticky notes. 

 

If you are still hesitant to ask certain questions, we have a few of the most common “unasked questions” listed here for you to gander. 

 

I haven’t been to the dentist in 5…10….15 years. Should I be embarrassed? 

 

No! The most important thing is that you’re here now. We won’t guilt you or make you feel bad for your time away. Instead, we’ll work together to determine why you hadn’t had an appointment during that period of time, and work through any anxieties or issues that you might have experienced in the past.  

 

I feel really, really nervous. Can I put in headphones, or can we create a hand symbol if I get anxious? 

 

Of course! We want you to feel comfortable and at ease at every appointment. If listening to music or a podcast helps you relax, then please take advantage of technology today! If you suffer from serious dental anxiety, we also offer options for sedation dentistry that can make the appointment pass quickly with very little memory of the event. 

 

Can you tell that I’m lying about flossing? 

 

Yes, we can absolutely tell if you stretch the truth about your flossing routine. Without flossing, you’re not cleaning 35% of the surface of the tooth. Due to this, your gums will be inflamed, and tartar will have built up around your teeth. We won’t admonish you or embarrass you for this, but we will remind you that flossing is an integral part of your oral health routine. 

 

Is my problem the worst you have ever seen? 

 

Some patients ask and we know others are thinking that their teeth are the worst we’ve ever seen. As dentists, let’s just say we have seen it all. You shouldn’t be worried about coming in to address lingering issues, or even for a cleaning. The most important thing is that you came in. We are here to help you rejuvenate your smile and alleviate any pain you are experiencing.  

 

I am afraid that I won’t be able to pay for my dental work. 

 

If you are uninsured or underinsured and have concerns that you can’t afford the work you need, please speak up. Prior to any procedure, you can meet with our finance team to discuss costs and payment options. Putting off necessary work due to cost might result in more costly work in the future. 

 

Do you need to know all my prescriptions? 

 

Discussing what medications you’re on might seem too personal to share with your dentist, but it is important. We are part of your comprehensive health team and it’s important that we’re in the loop to ensure we don’t prescribe anything that could adversely react with anything you’re taking. We want to work collaboratively with your other providers, so please be transparent!

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Radicalizing Kindness for Health: Learning from Bhutan

“Happiness is within, but not within you alone as it is among us. If we can create happiness in a community, then we will be able to attain happiness as individuals,” observed Saamdu Chetri speaking at the International Psychological Congress last week.

Chetri is health of Bhutan’s Gross National Happiness Centre, which developed the Gross National Happiness Index.

The phrase “Gross National Happiness” was first mentioned in 1972 by the 4th King of Bhutan, King Jigme Singye Wangchuck in an interview with the Financial Times. King Wangchuck said that, “Gross National Happiness is more important than Gross Domestic Product.” The GNH became part of Bhutan’s Constitution in 2008, and the first Index report came out in 2012.

The GNH’s nine domains appear in this wheel diagram. Underneath these nine measures are 124 variables which, taken together, represent the multi-dimensions of human well-being.

The Bhutan “good government” and other organizations use the GNH Index to either, “increase the percentage of people who are happy or decrease the insufficient conditions of people who are not-yet-happy,” a short guide to the GNH Index explains.

Here’s more on the history of the GNH Index.

Health Populi’s Hot Points:  I stayed away from Sunday morning news shows yesterday, shell-shocked from the triple whammy of letter bombs, the Kentucky attack on African-Americans at Kroger and threatened black churchgoers, and the murders of eleven congregants at the Tree of Life synagogue in Pittsburgh which has operated for over 150 years.

By 4 am this morning, I could deal with catching up with the news shows, and tuned into Kasie DC which was broadcast over the weekend. Kasie Hunt was interviewing Rick Tyler on the state of American politics and voters at this moment in our history. Tyler, who was  national spokesman for Ted Cruz’s 2016 Presidential Campaign, said that we in America need to, quote, “radicalize kindness.”

Tyler then talked about his wife and daughter, who are both teachers. In their classrooms, they bring students together in an inclusive way. The intent is, ultimately, to help raise up children to be adults who feel they belong in their communities, in society-at-large.

Look at the Bhutan GHN Happiness Index wheels. I bundle these into three categories:

• Community vitality, education, cultural diversity and resilience, ecological diversity and resilience, time use, living standards
• Health, psychological well-being
• Good governance.

In the context of social determinants of health, I look to the first line items that underpin the second two outcomes: physical health and psychological well-being. Check out any of the many excellent SDOH reports I’ve covered here in Health Populi, such as Aetna Healthy Communities, the Blue Zones, and the Gallup-Sharecare Well-Being Index, among others.

The third category, a single domain, lives on its own because it’s fundamental: good governance. Two words that have been used to explain good governance are “equilibrium” and “inclusion.”

A recent article in the BMJ talks about “Valuing health as development: going beyond gross domestic product.” In the essay, the authors (who all come out of public health schools) discuss developing alternative well-being measures beyond a nation’s GDP. “We need to teach our children and the rest of society that accumulation of wealth and money is not everything. We need to show that a developed society in which citizens are educated with the freedoms and capabilities to pursue happiness, which are not necessarily at odds with national GDP growth, but in support of it, is possible,” the authors say.

I leave you with two thoughts: first, this list of the eleven victims from the Pittsburgh shooting – they ranged in age from 54 to 97.

Joyce Fienberg, 75

Richard Gottfried, 65

Rose Mallinger, 97

Jerry Rabinowitz, 66

Cecil Rosenthal, 59

David Rosenthal, 54

Bernice Simon, 84

Sylvan Simon, 86

Daniel Stein, 71

Melvin Wax, 88,

Irving Younger, 69

Second:

 

 

 

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Competition matters

While the high price of branded drugs often gets a lot of attention in the public, few realize that after patent expiration, prices often plunge dramatically and high quality treatments are available for extremely affordable prices.  Granlund and Bergman (2018) estimate the size of this price reduction using data from Sweden.

In the long term, the price of generics is found to decrease by 81% when the number of firms selling generics with the same strength, form and similar package size is increased from 1 to 10. Nearly only competition at this fine-grained level matters; the effect of firms selling other products with the same active substance, but with different package size, form, or strength, is only a tenths as large. Half of the price reductions take place immediately and 70% within three months.

In short prices reductions are steep and rapid.

Source:

• Granlund, David, and Mats A. Bergman. “Price competition in pharmaceuticals–evidence from 1303 Swedish markets.” Journal of health economics 61 (2018): 1-12.

Competition matters posted first on http://dentistfortworth.blogspot.com

Healthcare Economist on President Trump’s plan to lower Medicare drug prices

A recent report from Assistant Secretary for Planning and Evaluation (ASPE) found that for about 30 physician administered drugs, prices are 8 times as high as those charged in other developed countries.

To address the high prices, President Trump unveiled a three-part plan to reduce drug prices.  Under the “international pricing index” proposal, U.S. drug prices would be benchmarked against 16 other nations: Austria, Belgium, Canada, Czech Republic, Finland, France, Germany, Greece, Ireland, Italy, Japan, Portugal, Slovakia, Spain, Sweden and the United Kingdom. Drug prices in these countries are lower so it is likely that prices would fall. Trump also proposes allowing private sector plans physicians and hospitals to negotiate directly with life sciences firms. Finally, Trump proposes offering physicians flat rate for each prescription rather than tie physician fees for drug administration to a share of the sales price.

These initiatives, if implemented, are likely to save cost, but may have an adverse effect on patient health.  Tying prices to other countries will drive down costs if other countries maintain their price. If this is the case, however, overall revenue given to innovators will fall. Previous academic research (Acemoglu and Lin, 2004; Finkelstein, 2004; Blume-Kohout and Sood, 2013) has shown that reduced market size leads to less R&D and less downstream innovation.  Research by my colleagues at Precision Health Economics (PHE) has shown that cancer mortality reductions were highest in countries that spent the most on cancer care (Stevens et al. 2015)

The impact of allowing price negotiation of Part B drug is unclear. Like the international price index case, if negotiations just lead to lower prices, innovation and long-run patient health could suffer.   It negotiations are based on treatment value, however, then high-value treatments could get higher reimbursement whereas low-value treatments would get lower reimbursement.  New programs such as the Innovation and Value Initiative use advanced economic modelling as well as feedback from patients to better measure treatment benefits, risks, costs and overall value. Value and cost are not the same thing. My own research (Lakdawalla et al. 2015) showed that even though the price of colorectal cancer and multiple myeloma treatment rose in recent years, the value that patients receive has remained flat or in improved.

The Trump proposition to impose flat rate reimbursement for physicians makes sense in theory, but could negatively affect patient access. Flat rate payment means that physicians will no longer be financially rewarded for prescribing more expensive medicines.  At the time, however, some physician-administered medications may cost tens or even hundreds of thousands of dollars over the course of a year.  Flat physician payments do not take into account the cost of capital needed to hold these treatments in inventory over an extended period of time.  Thus, physicians may begin refusing to stock high-value, but expensive treatments if the administration costs more than this new flat rate reimbursement level.

Overall, the President’s plan may success in reducing price in the short-run.  However, one must worry that long-run health of the nation may suffer to (i) decreased R&D and subsequent innovation, as well as (ii) decreased patient access to physician-administered drugs.

Healthcare Economist on President Trump’s plan to lower Medicare drug prices posted first on http://dentistfortworth.blogspot.com

AMA and the adoption of digital medicine

There is a lot of hype about digital medicine.  Though the definition of what digitla medicine mans varies, many digital devices are able to monitor patient physiology, medication adherence, or other behavior and communicate that with the patient as well as their provider team. One key barrier to having the provider team actually use these data is reimbursement.  Digital medicine offers physician the possibility of improved care, but spending too long reviewing digital medicine information means that there is less time in the day left to work on revenue-generating activities (like seeing patients).

Last week, the AMA took steps to rectify this issue.  The AMA is adding the following digital medicine related codes to their 2019 Current Procedural Terminology (CPT®) code set.  These codes include:

• 99453 Remote monitoring of physiologic parameter(s), (for example, weight, blood pressure, pulse oximetry, respiratory flow rate) initial; setup and patient education on equipment use.
• 99454 Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
• 99457 Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.

While there are a number of other barriers to digital medicine usage (e.g., integration into EMR, long-run patient adherence, easy of use, value of the information created etc.), the AMA decision removes one key barrier to using digital medicine in practice: making sure providers are reimbursed for their time reviewing these data.

AMA and the adoption of digital medicine posted first on http://dentistfortworth.blogspot.com

Is health care a luxury or a necessity?

I ask this question in economic terms.  Luxury goods are defined as goods that increase as a share of a person’s (or country’s) budget as income increases; necessity goods are defined as goods that decrease as a share of a person’s (or country’s) budget as income increases.  There is actually mixed evidence on the topic with some studies saying luxury (Kleiman, 1974; Leu, 1986; Newhouse, 1977) and others saying necessity (Baltagi & Moscone, 2010; Di Matteo, 2003; Farag et al., 2012,; Parkin, McGuire, & Yule, 1987).

A paper by Shaikh and Gandjour (2018) tries to answer this question using an instrumental variables strategy outlined in a paper by Brückner (2013).  A simplistic approach would run a regression of GDP per capita on pharmaceutical spending.  However, there may be reverse causality if higher pharmaceutical spending improves long-term health and thus GDP improves.  To address this issue, the authors use international tourist spending as an instrument for GDP.  The authors use data on pharmaceutical spending from the WHO’s World Medicines Situation 2011—Medicine Expenditures’ annex and GDP per capita data from World Bank Open Data or the IMF’s World Economic Outlook database.  The authors find that: 

income elasticity of public pharmaceutical expenditure is greater than unity in the full sample…[however], GDP per capita has a statistically significant positive effect on pharmaceutical spending only for high‐income countries…

In short, public pharmaceutical spending is a luxury good.

The authors also find that pharmaceutical spending has a negative effect on GDP per capita.  At first glance this is surprising.  If people are healthier, shouldn’t GDP per capita improve.  In some cases, the answer is likely yes.  In other cases, while increased pharmaceutical spending would increase GDP, it may not increase GDP per capita.  Consider the example where all people die at age 70.  Assume that a new drug expands life expectancy to age 80 and also increases productivity by 20%.  In the table below, under the low pharmaceutical spending case, GDP is $100,000 and GDP per capita among the 2 people alive is $50,000.  With high pharmaceutical spending, overall GDP increases by 20% to $120,000, but GDP/capita falls by 20% to $40,000 since the elderly man who would have died at age 70 is now alive.  Further, the likely effect of pharmaceutical spending on GDP may take a long time to appear, for instance treatments that improve the health of children will increase school achievement and likely long-run earnings.  In short, the story is more complicated than it seems.

 

	Income
	Low pharma spending	High Pharma Spending
Age 30	$40,000	$48,000
Age 50	$60,000	$72,000
Age 70	dead	$0
Total GDP	$100,000	$120,000
GDP/capita	$50,000	$40,000

Source:

• Shaikh, Mujaheed, and Afschin Gandjour. “Pharmaceutical expenditure and gross domestic product: Evidence of simultaneous effects using a two‐step instrumental variables strategy.” Health economics (2018).

 

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Financial Stress Is An Epidemic In America, Everyday Health Finds

One in three working-age people in the U.S. have seen a doctor about something stress-related. Stress is a way of American life, based on the findings in The United States of Stress, a survey from Everyday Health.

Everyday Health polled 6,700 U.S. adults between 18 and 64 years of age about their perspectives on stress, anxiety, panic, and mental and behavioral health.

Among all sources of stress, personal finances rank as the top stressor in the U.S. Over one-half of consumers say financial issues regularly stress them out.

Finances, followed by jobs and work issues, worries about the future, and relationships cause stress in the most people.

Financial stress is a factor ranking high for people dealing with both mental health challenges and chronic health conditions.

Our relationship with our self — “self-worth and purpose” — ranks high, too, for people dealing with a mental health condition.

Looking under the 52% of U.S. adults who attribute finances to their feelings of stress, fully 50% of people dealing with a mental health condition don’t feel in control of money: 17% feel “off the rails,” and 33% “not so great” when it comes to satisfaction with finances and money management.

Similarly, for people diagnosed with a chronic medical condition, 14% feel “off the rails” and 32% not so great when considering satisfaction with their financial situation (NET negative 46%).

In comparison 39% of folks with no chronic condition feel out of control with money issues.

Health Populi’s Hot Points:  Stress negative impacts consumers’ physical health and mental health. Sleep, bad feelings about one’s personal appearance, low self-esteem, and social isolation are manifestations of stress, shown in the third chart.

Note the fifth factor, worrying about the state of the country. This feeling of political stress was uncovered at the time of the 2016 U.S. Presidential Election by the American Psychological Association in their Stress In America study, which I discussed here in Health Populi.

As I look across the Atlantic Ocean from where I’m working at this moment in Dublin, Ireland, my perspective on this data is global. Earlier in my trip, collaborating for health in Italy, Belgium, and the UK, it became clear that citizens in each nation are also stressed — politically and financially. These feelings are translating into social and political impacts, just as they have in the U.S., in each nation. Election outcomes, public policies, and unemployment which underpins financial ill-health, is evident across-the-board.

While many of us in the U.S. have pointed to the need for greater attention to social determinants of health, which requires greater spending on social care versus technology-based healthcare and sick care in the U.S., we shouldn’t assume that by allocating more money to address these issues will be the panacea for course-correcting what has been decades of a public health challenge.

In a letter written from Paris in 1787, Thomas Jefferson wrote his friend Peter asserting that, “Traveling makes men wiser, but less happy.”

I return to the U.S. tomorrow having spent nearly three weeks getting smarter about health and healthcare in various parts of Europe. That perspective reinforces my perspective that, in the U.S., we must continue to wrestle down healthcare cost, quality and access challenges beyond siloed public policies, randomly throwing shiny new technology solutions at problems, and reallocating finances without attention to cross-policy synergies and fiscal rationale.

Ultimately, we must decide whether we, Americans, believe that we all deserve to live in a country where we truly value health for all, for ourselves and for each other.

We know that most Americans, across political party affiliation, believe that ensuring coverage for pre-existing conditions is a must. That is a unifying health principle that we can build on.

But this week, the Centers for Medicare and Medicaid Services issued “State Relief and Empowerment Waivers” that allow each of the 50 U.S. states to take their own fragmented approaches to healthcare. This means, for now, there will be no unified approach to address our national health-financial-stress diagnosis we see in the Everyday Health profile.

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Food and Cooking for Health: a UK Perspective from Hammersmith & Fulham

Food deserts aren’t just a U.S. phenomenon. They’re found all around the world. This week as I explore social determinants of health and technology solutions in several parts of Europe, I’ve learned more about food access challenges in the UK.

These are discussed in a report published this month by the Social Market Foundation asking, What are the barriers to eating healthily in the UK?  The research was supported by Kellogg’s, the food manufacturer. The first table comes from the report, and the topline shows that about 4 in 10 Britons shopped at a cheaper food store in response to high food prices. One-third of people in the UK purchased cheaper and less healthy food instead of healthier, higher-priced items.

I reviewed this report in the context of a conversation I had with one of my beloved and long-time colleagues, Ben Coleman. I worked with Ben over 20 years ago when we were very young collaborators on a program to educate U.S. businesses on the opportunities that the European Single Market represented for American businesses. This was in anticipation of “1992,” the launch of the European Economic Community. Ben was based in the UK, and I, in the U.S. Together, as a cross-Atlantic business strategy duet, we educated our clients on the opportunities to go European.

At the time, I was balancing my health advisory work with this transatlantic effort, while Ben was working on his core projects in the UK private and non-profit sector.

Today, Ben Coleman is Cabinet Member for Health and Adult Social Care, representing the London Borough of Hammersmith & Fulham (LBHF). Little did I know, way back in the 1992 days of our collegial work relationship and budding friendship, that Ben would one day play with me in my sandbox of public health and social determinants.

We met up last week to discuss his work with the LBHF and the Borough’s Health and Wellbeing Council (HWC). Two of Ben’s objectives these days focuses on loneliness (the topic of yesterday’s Health Populi blog) and food security.

In my work with him over the years, I’ve known Ben to be all about inclusion and convening people who represent a broad range of interests and political bents in a getting-to-yes ethos. He has such a creative and positive mind, always crafting new ways to solve difficult challenges facing us humans.

And so it is with the real human challenge of food security and nutrition access, which the Social Market Foundation recognizes throughout the UK — from northwest to southeast England and points in-between, in Scotland and in Wales. The map below illustrates the region’s food insecurity hot spots.

Ben told me of a recent meet-up organized in the H&F Borough that took place in a local church. A nutritionist from the area led a session on healthy cooking and ingredients. “I’ve learned all about the value of turmeric,” Ben told me with enthusiasm. I called out the turmeric in this Health Populi post highlighting consumer food trends via Nielsen earlier this year. I was also glad to hear about this program taking place in a faith-based institution, which research in the U.S. has shown can help drive health in local communities where people live, work, play and pray.

The Council is looking to develop a local approach to food strategy over the life course for health citizens in the Borough, from the youngest school-aged children to aging folks. Food, too, can address social isolation, we discussed, as part of the UK government’s macro loneliness strategy.

Some key elements of the Social Market Foundation report are that

• Food is a major component of household spending in the UK, accounting for one in every ten pounds spent by British homes. For people in the bottom 10% of incomes, food accounts for one-fifth of disposable household income.
• High and unaffordable food prices have resulted in people shopping in lower-priced grocery stores. One in four Britons have purchases cheaper and less healthy food as a result of too-high prices for healthier foodstuffs.
• One-fourth of people in the UK feel that healthy and nutritious food is unaffordable in the country — in particular, fresh products like meat and fish. 17% of UK consumers  said fresh fruit was the most unaffordable item, and 11% said that would be fresh veg. In contract, only 5% of people said “crisps” (chips) and chocolate bars were the most unaffordable items in the grocery.
• Some 10 million people in Great Britain live in food deserts, the report noted, illustrated in the map here.

In a related public health story, the level of obesity among children in the UK is rising, based on this report from the National Child Measurement Programme whcih found an 8% increase in childhood obesity over the past ten years.

Public Health England has met with organizations on the retail side of food, such as Domino’s Pizza, KFC, and McDonalds to discuss the merits of introducing “calorie caps” to their menu items. “Consumers [in the UK] are saying they want smaller portions and healthier options,” Dr. Alison Tedstone, who is the chief nutritionist of Public Health England, told The Telegraph newspaper as she discussed the implications of the measurement report.

Health Populi’s Hot Points:  As Dr. Tedstone has observed about her fellow UK health citizens, consumers are demading healthier options. This is also true in the U.S., as I’ve noted over the past decade in my growing work on food-as-medicine and retail health. Here’s a recent Health Populi post on peoples’ growing call for food as their personal social determinant of health.

 

 

As in the U.S., British grocers have been morphing into health destinations shoppers looking for well-being at retail. In this webpage from Sainsbury’s, the food retailer quantifies their commitment to health-through-food. This provides both data and knowledge along with a dose of good PR to health consumers seeking health, and a place to trust to share in good decision making.

Please take another look at the second chart above from the Social Market eating healthily report; it tells us that consumers are seeking both knowledge-empowerment and food-health literacy along with financial wellness — traits Americans share with their British peers.

There’s one final observation (among others I could name) to leave you to consider. That’s the role of ecommerce, like Amazon, Instacart and Ocado, among them, to deliver food to peoples’ homes that may be located in healthy food challenged geographies. Earlier this year in the U.S., Amazon began to offer discounted Prime membership to people enrolled SNAP benefits. The Social Market Foundation report found that a good proportion of folks in the UK might be interested in ordering fresh food via ecommerce. This could be one, among many, channeling/distribution strategies to help get nutritious food to those who need it most, and can little afford it. If an Amazon Prime membership [for example] could be socially prescribed and subsidized, that could ease an additional financial burden in the short run prevention model that could save bigger healthcare costs downstream.

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Open-Source tools for economic modelling

QuantEcon is an interesting site from some high profile economists advocating for open-source tools for quantitative economic analysis.  The organization describes itself  on their website as follows:

QuantEcon is a nonprofit organization dedicated to improving economic modeling by enhancing computational tools for economists.  Our activities include

• developing and facilitating the development of open source software for economic modeling, and
• building open, collaborative platforms for sharing, discussing and documenting open source software

Development is centered on open source scientific computing environments such as Python, R and Julia.

Creating quantitative tools for others to use is something that I also support through my work at the Innovation and Value Initiative’s Open-Source Value Project (OSVP).

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Video Review: Less Is More?

North Texans have been lucky that real estate costs haven’t been too astronomical compared with national trends, and generous-sized houses are the norm scattered throughout our suburban sprawl. But while this is great for ensuring that everything has its place, it also means that we are holding onto things that we don’t necessarily need…or purchasing more stuff just because we have the space for it! 

 

In this TedED video, Graham Hill explains how ditching extra stuff in your home can actually lead to increased happiness. But before you go throwing out all your children’s “stuff” (especially after you step barefoot on a Lego in the middle of the night), keep reading to hear more about the social science behind minimalistic living.  

 

Today, on average, houses have three times more space than houses did 50 years ago. Due to that, you’d have to assume that families have more than enough room for all their prized possessions! 

 

Well, guess again. The personal storage industry is a $22,000,000,000 industry today. That means that, although we have more space, we also have an excess of possessions that require offsite storage. 

 

So, in the grand scheme of lifestyle and metal health, what does this mean? While we may have more stuff, we also have more debt, an increased carbon dioxide footprint, and more stress. These effects are why Mr. Hill has concluded that less might equal more. 

 

The basis for Hill’s hypothesis is that less stuff—combined with less space—results in less of an environmental impact, more money in your pocket, and more overall happiness. He gives an example of living in New York City where he moved to an apartment that was 200 square feet less than his previous. He calculated that he would be able to save $200,000 by saving money on rent, utilities and the inability to impulse-buy products that only take up room.  

 

Next, Hill gives practical steps on how you can “live little” and increase your happiness. The first thing that you must do is edit ruthlessly. This means cutting extraneous stuff out of your life and slowing the inflow of what comes through the door. Experts on minimalism have varying forms of advice of how to purge items. For clothes, many agree that if you haven’t worn it in the last year then it can go. If you are an avid chef and have a kitchen overflowing with gadgets and gizmos, then one piece of advice to get rid of “single use items.” So…the avocado peeler that sits in the back of the drawer should get the boot since it can’t be used for other tasks. This also means you need to think before you buy. 

 

The next step is to think small. While this runs counter to our unofficial mantra that everything is bigger in Texas, it doesn’t have to mean that you need to trade your spacious home for the tiny apartments featured at Ikea. Instead, it means making smart purchases that nest (think measuring cups) or stack, or digitizing photos and documents, or shredding unneeded paperwork.  

 

Finally, Mr. Hill’s last piece of advice is to make things multifunctional. Look for pieces of furniture that can be used for several purposes or articles of clothing that can bridge seasons. This will cut down on the amount of stuff you actually need.  

 

Hill believes that by cutting out the stuff in your life, it can actually make you richer and happier. Editing down the things in your life will look different for every person. Take small steps to try out his ideas, be sure to watch the video, and see if you feel a burden lift! 

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Loneliness, Public Policy and AI – Lessons From the UK For the US

There’s a shortage of medical providers in the United Kingdom, a nation where healthcare is guaranteed to all Britons via the most beloved institution in the nation: The National Health Service. The NHS celebrated its 70th anniversary in July this year.

The NHS “supply shortage” is a result of financial cuts to both social care and public health. These have negatively impacted older people and care for people at home in Great Britain. This article in the BMJ published earlier this year called for increasing these investments to ensure further erosion of population and public health outcomes, and to prevent further health disparities in the UK.

Along with this provider-supply shortage, the UK recognizes a national social stress for which Prime Minister Theresa May created a Minister for Loneliness post. This initiative resulted in a strategy for tackling loneliness in the United Kingdom.

Here is a snippet from the UK government’s press release last week on the extent of the nation’s social isolation challenge:

“Loneliness is one of the greatest public health challenges of our time, Theresa May said today as she launched the first cross-Government strategy to tackle it.

The Prime Minister confirmed all GPs in England will be able to refer patients experiencing loneliness to community activities and voluntary services by 2023.

Three quarters of GPs surveyed have said they are seeing between one and five people a day suffering with loneliness, which is linked to a range of damaging health impacts, like heart disease, strokes and Alzheimer’s disease. Around 200,000 older people have not had a conversation with a friend or relative in more than a month.

The practice known as ‘social prescribing’ will allow GPs to direct patients to community workers offering tailored support to help people improve their health and wellbeing, instead of defaulting to medicine.

As part of the long-term plan for the NHS, funding will be provided to connect patients to a variety of activities, such as cookery classes, walking clubs and art groups, reducing demand on the NHS and improving patients’ quality of life.”

This topic set the context for my conversation with Maneesh Juneja, digital health futurist and global speaker on health, technology and people.

I spent time with Maneesh while in London this week. On his way walking to meet me, he shared the above image from his Apple iPhone sent to him through the Hugging Faces chatbot, texted via our WhatsApp connection. I wasn’t surprised that Maneesh was revealing this private message with me, because he is very transparent via social networks on his personal tests and hacks with wearables and apps. Maneesh goes well beyond tracking steps and heart rate: for example, air quality in his immediate environment. [On the morning we met in the café in Covent Garden, the data from his personal air pollution sensor showed very high levels of indoor pollution].

This moment was a different flavor: the Hugging Faces chatbot was speaking about friendship, and Maneesh texted me, “I’m just chatting with my new BFF.”

Now you know something important about this man. He studies digital health passionately, personally, viscerally. He wears many devices at once, putting the techs to his tests, and figuring out just what works well, and for whom.

“For whom” more often than not means those who have been long-overlooked by healthcare providers, technology developers, and public policy: the sicker, the frailer, the disenfranchised, the less affluent, the less educated, the geographically isolated, and folks without broadband access.

None of these factors is independent of the others for people who may obviously fit into one of them.

That’s why PM May’s public policy prescription has the potential to be so powerful: because the strategy is weaving in loneliness policy across many Ministers’ portfolios along with engaging private sector and NGO involvement.

Tackling loneliness touches on all aspects of daily life: economic, social, environmental, transportation, and to be sure, health and nutrition.

Here’s just one real-life scenario about baking health and social connection into public policy, across government siloes. In the same week as the UK government issued the loneliness strategy, the BBC (Britain’s public service broadcaster, and the world’s oldest national broadcasting organization) said they were evaluating whether to charge people who are over 75 years of age for a TV license. Since 2000, the BBC has offered a free TV license to over-75s which amounts to a £150 subsidy for some 4.5 million people in Britain.

Ironically — and this is where the right hand (call that the BBC idea) doesn’t know what the left hand (the loneliness strategy) is doing.

Here is a UK report from Ofcom (the UK’s communications regulatory agency, akin to America’s FCC) that found that two-thirds of Britons 75 and over would most-miss a TV set versus a mobile phone, radio, or computer.

Thus, the BBC policy of charging elders £150 for the right to watch television — when a TV could be that person’s major social connection to her outside world — would be counter to the isolation policy objectives.

“Everyone can play a role in connecting and collaborating to tackle loneliness,” the circle chart asserts. This graphic is reproduced from the strategy report, and represents the policy’s multi-stakeholder approach to addressing loneliness in the UK: government, employers, local authorities and health services, and community organizations are all named in the report in playing roles. At the center of this convergence are friends, families and peoples’ communities.

These policy recommendations are rooted in a tragedy: the murder of Jo Cox, the Labour MP who was murdered in 2016. Jo had campaigned about loneliness, and had worked with Oxfam for many years. Jo had set up the Commission on Loneliness before she was killed. You can learn more about Jo Cox and the loneliness agenda here.

For further information on loneliness in the UK, here was the New York Times’ take on the appointment of the Minister for Loneliness published in January 2018.

And here is an important essay, quite timely to revisit from 2016, from The New Yorker on Jo Cox, the Brexit Vote, and the Politics of Murder.

Health Populi’s Hot Points:  Maneesh snapped this photo of us as we were about to say so long, for now, in Covent Garden. In our conversation, we covered a lot of ground — starting and ending with “Cordelia” (the name that the Hugging Faces app chose to name Maneesh’s personal chatbot), AI, virtual friends, friendship, and what it means to be human in the 21st century. And, we talked about the fact that Nigeria will be the third most populous nation in the world by 2050 after China and India.

How can we scale health and well-being in a scarce resource world?

We talked about the potential for AI and data (the right data, not just all “Big Data,” to include linked and longitudinal data) to augment healthcare providers in terms of both sheer supply and geographic access. The NHS is always resource-constrained as it operates on a budget; for Americans, think about how difficult and/or painful the migration from volume-based payment to value has been. The NHS has never known about volume-based payment, which I learned on a steep learning curve when I worked in London and through the UK NHS regions over two decades ago. That’s when, here in the UK, I cut my own professional teeth on the role of health IT to help measure and manage health care resources, quality and patient outcomes under severe resource constraints.

With technology enablers like the cloud, wearable tech, and broadband, we have the potential to scale health and care to people who haven’t benefited from access to mental health and social services, tertiary and specialist care, and social connectivity via online patient groups.

I leave you with a sentence from May’s introduction to the loneliness strategy report: “For one of the best ways of tackling loneliness is through simple acts of kindness, from taking a moment to talk to a friend to helping someone in need.”

Building mental models and sharing perspectives with Maneesh was a moment of both learning and of kindness. It will take a village to help us make healthcare better, and to address loneliness. I’m so grateful and comforted to know Maneesh is on the march with me.

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Future directions for cost effectiveness analysis research

The Second Panel on Cost Effectiveness in Health and Medicine made a number of recommendations of how to improve cost effectiveness analysis (CEA).  Yet, CEA is far from “solved”.  In a recent article by Neumann et al. (2018), the Second Panel identifies seven CEA areas where additional research is needed.  This include:

• CEA and perspective: “Many issues require work before the field can reach agreement on summary measures for a societal perspective, particularly which elements to include in a summary, how these should be determined, and how to value them.”  While the Second Panel recommended taking a societal perspective and–if appropriate for the question at hand–also the health system perspective, it was unclear whether the goal should be to maximize health benefits or overall benefits (e.g., health but also labor market outcomes, schooling, or other non-health factors.).  The authors mention that cost-benefit analysis (CBA) may be appropriate.  As the name indicates, CBA  considers the value of costs and benefits to the losers and gainers of an intervention based on market prices [or if these are not available, then shadow prices.
• Modeling.  While many models conduct sensitivity analyses around models parameters, few CEAs conduct sensitvity analysis across model types.  The Innovation and Value Initiative (IVI) has done this with their IVI-RA Value Toll Model, but few others do this.  An exception is Cancer Intervention and Surveillance Modeling Network (CISNET), which does perform comparative model analysis.  Also, best practices recommend that modelers provide sufficient  detail about the model structure and parameterization to allow other researchers to reproduce it, other groups–such as IVI, have made their models itself available online.
• Valuing health outcomes. Measure of quality of life often can be translated into QALYs assuming that the health state persists over some fixed duration.  But what about temporary health states?  Chaining methods may be used to estimate the value of temporary health states (see Wright et al. 2009, Locadia et al. 2004, and McNamee et al. 2004).  In one case, “subjects were asked to compare health states associated with the process of prenatal diagnosis to a temporary health state of the same duration based on a description of the experience of undergoing chemotherapy (but not so labeled).”  QALYs are also problematic because they assume that individuals are indifferent to the order of when the events occur.  The Neumann et al. paper even asks whether using virtual reality would be helpful to better model health states.
•  Valuing non-health outcomes.  What happens if a medicine–such as an antipsychotic–is able to reduce crime rates?  Should this be included in a CEA model?  The answer is likely yes.  Also, the Second Panel argued that “the effects of morbidity on productivity in the labor market and in household production are not captured by standard utility measures and therefore should be assessed in pecuniary terms and included in the numerator of the CEA.”
• Evidence Synthesis.  Before building a CEA model, one must know the clinical benefits of different treatments.  Synthesizing available evidence when there is not a head to head trial is problematic.  Neumann et al. write that “Currently, there is no rigorous, internally consistent set of premises and theorem-based derivative propositions that motivates and justifies the practice of evidence synthesis. The exception may be the mathematical foundations of quantitative synthesis (meta-analysis).”
• Estimating CE thresholds. There are two options here, supply side or demand side.  Supply side calculates the CE threshold based on the opportunity cost; what would be the value of these funds if they were allocated to other activities.  The demand side looks at consumer willingness to pay for health gains.  Some CEAs–such as ICERs–have said that ‘a given intervention is high value, but not affordable as the CEA and budget impact analyses are done separately.  If this is the case, then the CEA criteria clearly do not reflect the scale and value of the opportunity costs.  While some argue that the supply side works better in single payer systems with fixed budgets, others would argue that the share of the government’s budget allocated to health is in fact a choice variable, and thus higher WTP would argue for more resources directed to health expenditures. Empirically measures of WTP for a QALY do vary greatly across countries and based on the methodology used to estimate these value (see Ryen and Svennson 2005).
• CEA communication.  Should I do a perfect CEA or do a good CEA and get it out fast?  As all diseases and treatments have their own idiosyncrasies, one could spend a nearly unlimited amount of time collecting information to make a CEA high quality. Yet, the Second Panel does make a few key recomendations including: (i) having a written protocol, (ii) having an impact inventory, and (iii) presenting the societal and health system perspective.  It would be helpful if CEAs could be graded using a scoring system such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group, but applying these principles in practice may be difficult and focus more on process/documentation rather than the actual scientific quality of the CEA.

Overall, cost-effectiveness analysis has come a long way.  Yet, there is still much work to be done to insured that treatment benefits, risks and costs can be adequately captured to inform stakeholder decision-making.

• Neumann, Peter J., David D. Kim, Thomas A. Trikalinos, Mark J. Sculpher, Joshua A. Salomon, Lisa A. Prosser, Douglas K. Owens et al. “Future Directions for Cost-effectiveness Analyses in Health and Medicine.” Medical Decision Making38, no. 7 (2018): 767-777.

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