Author Archive

Your Medical Records Are an Open Book

Bloomberg is reporting that states hungry for revenue and flush with the power to requisition individual medical records are moving to capitalize on the value of that information by selling the information in them to all comers. Unlike private companies, states and their agents are exempt from HIPAA requirements and therefore do not have to take data privacy especially seriously.

In an experiment, researchers were able to match several dozen people with their supposedly de-identified medical records by combining public record searchers and the information in a sample group of records purchased for $50 from Washington State. Among other things, “an executive treated for assault was found to have a painkiller addiction,” and a “retiree who crashed his motorcycle was described as arthritic and morbidly obese.”

Bloomberg reports notes that states that exclude zip codes, and admission and discharge dates are less vulnerable to records identification. But even “de-identified” data sets contain significant personal information that could be used to identify individuals, especially in rural areas with small populations.

Jun 07, 2013 | 11 comments | by

ObamaCare’s War on Men

ObamaCare institutes several types of price controls on insurance premiums. The elimination of gender-based ratings forces young men to subsidize the substantially higher claims of young women, ending claims-based differentials of up to 70 percent under age 40. The 3:1 age rating limit requires younger people to subsidize older people, ending the roughly 6:1 rating that was based on actual costs. The elimination of health status as a rating factor forces those in good health to subsidize those in poor health, whether or not good health is due to self-control or lucky genetics.

In 2012, Milliman calculated how much the price controls are likely to raise costs for those unlucky enough to be affected by them. Here are some examples of the variations caused by market pricing for an Anthem HSA policy for an individual living in Marion County, Indiana, in November, 2011:

May 28, 2013 | 128 comments | by

ObamaCare’s Unfair Treatment of Middle Class Families

Middle income families are about to encounter some real surprises as a result of the Affordable Care Act (ObamaCare). For example, many workers will soon discover that when they earn more money, they end up with less take-home pay. Others will discover that they are worse off if their employer offers them “affordable coverage” than if there is no health insurance offer.

What causes these bizarre outcomes? Read on.

May 13, 2013 | 23 comments | by

Does Lack of Health Insurance Kill?

The results from the Oregon Experiment, published in the New England Journal of Medicine on May 2, show that extending Medicaid to low-income adults did not improve basic clinical measures of health. Given that, it is a bit hard to see how being uninsured can cause 45,000 premature deaths every year — a figure rivaling the number of Americans killed in the Vietnam War. That’s the number physicians for a National Health Program say die prematurely in America due to a lack of health insurance.

The Oregon study results probably did not surprise those who have been paying attention to the serious academic literature, however. In independent empirical papers, Richard Kronick and David Card and his colleagues find little evidence that health insurance coverage significantly reduces mortality. Former Director of the Congressional Budget Office June O’Neill and her husband Dave also conclude that lack of insurance has little or no impact on mortality. See the discussion at this blog here, here and here.

One person who ordinarily pays scrupulous attention to the quality of research is Austin Frakt. Yet in a surprisingly irate blog post he makes this claim: the fact that health insurance improves health and reduces “mortality risk” is “well established” and “as close to an incontrovertible truth as one can find in social science.”

In another post he asserts that Megan McArdle “distorts the scientific record” in an Atlantic article in which she concluded that there was little evidence to support the claim that people die because they do not have health insurance. He accused her of cherry picking, of “misrepresent[ing] a body of work in support of that conclusion and further mislead[ing] readers that such work does not exist.”

Professor Frakt owes Ms. McArdle an apology.

May 08, 2013 | 30 comments | by

Another Reason Why Accurate Comparison of Health System Costs in Different Countries Is Difficult

In order to compare health costs in different countries, expenditures must be converted into a common currency. In practice, this is a more difficult problem than many people think.

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Here’s a graph from The Economist showing how the choice of exchange rate comparison can alter conclusions. The light blue line compares incomes in various countries using market exchange rates. The dark blue line compares incomes using purchasing power parity.

Market exchange rates are the price of one currency in terms of another when currencies are bought and sold on international markets. The demand and supply of international currencies is driven by the markets for internationally traded goods and by capital flows between countries.

May 03, 2013 | 23 comments | by

How to Lie With Statistics

Estimated Temperatures During A and E TimesSteve McIntyre of Climate Audit caught Professor Michael Mann of hockey stick fame misleading people about the quality of global climate models at the December 2012 American Geophysical Union meeting.

A problem for those who are convinced that mankind’s activities are influencing global temperature is that, as the top chart from the IPCC shows, recent observations of land-and-ocean temperature (red line) are considerably lower than midrange temperature model predictions (blue line). [The red and blue lines were added by McIntyre to aid in discussing the chart.] In fact, as previously reported at this blog, there has been no warming for the past 15 years.

Apr 26, 2013 | 8 comments | by

How Evidence-Based Medicine Went Wrong on Hormone Replacement

This is a case study in how “evidence-based medicine” can harm the very patients it is supposed to help.

In the late 1990s, the generally accepted opinion was that postmenopausal hormone replacement therapy (HRT) increased the risk of breast and endometrial cancer, but decreased the risks of coronary heart disease and hip fracture. On balance, it was thought that the gain from lowering heart disease and hip fracture outweighed the increased risk of breast cancer in all patients except those with the lowest risk for heart disease and the highest risk for breast cancer (e.g., see Col et al., JAMA, 1997 and Barrett-Connor, BMJ, 1998).

Then, in what looked like a clear example of the benefits of evidence-based medicine, the National Heart, Lung, and Blood Institute stopped the estrogen-plus progestin HRT arm of the Women’s Health Initiative (WHI) in 2002. The reason:  the women crossed a preset threshold for breast cancer risk that was equivalent to an increase of less than a tenth of a percent per woman per year. The WHI was a large randomized controlled trial (RCT) designed to study various aspects of women’s health, including postmenopausal hormone replacement therapy (HRT) using continuous combined estrogen plus progestin for most participants, and estrogen-alone for those without a uterus. The estrogen only arm was also ended prematurely in 2004, when nearly 7 years of follow-up suggested that although estrogen decreased hip fracture, it did not affect heart disease, and it increased the risk of stroke by 8 additional cases per year for every 10,000 women.

The WHI results were widely publicized in the media before outside experts had a chance to examine and discuss them. Because the WHI was billed as a “gold-standard” RCT, by 2009, U.S. women had decreased their use of HRT by more than 70 percent.

Apr 17, 2013 | 10 comments | by

You Probably Think a Meeting is Just a Meeting

The FDA has issued a request for comments on nonbinding regulations that would govern “Formal Meetings Between the FDA and Biosimilar Biological Product Sponsors or Applicants.”

The 17-page document begins by defining formal meeting as “any meeting that is requested by a sponsor or applicant following the request procedures provided in this guidance and includes meetings conducted in any format.”

17 pages? It gets worse.

Apr 11, 2013 | 11 comments | by

On the Anti-Cash Bias in Health Care

The patient needed a standard set of blood tests at LabCorp. The busy receptionist obligingly spent time querying her software to figure out the cash price for the tests. She came up with a quote of $537.00. Given the quote, the patient decided to go with his insurer’s network price.

Wise move.

As the statement of benefits shows, the network price was $68.63, a $468.37 saving over the cash price of $537.00.

This experience provides food for thought in several dimensions:

Apr 10, 2013 | 13 comments | by

Does Decreased Length of Hospital Stay Equal Lower Cost?

Based on a 20 percent sample of Medicare claims from 1985-2005 for people 65 and older, Brauer et al. 2009 provide data on length of hospital stay for people with hip fractures in the U.S.

The median length of stay for hip fracture over the period decreased from 12 days to 5 days. Risk-adjusted mortality at 30, 180, and 360 days improved for both men and women:

Men vs. Women

Source: Carmen A. Brauer et al. 2009. “Incidence and Mortality of Hip Fracture in the United States,” JAMA, 302, 14, 1573-1579.

Innumerable studies in the health care literature use reduction of days in hospital as a measure of reduced costs. Unfortunately, the simple reduction of days in hospital and death rates, while welcome, tells us little about readmissions, total costs, or extent of recovery.

With the passage of DRG reimbursement in 1983, hospitals began adjusting their business models to accommodate flat rate payments. One outcome was “quicker but sicker” discharges. In 1986-88, the paper notes that 34.3 percent of hip fracture patients went home with self-care and 33 percent were discharged into skilled nursing facilities. By 2003-05, only 5.3 percent of patients were discharged home with self-care. The majority, 52.9 percent, were discharged to a skilled nursing facility.

Apr 09, 2013 | 8 comments | by
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