One of the biggest problems in health policy is choosing the appropriate metrics to evaluate a complex good like health care. Value is in the eye of the beholder. All too often, the beholder is not the consumer, which leads to an affinity for numeric measures said to be more “rigorous” or “precise.”
As a result, many Medicaid evaluations use population health measures that have as much or more to do with individual behaviors as they do with the action of any part of the healthcare system. Things like number of primary care visits, BMI, cholesterol levels, and blood pressure, are easy to measure provided someone first decides to visit the doctor. And outcomes based on those measures depend upon whether someone decides to diet, exercise, and take the prescribed medications.
Because simple metrics abound, we have a lot of studies evaluating the health “system” that only observe changes in relatively simple and inexpensive treatments that are behaviorally dependent and are provided to a lot of people. Many policy makers are satisfied with this. It accords well with the views of U.S. health care reform advocates who favor more centralized gatekeeping and approve of policies that force people to consume more primary care as a condition of being allowed access to specialists. If people got more primary care, the mantra goes, they wouldn’t need to see specialists.
The choice of behaviorally and genetically dependent medical metrics — prevalence of high cholesterol, high blood pressure, and level of glycated hemoglobin — may even explain why the Oregon Medicaid experiment found that expanding Medicaid had no significant effect on clinical health measures.
In 2008 and 2009, Wisconsin ran another Medicaid experiment. It expanded Medicaid to a group of almost 10,000 very low income, childless, Milwaukee adults. It tracked how they used medical care before and after the expansion.
It found that expanding Medicaid decreased hospitalizations for complications from diabetes, hypertension, congestive heart failure, and dehydration.
While expansion increased outpatient visits by 65 percent, the “majority of the increase [61 percent] in visits was due to increased visits to specialists.” In the discussion, the authors flatly state that “no increase in the use of primary and preventive care was observed.”
Visits to the emergency room rose by 39 percent and almost all of the increase was due to visits for what were called “ambulatory care sensitive” conditions. A problem, as a JAMA article pointed out, is that the same symptoms that can signal a true emergency are often associated with much less urgent problems. It is often impossible for lay people to know which are which. After diagnosis, the emergency room statistics show a non-urgent visit.
Despite the increase in specialist visits, the authors concluded that
Wisconsin’s experience with covering uninsured childless adults, therefore, shows mixed results. On the one hand, hospitalizations declined substantially as did hospitalizations related to ACS [ambulatory care sensitive] conditions. This finding strongly suggests that the underlying health of this population improved as a result of increased access to preventive and primary care. On the other hand, the study finds a dramatic increase in emergency department visits for ACS conditions and no increase in the utilization of primary or preventive care in an outpatient setting. Public insurance coverage seems to be reducing hospitalizations and improving health through increased preventive care, but this care is being obtained in the emergency department rather than in a more appropriate primary care setting.