Summer Listening Hours for the Duke Community: Students, Staff or Faculty

The last few weeks have been difficult ones at Duke, but the high profile incidents have merely elevated awareness of simmering problems that have long plagued our community. I tend to quickly move into problem solving mode, and my training in Public Health means that I think in terms of harm reduction–looking for small improvements or small reductions in harmful things. However, this moment in our shared history at Duke feels like a time for me as Chair of the Academic Council to listen.

In that light, I would like to invite the Duke and Durham Community to open office hours over the Summer to discuss any topic of interest to you. I set out four days between now and the middle of June below, and if there is interest I will pick some more dates for the latter part of the Summer. If you want to chat but cannot make any of these times, or if you would prefer another time, just email me and we will work out a time and place to meet. If you have an event scheduled and you would prefer me to attend that event so that we can chat, I will try and work that out as well. I will be in Durham all Summer finishing a book so I have some flexibility.

My Academic Council Office is in 203 Flowers Building, near the Chapel. We have a conference room that can seat ~12 people, and if we need a bigger room than that, we will find one.

Friday May 18, 3:30-5:30pm

Wednesday May 30, Noon-2pm

Friday June 8, 9-11am

Thursday June 21, 3:30-5:30pm


Dear Duke: Let’s Not Normalize This Mode of Protest

The 25 Duke students who disrupted President Price’s address to gathered alumni last Saturday to issue a variety of demands announced today that their pending Student Conduct case has been closed with an informal letter of admonishment. The issues raised by our students are worthy of discussion, and I give them a lot of credit for activism focused on the well being of others.

However, I am worried that this episode will normalize a mode of protest that begins by telling someone who is scheduled to speak to get off the stage and not speak. I fear that this mode of protest will now be used (and reused) to shut down speakers with views that some find objectionable. That would be a terrible outcome for Duke, and much worse than last Saturday’s event, that could be viewed through the lens of a family squabble.

I would like to respectfully ask that all members of the Duke community pledge to not use this mode of protest to shut down the speech of others in the future, but instead that we commit to a robust ethic of free speech and flourishing academic freedom on campus, a task that can require special attention to insure that everyone has a chance to speak. Further, I would like for us all to imagine what it would look like for Duke to be a leader in this area.

In that vein, I highly recommend Free Speech on Campus, by Erwin Chemerinsky and Howard Gillman (Yale University Press, 2017) to us all.

Why did I stop blogging?

I realized over the weekend when someone asked me why I had stopped blogging that I haven’t written a blog post since August 20, 2017. I didn’t intend to stop (and I have greatly slowed blogging in the past two years, particularly as my administrative roles at Duke have increased). And I have commented some on twitter. However, blogging has increasingly felt like a waste of time to me of late, as I don’t think there is much interest in the policy nuances of pending legislation. That is a big change from when I started blogging in June 2009 as I started writing weekly columns (I did 29!; a great experience) for the Raleigh (N.C.) News and Observer on health reform. The blog was a place where I tried to ‘show my math’ and expound upon my attempt to document the debate over what became the ACA. I loved blogging in those days, as it seemed like there was a genuine policy discussion underway.

So, I never really decided to stop blogging. I mostly just drifted away over the past couple of years as I came to understand it as a waste of time. Maybe I will restart some day.

Thoughts on the Robert E. Lee Statue Removal from Duke Chapel

I became chair of the Academic Council at Duke on July 1, 2017, and was chatting with the Provost a few weeks ago and we agreed there “weren’t any hot button issues” on tap for the Fall semester. That, of course, is no longer true.

I support President Price’s decision to remove the statue of Robert E. Lee from the Duke Chapel Entrance, as well as with his commitment to preserve the statue in a way that will allows students, faculty and all of us to learn from it. The creation of a commission of faculty, students, staff, trustees and members of the broader Durham community to help guide the next steps shows that this will be an ongoing process. The removal of the statue is best understood as the beginning of a new chapter, not an ending.

Duke is a relatively young University, and I think this new chapter may provide a book end of what I often think of as the beginning of modern Duke–the Bassett Affair of 1903 (the University was then called Trinity College). Professor Bassett wrote that Booker T. Washington and Robert E. Lee were the two greatest Southerners of the previous 100 years:

….he inserted a sentence praising the life of Booker T. Washington and ranking him second in comparison to Robert E. Lee of Southerners born in a hundred years. Such a sentiment invited controversy at a time when race baiting was commonplace due to the revival of bitter partisan politics with the division of the Democratic Party, the rise of the Populist third party, and the revival of the Republican Party. State Democratic leaders in nearby Raleigh who were also represented on the Trinity College Board of Trustees demanded that Professor Bassett be fired. When parents were urged to withdraw their children from the college and churchmen were encouraged not to recommend the college to prospective students, Bassett offered his resignation.

The Trinity College Board of Trustees did not accept Bassett’s resignation, a founding chapter in Duke’s history that made clear the critical principle of freedom of speech for the University. Of course, it was non-controversial to so-praise General Lee in 1903, while today his likeness is the source of controversy.

The common denominator then and now is the life of the mind that should be the heart of the University, demonstrated first and foremost by the faculty and students engaging in scholarship, teaching and learning. This is a big moment for Duke and our country, and I believe that the University has special process and educational responsibilities not only to the members of our community, but to society at large. We have a chance to model that difficult issues can be navigated truthfully, respectfully and openly, and if done well, we can help to make our world a better place.

May we be up to the challenge.

N.C. Medicaid Managed Care Proposal

The N.C. Medicaid Managed Care proposal was put out today by the Cooper Administration NCMedicaidManagedCare. Don’t look now, but North Carolina looks to be engaging in bipartisan health care reform. You may recall that the Republican-controlled Legislature dictated that the Republican Governor develop and submit a 1115 Medicaid waiver by June 1, 2016, which he did. I submitted a comment on their plan with Aaron McKethan–some good ideas, some not so good. However, it was mostly an aspirational document and was not really detailed enough to warrant a CMS response.

Governor Roy Cooper’s Secretary of HHS Mandy Cohen (and former COO of CMS under President Obama) was confirmed last Spring and immediately set out to lead a process that is putting the meat on the bones of the Republican Medicaid reform aspirations. She fully committed to moving it ahead, demonstrating that both political parties are searching for common ground on Medicare reform.

It will take both sides to do something this big.

Counterproductive cost sharing

The theory behind cost sharing is that it should deter ineffective care. In reality, it is a blunt and crude instrument that places barriers in front of effective care as well as ineffective care. I want to highlight two papers that look at the misaligned incentives of cost sharing in a pragmatic context.

The first examines IUD utilization. It found that the pre-ACA up-front cost-sharing deterred utilization:

Results: Overall, 5.5% of women initiated an IUD in 2011. After adjustment, IUD initiation was less likely among women with higher versus lower co-pays (adjusted risk ratio = 0.65; 95% CI, 0.64–0.67). Women who saw an obstetrician/gynecologist during 2011 were more likely to initiate an IUD (adjusted risk ratio = 2.49; 95% CI, 2.45–2.53).

IUD’s are fix it and forget it contraception. Once an IUD is inserted correctly, it is very difficult for it to fail. It gives significant female autonomy and over the long run of its effective use span, an IUD is less expensive and more reliable than oral hormonal contraception. The big problem pre-ACA with insurers discouraging IUD utilization is that there is a high initial up-front cost which means that a significant portion of the women would experience significant benefits from the IUD including the net cost savings compared to oral contraception after they had stopped paying premiums to the insurer that paid for the IUD. It is a churn problem.

There is another set of problems that come from inefficient cost sharing designs.  It is the non-adherance of effective and high value treatment problem  From one of the same authors, an examination of medication adherence for a long term cancer (Chronic Myeloid Leukemia (CML)) treatment regime that has impressive survival effects.

Over the study period, the mean copayment required for a 30-day supply of imatinib was $108 (SD, $301). Mean copayments varied widely, with patients in the lowest 25th percentile paying $17 and those in the upper 75th percentile paying $53. Importantly, the median copayment required across all years was approximately $30 per fill, but copayments ranged from $0 to $4,792. Over time, monthly copayments increased from an average of $55 in 2002 to $145 in 2010….
Among new users of imatinib, approximately 10% of patients with relatively lower copayment requirements and 17% of patients with higher copayments discontinued therapy during the first 180 days following treatment initiation (Table 2). There was a 70% increase in the risk of discontinuing TKIs among patients with higher copayment requirements (upper 75th percentile; aRR, 1.70; 95% CI, 1.30 to 2.22). Similarly, approximately 21% of patients with lower copayments were nonadherent to their TKI therapy ( 80% of days with drug available) versus 30% of patients with higher copayments. Patients with higher copayments were 42% more likely to be nonadherent to their TKI therapy (aRR, 1.42; 95% CI, 1.19 to 1.69)…..

Okay, there is a lot going on in that results section.  The important take-away is that cancer patients with higher co-payments are far more likely to be non-adherent.  This is financial toxicity, a concept advanced by one of my Duke Margolis colleagues, Dr. Yousuf Zafar.  The cost of treatment forces people away from getting the care that they need.

People don’t elect to have cancer.  It is not an episode that is immediately deferrable.  Once you’re told that you have cancer, treatment usually needs to get started quickly.  And the effective drugs are expensive.  At this point the idea of cost sharing as a means of shaping choices and avoiding preventable conditions goes out the window.  It is merely a burden sharing between the insurer and the individual.  It is just a financial shock with no positive incentive effect when an individual is hit with a dozen other life altering shocks at the same time.

If we are trying to design a system that minimizes non-adherence for financial reasons, we want to change the benefit design.   A theoretically attractive solution would be to offer no cost sharing on effective but expensive courses of treatment for diseases that are not immediately preventable. This would be a value based insurance design approach.  VBID encourages people to get effective care by making it comparatively less expensive than ineffective care or care for preventable episodes.

There is a problem with a VBID approach.  It is an ugly selection problem.  Let’s imagine that there are two types of plans offered.  The first is a standard plan design with high cost sharing for imatinib (Gleevac).  The other is a low or no cost-sharing design for imatinib.  Individuals who are healthy at the start of open enrollment period will choose the standard plan.  Individuals who have CML will go to the low cost sharing pool.  An individual who was healthy at open enrollment and then is diagnosed with CML during the first policy year will switch over.  This incentive structure makes the VBID pool extremely sick.

Sick pools are not show stoppers.  There are tools that can be used to compensate insurers with sick pools.  The most common is risk adjustment where money from either other insurers with healthy pools or the general government funds are sent to the insurers with disproportionate number of CML patients to cover the high and recurring costs.  And given that the VBID design is meant to encourage more people to take more of a very expensive drug, the costs will be higher than the baseline average CML patient cost.  Reinsurance tied to specific diagnosis could work as well.

The other option is to mandate benefit designs that are based on VBID principles for high cost diseases. States could do this on their individual and fully insured group markets but they can’t touch the ERISA regulated employer sponsored self-insured segment.  We would still have a serious churn problem as people with expensive chronic conditions would still be moving between ESI and Exchanges and given the differences in after treatment incomes, these people will be far stickier to their preferred option than healthy people.

Benefit design right now is complex, confusing and ineffective at promoting health in the CML case.  Any changes will also be complex and confusing but hopefully more effective at enabling better health.



** Pace, L. E., Dusetzina, S. B., Fendrick, A. M., Keating, N. L., & Dalton, V. K. (2013). The Impact of Out-of-Pocket Costs on the Use of Intrauterine Contraception Among Women With Employer-sponsored Insurance. Medical Care, 51(11), 959-963. doi:10.1097/mlr.0b013e3182a97b5d

*** Dusetzina, S. B., Winn, A. N., Abel, G. A., Huskamp, H. A., & Keaton, N. L. (2013). Cost Sharing and Adherence to Tyrosine Kinase Inhibitors for Patients With Chronic Myeloid Leukemia. Journal of Clinical Oncology. Retrieved August 4, 2017.

RCT of Palliative Care in Heart Failure

A big team from Duke lead by Joseph Rogers has a new Paper (PAL HF) reporting the results of a RCT of palliative care in late stage Congestive Heart Failure, published today in the Journal of the American College of Cardiology. Patients who got palliative care had better quality of life, higher function and reduced anxiety and depression (with no survival difference, as hypothesized). Costs were not a primary endpoint, but will be analyzed in later work.

CHF_7-11-2017 8-56-05 AM.

After the publication of a RCT of early palliative care in stage 4 lung cancer in the NEJM in August 2010 showed improved quality of life, lower costs and longer survival, there was a move to see if such findings could be replicated in other diseases. This NHLBI funded study is part of that effort.

Real world evidence is provided imperfectly, especially with respect to policy. One example from this paper. This studies’ exclusion criteria ruled out patients with anticipated heart transplant or LVAD implantation within 6 months. Arguably, these patients aren’t ready for palliative care because they are seeking such aggressive treatments, but from a policy perspective, it is arguable that they definitely need the goals of care type of discussions that are a key part of palliative care. The successful conclusion of a trial of CHF without patients on the way to heart transplant or LVAD implantation leaves an evidence hole, even as we add to the evidence base.

Should patients thinking about an LVAD or a heart transplant get palliative care? I think the answer is yes, but this trial provides no direct evidence to inform this question. So, there remains an evidence gap (as always–good studies suggest more questions than they answer). However, the health care system often doesn’t and can’t wait for such answers, and in the case of palliative care there has been a tremendous increase in its provision at Duke, and across the nation since this study was began. The process and timing of research is slow, and the answers are often muddled, while the pace of change in addressing the needs of seriously ill patients is much more rapid. When one’s interest is policy applications, even an RCT–the gold standard of research–cannot answer all of the most pressing questions.