My Two Cents on Duke Tomorrow Demands

I attended the Duke Tomorrow event Friday and think there are a lot of good ideas that should be acted on in the demands that were presented to President Brodhead, Provost Kornbluth and Dean Ashby. Even where I might disagree with the demands, I give the students credit for raising issues they think will improve Duke in a forceful and thoughtful manner. Here are my thoughts, organized around the 10 points of the original document they issued. These are not meant to be a last word, but just a point in a conversation and I am happy to try and clarify if desired by anyone, especially students.

Point 1 “Bias Reporting Policy and University Standard” and Point 4 “Cultural Climate Consultations.”

  • Training in implicit bias, racism, cultural awareness and related topics that is grounded in historical reality and that focuses on societal, institutional and individual levels of change is needed and should be routinized. I learned a great deal from three types of training of this type in which I have participated at Duke in the past 2 years. All 3 events were conducted in the context of a team that was joined together for a task (Executive Committee of the Academic Council on which I served; a faculty search committee that I chaired; and a School of Public Policy retreat). These events were structured differently and each taught me things about myself, while producing a shared experience that raised awareness of these issues that could be referred back to as the teams I was on tried to do its respective job.
  • Students, Faculty and staff need to be a part of such training, education and discussion. Faculty/Staff interactions especially need to be improved on many levels–we faculty often miss the key role that staff play in running Duke. If all the staff disappeared and only the faculty were left, the University would cease to function.
  • I think we need a variety of approaches, including those developed and run by outside consultant organizations, as well as by internal units of Duke. Developing some of this from an outside assessment of cultural climate is a reasonable idea. We likely need many approaches to this task/topic.

Point 2. “Protocol for Hate Speech and Racial Incidents”

  • I am not a fan of hate speech codes of any type because I think it is impossible to precisely define all that speech that is objectionable and harmful, as well as the centrality of free speech principles to a university. I do think that speech that I would recognize as hateful is asymmetric in the sense that it disproportionately harms and excludes groups that have been and are marginalized from full membership in the free speech discussions that represent the University at its best. So, I am stuck here and unsure what we should do, but am willing to listen and want to give students who have been excluded the benefit of the doubt in figuring out how to rectify this situation (and make them full members in the University conversation).

Point 3 “Increased Diversity in High-Ranking Faculty and Administration”

  • This is a priority. The most important fact of the Diversity Task Force  (full disclosure, I served on the committee) that reported in May, 2015 to the Academic Council is that it was created by the faculty, birthed out of the Academic Council, and not started by the Administration. The faculty have a collective responsibility here and we will live into our aspirations or fail 3-4 of us at a time (on job searches, tenure review committees, at the like). The Administration has a role in resource allocation here, but the faculty have to do this, and own responsibility for success in how those resources are used in continually regenerating the faculty.

Point 5 “Increased Socioeconomic Diversity”

  • There has already been a discussion of altering our need-based financial aid structure this academic year in the normal functioning of the Duke budget review process. I chair the University Priorities Committee (UPC) this year, and have been a member for 3 years. UPC defines priorities in financial terms, and there are two long run unsustainable aspects of the existing Duke financial model as I see them. One* is that Duke cannot afford its existing need-based financial aid approach; at the same time, we cannot afford to not have it. The first use of “afford” above means that we don’t have endowment specifically allocated to produce the flows necessary to pay for our program, so we have to spend fungible dollars to make good on our program and will have to do so for the foreseeable future. We cannot afford not to do it because it is crucial to producing a student body that is more economically diverse than it otherwise would be, which is a key Duke priority.
  • The cost of Duke’s need based financial aid program rose rapidly during the financial downturn (students can re-apply if family situations change, as they should be able to do) in 2008 until about 2 years ago, when it stabilized and roughly returned to pre-2008 levels in real terms. This Fall there has already been discussion of whether we should increase our need-based financial aid spending, both in response to what other Universities have done as  well as due to our commitment to maintain economic diversity of the student body.
  • I am uncertain of the exact family income that now requires no family contribution (the demands ask that $75,000 be the cut point) as I tend to think in terms of the aggregate dollars spent on financial aid, but a change that increases this cut point has already been discussed and this is an active discussion.
  • On SAT/ACT scores, I am fine with these tests being optional for applicants. Other Universities have done this. We would be the highest ranked University to do it, but that sounds like an opportunity to lead to me, and I know from my days directing the Benjamin N. Duke Scholarship (when I reviewed many admission applications and worked with admissions on student selection) that the admissions office already has quite a holistic application review process.

Point 7 “Representation of Distinguished Black Individuals on Buildings and Monuments on Campus”

  • Naming the renovated West Union Building for West Campus architect Julian Abele and/or a statue erected in his honor seems like a good, reasonable and overdue thing to do. I concur with President Brodhead’s words on Friday that there was discussion (with President Brodhead at Executive Committee of Academic Council last year when I served) of renaming Aycock Dorm Abele Dorm last year, but that was not seen as a good idea because (1) he didn’t design that dorm and (2) it is viewed as an ugly building by many and likely to be torn down within the next 10-20 years and replaced by a new dorm.

Point 8 “An administrative position with the sole purpose of addressing institutional inequities and working with students of color to improve their experiences on campus.”

  • On this position, I would like to suggest a slight revision. What if we had a faculty member who took an “internal sabbatical” of sorts and focused on this post, in conjunction with whatever set of administrative positions were needed? The faculty need to lead in this area of seeing to it that all our students are full members of the University community, and having professors who work with undergrads take a focused period of time to do this might work better. Over time you would have a group of faculty who had done this post and they would take these experiences back with them to the various Departments at Duke.
  • Diverse students should be included on the Task Force on Bias and Hate that has just been created, I agree.
  • I served for three years on the President’s Council on Black Affairs (PCOBA) and did not find it to be the most meaningful service. If Black students don’t feel this structure is useful, maybe it should be ended and energies put elsewhere. From my perspective, a committee that meets once/semester doesn’t have much chance to be productive. I missed half the meetings during my tenure because they conflicted with a class I taught, so others may think this committee is valuable.

Point 9 “Living Wages and Rights for Staff and Adjunct Faculty”

  • One of my children has some interest in being a faculty member, and I think of these issues in that frame–this child of mine could have an adjunct faculty post somewhere. And that worries me. These issues were discussed in the Diversity Task Force and in Academic Council generally last year. I am unsure if a union is the best way to protect adjunct faculty, but the regular rank faculty at Duke need to step up here and help determine the Duke approach to hiring and employing these faculty who are key in running Duke, especially in some departments. I suggest we faculty use the thought experiment of how we would want our children who might be an adjunct faculty some day to be treated to figure this out.
  • Duke faculty don’t have any problem speaking out. Staff are members of the Duke community and they should be able to say what they wish about their views of how to make the community better.
  • It would surprise me if Duke is working with contractors that do not meet N.C. Dept of Labor standards. If we are doing so, we should stop.

I appreciate the Duke Tomorrow students being clear about what they want. There were other groups that spoke at Friday’s meeting and also issued demands, and I suspect there will be further groups of students coming forth with ideas. My responses are just my thoughts, meant to try and engage in dialogue and no one else has seen these ideas/responses–they are mine alone. If there are any students who want to talk, let me know and I am happy to meet with you.

*the other long run unsustainable feature of Duke’s financial model is the cost structure of our current biomedical research enterprise, due to the long run funding outlook (that is bad) of the NIH.

Safe Spaces on Campus

I have taught undergraduates at Duke since 1997, and now have two children who are in college elsewhere (a junior and a frosh). I attended the campus discussion last Friday and experienced it primarily as a dad–hearing Duke students share wrenching stories of their experience at Duke broke my ‘dad heart.’

On the broader discussion that I will term ‘safe space v freedom of expression‘ I think this dichotomy misses a basic reality. For some students and many faculty and those looking at the college campus from afar, ‘safe space’ connotes intellectual freedom to discuss anything and go where ideas, discourse and logic may lead. This of course is the University at its best. However, for some of our students, the desire for and language of ‘safe space’ is driven because they are afraid. Either for their personal safety, or because they have been told/shown that they don’t belong and aren’t valued at the University itself (or both).

As a Public Policy Prof, I usually have all sorts of ideas about how to address seemingly intractable problems. In this moment, I am unsure, but my ‘dad heart’ remains unsettled.

What effect do higher deductibles have?

A new NBER working paper shows that higher deductibles serve as a blunt tool that does reduce health care use (~12-14% in a large, self insured plan), but that they don’t appear to lead to better decision making by consumers. Several nuggets that are not such good news: consumers don’t seem to learn to shop around in response to higher out of pocket costs, they reduce spending across the board (both in preventive care as well as care more likely to be wasteful, like imaging), and around half of the reductions in spending accrued to individuals who were sick.

We have both overuse and underuse, and need a way to address the one without making the other worse.

This group of patients (large, self insured employee plan) might be expected to be the group most likely to respond to more “skin in the game” in positive fashion, but it didn’t happen. Sobering info as we wrestle with how to reign in spending while maintaining quality, especially as there is a bipartisan rush to do away with the cadillac tax and not replace it with other changes to the tax treatment of employer sponsored insurance.

Update: Sarah Kliff has a much better post on this paper than what I had time for.

A Few More Thoughts on N.C. Medicaid Reform

A few more thoughts expanding on my post last week on the Medicaid reform plan the North Carolina General Assembly passed yesterday:

  • North Carolina will have to get a waiver to implement this policy outline. I call it an outline because there are many details to be resolved before the initial waiver is due per the law (June, 2016); the law is 14 pages long, the waiver will be dozens if not hundreds of pages long.
  • The most likely thing to happen to North Carolina’s Medicaid program as a result of this law is nothing. I figure the passed law is 5% of the work, with 95% of the work to be done in the waiver process.
  • If Medicaid expansion is added as a part of the waiver, there is a chance to get a waiver from this policy outline that could be approved. Without expansion, I don’t think it will get approved.
  • The next President’s administration will almost surely judge the waiver. I am hearing the June, 2016 deadline is for a general outline of the waiver, and not the waiver itself to be submitted to CMS. If that is true, there is no way the Obama Administration will decide on this waiver.

North Carolina Medicaid Reform Bill Moves Ahead

The North Carolina General Assembly released what appears to be the compromise version of Medicaid reform that is poised to become law. It is similar to what was released in early August. Several big points.

  • The big idea is to allow private managed care companies to bid for the right to provide Medicaid services on a statewide basis (a bidding process will yield 3 options; full capitation), while also allowing up to 10 “provider led entities” (PLE) to bid to provide services regionally. On PLE, think big health systems and aggregations of same into new organizations here (Duke, UNC, Carolina’s Health Care, etc). The Senate wanted outside managed care companies to run a privatized Medicaid, the House wanted in-state solutions to move toward full capitated care (Sec 4, pp. 2-3). They have set up a test of the two approaches.
  • They have carved out the so-called “dual eligible” population. This makes sense in policy terms, and is something I suggested in my January, 2014 proposal for Medicaid reform along with a Medicaid expansion (they aren’t doing the expansion part). However, the dual-eligibles are also the most expensive part of the Medicaid program, primarily because they are receiving huge amounts of Long Term Care, most typically in nursing homes. The bill calls for study of how to bring dual eligibles into fully capitated plans in the future (Sec 5(11) p. 6). I don’t expect that to ever come about. Let me put it another way: if there are for profit private managed care companies who are (1) going to go fully at risk for widows in nursing homes with Alzheimer’s disease who are dual eligibles at (2) capitation rates that save North Carolina money, I want to make sure I don’t own their stock.
  • Community Care North Carolina (CCNC) gets a reprieve of sorts. They provide primary care case management and are well thought of nationally and in State, but the Senate has been desperate to get rid of them. Here is a post I wrote about 2 years ago on CCNC and statewide bidding for capitated Medicaid. CCNC can continue providing case management, but the bill imposes a contracted rate cut; they are legislating the outcome of a negotiation (Sec 7, p. 7). My hunch is that CCNC in whole, or in part, will turn up as important in some of the provider networks, most likely the homegrown PLE who will bid regionally.
  • Create a Division of Health Benefits to replace the Division of Medical Assistance, and run this program, with all employees exempt from the State Employee Act rules (Sec 13(e)(g)(1), p 10).
  • The sleeper section that I suspect will be revised. There are some very aggressive transparency provisions, that I applaud conceptually, but Sec 13(e)(9) p.10-11 says that the new Division of Health Benefits will put on their website monthly the number of enrollees by county and eligibility category for Medicaid, and the per member per month spending by category of services (itals mine). If they mean the premium the state pays to the company/PLE, then that is straightforward, but that is not what the text says. This sounds like claims based analyses (actual payments for care that the managed care company pays docs, hospitals, etc). The managed care companies will certainly consider this information to be proprietary. Reading this section makes me wonder if the NCGA really understands what they are passing.
  • The biggest fallacy in the entire bill is that the N.C. General Assembly “is not responsible for cost overruns” and so can wash its hands of future mistakes. This is how the entire enterprise has been messaged; if there are cost overruns then the state is not on the hook financially for them, but the managed care companies or or the Provider Led Entities are. That runs afoul of the provision above (if the companies have to eat the losses, why do they have to show the claims?). The impulse of the section above is that the General Assembly knows that cost if not the only important thing, but the care that North Carolinian’s receive is also important. There are some decent ideas in this bill, some bad ones, and most importantly some missed opportunities (not expanding coverage). However, the residual claimant if it all goes bad is the North Carolina General Assembly–they will never be arms length from Medicaid. It, along with education, tax code and corrections, is the fundamental essence of State Government.

We need better data to understand the ACA in North Carolina

Callie Gable and I have an op-ed in today’s Raleigh, N.C. News and Observer outlining why we believe that we don’t have enough information to evaluate the functioning of the North Carolina’s ACA insurance market (~500,000 persons in N.C. are enrolled in private plans). What do Callie and I want to see?

  • A population based tracking poll that answers basic questions about persons who are–and are not–enrolled in ACA plans.

California has the best such resource currently (methodology overview; attrition over time which is a big issue in a tracking poll). The big picture below [ellipsis mine]:

The Kaiser Family Foundation California Longitudinal Panel Survey is a series of surveys that, over time, tracks the experiences and views of a representative, randomly selected sample of Californians who were uninsured prior to the major coverage expansions under the Affordable Care Act (ACA). The initial baseline survey was conducted with a representative sample of 2,001 nonelderly uninsured Californian adults in summer 2013, prior to the ACA’s initial open enrollment period…..The third in the series…after the second open enrollment period in spring 2015 to find out whether more have gained coverage, lost coverage, or remained uninsured, what barriers to coverage remain, how those who now have insurance view their coverage, and to assess the impacts that gaining health insurance may have had on financial security and access to care. A fourth survey in the series will keep…The surveys are designed and analyzed by researchers at KFF and the fieldwork costs associated with the spring 2014 and spring 2015 surveys were paid for by The California Endowment.

We need to start with the population of North Carolina for whom the ACA exchange is most relevant–the uninsured–and understand their experience (anyone could become uninsured, of course). We can never do what California did which is select a random sample of the uninsured prior to the first ACA open enrollment period and follow them, but we could design a survey of uninsured at a future point plus those now covered in ACA plans and ask them retrospectively about their experience prior to the ACA (imperfect methodologically, but we can only start from where we are now).

This chartbook provides the type of information that this survey has answered in California. For example, transition in insurance status for the first to the second open enrollment in Cali (all of whom were uninsured prior to the first open enrollment):

KFFCaliforniasurvey.8.13. 15

The key thing to understand is that this starts with the population of California, and then looks at how they interact with the ACA. We need that in North Carolina.

  • What about premium increases for BCBSNC and other insurers?

California’s tracking poll asks about premiums, choices and options. For example, you can estimate how important premiums were to those who remained uninsured as compared to other reasons, because they asked people. The thing we most need is a population based understanding of how the ACA is affecting N.C.

I wish we had plan level enrollment data by county, on a retrospective basis. If insurer X listed 20 plans in county Y (5 bronze, 5 sliver, 3 gold, 2 platinum), then after the fact say how many people signed up in each plan, in each county. This is the point about a range of premium increases being incomplete information–it is hard to know what they mean without knowing what people actually choose, which is of course a function of the choices they have. Because N.C. has a federal exchange, this information is not released. I wish the federal government would release the data. And as an aside, about a year ago I (Don Taylor, not Callie who co-authored the op-ed) spent some time asking for this plan by county level sign up information, and one federal official told me the State Insurance Commissioner could release the data, but that they could not. Some contacts in the State Insurance Commissioners office told me if was the opposite (feds could release, but they could not). I dropped asking about it, and didn’t make any sort of official request.

The big picture questions people have about the ACA are best answered by a population-based tracking poll, so that is where my focus is going. We are actually trying to raise money and develop such a N.C. tracking poll. Let me know if you are interested in being involved–especially if you want to help pay for it! A credible effort will be in the $500,000-$800,000 (per year) range, we think.

January 1, 2016: Huge Day for Medicare End of Life Policy Changes

January 1, 2016 will be a huge day of changes for Medicare end of life policy. As noted earlier, Medicare will begin paying for advanced care planning and will begin a concurrent hospice care demonstration on New Year’s Day. We now know that on the same day the program will institute the most consequential change in Medicare hospice payment policy since the beginning of the benefit in 1982:

  • Medicare will move from a straight per diem base payment for hospice, to a two-tiered base payment of $187.54/day for the first 60 days in hospice, with a lower payment of $145.15 for subsequent days (column 6 below from August 6, 2015 Federal Register).


Section 1814(i)(6)(D)(ii) of the ACA required the Secretary of HHS to consider a new payment methodology for hospice, and the primary discussion by MEDPAC and others had been the development of a so-called “U shaped” payment approach that better matched the differential intensity of care across different links of hospice use. The primary goal of the payment changes seems to be better alignment of the payment methodology with the actual resource use of hospice providers, with tremendous interest in reducing very long hospice stays that many view as fraudulent, or at least not in keeping with the best use of hospice. However, very short hospice stays are also a problem.

The actual payment change is simpler than a U shape payment would have been (higher in the first few days and the last few days and lower in the middle) approach suggested by MEDPAC, though they have publicly supported the change as a first step.

My guess is that it won’t be 3 decades before the next hospice payment approach change is announced by Medicare, and that we are likely entering a period when change is relatively common. I hope we are also going to be clear about policy goals, and collecting data to inform evaluations of same.


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