Academic Freedom, Racism & Bad Social Science

The title of my post sums up my thoughts on Duke Political Science Professor Jerry Hough’s comments on a NYT editorial on racism (via Mark Anthony Neal) over the weekend.

  • He is free to say what he wishes, and I defend this right
  • I think his words are racist; to me, the plain meaning of racist is believing you know everything about someone else, including their motives, based on the color of their skin
  • When he identifies himself as a professor (and social scientist), then it is reasonable to expect evidence to back up claims, which he does not provide. The more sweeping the claims (“Every Asian student”…”Virtually every black”…) the more one should expect evidence, especially from a professor

Our students deserve our best, and at least the benefit of the doubt. In this case, a professor makes claims about his students to justify his broader views about macro issues such as the role of racism versus other etiologies in explaining poor life outcomes among African Americans. The students deserve better. And coming on the heels of the noose incident at Duke this Spring, and subsequent adjudication that concluded the act was caused by “a lack of cultural awareness” this has been a very hard year at Duke for many black students.

I just want to say to our black students that I am sorry, and that I am glad that you are at Duke.

Impact of hospice on costs for patients in Nursing Homes

A new study by Pedro Gozalo and colleagues from Brown finds that Medicare beneficiaries who die in nursing homes have less intensive treatment in the last year of life, but the overall cost to Medicare of their care in the last year of their life, is higher.

Some key bullet points and issues:

  • What did they find? Hospice was associated with less hospitalization and fewer ICU days during the last year of life, but higher overall costs incurred by the Medicare program (around $6,700 more).
  • What didn’t they study? The impact of hospice on quality of life of the patients (at least directly; you could normatively infer benefit from less ICU use and hospital days; they discuss this), or families. However, they were using Medicare claims that don’t measure such variables.
  • What is new about the study? They use a clever, three part counterfactual strategy to identify the impact of hospice on costs. A key issue in observational assessments of the impact of hospice on cost is that persons who choose hospice differ from those who do not. Past work (our study from 2007; Amy Kelley’s from 2013) has used cross-sectional matching using observed variables to identify the most relevant comparisons to hospice users in order to isolate the hospice impact. Gozalo et al. use traditional observed covariate matching as well (part 1) but within a difference-in-difference approach (part 2) that takes advantage of secular trends in hospice use from 2004 to 2009 (much more likely later) to isolate the impact of hospice on Medicare costs. In short, there are decedents in 2004 who did not use hospice who would have done so under 2009 rates, and vice versa. This allows for isolating the impact of hospice on costs in 2009 on persons who were “new” users due to increasing use rates as compared to those who would have used hospice even without an increase. The same comparison is done in 2004, and the difference in the difference provides the estimated impact of hospice on costs. Finally, because all the subjects lived in Nursing Homes (NH), some variables like DNR or do not hospitalize orders that are unobserved but important are available for matching (part 3).
  • Who did they study? All subjects lived in Nursing Homes. This is a key contextual variable, and one that is missed if you say “this study shows hospice increases Medicare costs” because it is found to increase Medicare costs only among persons who died in NH. Most persons receive hospice in their homes, but the subgroup of those receiving it in NHs may be key from a cost standpoint.
  • Around 6 in 10 subjects had dementia, the disease associated with the longest period of hospice use in this as well as past studies. This is largely due to the unpredictability of death (as compared to other primary diagnoses) and does not invalidate the study by any stretch, but it helps to highlight the study patients. The hospice benefit has had a per diem payment that was not modified by diagnosis since its inception in 1983. The general trend toward increasing use of hospice, which has meant an increase in dementia as a primary diagnosis, along with a related increase in hospice length of use for dementia that has been widely noted, really signals that a disease specific hospice benefit may be needed if cost is a concern.
  • Last year of life costs are an easy concept to grasp, but may not be the best way to assess the impact on hospice on Medicare costs. The limitations of cross-sectional propensity score matching such as what I and colleagues used in a 2007 paper deserve to be noted (Amy Kelley et al added covariates, but has the same general problem), but the focus on measuring cost of cases (hospice) and controls (not hospice) from the point of hospice initiation until death strikes me as a more precise means of estimating the impact of hospice (regardless of how the counterfactual used to identify cases and controls is constructed). Further, the savings identified in past work accrues primarily in the last few weeks prior to death, and it seems conceptually suspect to infer that something used for 90 days should reduce cost over the last 365 days of life. It is a fair point to say that in our paper as well as Amy Kelley’s, all cases of hospice do not match to “statistically good” controls but Medicare has to pay for the care for all patients, but the same can be said for the new paper as well. Pedro and colleagues rightly note that the last year of life is a commonly used time frame, but that doesn’t do away with this conceptual issue. It is an interesting conceptual discussion about the appropriate dependent variable for such a study: full last year of life costs or costs from the date of hospice initiation until death. To push it ahead, I would just like to see more analysis. Pedro and colleagues could update their estimates using the approach that we used and that Amy Kelley etc followed–measuring savings (or not) from the onset of hospice to death and assess their cost findings.

This is an important paper with a very clever estimation strategy, that deserves to be discussed, technically and conceptually (especially my last point above), as well as for what it might mean in terms of policy adjustments. I will have some thoughts on this in a follow up post.

Post Doc Position in Health Policy at Duke

I am searching for a post-doctoral research fellow at Duke; I will be the primary supervisor of the fellow. The Post Doctoral Fellowship Description.4.13.15 is also pasted below.

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Post-Doctoral Fellowship in Health Policy and Health Services Research

Duke Clinical Research Institute (DCRI), Duke University

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The Duke Clinical Research Institute (DCRI) seeks a full-time Post-Doctoral Research Fellow with training in Health Policy, Health Services Research, Public Policy, Epidemiology, Informatics/Statistics, Economics, Sociology or related discipline. The successful candidate will join a multi-disciplinary team of investigators working on a variety of policy-relevant projects, with a focus on projects that are seeking to develop new models of delivering care to persons with advanced, life limiting illness. The goal of the fellowship is to advance the intellectual and professional development of the fellow as they transition toward being an independent researcher.

Funding, Role and Primary Tasks:

  • Funded 100% by the Duke Center for Medicare and Medicaid Innovation (CMMI) Award that is demonstrating Community Based Palliative Care and assessing its impact on patient outcomes and costs to the Medicare program and developing new ways for the Medicare program paying for palliative care services. Funding can remain 100% on this project for 2 years. There will also be options to shift funding to other projects based on shared interests.
  • The CMMI Innovation award is a demonstration project that is being implemented in 12 Western North Carolina counties by Four Seasons Hospice, and Duke’s role in the project includes collection of quality monitoring data; assessment of the acceptability of palliative care to patients, providers and others; linking demonstration data with Medicare claims records using Duke’s Virtual Data Research Center (VRDC) which is a secure linkage that allows access to CMS data; identifying propensity score matched controls to allow for assessment of the impact of palliative care on cost to Medicare; the extrapolation of the impact of palliative care on Medicare costs to simulate the impact of broad uptake of palliative care nationally; and development of proposed modifications to the existing Medicare payment structure in order to incentivize the increased use of palliative care. The post-doctoral fellow will work on all aspects of this project described, working as a member of a growing interdisciplinary team.
  • The purpose of the post-doctoral fellowship is to both complete the work of the CMMI innovation award as well to assist the fellow in developing their own research agenda. This will include working on grant proposals that are of mutual interest to the DCRI and the fellow.

There are opportunities for the fellow to transition into a faculty position in one of several departments at the Duke Clinical Research Institute (DCRI), Duke University School of Medicine, Duke University and/or the Duke University Health Care System. Salary is commensurate with experience and background, and includes the full Duke University benefit package. The fellowship is open immediately.

The fellow will be supervised by Donald H. Taylor, Jr. Ph.D., Professor of Public Policy, Duke University and Faculty member, Duke Clinical Research Institute (DCRI). To apply, please send a CV, a cover letter outlining the candidate’s interests, and the names and contact information of 3 references. Please send materials via email to Don Taylor (don.taylor@duke.edu) and Abby Hardaway (abigail.hardaway@dm.duke.edu) with DCRI Post Doc in the message line with the noted items attached. The post is open until filled.

Statin Discontinuation

The Palliative Care Research Cooperative‘s RCT of statin discontinuation came out in JAMA Internal Medicine yesterday. The patient population had a variety of terminal illnesses with an expected life span of greater than 1, but less than 12 months. Highlights of findings:

  • No survival difference
  • Quality of life was better on some measures, and no different on others
  • Modest cost savings were realized by stopping a statin ($3.37/day; mean savings observed in trial $716)

The main story is that stopping statins in terminally ill patients can be done safely, and that doing so makes the lives of very ill people a little better, while costing a little less. Imagine how rich we would be if the RCT reported had been of a new drug that produced the same results. People would be desperate to take it!

The study was a bit different than most RCTs because it was not double blind (all persons consented to being randomized to stopping or continuing their statin; those that were in the ‘stopped’ arm knew that they had stopped taking the medicine). This was important because a key worry was whether stopping a statin would lead to a loss of hope, or other negative psychological outcomes for patients. We did not find this to be the case, but it is an important question with respect to patient well being that could not be answered via a double blind RCT. Several top medical journals wouldn’t even review the manuscript because of this issue. I would never say a journal “has to”publish a given paper, but not reviewing this paper for that reason shows they don’t get palliative care, and the very important intervention of knowing when to stop doing something.

Cost v value as policy focus

Ezra Klein has a nice post running over the political and policy problems of focusing on “cost reduction” in health care, and instead suggest focusing on the receipt of value for the dollars spent. He frames the decision in partisan terms–what should the guiding health policy be for the Ds as opposed to the Rs, but there are some limitations to a cost focused strategy in policy terms, even if you believe the health system is unsustainable.

Two questions are paramount here. The first is what is the appropriate out of pocket exposure that an individual should face prior to receiving care? Does it differ by age? Income? Health Status? You tell me….The problem with blunt tools like large deductibles is that they likely reduce good and bad spending (high value and low or no value). The roll out of the ACA has helped to crystallize this question, if only we could get to the policy and off of the macro political narrative.

The second question (how to get to higher value for the dollars spent?) is laid out in some of our recent work at Duke looking at the preferences of Medicare beneficiaries who have cancer. Simply put, could expanded patient and family choice in they types of care covered  by the program (that pays for the care of 8 in 10 persons who die each year) lead to a more productive expenditure of resources? And in doing so, possibly reach what sounds too good to be true–lower spending with higher benefit to patients? We are about 3 months into enrolling patients into a Center for Medicare and Medicaid Innovation Center grant (CMMI) to demonstrate, evaluate and propose potential payment changes for how Medicare reimburses palliative care. This feels like it might be the most important work I might do in my professional career. If you change the incentives in how Medicare pays for end of life care, it will filter down into the rest of the health care system.

I am at the American Academy of Hospice and Palliative Medicine Annual Assembly (follow #HPM15) in Philly for the next two days, and many parts of the questions and answers under the “value proposition” will be on display here. We as a field (hospice and palliative care) need to do a better job of translating the research evidence base into usable information for policy makers. I think the country is ready to listen, with IOM report Dying in America helping in this manner. When will the political system be ready for the next steps in health policy? (and the next, and the next?, etc)). Not sure, but we need to be ready to lead into the most difficult health policy questions when they are, and the biggest goal–focusing on maximizing value for the health care dollars we spend.

Could North Carolina circumvent King v Burwell?

Adam Linker has an op-ed this morning in the News and Observer encouraging the North Carolina General Assembly and the Governor to:

re-establish(ing) state control over our insurance marketplace. In fact, most of the pieces are already in place. Our Department of Insurance is proactive about reviewing insurance policies. Our health care and insurance communities meet regularly and could easily form an oversight board. Our outreach and enrollment efforts are national models. All we need is for the governor to work with legislators to vest these organizations with the power to form a state marketplace.

I wrote a post last summer asking what does it mean for a state to establish an exchange with respect to the looming Supreme Court case that will determine if tax credits (515,000 North Carolinians have just signed up for coverage and are getting such subsidies) can legally flow to states using the federally facilitated exchange. My post is wonky and complicated, but health policy is wonky and complicated and runs through the various ways that States could move forward on a state-specific exchange.

However, I am less certain now than I was last summer that North Carolina could do something in the short run to definitely make the tax credits flowing to our state safe regardless of what the Supreme Court rules (there isn’t enough time to set up all the functions). It is unclear if a simple statement of establishing an exchange and then pointing to healthcare.gov for people to shop for coverage would be enough, in large part because of the uncertainty of what the Supreme Court may say (I know no one who predicted the mix of what they said in 2012). The North Carolina Attorney General Roy Cooper has already signed onto an amicus brief that argues that the actions taken by the State to use the federal exchange was made under the belief that the citizens of North Carolina would be able to receive such tax credits.

Even a simple statement of the intent of the North Carolina General Assembly to have the tax credits flow to our citizens with which to purchase private health insurance could prove important, and certainly wouldn’t hurt anything, if our leaders are worried about over half a million North Carolinians losing these tax credits.

N.C. Hospitals to help finance Medicaid expansion?

North Carolina Gov. Pat McCrory says that he is still exploring options for expanding Medicaid, including having hospitals help finance the 10% of the total cost not covered by the federal government in the out years.

“They would have to have skin in the game to cover the extra 10 percent,” McCrory said.

This comment is the strongest signal I have seen that the Governor is serious about moving ahead, because he has laid down the marker of what the hospitals who so favor expansion will have to give to get it (and they will go along under terms like this).
The simplest mechanism through which the largest hospitals (that are most typically linked to University health care systems) would be via the capping of the North Carolina sales tax exemption granted to Not for Profit organizations in the state. This post from Summer, 2013 notes that around 75% of the value of this tax exemption flowed to hospitals. During the last long session of the North Carolina General Assembly, the hospitals were at odds with the N.C. Chamber over this policy, but the real issue between them was Medicaid expansion. Essentially, they were willing to give up the heretofore unlimited state and local sales tax refund, but only if they got Medicaid expansion in return.
The tax reform passed in 2013 capped the amount of state and local sales tax refund that a Not for Profit organization (hospital, University, small 501 c 3) at $45 Million dollars, which was just above the amount that Duke (combining University and Health System) received in 2014, the biggest in the state (G.S. 105-164.14(b) see page 55).
G.S. 105-164.14(b) – Cap on Refunds for Nonprofit Entities and Hospital Drugs: This subdivision is amended to add “[t]he aggregate annual refund amount allowed an entity under this subsection for a fiscal year may not exceed thirty-one million seven hundred thousand dollars ($31,700,000).” The amount applies to refunds of State tax only. A local aggregate annual cap is added in G.S. 105-467(b) in the amount of thirteen million three hundred thousand dollars ($13,300,000). (Effective July 1, 2014 and applies to purchases made on or after that date; HB 998, s. 3.4.(b), S.L. 13-316.)
So, the General Assembly set a cap in 2013 that didn’t apply to anyone yet. Over time it will start to apply, but there are very few Not for Profit organizations that have more than several hundred thousand dollars of this refund, so dropping the cap well below $45 Million annually will most hit (1) Universities; and (2) large hospitals/health care systems. The 10 or so biggest would essentially pay the way for the rest of the hospitals, and smaller 501 3 c organizations could maintain their state and local sales tax refunds.
Inside baseball for sure, but look for this to be the way that hospitals/health systems and the Universities that own the big ones to be the way they “help pay the state’s cost of Medicaid expansion.”
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