Which Health Policies Actually Work?

by birtanpublished on September 10, 2020

Part of all that money we spend on health care goes to making sure that we're instituting good health policies right wrong that's the topic of this week's healthcare triage special thanks to austin pratt from who's upshot column this episode was adept a few years ago

Oregon found itself in a position that you think would be more commonplace it was able to evaluate the impact of a substantial expensive health policy change in a collaboration by the state and researchers medicaid coverage was

Randomly extended to some low-income adults and not to others and researchers have been tracking the consequences ever since rigorous evaluations of health policy are exceedingly rare the united states spends a tremendous amount on

Health care but very little of it learning which health policies work and which don't in fact less than 0.1 percent of total spending on american health care is devoted to evaluating them as a result there's a lot less

Solid evidence to inform decision making on programs like medicaid or medicare than you might think there's a similar uncertainty over common medical treatments hundreds of thousands of clinical trials are conducted each year

Yet half of treatments used in clinical practice lack sound evidence as bad as this sounds the evidence for health policy is even thinner a law signed this year the foundations for evidence-based policymaking Act could help intended to

Improve the collection of data about government programs and the ability to access it the law also requires agencies to develop a way to evaluate these in other programs evaluations felt policy have rarely been as rigorous as clinical

Trials a small minority of policy evaluations have had randomized designs which are widely regarded is the gold standard of evidence and commonplace in clinical science nearly 80% of studies and medical interventions are randomised

Trials but only 18 percent of studies of US health care policy are because randomized health policy studies are so rare those that do occur are influential the rand health insurance experiment is the classic example this 1970s

Experiment randomly assigned families to different levels of health care cost sharing it found that those responsible for more of the cost of care use far less of it and with no short-term adverse health outcomes

Except of course for the poorest families with relatively sicker members the results of influenced health care insurance designed for decades in large part you can thank or curse this randomized study and its interpretation

For your health care deductibles and co-payments more recently this study based on random access to Oregon's Medicaid program has been influential in the debate over Medicaid expansion a state lottery which provided the

Opportunity for Medicaid coverage to low-income adults offered rich material for researchers the findings that Medicaid increases access to care diminishes financial hardship and reduces rates of depression have

Provided justification for program expansion but its lack of statistically significant findings of improvements and other health outcomes has been pointed to by some as evidence that Medicaid is ineffective although there are other

Examples of randomized studies in health policy the vast majority have far less rigorous designs some of them are sponsored by the Center for Medicare and Medicaid innovation created by the Affordable Care Act it is spent about a

Billion dollars a year on dozens of programs that pay for Medicare and Medicaid Services in new ways intended to enhance quality and reduce spending most of the Innovation Centers pilots lack randomized designs for which it has

Been criticized also potentially problematic most of its programs rely on voluntary participation by health care organizations there might be crucial differences between those that opt-in and those that don't mandatory

Participation poses its own set of financial political challenges randomization can also be challenging it can be complex and hard to maintain problems can also plagued rollouts that are voluntary and not randomized

Programs showing promise suffer from diminishing participation as healthcare organizations drop out the Innovation Centers pioneer accountable care organization program offered healthcare organizations the opportunity to earn

Bonuses in exchange for accepting some financial risk provided they meet a set of quality targets it started with 32 participants in 2012 although studies showed a reduced spending and at least maintained if not improved quality only

Nine remained by 2016 when the program ended some of the largest Innovation Center programs involving thousands of providers bundle payments Crosse services for some common treatments like knee and hip

Replacements instead of paying separately for each one more efficient providers that can deliver the care for less than that price can keep some of the differences profit those that can't lose money of six bundled payment

Programs only one included random assignment beginning in April 2016 Medicare randomly assigned 75 markets to be subject to bundle payments for knee and hip replacements and 121 markets to business as usual but the Innovation

Center didn't maintain the design announcing in November 2017 that hospitals could leave it this will greatly limit what can be learned from the program just as in clinical care there are examples of incorrect thinking

Based on low rigor studies that more rigorous ones later overturned for example many low quality studies suggest that wellness programs reduce employers healthcare costs as they improve health outcomes but when the

Programs have been subject to randomized controlled trials none of these findings hold up Hospital cost shifting the idea that shortfalls from Medicare Medicaid caused hospitals to charge higher prices to private

Insurers can also seem commonplace from studies without rigorous designs but when subjects are more careful evaluation the phenomenon is almost never observed an apparent preference for ignorant is not unique to health

Care policies across government's at all levels are routinely put in place without plans to find out if they work or how to unwind them if they don't or how to build under if they do a 2017 Government Accountability Office report

Found that the vast majority of managers of federal programs were not aware of any recent evaluation of the programs they oversaw in most cases none had been done and others none had been done in the past five years it's hard to rid

Ourselves of ideas that are a little more than wishful thinking or to end policies that don't work the first step would be to do more rigorous policy evaluations the next would be to heed them hage enjoyed this episode you might

Enjoy this other episode on the randomized controlled trial and how wellness programs were busted by them it's a really good episode you can also support the show if patreon.com slash healthcare triage where like our

Research associate jos Evans or our surgeon mo Sam you can support the show as much as you like help us make it big I'm better

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