Going Below the Surface E-Newsletter: March 2019

This month, we dig deeper on two things we never seem to have enough of: time and high-quality data. We know that some of these conversations might spark some fierce debates, but we welcome dialogue on health care spending. It’s important to have difficult conversations so that we can find common ground on solutions. Drop us a line or tweet using #GoingBelowTheSurface.

Digging Deeper

Physicians and Patients: Having Difficult Conversations About Limited Time

When we talk about health care resources, it’s usually in terms of money or expenditures. But there’s another important resource that we haven’t addressed in this space before, and that’s time. For patients facing terminal diagnoses, time is a precious resource. Two studies (see here and here) and an editorial in JAMA Oncology explore why physicians should discuss important time-related topics with patients sooner, without causing harm, and with potential benefit. The studies found that in the field of oncology, these conversations significantly decreased the rates of anxiety and depression symptoms experienced among patients. These discussions may also have a positive impact on a patient’s care and the trajectory of the illness.

Why It MattersPatients want to have these difficult conversations with their physicians and can benefit from them. The studies found that while these discussions were useful, physicians still have work to do in making sure that treatment plans mesh with patient goals and peacefulness. What we spend on health care is important, but how we spend our time matters, too.  

Data and Its Discontents

All research data have limitations, and failing to pay heed to those limitations can not only mislead or confuse, but – even worse – send policymakers chasing the wrong solution. A case in point: the January Health Affairs paper by Inmaculada Hernandez et al. that attempted to assess what drives the cost of pharmaceuticals, but used only list prices. In a response in Health Affairs this month, NPC Chief Science Officer Robert W. Dubois, MD, PhD, takes a closer look at the potentially far-reaching conclusions drawn from the study’s narrow analysis. Dubois’ takeaway message: “Researchers must be careful not to extend their analysis or the implications they draw from it beyond the limits of their data.”

Why it Matters: Today’s environment requires thoughtful consideration into the way that we evaluate and communicate research. Going beyond the questions that we ask in our analyses of data runs the risk of misinforming the conversation around drug prices – and, more broadly, health spending. More importantly, it’s also a time when we must engage in sometimes difficult dialogues around research methods and outcomes. In response to Dr. Dubois’ rebuttal, original author Hernandez shared her thoughts on the limitations and critiques of her analyses. Disagreements in research will always exist, but so do solutions, and that’s what Going Below The Surface is all about.

What We're Reading

It was hard to choose just a handful of articles this month, as there were a number that took a deeper dive on the drivers of health care spending in the commercial sectors and public programs like Medicare, whether we should consider “rationing” a dirty word, and how we value curative therapies. If the articles below can’t quench your thirst on this topic, then we recommend checking out Health Affairs’ Considering Health Spending series, featuring provocative dialogues on health spending. (Note: the series is supported by NPC and Anthem, Inc.)

  • Explaining the Slowdown in Medical Spending Growth Among the Elderly, 1999–2012 Cutler DM, et al. Feb. 2019, Health Affairs Why has per-capita spending for Medicare beneficiaries ages 65 and older declined in recent years? By digging deeper into the drivers of Medicare spending, researchers found that half of the spending slowdown was attributable to slower growth in spending for one particular condition: cardiovascular disease. Looking even deeper, “roughly half of the reduction in major cardiovascular events was attributable to medications controlling cardiovascular risk factors.”
  • New Research Spotlights Different Drivers of Spending Growth in the Public and Commercial Sectors Chernew ME, Frakt AB. Feb. 15, 2019, Health Affairs Blog How we pay for health care is an evergreen challenge for policymakers. Cost growth challenges for the aging population and the working age population — "the former covered largely by Medicare and the latter by commercial insurance — are quite different and require different interventions.”
  • Rationing of Health Care in the United States: An Inevitable Consequence of Increasing Health Care Costs Bauchner H. Feb. 13, 2019, JAMA "Controlling health care costs is critical," but "[g]reater rationing of care is inevitable if health care costs continue to increase." The author considers which rationing option is preferable: having patients make their own pocketbook choices because of high-deductible health plans, or leaving the decision to others, “including rationing by access (type of insurance), by cost (out-of-pocket expenses), by restriction (the service is not available or paid for by a third party), or by long waits (Canada and parts of the United States).”
  • Value-Based Pricing for Emerging Gene Therapies: The Economic Case for a Higher Cost-effectiveness Threshold Garrison LP, et al. Feb. 19, 2019, Journal of Managed Care & Specialty Pharmacy How do you value and reward a cure? Researchers “characterize challenges for traditional approaches to assessing the value of one-time gene replacement therapies and to provide a health economic rationale for a higher value-based cost-effectiveness threshold.”

Dialogues on Health Care Spending

  • Webinar: On the Rise: Out-of-pocket Healthcare SpendingAcademyHealth will host a webinar focused on estimates of out-of-pocket health care spending levels and the associated burden at the state and county levels, including a first look at 2017 health care out-of-pocket spending trends. Join speakers Fiona Greig of the JPMorgan Chase Institute and Niall Brennan of the Health Care Cost Institute at 2:30 p.m. ET on March 20 for the discussion.
  • Tackling Low-value Care—With more than 14 percent of all health care spending going toward low-value care according to Institute of Medicine estimates, it’s a sizable problem in the United States, but one that can be tackled. Through research and education on the issue and support from all corners of health care, we’re already seeing progress at the state level. Stay tuned to this space for more from the Going Below The Surface Forum on next steps, as well as a summary of a recent Going Below The Surface conversation on the topic.

Join the conversation by following us on social media using #GoingBelowTheSurface or send us an email at info@npcnow.org. Want to receive this e-newsletter in your inbox? Subscribe via this website.