Considering whether Medicaid is worth the cost: revisiting the Oregon Health Study

Prioritizing Early Disease Intervention

Scholars and practitioners have described how investing in health care earlier rather than later can be beneficial, from how "biomarkers" offer promise for early disease detection to healthcare system "incentives" that can promote early preventive medicine. Work by health economists has also made clear that the "health capital" of an individual depreciates over time in the absence of investments in health. Yet, our current policy makers and healthcare system continue prioritizing care of late-stage complex symptomatic illness, often when cure is impossible and disease reversal is improbable, thus exacerbating public health burdens. Critically missing are predicates to address this challenge include the following: first, identifying and validating the specific set of presymptomatic biomarkers that will inform the most appropriate intervention timing for those medical conditions amenable to early intervention; second, shifting fundamental health economic incentives to influence the appropriate disease prevention market; and third, formulating and executing a viable economic framework of reimbursement. We examine these predicates and propose actionable policy recommendations that may help align stakeholder interests to improve public health.

The promise of big data for precision population health management in the US

OBJECTIVES

As we enter the year 2020, health data in the United States (US) is still in the process of being curated into a usable format. With coordinated data systems, it becomes possible to answer, with relative certainty, what preventive and medical interventions work in the real world and for whom they might work.

STUDY DESIGN

This is a non-systematic expert review.

METHODS

A non-systematic expert review was undertaken to identify relevant scientific and gray literature on the current state and the limitations of evaluation of health interventions and the health data infrastructure in the US. This review also included the literature on nations with unified data systems. We coupled this review with non-structured interviews of data scientists to gain insight into the progress in establishing the components necessary to support a unified data system and to facilitate data exchange for evaluations, as well as further guide our review. Our goal was to produce a critical analysis of the existing attempts to standardize and use data collected during patient encounters with physicians for public health purposes.

RESULTS

Data obtained from electronic health records are produced in a way that is challenging to use and difficult to compile across platforms in the US. One response to this problem has been to encourage the exchange and standardization of health record information through Distributed Research Networks and Common Data Models (CDMs). These data can be combined with mobile health, social media, and other sources of data to radically transform what we know about the prevention and management of disease. However, issues with the variety of CDMs and growing sense of distrust of institutions that maintain data continue to impede medical progress.

CONCLUSIONS

We present a framework for data use that will allow public health to answer a swath of unanswered research questions that can improve public health practice.

Health and economic consequences of applying the United States' PM2.5 automobile emission standards to other nations: a case study of France and Italy

OBJECTIVES

The US has among the world's strictest automobile emission standards, but it is now loosening them. It is unclear where a nation should draw the line between the associated cost burden imposed by regulations and the broader societal benefits associated with having cleaner air. Our study examines the health benefits and cost-effectiveness of introducing stricter vehicle emission standards in France and Italy.

STUDY DESIGN

Quasi-experimental study.

METHODS

We used cost-effectiveness modeling to measure the incremental quality-adjusted life years (QALYs) and cost (Euros) of adopting more stringent US vehicle emission standards for PM2.5 in France and Italy.

RESULTS

Adopting Obama era US vehicle emission standards would likely save money and lives for both the French and Italian populations. In France, adopting US emission standards would save €1000 and increase QALYs by 0.04 per capita. In Italy, the stricter standards would save €3000 and increase QALYs by 0.31. The results remain robust in both the sensitivity analysis and probabilistic Monte Carlo simulation model.

CONCLUSIONS

Adopting more stringent emission standards in France and Italy would save money and lives.

The cost-effectiveness of limiting federal housing vouchers to use in low-poverty neighborhoods in the United States

OBJECTIVE

Residents of low-income neighborhoods are exposed to relatively higher rates of crime, fewer opportunities to exercise, poorer schools, and few opportunities to eat healthy foods than residents of middle-class neighborhoods. Policies that influence neighborhood context could therefore serve as health interventions. We seek to inform the policy debate over the wisdom of spending health dollars on non-health sectors of the economy by defining the opportunity cost of doing so.

STUDY DESIGN

Cost-effectiveness analysis with Markov model and Monte Carlo simulation.

METHODS

We assess the long-term health and economic benefits of Moving to Opportunity-type housing vouchers vs traditional public housing. Our Markov model draws heavily from decades of follow-up data from a large randomized-controlled trial, from which we make projections about health outcomes and costs.

RESULTS

Restricted housing vouchers cost less over the lifetime of recipients than traditional vouchers ($186,629 [95% credible interval: $148,856-$229,235] vs $194,077 [$153,831-$240,904]), while improving health and longevity (19.39 quality-adjusted life years [15.83-21.35] vs 19.16 [15.65-21.03]). Over 99% of the model simulations favored restricted housing vouchers over traditional public housing or non-restrictive vouchers.

CONCLUSIONS

Restrictive vouchers appear to improve population health, save money, and save lives.

The cost-effectiveness analysis of the New Rural Cooperative Medical Scheme in China

OBJECTIVE

The New Rural Cooperative Medical Scheme (NCMS) is a universal healthcare coverage plan now covering over 98% of rural residents in China, first implemented in 2003. Rising costs in the face of modest gains in health and financial protections have raised questions about the cost-effectiveness of the NCMS.

METHODS

Using the most recent estimates of the NCMS's health and economic consequences from a comprehensive review of the literature, we conducted a cost-effectiveness analysis using a Markov model for a hypothetical cohort between ages 20 and 100. We then did one-way sensitivity analyses and a probabilistic sensitivity analysis using Monte Carlo simulations to explore whether the incremental cost-effectiveness ratio (ICER) falls below 37,059 international dollars [Int$], the willingness-to-pay (WTP) threshold of three times per capita GDP of China in 2013.

FINDINGS

The ICER of the NCMS over the lifetime of an average 20-year-old rural resident in China was about Int$71,480 per quality-adjusted life year (QALY) gained (95% confidence interval: cost-saving, Int$845,659/QALY). There was less than a 33% chance that the system was cost-saving or met the WTP threshold. However, the NCMS did fall under the threshold when changes in the program costs, the risk of mortality and hypertension, and the likelihood of labor force participation were tested in one-way sensitivity analyses.

CONCLUSION

The NCMS appears to be economically inefficient in its current form. Further cost-effectiveness analyses are warranted in designing insurance benefit packages to ensure that the NCMS fund goes toward health care that has a good value in improving survival and quality of life.

Cost-effectiveness of national health insurance programs in high-income countries: A systematic review

OBJECTIVES

National health insurance is now common in most developed countries. This study reviews the evidence and synthesizes the cost-effectiveness information for national health insurance or disability insurance programs across high-income countries.

DATA SOURCES

A literature search using health, economics and systematic review electronic databases (PubMed, Embase, Medline, Econlit, RepEc, Cochrane library and Campbell library), was conducted from April to October 2015.

STUDY SELECTION

Two reviewers independently selected relevant studies by applying screening criteria to the title and keywords fields, followed by a detailed examination of abstracts.

DATA EXTRACTION

Studies were selected for data extraction using a quality assessment form consisting of five questions. Only studies with positive answers to all five screening questions were selected for data extraction. Data were entered into a data extraction form by one reviewer and verified by another.

EVIDENCE SYNTHESIS

Data on costs and quality of life in control and treatment groups were used to draw distributions for synthesis. We chose the log-normal distribution for both cost and quality-of-life data to reflect non-negative value and high skew. The results were synthesized using a Monte Carlo simulation, with 10,000 repetitions, to estimate the overall cost-effectiveness of national health insurance programs.

RESULTS

Four studies from the United States that examined the cost-effectiveness of national health insurance were included in the review. One study examined the effects of medical expenditure, and the remaining studies examined the cost-effectiveness of health insurance reforms. The incremental cost-effectiveness ratio (ICER) ranged from US$23,000 to US$64,000 per QALY. The combined results showed that national health insurance is associated with an average incremental cost-effectiveness ratio of US$51,300 per quality-adjusted life year (QALY). Based on the standard threshold for cost-effectiveness, national insurance programs are cost-effective interventions.

CONCLUSIONS

Although national health insurance programs have been introduced in most developed countries, only a few studies have examined their cost-effectiveness. All the selected studies revealed strong evidence to support health insurance programs or health reforms in the United States. The average ICER in this study is below the standard threshold for cost-effectiveness used in the US. The small number of relevant studies is the main limitation of this study.

Undiagnosed depression: A community diagnosis

Many large provider networks are investing heavily in preventing disease within the communities that they serve. We explore the potential benefits and challenges associated with tackling depression at the community level using a unique dataset designed for one such provider network. The economic costs of having depression (increased medical care use, lower quality of life, and decreased workplace productivity) are among the highest of any disease. Depression often goes undiagnosed, yet many believe that depression can be treated or prevented altogether. We explore the prevalence, distribution, economic burden, and the psychosocial and economic factors associated with undiagnosed depression in a lower-income neighborhood in northern Manhattan. Even using state-of-the art data to "diagnose" the risk factors within a community, it can be challenging for provider networks to act against such risk factors.

Cost Effectiveness of the Earned Income Tax Credit as a Health Policy Investment

INTRODUCTION

Lower-income Americans are suffering from declines in income, health, and longevity over time. Income and employment policies have been proposed as a potential non-medical solution to this problem.

METHODS

An interrupted time series analysis of state-level incremental supplements to the Earned Income Tax Credit (EITC) program was performed using data from 1993 to 2010 Behavioral Risk Factor Surveillance System surveys and state-level life expectancy. The cost effectiveness of state EITC supplements was estimated using a microsimulation model, which was run in 2015.

RESULTS

Supplemental EITC programs increased health-related quality of life and longevity among the poor. The program costs about $7,786/quality-adjusted life-year gained (95% CI=$4,100, $13,400) for the average recipient. This ratio increases with larger family sizes, costing roughly $14,261 (95% CI=$8,735, $19,716) for a family of three.

CONCLUSIONS

State supplements to EITC appear to be highly cost effective, but randomized trials are needed to confirm these findings.

The Supreme Court Ruling That Blocked Providers From Seeking Higher Medicaid Payments Also Undercut The Entire Program

In Armstrong v. Exceptional Child Center, Inc., the US Supreme Court revisited the question of whether Medicaid providers may seek relief in federal courts when states fail to pay "sufficient" Medicaid rates. A divided Supreme Court held that the Supremacy Clause of the US Constitution does not support such actions, even when states violate the Medicaid Act of 1965. Payment sufficiency is vital to Medicaid's success in expanding health insurance coverage under the Affordable Care Act. By terminating providers' ability to seek relief in federal courts, Armstrong makes it easier for states to cut Medicaid payment rates at the same time that millions of new enrollees will enter the program, undercutting operation of the Medicaid program and its role in health care reform.