The application of behavioral economics to health and health care has captured the imagination of policymakers across the political spectrum. The idea is that many people are irrational in predictable ways, and that this both contributes to unhealthy behaviors like smoking and holds one of the keys to changing those behaviors. Because health care costs continue to increase, and a substantial portion of costs are incurred because of unhealthy behaviors, employers and insurers have great interest in using financial incentives to change behaviors. However, it is in the details that complexity and controversies emerge. Who should the targets be, and what outcomes should be rewarded? How should incentives be structured, to maximize their effectiveness and minimize unintended consequences? In what situations should we be intervening to affect decisions by people who may prefer to be obese or to smoke, and in what situations should we accept their preferences? To begin to answer these questions, the Penn-CMU Roybal P30 Center on Behavioral Economics and Health held its first annual Behavioral Economics and Health Symposium on March 24-25, 2011 with support from the Robert Wood Johnson Foundation. The symposium drew more than 50 researchers, scholars, and health professionals from a variety of disciplines, including medicine, public health, economics, law, management, marketing, and psychology. They heard perspectives on behavioral economics from public and private funders, the CEO of the University of Pennsylvania Health System, and the CEO of stickK.com, a start-up company that uses online, voluntary commitment contracts to help people achieve their goals. Participants formed eight working groups to review the current state-of-the-art in a variety of clinical contexts and to consider how behavioral economics could inform a research agenda to improve health. This Issue Brief summarizes the findings of these working groups and the symposium.
Identifying and paying for value has become a recurrent theme of health care reforms. Its corollary, reducing the prevalence of, and resources directed to, ineffective or marginally effective care, has received far less attention. In July 2016, the University of Pennsylvania’s Leonard Davis Institute of Health Economics (LDI) convened a diverse set of national leaders and stakeholders representing industry, think-tanks, provider and patient groups, and academic experts to tackle how health systems, payers, and providers can spur the ‘de-adoption’ of medical practices and technologies no longer considered valuable. While the roundtable of experts unanimously supports the need for de-adoption and current efforts to curb the use of low-value practices or technologies, they identified four specific polarities at the heart of the debate about how best to build the momentum around deadoption, and move it forward. They are: 1) value (targeting ineffective, even harmful, care or expanding efforts to address care of limited value); 2) resource allocation (spending less or redirecting spending); 3) quality improvement (a subset of QI or a distinct process); 4) level of intervention (policy, payment, provider, or organization). In addition to these polarities, several key questions emerged that form practical next steps for advancing de-adoption activities. With an eye toward advancing de-adoption, this brief summarizes the polarities and questions that suggest priorities for a future research agenda and policy-relevant action steps.
Community-based participatory research (CBPR) is a collaborative process between community-based organizations and academic investigators. It has the potential to make research more responsive to existing needs and to enhance a community's ability to address important health issues. But CBPR is often unfamiliar territory to academic investigators and community organizations alike. We interviewed CBPR investigators at Penn and community leaders to ascertain best practices in CBPR and to compare academic and community perspectives. A number of models of community-academic partnerships emerged, each with its own advantages and disadvantages. The perspectives of the investigators sometimes matched those of the community leaders, but diverged in important ways.
This Issue Brief describes the breadth of physician networks on the ACA marketplaces in 2017. We find that the overall rate of narrow networks is 21%, which is a decline since 2014 (31%) and 2016 (25%). Narrow networks are concentrated in plans sold on state-based marketplaces, at 42%, compared to 10% of plans on federally-facilitated marketplaces. Issuers that have traditionally offered Medicaid coverage have the highest prevalence of narrow network plans at 36%, with regional/local plans and provider-based plans close behind at 27% and 30%. We also find large differences in narrow networks by state and by plan type.
In 2009, more than 2.8 million housing units in the U.S. received a foreclosure notice. That represents about 1 in every 45 properties and a 120% increase in the number of foreclosed properties since 2007. Real estate experts predict even more foreclosures in 2010 as high unemployment continues. The cascading effects of the foreclosure crisis on the U.S. economy are all too clear; the effects on individuals' health status are less obvious. This Issue Brief summarizes two studies that examine the health implications of foreclosure and reveal a vulnerable population that may benefit from coordinated health and financial services.
One aspect of the quality of surgical care is the length of the time patients spend in the operating room and under anesthesia. It is generally believed that the longer a surgical procedure, the greater the chance of a complication. But because obtaining procedure and anesthesia times usually involves a direct review of medical records, few large-scale studies are able to examine procedure times. This Issue Brief summarizes new work that validates the use of Medicare billing data as a proxy for anesthesia times, and illustrates how these data can shed light on hospital and patient characteristics that affect procedure duration and surgical quality.
For the second straight year, large cities on the U.S. are experiencing an alarming increased [sic] in homicides, mostly committed with firearms. Philadelphia reported 406 homicides in 2006, giving it the highest rate of homicides among the ten largest cities (27.8 per 100,000 people). This trend has renewed interest in policies to limit the availability of firearms. However, the effectiveness of such policies at reducing injury remains controversial, often creating political deadlock. To inform this debate, we look at evidence from Brazil, a country with even greater levels of violence than the U.S. This Issue Brief analyzes recent gun legislation and other violence reduction policies in Brazil and their effects on firearm violence.
Medicaid and the state-run Children's Health Insurance Program (CHIP) cover about 42 million children, many of whom would not have access to care without public insurance. Federal law requires that this access be equivalent to that of privately insured children for covered services, and many states have implemented policies to improve longstanding disparities in primary and preventive care. Reimbursement rates are up, but significant disparities remain, especially for dental and specialty services. It is important to understand the distinct effect of provider-related barriers, because they are potentially more modifiable through health policy than patient-related ones. This Issue Brief summarizes research that directly measures the willingness of dental and medical providers to see publicly-insured children, using research assistants posing as mothers calling for an urgent appointment for their child.
In the current debate in Congress over the Affordable Care Act (ACA), the issue of provider access is a major concern. Fortunately, our 10-state audit study published in JAMA Internal Medicine finds that primary care appointment availability for new patients with Medicaid increased 5.4 percentage points between 2012 and 2016 and remained stable for patients with private coverage. Over the same period, both Medicaid patients and the privately insured experienced a one-day increase in median wait times. Higher appointment availability for Medicaid patients is a surprising result given the increase in demand for care from millions of new Medicaid enrollees. In this Issue Brief, we summarize our study’s findings, expand on possible explanations, and extend the analysis by examining the relationship between appointment availability and state-level Medicaid expansions. We find that access to primary care increased for Medicaid patients only in states that extended Medicaid eligibility to low-income, nonelderly adults. Combined, these results suggest coverage provisions in the ACA have not overwhelmed primary care capacity.
Comparative effectiveness research (CER) has received widespread attention and federal funding because of its potential to inform and improve treatment decisions. Since 2005, patients and their ophthalmologists have faced a dilemma in treating age-related macular degeneration (AMD)--the leading cause of blindness in the United States. Two closely related drugs have produced dramatic improvements in vision; one has been rigorously tested for use in AMD patients, while the other has been rigorously tested for use in cancer patients, but is now widely used to treat AMD. One drug costs 40 times as much as the other. This Issue Brief summarizes a CER study comparing these drugs head-to-head, and provides the most definitive evidence to date about the safety and effectiveness of the two alternatives.
About 10-15% of all adults report that they are allergic penicillin or other antibiotics, although the accuracy and significance these reports remain unclear. In the outpatient setting, clinicians face a dilemma in prescribing for patients with a history of an allergic reaction to antibiotics. Which drugs should these patients avoid? Are these patients at increased risk for an allergic reaction to related drugs? This Issue Brief summarizes several large studies that can help guide improve the management of patients with antibiotic allergies.
In 2005, nearly 21% of American adults smoked cigarettes, and 81% of them smoked every day. For smokers unable or unwilling to quit, tobacco products that reduce the adverse health effects of smoking may be an attractive option. Potentially reduced exposure products (PREPs) were developed by the tobacco industry in response to smokers' health concerns. PREPs purportedly lower the tar and/or nicotine levels of cigarettes, although the actual harm reduced remains questionable. One of the most recent additions to this product class are cigarettes that use genetically modified tobacco to reduce nicotine levels. This Issue Brief summarizes studies that investigate [1] how this product is used and [2] the messages smokers take away from product marketing. These complementary studies send a cautionary signal about the ability of these new cigarettes to reduce the harmful effects of smoking.
Preventable and treatable diseases have taken a devastating human and economic toll on many developing countries. That economic toll is likely to be underestimated because most studies focus on productivity losses in the formal, or large-firm, sector; yet, a large portion of the population of developing countries works in the informal sector in very small businesses, either as an owner-worker or as an employee. It is plausible that ill health might affect small businesses most severely, possibly putting the entire business at risk. This Issue Brief summarizes a three-year study that tracks small businesses in Durban, South Africa, and investigates the connection between the owner's health and business growth, survival, or closure. The results bolster the economic case for investing resources in the prevention and treatment of disease in developing countries.
Rising obesity represents one of the most disturbing health trends in the U.S. and elsewhere. Obese people are at greater risk for diabetes, cardiovascular disease, disability, and mortality. However, recent studies also suggest that the obese population has grown "healthier" since the 1960s, probably due to improved medical care for cardiovascular disease. It is unclear whether these improvements have resulted in more or less disability in obese people as they age. This issue Brief summarizes two studies that examine the prevalence of obesity over time in the elderly and disabled, and the changing relationship of obesity and disability.
Health care spending represents a growing share of our national income, and based on current projections, will increase from 16% of the gross domestic product today to 20% by 2018. What does this mean for typical working families with private health insurance, who shoulder the financial burden of maintaining the current system? In this Issue Brief, Polsky and Grande construct a typical health care budget for working families of various income levels, calculate the percentage of total compensation devoted to health care over time, and project how rising health care costs will affect standards of living in the future. Their findings remind us that what works today also has to work tomorrow. Sustainability depends critically on successful cost containment.
Despite national guidelines and proven health benefits, vaccination rates for the human papillomavirus (HPV) remain far below those of other vaccines recommended for adolescents. HPV is the most common sexually transmitted infection in the U.S; it is responsible for about 25,000 new cancers each year. A series of three shots is recommended for all girls and boys at age 11-12, but significant barriers exist to starting and finishing this series. This Issue Brief examines some of the barriers and summarizes a successful, multipronged clinical intervention to improve vaccination rates.
Much of the public was introduced to the implantable cardioverter-defibrillator (ICD) when Vice President Cheney, a survivor of four heart attacks, received the device in 2001. Although ICDs were initially limited to patients with previous cardiac arrests or arrhythmias, more recent studies have demonstrated that ICDs can prevent sudden cardiac death in patients who have not had a cardiac arrest, but are at greater risk for one (for example, those with congestive heart failure and reduced cardiac function). This Issue Brief summarizes studies that analyze health outcomes, costs, and quality of life for patients-at-risk who receive ICDs in real-life settings.
About two years ago, the death of a high school student athlete brought methicillin-resistant Staphylococcus aureus (MRSA) into the national spotlight. Preventing the spread of MRSA in schools, gyms, and other public facilities is an important public health goal. This Issue Brief presents current information on the prevalence and transmission of MRSA in community settings, and describes ongoing research on interventions to limit the spread of this increasingly common infection.
The United States is in the midst of a prolonged nursing shortage, one that could reach a deficit of 800,000 registered nurses (RNs) by 2020. Increasingly, foreign-trained nurses are migrating to the U.S., particularly from low-income countries, seeking higher wages and a higher standard of living. Increased reliance on immigration may adversely affect health care in lower-income countries without solving the U.S. shortage. This Issue Brief analyzes trends in medical migration, and explores its short- and long-term effects on the health care workforce in the U.S. and in developing countries.
In families with genetic disorders due to a known genetic mutation, presymptomatic genetic testing can lead to early detection and treatment of inherited disorders that may manifest later in life. The health benefits for family members at increased risk, however, is limited by the predictive value of the genetic test, the availability of effective treatments, and individuals' and families' willingness to undergo genetic testing in the first place. This Issue Brief describes the case of a genetic condition for which genetic screening of family members is clearly useful, and just as clearly underused. It explores the barriers to the use of genetic screening and has implications for the future as genetic technologies become more complex and produce more uncertainty.