Category Archives: #allan

Hope and Skepticism about the New MCAT

by Karan Chhabra and Allan Joseph

The MCAT (better known as every pre-med’s recurring nightmare) just went live with some pretty big changes intended to better prepare premedical students for the healthcare system of tomorrow. We’ve got a guest post over at Dan Diamond’s Forbes blog examining and reacting to the changes. A small excerpt:

That’s why we applaud the AAMC for resisting this bias and placing social science, psychology, and the humanities on the same plane as pure science — where they belong. The new MCAT sends a new signal to aspiring docs: they need this knowledge just as much as they need hard science, and the medical community now demands they have it…

But unless admissions committees firmly commit to selecting “broader” applicants in all aspects of their applications, the newest version of the MCAT will fail in the same way its ancestor did.

This is something we’ve thought a lot about, but we’re really interested in hearing your thoughts — take a read and let us know your thoughts on Twitter (see below) or in the comments.

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Karan is a medical student at Rutgers Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives. Follow him on Twitter @KRChhabra.

Allan is a third-year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

The CO-OP program, 5 years later

by Allan Joseph

Most PM readers can remember the heated debate over the public option that took place half a decade ago (!) during the ACA’s drafting — and are well aware that there is no public option in the law. What many don’t remember, however, is what was put into the law instead of the public option — the Consumer Operated and Oriented Plan program, or the CO-OPs.

I’ve been working with Dr. Eli Adashi, the former medical-school dean here at Brown, for some time now looking into the CO-OP program, which is a fascinating, under-studied provision of the law. We published a Viewpoint in JAMA that went online this week (ungated) that summarizes the CO-OP program and looks towards its future. Go take a look!

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Allan Joseph is a second-year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPH. You can follow him on Twitter @allanmjoseph.

What are tomorrow’s policy problems?

by Allan Joseph

In a few weeks, my institution is hosting the AMA’s Northeast-region meeting for medical students who are interested in policy and advocacy, among other topics. I’ve been asked to give a presentation on the policy problems of the future, and ways for the attendees to prepare for those problems and to help shape their solutions.

I thought I’d take an informal poll to help guide my talk. So what do you see as the biggest healthcare policy problem of the next 1 year, 5 years, 10 years, and/or 25 years? What can medical students do to prepare for them, and how should physicians shape the solutions?

Send me your answers to any or all of those questions via email, on Twitter, or in the comments below.

Thanks!

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Allan Joseph is a second-year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPH. You can follow him on Twitter @allanmjoseph.

Saving money in healthcare, PCMH edition

by Allan Joseph

I wanted to quickly follow up on Tom’s excellent post from yesterday on patient-centered medical homes (PCMHs), which nicely outlined some conflicting results from recent research on the model. (Edited to complete the sentence.)

It really shouldn’t surprise us that PCMHs only saved money in the 10% of patients with the highest risk. Why? Take a look at this chart from the NIHCM, which is one of my favorites in all of health policy:

Distribution of Healthcare Spending

Notice that the top 10% of spenders (not the same as the top 10% of risk scores, but pretty close) account for just about two-thirds of healthcare spending. The vast majority of patients account for very little spending — there’s no savings to be had there. Healthcare spending is highly concentrated at the top.

Now let’s look at spending from another angle. According to the Robert Wood Johnson Foundationtwo-thirds of healthcare spending is on patients with multiple chronic conditions. That means at minimum, roughly one-third of healthcare spending in America is spent on those patients in the top 10% with multiple chronic conditions. (To get even deeper, at least 16% of spending is on patients in the top 10% with three or more chronic conditions.) Of course, that’s only a lower bound — I’d be surprised if the number wasn’t much higher.

So what does this have to do with PCMHs? Well, the core idea behind a PCMH is greatly increased care coordination. That’s precisely the type of intervention that will help sick patients who have multiple chronic diseases — or the very group that accounts for a huge portion of our healthcare spending. No wonder the investment in PCMHs paid off for the sickest patients. They’re the ones where all the money to be saved is.

Given that the vast majority of patients who might use PCMH services account for little health spending, we should expect spending money to build a broad PCMH structure to save money on net. Nor should we be surprised that there’s money to be saved by better coordinating the care of the sickest patients. That’s the whole idea of the “hotspotting” movement. That’s also why Tom was spot-on to focus on the idea of “risk-adjusted population health,” such as focusing care managers on the sickest patients or designing separate clinics that focus exclusively on high-risk patients.

Sometimes it’s worth stepping back and taking stock of our intuitions about what might reduce healthcare costs. If an intervention isn’t aimed at the sickest patients, it’s probably not going to save a lot of money. Don’t be surprised when it doesn’t.

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Allan Joseph is a first year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

Walking uphill both ways

by Allan Joseph and Emily Flower

Sometimes, good data visualization just has a way of grabbing your attention. That’s what the Providence Plan, a data-focused organization here in Rhode Island, was able to do last week with this stark map (click to see a larger version):

Current Busing Policy Maps

Some background: These maps represent the distances high school students have to walk before qualifying for access to free transportation services through the Providence Public School District (PPSD). Or in layman’s terms, if you live in a green area on your high school’s map, you get a free bus pass. If you live in the red area, you’re on your own. A monthly pass costs $62 a month, and that’s the cheapest option.

Middle school students in PPSD receive transportation services if they live more than 1.5 miles from their school. When students transition to high school (when they can pick their school based on their interests), they get a free bus pass only if they live more than 3 miles away — measured as the crow flies, not in walking distance.

It may be cliché, but more than a handful of students do actually walk uphill, both ways, during their often hour-long commute to and from school each day. The city is built primarily on two hills; it’s difficult to get anywhere here without traversing a highway, waterway, or climbing up or down a hill — often all three in the same walk.

For many students, this daily trek is enough of a reason to not attend school. Between middle school and high school, the transportation requirement doubles. So does the chronic absenteeism rate. The chronic absenteeism rate jumps too. (Edited for miscalculation.) PPSD middle schools see a 26% chronic absenteeism rate, defined by a student missing 18 instructional days (roughly the entire month of November). PPSD high schools reported a 36% chronic absenteeism rate in the 2012-2013 school year. Obviously that’s not exclusively due to the transportation issue, but it doesn’t seem like a stretch to say that buses are a major factor — especially since absence rates are sky-high in the winter, even compared to neighboring districts.

But this isn’t just about chronic absenteeism, nor is it limited to education policy. Schools are some of the most important forces for health in the life of poor children — and with 83% of students in PPSD qualifying for subsidized lunch (family income below 185% of the federal poverty level), the majority of students in PPSD are poor or near-poor. In the short term, many students depend on subsidized lunch for food security. Their most familiar and important healthcare provider? The school nurse. Their easiest access to health resources? The school nurse, again. When they don’t go to school, they’re cut off from all of those resources. That’s not to mention that if they do decide to walk to school from nearly 3 miles away as the crow flies, they could be placing their health at risk, as frostbite, heatstroke, and violence are all real risks at various times of the year.

Long-term, there’s a relationship between educational attainment and health outcomes. Though the literature isn’t clear on how much of that is causal, we think it’s a fair bet that students who do better in school (by attending more often) will have a better chance at attaining better health. (Here’s some tentative evidence.)

But there’s some movement towards changing the policy. Recently-introduced House Bill 7012 aims to change the policy in order to bring PPSD’s policy in line with the other school districts in the state: a 2-mile walk zone. That’s far from ideal, but it’s certainly an important step: about 2,100 students would gain access to busing, and it stands to reason that those are the students who would most benefit from expanded busing, as they live the farthest away. Here’s what the new maps would look like (again, click to enlarge):

New Policy Maps

As you can see, that one mile covers quite a bit of the city. But H.B. 7012 isn’t an easy sell, not by a long shot. For one, the policy would cost the city $1.35 million at a time of strict belt-tightening in the Ocean State. But look at it another way: Gov. Lincoln Chafee’s latest budget proposed a large cut to Medicaid — to $819 million in state spending, or $1.9 billion when federal matching funds are added. The policy would cost just 0.1% of the Rhode Island Medicaid program’s annual budget. And therein lies the key to understanding the problem.

Targeted, “low-hanging fruit” interventions on the social-service side can help promote health outcomes at relatively low cost. We can, and should, pursue those interventions — and it shouldn’t take a well-made map to draw our attention to them.

We’re not arguing that Rhode Island’s Medicaid program should pay for the busing solution, of course. That would be an admittedly silly ad hoc way to make policy. What we’re trying to say is that healthcare and medical care are not synonyms. What we talk about in “health policy” is often more properly termed “medical care” — how to finance health insurance, the difficulties of narrow networks, how to manage our medical-care costs as a country, etc. But health is affected by more than medical care — and it’s definitely affected by social services, school transportation included. Yet we’ve separated the ways we pay for social services and medical-care services in ways that don’t always make sense. Moreover, bad health limits the ability of poor Rhode Islanders — and Americans — to take advantage of social services designed to give them a leg up, while limited social services can make pursuing health a Herculean task.

Talk about climbing uphill both ways.

*Much more on this topic coming soon: a review of The American Health Care Paradox, a new book by Elizabeth H. Bradley and Lauren A. Taylor.

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Allan is a first year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

Emily works in civic education in Providence, Rhode Island. She graduated from The Ohio State University with a degree in Public Affairs. You can follow her on twitter @emilygflower.