A far more interesting lesson from the Oregon experiment

It has been a couple of weeks since the landmark Oregon experiment paper came out, and the buzz around it has subsided.  So what now?  First, with passage of time, I think it is worth reflecting on what worked in Oregon.  Second, we should take a step back, and recognize that what Oregon really exposed is that health insurance is a small part of a much bigger story about health in general.  This bigger story is one we can’t continue to ignore.

So let’s talk quickly about what worked in Oregon.  Health insurance, when properly framed as insurance (i.e. protection against high, unpredictable costs) works because it protects people from financial catastrophe.  The notion that Americans go bankrupt because they get cancer is awful and inexcusable, and it should not happen. We are a better, more generous country than that.  We should ensure that everyone has access to insurance that protects against financial catastrophe.  Whether we want the government (i.e. Medicaid, Medicare) or private companies to administer that insurance is a debate worth having.  Insurance works for cars and homes, and the Oregon experiment makes it clear that insurance works in healthcare.  No surprise.

The far more interesting lesson from Oregon is that we should not oversell the value of health insurance to improving people’s health.  While health insurance improves access to healthcare services (modestly), its impact on health is surprisingly and disappointingly small.  There are two reasons why this is the case.  The first is that not having insurance doesn’t actually mean not having any access to healthcare.  We care for the uninsured and provide people life-saving treatments when they need it, irrespective of their ability to pay.  Sure – we then stick them with crazy bills and bankrupt them – but we generally do enough to help them stay alive.  Yes, there’s plenty of evidence that the uninsured forego needed healthcare services and the consequences of being uninsured are not just financial.  They have health consequences as well.  But, claims like 50,000 Americans die each year because of a lack of health insurance? The data from Oregon should make us a little more skeptical about claims like that.

So what really matters?  Right now, we are pouring $2.8 trillion into healthcare services while failing to deliver the basics.  To borrow a well-known phrase, our healthcare system is perfectly designed to produce the outcomes we get – and here’s what we get: mediocre care and lousy outcomes at high prices.  Great.

Let’s use cardiovascular disease as an example.  We know it kills more Americans than any other condition.  The CDC estimates that we spend about $500 billion on CV disease.  With that kind of spending, you’d think we would be really good at managing it.  When it comes to cardiovascular disease, management is relatively straightforward: there are four risk factors worth thinking about: hypertension, diabetes, high cholesterol, and smoking.  But guess what?  We’re really not that good at managing these conditions, and evidence suggests that health insurance has almost nothing to do with it.  Here’s the evidence:

  1. Hypertension: Nearly 70 million adults (1 in 3) have it.  More than half of these Americans’ blood pressure is poorly controlled.  Rates of poor control are only marginally worse among the uninsured (58%) than among the insured (51%).
  2. Diabetes: Nearly 26 million people have it. Rates of poor control?  You guessed it: about half, and the same between the uninsured (46%) and the insured (44%).
  3. High cholesterol:  Again, about 70 million adults (1 in 3) have it.  Rates of control?  Even worse!  About 1/3 have their cholesterol under control.  The proportion with poor control is lower among the insured (60% versus 77%) than the uninsured, but even among the insured, frankly, cholesterol management is terrible.
  4. Smoking: About 50 million people smoke.  None of them have it under adequate control (by definition).  Most of these people have health insurance.

Type of insurance really doesn’t matter. A landmark New England Journal of Medicine paper in 2003 found that the quality of care for privately insured Americans was about as bad as it was for those on government insurance or who were uninsured. On a global measure of how often patients get the right care, insurance really doesn’t make a big difference.See below:

Adjusted Percentage of Recommended Care Received by Participants

P- value

Uninsured

53.7

Medicaid

54.9

0.50

Medicare

56.9

0.03

Managed Care

55.2

0.27

Private non-managed care

53.6

0.94

*From: Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, et al. Who Is at Greatest Risk for Receiving Poor-Quality Health Care? New England Journal of Medicine. 2006;354(11):1147-56. PubMed PMID: 16540615.

This, of course, begs the question: how can we be spending so much money and not doing better on cardiovascular disease management?  How can this be?  The knee-jerk reaction that I hear over and over again is to blame the patient – they are not compliant with their medications.  They don’t follow up.  They don’t understand their condition.  But these are weak excuses for a healthcare system that only pays when a patient visits a doctor’s office or an ER or a hospital.  We have a supply driven healthcare system because of a failure of imagination – we only seem to know how to pay for visits and medications and tests and procedures.

If we’re going to get healthcare to improve health, we have to seriously rethink the way we pay for it.  I don’t mean adding a 1% incentive to a doctor’s reimbursement for measuring blood glucose.  That doesn’t do much and is usually just insulting.  I mean adding incentives to make providers focus on managing patients’ health.  The problem right now is that no one gets paid if they figure out how to get patients to take their medications regularly.  No one gets paid to communicate more effectively with their patients or get them to quit smoking.  We don’t financially reward providers who improve health.  In fact, we punish them: because as people get healthier, they will have fewer visits, decreasing provider revenue.

This is more than a diatribe against fee-for-service.  It’s a diatribe against paying for healthcare. We need to find a way to pay for health.  Yes, it sounds naïve, but we have to start thinking outside the box if we want transformative changes rather than iterative ones.  For instance, what if we paid for better blood pressure control?  Instead of getting paid to measure every patient’s blood pressure (as many pay-for-performance schemes do), what if we paid for lowering blood pressure among those with severe hypertension?  Yes, there are issues of case-mix adjustment, but those are solvable.  For each one of us, the things that would improve our health surely vary.  What if the payment system could take patient preference into account, paying for things that we each individually valued as important to our health and well-being?  None of this is easy.  But we surely haven’t built this insanely complex and dysfunctional payment system because it’s the easiest way to pay for healthcare.  We got here despite ourselves.

My lesson from the Oregon experiment is that our system pours hundreds of billions of dollars into stuff, but pays little attention to whether any of that stuff is improving people’s health.  Adding more people to the insurance rolls –pouring more money into a low value healthcare system – isn’t going to improve people’s health.  Will it help the uninsured financially?  Sure.  Is providing financial security to poor Americans a good thing to do?  Absolutely.  No American should be one car accident away from bankruptcy.  But until we improve the underlying functioning of the healthcare delivery system, we shouldn’t expect any intervention that improves access to more healthcare services to have a meaningful effect on people’s health.

Ashish Jha is an associate professor of health policy and management, Harvard School of Public Health.  He blogs at An Ounce of Evidence and can be found on Twitter @ashishkjha.

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  • buzzkillerjsmith

    Dr. J. focuses a lot on the payment system, as if coming up with some magic formula would induce doctors to practice better preventive care. His analysis neglects perhaps the most important point: Those physicians, NPs, and PAs who in his opinion should have better incentives to do what he thinks it right–those persons do not exist in anything close to sufficient numbers to do the job. They’re doing something else, like procedural subspecialities.

    Say a proceduralist gets paid 150k more per year than a generalist. Is it really reasonable to expect that for a few thousand bucks or even a few tens of thousands of bucks per year we’ll get the primary labor force we need? The idea is risible. Yet he’s talking at micro-solutions like blood pressure control payments and risk adjustment, when these are mostly irrelevant to the main problem, which is that you can’t stuff 30 lbs of blood pressure pathology into a 10 lb sack.

    Trying to put up a tent without the poles, Dr. A.

    • charles_beauchamp

      The application of evidence-based chronotherapy (using self-protection instinct based motivational interviewing about when to take anti-hypertensives for 24 hour coverage) will result in a significant reduction in strokes, heart attacks, sudden death, onset of diabetes and occurrence of diabetes complications. Bet that was not done in the Oregon “experiment” that, to me, invalidates the conclusions about its effects on significant health outcomes. Sorry to say that very few physicians know the evidence concerning chronotherpay of hypertension, much less “translate” that knowledge into their treatment regimens.

      When done right with emphasis on its “self-protective effects” and coupled with reasonable continuity of care, evidence-based chronotherapy of hypertension can have enormous effects on cardiovascular and diabetes care outcomes.

      • Fred Ickenham

        Golly how puzzling: (translation-What a load of nonsensical jargon!! Like doctors don’t know how to treat hypertension! ) This is an example of the kind of bureaucratic pseudoscientific claptrap that policymakers apparently listen to! It seeks to blame the “providers”, and to disguise the fact that ultimately only patients can change their own behavior. The designers appear to intend this temporary experiment to fail, Voila!

        • charles_beauchamp

          You know how to treat hypertension so that it is 70% more effective in preventing strokes and heart attacks by using ACE-Inhibitors at bedtime and long acting (~24 hour+) diuretics as indapamide in the am AND consider this “nonsensical jargon”. OK, if you have hypertension and are not being treated at bedtime with at least one anti-hypertensive medication you might want to ask your doctor when ramipril was dosed in the HOPE trial and what were the results of three randomized controlled trials published in 2011 regarding dosing anti-hypertensives in the am versus at bedtime. It is very doubtful that 15% of physicians treating patients with anti-hypertensives have “translated” these RCT findings into their everyday practice. But then ago maybe you know the statistics about how well physicians know about “chronotherapy” and its effects on the hard core clinical outcomes of stroke, heart attack, sudden death, onset of diabetes, and onset of diabetes complications.

  • Elvish

    “”Adding more people to the insurance rolls –pouring more money into a low value healthcare system – isn’t going to improve people’s health””

    Let me get this right, if an uninsured diabetic becomes insured, even with minimal health care provided;this is not going to improve his health ? What about coronary artery disease , cerebrovascular disease, nephropathy, retinopathy complications ? because these complications are what`s going to get them blinded, limb-amputated, stroked or even dead.

    If your numbers are right, accurately measured and there is nothing wrong with the methodology, then maybe we are doing a bad job and were are not treating our patients properly ..

    The term ” People`s health ” is so vague here !

  • Dr. Drake Ramoray

    I agree with Buzz. That being said let’s use a real world example and see where the author takes it. We will go with diabetes and only look at A1c.

    I am an Endocrinologist. At one time I was working for a Multispecialty group in the poorest part my state. I was the only Endocrinologist in two entire counties. We participated in a state pilot program. Of the over 30 physicians I had the worst HgbA1cs of the entire practice (because I got everyone else’s non-compliant and/or complicated patients.

    What would your suggestion be for how I get paid. Worse than the primary care docs since my A1c is worse? I have two years of extra specialty training. Like another Endocrinologist in my state who practices in a more affluent area? If I was to work in a patient centered medical home, how would you make it so it was worthwhile for a practice to have me? All of the poorly controlled diabetics would be shunted to the PCMH that I am part of. Would that whole practice get paid less since they have decided to bring on an Endo instead of just trying to fly under the radar and accumulate only healthy patients?

    And lastly, if the major acheivement of the Oregon Study which is also simultaneously a avoiding bankruptcy why doesn’t anyone lobby for high deductible catastrophic plans.

    • mmer

      // Like another Endocrinologist in my state who practices in a more affluent area?//

      Yes, and if anything, caring for a more difficult patient population (by difficult I mean compliance, etc) should be compensated more heavily. You should most certainly not be financially punished for events completely beyond your control. One thing we talk about is making medicine more egalitarian, well, one way to approach this is to follow where the incentives lead (financial and otherwise) – does compensating a physician working with a more affluent patient population deserve to be compensated more for events that he has nothing to do with (aside from joining a practice in a specific geographic location). That logic sounds ridiculous.

      Also with an increasing focus on pay per performance, we have to look at what improvement means in the context of different patient populations. IE. How does compliance and other measures more outside of physician control (albeit he does have some in this area) stack up against socio-economic status and your patient population – and this isn’t a place to be PC.

      At the end of the day, compensation should hinge on matters we have most control over, incentives should be looked at within the context of specific patient populations, and we must look at the broader picture of what this all means within the context of creating a more egalitarian society, which medicine plays a pivotal role in.

      • Dr. Drake Ramoray

        I think that your plan for compensation is a utopia that will never exist. I can’t think of anything that pays better in rural areas compared to affluent areas and the cost of living tends to be much less. That part of the state has the worst levels of education, the worst paying jobs, and the worst schools in the whole state. The teachers there have worse pay, the city managers have worse pay, and retail employees have worse pay than their affluent community counterparts. So everyone there has worse pay but the physician who agrees to go there gets paid more than his physicians in affluent community counterparts?

        • buzzkillerjsmith

          I agree . I had a rural poverty practice in southern Oregon (sure know how to pick ‘em, don’t I ?)for a couple years before I wised up and got the hell out of there. Exceedingly nasty indeed, especially the night call for “unassigned patients. ” No hospitalists at that time.

          But you forgot are couple areas where rural areas are ahead: meth and prescription opioid abuse.

        • mmer

          Yes, perhaps I was a little overzealous there – let me rephrase in that I’m not saying he should necessarily get paid more, but that a more difficult to manage patient population should be tied to some sort of financial incentivization – and certainly physicians should not be punished for having a more difficult to manage patient population.

          Of course, other things play into this such as cost of living and the market forces which determine wage difference between rural and urban areas.

    • buzzkillerjsmith

      Hi Dr. D.

      Your example illustrates the complexity of how this stuff should be paid for and indded how care should be delivered. And you already know the skepticism we PCPs have about the Medical Home. The optimism that it induces makes no sense to me.

      At bottom, someone really needs to get into the guts of care, needs to actually go into physician offices and see what we do pt to pt. And that someone needs to go in with an open mind. Perhaps non-physician scientists. Political hacks will simply tell their masters what the masters want to hear.

      I have noticed no inclination to do this but the game seems to be rather to blunder into mandates that do more harm than good by neglecting unintended consequences. And then policy makers are shocked, shocked that their grand schemes do not improve care, save money, or make pts or doctors happy.

      This is no way to run a railroad. Yet given the current (and perhaps future) administration’s tendency to rely on grand schemes, I think we should gird ourselves for further foolishness. It would all be quite comical if it did not run the risk of ruining the American medical system.

      • Dr. Drake Ramoray

        There are definately scary times ahead. I actually still miss that practice. The people were so nice and well meaning. Definately some country bumpkins there but Im a small town kind of guy.

        I used to have a room that I would use for IV fluids and insulin for patients who would refuse to go to the hospital with dangerous levels of hyperglycemia. Quite a few people would be there for half a day. The reimbursement for that service was terrible (a level 5 visit and minimal supplies). That won’t happen with corp med. Need those ER charges and facility fees.

        Sad really. I had a pretty good thing going. I doubt they will find a replacment.

        • buzzkillerjsmith

          I doubt they will elther. I left a CorpMed practice in Minnesota (if you’ve never been there, don’t go) 10 years ago and they still haven’t replaced me and the other docs who subsequently left. Money left on the table at CorpMed.

  • mmer

    //we have to start thinking outside the box//

    Here’s a related thought –

    What does lowering rates of depression mean (as found in the Oregon Experiment – “This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years, but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain.”) in the context of lowering health care costs?

    From “Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence”:
    “the odds are 3 times greater that depressed patients will be noncompliant with medical treatment recommendations”

    From “Clinical and health services relationships between major depression, depressive symptoms, and general medical illness”:
    “Depression is also associated with an approximately 50% increase in
    medical costs of chronic medical illness, even after controlling for
    severity of physical illness. Increasing evidence suggests that both
    depressive symptoms and major depression may be associated with
    increased morbidity and mortality from such illnesses as diabetes and
    heart disease. The adverse effect of major depression on health habits, such as smoking, diet, over-eating, and sedentary lifestyle, its maladaptive effect on adherence to medical regimens, as well as direct adverse physiologic effects (i.e., decreased heart rate variability, increased adhesiveness of platelets) may explain this association with
    increased morbidity and mortality.”

    • Gus

      But were these patients actually diagnosed as clinically depressed, and then getting free healthcare cured them of that clinical depression, or was it more sort of a self-reported, “Yeah, I’m happier now that I get free stuff”?

  • AKK

    Despite the fact that the current reimbursement system doesn’t reward performance, I believe most physicians work very hard to help their patients have good health outcomes and genuinely want their patients to get healthy. But why is health their responsibility- shouldn’t it start and end with patients? The examples of health you listed above (quitting smoking, taking medications regularly, even lowering blood pressure) can be improved if the patient changes his or her behavior. Why do physicians suffer the consequences if patients don’t modify their behavior?

    • Guest

      I agree with you. My father’s long-time family doctor, for instance, is an incredibly caring and talented man, really you couldn’t wish for a better health care provider. But dad is 81 and he’s been smoking for over 60 years, and he just plain isn’t going to quit at this point in his life. He’s a grown-up, he’s made his decision, and that’s all there is to it. Why should his doctor be punished for that?

  • ninguem

    I agree, Medicaid/Oregon Health Plan is, at lest sometimes, useful for preventing MEDICAL BANKRUPTCY, even if not helping with overall health.

    One time, I had a rural resident, living alone in the country, getting by with odd jobs here and there, come into my office for the first time, with a visual field cut and hemineglect that made me very scared for a brain tumor. Sure enough, glioblastoma multiforme.

    Private neurosurgeons had this person on the table in about a day. I saw this person, I think Wednesday, MRI that day or the next, and the patient was on the operating table that weekend.

    Of course, prognosis is bad no matter what, with that tumor. Patient lived about two years.

    Oregon Health Plan has (had?) ways to get that uninsured patient, retroactively covered, backdated to the beginning of that month, and Medicare/Social Security fast-tracked the disability stuff.

    It prevented the medical bankruptcy of the patient…….not to mention the “medical bankruptcy” of a hospital asked to do state-of-the-art brain surgery for free.

  • Virginia Cusick

    Health care coverage doesn’t really matter if the doctors you
    are allowed to see are all uneducated Good Samaritan doctors. For 2 years I
    went to the Dr. regularly. A GS Dr. and her colleagues} due to pain in my groin
    and constant collapsing when I tried to stand or walk. After many MRI’S, CT
    scans & x-rays during that time by this group I was told over & over
    that my hips were in better shape than most folks my age, 56 at the time.

    After finally changing Dr.’s it was discovered {by ACCIDENT I
    was told as the Ct scan I had then was for soft tissue} I had bi-lateral AVN and
    needed both hips replaced immediately. This same Dr., a Gerontologist &
    Internist also told me that I didn’t have nerves in/along side my spine! Thank
    heavens I had a witness to all this on every visit.

    My hip has now been recalled, 16 months after getting it {and
    being in extreme pain around 8 months out} & I don’t trust anyone to touch
    me again so I will live in a wheelchair. Are patients ever contacted when there
    is a problem with an implant? Ha! The surgeon who did this was not even
    interested in talking to me or examining me. IF my AVN had been diagnosed in
    time I could have had a vein graft and fixed both hips easily, BUT, I had a GS
    Dr. and no one will let me out of this system. I will die w/o ever going back,
    I live in extreme pain 24/7 with both hips, my thighs, back & groin; I am no
    longer treated for my diabetes, lupus, MS, high bp, etc..

    I was also being given 1350 mgs of cholesterol meds at the
    same time and she added one more and my muscles froze & left me in a fetal
    position; at the hospital ER {GS} the Dr. wrote in my medical records that I was
    too stupid to know the difference in statin induced muscle pain & my MS. GS
    pharmacy in Corvallis, OR did NOT catch that I was being given an extreme dose
    of statins for several years. My Dr. asked me where I heard such an idiotic
    thing cuz statins don’t cause muscle problems! In my med records she wrote that
    I searched for that on the internet.

    For one hip replacement I was given versed {midazolam} but was
    never informed of the amnesia side effects, the rage, crying jags, paranoia,
    etc. and when I asked the surgeon why they didn’t inform me of the side effects
    that have caused an Alzheimer like condition that is permanent now, he patted
    the top of my head and said, “It’s not REAL Alzheimer’s cuz it was chemically
    caused!” I WAS an educated person, then dealing with complete aphasia, 3
    years of attacks of amnesia, crying and sobbing for days on end with no
    cause…3 years out and my amnesia is still here, grasping for words I used to
    know, names of plants I have grown for decades, friends names, memories of my
    only child now deceased 11 years and my only family.

    I also know 4 other people who were seriously injured at the
    hands of GS Dr.’s and hospital.

    IF anyone is actually interested in treating Alzheimer’s then
    they better start with removing this drug! It is causing Alzheimer’s by the
    thousands of patients every day & the Dr’s know it & do not care about
    all the ‘chemically caused” devastated people they are leaving in their
    wake. It IS time to hold someone responsible for care like this, as the patient, I don’t care who! When you get medical care like this poor excuse then you are wasting your & the taxpayers money and using us for guinea pigs.

    • ninguem

      And Samaritan owns everything in the area, two, three counties, so you have no choice.

  • katerinahurd

    Do you think that the concept of the uninsured has become synonymous with the concept of the unemployed? Physicians do treat at ER departments patients without asking about their insurance coverage. For these acute care patients who will restock the ER department supplies that have been depleted? What is the association of medical insurance companies and the medical industrial complex? If the underlying philosophical principle of utilitarianism is found in health policies why do you suggest that a group of severe hypertensive patients must be treated? Is it you opinion that the Oregon experiment demonstrated the failure of the business model of medicine?

  • AKMaineIac

    You cannot pay someone else for something which you, and only you, can provide to yourself. “Paying for health”? Like “paying for knowledge.

    You send them to school and they eat the books.

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