America’s Healthcare Improvement Prescription: What Gets Measured, Gets Done!
On November 17 and 18 in Cambridge, MA, J-PAL (the Abdul Latif Poverty Action Lab) North America presented some 200 researchers, practitioners and policy makers the problem: Can Innovative Health Care Reduce Poverty?
The U.S. can use all the ingenuity it can find in battling in its two intertwined and seemingly intractable problems – poverty and the U.S. medical system; ironically, a patchwork of approaches that depletes the savings of its citizens and leads to 60% of all personal bankruptcies.
“We do know that when researchers and government work together, the results can be powerful. But, how do we know what works?” asks Quentin Palfrey, J-PAL’s North America Executive Director. “And, what is its impact?”
Those are exactly the questions we are asking ourselves at our charity, RIP Medical Debt, having been invited to the conference through the aegis of MIT grad student Ray Kluender who is developing a study of the economic impact of medical debt forgiveness in tandem with his counterpart Francis Wong of UC Berkeley, both of their respective Economics Departments.
“We felt our teaming together was that important,” Ray says. “And, we knew that combining the powerful resources of both schools could only improve the results of any study,” Francis adds.
RIP is receiving academic and policymaker attention because our work may address – and even answer – stubborn questions. How can quality healthcare be provided at a cost that invites its use without bankrupting the patient, the providers and even our federal government?
Could RIP’s unusual mission, that of locating, buying and abolishing unpaid personal medical debt, be a “social determinant” that will positively affect health outcomes? Could our task of also removing this debt from credit reports provide salutary benefits for vulnerable populations?
We think so, but no amount of personal stories and letters of thanks will do when research and investment dollars are at stake. Perhaps J-PAL, which supports randomized evaluations of strategies that aim to improve the effectiveness and efficiency of health care, might provide the critical analytics to support our role in this battle. Would our innovations to be quantifiable enough to satisfy the standards set by famous business consultant, Peter Drucker?
What we learned at J-PAL is that rigorous tools to supply the evidence to prove our case are plentiful. And, that their use along with rigorous research will be essential to authenticating RIP’s unusual “out-of-the-box” approach.
Randomly Controlled Trials (RCT’s)
The essence of an RCT is that it aims to reduce bias in studies. Considered the “gold standard” when it comes to clinical trials, it will be put to the test in determining statistically relevant evidence when comparing RIP’s population of forgiven debtors against an equivalent population yet to be reached by us.
One important example of how RCT’s are important to the process of health care delivery was found in a presentation by Professor Wesley Yin of UCLA: “Engaging the uninsured and demystifying health insurance decisions.”
California was the first state to set up a health insurance marketplace in 2010 when Governor Arnold Schwarzenegger signed the bill into law. Its challenge lay in educating 1.5 million Californians to choose wisely among the plans offered. Which is where the statistical analysis came in – some $37 million in grants to 48 organizations invested to both improve and support the project.
“Letters in Spanish and English were sent to carefully selected population segments stratified by income, race and language,” Professor Yin describes. This letter, basically a reminder to enroll, included carefully described and illustrated price comparisons and explanation of subsidies vs. penalties (the classic carrot/stick).
Where “Big Data” comes in
TheNumber will design and implement the data underpinnings of the system that will enable universities access to anonymized data for their research. These secure data panels – the before/during/after data points – are measurable outcomes of the work and is essential for the random controlled trials (the gold standard of research methodologies) being designed by MIT, UC Berkeley and the University of Chicago and evaluated by J-PAL.
TheNumber is also working with RIP to develop Internet platforms to allow donors to locate the most needy, along with their geography and/or particular affiliation. As example, this allows donors to focus on abolishing medical debt by disease first-responder status.
“We have limited resources at this point,” says Craig Antico, CEO of RIP. “TheNumber enables us to prioritize and give our benefactors greater bang for their dollars.”
“What excites us about working with RIP Medical Debt is that their intentions mirror our own – to apply socially-conscious centered approaches which can employ Big Data to help people make better financial decisions. And, on the creditor side, give good reason for adjusting payments when an individual’s economic picture has changed – and do that in real-time,” describes Guhan Kandasamy, CEO of TheNumber.
Applying the keen eye of Philanthropy
Who pays for all this?
Certainly, a lot of investment in time and money comes from the J-PAL organization, from the economics departments of the schools involved, and from the technology partners who have both a responsible corporate citizen stake as well as potentially beneficial commercial realization at some future point.
Philanthropic institutions, family foundations and corporate sponsors also find this work of importance. One of the conference goals – which we believe RIP helped realize – was to explore “key unexplored issues” in U.S. health care delivery.
Nothing is less explored, up to this point, than the social/political/economic impact of unpaid and unpayable medical debt – and the need for innovative remedies such as found in RIP’s work.
The bottom line is that it takes money to fund studies of this sort. That subject was addressed by Dr. Katherine Hempstead, Senior Advisor at the Robert Wood Johnson Foundation in her talk: “The Role of Evidence in a New Era of Health Care Policy.”
“Our foundation funds a lot of analyses,” she tells the audience, “but the real challenge for the funder is determining the impact of these programs. What is the effect of high deductibles? Medical debt? How is wellness impacted in the workplace, and what will be the role of telehealth?”
“I am here to collect ideas,” she ends.
I trust she came away with a bushel full.