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Why Is Good Healthcare Policy So Hard? | UPenn LDI Director Dr. Rachel Werner
25 Plays23 days ago
Today's guest, Rachel Werner, is a physician, health economist, and Executive Director of Penn’s Institute of Health Economics whose work explores how healthcare policy can improve care without creating harmful unintended consequences.
In this episode, we discuss why public quality report cards can push providers to avoid high-risk patients. We examine why pay-for-performance often improves the metric being rewarded without meaningfully improving patient outcomes. We also explore the debate over nursing home staffing mandates and the evidence that stronger staffing requirements could save thousands of lives each year. Finally, we discuss why rigorous research does not always translate into policy, and what it takes to build a more evidence-informed healthcare system.
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Transcript
Introduction to Healthcare Theory Podcast
00:00:00
Speaker
Welcome to the Healthcare Theory Podcast. I'm your host, Nikhil Reddy, and every week we interview the entrepreneurs and thought leaders behind the future of healthcare care to see what's gone wrong with our system and how we can fix it.
Guest Introduction: Dr. Rachel Warner
00:00:15
Speaker
On today's episode of the Healthcare Theory, I'm joined by Dr. Rachel Warner, a physician and health economist, and now the executive director of Penn's Leonard Davis Institute of Health Economics, PennLDI, which is one of the largest institutes of health economics in the United States and Dr.
Unintended Consequences of Healthcare Policies
00:00:32
Speaker
Warner specifically has explored a fundamental question in healthcare policy, which is why do these policies that go through years of iteration and that actually improve care end up creating harmful unintended consequences? For example, in this episode, we discuss why public are report cards and paper performance often distorts provider behavior,
00:00:52
Speaker
how quality measurement can turn medicine into checking up checkboxes, and why nursing home staffing mandates actually kind of construe things that we don't want in healthcare. care
Dr. Warner's Academic Journey
00:01:01
Speaker
So we get into the nuances of why policy isn't so simple as a new rule.
00:01:05
Speaker
So thank you, Dr. Warner. thank So hi, Dr. Warner. Thank you for coming on today. I'm really excited to have you on. Thanks for having me. Yes, it's it's great to have you on. And i mean, you studied political science at Macalester and then um came to Penn in 94 for medical school, which I think is interesting. We've spoken to a few physician economists before, Dr. Jana at Harvard, Dr. Summers at Harvard. who both spin both of those lenses. And I think it's it's uncommon, but it's still getting and maybe getting more and more common.
00:01:35
Speaker
um But I'd love to hear from you. i mean, as a physician, you're already dealing with so much in medical school. And what specific moment or pattern or something you saw really drew you into health
Entering the World of Health Economics
00:01:45
Speaker
economics as a field? Like what made you realize that you needed to answer something yourself that you couldn't just be answered as a doctor? I mean, a PhD is a big commitment. So I'd love to hear what pulled you that way as ah to be a physician economist at the same time. Yes, absolutely. So um as you said, I studied political science as an undergrad and um then went to medical school. And i actually finished medical school. I didn't enroll in an MD-PhD program. I finished medical school and then did my residency in internal medicine. um But the the lens of the political science and social sciences more broadly um really made me curious about the way health care was delivered.
Impact of Transparency in Healthcare
00:02:19
Speaker
And as a resident um and working in the hospital,
00:02:22
Speaker
I got the chance to see firsthand a lot of the inefficiencies in the healthcare system and a lot of the challenges and delivering high quality healthcare care and so I really wanted to do more to understand. How the healthcare care system works and how to improve it, which led me to want to do research and then when I was looking at the options for research, I really was drawn to. economics as a lens because it provides a very, um to me, it was a very sensible way of trying to understand how the world works and a set of tools, empirical tools, to try and answer questions about how to make it better. And so I enrolled in a PhD program in health economics at that time. um
00:02:59
Speaker
And it was really motivated by trying to improve clinical care and care delivery. And then I think as I went through graduate school and learned more about healthcare delivery and health policy, some of those questions broadened to be more generally about healthcare markets, healthcare care payment, and those kinds of things.
00:03:20
Speaker
Yeah, there's so many different
Public Reporting and Healthcare Disparities
00:03:22
Speaker
verticals in healthcare. care I think it's interesting. i can understand that around around that time, there was this big push for transparency at the CMS level, which is very interesting. I mean, your PhD advisor, Dr. McPauly, you've had on before, um i read that he didn't ask for a single revision on your dissertation, which I think is somewhat unheard of and very difficult. So that's that's great to hear. But I want to get into this. I mean, you have the physician lens, you've you are doing internal medicine, and now you're trying to understand um how using empirical economic tools to understand clinical care delivery.
00:03:52
Speaker
I saw you a really interesting study in terms of understanding the role of like surgeons and hospitals and how you can make incentivize better choices on the physician and and and the institutional level within health care. And then one of them was with cardiac surgeons trying to see risk adjusted mortality with surgeries and seeing how that would change the way that things are done. And I would love to hear from you. I mean, now you had your PhD in economics and with this dissertation, what were the early questions you were trying to explore? um And especially with this study, could you try to walk through what you expected to find and what the data actually showed?
00:04:28
Speaker
um It's interesting because you think that transparency is inherently a good thing and it sounds like a good thing, but sometimes I guess I can work backwards a little bit,
Economic Incentives in Healthcare
00:04:35
Speaker
but I'd love to hear from you. what was the study like? Why did you explore it? and And what did it make you realize about healthcare care that you might not have expected?
00:04:41
Speaker
Yeah, well, let me give you a little bit of context, which is, as I said, i went through medical school and residency before doing my PhD. And one of the things when I was a medical student um and on a surgery rotation that I heard was from the surgeons who were very worried about what was then a new trend, which was the public reporting of quality information. And Pennsylvania, the state that I was training in or was in school in, um was a little bit ahead of the curve along with New York state in terms of publishing risk adjusted mortality rates for surgeons who were doing cardiac bypass surgery.
00:05:11
Speaker
And the idea there was that it's actually a lesson straight from economics. Kenneth Arrow, many years ago, decades ago, um described what we call it as asymmetric information. And so um patients, when they come to the doctor, have very little little information about the quality of care that they're receiving because it's hard to observe. It's difficult to understand. It's a technical field. Often things like cardiac surgery, you don't get repeated opportunities, hopefully, to have cardiac surgery. um And so it's hard to choose who the best surgeon is.
00:05:41
Speaker
And um the idea was that surgeons, therefore, um didn't have incentive necessarily to provide the highest quality of care or if they faced barriers that might prevent them from um providing high quality care. it was They didn't have the incentive to overcome
Challenges in Measuring Healthcare Quality
00:05:56
Speaker
those barriers. And so, um, uh, New York and Pennsylvania and later CMS started publicly publishing, risk adjusted mortality rates for surgeons. Surgeons, uh, as I started to tell the story, um, weren't, we're very worried about this in some ways. And what they were worried about was that they would be penalized for taking care of the sickest patients. So when patients are complex and very sick and they undergo emergent surgery or other kinds of high risk surgeries, they're more likely to have poor outcomes, more likely to die, more likely to have complications. um
00:06:31
Speaker
We try and you know level the playing field for surgeons when we publish these risk adjusted mortality by um making risk equal statistically using statistical methods across patients. But it's an imperfect method. Surgeons sort of realized that imperfect. And what I heard surgeons talk about when I was a medical student was that they ah didn't want to take care of the highest risk patients and they were no longer going to do it.
From Public Reporting to Pay for Performance
00:06:53
Speaker
um And actually some of the most junior surgeons were the ones that were um ah therefore being required to take care of the highest risk patients or the most emergent patients. And the patients that they described as being high risk, um it wasn't all about having you know poorly controlled diabetes or hypertension or being old or frail. It was had a lot to do with um what we now call social determinants of health or um um you know, social risk factors like um poverty, homelessness, drug use, things like that. um And so, you know, I saw firsthand that surgeons were worried about these and that surgeons were avoiding ah patients. And so by the time I got to grad school, um there was a lot more data available about how physicians were reacting to the public reporting of information, public reporting was growing and becoming much more common across a variety of different fields. And so I had the opportunity to study, um ah you know, use the data to really try to understand how much surgeons were avoiding highest risk patients. One of the members of my dissertation um was someone named Dan Kessler, who's an economist at Stanford, um had done some work before I started showing that
00:08:01
Speaker
um their surgeons were avoiding the highest risk patients. um The work I did in my dissertation was to try and understand like what signals surgeons were using or who exactly surgeons were trying to avoid. And specifically what I was interested in and was whether or not it had an adverse impact on disparities and access to
Debate on Nursing Home Staffing Mandates
00:08:21
Speaker
cardiac surgery. And so there's been many decades of Evidence showing that racial and ethnic minorities have forced access to care, worse quality of care. This was also true in cardiac surgery. um The question I wanted to answer as part of my dissertation was whether or not when this public when um these public report cards became available, did surgeons different? Did those disparities get worse? Did surgeons use race or ethnicity as a signal for risk um and um was access to care therefore worsened for racial and ethnic minorities. And the results show that they were, that um disparities, I was specifically studying New York state, disparities in New York state became worse for access to cardiac surgery compared to other states around New York that did not have public report cards at the same time.
00:09:07
Speaker
And so that was sort of the, my dissertation. and that was the beginning of, um, uh, a lot of the research I've done since then trying to look at economic incentives to try and improve quality of care.
00:09:19
Speaker
I think it's very interesting because I know with that study, cardiac bypass, the discrepancies change, but with other things that weren't directly created, like catheterization and geoplasty, you didn't see the same thing. So it's not like they just behavior changed across the board. It changed with regard to the metrics. So think that type of study design very much isolates that mechanism, which is interesting. I
Translating Research into Policy
00:09:39
Speaker
guess like a clear example is that um For example, if i went to school and my grades didn't matter, I'd probably take whatever classes I liked and I'd take any type of class. But my GPA was the only thing that mattered for grad school and PhD admissions.
00:09:50
Speaker
I might not take the hard classes that don't help me too much. um Whether I work harder in my classes, like probably, but I wouldn't take the hardest classes as often as I would otherwise. So I think you definitely would see that dynamic and and intuitively make sense. But I imagine back then, if you're at the economic level, it sounds like it, or ah at the policy level, it sounds like a good thing
Role of LDI in Evidence-Informed Policy
00:10:10
Speaker
whatsoever. And I think since then, we've seen and the past 20 years, like quality measurement has expanded. We have like um more systems for nursing homes, like five-star ratings for Medicare Advantage plans, kind of more variables in on terms of understanding good quality.
00:10:24
Speaker
So in terms of the impact of this study, do you think it... What was the discourse around it immediately after? And do you think when did it like disseminate into how we think about quality metrics today? I know you've had a lot of other studies that I want to get into, but what was the initial reaction to your dissertation in the field? Was it um what did that look like for you? Well, i think there were two things. One is that um
00:10:47
Speaker
I think that it demonstrated that we need to seriously consider or do ah rigorous evaluations of policy and of changes to healthcare care delivery. And that wasn't always routinely done. It was probably, you know, um data was at the time I was doing this study was becoming much more broadly available. Computing power was becoming much greater.
00:11:05
Speaker
you know not not like it it is today, but enabling a lot more of these kinds of large scale studies to
Engaging in Health Policy Conversations
00:11:10
Speaker
be done. And I think it demonstrated the value of doing rigorous studies, not just for new therapeutics, new devices, new drugs, but for new policies that affect very large portions of the population. um So that was one thing. And the other thing was it really highlighted the need to think specifically about the effect of these kinds of policies on disparities and whether or not they were helping disparities. And, you know, we can talk more about the specifics of why they might hurt disparities or why they might harm certain populations. But um
00:11:42
Speaker
uh you know at phase value it seems like public reporting should be a really great thing and it seemed seems like um it would it increases transparency it increases accountability and i actually think it is really valuable because it does do those things um but it's very hard to get these policies right and the people didn't i don't think quite anticipate the ah negative reactions or the average know the unanticipated reactions that um individual providers were going to have and so i think that it highlighted the need to think more seriously about how not to just improve quality, but at a minimum prevent worse negative disparities and even ah and you know a better goal would be to decrease disparities with these policies.
00:12:22
Speaker
And at the risk of being naive here, I think that with GPA, for example, back to my example, I mean, I wouldn't want to take the hardest classes, but one way to get around that is that your PhD program that you're applying to, the med school you apply to, mandates you take organic chemistry or something like that, right? And so you can, in theory, maybe the similar parallel with this is that you mandate physicians to see all types of patients or whoever comes in the door or nursing homes not to deny people and make sure they stay long-term. I know that was a study You had a little while after, but what was the issue or a kind of situation there? I mean, in theory, you can have quality metrics and still have them see the same patients if there's some enforcement mechanism. But I know everything's easier said than done. What did that look like? Why would that maybe it not have worked? Or do you think it could have but just wasn't implemented in the right way?
00:13:07
Speaker
Yeah, so it's really hard. As I said, it's really hard to design these policies to prevent the right way the first time, prevent any adverse consequences from them. And so I have done a variety of follow up studies, follow up studies looking at responses to quality incentives, including other report cards. One of them is in the nursing home setting. And there's some unique issues around measurement of nursing home quality, which is that we measure when people are discharged from the hospital to a nursing home for rehabilitation, rehabilitation their quality is measured on the 14th day, ah just because that is when we collect the data. and um
00:13:46
Speaker
one I did a study with one of my colleagues, Tamara Kneska, who's at the University of Chicago, um who and we we looked at this and we said, well, if people are going to do badly, maybe they're sending them back to the hospital on day 13 or day 12 before the quality measurement happens to try and improve their ratings.
00:14:05
Speaker
And so you know we have a lot of data. We're able to see patients going back and forth between hospital nursing home. And what we found was that there was actually a lot of um a bump in the number of people who were being discharged from the nursing home back to the hospital when they looked like they were doing poorly. And as a result, nursing homes were trying to gain their quality ringing ratings. And so it's just another example of um sometimes, even when we're we think that we've got great data and the nursing home data is actually really quite good, um we're still stuck with the way it's measured or when it's measured, which makes it really hard to, and and it you know, there's, if,
00:14:42
Speaker
there's the doors open a crack to try and um sort of gain these incentives or for providers to work around them, they will do it. And those are just the incentives that we set up. but I'm not suggesting that this is nefarious in some way or that providers are doing something they shouldn't be doing. This is they're responding to the incentives that we give them. But it does make it really, really hard to get this right.
00:15:02
Speaker
And i guess speaking from the perspective as you being a physician, I imagine you, I know you're still working with the hospitals um and as a pra practitioner today. So I guess during these studies, you would have had that perspective too.
00:15:14
Speaker
At the policy level, it seems like there was probably a lot of excitability. people were excited for this study. And then at the researcher level, maybe we realized there's some nuance, but for the physicians, what did this look like? Was there, um did they dislike these policy changes? Was transparency something they actively disliked or was it something they wanted more nuance on? What did that look like on the ground in hospitals and clinical care settings?
00:15:35
Speaker
What was their doctor doctor's reaction to this? I know empirically we've seen that it changes the way they make decisions, but what was the sentiment like at that level? Yeah, and so I practice at the VA, and mostly I do outpatient care in a primary care clinic. um And I will say that over the period of time when i first started seeing patients, there was a huge growth in the amount of emphasis on quality of care, and therefore in measurement of of quality. um And we as physicians at the VA were ranked on a lot of different things. metrics about how we were delivering care among our primary care patients. And I think one of the things that primary care physicians and probably physicians everywhere felt was a huge amount of fatigue, measurement fatigue around these um these measures. And so I think that we forget sometimes as researchers and as policymakers what it's like for the people who are providing care on the front line. But you know if you're being ranked against 20, 30, 40, 50 quality measures for every single patient you're seeing, it's hard to actually provide
00:16:35
Speaker
patient person-centered holistic care to patients. And instead what you end up doing is checking boxes. Did I check hemoglobin A1C? Did I check the blood pressure? Did I check their feet for ulcers? You know, have I screened for the 13 different things I need to screen for?
00:16:50
Speaker
And you can go through all those things and and forget to stop and say like, how are you doing? What's going on with your kids and things like that. and so I think that um we can, we measure what's easily measurable.
00:17:02
Speaker
There's ah actually a lot of things that are easily measurable, but what those um measures fail to sometimes capture is um the person who's at the center of it, which is the patient and how they're actually doing and what that relation, how that you know relationship with the healthcare care system is. And so um I um say that not to criticize the effort to improve quality or quality measures in general, but I think we do we are sort of facing a need to rethink how we're measuring quality and to focus more on patient outcomes and sort of more patient-centered metrics.
00:17:41
Speaker
Yeah, is it's funny to me in some ways, because like you would see this transparency of movement and it was exciting to a lot of people. And of course, um we realized with more rigorous understanding, realize it's not an object. There's some trade offs with any policy that you basically implement. But what's interesting to me is that the CMS still kind of went forward and the next logical step behind this was like pay for performance, um which is like just instead of now you can assign, you understand performance based off these quality metrics, so why not pay to incentivize them even more? so
00:18:12
Speaker
basically doubling the incentive and how strong that is. And hospitals was a really big area in which this took place because at the institutional level, I mean, a doctor paying them for performance could work. But at at a hospital level where hospitals are generally budget strapped or they're run by local municipalities, getting out of a budget deficit very important. So pay performance probably is likely also just as important. But in terms of that, now you have these quality metrics. like What did pay performance do? Did it amplify this effect?
00:18:41
Speaker
Did it misconstrued in some way? What did this look like at the hospital level? And how did your studies kind of come across these effects? Yeah, so um as you said, public reporting was sort of the first step in quality improvement. And actually, we we've talked about some of the documented unintended consequences of public reporting, ways in which it's gone wrong.
00:19:01
Speaker
At the same time, there wasn't a lot of evidence that it was really helping. people weren't Quality wasn't really improving in a meaningful way. um And so there was a move towards pay for performance, which was trying to add financial direct financial incentive to do the right thing at the right time. um And pay for performance, you the evidence around pay for performance generally um shows that it works better than public reporting on the measures it's tied to. So if I tell you I'm going to pay you more, if you check your diabetic, your patients with diabetes, their hemoglobin A1C regularly, you will check their hemoglobin A1Cs regularly. um,
00:19:39
Speaker
it um
00:19:43
Speaker
Despite that, it doesn't really improve patients outcomes. And so the likelihood of hospitalization um amputation, death, things like that, pay for performance has relatively little impact on that. um And it's um it's sort of subject to the same limitations that that public reporting is in that we can only measure what's easily measurable. Providers um end up focusing on what's being measured at the expense of what's not being measured. And so there's a lot of stuff that's outside of these specific metrics that I am mentioning um that get neglected. um And um
00:20:20
Speaker
it wasn't really the the sort of cure all solution that we, that people had hoped it might be. I think it works slightly better than public reporting in some settings, but not in all settings. And then it, because you're adding direct financial incentives, it also runs the risk of ah financially not harming providers who really need, um who you are resource strapped because they care for, you know, the safety net basically.
00:20:47
Speaker
Yeah, I read that there's this quote where any metric used, um if you if there's a metric used for too long, it ceases to be a good metric because people um it's not going to it's people start gaming it. And I think that happens in so many different ways. And it's it's pretty clear that it happens in healthcare care too.
00:21:05
Speaker
And I definitely agree with you. I don't think it's... um something malicious or something with bad intent. um yeah These are people who actually care about the patients. They go through 10 years of schooling just to um be able to help these people out. And a lot of people who run hospitals are likely um very socially driven too. But the issue is that at the end of the day, the things that we see immediately in front us is like what metrics we provided. And sometimes that does get misconstrued. It's it's not like an irrational, it's not like a active decision. um
00:21:36
Speaker
So, I mean, stepping back a little bit closer today, I know that there's been a lot of discourse in the field and the CMS has likely i luckily added some nuance to these reporting measures, but they still face the same trade-off where um Not every like every metric has a set of tradeoffs. There's no perfect one that will incentivize good behavior without incentivizing so some adverse effects, too, with it.
00:21:57
Speaker
But there was something interesting recently. i think in 2024 in June, Senator Elizabeth Warren um wrote to you and Norma Coe at LDI basically asking about a new federal rule at the CMS.
00:22:09
Speaker
um and about how like a minimum federal staffing rule how that would impact lives and from my understanding it was the idea that nursing homes should have like a minimal staffing but this was set to be repealed and I would love to hear about your analysis here and maybe some context too so what was the context behind the situation I want I'd love to get into your study and everything also but um to set the ground layer what was this about like why was minimum staffing important what does that really mean and what does that really mean, especially within the nursing home market and in relation to your past work? Yeah, so um a lot of the work I had been doing was related to nursing home, nursing home quality. Nursing home quality is not surprisingly very um tied to nursing home finances and how ah how much money they have to invest in quality improvement. um One of the most expensive parts of a nursing home but nursing home's budget is staffing levels. And so unlike hospitals or outpatient settings, staff in the nursing homes, you know, um
00:23:08
Speaker
nursing homes are places where people reside and many of them have limitations in their functional status and need a lot of help with getting out of bed, eating, showering, getting into ah you know into the dining hall, things like that. um And so it's a very staff intensive setting um and staff are can be very expensive. um and so And because staff are so important, the level the quality level of nursing homes is really It's been very well demonstrated that quality is um is tightly tied to the level of staffing.
00:23:39
Speaker
um As I said, staffing is expensive. Nursing homes have very slim margins. Some people will often tell you that they have negative they operate with negative margins, which I'm not sure is actually possible. But yeah ah they it does seem that they have low margins and that um historically nursing homes have been very understaffed. After the COVID pandemic, a lot of attention was on nursing homes because nursing homes were very hard hit during the COVID pandemic with a lot of deaths. um And there were recommendations um to to institute a federal standard for staffing levels within them the nursing home, which there had never really been a meaningful one before. and so The Biden administration, CMS under the Biden administration, proposed a standard, um which was to increase the level of ah staffing to sort of a moderate level across all states in the United—all nursing homes that receive Medicare and Medicaid funding. um
00:24:34
Speaker
When the mandate was um proposed, um there was immediate pushback, largely from the nursing home industry. And the concern was that they this was an unfunded mandate and they just weren't going to be able to afford to do this. As I said, nursing homes operate very slim margins. They had been really hard hit by the COVID pandemic. There were workforce shortages. There still are workforce shortages.
00:24:57
Speaker
And so nursing homes were like, there's no way we can do this and it's going to make us close. and So there was just a huge amount of lobbying to overturn this this mandate. And so Warren's office reached out to us to ask whether or not we could um estimate the health impacts of having this mandate in place or of not implementing this mandate. um There is very strong evidence, as I said, that when nursing homes increase their staffing levels, mortality within the nursing homes go down. And so we were able to sort of look at ah staffing levels across nursing homes in the U.S., estimate how much staffing levels would go up if the mandate was fully implemented, and then, you know, using simple math, estimate the number of lives that would be saved if that that mandate was fully implemented. um And what we found was, what we estimated was that there was, there would be 13,000 people a year whose lives, who would not die if the mandate was fully implemented, which was um a number that Warren and her staff found helpful in terms of when they were talking to other people in Congress about the importance of maintaining this mandate.
00:26:03
Speaker
This mandate has actually since been repealed um in the current administration. It was initially the um implementation of the mandate was delayed by 10 years under the One Big Beautiful Bill Act um to try and it was part of the the budget calculation for the CBO, was save the money by delaying the implementation. And then later, this just this spring, it was fully overturned. And so the mandate is now off the table. But there you know there was a lot of concern that if it had been implemented, it would harden harm nursing homes.
00:26:34
Speaker
Yeah, and I want to get into that mandate a little bit. um So we have one understanding that the mandate would most likely save lives at the order of 13,000. Because and it makes it does make simple sense. like You have more people helping patients out.
00:26:47
Speaker
um In theory, less patients with diabetes, better monitoring, better monitoring. intra-day care and that that would be very important but I guess I'm an even more interesting debate is whether like this should like whether nursing homes could survive this so obviously you have the argument from nursing homes that yes there are negative margins they won't be able to but you published an op-ed with in the New York Times basically arguing that these claims don't hold up.
00:27:11
Speaker
And i get that's that's really interesting because it does make intuitive sense. The nursing home argument does make sense. that I mean, they're already strained. You're getting more employees. That makes it more expensive. So they can't do it. But obviously, I think you did you did a study here that basically showed that if you raise staffing levels, yes, labor costs go up, but so does net patient revenue. And net patient revenue goes up higher than your labor costs, basically meaning you might be actually more profitable. Yeah.
00:27:36
Speaker
Yet, I mean, it was still repealed, but love to hear from this perspective. like How did you go about studying that? What did you realize? And and do you think they still had the same reaction? like What was the debates here? Because i imagine nursing homes weren't like, hey, okay, I agree with you now. Let's go hot. Let's do the mandate.
00:27:50
Speaker
So what was the pushback on this? like Did your evidence really change the way people think about it? or Well, i love to walk you walk me through the story. Yeah, well, so at this time when we were making it, we were estimating this 13,000 deaths for Warren's office, um it occurred to us that we could actually, and that we could actually also, ah there was enough data out there that we could estimate whether or not these mandates who were harmful to nursing homes themselves. And so there was no, as I said, there is has never been a federal mandate for nursing home levels at a reasonable level, but there, which left the, the,
00:28:24
Speaker
ah regulation of nursing home staffing levels to the states. And um there was a wide variety of ah variation across states in which states had mandates and which didn't have mandates and at what level they mandated um the nursing home staffing. And so we took advantage of that and gathered information across all 50 states in which states had mandates when they were implemented and then just studied what happened when these mandates were implemented across these states.
00:28:47
Speaker
um And so it turned we you know we looked over about a decade and a half. Over that period of time, there were 11 states that implemented new mandates, and we compared those states to states that didn't have a mandate that entire time um and found that, as you said,
00:29:01
Speaker
like Well, first of all, the mandates were effective at raising at increasing staffing levels, which is important because one of the things nursing homes said was like, this is never going to work. But these mandates did increase staffing levels, so that was good. um They increased labor costs, which is what you would expect. ah But as you said, they did they also increased net patient revenue.
00:29:19
Speaker
I don't know why they increased net patient revenue. The data we were using didn't really allow us to figure that out and we could speculate. But... The net result was that margins didn't change at all. And so not surprisingly, closures didn't change either. There were no more closures than in states that implemented mandates after the mandates were implemented than there were in other states.
00:29:39
Speaker
And so we thought this was great evidence that you know um all of those fears could be allayed and we could implement mandates. Yeah. put um The people who, we live in a little bit of an echo chamber, the people who believe that nursing home mandates are going to harm nursing homes continue to believe that nursing home mandates are going to harm nursing homes. um There was a lot of um you know i think the criticism of the study was that it's only it was only 11 states that implemented mandates, for one thing. um And it was a total of 22 states that we looked at. And so it wasn't the entire United States.
00:30:15
Speaker
We thought we were doing pretty well because we had almost half of the states in the study. um So I guess it's like a half-empty, half-full situation. The other thing that... um the advocates who opposed mandates said was that ah the study took place over the last decade and a half, as I said, starting in 2010.
00:30:36
Speaker
um And we are living in a different time now than we were in 2010 in terms of the workforce. And that is true. And actually, if you look at our data, and we we said this in the paper, the mandates that were implemented after COVID-19 occurred were less effective at increasing staffing levels because the staff just don't seem to be available right now. And that's a real problem that can be addressed through other mechanisms. That is not a problem of mandates. It's a problem of the way we weigh and how much we pay staff in nursing homes. um But um I don't know. I think the short answer is we didn't convince anybody that we were right other than ourselves.
00:31:11
Speaker
Yeah, I'd love to. And I'd love to get into that. i mean, so far in the episode, you've established a couple of things like not all metrics are great metrics. They might incentivize what you're trying to incentivize, but they also might have adverse incentives, too.
00:31:22
Speaker
And we've also I think this is a very interesting case study in the nursing homes that you can have great research, but that doesn't always mean. it'll translate directly into policy. I mean, we've seen this in so many other disciplines, but so maybe it's unsurprising to see it in healthcare, care but it's a little bit unfortunate too. But now you're running one of the oldest and largest health economics institutes in the country.
00:31:42
Speaker
i think LDI has been around since the 60s. So, i mean, hundreds of people are spending medicine, warden, um nursing law, I mean, all of these different areas. And I think I would love to get your perspective. And more and more, I feel like I'm seeing that it's harder for policy to or sorry economic research to translate into policy.
00:32:00
Speaker
um Do you see this tension or do you think it's something that's always been there, something that maybe it's more recent? I know we have a new administration that's changing the way things are done a little bit. But um to what extent do you see this translatability between policy?
00:32:14
Speaker
research and and policy, do what what does that look like for you as someone who's seeing all the work that Ordon's been producing within healthcare care economics? Yeah, um I mean, think this is an important question, and I don't have a great answer to it.
00:32:27
Speaker
so I think that um LDI for me, one of its main, um the the most important part of its mission is to take evidence and translate it for policymakers um and to try and create what we call evidence informed policy, because I think otherwise we're just we're just throwing darts with our eyes closed. And there is a lot of evidence and we should be using it to make the system better. um I think that.
00:32:52
Speaker
um ah people have always had the ability to look at the same set of information and the same results and come to different conclusions. And what I described related to nursing home mandates is really just an example of that. Like I look at that data and that the research and I say that's pretty high quality research. I mean, I did it myself. So I think that, you know, it's a lot of states. It's a lot of data we used, I think, rigorous methods. Other people look at it and say that's it's out of date and it only covers half of the country. I think the important part is then being able to come together and have a conversation about where we're, where we agree, where we disagree and how we can get to a better solution. I think that's the part that we're missing. When I said we're living in an echo chamber, i mean, literally people are not talking to each other.
00:33:37
Speaker
Part of what I've tried to accomplish at LDI is we have a lot of public facing events where we bring people together to discuss important health policy issues of the day and have increasingly tried to make sure that we have ah people representing a wide variety of views who want to engage in a conversation and see where the agreements are, where the disagreements are, and how we can make some progress. Because I think people do, there are lots of people who want to do that. Some of them even want to do it in a public forum. um But I think that demonstrating the value of those kinds of conversations and how we can use evidence to to help inform our thinking um And that is sometimes okay to disagree and how we interpret that evidence, but also even when we disagree, it helps me ah be more precise and more clear about what what my thinking is and why I think the evidence should be interpreted in in a specific way. And so these conversations I think are super important
00:34:26
Speaker
And we, I think, have been tend to shy away from, you know, unfortunately, sometimes tend to shy away from them because they can be difficult and we don't live right now in a time that embraces uncertainty and disagreement. But I think that because of that is more important than ever.
00:34:43
Speaker
I definitely agree. It's you can have the best research study ever and it influences nobody. And you can have the most terribly designed study in the world and it could change the way a million people think about the world. i mean, you see things all the time like this study says this and it's just not a regular study at all. So I think the important thing is having conversations and also.
00:35:04
Speaker
um I think opening up the doors to like how academic research is done is going to be important because people see a researcher can mean so many different things, but to understand what are these methods that people are using, why are they rigorous is is is very important. I think that um we're seeing a new generation, at least my generation, seems to care more um about health care more and more. But at the same time,
00:35:28
Speaker
academic literacy is probably getting harder and harder at a more universal level. So we're seeing those tensions, but I'm very excited to see what LDI produces in the future. I mean, it's been kind of a staple here. We've had a few great guests on in the past, so it's been really great. I really appreciate you coming on, kind of walking through your story, but also, i mean, there's so many interesting policy things that are um policy decisions that are going on relation to your research. So I'm excited to see where that goes and also where your research goes in the future. So thank you. Thank you again for coming on. Yeah, it's been a fun conversation. i appreciate it.
00:36:00
Speaker
Thanks for listening to The Healthcare Theory. Every Tuesday, expect a new episode on the platform of your choice. You can find us on Spotify, Apple Music, YouTube, any streaming platform you can imagine. We'll also be posting more short-form educational content on Instagram and TikTok.
00:36:17
Speaker
And if you really want to learn more about what's gone wrong with healthcare care and how you can help, check out our blog at thehealthcaretheory.org. Repeat, thehealthcaretheory.org. Again, i appreciate you tuning in and I hope to see you again soon.