Aaron Schwartz
@A_Schwa
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MD-PhD professing @PennMEHP , @PennDGIMProud . West Philly VA PCP. Tweeting on health, economics, and health economics.
Philadelphia, PA
Joined January 2012
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Pinned Tweet
What will happen to Medicare Advantage enrollment if payments to MA plans fall? Our latest paper looks at ACA reforms for clues. (1/5)
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One of my COVID patients, a young woman, miraculously survived weeks on a ventilator, ECMO, and a catastrophic bleed.
After days of delirium, her mind cleared and she could speak for the first time in a month.
"I want to tell everyone," she said to me, "Stay the f*** at home."
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The strangest case of my primary care career began with an electronic patient request.
I get these a lot. 99% are med refills, forms, or questions about symptoms. This was different. My patient felt fine. But, he was worried he’d be sent to jail…
1/13
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(Shared with her permission, on the condition that I include the expletive).
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I’m very pleased that my patient enthusiastically agreed for me to share the details of this case, which appears in this issue of the
@NEJM
. 11/13
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I have COVID and a 5-day exclusion from hospital. My asymptomatic doctor spouse has no hospital exclusion. Asymptomatic toddler has 10-day daycare exclusion.
Planning work/childcare now like that riddle where you have to cross a river with a fox, a chicken and a sack of grain.
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During yesterday’s 9-hour in service exam, 📱💻📚 were strictly forbidden.
Diagnosing and treating illness in 2018 without 📱💻📚is basically malpractice.
IMO, the boards are fossils, teach doctors malpractice, and need to be radically overhauled.
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After a day at room temperature, we tested the same urine again for alcohol. This time, the test was positive.
Microbes + sugar + time = alcohol.
The culprit (I think) was microbial fermentation! 7/13
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Wow, what a response. I'll use the platform to promote the
@GiveDirectly
COVID response. Consider donating if able and interested.
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Obviously, this was unusual. And puzzling. This guy had been on the right track; we had just made so much progress with his diabetes. What was going on?
I had him come to our lab. There, his urine had no alcohol in it, and no ethyl glucuronide (an alcohol metabolite). 3/13
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The same process that turns grape juice into wine turned this patient’s sugary urine into a urine cocktail.
Urine fermentation isn’t a new phenomenon. In 1868, fermentation was proposed as a method to estimate the amount of sugar in diabetic urine. 8/13
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They say being a professor is hard but honestly the job is mostly just two-factor authentication and resetting passwords.
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My favorite turn of phrase this time of year: “Today you have a cold. If I give you an antibiotic you will have a cold and diarrhea.”
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Case studies have noted rare false positive tests for urine alcohol in patients with diabetes. But, historically, patients only had sugary urine if their disease was poorly treated. The SGLT2i medications, like the one my patient was taking, make urine sugary all the time. 9/13
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These medications are widely used, in diabetes, kidney, and heart disease. Urine toxicology testing is also common, especially for patients with substance use disorder or chronic pain. So, these drugs might expose many patients to the risk of a false positive. 10/13
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I called him and he explained. He was worried about an upcoming court date. Why? He was subject to urine testing at a probation/parole office. The last 4 tests had been positive for alcohol. But he hadn’t been drinking. 2/13
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@NEJM
PS- Many thanks to the doctors who provided comments on this case, including
@PaulNWilliamz
,
@kidney_boy
, Jeffrey Petersen, John Samuelson,
@paulsaxmd
,
@especially_APT
,
@AlexanderMcAda5
,
@BenMazer
,
@ChatterjeePaula
, and
@jastefely
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Hmm. Months ago I prescribed this patient empagliflozin (Jardiance) for diabetes.
High blood sugar levels are toxic (to eyes, kidneys, heart etc). So, treating diabetes is a game of hiding sugar from the blood, e.g. insulin hides sugar in cells. Empag hides sugar in urine. 5/13
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Indeed, when we tested his urine, it was full of sugar, despite normal blood sugar levels. This can attract microbes. I had our lab test the urine for bacteria. Yes, there were bacteria.
I also had them remove the urine from the fridge... 6/13
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If you think all internal medicine docs should memorize gene translocations for tumors or rheum autoantibody names, your priorities are way off.
A culture of memorization rather than a culture of fact-checking will harm patients in the end.
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I called the parole office and spoke to the person in charge or urine collections. I asked:
Did they test the urine on site? “No.”
How often did they send the urine off to a lab for testing? “Once a day.”
Did they refrigerate the urine prior to transport? “No.” 4/13
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Minutes ago, I finished 28 years education and training.
Gratitude is the feeling of the moment.
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I received several emails about this case. One came from a young attending cardiologist at a very prestigious hospital. I've never met this doctor.
He asked, "how did you possibly find time and mental bandwidth to investigate and write up this case?"...
The strangest case of my primary care career began with an electronic patient request.
I get these a lot. 99% are med refills, forms, or questions about symptoms. This was different. My patient felt fine. But, he was worried he’d be sent to jail…
1/13
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Wow. Study suggests mergers in dialysis industry increase mortality 1-3% and hospitalizations 4%, decrease transplant listing 8.5%. Also, 130% more EPO.
This is a clearly written study with an accessible research design. I hope it is widely discussed outside of econ academia.
Recently accepted by
#QJE
: “How Acquisitions Affect Firm Behavior and Performance: Evidence from the Dialysis Industry,” by Eliason (
@PaulEliason2
), Heebsh (
@benjaminheebsh
), McDevitt (
@ryanmcdevitt
), and Roberts:
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🚨🚨New Paper Alert🚨🚨
Private health insurers have very different medical necessity policies than Medicare.
25% of Medicare Part B spending would require prior authorization under a private insurer's coverage rules.
THREAD. (1/10)
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So much depends
upon
a paper patient
list
scribbled with check
boxes
folded in a white
pocket.
#internship
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A family member had sniffles this morning. Rapid home test positive for COVID. Got nirmatrelvir/ritonavir (paxlovid) pills from a Walgreens in the evening.
We are getting better at this.
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Check out what
@sherrirose
is doing as a journal editor to improve the culture of academia.
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Econ twitter: "Here's a 100-page working paper full of dazzling creativity and sophistication"
Also econ twitter: "Any day now, we'll figure out what the heck a regression does."
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🚨Accepted Paper, coming to
@AJHE_journal
. 🚨
The topic is performance metrics in policy settings like health and education.
This paper, a saga, has been very important to me. So, I’ll be tweeting the heck out of it.
1st, a policy-focused THREAD (1/11)
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“My dad lived to be 104. So instead of talking about my retirement I’m going to be announcing my research plan for the next 24 years”- Mark Pauly
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What happens when you make cardiac drugs free to heart attack patients? Stratifying the results by race makes for some dramatic graphs:
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.
@FranciscoMarty_
may be the hardest-working doc
@BrighamWomens
during this pandemic. He's walking the wards all hours of day and night, constantly enrolling patients in COVID clinical trials.
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Here's our new study on the effects of Medicare Advantage versus Traditional Medicare on utilization and spending, out today in
@JAMAHealthForum
(1/9)
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Today I became both an MD and a GIF. Thanks
@harvardmed
!
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A friend quipped we should be calling them “tax-exempt health systems” rather than “non-profit health systems” to avoid confusion.
New: A non-profit health system brings in $4 billion each year.
It denies care to patients with too much medical debt. The policy means that poor patients and kids, some just 3 years old, are turned away because of outstanding bills. With
@jbsgreenberg
:
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To be clear, I support rigorous quality standards for MDs, and content knowledge should be an important element of those standards (especially when it comes to managing acute conditions). But, it is alarming how far we are from optimally testing core competencies.
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What does a 1993 paper on the theory of economic development have to do with failed interventions for complex medical patients? A brief thread (1/7)
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Just finished my first lecture for the first class I am teaching as a professor. Feeling great.
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This year, the syllabus for Joe Newhouse's Masters-level course in the economics of health policy was 195 pages.
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I get many inquiries from college students seeking advice about whether to pursue combined MD/PhD training in the social sciences.
This thread, which I will add to periodically, summarizes the advice I tend to give. 🧵 (1/ ?)
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Silver lining: The controversy about annual well visits will subside once we classify everyone as unwell.
BREAKING: New guidelines classify nearly half of U.S. adults as having high blood pressure.
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"Is U.S. health care efficient?" is not a very tractable research question. So, researchers tend to ask one of the following four questions instead: (1/5)
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Congrats to new
@nberpubs
faculty research fellow
@atheendar
, scholar-mensch extraordinaire!
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Jacob's talk made me remember this warning from Joe Newhouse's Masters health econ course slides. It was followed by 140 slides on Medicaid.
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It was my first time leading an inpatient medical service as a resident. The patient had a lactate of 10.* I didn’t know why.
*for non-clinical folks, this is very, very bad.
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Notable feature of HMS match list: Nine Harvard med students matched into general surgery. Seven are women.
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If this paper interests you, have I got some news for you. Some of the largest health care providers have eliminated 100% of the profits from their books. AND they don’t pay taxes.
🚨New
@nberpubs
with
@andrewolenski
on major hidden profits in the healthcare sector! Bear with me as I explain how nursing homes are able to hide almost 2/3 of their profits from regulators and the public! I promise it's worth it!
🧵1/17
Paper:
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Thrilled to say I'll be joining Brigham and Women's for internal med / primary care residency! Thanks to all you taxpayers for subsidizing.
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@PortiaCornell
As the saying goes- sleep when the baby is sleeping, clean when the baby is cleaning.
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First question for my students when discussing the work of
@jenniferdoleac
and
@lukestein
today: "Who can tell me what they are holding here?"
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Help build my health economics syllabus? I'm looking for readings for a class session focused on equity. The ideal reading would address utilitarianism and its limits. Bonus points if it is by an economist, is non-technical, and discusses health applications.
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Covid milestones I’ll remember:
-Meeting my 1st patient with covid. He died before I entered his room.
-Discharging a grateful post-ECMO patient.
-Seeing my family members survive covid.
-Getting my first vaccine dose in my arm (minutes ago).
Feeling hopeful & grateful.
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First that Science paper showed that Epstein-Barr virus causes MS.
Now, new evidence that varicella zoster virus could cause dementia.
I have a feeling we will be learning a lot more about viruses and the brain in the coming years.
It does! We estimate that over a 7-year follow-up period, getting vaccinated averts one in five new dementia diagnoses. In the paper, we demonstrate through extensive robustness checks that it is essentially impossible that this finding is due to confounding.
8/
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People underestimate how much power they have to shape their jobs and daily lives (especially people with enormous human capital like academic cardiologists at prestigious institutions). If you feel like a cog, then you can make changes in your situation.
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Want to learn more about health insurers’ coverage policies?
In this paper, we studied all the claims denied by a large insurer for medical necessity reasons. We look at differences in denials due to govt and private insurer rules.
1/5
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Just saw an observational cohort study in a medical journal that called itself a “hypothetical randomized trial”.
Come on. Let’s stop this nonsense.
Otherwise, I need to expand my CV to include all the award/honors/publications I hypothetically received.
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He noted that the case "harkens to the aspirational idea of physicians as thoughtful detectives helping their patients - rather than cogs in the wheel of medical care." I found it compelling/depressing that such an extremely accomplished academic cardiologist felt like a "cog".
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On the loan forgiveness debate, consider the following.
According to the AMA, nearly 80% of 2020 med school graduates planned to pursue loan forgiveness via the PSLF program.
And according to
@GottliebEcon
et al....
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“Your paper was accepted at the Annual Health Econometrics Workshop” 🙂
“A discussant will present your paper for 30 minutes” 🤔
”Your discussant is legendary econometrician Bill Greene” 🤩
Feeling thankful for Bill & for a great experience.
Consider submitting next year!
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Is a false positive urine alcohol test "really a harm? or more of an inconvenience?"
Here's another case in
@AnnalsofIM
from 2020 (no SGLT2i involved). The patient was being kept off the liver transplant list.
Social harms are real harms.
Very interesting case. I noticed that the word "harm" was mentioned a few times in the text... Was it really harm? Or more of an inconvenience... ?
SGLT2 Inhibitors and False Positive Toxicology Tests
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This is really bad. Incredibly expensive VRDC access cannot be the only way to access CMS data.
My dissertation would not have happened if not for physical CMS data at Harvard and NBER. So many great dissertations wouldn't have happened.
CC:
@AcademyHealth
@ashecon
Just got the email from
@CMSGov
that they are planning to discontinue physical access to the Medicare/Medicaid research files and force everyone to use the (incredibly expensive) VRDC. In the transition, they'll charge physical data users $10K/year to renew DUAs. This is bad.
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We've lost Kenneth Arrow, author of the most influential paper in health economics. You can give it a read here.
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TFW you submit a complete manuscript review in <4 days for a journal that took 5+ months for your last initial decision.
#bethechangeyouwishtoseeintheworld
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When hospitals buy physician practices, the prices for those docs’ services go way up, according to ongoing work by
@stuartcraig
and colleagues.
#ASHEcon2023
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Great advice I just heard on maintaining sanity around brilliant colleagues: "Don't compare your insides to someone else's outsides"
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The Pepsi halftime show was very Pepsi. As in “we don’t have Beyoncé but we do have Maroon 5. Is Maroon 5 ok?”
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“The Imperfect Science of Evaluating Performance: How Bad and Who Cares?”
Writing this
@AnnalsofIM
editorial with
@rm_werner
@PennLDI
was a LOT of fun. Here’s a sample…* (1/8)
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Will avoid twitter sulking, but suffice to say that COVID hospital care and its necessities (isolating from family, etc.) can be quite draining. If there are health care workers in your life, I bet they would appreciate whatever words of support you have.
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Covid daycare closure for second week in a row. Pardon my complaint, but this tweet is my main coping mechanism.
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Clinical trial participation lacks diversity.
Unfortunately, fixing this problem may not meaningfully improve biomedical knowledge about underrepresented groups.
But, there are still very important reasons to boost trial diversity: fairness and trust.
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Do insurers often deny claims on the grounds that the services are not "reasonable and necessary"? Do private Medicare Advantage insurers have more/different medical necessity criteria than government Medicare? Find out in our new
@Health_Affairs
paper.
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I am so incredibly grateful that vaccination will allow me to celebrate Passover with family.
I may never see the Red Sea part. But, seeing the rapid invention and distribution of Covid vaccines comes pretty close.
Chag sameach.
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It feels really good to discharge patients from month-long COVID hospitalizations.
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New paper
@bmj_latest
w/
@rgupta729
, Fein and Newhouse. We compared prior authorization rules across Medicare Advantage plans.
Part B services and drugs (especially) face lots of PA, with lots of variation across plans.
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Wow I've never before seen a study like this: a field experiment with fake patients getting real recommendations for wasteful care.
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This is a study on "removal of financial incentives" from medical care.
At the risk of sounding pedantic, I'll say this: Financial incentives cannot be "removed" from medical care. They can only be modified. No payment system is without incentives. (1/2)
Special Article: Quality of Care in the United Kingdom after Removal of Financial Incentives
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I'm halfway through studying practice questions for my medical board exams. The last practice question was about indications for mepolizumab vs omalizumab, two drugs I've never heard of.
Still no questions on opioid use disorder yet.
Medical education could be so much better.
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Colchicine, a common gout drug, is centuries old
After doing a 1-week trial (n = 185), a drug manufacturer gets 3 years of US market exclusivity
After FDA removes all competitors, price goes up 16x.
Much of health policy is about tough tradeoffs. This is a counterexample.
Hi all! Wanted to share a 🧵 on a new paper; this one published in
@JAMAInternalMed
. We examine what happens when your previously generic medication has a 🚨16-fold🚨 price increase.
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During early COVID, he was the hardest working doctor in the hospital, continuously present, smile on his face.
Many are reeling at this loss. He had a rare combination of brilliance and and devotion. Rarer still, he also exuded such joy in practicing medicine.
Today we mourn the loss of Dr. Francisco Marty, a brilliant clinician, clinical researcher, teacher and photographer. He taught us so much. My heart just breaks.
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Big labor policy news.
Non-competes in medical practice are a big issue. Interested to see where this goes.
1. One in five US workers is bound by a noncompete clause, which restricts them from freely switching jobs, lowering wages and undermining fair competition.
Today
@FTC
proposed a rule to prohibit firms from imposing noncompete clauses on their workers.
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@MaxJordan_N
I really admire this tweet, in style and substance. It's so difficult to publicly talk about these experiences from clinical training and practice. Ultimately I decided not to tweet about them. I'm glad you have figured out a way to do so.
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Full text is here.
In his Class Day speech, HMS graduate Aaron Schwartz spoke of transforming successes into a life in medicine
#HarvardMed17
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Metrics-oriented folks: I’m looking for papers on using Lasso or ML approaches to select controls (i.e. included instruments) for IV. Bonus if it covers the special case of RD. I know Gilchrist and Sands JPE. Other suggestions?
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Getting to a high-value health system will require refocusing from high-cost patients to low-value services.
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PS- It was a particular privilege to collaborate with Joseph P. Newhouse on this study. Keep an eye on this guy. I predict great things for him in the field of health policy.
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@mattkahn1966
This is a confusing tweet to me. Top schools of public health tend to have economists on faculty who teach health economics. Many public health schools even have doctoral programs in health economics.
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Feeling spent and happy with ASHEcon in the books. Presented 1 paper and discussed 3. Met collaborators for the first time. Caught up with old friends and mentors. Thought hard. I was very impressed by the quality of presentations, especially from PhD students. And what an arch!
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Metrics/stats twitter: I'm seeking intuition for a puzzling aspect of Cox hazard models, nowadays the main method for assessing medical treatment effectiveness in trials.
Adjusting for covariates doesn't improve power in balanced experiments. Why?
(Formula from Stata manual)
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This AcademyHealth
#ARM23
, my coauthors and I are presenting three studies on Medicare Advantage. Interested in this market? Stop by our talks...
1) "Growth of Medicare Advantage after Benchmark Payment Reductions" Saturday 12:30 602-604
...
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In the spirit of all the grad school advice floating around:
If you or your students are thinking about pursuing MD-PhD training in health economics or health policy research, I would be happy to provide advice. Email me and we can set up a time to talk.
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"Is Good Research Worth It?" by
@MaryalineC
, is so fascinating, I'm pausing my twitter break to tweet about it. She checked the quality of 23k drug RCTs & found 1) lots of bad methods 2) bad methods predict positive results, 3) bad methods predict low paper impact 1/n
#ASHEcon19
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“So what are you studying in your clinical trials?”
Oncologists: “salvage carboglutinib + radiation versus blah blah in refractory…”
Anesthesiologists: “Going home early.”
In this RCT, among adults undergoing extended surgical procedures, there was no difference bw handover of anesthesia care compared w no handover of care in the primary outcome of mortality, readmission, & serious postoperative complications within 30 days.
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It all started with an unsolicited grant proposal written by a young economist named Joseph P Newhouse.
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A couple weeks ago,
@BMJ
published our paper on prior authorization.
Here's a bit more detail on what we did and what we found. (1/13)
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