Thanks to Pennsylvania, lottery, scratch, ass, pennsylvanians or scratching their way to fine, and we new games every month, big top rises and said enchants drawings excitements, always in order so TRY Pennsylvania Lottery Scratch offer your ticket to fund and get yours today. Keep on scratching must be eighteen or older. Please play responsibly benefits older pennsylvanians. Every day. Fr Economics, radio sponsored by three m. What do the adhesives used in both posted? notes and aeroplanes. Having common to both made with innovations from three m. In fact, there are lots of three m product. Hiding in plain sight that you might not realise including endless. me five respirators in response to that, the banking pandemic. Three M has increased respirator, pretty to make more respirators than ever before, helping those on the front I now continue the fight learn more at three p m, calm, slash covered

Yes, your mind My parents are both biologists and I did not follow their route I didn't go into the natural sciences. That's Amy, Frankenstein in college. I was, in political science, and most of my work was qualitative and aid bring home a term paper I was proud of, and- and I have made some argument and at my father would read it and say: well, that's nice, but you could have just as easily argued the other side. You could have just as easily argued the other side in a family researchers of imperial thinkers, though were fighting words? Amy Frankenstein eventually came around to her fathers view. Today. She's is impatient with a certain kind of argument, as he was. You know. If I talk to a friend of for example, whose allow professor, though often describes a research as I'm trying to make the following argument. I never hear my

hello, empirical economists ever describing the researchers I'm trying to make the following argument: that's right! Frankenstein wound up entering the dismal science armor professor of economic set, gee I'm one of the scientific directors of J Pound, North America Pull explained J Pow later, but first health impulses and her fellow economists do describe their research, they say I'm trying to figure out something right. I'm trying to figure out what is the effective health insurance or what is the effect of this hospital discharge programme I think ultimately yeah the more we can learn from data, the more we can figure out what's going on, rather than just economic return uncle arguments that may or may not when the day, because you're a clever debate are that sounds good right. Let the deed do the talking. That is essentially the gospel we preach on this programme every week. But when you trying to answer certain tough questions in the real world

the data? You need aren't necessarily just sitting there in any little pile free to gather up so what he was to do about. It will tell you what to do about it right after that. Here sing it with me. What was not not lump have not a bump bump from W, and my see this is free economics, radio, the pot calves that explores the hidden side of everything. Here's your host, Stephen Governor so let us how important it in your work as an economist, r, r C keys, randomize control triumph. I think randomize trials. Have not history

They ve been that big, a part of economics, and certainly when I was twenty five years ago- and I was in greatest go- it was barely even thought of his being part of the two. We have an I think over the last ten or fifteen years it become increasingly important. Will you answered the question, help they are, but I want to know how valuable they are. Let's say so. I think the randomized trial is the very best way to learn about the world around us and for a couple reasons. One is because Random invasion is gesture. best friend, when you tryin to find causality because absent rationalization, you always have to tell stories about, Why what we observe in the world, which are correlations actually can be mapped into causal relation? but but the beauty, random invasion have done well and at least in large numbers would large samples. Is that big?

she randomized. On average, you expect the outcomes to be the same. Exactly the same for the treatment group and the control group. and so any difference you observe you can vary plausibly a tribute to being causal effects of the treatment they they buy so incredibly powerful. Incredibly simple idea: incredibly powerful idea as I think that there is no better way of learning about the world than through a randomized trial. You know it makes me wonder: Levitt your dad as a doctor, medical researcher whose concentration is intestinal gas. Therefore, the known as the king of farts around the world. How influential was for you as an economist who now does like to do randomized trials? When you can't grow up in a home where medical randomize trials, words Nor am I mean that's the way he learned what he learned right yeah I absolute tomorrow, my father from almost birth trained me

think about the power of randomized experiments. But what so interesting, but also as an aid ten year old. I understood random innovation PA renovation. What I think is really telling them is when I turned into an economist eventually, it just seemed like why dont have how am I gonna run an experiment on the issues I care about, and I couldn't really seen I've his way, and so I thought well I'll do the best. I can dope approximate randomize experiments by looking for natural experiments or the exit all all the things that in my early research for it, where the folks are what I did and it was, it was motivated by the idea that a randomized trial will be wonderful if you could do it, but really somehow limitation- that it would be absolutely impossible for me to do randomized trials as an economist was one that was fun amount adjust. It felt too

binding, and I mean I'm eating and there's something that you ve looked at, where it would be impossible to do randomize trials like if you want to look at the impact of abortion on crime or if you want to look at how, whether in I mean really deters crime. You can't you know let a bunch a prisoner go in one place and lock up a bunch of innocent people another you can't mandate that people get abortions in one place in and have no access another and for the natural experiment is the best you can ever hope for his net. Absolutely so sure, given binding constraints, were you can't run random experiments in the sort of natural experiments that I've of used are a good second best, but but I think the real mistake I made a looking Back in my life was, I really came to adopt the view that this accidental experiment methodology was the right way to think about the world,

in that a much better way to think about the world would be the first thing I should do every time I come to a problem, as I should say, can I somehow managed to run randomize experiment and, having failed that Dutch, they ok, given that Is there a way to find accidental experimental variation, and indeed absent, isn't the where looked at the world, but then the people came along. John, listen and others like him, and they really he's, in my view, to the idea that did to open their eyes and said that, like a scientist, economist could generate dated, an economist could generate data that doesn't sound like such a radical idea. Does it but a Steve? Let it points out. It wasn't until quite recently that economists, like John List and others have turned the world into one big con laboratory, because you can gather up all the found data. You want analyze its death, but he can't necessarily answer every question.

Let's say: there's one elementary school in one state where the kids do really well, much better than all the other schools near by this also happened. be the only school that gives its kids breakfast everyday in addition to lunch and be tempting to conclude that the good grades that school are due to the bracket, and if you could only serve breakfast at all the other schools there grades would shoot up tube. But how can you tell for sure? Maybe breakfast is one of ten things. School does differently, or maybe the kids are different for the parents of the teachers at the curriculum, maybe they're, the only school that plays dodgeball at recess. So how do you find out? How do you isolate the effect of the breakfast, you set up an experiment, a randomized, controlled trial or our city, like the ones used in bench, science in drug studies you take one pocket.

nation, you randomly divided into groups and give some groups a treatment that the others don't get. Then you can measure whether the treatment group came out any differently from the control group. These days. Economists and Their researchers are using our cities to learn more about everything, from altruism to dieting to fighting poverty, and that's where Amy, Finkel, Stein and J Pow comment: J, pal standing for the Abdul teeth, female poverty, action lag, whose mission is Jape? How is a centre at MIT that a network of high quality? max around the world is composed of regional offices. I run J pound. North America and J pals mission is to promote and encourage and amazed evaluations on important public policy issues and then to disseminate the results of those randomized evaluations too.

Key actors and decision makers. J Pow was established in two thousand three four years. Its primary focus was overseas. Esther do flow and award winning. Economists in one of great help founders has helped run many our cities and India, Kenya and elsewhere, trying to learn how best to prevent teen pregnancy, Nemea, drunk driving and how to better incentivize nurses and small business growth and modern farming techniques in the? U S: Amy Finkel style in her J Pow colleagues, we're interested in healthcare delivery. We take a a rather broad view of poverty alleviation and so anything that improves the efficiency of healthcare delivery. I think it's important for the public for two reasons. First, you know the poor are disproportionately unhealthy and therefore I have the burden of healthcare,

relative to less poor people also, given that healthcare spending is currently about a fifth of public sector projects of the state and federal level? Anything we can do to improve the efficiency of healthcare delivery, Freeze up more money to spend on other programmes as well or to spend on getting even better health, along with their colleagues. Sarah Topman Frankenstein found that randomized I also very much the norm in medicine, drug studies, medical treatment and so on, but when it came to healthcare delivery, how those drugs and treatments are actually consumed by patients, our cities were quite rare for that to us it was a striking disparity and you know: well, we don't think can or should be randomized. We would like random, evaluations to be closer to the north rather than the exception and healthcare delivery, though

they are in medical research, alot of people when they hear you or other economist talk about well yeah. Yet if you take five thousand people, you could randomize men give half of my insurance. Other half not near you control Group, and then you measure depression and you measure job outcome and an that's great and that's exciting. There are some people are there, who here that say man? No, I don't want any part of that. I don't want to hear about it. It is wrong to do that. Kind of experiment in a realm where people's livelihoods, health and so on are involved. So can you talk about that kind of

no, what you call it quite moral order, Baron S native about and the ethics of, randomized evaluation. So let me start by telling you an interesting story, which is the Oregon Health insurance experiment. The Oregon half insurance experiment was not something that came about because a bunch of researchers dreamed up and convince the state to do it. We found out about the lottery after the state had decided to do it and they decided to do it, not for research reasons, although it turned out to be wonderful for research but for fairness reasons. Like many states, organ was expanding its medicate programme, in addition to covering the standard patients like poor children and pregnant women and the disabled, it was now offering free or low cost healthcare coverage to some able bodied low income adults and, at the start of two thousand and eight, this state of organ realised that they had enough money in their next by

it cycle to cover an additional ten thousand individuals. However, they also correctly realise that if they just reopen the programme to low income, uninsured able, bodied adults in Oregon that there were many more than ten thousand who would be eligible. In fact, we subsequently estimated that about two hundred thousand such individuals would have been eligible for the programme, so they decided. The fairest thing to do was actually a and eligibility for Medicaid based on a lottery. They ran a huge public relations campaign for two months and they got about seventy five thousand individuals to sign up and then A letter awaiting a ran, a random number programme to determine which of them could apply for Medicaid and which couldn't this gave single Stein a great and rare opportunity to learn what really happens when a bunch of poor, uninsured people get access to health insurance, because now there were no confounding factors. What you had were choose statistically equivalent

groups of people, those who are eligible for Medicaid and won the lottery and got it and those who are eligible for medicate and was the lottery and didn't get it? So what did Frankenstein learn? That's coming up on economics, radio, along with another healthcare project, she's working on sound, so simple, and yet you know this can really potentially make the difference between ending up back in the hospital and not, and even if you dont care much about people generally, why you might want to care about improving healthcare delivery. As we ve gone around the country, we have heard many many stories of patients up to a million dollars a year bouncing around the healthcare system the absurd reasons

thanks to Pennsylvania, lottery, scratch, ass, pennsylvanians or scratching their way to fine, and we new games every month, big top rises and said enchants drawings, excitements, always in order so try, Pennsylvania, lottery, scratch, offer your ticket to fund and get yours today keep on scratching must be eighteen or older. Please play responsibly benefits older, Pennsylvanians, every day, economics radios, brought to you by square. If you run a business, you know how important it is to have a healthy cashflow. That's why Will you take payments with square either in person or online? You get your money fast act. does it instantly? Vs? Where card a free business, debit card or a transfer? It to your bank account on. You reschedule see all the ways Square can health at square dot com slash, go slash. Freak though nonsense,

disappeared. I am guilty and Jacobs and I'm Deanna reasonable. We ve got a new path task called if that worry politically talked to scientists, engineers NASA folks, just a punch of really smart, curious people about cool stuff Gillian. I think most people know you from your work on love and community and must be No you as forensic scientists, Casey Heinz on Anti, I ass, so we were both actors for what most well don't know. Is that we're both really curious in passionate about stem. If we have a more diverse outlook in how we look at science and engineering and technology and map, then what This is possible. I get giddy when I get to speak to these people, get a chance tat back into my curiosity excitement. You know that I have about all these topics. So come on this journey with

as we learn from some of the poorest smartest people in their fields. If, then, is out now just search, if slash than to find the show that, if slash then knows listen in stature, apple, the serious ex em up or wherever you get your PA casts. From W and Y see. This is for economics, radio, here's, your host Stephen Governor,

The economist, Amy Finkel Stein, believes in the power of a randomized trial to figure out things like what happens when a bunch of poor. Previously, uninsured people suddenly get health insurance. She stumbled upon a gold mine, a Medicaid expansion in Oregon that had been randomized by lottery. Finkel Stein, inner colleagues began analyzing the data and they started to release their findings. As your mama cared debate was raging one of the results that came out that, I think surprised. A lot of people is that when you cover the low income, uninsured people with Medicaid, they use the emergency room more rather than less. In fact, we found that's very much is very counter to everyone's assumption. I guess was: it was apparent, even yours, going in LA, I didn't know what I

Fine and that's what the fun things about doing research- and I think it was, I think, you're right- everyone assumed emergency room use would go down. In fact, one of the arguments people make for covering the uninsured is to get them out of the expensive emergency room and into primary care clinics and other services, and we found that covering the uninsured, increased emergency room used by forty percent, so that is so fascinating rate. And what does that say, you think Amy? Maybe you don't have an answer this about the underlying, as some Of why we thought that uninsured people, or how often they thought they were using the emergency room already and in other words, you start to think that Well, maybe people or uninsured, don't even think about access to the emergency room as a right. Well, so that's one possibility right, because it is the case that the law requires hospitals to treat people who show up in the emergency room right, but they can charge them for them if there are ensured

We wish you do see the uninsured using the emergency room. You just see him using more when they get insurance. The premise for why covering we have ensured with Medicaid would get them out of the emergency room. Is it Medicaid makes the doctors office free, and so now people would go to the doktor, instead of to the emergency room, but what you forget, as it medicate, also makes the emergency room free and so to go to your point, while you're alive out to go to the emergency room and you have to be treated even if you don't have insurance you can be charged for at after the fact, which means you either have to pay out a pocket, or you may have collection agencies harassing you in that can affect your credit rating or just me, unpleasant Obamacare. Opponents seized on the It's that the expansion of Medicaid led to substantially more emergency room visits. There is a new study out that says that the Spanish of Medicaid under Obamacare will actually increase e visits,

where's the Obama administration repeatedly, claiming that the healthcare law would actually reduce those costs. Another Frankenstein paint profound- and I quote, no significant effect of medic coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication. For these conditions, bad news, Democrats who support Obamacare study out organ suggests that the government's health care push for all not necessarily make people any healthier. On the other hand, another set of results we found is that again through this round, mine's devaluation covering low income, people with Medicaid reduces depression. You got about a thirty percent reduction in depression and also and perhaps most interesting to me as an economist covering the uninsured with Medicaid, improves their

financial stability. It reduces the risk of catastrophic out of pocket. Expenditure is to virtually zero. So it's providing important financial security as well as you might have guessed, Obamacare supporters played up this fine, is almost anything or the organs of the Oregon study, which has been litigated a tremendous madman. I wanna let it get here, but one thing that they take away was that people were much happier and much less depressed financially secure right, and you know what I say that I feel so. You ve got both sides in the medicate expansion debate, finding evidence in single Stein study the supports their position, which mean that sound like much of an improvement or the standard political shouting at but remember at least there talking about evidence here rather than hunch or pure ideology, and that says Steve Love. It is what may a randomize trial, so useful Joe remonstrance can tell you in setting you're in whether or not

a change that you make makes outcomes better worth if touch it, but that's only one thing that does. It also is an incredibly effective way of of of changing the process. So, even if you could do higher consulting from to carry out an analysis which would tell you with exactly as much certainty that you should do something differently it harder to get people to actually change

when they can use arguments like oh well, I think the analysis mine are done right or data analysis was paid for by the doctors and the doctors. Don't like the nurses until can't be believed it. It really is the kind of the Ex Ante agreement that okay. If the study comes out like this in a randomized trial, we will agree to change that is incredibly powerful an organization's, so people are still free to argue their positions, but as the researcher you can leave the arguments to the argue words to the people with horses in the race. As the researcher you get to prove a real causal relationship that people were only guessing it before, and that is how you start actually solve problems by learning the real cause, which is especially valuable,

realm, is complicated and expensive, as healthcare will tell you that a patient who is up in Trenton New Jersey, that's Jeffrey Brenner, I my family doctor also the executive director and founder of the Camden Coalition of health care providers. came the New Jersey he's. Also Macarthur Genius Grant winner and medical iconoclasts, but we'll get there, lay so we have a sister organization, similar nonprofit, in work up there and they found a patient had been for honey fifty times in a single year to what to an ear to a hospital to the local emergency rooms and but also occasionally patient was admitted as well. Well, so I don't even understand hotspots what more than once a day you up. More than once a day to local hospitals and emergency rooms. How do you do that? It's a lot of work is not ok, so for fifty times

this was a woman who was inner fifties who had asked we're alcoholism, mental illness and had significant medical issues as well and was literally bouncing from emergency room to emergency room hospital. The hospital. I should also homeless, as well, and very cut off from her family, and it there sk of sounding cruel. What did it cost for those four hundred fifty visits and who paid for that Let's take five hundred thousand dollars a visit like no matter how you do the math on that that's pretty expensive right, I mean this is probably could be a hundred two hundred thousand dollars care as we gonna the country. We have heard me many stories of patients up to a million dollars a year bouncing around the healthcare system for peace, absurd reasons. can you talk for a minute about what you began to learn about

those it as you call them super utilizes people who use that kind of health care so much so that one percent of the patients is thirty percent of the payments to the hospitals and that fibre The patience is about fifty percent of the payments to the hospital, so a very small sliver patients are driving all of the revenues of the system and this top one can't. We we used the term super utilizes and in the question Is this the fault of the patient, or is this a system failure and, I think our journey over the last couple of years is really demonstrated to us that it's a system failure and that we could be doing much much better for these patients. Brenner did not have this understanding of the problem from the outset. He came to it through a side door so about ten years ago the city Camden became the most dangerous it in the country, and I lived here and it was terribly frightening time.

Wave and I had had a baby here and you know daily patients coming into my practice. Who'd been hurt and crimes. They would often say wouldn't even call the police department, because the police would even com or if they did they weren't harmful. I had patients tellingly horrific things about being beaten up by the police department, I mean the police department was in free fall The city was in freefall very frightening time to be here. I had appointed the M c took over the Camden Police Department, put it in receivership, and I got pointed is one of two city residence to be on a police reform commission and then got a chance to be behind closed doors, where state official so having all these really intense conversations about the police department and just realized how this thing was really melting down, they brought in a whole crew of people who had held to reform the New York City Police Department under Breton, and

It took me into their wing and started teaching me what had been done up there and learned a lot about come stat and all all the management theory and data theory behind it and just in awe the Brenner was exposed to a data driven approach to policing that potentially found trouble before it happened by identifying patterns in the data by identifying hotspots. Brenner begin to wonder if hot spotting could help the police were not him. At the very least, there was one big parallel, just as a relatively tiny number of criminals cause a whole of trouble and expense for everyone. A relatively tiny number, sick people were going up. The healthcare delivery system he got hold of some hospital data, it was a stunning dataset. We found out incredible things about rates of falls in the city about assaults on the city that I think concurred with our hypothesis, which is that people are being

editing ridable rate in the city, far higher than even the reported police rate so weeks indeed the dataset after this initial did analysis. We were really turned on by this idea of mapping graphic charting the data and. we would sit for hours and hours. You know cutting the data up in different ways and em. My patients when the date I recognise names in the data of people. I knew and was taken care of. And I was just shocked by how much money was being made over on the hospital side of this care and how often people are going back, over and over, number. One reason to go to the hospital in Camden was head colds number two was viral infection number three was sore throat. There were twelve thousand visits for head colds over five years. We know what the hell does it cost it can cause three five

thirty, eight hundred thousand dollars. I mean it's ridiculous, as Brenner saw. The problem was twofold: at the very least one, a certain kind of patient was consuming a ton of healthcare treatment, but still not getting healthy and to the healthcare delivery system. The hospitals, in particular, were set up to profit from these super utilizes, the profit they did at the expense of the taxpayers. So those were the problems was a solution in two thousand. Seven Brenner got his group, the Camden Coalition, to start focusing on super utilised, five years later. They set up a programme called link to care, and it includes all of the local stakeholders, so primary care providers, hospitals, long term care behaviour, hull. addiction, homeless, shelter and might killing was. This was a game theory problem of how do I get people to collaborate? Instead, a compete

mad competing over market share of homeless, medically complex, addicted patience? it's not a great way for society to exist and Great, a set of rules for the healthcare system to function by so linked to care would be an aggressive, proactive plan meant to help these super utilized by making sure they got the attention they needed, whatever kind attention that might be, which sounds potentially wonderful but also potentially expensive, and who knows potentially not wonderful. Furthermore, how would you measure the success of the programme by random, rising it? Of course, Jeffrey Brenner and his people got together with Amy Frankenstein and her people to set up link to care as a randomize, controlled trial So we have real time data feeding in from all the local hospitals of demographics utilization labs.

geology and hospital distort summaries. They don't have unlimited resources and also there trying to figure out the kings as they go and learn from their experiences as they grow up every morning, where alerted who's been admitted to the local hospitals, we again remotely to the electronic health record systemic each hospital we do trying to identify patients who are medically complex, socially complex and had been readmitted more than times in six months. We go then of teams located in the hospital go right to the bedside explained the programme to the patient, and what was really striking is is you saw people who were quite ill and quite lonely. They were usually alone in the hospital and they were extremely eager to talk to to the people from Dr Bronner's team, who came in who are people from the community. You know who are sensitive and and understand the needs, and they were, you know, just very happy to have someone listen to their story, and here you know much more than a

physician can, in the brief healthcare visit, knew what was going on in their lives and, if they're interested, we can send them with walk out of the room It's a randomized control trial, retesting, The intervention and we hit the random button and they randomly get assigned to either the intervention, which is ninety two hundred and twenty days of careful nation poor to default, air which is just the normal discharge process. If they, up in the intervention. We have a whole multidisciplinary team made up of community health workers, social workers, nurses, America. volunteers who go right to the bedside and do a care plan. We spend hold her tongue, really to get to know the patient and understand what their needs are and where they want to see their life go We then go to their house within seventy two hours go with them to the prom,

the care appointments with them to their specialty appointments if their homeless, something good housing. You see these people, often with unstable housing and family and employment situations who are coping with really serious illnesses and pages of instruction. from having left the hospital in and bags of medication from in a previously proscribed and trying to keep it all straight and are supposed to be taking six different things a day. Some with food, some without food and just seeing the health coach, something so simple, set with them in very calm methodically go through. Let's see what the list of instructions are you're supposed to take. Can you find me that medication, let's look at it? Is it expired? Let's put it here and let's taken, if they have outstanding warrants, sometime settle them. If they ve got so The service needs that they need help signing up for insurance. Whatever the issues are across fifty,

different domains. We work with them for that. Ninety two hundred and twenty days on independence, autonomy and self efficacy and then graduate them. we tagged along one day this winter, on a link to care visit encamped, and it is one of the poorest cities in the: U S Johnny Skinner is a nurse and nurse care coordinated with the captain coalition. She is now driven to a housing, complex, yellow, two story, building How are you There may be a good time. name. Susan commoner were my home in Canada,

cardiologist cheese entered in establishing that I'm a diabetic and high blood pressure. Congestive heart. They help arranged my appointments and get me to the right. does dad need to go to and monitor my blood pressure on my sugar to tell me what to eat and stuff like that, the treatment is very, very, very helpful and they feel like a family, mind, if I give up check with your cooperation. And one day Take the other, didn't you have a year's number one, eighth of Babylon, already, ok, Jeffrey Brenner again, and this

work for every patient. Not everyone is ready to change, not everyone's ready to make different choices, but we found that this works for many many patients, but for how many patients and at what cost, might there be better alternatives? These are the kind of questions that Brenner and Amy Finkel Stein and all their cause. I will try to answer through the data, so we're looking to randomize eight hundred patients. We have randomized about two hundred and forty so far, It has been an enormous amount of work, we're looking at hospital, readmissions and other things that are regularly collected in health care data if we don't find in effect on red, actions we want to know. Is that because they're not there are not actually achieved, the intermediate goals, if they think are important or is it because our achieving them and they turned out not to be important? And you know: Amy's team has been

so helpful. There's no way that we would have been able to launch something like this ourselves. We also want to luck, prescription, drug use. We wanted to do this for a long time, but we just didn't have the This declaration, the structure and then the know how to be able to do it, and what do you know so far as it too early to say any? it's really early, that data is very noisy early on. There are positive trends, but you know we have to wait till it reaches statistical significance. How long will it take for these eight hundred patients to go through the the man? You know one of our biggest challenges that our federal grant runs out. time and the fall in maybe winner we're Jigsaw puzzle of twenty eight different sources of funding and others a special place in her. For delivering better care at lower cost, but there's no business model for it and theirs Currently, no business model for trying to figure out how to prove it or do research on it and I want to say we're holding big sales, but we're in a race.

against time to get. You know enough patient. through this study, in order to get to their statistical significance. The other problem is that, even if we prove this with the perfect New England Journal, JAMA article that, Elbows and change Medicaid policy would have to think of all the players involved here: medicate the care, are those who are most eager to find real ways to cut costs for this kind of area, I don't know about that. So there is a helmet why? Why would that not be the case, so there's there is a a really well. funded randomized control trial. It's the largest randomized control trial in my field. That's ever been done. It was seven. Ten hundred elderly Medicare patience over a ten year period and it was actually part of the contest it, was launched as part of a balanced budget act about twelve fourteen years ago. An com

let's get tired of all these disease management companies coming in saying they conceive Medicare money, they they want, the contest- and they heard mathematical, be the judge and randomly given a group of patients. and then there was a random control group that just got normal default care in the medical system. And there were about fourteen different entities across the country that applied and got into it within a year. The mathematical and the federal government pull the plug on it and all, but three of them had the plug pulled on him, and I turned out that they had driven cos up, so the three that were allowed to move forward were messy boots on the ground, difficult programme two to run. They were nurses out the field, bang and endorse two them dropped out cause hard to do, and there's only one still outstanding endorsed on Pennsylvania. They are community nonprofit a lot like us that works with all the

local providers and hospitals to do care coordination for very complex Medicare patients and They have ten years worth of data, that's been published and journals and published in the congressional record, and basically, they reduced the death rate by twenty five percent. They didn't receive money, they reduce the death rate just by having a nurse come out to your house every week or every other week in a highly structured. Well organised intervention to make sure that your mama grandmother we're having you know needed. Services were having a wellness. Interventions, exercise fall prevention, so people over eighty five with complex chronic illness. They had a forty nine percent reduction in the death rate in this society every ten years, they so how reduction of about not for the middle cohort but the most complex patients, the middle cohort, they even the most complex cohort. They reduce costs

and hospitalization by about twenty to thirty percent. That's a stunning accomplishment, so You know I don't understand, given the thence that this project works. Why medic hasn't scaled it and I'm not confident and the ability of government to make This decision on the best evidence. The way they shed, I mean, One cynical guess might be that when you ve got a budget baked didn t you're universe, whether it's a governmental universal for profit or not for profit universe, that when there's something that threatens to diminish that budget by ten twenty forty percent, Even though it makes a lot of sense for a lot of people involved, taxpayers friends, since it might not make sense for you, Europe absolutely and frankly, I think Medicare comment was that it's real hard to do we're, not sure we can scale it well, we fucking scaled open heart surgery. We scaled, you know separating siamese twins. We scaled transplant

the hearts and lungs curing complex cancers were sequencing. The human genome. You telling me we can't have a nurse gladdened check on your Mama grandmother in a high the organised a well structured, well trained intervention, for which some is already doing it for hundreds and hundreds of patients every day. So it sounds as though, even if you, you and all your colleagues Navy, Frankenstein and all her colleagues come to the conclusion that this project that working on is both effective and very cost effective use. don't sound very optimistic that it will move the needle in the direction, at least if you want to move. You know, I think, at this juncture in life and based on the medical history and social history that have read, I think, that evidence alone is not enough to fix a complicated problem Thank you need to have the combination of evidence and advocacy and- some point. The american public needs to stand up and say we're sickened.

Yoda being cut scans out than hospitalized in a two point, eight trillion dollar industry that's running out. control and is not take good care of us. At the beginning of this episode, we propose the idea that the hour see tee the randomized controlled trial is a valuable tool in sorting out hard problems, including health care, deliver. I think our com section two? They prove that value, but that rather narrow issue. Let us into a much larger argument: Jeffrey Brenner, an M d, healthcare delivery, innovator. Our city believer has, as you just heard, very strong feelings about how our healthcare system is set up and who it's really serving, and so next week will continue. This conversation push even further in that direction, will hear more from Brenner about what it would take to truly revolutionise health.

Delivery, so that no one in the sea, I could imagine Mubarak ever being out of power right. You know complex adaptive system sky through state changes and they do it in very complex and unpredictable ways where one day there one way and the next day, there's been a dramatic shift. We also talk about whether the central tenet of medicine should perhaps be less is more The perception of health care is that by doing more, we can improve health and what need to recognise. Is that so much of health care? So many in the clinical decisions that we make operate in this grey zone? It's not black and white, and it could very well be the case that in the gray, less may be more. That's coming up next time on for economics, radio, if you like what you here, please tell your friends about this. Free podcast can even tell your enemies,

spread. The word on Twitter, Facebook feel free to rate or review our show on Itunes or whatever else you get your podcast thanks for this Fr Economics. Radio is produced by The? U? N Y see and dug nor productions. Our staff includes Gregg resolves Ski Caroline, English, Susie, lectern, Burke, marriage Jacob in Christopher Worth, with help from David Herman, Anna Hyatt, Rick, Kwan, Daniel designer and Paul Schneider. If you want more frequent onyx radio, you can subscribe to our pod cast on Itunes or good a friggin amish stock. we'll find lots of radio, a blog, the books and more.