This episode features an interview with Dr. Bapu Jena, an economist, physician, and professor at Harvard Medical School. He bridges his professions to explore the economics of healthcare productivity and medical innovation. Bapu is also a faculty research fellow at the National Bureau of Economic Research and practices medicine at Massachusetts General Hospital. In this episode, Sasha and Bapu discuss his book Random Acts of Medicine, provider-level quality scoring, and designing employer-sponsored benefits.
This episode features an interview with Dr. Bapu Jena, an economist, physician, and professor at Harvard Medical School. He bridges his professions to explore the economics of healthcare productivity and medical innovation. Bapu is also a faculty research fellow at the National Bureau of Economic Research and practices medicine at Massachusetts General Hospital.
In this episode, Sasha and Bapu discuss his book Random Acts of Medicine, provider-level quality scoring, and designing employer-sponsored benefits.
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“If you're an employer and you're thinking about how to structure your benefits for your employees, you're going to think about which hospital systems you want them to have access to. You're going to think about what doctors’ groups or doctors’ practices you want them to have access to. Naturally, you're going to want to have information on what is the quality of those places. But then how do you measure quality? What we might say about a particular doctor in terms of their quality, might be a function of their actual skill and the true quality that they provide. It could also be a function of the resources that their practice has, or the types of patients that they see. If you want to know something about what is the true effect of seeing that particular doctor, you've got to sidestep all these thorny empirical problems.” – Dr. Bapu Jena
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Episode Timestamps:
*(01:09): How the fields of healthcare and economics correlate with each other
*(04:02): Bapu dives into his book Random Acts of Medicine
*(10:09): What provider-level quality scoring is and how it works
*(18:00): Bapu’s thoughts on employer-sponsored benefits
*(25:21): Good spend versus bad spend when building benefits plan designs
*(27:29): Challenges providers and payers will face as healthcare evolves
*(36:33): Bapu shares his favorite healthcare story
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Links:
Read Bapu’s book Random Acts of Medicine
Random Acts of Medicine Substack
Listen to Freakonomics MD Podcast
Connect with Sasha on LinkedIn
Learn more about Collective Health
Sasha Yamaguchi: Let's face it, healthcare is confusing and costs are continuing to rise. Employers are looking for ways to improve the health of their people and their bottom lines. The good news? Many leading companies are leveraging self funded health plans and innovative benefit solutions to do just that. Learn from some of the best minds in employee health.
Sasha Yamaguchi: Welcome to the Benefits Playbook, Strategies for Self-Funded Health Plans. I'm your host, Sasha Yamaguchi. Commercial Leader at Collective Health. On today's episode, we are joined by Dr. Bapu Jena, physician, economist, researcher, and Harvard Medical School professor. He is the co-author of the recent book, Random Acts of Medicine: The Hidden Forces That Sway Doctors, Impact Patients, and Shape Our Health.
Sasha Yamaguchi: Thank you so much for being here with us today, Bapu.
Bapu Jena: That's a generous introduction. I appreciate it. Thank you. Thank you for having me.
Sasha Yamaguchi: Thank you. I'm excited to spend time with you. So I thought to start off, I would love to hear a little bit about your background. You have a very interesting background and your career sits at the intersection of healthcare and economics.
Sasha Yamaguchi: How do these two fields correlate with each other?
Bapu Jena: Yeah, so the short of it is I'm a medical doctor and also an economist. I kind of fell into this a little bit by chance. I always wanted to be a doctor and I wanted to do research, but I wasn't sure what kind I wanted to do. Now, more than almost 20 years ago when I was visiting the University of Chicago, which is where I ultimately went to medical school and did my PhD in economics, the person who directed that program at the time happened to notice I'd studied economics in college and said to me, do you want to do your PhD in economics instead?
Bapu Jena: And I thought, well, it's worth a shot. And if I didn't like it, I would become a cell biologist or cancer biologist, something like that. And fast forward now more than 20 years, it's worked out well for me, and medicine and economics, they don't seem like natural bedfellows, but if you think about what economics is, it's trying to understand human behavior in part through the lens of economics and the sorts of decisions that people make, what factors affect them, market and price or otherwise.
Bapu Jena: And medicine is an area where the stakes couldn't be higher. And a lot of the problems that economists worry about, like information problems, doctors know something that patients may know and vice versa. It's a place where the stakes, as I said, are high. There's tons of information differences or asymmetries is the word we sometimes use.
Bapu Jena: The costs are very high. So, it's sort of ripe for study by an economist.
Sasha Yamaguchi: Fascinating. Tell us a little about being a professor of healthcare policy at Harvard. What do you teach within your program and what do you hope that your students will walk away with?
Bapu Jena: I'm fortunate. It's a good life. I can't complain.
Bapu Jena: So, I teach a couple of different courses. Yeah, but one of my favorite ones is an undergraduate course in Harvard College called The Quality of Healthcare in America. And there's a lot of quality problems, so there's a lot to talk about and teach. But it's a survey course that talks about what are all the factors that affect quality of healthcare.
Bapu Jena: And, um... I teach about a third of the course. We have outside lecturers come in and talk about things like malpractice, innovation, competition, health equity, international health systems, all sorts of different topics. My ultimate goal at the end of the day is for students to understand something about how healthcare works, what are the drivers of healthcare quality.
Bapu Jena: So it's a kind of a fun course.
Sasha Yamaguchi: Sounds like it. I should stay in touch with you and, and get some folks over to Collective Health that have gone through your program. I will say my husband did a couple of development sessions through his company there and it was such a great experience. So I would love to get into the book, but also a couple of things that really stood out to me. You recently co authored the book, Random Acts of Medicine with Christopher Worsham. Tell everyone about the book. What is it about and then what was the inspiration to write it?
Bapu Jena: So the book is about how chance affects our health. It's not a surprise to anybody that random things impact our health, our lives, actually, and all the time.
Bapu Jena: So, the story I'll sometimes give is, I met someone not too long ago who was telling me how they met their significant other. They're now married, and he said that they met at the DMV, Department of Motor Vehicles. He was waiting in line, and they were there for a couple hours, and next thing you know, a few years later, they get married.
Bapu Jena: And I was thinking to myself, as a... Thinking about this book, you know what? That's sort of a random occurrence, but you can't learn anything from it. You wouldn't tell your son or daughter, you know what? I know you're struggling to find your soulmate. Why don't you just go to the DMV, hang out there for a couple hours and see what turns up, right?
Bapu Jena: That's not like a recipe for success. But there's these other ways in which chance affects our life and in particular our health, where I think we can learn something from. And the book Basically goes through all of these different examples and I'm sure we can walk through some of those examples where people's lives are affected.
Bapu Jena: They sort of go down these different paths because of some chance occurrence and that impacted the type of medical care they received, the quality of medical care they received, and it helps us, for example, understand when is it that more medical care is better and when is it that more medical care is sometimes harmful, as well as an assortment of other interesting questions.
Sasha Yamaguchi: Out of curiosity, of the chances in the book, is there one that stands out to you as the most surprising, or that you tell people the most about, out of curiosity?
Bapu Jena: Oh, Sasha, they're like all my babies. This is what I've been spending the last ten years doing, so I feel like I can't pick one. Like any good parent, if push comes to shove...
Bapu Jena: Yeah, I'll pick one. No, I'm just joking.
Sasha Yamaguchi: I'll change the question. What is the one, maybe, when you talk to people, what was kind of the one that stood out to them? How about that?
Bapu Jena: Yeah, so let me tell you one that's one of the famous ones that we did is, it was actually on the Freakonomics podcast years ago in 2015 or 2016.
Bapu Jena: This chapter is called, What Happens When All the Cardiologists Leave Town? And it's a chapter that starts by talking about this finding of ours that when major cardiology conferences occur in the United States, like the American Heart Association or American College of Cardiology, if someone happens to have a cardiac arrest or a heart attack during the dates of those meetings and they get taken to the hospital, if I ask people, what do they think happens?
Bapu Jena: Do people do better or worse? Most people will say that they think patients would do worse because the staffing might be less or the expertise might be lower because all the the quote unquote best cardiologists are away at these meetings. And what we find actually is that people do better. They're more likely to survive the hospitalization and live longer than if they came on other weeks of the year, which is sort of surprising.
Bapu Jena: The other data point is that if you look at rates of certain procedures, they fall by about 20 to 30 percent during the dates of these meetings. And so we're kind of left with a story where People are exposed by chance to a different type of care. No one picks to have a heart attack or cardiac arrest when these meetings are occurring.
Bapu Jena: They don't know when these meetings are occurring. It's totally random to them. They're more likely to survive because the care that's provided is different. What is the care that's different? Well, we see that the rates of certain interventions fall considerably. The story then is that it might be a situation where sometimes in the rest of the year we might be doing too much.
Bapu Jena: We might be Over intervening on people and maybe it's less is more in that sort of context. So that's sort of an interesting story and there's a lot to unpack in that which we could talk about for a while. But I think people like that one a lot.
Sasha Yamaguchi: Yeah, I would think that'd be very surprising to people that are reading that.
Sasha Yamaguchi: Really interesting. And I love that you said less is more because I think we're always tending to do more, more, more and sometimes The basics or not doing too much can benefit people as well. And then I'd be curious, as you find these in your book, are people changing or doctors, or is the system changing based on some of those learnings?
Bapu Jena: Yeah, good question. I would say. Probably not. I don't know whether people look at the findings from the book and think, Oh, we should be doing this differently in our hospital system. And that's, you know, it's a little bit by design. I sit in a department of healthcare policy at Harvard. And when most people think about healthcare policy, they literally think about policy.
Bapu Jena: So there is a policy to reduce costs and improve quality of hospital care. Does that policy work? That's sort of a policy evaluation question, and the answer to that question can directly inform you as to whether you should be doing more or less of that kind of policy. What I do is, I think of it as a little bit different, it's more...
Bapu Jena: of the basic science, if you will, to try to understand what it is that impacts how doctors think, how they practice, how patients might think. And so the take homes are not always so clear and cut and dry. Like, okay, here's the policy that you should implement if you believe Bapu and his colleague studies on X, Y, and Z.
Bapu Jena: It's not, I think, as linear as it would be if you're directly studying the impact of a particular already existing policy.
Sasha Yamaguchi: Yeah, interesting. So, going to the doctor side, I think a huge part of the healthcare industry is the providers, the networks, right, and all of the tracking of what makes a good doctor.
Sasha Yamaguchi: I know members are always asking, They'll call in and say, who should I go to, right? So in the book, you have a entire chapter called what makes a good doctor. It discusses provider level quality scoring, stronger tooling for people to find those high value doctors. Can you explain, especially for those that may not be really familiar with it, what provider level quality scoring is and how that works?
Bapu Jena: Sure. So first of all, I would say it's an early science and what it is, is it's an attempt to try and determine and ascertain what is the clinical quality that an individual provider provides his or her or their patients. And what do I mean by that? It could be a doctor, it could be a nurse practitioner, it could be a physician assistant, it could even be a hospital system.
Bapu Jena: So if you're an employer and you're thinking about. How to structure your benefits for your employees. You're going to think about which hospital systems you want them to have access to. You're going to think about What doctors’ groups or doctors’ practices you want them to have access to. And naturally you're going to want to have information on what is the quality of those places.
Bapu Jena: If you care about your employees, you want them to stay with you, you probably want to give them access to a healthcare system or systems that are high quality. But then how do you measure quality? There's a science behind quality measurement and defining quality. It's now about 30 years old. It's not enormously old, but there's ways to think about how to define and measure quality.
Bapu Jena: But the rubber hits the road when it comes to actually measuring it and saying, all right, what kind of data do I need to get the right answer? Because it's difficult. What we might say about a particular doctor In terms of their quality, might be a function of their actual skill and the true quality that they provide.
Bapu Jena: It could also be a function of the resources that their practice has, or the types of patients that they see. And if you want to know something about what is the true effect of seeing that particular doctor, You've got to sidestep all these thorny empirical problems. But at its core, it's basically trying to figure out what is the clinical quality you could expect to get if you saw this doctor, this nurse practitioner, went to this hospital.
Sasha Yamaguchi: How can we help people? Do you have advice when they're trying to find those high value doctors? Where would you steer them to and what to look out for?
Bapu Jena: It's really difficult. I mean, I think if you look at most people and you're to survey people who have doctors, patients, I think most of them will probably say that they appreciate their doctor, that they think they have a good doctor.
Bapu Jena: And there's going to be tremendous amounts of variation across those doctors and the types of quality measurements that we might get. Or we might obtain if we look at their underlying data. So either we're getting the quality measurements wrong or something doesn't add up in that case. The things that I look for are, or I think people should look for, and the question is, how do you find this?
Bapu Jena: Is, you know, a doctor who's knowledgeable about the issues that you have. So if you have a neurologic problem, you want to see a doctor who's familiar with Neurologic diagnoses, who's seen and treated patients like you. I think for lots of people, something like bedside manner and receptiveness and timeliness are also really important.
Bapu Jena: So if you need questions answered and you can't get them answered in a timely way or in a thorough way, that's going to be a problem. I think the challenge is figuring out how do you measure those different attributes in a way that is Rigorous and credible because at the end of the day, medicine is very much sort of an experience good so you can see a doctor and say alright, this is not working for me and then you find another doctor.
Bapu Jena: It's hard to do that if you have surgery, for example, you kind of want to pick the surgeon who's going to do the surgery right that first time. You don't have multiple shots on goal, but when it comes to another doctor, like a primary care doctor, you might have that opportunity, but you know, the book, we talk about things like the doctor's age, their gender, whether they went to a foreign medical school or not.
Bapu Jena: And we might have preconceived notions about how each one of those things. Affects the quality of care that we might receive and we talk about like, why is it the case that female doctors seem to have better outcomes? Why is it the case that foreign medical graduates, people who went to school in another country, why do they seem to have better outcomes?
Bapu Jena: Which they do. In some cases younger doctors have better outcomes. So there's a lot to unpack there.
Sasha Yamaguchi: Interesting, and I'm curious what the answer is to a few of those with the female doctors, with the young doctors, but also I feel like for the member, what they look at as a value may be different than another person as well.
Sasha Yamaguchi: They may value things differently also, so you can go in, maybe someone's told you about this physician, you go in and visit with them and it's not the right fit for you, whereas that doctor may be the right fit for others, so.
Bapu Jena: It's an interesting idea that I've heard people say, which is, right now, when we try to measure the quality of doctors, we look at their data.
Bapu Jena: How are their patients with hypertension faring? How are their patients with diabetes faring? There's another approach, which is to say, maybe we could assess the quality of doctors by looking at what doctors, when they are themselves patients, do. So, there's about a million doctors in this country, and there's many more that are retired.
Bapu Jena: If we were to look at who are the doctors... That doctors themselves choose when they need medical care, who are they picking? Are they picking the types of people who would show up or score well on a report card that an insurance company or an employer, or that the government might? Produce about different positions sort of an open question, but I don't know that it would always align and I would kind of say All right.
Bapu Jena: Well, I'm curious who the doctors are going to maybe I want to go see those people.
Sasha Yamaguchi: Oh, well, yes, I think I would although I've heard doctors and nurses are the hardest to engage right because
Bapu Jena: That might be true. Yeah
Sasha Yamaguchi: Yeah, I've worked with a couple hospital groups and we always found that interesting, trying to get the nurses especially to get into their care.
Sasha Yamaguchi: Really quick, I would love to know your thoughts on PCPs. Do you feel it helps, because I feel like this would be a great topic for our audience. There's still programs out there that build in a primary care physician. Do you feel that that does help the member to kind of have that home based physician before seeing the different specialties?
Bapu Jena: It depends on the person, but for some people, it is really helpful. If you're a person who has really one single medical problem that is predominant, that's the type of person who, oftentimes, the specialist who cares for them almost functions a bit like a PCP. Not completely, because there's, there are things that internists...
Bapu Jena: will do that even a very devoted specialist might not do. They might not think about particular cancer screening or other screening and things like that. But in general, I think it is a good idea for people to have primary care doctors. There's a lot of evidence that looks at what is their benefit. And in fact, we've done some work which looks at what happens to patients when they lose a primary care doctor.
Bapu Jena: Under the idea, look, if primary care isn't that useful, then when you lose your primary care doctor, we wouldn't expect to see much worse health outcomes, much more health care utilization. And we do see that. Adrian Sabetti, Michael Barnett, and I had this study which looks at what happens when people lose their primary care doctor.
Bapu Jena: And there seemed to be some adverse effects. So, if you can have one, I think that matters a lot. They can help coordinate care. And if you've got a lot going on, medically complicated, It can be difficult for any given physician to sort of take quote unquote ownership of all of the medical issues, uniting them under one umbrella to figure out how they interplay with one another.
Bapu Jena: And a good dedicated primary care doctor can really serve that role.
Sasha Yamaguchi: Oh, that's great. Well, I think that leads right into, I want to talk to you a little bit about employer sponsored programs and benefits and the experience that a lot of employers are trying to bring to their members. Have you worked with employers or do you have thoughts around, as they're building their benefit designs, how can they be creative and design a plan that steers members the right way or just allows them to engage more in their health care?
Bapu Jena: Yeah, I think it depends on what the employer's goals are. I would think that employers have two different goals and the health care benefit is just sort of a path to achieve those goals. I mean, employers, by definition, they are employing you to help them run the company that they are running, right?
Bapu Jena: They're not primary care. Physician groups. They're not hospitals. They're not invested directly in your health care because they're concerned about your health care. Specifically, they are, as they should be concerned about you as an employee. And so what do they worry about? They would worry about two things.
Bapu Jena: Primarily, they want to make sure that you're productive at work, and they want to make sure that If you are productive at work and you're doing a good job, that they're able to retain you because the labor market is pretty competitive and they might lose you to another employer. So they think about those things.
Bapu Jena: And one of the ways in which employers will try to compete for employees is through the health benefit. So, if you offer more generous health insurance, you can expect to get higher quality workers, I think. That's what they would say. So, I think what it comes down to, well, what are you trying to do? Are you trying to improve productivity?
Bapu Jena: Are you trying to attract and retain certain types of employees? The way you design your health benefits matters for those types of things. We've seen an explosion in wellness programs, things of that form, which I think are primarily going to be focused on trying to improve worker productivity. So, those are, I think, the incentives that are at play.
Bapu Jena: In terms of what they could do that's different or creative, I think there's two things. The easy thing is they can experiment. They can try to figure out whether or not wellness programs work. They can figure out how different benefits do in terms of retaining workers. But what I think is really the most creative thing that they could do, taking the data that they generate and answering questions.
Bapu Jena: In a rigorous way. So what do I mean by that? An employer cares about two things, the productivity of the worker and their ability to retain workers. That's what they care about. So wouldn't it be interesting if they were able to do the experiments where they. Randomize employees, perhaps across sites, to a wellness program.
Bapu Jena: Randomize them to a primary care office that is close to the work, or maybe even on site a couple of days a week. Maybe they randomize their employees to access to telemedicine for mental health counseling. Whatever it may be, and then they study the effect of those things on what they care about, which is worker productivity and worker retention.
Bapu Jena: And again, the idea is that they're doing these things because it ultimately helps them retain good workers and make those workers productive. And they believe that. But in order to know it's true, you actually have to show that, you actually have to study it, and they have the ability to do that.
Sasha Yamaguchi: No, I love that because I like the study aspect of it, because groups will do some of these things, but are they looking at how it, the results come out?
Sasha Yamaguchi: And I think that's super important. And then I would say, in addition to member experience, For self funded employers, which groups are moving to self funded more than ever, this is also important from a utilization standpoint, right? You want to get your population healthy. And ensure that you're having a positive outcome on the utilization.
Sasha Yamaguchi: I feel like all the things you just said, the experimenting, trying new things, helps the member, helps their experience, and then also helps the actual plan.
Bapu Jena: Yeah, that's a really important point. I would say that's an omission on my part. You're absolutely right. I mean, I kind of focused on the things that the employers directly care about, like productivity, retention.
Bapu Jena: But, For most employers, the health care costs are a huge line item for them. So it's the same thing as the cost of capital to house workers, the computers, all that other stuff. And so being thoughtful about the benefit design to make sure that the costs, whatever you do, might affect costs one way or the other.
Bapu Jena: Some things that you do are going to clearly increase costs, but they're valuable to the employees. And so that's good for you as a company. Other things that you do. Might actually reduce costs, but they might require investments for you to make. And so they would think about those things as well, but again, because healthcare is a significant cost for most employers.
Sasha Yamaguchi: Yeah, no, I was going to say the financial teams are what care about how the plan is running. But I also love what you just said is when I used to, or still do, meet with clients, it may be an investment up front, but your member experience and the health is going to get better. And then you may even have dollars to reinvest and continue to roll programs out, which I think is really important.
Sasha Yamaguchi: And I know a lot of groups on sites are very popular. You kind of mentioned that as part of your response. And I think when employers are able to do on site services, that's really valuable as well.
Bapu Jena: Yeah. And, you know, on site services, I mean, it could be health provided to not just to the employee, but to the family members as well.
Bapu Jena: But it's the sort of thing where you can kind of. Study the use case. You can look at what happens when you put in onsite care. Cause two things could actually happen. One is sort of the optimistic view, which is you put in onsite care and people who would have otherwise taken half a day off. To go to the doctor, which is what I would probably have to do if I go to the doctor a third or a half day off.
Bapu Jena: They're less productive for that time, so you could measure how much more productive they are and see if it's worth it. And maybe it is, but there's a different view, which is that if you make care easier for people, they're going to use more of it. And I think things like telemedicine. Are probably a good example.
Bapu Jena: When we initially conceived of telemedicine, most people were thinking about it as perhaps saving, saving money because people would substitute telemedicine from in person for in person visits and that might save money. Well, that doesn't work if what people do is just add on additional care and say, okay, well, I wasn't ready to go to the doctor for this because I don't think I really need to, but well, I can hop on the computer and just get evaluated really quickly.
Bapu Jena: You're just adding on care. So. Again, it's a thing where an employer can put the data together and then understand what is the impact on cost of medical care, what are the impacts on the job side of things.
Sasha Yamaguchi: No, you're right. And as you're saying that, it is amazing telemedicine, right? It, over the years, how it's evolved where you can video chat with a doctor and, and talk to them about something.
Sasha Yamaguchi: What a great thing to have available, but you make a really good point that they're probably also now doing more than they did before. So.
Bapu Jena: And sometimes it can be good, sometimes it's not.
Sasha Yamaguchi: Right, right. Especially if they call every week with maybe something similar that they know how to resolve. What factors do you think go into what companies perceive as good spend versus bad spend when they are building that benefit design?
Bapu Jena: My guess is that what they mostly focus in are the things that you were talking about, which is it's an investment. What is the impact of that investment on the overall cost of care? Sometimes they might be focused on quality, so there are things that cost more money, but they give you more quality care.
Bapu Jena: I'm going to give you a good example, like a hepatitis C drug. Those drugs, when they came out several years ago, were very expensive, and employers who had patients who had hepatitis C, chronic hepatitis C infection, were rightly concerned about what would be the impact of that spending on their health care spending.
Bapu Jena: And there's a situation where, look, these are important drugs. Are you really going to deny people who have hepatitis C access to these important medications? Some did, and many probably did not. They found ways to make it work. But they're increasingly thinking about What they get for what they spend and by that I mean, what is the quality improvement?
Bapu Jena: Do people live longer? Are they healthier as a result? And then also they think about what is the impact on spending? So if you subsidize prescription drug medications, people might use more of them and that might cost you more money But if that keeps people out of the hospital That could save you money as an organization.
Bapu Jena: So organizations think mostly about the healthcare spending bucket. But going back to what I said earlier, I think where the really interesting or as interesting line of questioning is, is how does how you design your health benefit affect what you do as a company, how productive your workers are, how likely you are to retain them.
Bapu Jena: That is an avenue of inquiry that I think has received less attention than it probably should.
Sasha Yamaguchi: Interesting. And I, I do remember when that hepatitis C drug came out and the conversations that employers were having around that. So that's a great example of what can come up. What do you foresee as the biggest challenges for providers and payers as the healthcare business becomes Increasingly more patient centric and value oriented, which we were talking about earlier.
Bapu Jena: I think there's going to be a lot of things that they're going to be thinking about. Let me just pick one, which is, I think, a major part of the efforts to improve quality, to improve value, have centered around data. And first, obtaining data that allows you to measure quality. And then two, Trying to directly measure quality and this is something that providers they realize that there's a value there But they also have a problem with it.
Bapu Jena: So when you have a doctor, for example, whose Patients with hypertension don't perform as well Is that because the doctor is not doing something correct or because those patients are less likely to be adherent to the medications? That would allow them to have better health outcomes. So quality measurement is challenging Because it's hard to separate what is the effect of the doctor or the nurse, practitioner, or the hospital from what's the effect of the patient.
Bapu Jena: And I think that there's ways that you can get around that and people are starting to think more about measuring the processes by which care delivers good outcomes. The data angle, I think, is an interesting one, which probably people are spending a lot of time thinking about. Obtaining the data to allow them to do robust quality measurement, because then you have a sense of, all right, well, if you're spending money on this, are you getting something from it?
Bapu Jena: In terms of improved quality. It's the thing that everybody's trying to figure out.
Sasha Yamaguchi: And when you think about members and employees taking more charge of their health, how can employers help and inspire that positive behavior change? in the employees to take care of their health. I think this started back when high deductible health plans started, right?
Sasha Yamaguchi: That was the whole reasoning for those programs. But overall, how can we start affecting that behavior change with employees to really continue to take charge of their health?
Bapu Jena: It's very difficult. Sasha, if I knew the answer, I would have my own company right now. I think it's really hard. I mean, you spoke about high deductible health plans.
Bapu Jena: There is a lot of interest in those now. They're not as interesting and there's a major question of what kind of insurance do they actually provide people and whether or not. Putting more quote unquote skin in the game actually delivers good things, or is it actually harmful because people don't invest in things like certain Lifesaving medications that they should be taking because they have too much quote unquote skin in the game But I think behavior change is really difficult.
Bapu Jena: My own view is that The solution to changing people's behaviors has got to focus mostly on technology because we try to do a lot of things to incentivize people to be healthier, to eat better, to exercise more. Companies give employees gym memberships. Right? Like by and large, I think the evidence would suggest that those sorts of things don't do too much to improve outcomes.
Bapu Jena: The environment that workers are in, like if you have on site gym facilities, if you have healthy eating options or majority of your eating options are healthy on site, what impact does that have? And how much does it cost? I mean, those are interesting questions. You might predict that having access to those things would improve outcomes.
Bapu Jena: I don't know if they do. In general, it's sort of something that a company would have to study. But I think the big barrier to a lot of these behavior change initiatives is that they're just costly to do. They require time. They require effort of people. One of the things that people think about a lot are nudges.
Bapu Jena: Trying to get... People to get nudged into behaviors that they want to do, but otherwise there's some sort of barrier, maybe not a significant one, that prevents them from doing it. And so when it comes to gym membership, okay, instead of giving somebody 50 gym membership, which requires them to drive 20 minutes, 30 minutes after work to go to the gym, Maybe what you do is you allow them 45 minutes in the middle of the day.
Bapu Jena: It's scheduled, gym on site, you see what impact it has. It may be worth it, maybe not.
Sasha Yamaguchi: So I would love your thoughts on this. As you're talking, I'm thinking about, and this is something that I've talked to a lot of people within my company, and it kind of goes to remote work. And as you're talking about going to the gym and getting healthy, I feel that a lot of people enjoy the flexibility of remote work, right?
Sasha Yamaguchi: Which is a great... Evolution over the last few years because of COVID that people are able to work at home, but I will tell you and I would love your thoughts. I feel like there's more people that it's affected their health. They may be more productive, but they're sitting all day. And I've been thinking a lot about this of if you're on video, you're on calls, you're working all day sitting, that has got to also affect employees health, members health.
Sasha Yamaguchi: And it's just, it's been on my mind of Is that going to be the new push or incentive to, yes, have this great flexible work situation in our new world, but how is that affecting people? And it's just been something that's been on my mind a lot lately of it can't be good for our physical health or mental, right?
Sasha Yamaguchi: To be inside all day. So.
Bapu Jena: Yeah. Well, here's the thing. Like, from an economic perspective, it's hard to argue that it's not good for mental health. It may not be, but my initial instinct would be that people who are working remotely right now, they have the opportunity to go into work. And so if they're not going into work, they're choosing to work at home, why is that?
Bapu Jena: I would presume that they're choosing to do that because it's utility enhancing, it makes them happier to do that. Now, it is true that sometimes we do things that... Make us happy, but that long term are worse for us. That might be going on here, but I think that people are probably better off from an emotional or happiness perspective by being able to work at home for the reasons that you described.
Bapu Jena: And people are quite, quite averse to going back to the office when they're forced to do it. You raised another interesting question. What is the impact of that remote work on health? Also, a really interesting question, and I don't know which way it would go. Like, on one hand, yeah, you're right, sitting at your desk in your home, if you have that kind of job, may be more sedentary than what you were doing before, where you'd hop in the car, drive to work, maybe walk around, talk with some colleagues, that sort of thing.
Bapu Jena: But it's also the case that you now potentially have an extra hour and a half or two hours to do something that would otherwise have been difficult for you to do. What do I have in mind? Food prep. Right, if you have a busy job and you're coming back home at 630 at night, it is difficult for you to prepare home cooked meals.
Bapu Jena: Now you're at home in the middle of the day, you can start something up in the morning, it sits, marinates for a couple hours, and you take another 10 minutes off to do something else. What's happening to the quality of food that's being eaten at home? Is it better or worse? Same thing would be true for exercise, right?
Bapu Jena: Like, you now have an hour and a half that you no longer have to spend commuting. Do you have time to exercise more? And there's some, some work I think, I don't know what direction it goes, like looking at things like BMI and blood pressure and things like that. It's sort of select samples to study, but I wouldn't be surprised if you actually found that health was actually improving.
Bapu Jena: But it's ultimately, it's an empirical question. And a company could do that, right? They could say, We're going to randomize some people to at home work and randomize people to coming into work. If people are averse to it, they pay them extra to do one or the other, whichever one they don't want to do. And then they study the impact on productivity.
Bapu Jena: Which is that they're probably mostly concerned about and study the effects on health as well.
Sasha Yamaguchi: Interesting. I feel like again, I think soon we're going to start seeing some of those studies, right? There's so many companies struggling with remote versus in office and I think it'll be a big topic coming out where we'll start seeing some of those studies.
Bapu Jena: Yeah, I mean, I'll just say that anecdotally, the companies that I work with, I've talked to, most of them would say that their productivity has gone up by pretty objective criteria.
Bapu Jena: I don't know how that's true generally. For certain types of occupations, productivity might have gone up, though people are concerned about spillover effects, where again, you're not having the water cooler chats, etc. Those are sort of feelings. What do you, this is something that you can quantify. So I'd be curious to know if you looked at this in a systematic way, what do you see?
Sasha Yamaguchi: Interesting. Well, well, we may have to have a follow up discussion once we see some of those outputs in those studies. Cause it's just, it's been on my mind lately and I feel like it will be similar to the way wellness programs were popular a few years ago. Is there something coming around just employee health when they're fully remote or not?
Sasha Yamaguchi: So, Last question, I feel like those of us that work anywhere within the healthcare space, you may be at the airport or running around and you run into someone and people will always ask, what do you do for work? Sometimes people don't necessarily say healthcare right away because they know there could be lots of questions that come from that person.
Sasha Yamaguchi: So sometimes you maybe want to say it and then they ask. You all the questions or shy away from it, but have you had anybody that you've interacted with where you told them exactly what you do and it led to a really interesting conversation?
Bapu Jena: Oh, it always does, they'll ask me what I do and I'll say, let me just give you an example.
Bapu Jena: I worked on a study which showed that when cities host marathons, people are more likely to die because. Older Americans who live near the marathon route can't get to the hospital if they have a heart problem, and it's because all the roads are closed. When I talk to people about what I do, I just tell them an example of the kind of studies that I work on.
Bapu Jena: They get excited about it. They're like, oh, well, what did you think about this? Did you think about that? Well, all right, well, Does that mean we should not have marathons anymore? You know, that's chapter one or chapter two of the book, by the way.
Sasha Yamaguchi: You have really interesting examples to give, too. So I think it's fascinating for people when you tell them what you do and then make it real for them.
Sasha Yamaguchi: I'm sure they want to ask all kinds of questions. Has someone ever said, did you think about this and given you a new idea? To look and make a connection point.
Bapu Jena: Oh yeah, all the time. I'm really lucky because, because the type of work that I do, it's sort of specific. It's sort of like, the way I describe it is Freakonomics meets medicine.
Bapu Jena: And anytime people have those sorts of ideas, like, I think they think about me. And so, one of my favorite studies that I was lucky to be a part of wasn't my own, but it was one that a friend and colleague of mine brought me in on. It was an idea that He and his buddy had, which was to look at what happened to NFL players when the league went on strike in 1987, I think it was.
Bapu Jena: There was an NFL player strike and there were a bunch of replacement players who replaced the NFL athletes because they were on strike for a few games. And... My buddy, Athene Darvin Kataramani, who's an economist doctor at University of Pennsylvania, his idea was, well, maybe we could use that as a natural experiment to look at what is the effect of playing football on your health.
Bapu Jena: And he had the idea of taking NFL athletes and comparing them To the replacement players. These are people who are almost good enough to play in the NFL, but for some random reason didn't. They didn't quite make the cut, but they were close to making the cut. And so that's sort of a good control group because you can't compare NFL athletes to the general population.
Bapu Jena: That's not the right comparison, but you can't compare them to the replacement players. And you know what? People have to read the book to find out what we found, but that's an example of somebody coming to me with a really terrific idea.
Sasha Yamaguchi: That's a fascinating one and I love that and I will share with you because I know you did a study around twins and marital status and I will just share with you that I have twins. I had three children under the age of two.
Sasha Yamaguchi: So my son was very young when I had my twins. And I just celebrated my 22nd wedding anniversary. So um, and I will share with you, I mean, we made it through because we would just look at each other and be like, we just got to laugh and get our way through it. And it was crazy, but we're thriving after surviving three under two.
Bapu Jena: That's good to hear.
Bapu Jena: Sasha, let me ask you a follow up question. Do you mind telling me the genders of your kids?
Sasha Yamaguchi: So, our oldest is a boy, so he was 20 months, and then we had twin fraternal girls.
Bapu Jena: Oh, okay. Good.
Sasha Yamaguchi: So, does that make a difference?
Bapu Jena: Well, no, the reason I ask is because in the study that you're referring to that we did, this is something I, actually, this is a study I did in grad school as part of my thesis.
Bapu Jena: We found that couples who have twins, this is pre IVF, couples who have twins were more likely to get divorced. Then couples who did not have twins, and again, this is pre IVF, so this is sort of random, like holding maternal age constant. But the effect was mostly among couples who had twin girls. That was sort of the most quote unquote destabilizing compared to twin boys.
Bapu Jena: And so if you said to me, I've got twin boys, I'd say, all right, okay, you're kind of consistent with what we found, but I'm an outlier. You're an outlier. You are the outlier. Well, congratulations on your anniversary.
Sasha Yamaguchi: Thank you, thank you. And mine were spontaneous twins, by the way, so not planned. It was quite the shock, but anyways, I had to mention that to you because I knew you had done a study on that, so maybe we'll have to talk about that more at another time.
Sasha Yamaguchi: Well, thank you so much. This was wonderful. I would love for you to share with the audience how to find you, and again, tell them about your book, where to find it, and let them know how to reach out to you.
Bapu Jena: So my book is titled Random Acts of Medicine. It's with my colleague Christopher Worsham. He's a Harvard critical care doctor and researcher.
Bapu Jena: And we also have a sub stack called Random Acts of Medicine where we have a weekly newsletter where we talk about all sorts of different ideas that are related to the ideas in the book. And I have a podcast called Freakonomics MD, which you can download wherever you listen to your podcasts.
Sasha Yamaguchi: Great. Well, thank you so much for joining me.
Sasha Yamaguchi: I am a beginner podcaster, so I'm honored to have you on as part of our first season, and we really appreciate it, and thank you so much.
Bapu Jena: Oh, pleasure was all mine.
Producer: This podcast is brought to you by Collective Health, a health benefits solution that guides employees toward healthier lives and companies toward healthier bottom lines. Check us out at collectivehealth.com.