In a recent panel discussion at Penn, Leana Wen, MD, MSc, Baltimore City Health Commissioner, spoke about the role of public health in Baltimore and how academic institutions can work with public health departments. I spoke with Dr. Wen before her panel about how policymakers use economic evidence, and how we can make evidence more useful to policymakers. What follows is an excerpt from our conversation, edited for length and clarity.
Q: As part of our translation and dissemination work at LDI, we try to understand what policymakers need and how to bridge the gap between the kind of evaluations that economists do and the kind of things that you need to actually influence policy.
LW: Absolutely, I think it’s so important. That’s one of the aspects that we don’t do well in public health. We talk about cost – we don’t talk about value.
Q: That gets right into some of my questions. Let’s take the example of the economics of substance abuse treatments. I notice that in your statements, you use a 12 to 1 ratio for broad societal savings for every dollar you spend on substance abuse treatments…
LW: Right. I would love to be able to say more, because everything that I do is about marrying stories to numbers, but I don’t have the right numbers. I would love to be able to say that over the course of the next five years, by investing one dollar in treatment, we’re saving X number of lives and we’re saving X amount in terms of medical cost and we’re contributing back to society X amount in terms of criminal justice and other costs.
Q:From what you’ve seen, do policymakers care about the nature of the evidence or methodological rigor?
LW: I think it depends on who you’re speaking to. We do lots of calculations, but it would be a lot better if we have a preliminary study that we can point to. It would be extremely helpful if we could say that this is the approximate cost of incarcerating somebody for three years and if we’re able to keep them out of jail for that period…any of those numbers would be extremely helpful.
Q: Economists often talk about cost-effectiveness in terms of QALYs [quality-adjusted life-years] but we’ve heard that there is a gap between the way economists talk and the way policymakers want to hear that information. Is a conversation that sounds like, “This intervention costs $30,000 per additional quality adjusted life year”, useful or how might we turn that into something useful?
LW: I think that if you use the terminology of QALYs, it’s so abstract to policymakers…by the time you explain what a QALY is, you’ve probably lost their attention. So I think it needs to be something more easily understood. I come from a journalism background and so I think of everything as journalism. I think of everything as, “What would I be writing to a person? What would I be writing to the public in a way that they would understand?” So, for example, if I said “When someone is leaving jail, their chance of returning, because they haven’t gotten connected to services, is (I’m making up all these numbers as an example)_ there’s a 50% chance that they’ll end up in jail the first year. But if we’re able to invest $20,000 in a case management program, the chance of them not going back to jail is 20%. And then if we multiply that by the number of people who could be at risk we are saving society $2 million.” That I can get, but a QALY?
Q: And is that persuasive? I’m thinking that the societal point of view is important but because the benefits are so diffuse across agencies, across budgets, that it doesn’t actually address what one silo is going to save. Let’s say you want all insurance to cover treatments but the insurance companies aren’t going to save $12 for every dollar. How do we promote that kind of evidence and make it meaningful?
LW: What if you looked for where your levers are? For example, we’ve been thinking about how we can do social impact bonds for school health. One of the problems we encountered – and we actually have a fellow down from Harvard working on this project with us – is that by preventing asthma visits to the ED for kids we are saving hospitals and Medicaid money, but then how can we convince the city to invest in the social impact bond, when that’s not where the savings are going to be? But I can imagine, for something like incarceration, there is going to be a cost to a broader system, even if it’s not as specific as this is going to save the jails versus hospitals. What if we say we want to design an intervention that can either save the city or the state funding, because that’s one way of breaking down the silos. If you could pitch it to the governor or the mayor that’s one way of getting that point across.
Q: One of the reasons economists use QALYs is to have some sort of standard outcome so that policymakers can compare spending on different things. But if we’re not going to be talking about QALYs, then what, if anything, can we do to show policymakers that comparison – well, you can spend it one way or another way, and here’s what you’re getting for your money? Or doesn’t it work that way?
LW: That’s a very good point. You need those numbers and economists are the ones who will be able to produce those numbers and tell us what the data show. But I think that the people communicating that message may not necessarily be economists. Maybe the communicator of that message needs to be someone from within those worlds. So perhaps you could show those data to policymakers or a specific staff on teams who may come from an econ background but who also know how policymakers think. And they would be the ones to communicate that message because I still don’t think that the QALY message quite works but I think it could; I just don’t know what that that would be.
Q: If you had some advice for health economists doing this kind of research, and usually they’re measuring willingness-to-pay or cost versus benefit, what would you say to them about what you need?
LW: There is a way to bridge that disconnect between what researchers want to do, and what policymakers and community members actually care about. We’ve started reverse research forums, where community members and government entities and others that don’t have the capacity to do research present our needs. And then the researchers will understand the language they need to use and actually a lot of what we’ve discovered is they say, “We already have these data but we didn’t know that you needed to hear it this way.” So it’s those types of conversations that have to occur. There’s no reason it can’t happen in Philadelphia. There’s no reason it can’t happen nationally. But I think you need the community voices in the room and you need to know what the community is looking for.