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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
As listeners know, the month of May marked the release of a full theme issue of Health Affairs Journal dedicated entirely to research and analyses at the intersection of climate, health, and equity. Now, at this point, it's pretty clear that climate change has significant and serious impacts on people's health. We also know that different populations are affected differently with the most vulnerable populations paying the highest price. And yet there's still so much we don't know, including how this variation and these costs manifest when controlling for factors like insurance status, geography, and age. That information sure would be good to know, especially as we think about potential policy interventions aimed at mitigating the health consequences of climate change.
Rob Lott:These are some of the questions we're going to consider on the podcast today. I'm here with Doctor. Jeff Romine, a research scientist with Carillon Research. And together with coauthors, he has a new article in the May issue of Health Affairs describing, quote, Extreme heat, healthcare use and costs, Evidence from Commercial Insurance, Medicaid and Medicare Advantage. This is such an interesting paper, a lot of really illuminating findings, I can't wait to hear how they did it.
Rob Lott:Doctor. Romine, welcome to our Humble podcast.
Jeff Romine:Yeah. Thanks for having me. Very excited to, be here and always love talking about research.
Rob Lott:Awesome. Well, you're in the right spot for it. Why don't we, maybe start with the existing literature, in this space? And I'm hoping maybe you can tell us a little bit about what we know about the impact of extreme heat on people's health, especially things like emergency department visits and mortality.
Jeff Romine:Yeah. That's a great question, and my answer will not cover the totality of the body of literature. There's a very strong body of evidence showing that extreme heat is definitely associated or depending on you're if an economist like me or not, would say, causes, increased utilization when it's hot. So, as you had in the question, ED utilization is where there's some strongest evidence. There's really good data on ED utilization that, academics can use, really good public access data there.
Jeff Romine:So very strong evidence from many different papers showing that all cause utilization increases, heat related illness increases, and just very many different types of conditions. So, like, illness, chronic kidney disease, mental health. Mental health is especially impacted by extreme heat, so very detrimental to mental health. Can definitely increase the utilization of four severe mental health disorders. So very strong evidence of many different great authors doing great work showing that, yes, there's there's a strong association between extreme heat and ED utilization.
Rob Lott:Okay. So we've got great data on emergency department visits. How about mortality?
Jeff Romine:Yeah. There's, very strong evidence showing that mortality increases when it is hotter, especially among the more elderly populations and especially more, among individuals that have, higher chronic disease load. So there's also for mortality, there's also very strong evidence that mortality increases when it's cold. So, not just extreme heat impacts mortality, but also, extreme cold. So on both ends of the temperature spectrum having impacts.
Rob Lott:So we know less about outpatient use. Is that right? And I'm curious if you can tell us a little bit why there's less of an evidence base in that space.
Jeff Romine:Yeah, yeah. So ED utilization has very strong body of data to be able to be used, and there's just not this data to be available for studying outpatient use. It really requires an administrative claims like insurance database. You'd have to go to CMS or like a pay all payer database, people would have this sort of outpatient utilization data. So much more rare data to be available.
Jeff Romine:And there's also some suggestions that the signal could just be smaller for outpatient utilization. So there's just not as much research being done there as it's not the focus.
Rob Lott:So you said the signal might be not as strong. I guess what you're sort of getting at is that if there's an impact, it might not be as sort of pronounced as sort of a increase in emergency department visits after a heat wave, that kind of thing. Is that sort of what you're getting at?
Jeff Romine:Right, right. So it could be that there has been research in this field that just hasn't been, could've or might not have been published because it's just a weak signal or might just be that the methods that were being used couldn't detect, any changes in ED or in outpatient utilization associated with heat. So it's one where it's almost hard to guess at because there is just such a lack of evidence in outpatient utilization. The little bit of outpatient use, and its association with heat is from a few different papers showing that there's cancellations of outpatient visits, like planned outpatient visits when it's hot, so almost an avoidance behavior there. And there's a few papers from China showing that, cause specific utilization increases, so respiratory and other conditions like that, but nothing looking at the totality of outpatient use.
Jeff Romine:It's really and especially totality across an entire country. It's really just challenging data to have.
Rob Lott:Got it. Well, you attempted to, fill some of that gap, with your paper in the May issue. You looked at the relationship between extreme heat and ED inpatient and outpatient use among people with different kinds of coverage, a large national insurer with commercial insurance, Medicaid managed care, and Medicare Advantage plan. You also looked at costs. What were some of your top line findings?
Jeff Romine:So really the top line findings are that we find similarities between our paper and other work showing that when it's hot, that ED utilization increases. We also see some increases in hospitalization or what we call in our paper in inpatient utilization, and that's been documented in some papers, but not nearly to the extent of ED utilization or mortality. And then our final place of service that we looked at is base unsurprisingly based on the questions we've talked about so far is outpatient use. And because of the dataset that we're using, we actually outpatient utilization for around forty million people in our sample. So we find that there really was not much of an association between outpatient use and hotter temperatures.
Jeff Romine:So could be many reasons why this would be, but really just going into more detail on some of these, we find similar impacts on ED utilization as other papers, but what we add to the table or bring to the table is that we actually have direct cost data. So by having direct cost data, we're not we don't have to approximate a change in cost based on how assuming that the change in cost is the same as the change in utilization. So we're actually modeling cost directly, and we actually find that there's actually similarities between ED cost and ED utilization. It's about the same percent change in ED cost and ED utilization, so that is something new that we bring to the table there. For inpatient utilization, see that there are a couple different groups, ones that we might think of as more vulnerable, such as individuals who have Medicare Advantage coverage or children or some insurance types of children, as well as some member or some individuals on Medicaid.
Jeff Romine:So see that they actually have increases in inpatient utilization and hospitalization, which not totally new, but a little bit new that we divided up by age group and insurance type. And then finally, for the outpatient, we, as I said earlier, really don't see too much there, which is new and also a bit surprising.
Rob Lott:Great. Well, I want to ask you a little bit about that surprise, if you will. But first, let's take a quick break. And we're back. I'm here with Doctor.
Rob Lott:Romine, a research scientist with Caroline Research, talking about, evidence from commercial insurance, Medicaid, and Medicare Advantage of the effect of extreme heat on healthcare use and costs. And you just a moment ago said that there was a bit of a surprise in your findings. Can you dig into that a little bit? What was unexpected?
Jeff Romine:Yeah. So what we found is that outpatient utilization, unlike ED utilization, hospitalization, mortality really didn't have a clear trend across the temperature distribution. The other outcomes, we'll see decrease when it's colder, and as the temperature increases, we'll see an increase relative to a temperate temperature. So everything we do in our paper is relative to essentially 60 to 70 degrees. What we find is that over a 100 degrees, there's not more outpatient utilization than between 60 to 70 degrees, which seeing as all of our other other outcomes, we actually ran outpatient last.
Jeff Romine:It was just our final outcome. We had seen everything up to that point. We have this clear trend. It utilization goes up when it's hotter, and we don't see that for outpatient utilization. And there's a couple different things that we hypothesized in the paper and that based on some papers that look at planned outpatient utilization, it could be that it's just an avoidance behavior.
Jeff Romine:People are people are canceling planned outpatient surgeries or outpatient visits because they want to avoid really hot temperatures, which is totally reasonable, mitigation behavior. Don't wanna go out when it's hot, but it also, beyond the scope of this paper, mean that there's just missed appointments, missed care. So even though there isn't an increase, it could be because not for good reasons. So we don't it's hard for us to get that in our paper, but that's based on other papers. The other unexpected finding that we had is when we were first starting this project, we hypothesized that cost would actually increase more than utilization, and that would kind of indicate that there's actually increase in the average cost of visits when it's hotter, but we really don't see too much of a difference in percent change in cost or the percent change in utilization.
Jeff Romine:So we're actually kind of surprised by that aspect as well.
Rob Lott:Got it. And can you say a little more about sort of the time frame where you were looking at these these costs and the the utilization in relation to these extreme heat events? And I guess what I'm getting at is, is it possible that the the increased costs or increased utilization might might be taking place further downstream than than what you're looking at.
Jeff Romine:Yeah. A fantastic question. So, just to to help the listeners get context of just our the years we're looking at, we were looking at 2016 to 2023. And then for our actual analysis of how is heat associated with utilization and cost, our main specification, our main model is looking at in the same week. So we allow for how We look at the number of days in different temperature bins within the same week.
Jeff Romine:So we know how many days are above 100 degrees, how many days are between 80 to 90, and so on, and we run a regression with a bunch of controls to account for seasonality, different factors, and that's really looking at how does same week temperature, how is that associated with cost utilization in that same week? So to kind of test whether there are lagged effects, so does heat now increase utilization later, we actually allow for three weeks, the following three weeks to be included as well. We can understand how does heat now affect utilization three weeks later. And it changes our results number we're getting, but doesn't change the magnitude or the relative significance of our results. So we actually see most impacts contemporaneously, so within the week, and that really matches other papers in the literature that really show that most of the impact is happening in the same week, the same day even, and then just the next day.
Rob Lott:Got it, got it, okay. So one could envision a world where someone, you know, is stuck at home on an extremely hot day, they, you know, they are, you know, suffering and affects their health and maybe it exacerbates a chronic condition and, you know, they're still struggling with that a week down the road or two weeks down the road or even, you know, months and beyond. So I can imagine that sort of timeframe could have an effect on how, act I don't want to say how accurate. So the timeframe could sort of affect the downstream outcome that you're measuring. Is that a fair take?
Jeff Romine:Yeah, yeah. So there will be sort of off set as it's delayed care, have utilization later, but it also could be that heat is actually pushing care that would have needed to happen later earlier. So it could exacerbate conditions sooner. So there's this trade off between delay but also delaying more possibly less acute care but also pushing more acute care sooner. So there's this trade off and this tension between these two.
Jeff Romine:So that's why we account for this month long lag as well to ensure that there's not these longer, what you call medium term effects that would change our results. But it definitely could be that we're we are not including years long. So we're not looking at how it heat may increase the progression of chronic kidney disease or something like that. So we're not looking at progression of disease, but we are seeing that most of the effect is contemporaneous, is within the same week. We're not seeing too much of a difference when we account for this more medium month long impacts.
Rob Lott:Got it. Well, as with most of the papers we publish here, it's not so simple as you're suggesting there's a lot of trade offs and a lot of overlapping factors that have different impacts. I guess in that context, you know, on one hand, the fact that different populations feel different impacts from extreme events is not very surprising. On the other hand, this complicates any effort to find the kind of interventions that might be most effective in the face of these events. In other words, like one size fits all solutions may not be sufficiently targeted.
Rob Lott:And I'm curious, how, you think we should be thinking about this tension.
Jeff Romine:There are differences in how heat is going to impact different populations. What we find in our paper is that almost all or all populations have an increase in need of utilization, but only some have an increase in inpatient utilization. So we see that targeting older individuals may provide an opportunity to have a more focused and per person higher impact and have a higher improvement in health per person. So there's always gonna be limitations in what can be done, so there is evidence that some individuals are gonna be more impacted, more susceptible to heat, and allows for targeting there. And there's many other papers showing that there are specific chronic conditions where individuals are more impacted.
Jeff Romine:The paper that we did previously to this one looked at only the chronic kidney population. We saw they were actually impacted more by heat than just the average individual in this paper. So having cuts of the population and understanding how heat differentially impacts groups allows for, in the time being, there to be more targeted interventions and allows for, just as a from a research perspective, the possibility to find, like, statistically significant impacts of these interventions. Are these interventions effective? Are they decreasing the utilization and cost that is associated with heat?
Jeff Romine:So by targeting different populations, it allows for larger improvements in health per person on these targeted pilot interventions or so on, and really allows for intervention to be most helpful by doing this targeting.
Rob Lott:Got it. Well, a great framework for us to think about future research as well. Doctor. Romine, thanks so much for taking the time to talk with us today. I had a really good time.
Jeff Romine:Thanks for having me.
Rob Lott:Well, everyone, thanks for tuning in. If you enjoyed this episode, please recommend it to a friend, leave a review, and of course, tune in next week. Thanks, everyone.
Jeff Romine:Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about A Health Podyssey.