In the three-and-a-half years since the U.S. Supreme Court overturned the constitutional right to an abortion in Dobbs v. Jackson Women’s Health Organization, the fragmented state of abortion access has put medical professionals in a precarious position. Many states have tightened abortion restrictions, with some enacting criminal penalties up to in for physicians who perform abortions. Medical schools have

New research led in part by the 91±ŹÁÏ found that the new restrictions are not only affecting the current medical workforce — they may be shaping the next generation of physicians. The study, , found that applications to medical residency programs in states that enacted new abortion restrictions dropped sharply following the Dobbs ruling.

The decrease occurred among both male and female applicants. Applications to specialties related to reproductive health — obstetrics and gynecology, family medicine, internal medicine and emergency medicine — saw the largest decreases.

The new study builds on that had shown decreased application rates to residency programs in states with abortion restrictions by applying causal methodologies to understand the impact of the Supreme Court decision and isolating results from male and female applicants.

“This research provides important empirical evidence about how state-level policy changes following Dobbs may influence decisions made by medical trainees about where to pursue their graduate medical education,” said co-author , a 91±ŹÁÏ professor of health economics and director of the Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute.

To learn more about the research, 91±ŹÁÏ News sat down the paper’s three authors: Basu; lead author , assistant professor of medicine at the University of North Carolina at Chapel Hill; and co-author , assistant clinical professor of internal medicine at the University of Arizona. Both Ganguly and Morenz completed their internal medicine residencies at the 91±ŹÁÏ School of Medicine.

The medical residency match process is quite different from traditional higher-ed applications. Can you explain how that works, and how it relates to your study’s findings?

Dr. Anna Morenz: Applicants may apply to as many programs as they want, with some applying to dozens of programs. At the end of interviews, they’ll rank those programs based on their preferred landing spots. The programs, in turn, will rank all the applicants that they received. A computer algorithm then matches everyone with the goal of filling all the residency slots, and it’s very good at that. We know that . So programs are still filling their residency slots even in states with restrictions.

What concerns us about these findings is that there’s an early signal of people avoiding applications to these states. That has potential implications for the quality of the applicants to restricted states, which could not be assessed in our data. There’s typically a high likelihood that people stay where they train for their residency, but if you landed in a restricted state that was low on your rank list, you may be more likely to complete your training and then leave to a non-restricted state. We aim to look at this very important question in projects to come.

Anisha and Anna, you’re both practicing primary care physicians. How big a part of a physician’s training is abortion and other pregnancy-related care? 

Dr. Anisha Ganguly: It’s not a big part of our training traditionally, though there has been a movement to integrate more abortion care into primary care residencies. That’s more the case in family medicine rather than internal medicine, because medication abortion has now become the most common means for abortion care. As internists, we commonly diagnose pregnancies and care for women with medical conditions as they consider family planning.

AM: I do think it’s important to note that a huge percentage of primary care physicians are trained in family medicine. And family medicine physicians are trained in delivery of babies, management of prenatal care, miscarriage management, contraception and abortion. Anisha and I trained in internal medicine, and there is increasing interest to include medication abortion training in internal medicine, as it is fully within our scope of practice.

The effects of the Dobbs decision have been well-documented, and previous work on this topic highlighted changes in OB/GYN residency applications. What’s new in your study specifically? 

Anirban Basu: We had a much longer pre-period than previous studies. We looked back to 2019 to see what had been happening to application rates in these two kinds of states — those that eventually restricted abortion access and those that didn’t — and we showed that these rates had been moving similarly until the ruling. That gives a little more weight to the evidence to say the change is due to the ruling. 

The second big thing is that previous studies did not distinguish whether men and women were changing their behavior similarly. I think that’s a very important finding in our study, that male applicants are changing their behavior at an even higher rate. 

AG: I agree that the gender stratification was an important contribution. The other stratified analysis that we explored was about how specialty type may be driving some of the effects that we saw. A lot of people can reason that OB/GYN applicants would be affected by this directly, and there’s a lot of literature to support that. But what we’re showing is that it’s not just the OB/GYN workforce that’s going to be impacted. It’s the primary care workforce and the emergency medicine workforce. 

We’re hoping that message spreads a little more broadly. This is not just about women’s health. It’s about the future of primary care and the person who’s going to save you from your heart attack in the future.

Let’s talk a little more about that gender stratification. You found that male applicants changed their application preferences at a greater rate than female applicants, which looks like a surprising result. What’s going on there? 

AG: When we generated our original hypotheses, we thought we were going to see increased effects among women applying to residency, but we actually ended up seeing that there were long-term disparities that existed pre-Dobbs between restricted and non-restricted states. This was likely because of the and other state-level laws that were affecting women’s behavior. What we’re seeing is that women had been reading the tea leaves about access to reproductive health care prior to the Dobbs decision, but the decision did unmask a wider problem that drove a lot of new behavior among men.

One of the messages that we are getting from this paper is this is an “all of us” problem. It’s not just about women physicians. It’s about men who are also making choices about their professional autonomy and also about access to reproductive health care for their families. Women have been and will be considering their personal access to care and autonomy before this decision, but perhaps these state restrictions after Dobbs may have newly increased awareness among men. 

Among all these shifts, you found one group whose application rates didn’t change significantly: people applying to highly competitive medical specialities. What do you think explains that stickiness? 

AG: Anna and I had brainstormed about this being a potential effect modifier, because people who are applying in highly competitive specialties like orthopedic surgery or dermatology apply very broadly and don’t get to exercise a lot of choice about where to go. Whereas for large specialities like internal medicine, family medicine or pediatrics, there are a lot of programs in a lot of places, so applicants have more options. In those cases, state-level policies like abortion restrictions can factor more into people’s decision-making.

At an institutional level, what changes could be made to address these trends? 

AG: Institutions can make choices to mitigate some of these effects by supporting candidates with access to reproductive care within the scope of the restrictions that exist. Other industries are building in travel benefits for women who may need to travel to access these services. 

It’s not this aspect of a decision alone that shapes a residency applicant’s choice to go to a specific place or program. But there are other things that institutions can do to make trainees, particularly women, feel supported and valued. If you’re existing in an environment where state policies make women feel a lack of autonomy, then there are workforce policies that can be in place to bolster that sense of autonomy. That could take the shape of parental leave policies, lactation policies, other things that institutions can do to make women feel like, even if this part of your voice has been taken away, we’ll help you with the rest.

AB: One policy that has a long history of literature supporting it is financial incentives. Physicians do respond to financial incentives, but in many cases those incentives need to be quite steep to get people to change their decisions. 

AM: The other option is training opportunities. A lot of programs in states that had laws or restrictions that preceded the Dobbs decision would set up partnerships with organizations in another state where they could send their trainees to learn about pregnancy termination and miscarriage management. That’s a burden on residency programs and residents both. You have to set up housing and travel agreements. But that’s another key thing that programs need to keep in mind in order to recruit applicants. 

For more information or to contact the researchers, contact Alden Woods at acwoods@uw.edu.

Federal agencies that regulate drug pricing and healthcare insurance that an industry practice of using rebates to lower drug costs for insurers has led to increases in list prices and out-of-pockets costs for patients.

To investigate whether patients with or without insurance were paying more because of rebates to insurers, researchers led by the 91±ŹÁÏ examined cost and price data on more than 400 branded drugs. The found that rebates were associated with increases in out-of-pocket costs for patients by an average of $6 for those with commercial insurance, $13 for Medicare patients and $39 for the uninsured.

“We know that list prices have been increasing quite dramatically as have rebates, but no one has looked into the association between rebates and out-of-pocket costs,” said study lead author , an affiliate assistant professor at the in the 91±ŹÁÏ School of Pharmacy. “Increases in out-of-pocket costs are associated with rebates, however rebates also help keep premium costs down.”

Consequently, said Yeung, who is also an assistant professor at Kaiser Permanente Bernard J. Tyson School of Medicine, “There has been inadequate focus on the impact the pricing mechanism has on the uninsured, who are most affected.”

For the , the researchers used data on 444 branded drugs without generic equivalents from national datasets involving healthcare costs and drug prices from 2007 to 2018 including the federal and , a private company that collects and analyzes prescription drug pricing data.

Researchers point out that the cost increases can impact patient health, since higher costs can cause patients to take their medication less often. That, in turn, can lead to increased emergency room use and hospitalizations. People in their study who did not have insurance had the poorest health and those with lower incomes were less likely to take medication as prescribed when costs increased.

“Further,” the researchers wrote, “uninsured individuals were more likely to be in racial minority groups, amplifying pre-existing disparities in healthcare access.”

As a result, the authors suggest future research and policies should focus on decoupling list prices from what patients pay out of pocket, “especially for uninsured individuals.”

“The biggest takeaway is understanding that the rebates work to reduce the cost of prescription drugs for insurance companies and may reduce premiums,” said co-author , the Stergachis Family endowed director of the CHOICE Institute and professor of health economics at the 91±ŹÁÏ School of Pharmacy. “And while it’s unclear how much the discounts are reducing premiums, they are definitely not translating to lower out-of-pocket costs for the patients who are using the treatment because of this structure of coinsurance and copayments tied to the list price.”

Stacie Dusetzina, Vanderbilt University School of Medicine, Nashville, Tenn., is also a co-author. This research wassupported in part by grant funding from the Donaghue Foundation’s Greater Value Portfolio.

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For more information, contact Yeung at Kai.Yeung@kp.org and Basu at basua@uw.edu.

As universities and colleges struggle to find the right combination of in-person and online classes combined with protective measures to help prevent the spread of the novel coronavirus, a new study by researchers from four institutions has reached a troubling conclusion.

Reopening university and college campuses with primarily in-person instruction is associated with a significant increase in cases of COVID-19 in the counties where the schools are located.

“Consequently, we are able to predict between 1,000 and 5,000 additional cases per day due to colleges reopening for face-to-face instruction, with our best estimate being somewhere around 3,000 cases per day or around 21,000 cases per week,” said study co-author , professor of health economics and Stergachis Family Endowed Director of the at the 91±ŹÁÏ School of Pharmacy.

More specifically, campuses with mostly in-person instruction contributed to increases in COVID-19 cases in their county by 0.024 cases per 1,000 residents. And, when students come from outside counties with surging cases, an additional 0.0119 per 1,000 residents come down with COVID-19.

“We don’t see similar spikes in cases for counties with colleges that reopened with primarily online instruction. The total spike attributed to face-to-face campus reopenings accounts for nearly 6 percent to 7 percent of all cases in the U.S. during this time,” Basu said.

Researchers from the University of North Carolina at Greensboro, Indiana University Bloomington, 91±ŹÁÏ and Davidson College conducted the study, which has not yet been peer reviewed. The study was posted Sept. 23 and has been submitted to a journal for peer review.

“Given the timing of the mobility and case spikes,” Basu added, “these results are not likely a manifestation of additional testing or sick cases moving onto college campuses.”

The researchers sampled 1,409 colleges from July 15 to Sept. 13 and out of those classified 886 schools as conducting classes primarily in person, while 483 are teaching primarily online. Out of 1,142 U.S. counties examined in this study, only 779 contained a college in one of these categories, with 15 campuses not open during the sampling period. The researchers then compared these counties to counties without a college and looked at the periods of two weeks before the start of classes and two weeks after instruction began.

One of the signals the researchers used to determine the increase of visitors to a campus, whether for in-person instruction or on campuses with primarily online courses, was the increased presence of cellphones. Regardless of the type of instruction offered, the number of cellphones visiting campus increased significantly, in the week leading up to the start of classes and after classes had begun. However, cellphone traffic was higher on in-person campuses. And, counties with primarily online campuses did not see a statistically significant increase in COVID-19 cases.

“Our main data track cellphone movement on and off campuses and county-level COVID-19 daily reported cases,” Basu explained. “And, all evidence suggests there is a distinct local transmission component, given spikes in cases are happening two weeks after college opens. We also found spikes in cases to be higher for face-to-face colleges that drew students from communities that have seen recent spikes in cases.”

The researchers add that campus administrators and other local authorities should use these findings when considering additional strategies to mitigate COVID-19 outbreaks, and “think carefully” about cases in their counties as well as where students are coming from when planning their spring 2020 semesters.

Co-authors include Martin Andersen, Department of Economics, University of North Carolina at Greensboro; Ana Bento, School of Public Health-Bloomington, and Kosali Simon, O’Neill School of Public and Environmental Affairs, Indiana University; and Chris Marsicano, founding director of The College Crisis Initiative at Davidson College.

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For more information, contact Basu at basua@uw.edu

New by the University of Minnesota and the 91±ŹÁÏ finds that every six additional ICU beds or seven additional non-ICU beds filled by COVID-19 patients leads to one additional COVID-19 death over the following week.

“A spike in hospitalization naturally leads to more deaths, but these deaths may not only come from those who are hospitalized, but also from those who should have been hospitalized but were not,” said co-author , a 91±ŹÁÏ professor of health economics.

Results of the , published in the Journal of General Internal Medicine, show the impact of ICU bed use remains fairly constant as ICU bed availability changes. These effects are also in line with estimates for the mortality among COVID-19 patients receiving critical care that show mortality rates increase as ICUs fill up.

What was surprising, Basu explained, was the effect of non-ICU beds. For additional seven hospitalized patients not in intensive care, one would expect about 0.5 deaths over the next seven days based on general data put out by However, this new research finds that the total number of COVID-19 deaths actually occurring is much higher.

“This may indicate that constraints in available capacity of non-ICU beds may have a spillover effect to non-hospitalized patients. In fact, the study found that the effect of non-ICU beds rises steadily as more and more non-ICU beds are occupied by COVID-19 patients,” said Basu, who is also director of the  Institute at the 91±ŹÁÏ School of Pharmacy.

For example, when 20% of non-ICU hospital beds are occupied by COVID-19 patients, an additional seven COVID-19 admissions to non-ICU beds will produce two additional COVID-19 deaths over the next seven days.

“Even when, say, 80% of non-ICU beds are still available, a further increase in COVID-19 admissions leads to significantly more numbers of deaths than what we would expect from only the hospitalized patients. This may be because the health care delivery within a hospital is not only driven by hospital beds but also personnel and COVID-specific supplies, which may be stretched thin, and affecting COVID-19 admission policies of the hospitals.”

Consequently, Basu said, efforts to “flatten the curve” — that is, reduce or stop the increase of people infected with the novel coronavirus through public health measures such as mask-wearing and physical distancing — are more important than simply keeping hospitals from becoming overwhelmed. Failure to flatten the curve, even before hospitals reach capacity, is killing more people than just those who end up in hospital beds.

“These results have very important implications as large numbers of students head back to schools and colleges across the nation and resistance to public health measures continues to stymie efforts to reduce the number of infected,” Basu said.

“Our study quantifies the relationship between COVID-19 deaths and COVID-19 hospitalizations using actual data,” write the study authors. “These estimates provide a better understanding of the projections of the COVID-19 pandemic in the USA especially when states are gearing up to restart economic activities and provide important practice insights for hospitals in terms of assessment of hospital bed and ICU bed capacity and preparedness.”

The study’s lead author is , University of Minnesota professor and academic director of the  in the university’s . The researchers used the University of Minnesota’s  to examine data from 23 states that reported daily percentages of ICU and non-ICU-bed use by COVID-19 patients. The research was partially funded by the University of Minnesota Office of Academic Clinical Affairs and the United Health Foundation.

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For more information, contact Basu at basua@uw.edu.

Is COVID-19 more deadly than the flu?

It’s a lot more deadly, concludes a new study by the 91±ŹÁÏ May 7 in the journal Health Affairs. The study’s results also project a grim future if the U.S. doesn’t put up a strong fight against the spread of the virus.

The national rate of death among people infected with the novel coronavirus — SARS-CoV-2 — that causes COVID-19 and who show symptoms is 1.3%, the study found. The comparable rate of death for the seasonal flu is 0.1%.

“COVID-19 infection is deadlier than flu — we can put that debate to rest,” said study author , professor of health economics and Stergachis Family Endowed Director of the Institute at the 91±ŹÁÏ School of Pharmacy.

The School of Pharmacy and Basu have that explores the infection and fatality rates by U.S. counties for people with symptoms. For this study, 116 counties in 33 states had COVID-19 data that fit Basu’s robust criteria for inclusion in the analysis. The site’s projections will be updated as new data becomes available, Basu said.

91±ŹÁÏ’s CHOICE Institute Interactive:

Basu stresses that this website is not a forecasting tool — it does not predict what will happen in the future. Rather, it uses the estimated death rate among symptomatic COVID-19 cases to project what is happening currently in these communities, such as what are the likely numbers for total infections and symptomatic cases. The tool will also detail how the daily incidence of infections changes.

In the state of Washington, for example, the county-specific fatality estimates ranged from 0.5% to 3.6%. King County at 3.6% is the highest among all 116 U.S. counties studied. Among the state’s other counties that could be included in this analysis were Chelan County at 2.3%, Island County at 2.2% and Spokane County at 2%.

The COVID-19 death rate, the study adds, means that if the same number of people in the U.S. are infected by the end of the year as were infected with the influenza virus — roughly 35.5 million in — then nearly 500,000 people will die of COVID-19.

However, the novel coronavirus is more infectious than the influenza virus, Basu noted. So, a conservative estimate of 20% of the U.S. population becoming infected by the end of the year — with the current trends in social distancing and health care supply continuing, while accounting for those infected who will recover asymptomatically — could result in the number of deaths climbing to between 350,000 and 1.2 million.

“This is a staggering number, which can only be brought down with sound public health measures,” Basu said.

To build county-by-county models that could more accurately show how deadly the pandemic is, Basu used publicly reported data on the total COVID-19 cases and deaths. Realizing that both of these reported quantities likely are undercounts and change over time, Basu looked at the trends in the ratio of these two numbers, or the reported “case fatality rates,” to more accurately reflect how deadly the virus is among those who fall sick because of it.

“Our hope is that our study results can help inform local and national policies that will save lives in the future,” said Basu. “Ultimately, we want this work to advance the health of people around the world.”

Basu also noted that the model should not be viewed as the “last word” on estimating the COVID-19 fatality rate, but as one of several methods used to measure the impact of the virus.

“The infection fatality ratio estimate is itself dynamic in nature,” Basu said. “The overall estimate can both increase or decrease in the future, depending on the demographics where the infections will be spreading. It is possible, as the infection spreads to more rural counties of the country, the overall infection fatality rate will increase due to the lack of access to necessary health care delivery.”

This research was funded by the 91±ŹÁÏ CHOICE Institute and the School of Pharmacy.

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For more information, contact Basu at basua@uw.edu.

Learn more about the ±«°Â’s Population Health Initiative: a 25-year, interdisciplinary effort to bring understanding and solutions to the biggest challenges facing communities.

91±ŹÁÏ-SHARE’s first step is to capture the current, one-time pre-implementation moment using a mail survey of 40,000 households. The households, with at least one person between ages 18 and 64 years, were chosen randomly from the publicly available list of registered voters in Washington state.  (Residents in some of the smaller counties are being oversampled in order to obtain county-level estimates).

The overall purpose is to obtain a benchmark, pre-ACA picture of health-care use, health, health-related attitudes, and access to health insurance. According to Anirban Basu, an associate professor in the Department of  Health Services, which is leading the 91±ŹÁÏ-SHARE effort, the primary goals are to understand:

–          How the ACA will affect access to health insurance;

–          Health care use and the burden of illness before and after the ACA;

–          Challenges in accessing needed care before and after the ACA;

–          How much of the enrollment in health care exchanges is driven by medical needs vs. political ideology.

“The results of this and another survey next year will inform the state and federal governments about what they might do in the future to help residents meet health care challenges, such as how to make the exchanges more efficient and identify counties with unmet needs,” said Basu.  Depending on funding, the School would like to do this survey annually, he added.

The four-page survey, which should take 10 to 15 minutes to complete, is being mailed this week. Participation is voluntary, but returned surveys will be eligible to win an iPad or Surface tablet.

The results should be available in the spring and will be published on the website: