TAMEST Member Profile: Health Economist Dr. Vivian Ho (NAM), Rice University and Baylor College of Medicine, Looks at COVID-19 Through the Eyes of Big Data

When the pandemic hit, TAMEST Member Vivian Ho, Ph.D. (NAM), Rice University and Baylor College of Medicine, pivoted her research examining the effects of economic incentives and regulations on the quality and costs of health care to focus on how lockdowns early in a pandemic can impact related deaths months later.

She says her career in big data and health outcomes prepared her to look at the spread of disease in populations and understand the economic incentives involved. More recently, her work has focused on inconsistencies of how states report health data to the Centers for Disease Control and Prevention (CDC) and how we might standardize reports to more effectively handle the next pandemic.

Dr. Ho is the James A. Baker III Institute Chair in Health Economics, Director of the Center for Health and Biosciences, a Professor in the Department of Economics at Rice University, and a Professor in the Department of Medicine at Baylor College of Medicine. Her research is widely published in economics, medical and health services research journals.

In 2020, she was elected to the National Academy of Medicine and became a member of TAMEST. Dr. Ho’s research has been funded by the National Institutes of Health, the Agency for Healthcare Research and Quality and the American Cancer Society.

TAMEST spoke with Dr. Ho to learn more about her work before, during and after the pandemic.

How did you find the field of health economy?

Oh, I definitely stumbled into it. I knew I loved economics and I loved applied economics. I learned that you could actually tell a story with data and I was just fascinated with the concept of doing that, but I didn’t know what subject to pick.

I was actually working on a dissertation topic having to do with the newspaper industry and one of the professors suggested I instead focus on Medicare hospice benefit programs, because no one was looking at it at the time. This was in the late-1980s and I said okay and switched topics.

It was history from there and it turned out to be this wonderful gift of learning about the health care industry right when we as researchers were beginning to gain access to so much richer data. When I was first researching my dissertation, there were very few Ph.D. candidates on the market saying, “I’m a health economist.” I was one of the first in that cohort and now it is extremely common. I was lucky to get in at the beginning.

It’s a little unusual to straddle positions at two academic institutions. Tell us more about how that came to be and how you make that balance work.

Mine is a little unusual of a position. It arose because the late Dr. Bobby R. Alford from Baylor College of Medicine wanted a health economist at the same time Ambassador Edward P. Djerejian, the Director of the Baker Institute for Public Policy at Rice University, was also looking for one. So, they pooled their resources to bring me to Houston.

They both realized how important access to health care is to the Houston community and to Texas and they realized cost was a very important component, but they didn’t have any other restrictions beyond that. They knew health care was getting more costly and they wanted something done about it, which is where my research comes in.

That’s how I ended up working for both of them. In terms of how I manage that, I’m lucky that my bosses let me choose the research topics that I want to pursue.

Can you tell me a little more about your work and how it changed during the pandemic?

I’ve built my career on studying big data and looking a lot at cost and outcomes in acute care, primarily in cancer care, cancer surgery and cardiovascular disease. So, when COVID-19 came along, it was relatively easy for me to pivot to try and understand what was going on.

Thankfully, in my first job, I’d learned epidemiology from the clinicians that I was working with and so I had the advantage of that sort of background looking at the spread of disease in populations.

In December you published a study on how state restrictions early on in the pandemic impacted COVID-19 deaths months later. What made you choose this topic?

This was not the way a research question usually comes about. I actually had done an interview over the summer with WalletHub and there happened to be a person who works on strategy here in Texas who saw my interview and was also interested in lockdowns. So, the basis of the study was because this person, Michael C. Saletta, and his son took the WalletHub data on the strictness of the state restrictions and pulled the data from the CDC on death rates by state, by day, and did the correlations.

In general, I get all sorts of emails and a lot of them I just do not have time for, but this one was so compelling. I just cannot think of another economist who would think to plot the data this way, in terms of taking restrictions way back in early May and saying, “do those restrictions have an effect on death rates all the way through the summer and most of the fall?” They found there is always a correlation between restrictions by state on any given day and what happens to death rates in that state many days and months later.

The part he didn’t quite see initially is that the tightest correlation was actually from the earliest restrictions. This is not a causation study, but it suggests that whatever happens earliest on in terms of restrictions has enormous implications for saving lives many months down the road.

What do you hope this study teaches us about how we can handle the next pandemic?

We’re never going to get a full lockdown like Australia or China here in the United States. However, if a policymaker is ever in doubt in a future pandemic, what these studies suggest is that what you do earlier on can have an impact for months and months to come.

You won’t realize it, but six months down the road that decision you made back in May is going to be extremely important.

You’ve published an even more recent study, looking at how states report health data federally and found some discrepancies. Tell us about that.

We got access to all of the CDC’s case report forms in August through a Freedom of Information Act request. After analyzing them in a uniform fashion we realized they were woefully incomplete and did not show the bigger picture.

For example, when we divided the CDC’s count of Texas cases during early-May to mid-July, to the number of Texas cases the New York Times’ COVID-19 database was counting during the same time period, you got 5.5%. That means virtually 95% of the data from our state never made it to the CDC. Some states were much better than others and you could tell a bit of the story that happened during the pandemic.

However, if you go through and look at the regulations – it turns out required reporting is set at the state level and for some territories. They are the ones who set the recommendations for reporting and then it is voluntary for them to report COVID-19 data to the CDC.

How would you suggest future health reporting be handled?

We really should have one mandated form. Currently, if you google “coronavirus case form” you find a lot of different forms asking for different things. In the next pandemic we should have a mandate that says the CDC has a case report form and everyone needs to use it.

I just find it mind-boggling – you would have thought that would have been a no brainer.

Do you think the research you’ve done in the past year will shape your future research?

Unfortunately, I’m already pivoting back because I have to. Before the pandemic started, we already knew Texas had a problem because we have the highest rate of uninsured people in the United States. Since the pandemic, that number hasn’t gotten better, it has gotten worse.

The main reason it has gotten worse is that health care is too expensive. Some people want to blame it all on insurance companies, but the Affordable Care Act actually regulated the profit margins for insurers.

We have to be focusing on controlling health care costs. I’m already back to working on research projects having to do with emergency care because I’ve done a lot of research on free-standing emergency care centers. I am currently looking at more general issues of the “upcoding” of emergency care and the cost of trauma services.

I’m also looking very closely at notions of profit margins at non-profit hospitals and how the consolidation of health care systems impacts increases in prices. I’ve done recent work looking at vertical integration of hospitals and physicians as well.

Why do you live and work in Texas?

Oh, I love it here. At Rice, I am at the Baker Institute and if you ever visit the campus, you’ll see these inscriptions at the top of Baker Hall and it says, “a bridge between the world of ideas and the world of action.” That is something that the Ambassador and the Fellows at the Baker Institute really take to heart.

There’s encouragement and the help to be able to not just analyze data, but to widely disseminate the story the data tells us. It’s helpful to be with colleagues who care deeply about analyzing problems of importance to Texas and to the community.

And it is not just about academics. I sit on the Board of Community Health Choice, which is a non-profit arm of Harris County’s health department that sells Medicaid and Affordable Care Act plans. There are all sorts of things that need to be done to improve affordability of healthcare and that I value.

As one of our recent members, talk to us about your thoughts on TAMEST’s value to Texas.

I’ve only been able to attend the 2021 TAMEST Virtual Members Meeting, but it is really just jaw-dropping how impressive of an organization TAMEST is. Texas is so big and it is easy to get lost, so it is nice to have an organization like TAMEST here to network not just across the state, but regionally as well.

There are a lot of things that Texas researchers are excited about doing, and the fact we can convene and do it together collaboratively is a great opportunity.