Medicine

But it is also a question of history and, more specifically, of how welfare states in the rest of the world developed alongside warfare. European welfare states began in Prussia at the end of the 19th century, when war with France required the mobilisation of a large number of civilians. Britain’s welfare state has its origins in the discovery that many of the men who presented themselves to recruiting offices during the Boer war were not healthy enough to fight. Before the second world war, British liberals would have seen the creation of a government-run national health service as an unwarranted intrusion of government into private life. After 1945 it seemed a just reward for a population that had suffered.

In America this relationship between warfare and health care has evolved differently. The moment when the highest proportion of men of fighting age were at war, during the civil war (when 13% of the population was mobilised), came too early to spur the creation of a national health system. Instead, the federal government broke the putative link between war and universal health care by treating ex-servicemen differently from everyone else. In 1930 the Veterans Administration was set up to care for those who had served in the first world war. It has since become a single-payer system of government-run hospitals of the kind that many Americans associate with socialised medicine in Europe. America did come close to introducing something like universal health care during the Vietnam war, when once again large numbers of men were being drafted. Richard Nixon proposed a comprehensive health-insurance plan to Congress in 1974. But for Watergate, he might have succeeded.

That is from The Economist.

One of Beijing’s busiest public toilets is fighting the scourge of toilet paper theft through the use technology – giving out loo roll only to patrons who use a face scanner.

The automated facial recognition dispenser comes as a response to elderly residents removing large amounts of toilet paper for use at home.

Now, those in need of paper must stand in front of a high-definition camera for three seconds, after removing hats and glasses, before a 60cm ration is released.

Those who come too often will be denied, and everyone must wait nine minutes before they can use the machine again.

But there have already been reports of software malfunctions, forcing users to wait over a minute in some cases, a difficult situation for those in desperate need of a toilet.

The camera and its software have also raised privacy concerns, with some users on social media uneasy about a record of their bathroom use.

Here is the full story, via Michelle Dawson.

Fatigued drivers cause accidents. In response to this obvious fact, we limit bus and taxi drivers to a maximum of 10 hours of driving after 8 consecutive hours off duty. Yet when it comes to physicians, the current standard is significant more lax; first-year residents are restricted to 16-hour shifts! That already is nuts. I often teach a night class, 7:20-10 pm and I always try to teach the more difficult material early because by 9pm I am not at the top of my game. Needless to say, medical residents are far more stressed and fatigued than teachers. Moreover, while first year residents can work up to 16 hours, second year residents can work up to 24 hours straight and even up to 30! Isn’t it amazing how one year of residency can teach physicians how to function without sleep?

The current standards, which strike me as absurdly low, are actually due to restrictions put in place in 2003 and 2011–restrictions which are now being lifted. The new plan is to allow longer hours for first year residents:

Rookie doctors can work up to 24 hours straight under new work limits taking effect this summer — a move supporters say will enhance training and foes maintain will do just the opposite.

A Chicago-based group that establishes work standards for U.S. medical school graduates has voted to eliminate a 16-hour cap for first-year residents. The Accreditation Council for Graduate Medical Education announced the move Friday as part of revisions that include reinstating the longer limit for rookies — the same maximum allowed for advanced residents.

An 80-hour per week limit for residents at all levels remains in place under the new rules.

Studies have found that physicians who work longer hours are much more likely to get into auto accidents on the way home. Physicians and nurses who work longer hours also make more medical mistakes.

The main argument in favor of long hours is that the 2003 and 2011 restrictions do not seem to have greatly improved patient safety. That is surprising but the micro and experiential evidence that fatigue makes for mistakes is so strong that the lesson to be drawn isn’t that longer hours don’t lead to mistakes–the lesson is either that the restrictions were routinely ignored (as the National Academy of Science study found), that the studies done to date are misleading for a statistical or design reason or that there is another constraint in the system that needs to be examined. One possibility for another constraint is that handoffs of patients between physicians aren’t handled well. But that means that poor handoffs are killing as many people as fatigue!

In no other field do we tolerate error as much as we do in medical care. Why does the government regulate driving hours more than medical hours? It’s not just the government. It’s amazing that in a society where McDonald’s can be sued for making people fat that the tort system hasn’t shut down absurdly long residency hours (there have been a few cases). Medical care is a peculiar field (cue Robin Hanson).

Aside from Hanson-type factors, a key factor that explains what is going on is that residents are a huge profit source for the hospitals. Much like student athletes, residents are underpaid. As a result, hospitals want to use residents as much as possible so they lobby for longer hours even at the expense of patient safety.

The state of West Virginia has paid for so many burials for indigent people who have died from drug overdoses that the funding has run out five months before the end of the current fiscal year on June 30.

Kitchen said there have been so many drug overdose deaths in West Virginia, it often takes two to three weeks for the state medical examiner to complete the required autopsies. He said families then have the added stress of not being able to carry out a funeral for weeks after a death occurs.

Here is the article, via Anecdotal.  Here is a good Christopher Caldwell piece on opioids.

It is not easy to excerpt, so do read the whole thing.  But here is the closing bit:

And in any case, momentum depends on a strong, successful push at the start. This could have started better, and it needs to end smarter.

That is the title of a recent paper in the Journal of Development Economics (NBER version here, 2013 ungated version here), and although the piece does not feel dramatic at first it is one of my favorite articles of the year.  It pins down some critical features of economic underdevelopment better than any study I know.  The subtitle, by the way, is “The Successes and Limitations of Bureaucratic Reform in India,” the authors are Iqbal Dhaliwal and Rema Hanna, and the work is set in rural Karnataka.

It is not easy to excerpt from, so I will summarize the narrative:

1. Using biometric technology — thumbprints — to monitor absenteeism induces staff attendance for public health workers to rise by almost 15 percent.

2. That in turn leads to a reduction in low-birth weight babies.

3. Yet the government proved not so interested in monitoring attendance on a more regular basis, not even to enforce their pre-existing human resource policies.  Potential penalties against late or absent doctors were not, for the most part, enforced.

4. Following the implementation of monitoring, the doctors showed the least improvement in attendance of all the workers, in fact virtually no improvement.  The entire positive effect came from nurses, lab technicians, and lower level staff.

5. The government was reluctant to continue the monitoring because it feared staff attrition and staff discord, especially from the doctors.  There is growing private sector demand for doctors, and many doctors are considering leaving these clinics for superior pay elsewhere, and perhaps also superior location.  Therefore the doctors are given, de facto, a very lenient absence and lateness policy, in lieu of a pay hike.

6. It is already the case that many of these doctors moonlight on the side, or have separate private practices, and that spending more time at the public clinic is not their major priority.

7. It is not easy for the underfunded local government to pay these doctors more, and thus a high level of lateness and absenteeism continues.  I wonder also what would be the morale costs on the non-doctors, if the monitoring were to be continued to be enforced in this differential manner over a longer period of time.

Here is Ezra Klein on the new health care bill.  Avik Roy doesn’t seem entirely crazy about it either.  I don’t have anything to add to their two fine reports.  Read Bob Laszewski too.

We find that as the county unemployment rate increases by 1 percentage point, the opioid death rate (per 100,000) rises by 0.19 (3.6%) and the ED visit rate for opioid overdoses (per 100,000) increases by 0.95 (7.0%).

That is from a new NBER working paper by Alex Hollingsworth, Christopher J. Ruhm, and Kosali Simon.

China fact of the day

by on February 25, 2017 at 12:57 am in Data Source, Medicine | Permalink

During one of the greatest economic booms in the history of the world, working-age men had trouble staying alive.

That is the disheartening news from China, where its insurance regulator recently updated a more-than 10-year-old table of mortality rates. A key finding: Mortality rates among Chinese men aged 41 to 60, who account for nearly three-quarters of the working-age population, increased by 12% over the decade through 2013, the most recent data available. This was even as mortality rates generally improved across other age groups and genders.

It could be that financial success breeds bad health habits. Disposable income per capita has risen 90% in the past six years and probably more than that over the past decade, though official government data is limited. Chinese liquor consumption—where men consume 60% more than women—has risen 5% compounded annually over the past 15 years, considered fast by global standards, according to Bernstein analysts. Richer diets go along with high incidence of lung and coronary issues for Chinese men.

That is from Anjani Trevedi at the WSJ, via the always-interesting Dan Wang.

The basic post is too long, but some of it is interesting and here is the best part:

The pattern of Cost Disease seems to be related to things that inextricably require the unsubstitutable labour and attention not just of human beings but of human beings somehow comparable to the buyer. (Americans, for the US focus of most of this discussion.) Education not only requires teachers who are part of the same cultural milieu as their students, but it requires the attention of the students themselves, and attention is inherently expensive. As the only thing that can be expensive in the final Strong Heaven, attention predictably gets more expensive in a culture that moves more and more toward general post-scarcity. Health care similarly requires local human involvement.

That is from Ansuz, via Matthew Fairbank.  And here is Scott Alexander’s survey follow-up post.

The Elephant in the Brain: Hidden Motives in Everyday Life, and here is the opening bit of the summary:

Human beings are primates, and primates are political animals. Our brains were designed not just to gather and hunt, but also to get ahead socially, often by devious means. The problem is that we like to pretend otherwise; we’re afraid to acknowledge the extent of our own selfishness. And this makes it hard for us to think clearly about ourselves and our behavior.

The Elephant in the Brain aims to fix this introspective blind spot by blasting floodlights into the dark corners of our minds. Only when everything is out in the open can we really begin to understand ourselves: Why do humans laugh? Why are artists sexy? Why do people brag about travel? Why do we so often prefer to speak rather than listen?

Like all psychology books, The Elephant in the Brain examines many quirks of human cognition. But this book also ventures where others fear to tread: into social critique. The authors show how hidden selfish motives lie at the very heart of venerated institutions like Art, Education, Charity, Medicine, Politics, and Religion.

Acknowledging these hidden motives has the potential to upend the usual political debates and cast fatal doubt on many polite fictions. You won’t see yourself — or the world — the same after confronting the elephant in the brain.

Due out January 1, 2018, of course this is essential reading.

For years, muscular dystrophy patients in the United States have been purchasing the drug deflazacort — used to stabilize muscle strength and keep patients mobile for a period of time — from companies in the United Kingdom at a manageable price of $1,600 a year.

But because an American company just got approval from the Food and Drug Administration to sell the drug in the United States, the price of the drug will soar to a staggering $89,000 annually, the Wall Street Journal reported last week.

Because the FDA restricts the importing of drugs from overseas if a version is available domestically, patients are stuck with the new, expensive version. This makes deflazacort the perfect case for advocates of international drug reciprocity — a reform that would make it easier for consumers to buy drugs that have been approved in other developed countries.

That is the introduction to an interview with yours truly in the Washington Post. I discuss thalidomide and the race to the bottom argument. Here is one other bit:

IT: Do you have any thoughts about the potential for FDA reform under this new administration and Congress?

AT: Peter Thiel’s speech at the Republican National Convention reminded us that we used to take big, bold risks — like going to the moon. Today, to say a project is a “moon shot” is almost a put-down, as if going to the moon never happened. We have become risk-averse and complacent, to borrow a term from my colleague Tyler Cowen. The result of the incessant focus on safety is playgrounds without teeter totters, armed guards at our schools and national monuments, infrastructure projects that no longer get built, and pharmaceutical breakthroughs that never happen.

The new administration is unpredictable, but when it comes to the FDA, unpredictable is better than business as usual.

The administration has yet to appoint a great FDA commissioner. Early names floated included Balaji Srinivasan, Jim O’Neill, Joseph Gulfo, and Scott Gottlieb but Srinivasan seems to have removed himself from the running. O’Neill would be great but I don’t think the US is ready, so that leaves Gulfo and Gottlieb. My suspicion is that Trump will like Gulfo because of Gulfo’s entrepreneurial experience but, as I said, the new administration is unpredictable.

I don’t have a similar graph for subway workers, but come on. The overall pictures is that health care and education costs have managed to increase by ten times without a single cent of the gains going to teachers, doctors, or nurses. Indeed these professions seem to have lost ground salary-wise relative to others.

That is just one bit from a very excellent blog post by Scott Alexander.

They have a new book out, namely Governing Global Health: Who Runs the World and Why?  It is to the point, clear, uses economic reasoning very well, and serves up the information you actually want to learn.  It is a look at some major public health organizations, specifically the Global Fund to Fight AIDS, TB and Malaria, the Gavi Alliance, the WHO, and the World Bank, and how they operate, from a public choice point of view.  It’s hard to think of many books I’ve looked at over the last year or two that so well understand the notion that readers want a “landscape” of sorts painted for them.  So if you have an interest in public health issues, or in either or both of the two authors, I can gladly recommend this to you.

Here is an earlier Chelsea Clinton memo on Haiti.

There is a new paper on this topic, by Gigi Moreno, Emma van Eijndhoven, Jennifer Benner, and Jeffrey Sullivan.  The upshot is to beware price controls:

Price controls for prescription drugs are once again at the forefront of policy discussions in the United States. Much of the focus has been on the potential short-term savings – in terms of lower spending – although evidence suggests price controls can dampen innovation and adversely affect long-term population health. This paper applies the Health Economics Medical Innovation Simulation, a microsimulation of older Americans, to estimate the long-term impacts of government price setting in Medicare Part D, using pricing in the Federal Veterans Health Administration program as a proxy. We find that VA-style pricing policies would save between $0.1 trillion and $0.3 trillion (US$2015) in lifetime drug spending for people born in 1949–2005. However, such savings come with social costs. After accounting for innovation spillovers, we find that price setting in Part D reduces the number of new drug introductions by as much as 25% relative to the status quo. As a result, life expectancy for the cohort born in 1991–1995 is reduced by almost 2 years relative to the status quo. Overall, we find that price controls would reduce lifetime welfare by $5.7 to $13.3 trillion (US$2015) for the US population born in 1949–2005.

I would insist that we do not have good enough models of the innovation process to really understand the price elasticity of supply.  Nonetheless it is surely not zero, and under plausible assumptions the price controls are a bad idea.

We need a new rooftop chant: “Beware analyses that neglect supply elasticities,” to sweet cadences of course.  They should play that on AM radio as well.

For the pointer I thank the still excellent Kevin Lewis.