Medicine

Do peer effects have inegalitarian implications?

by on May 20, 2013 at 7:14 am in Medicine | Permalink

By now it is well known that hanging out with healthy peers predicts (causes?) good health, and unhealthy peers predict (cause?) bad health, for instance as it applies to weight and diet.  So what might that mean?

But perhaps medical care should indeed be given preferentially to those who, in receiving such care, will yield a better return on the investment? Maybe people with families, or people who are merely very popular, should get more care?

That is from Nicholas A. Christakis, who also notes:

Taking network effects seriously means that we should value socially connected people more. From a policy perspective—if not from a moral perspective—the connected should get more healthcare attention.

That is a speculation and a question, so I don’t think you should read him as necessarily endorsing that as a final conclusion.  There is more here, as pointed out by the still under-followed @jflier.

Indeed, once you take peer effects seriously, the popular become very busy people indeed, adding to their already-existing popularity-related busyness.  All sorts of things must be done to help them and to improve them, and for the same reason that people worried about Charles Barkley as a role model.  Of course on average the well-connected are successful and relatively well known or even famous, so the medical attention is not going to the poor or for instance to those unemployed whose weaker networks make it harder for them to get jobs.

I would stress the general point that utilitarian theories are less egalitarian than we often like to think.  The differential marginal utility of money point is very popular, and often true, and it does generally point in an egalitarian direction.  You hear somewhat less about many of the other implications of utilitarianism.

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Compare hospital charges, http://www.opscost.com/

by on May 19, 2013 at 4:11 pm in Medicine, Web/Tech | Permalink

The web site reads:

On May 8th, 2013, the federal government released data on list prices and medicare reimbursements for the 100 most common procedures at over 3,300 hospitals.

This tool allows users to easily search and compare hospital charges.

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Bayonne business practice of the day

by on May 17, 2013 at 2:28 pm in Economics, Medicine, Uncategorized | Permalink

The most expensive hospital in America is not set amid the swaying palm trees of Beverly Hills or the luxury townhouses of New York’s Upper East Side.

It is in a faded blue-collar town 11 miles from Midtown Manhattan.

Based on the bills it submits to Medicare, the Bayonne Medical Center charged the highest amounts in the country for nearly one-quarter of the most common hospital treatments,  according to a New York Times analysis of 2011 data, the most recent available. No other hospital was at the top of the price list more often.

Bayonne Medical typically charged $99,689 for treating each case of chronic lung disease, five times as much as other hospitals and 17 times as much as Medicare paid in reimbursement. The hospital also charged on average of $120,040 to treat transient ischemia, a type of small stroke that has no lasting effect. That was six times the national average and 24 times what Medicare paid.

For those prices, the quality of care at Bayonne Medical is no better — or worse — than that at most other New Jersey hospitals.

The back story is this:

Bayonne Medical, which was founded in 1888, was losing nearly $1.5 million a month before it filed for bankruptcy in 2007. By 2011, under new ownership and a new financial model [sic], its patient revenue had nearly tripled and its operating income had reached $9.3 million, according to the American Hospital Directory, a publication that compiles data from Medicare and other sources about health care facilities.

Here is one commentary:

“Their model is to charge exorbitant rates, particularly for emergency room services, and if the insurance companies don’t pay them, they threaten to go after the member for the balance of billing,” said Carl King, head of national networks for Aetna, whose in-network contract was also ended by Bayonne in 2008.

You can read more here, interesting throughout.

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Sentences to ponder

by on May 17, 2013 at 1:18 pm in Law, Medicine | Permalink

A family can get implicitly taxed 238% on that additional $501.

The thing is, I don’t even need to tell you what the topic is.  The original source is here.

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Jim Manzi on the Oregon Medicaid study

by on May 13, 2013 at 1:19 pm in Medicine, Science, Uncategorized | Permalink

Via Megan, here is an excellent discussion of the study, here is one excerpt:

In summary, based on statistically insignificant effects of coverage from the Oregon Experiment: (1) The effects that are closest to statistical significance are that coverage would increase the rate of smoking and damage the cardiovascular prognosis of sick people; (2) the best estimated net effect on total population cardiovascular health is extraordinarily tiny; (3) this effect would be achieved by making the sick sicker, while very slightly improving the health of already healthy people ; and (4) this effect is almost certainly unattractive on a risk-adjusted basis. This is not a series of effects that makes a very attractive argument for an increase in health from the experiment.

…When interpreting the physical health results of the Oregon Experiment, we either apply a cut-off of 95% significance to identify those effects which will treat as relevant for decision-making, or we do not. If we do apply this cut-off (as the authors did; as is consistent with accepted practice for medical RCTs; and as is what I believe to be a good way to make decisions based on experiments), then we should agree with the authors’ conclusion that the experiment “showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years.” If, on the other hand, we wish to consider non-statistically-significant effects, then we ought to conclude that the net effects were unattractive, mostly because coverage induced smoking, which more than offset the risk-adjusted physical health benefits provided by the incremental utilization of health services.

Do read the whole thing, there are many more points of interest.  For instance “Almost half the people offered free health insurance coverage didn’t bother to send back the application to get it.”

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More on the bending of the health care cost curve

by on May 10, 2013 at 3:36 pm in Economics, Medicine | Permalink

If Slow Rate Of Health Care Spending Growth Persists, Projections May Be Off By $770 Billion

David Cutler & Nikhil Sahni
Health Affairs, May 2013, Pages 841-850

Abstract:
Despite earlier forecasts to the contrary, US health care spending growth has slowed in the past four years, continuing a trend that began in the early 2000s. In this article we attempt to identify why US health care spending growth has slowed, and we explore the spending implications if the trend continues for the next decade. We find that the 2007–09 recession, a one-time event, accounted for 37 percent of the slowdown between 2003 and 2012. A decline in private insurance coverage and cuts to some Medicare payment rates accounted for another 8 percent of the slowdown, leaving 55 percent of the spending slowdown unexplained. We conclude that a host of fundamental changes — including less rapid development of imaging technology and new pharmaceuticals, increased patient cost sharing, and greater provider efficiency — were responsible for the majority of the slowdown in spending growth. If these trends continue during 2013–22, public-sector health care spending will be as much as $770 billion less than predicted. Such lower levels of spending would have an enormous impact on the US economy and on government and household finances.

This was sent to me in an email from Rob Raffety, but I believe it emanates from Kevin Lewis.  A link to the content is here.  Another relevant article is here, and it also sounds a cautiously optimistic note.

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Markets in everything

by on May 9, 2013 at 3:39 pm in Law, Medicine | Permalink

The market for methadone vomit in prison is lively, and the preferred recipe for this cocktail is one part puke (strained, please, bartender) to one part Tang.

Here is more, interesting on other points too, by Graeme Wood, mostly on the drug problem in the country of Georgia, and the pointer is from Wonkbook.

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In praise of Bernie Sanders

by on May 7, 2013 at 3:36 pm in Law, Medicine | Permalink

This is an email from his press secretary:

I wanted to write to applaud your great piece in the NYT this weekend, and make sure you were aware of Sen. Sanders’ legislation on the issue.

During the last congress Sen. Sanders introduced a bill to create a $3 billion fund tasked with giving away prizes for drug breakthroughs.  Here’s a release for the bill and here’s a video of a hearing the senator held on it where Joseph Stiglitz, Lawrence Lessig and Jamie Love all testify in support.

I thought you might be interested.

He is referring to my piece from this Sunday.

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Pandemics and public goods, and why we are failing at both

by on May 5, 2013 at 3:47 am in Economics, Medicine, Science, Uncategorized | Permalink

Here is my latest New York Times column, which has a specific part on how to address pandemics and a more general section on the evolving role of government in American society.  In neither area are matters running especially well.

Here is one initial point, namely that it is difficult to commit to allow high prices upfront:

Research and development grants are a way to pay potential innovators up front — an important move, as an innovator can’t always charge high-enough prices for the value of its remedies when they’re actually needed.

That will lead to institutional failure, rooted in a mix of government and market failure.  Therefore other rewards are needed, since the prospect of high prices does not adequately motivate.  I thus call for some key drugs to be rewarded with prizes and for government to buy out the patent rights, if need be:

If anyone doubted a government pledge to pay big money for the rights to remedies, the patent’s value could be established by a competitive auction. Michael Kremer, a Harvard economics professor, outlined the procedure for such an auction in his research paper “Patent Buyouts.”

The larger problem is this:

OVER all, the American government seems to be turning its back on its traditional role of producing and investing in national public goods. If there is any consistent tendency in recent government spending, it is that spending on entitlements like Social Security and Medicare — which provide mostly private benefits — is rising and that investment and spending on national public goods is falling.

Do read the whole thing.  I also suggest that (non-paternalistic) public health could be a suitable health care issue for Republicans, who presumably should be looking for alternatives to the status quo.

There are by the way two points which did not make the final cut for reasons of space.  First, the current coronavirus in Saudi Arabia has not gone away as a source of potential problems.  Second, the Bush Administration (43) did take some notable steps to return vaccine capacity to the United States, through both regulatory forbearance and HHS procurement.  These are likely good policies since in a pandemic one cannot expect to rely on free international trade in a remedy but rather export controls are to be expected.

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A few remarks on the Oregon Medicaid study

by on May 3, 2013 at 6:13 am in Medicine, Uncategorized | Permalink

There is a simple quotation from Josh Barro, who by the way has supported ACA.  Josh wrote:

Despite efforts to spin it to the contrary, this is bad news for advocates of the Medicaid expansion. While Medicaid is clearly good for some things, it was supposed to be good for all of the measures tracked.

Or here is Ray Fisman:

Now that the clinical results have started to come in, it’s time for liberal media types like myself to eat some humble pie. Today’s New England Journal article presents a set of findings showing that Medicaid had no effect on a set of conditions where you would expect proper health management to make a difference. There are effective treatment protocols for hypertension, cholesterol, and diabetes, yet insurance status had no effect on blood pressure, cholesterol levels, or glycated hemoglobin (a measure of diabetic blood sugar control).

Do read the rest of those posts for a more complete picture of the results, but many commentators are overlooking these rather simple upshots.

The key question here is how we should marginally revise our beliefs, or perhaps should have revised them all along (the results of this study are not actually so surprising, given other work on the efficacy of health insurance).  For instance should we revise health care policy toward greater emphasis on catastrophic care, or how about toward public health measures, or maybe cash transfers?  (I would say all three.)  One might even use this study to revise our views on what should be included in the ACA mandate, yet I haven’t heard a peep on that topic.  I am instead seeing a lot of efforts to distract our attention toward other questions.

I am sometimes reluctant to speculate about motives, but I believe there is currently a fear of stating the actual truth, given that ACA and the Medicaid expansion are coming under increasing political fire, very often involving mistruths from the Republicans I might add.

You are seeing obfuscations of reality when you encounter two particular responses to the new Medicaid results, which I have been seeing with disturbing frequency.  The first is something like “But you still buy health insurance, don’t you?”  The second is when the debate is steered into showing that Medicaid does indeed benefit poor people (which is obviously true, and was so before and after this study).

Those are both examples of running away from the idea of thinking at the margin.  A better response would run more along the lines of “The Medicaid expansion had been oversold, we now should think more along some other lines for improving our health care system.  Let’s admit that we have more of a mess on our hands than we had realized or let on.”  You don’t have to deny that Medicaid might help with long-term care problems, for instance, or advocate the abolition of Medicaid.  The real results from the new study are most likely about health insurance and health care, not so much about Medicaid per se; see Ezra’s on-target remarks.

Compare what you have seen over the last two days with the writings on the earlier phases of the Oregon study, when it seemed to be yielding a more positive picture of Medicaid.  Those earlier writings often were preparing for a coronation of this study (please do read that link) but now we are seeing hand-wringing and all sorts of talk about the study’s limitations.

For varying and useful perspectives, here are Carroll and Frakt and Megan McArdle.

Coming on the heels of the debate over Reinhart and Rogoff, I find this all sad.  If there is any cheery lesson it is that, in relative terms, macroeconomics is in better shape than we had thought!

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The follow-up study on Medicaid coverage in Oregon

by on May 1, 2013 at 5:34 pm in Data Source, Medicine | Permalink

Here is some overview coverage from Annie Lowrey, an important issue of course with some striking results.  Here is coverage from Sarah Kliff.  Here is commentary from Justin Wolfers, and here.  After the R&R saga, I say it’s time for someone to stand up and admit “We have some egg on our face with this one.”

Addendum: Reading more carefully through the quotations from Finkelstein and Holahan in the Lowrey piece, I find it amazing, and I suppose even embarrassing, what those commentators are claiming as a positive result.  Of course it is worth comparing the program to simply giving people the cash.

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The thinning out of the medical middle

by on April 26, 2013 at 1:25 pm in Medicine | Permalink

From Ben Casselman at the WSJ:

The health-care sector, one of the last redoubts of stable and well-paying jobs for less-educated workers, is beginning to look less secure.

A variety of factors, from technological advances to increased attention on both costs and patient outcomes, are driving hospitals and other health-care providers to demand more from both the most- and least-skilled workers, while gradually eroding opportunities for those in the middle.

The result: the gradual disappearance of semiskilled occupations that don’t require a college degree. Positions such as licensed practical nurses and medical-records clerks are being eliminated or pushed out of hospitals into lower-paying corners of the field such as nursing homes. Meanwhile, positions that were once an accessible first rung on the career ladder, such as registered nursing, increasingly require at least a bachelor’s degree.

The trend is worrisome to economists, because health care had been a relative haven from the erosion of middle-skill jobs elsewhere in the economy. Automation, outsourcing and other forces have eliminated many formerly secure jobs in manufacturing, clerical work and other fields. Now health care is following the same path with unforeseen speed.

Here is more.

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Cousin Marriage and Democracy

by on April 26, 2013 at 7:29 am in Economics, History, Law, Medicine | Permalink

In the United States consanguineous marriage (marriage between close relatives, often cousins) is frowned upon and in many states banned but it is common elsewhere in the world. Approximately 0.2% of all marriages are consanguineous in the United States but in India 26.6% marriages are consanguineous, in Saudi Arabia the figure is 38.4% and in Niger, Pakistan and Sudan a majority of marriages are consanguineous. Cousin marriage used joffreyto be more common in the West and was particularly common among royal families which gives some hints as to why it may sometimes be useful. Among families with titles or estates, cousin marriage will tend to keep the wealth intact–literally within the family–whereas wealth becomes more dilute more quickly with outside marriage. Cousin marriage may also increase cooperation within the extended family and help to fight off parasites.

A recent paper finds that consangunuity is strongly negatively correlated with democracy:

How might consanguinity affect democracy? Cousin marriages create extended families that
are much more closely related than is the case where such marriages are not practiced. To illustrate,
if a man’s daughter marries his brother’s son, the latter is then not only his nephew but also
his son-in-law, and any children born of that union are more genetically similar to the two grandfathers
than would be the case with non-consanguineous marriages. Following the principles of
kin selection (Hamilton, 1964) and genetic similarity theory (Rushton, 1989, 2005), the high
level of genetic similarity creates extended families with exceptionally close bonds. Kurtz succinctly
illustrates this idea in his description of Middle Eastern educational practices:

If, for example, a child shows a special aptitude in school, his siblings might willingly
sacrifice their personal chances for advancement simply to support his education. Yet once
that child becomes a professional, his income will help to support his siblings, while his
prestige will enhance their marriage prospects. (Kurtz, 2002, p. 37).

Such kin groupings may be extremely nepotistic and distrusting of non-family members in the
larger society. In this context, non-democratic regimes emerge as a consequence of individuals turning to reliable kinship groupings for support rather than to the state or the free market. It has
been found, for example, that societies having high levels of familism tend to have low levels of
generalized trust and civic engagement (Realo, Allik, & Greenfield, 2008), two important correlates
of democracy. Moreover, to people in closely related kin groups, individualism and the
recognition of individual rights, which are part of the cultural idiom of democracy, are perceived
as strange and counterintuitive ideological abstractions (Sailer, 2004).

By the way, cousin marriage results in an elevated risk of birth defects but on the same order as a 40 year old woman having children as opposed to a 30 year old. In other words, the risks are small relative to other accepted risks. Results do get worse when cousin marriage is prevalent over many generations.

Hat tip to Chris Blattman and Joshua Keating. FYI, Steve Sailer wrote an interesting piece on this issue.

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Will Congress exempt itself from ACA exchange provisions?

by on April 25, 2013 at 7:32 am in Current Affairs, Law, Medicine | Permalink

Congressional leaders in both parties are engaged in high-level, confidential talks about exempting lawmakers and Capitol Hill aides from the insurance exchanges they are mandated to join as part of President Barack Obama’s health care overhaul, sources in both parties said…

There is concern in some quarters that the provision requiring lawmakers and staffers to join the exchanges, if it isn’t revised, could lead to a “brain drain” on Capitol Hill, as several sources close to the talks put it.

The problem stems from whether members and aides set to enter the exchanges would have their health insurance premiums subsidized by their employer — in this case, the federal government. If not, aides and lawmakers in both parties fear that staffers — especially low-paid junior aides — could be hit with thousands of dollars in new health care costs, prompting them to seek jobs elsewhere. Older, more senior staffers could also retire or jump to the private sector rather than face a big financial penalty.

Plus, lawmakers — especially those with long careers in public service and smaller bank accounts — are also concerned about the hit to their own wallets.

Here is more, via these guys.

Addendum: Here is a response from Ezra Klein to the Politico story, but I don’t see that it counters the basic point, as reflected by this brouhaha, that the exchanges are not necessarily such a wonderful place to be, especially for low wage workers.  Megan McArdle also comments.

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Why did Cuba become healthier during the economic meltdown of the 1990s?

by on April 21, 2013 at 4:06 am in Food and Drink, Medicine | Permalink

One should interpret anything about Cuba, or coming out of Cuban data, with extreme caution.  Nonetheless I thought this was interesting enough to pass along:

The economic meltdown should logically have been a public health disaster. But a new study conducted jointly by university researchers in Spain, Cuba, and the U.S. and published in the latest issue of BMJ says that the health of Cubans actually improved dramatically during the years of austerity. These surprising findings are based on nationwide statistics from the Cuban Ministry of Public Health, together with surveys conducted with about 6,000 participants in the city of Cienfuegos, on the southern coast of Cuba, between 1991 and 2011. The data showed that, during the period of the economic crisis, deaths from cardiovascular disease and adult-onset type 2 diabetes fell by a third and a half, respectively. Strokes declined more modestly, and overall mortality rates went down.

This “abrupt downward trend” in illness does not appear to be because of Cuba’s barefoot doctors and vaunted public health system, which is rated amongst the best in Latin America. The researchers say that it has more to do with simple weight loss. Cubans, who were walking and bicycling more after their public transportation system collapsed, and eating less (energy intake plunged from about 3,000 calories per day to anywhere between 1,400 and 2,400, and protein consumption dropped by 40 percent). They lost an average of 12 pounds.

It wasn’t only the amount of food that Cubans ate that changed, but also what they ate. They became virtual vegans overnight, as meat and dairy products all but vanished from the marketplace. People were forced to depend on what they could grow, catch, and pick for themselves– including lots of high-fiber fresh produce, and fruits, added to the increasingly hard-to-come-by staples of beans, corn, and rice. Moreover, with petroleum and petroleum-based agro-chemicals unavailable, Cuba “went green,” becoming the first nation to successfully experiment on a large scale with low-input sustainable agriculture techniques. Farmers returned to the machetes and oxen-drawn plows of their ancestors, and hundreds of urban community gardens (the latest rage in America’s cities) flourished.

And this:

During the special period, expensive habits like smoking and most likely also alcohol consumption were reduced, albeit briefly. This enforced fitness regime lasted only until the Cuban economy began to recover in the second half of the 1990s. At that point, physical activity levels began to fall off, and calorie intake surged. Eventually people in Cuba were eating even more than they had before the crash. The researchers report that “by 2011, the Cuban population has regained enough weight to almost triple the obesity rates of 1995.”

That is by Richard Schiffman, the full article is here, and for the pointer I thank Jim Oliver.

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