Medicine

From the comments

by on May 23, 2013 at 12:48 pm in Medicine | Permalink

Hazel Meade wrote:

The banning of catastrophic-only plans infuriates me the most. Those are the only plans that are actually financially sensible for a healthy individual to purchase. Everything else on the market is a perverse by-product of the employer-based insurance system.

Worst case scenario with a catastrophic-only plan is you end up with $10,000 in debt. That’s a debt load many times smaller than what the Federal government thinks students should take out to get a college degree. We’ll let you borrow $100,000 to get a sociology degree but, we think that $10,000 is an unconscionable amount to pay for medical expenses? So unconscionable that we have to FORCE YOU to buy a plan with more extensive coverage?

Of course, we all know the real reason for this. it’s meant to force healthy young people to subsidize healthcare for older sicker people. Just force them to pay more for insurance than they ought to, and force them to buy more extensive coverage than is rational.

279 comments

For how long will the U.S. suicide rate remain elevated?

by on May 22, 2013 at 2:08 pm in Medicine, Philosophy, Science, Uncategorized | Permalink

In the United States, Julie Phillips, a sociologist at Rutgers University, was among the first researchers to frisk these middle-age suicides for deeper meaning. In 2010 she and a colleague declared the age range a new danger zone for self-harm. Many commentators took this as another fun fact about the boomers, not a cause for general alarm. But earlier this month, Phillips presented the results of a second paper, an attempt to settle the question of whether the boomers were especially suicidal. She sifted through eight decades of U.S. suicide data, wrenching it to separate the influence of absolute age, peer effects, and the events of the moment, and she found something shocking: the boomers have the highest suicide rate right now, but everyone born after 1945 shows a higher suicide risk than expected—and everyone is on pace for a higher rate than the boomers.

Here is more on that topic.  There is also this:

In her next bundle of research, Phillips hopes to pinpoint the massive, steam-rolling social change that matters most for self-harm. She has a good list of suspects: the astounding rise in people living alone, or else feeling alone; the rise in the number of people living in sickness and pain; the fact that church involvement no longer increases with age, while bankruptcy rates, health-care costs, and long-term unemployment certainly do.

I would think also that these days committing suicide involves less shame than it used to.  Here is one of the cited papers.  Here is her home page.

64 comments

Adjusting measures of economic output for health

by on May 22, 2013 at 4:19 am in Data Source, Economics, Medicine | Permalink

This is the kind of argument which no one will successfully rebut, but no one really will take on and adopt either.  Does that mean we are defective?  Or is there simply ineffable wisdom in “how things have been done”?  Must we keep closed all Pandora’s boxes?

Here is the abstract from Mark L. Egan, Casey B. Mulligan, and Tomas J. Philipson:

Many national accounts of economic output and prosperity, such as gross domestic product (GDP) or net domestic product (NDP), offer an incomplete picture by ignoring, for example, the value of leisure, home production, and the value of health. Discussed shortcomings have focused on how unobserved dimensions affect GDP levels but not their cyclicality, which affects the measurement of the business cycle. This paper proposes new measures of the business cycle that incorporate monetized changes in health of the population. In particular, we incorporate in GDP the dollar value of mortality, treating it as depreciation in human capital analogous to how NDP measures treat depreciation of physical capital. We examine the macroeconomic fluctuations in the United States and globally during the past 50 years, taking into account how depreciation in health affects the cycle. Because mortality tends to be pro-cyclical, fluctuations in standard GDP measures are offset by monetized changes in health; booms are not as valuable as traditionally measured because of increased mortality, and recessions are not as bad because of reduced mortality. Consequently, we find that U.S. business cycle fluctuations appear milder than commonly measured and may even be reversed for the majority of “recessions” after accounting for the cyclicality of health. We find that adjusting for mortality reduces the measured U.S. business cycle volatility during the past 50 years by about 37% in the United States and 46% internationally. We discuss future research directions for more fully incorporating the cyclicality of unobserved health capital into standard output measurement.

The NBER link is here, does anyone know of an ungated copy?  Of course other forms of depreciation could be included as well (environmental?) and that too may smooth out business cycles, if we are willing to countenance such factors in the first place.

27 comments

Further problems with ACA implementation

by on May 20, 2013 at 3:41 pm in Law, Medicine | Permalink

From Christopher Weaver and Anna Wilde Mathews:

Employers are increasingly recognizing they may be able to avoid certain penalties under the federal health law by offering very limited plans that can lack key benefits such as hospital coverage.

Benefits advisers and insurance brokers—bucking a commonly held expectation that the law would broadly enrich benefits—are pitching these low-benefit plans around the country. They cover minimal requirements such as preventive services, but often little more. Some of the plans wouldn’t cover surgery, X-rays or prenatal care at all. Others will be paired with limited packages to cover additional services, for instance, $100 a day for a hospital.

Federal officials say this type of plan, in concept, would appear to qualify as acceptable minimum coverage under the law, and let most employers avoid an across-the-workforce $2,000-per-worker penalty for firms that offer nothing. Employers could still face other penalties they anticipate would be far less costly.

It is unclear how many employers will adopt the strategy, but a handful of companies have signed on and an industry is sprouting around the tactic. More than a dozen brokers and benefit-administrators in 10 states said they were discussing the strategy with their clients.

There is more detail at the link, including a discussion of some of the legal uncertainties.  Veronique de Rugy adds comment here.

103 comments

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.

32 comments

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.

29 comments

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.

49 comments

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.

46 comments

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.”

77 comments

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.

25 comments

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.

20 comments

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.

35 comments

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.

90 comments

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!

162 comments

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.

97 comments

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