Category: Medicine

In Conversation with Próspera CEO Erick Brimen & Vitalia Co-Founder Niklas Anzinger

During my visit to Prospera, one of Honduras’ private governments under the ZEDE law, I interviewed Prospera CEO Erick Brimen and Vitalia co-founder Niklas Anzinger. I learned a lot in the interview including the real history of the ZEDE movement (e.g. it didn’t begin with Paul Romer). I also had not fully appreciated the power of reciprocity stacking.

Companies in Prospera have the unique option to select their regulatory framework from any OECD country, among others. Erick Brimen elaborated in the podcast how this enables companies to do normal, OECD approved, things in Prospera which literally could not be done legally anywhere else in the world.

…so in the medical world for instance you have drugs that are approved in some countries but not others and you have medical practitioners that are licensed in some countries but not the others and you have medical devices approved in some countries but not others and there’s like a mismatch of things that are approved in OECD countries but there’s no one location where you can say hey if they’re approved in any country they’re approved here. That is what Prosper is….Our hypothesis is that just by doing that we can leapfrog to a certain extent and it’s got nothing to do with the wild west or doing weird things.

…so here so you can have a drug approved in the UK but not in the US with a doctor licensed in the US but not in the UK with a medical device created in Israel but not yet approved by the FDA following a procedure that has been say innovated in Canada, all of that coming together here in Prospera.

As it should be

The next time you send your doctor an email, don’t be surprised if they charge you a fee to answer.

More healthcare groups are charging fees to answer patients’ electronic messages, often the ones you exchange via their portal. Doctors say it’s only fair if they’re spending time on the messages and note that an email discussion can often save you the time of having to come in.

The typical cost of an email message claim was $39 in 2021, including both the portion paid by insurance and by the patient, according to a Peterson-KFF Health System Tracker analysis.

Some patients have been taken aback by the charges. They are surprised at the notifications on portals about the change, and irritated at the idea of a new fee.

Dr. Lauren Oshman, a family physician and associate professor at the University of Michigan Medical School, says she initially experienced some patient resistance and anger about the prospect of being billed for emails.

Now, she says, patients are typically pleased that they are able to get a direct response from her through a portal message.

“They’re thrilled when they get me directly,” she says.

Here is more from the WSJ, via the excellent Daniel Lippman.

What can be learned from Singaporean health care institutions?

Besides the usual, that is.  Max Thilo of the UK has a new and excellent study on this, here is one excerpt from the foreword by Lord Warner:

Second, and critical, the Singaporeans are not fixated on delivering services from acute hospitals – the most expensive part of any healthcare system because of its fixed overheads and expensive maintenance. As this report demonstrates “the reason why Singapore spends so much less on health than other developed countries is its low hospital utilisation.” Instead, Singapore has invested in highly productive polyclinics and low-cost telemedicine. The result is that Singaporeans can visit their GP more often than English patients. In their polyclinics they also improve productivity by separating chronic and acute care.

And from Max:

During a recent trip, I met with the CEO of the largest telemedicine provider in Singapore. He casually mentioned that UK patients were already using his service. This seemed surprising. No comprehensive data is available for the costs of UK telemedicine services, so I googled the cost of online appointments in the UK and Singapore. Singaporean appointments are less than half the price of those in the UK. The most affordable online appointment I found in the UK was £29. Yet, many providers charge significantly more – for instance, Babylon Health lists its price for private GP appointments at £59. In contrast, Doctor Anywhere, Singapore’s leading telemedicine provider, offers services for just £12.27 Doctor Anywhere has an app where patients can log on and see patients virtually. They make and then register the diagnosis. The rest of the process, including referrals and prescriptions, is automated.

Recommended.

U.S.A. yikes fact of the day

Between January 2016 and December 2022, the monthly antidepressant dispensing rate increased 66.3%, from 2575.9 to 4284.8. Before March 2020, this rate increased by 17.0 per month (95% confidence interval: 15.2 to 18.8). The COVID-19 outbreak was not associated with a level change but was associated with a slope increase of 10.8 per month (95% confidence interval: 4.9 to 16.7). The monthly antidepressant dispensing rate increased 63.5% faster from March 2020 onwards compared with beforehand. In subgroup analyses, this rate increased 129.6% and 56.5% faster from March 2020 onwards compared with beforehand among females aged 12 to 17 years and 18 to 25 years, respectively. In contrast, the outbreak was associated with a level decrease among males aged 12 to 17 years and was not associated with a level or slope change among males aged 18 to 25 years.

That is by Kao-Ping Chua, et.al., from the high-quality journal Pediatrics.  So that is how we respond to crises?  By doping up the young women?  Yikes!

Via the excellent Kevin Lewis.

Genetic Insurance

Genetic testing identifies disease risk, enabling individuals to dodge environmental triggers, optimize treatments, and improve planning. Yet, the fear of increased insurance premiums deters many from undergoing tests. Genetic testing offers societal benefits but also presents significant distributional challenges. To address this, my 1994 paper proposed the idea of genetic insurance.

For a small fee genetic insurance would insure against the possibility of a positive test result. If the test came back positive the customer would be paid a large sum of money, enough to cover the expected costs of his disease or equivalently enough to allow him to purchase health insurance at the new risk premium. If the test turns out negative the customer would lose his genetic insurance fee but would gain the results of the test and also lower health insurance premiums. Those who have positive tests results would be paid enough money to pay their health care costs and would also benefit from being able to plan in accord with the test results. Under this proposal average insurance rates will fall and everyone will be made better off.\

Genetic insurance is insurance against changes in the cost of health insurance due to genetic information. John Cochrane would later generalize this idea to show that it’s possible to insure against changes in the cost of health insurance due to any new information. Cochrane called this time-consistent health insurance or health-status insurance; it’s a way of creating long-term health insurance contracts without binding an individual to a firm.

In an interesting paper, Helene Schernberg extends my 1994 paper. Schernberg shows that even if an individual has full-health insurance that can’t be taken away, there are other reasons to want genetic insurance. She focuses on the planning aspect. Genetic insurance could be used to shift consumption earlier, to better health states and thus improve life-time allocation.

Genetic testing could soon be a routine part of your medical journey. It offers insights into inherited disorders or susceptibility to various conditions. For example, if you are a woman with a BRCA mutation, you have a 55 to 72% lifetime risk of breast cancer.

This suggests that genetic information is valuable while providing a theoretical argument in favor of genetic insurance. The mechanism is described in Tabarrok (1994): Individuals purchase genetic insurance before taking a genetic test, thus receiving a compensation upon being identified as a high-risk. Tabarrok (1994) relates this genetic insurance payment to the need to cover expensive health insurance premia. I show that it also relates to the fact that a temporally risk-averse individual wishes to insure against the lifetime utility losses she may experience when her health prospects deteriorate after taking a genetic test.

Monopolized organ collection

The nation’s 56 organ procurement organizations collect organs — mainly kidneys — from deceased donors at hospitals and arrange for them to be transported to surgeons at the 250 U.S. medical centers that perform transplants. Each procurement group holds a government-guaranteed monopoly over a swath of U.S. territory where it operates.

Some have failed for years to collect enough organs to meet demand, according to government records. But the Centers for Medicare and Medicaid Services, the part of HHS that licenses the nonprofits to operate, has never decertified one. In response to critiques, the CMS issued new benchmarks that will allow the agency to weed out poor performers beginning in 2026.

Now many of these organ collection groups are under investigation for fraud and overbilling the government.

Access to Medical Data Saves Lives

ProPublica: In January, the Biden administration pledged to increase public access to a wide array of Medicare information to improve health care for America’s most sick and vulnerable.

…So researchers across the country were flummoxed this week when the Centers for Medicare and Medicaid Services announced a proposal that will increase fees and diminish access to claims data that has informed thousands of health care studies and influenced major public health reforms.

Using big Medicare databases has never been cheap or easy. Under the current system, researchers could have the data transferred to secure university computers for about $20,000–that’s a lot but once the data was on the university computers it could be accessed by multiple researchers, cutting costs. A professor could buy the data and their PhD students, for example, wouldn’t have to pay again. Under the new system it will cost $35,000 for one researcher to access the data which will be held on government (CMS) computers. Moreover, it’s unclear how complex statistical analysis will be performed or how congested the CMS systems may become.

Research teams on complex projects can include dozens of people and take years to complete. “The costs will grow exponentially and make access infeasible except for the very best resourced organizations,” said Joshua Gottlieb, a professor at the University of Chicago’s Harris School of Public Policy.

Public data should be open access to researchers, with appropriate anonymization. We know from IP law that barriers to access reduce research and innovation; and in the medical sphere research and innovation saves lives. Open access is also a check on how governments spends taxpayer money and the effectiveness of such spending. I also worry that raising the dollar cost of access is a prelude to other restrictions. The NIH, for example, is restricting access to genetic data if it thinks the researcher will be asking forbidden questions. Even without such explicit restrictions, there is a chilling effect when researchers are beholden for access to the government and indeed to the very agencies they may be researching.

I place a high value on privacy but I get suspicious when governments invoke privacy to block citizen access to government data but not to block government access to citizen data. Medicare databases have always been appropriately anonymized and care is taken so the data are secured but the dangers of these databases in anyone’s hand, let alone researchers, is far less than anti-money laundering, KYC laws and suspicious transaction reports in banking, automated license plate readers that the police us to scan billions of license plates or mass surveillance of the communications of US citizens under FISA. Sadly, this list could easily be extended. Liberty thrives on the people’s privacy and the government’s transparency.

Give Innovation a Chance

Elizabeth Currid-Halkett writing in the NYTimes discusses her son’s muscular dystrophy and his treatment with the controversial gene-therapy Elevidys. Currid-Halkett, like many parents whose children have been treated with Elevidys, reports much better results than appear in the statistics.

On Aug. 29, [my son] finally received the one-time infusion. Three weeks later, he was marching upstairs and able to jump over and over. After four weeks, he could hop on one foot. Six weeks after treatment, Eliot’s neurologist decided to re-administer the North Star Ambulatory Assessment, used to test boys with D.M.D. on skills like balance, jumping and getting up off the floor unassisted. In June, Eliot’s score was a 22 out of 34. In the second week of October, it was a perfect 34 — that of a typically developing, healthy 4-year-old boy. Head in my hands, I wept with joy. This was science at its very best, close to a miracle.

…a narrow focus on numbers ignores the real quality-of-life benefits doctors, patients and their families see from these treatments. During the advisory committee meeting for Elevidys in May 2023, I listened to F.D.A. analysts express skepticism about the drug after they watched videos of boys treated with Elevidys swimming and riding bikes. These experts — given the highest responsibility to evaluate treatments on behalf of others’ lives — seemed unable to see the forest for the trees as they focused on statistics versus real-life examples.

Frankly, I side with the statistics. We don’t hear from the parents in the placebo group whose children also spontaneously made improvements.

Even though I side the statistics, I side with approval. Innovation is a dynamic process. It’s not surprising that the first gene therapy for DMD offers only modest benefits; you don’t hit a home run the first time at bat. But if the therapy isn’t approved, the scientists don’t go back to the drawing board and keep going. If the therapy isn’t approved, it dies and you lose the money, experience and learning by doing that are needed to develop, refine and improve.

Approval is not the end of innovation but a stepping stone on the path of progress. Here’s an example I gave earlier of the same principle. When we banned supersonic aircraft, we lost the money, experience and learning by doing needed to develop quieter supersonic aircraft. A ban makes technological developments in the industry much slower and dependent upon exogeneous progress in other industries.

You must build to build better.

Addendum: Peter Marks is the best and perhaps the most important director CBER has ever had. CBER, the Center for Biologics Evaluation and Research, is responsible for biological products, including vaccines and gene therapies. Marks has repeatedly pushed and sometimes overruled his staff in approving products like Elevidys. Marks named and was the driving force at the FDA behind Operation Warp Speed, a tremendous FDA success and break with tradition. Marks has been challenging the FDA’s conservative culture. I hope his changes survive his tenure.

Avoiding Repugnance

Works in Progress has a good review of the state of compensating organ donors, especially doing so with nudges or non-price factors to avoid backlash from those who find mixing money and organs to be repugnant. My own idea for this, first expressed in Entrepreneurial Economics, but many times since is a no-give, no-take rule. Under no-give, no-take, people who sign their organ donor cards get priority should they one day need an organ. The great virtue of no-give, no-take is that it provides an incentive to sign one’s organ donor card but one that strikes most people as fair and just and not repugnant. Israel introduced a no-give, no-take policy in 2008 and it appears to have worked well.

In March 2008, to increase donations, the Israeli government imple­mented a ‘priority allocation’ policy to encourage more people to sign up to donate organs after their deaths. Once someone has been registered as a donor for three years, they receive priority allocation if they themselves need a transplant. If a donor dies and their organs are usable, their close family members also get higher priority for transplants if they need them – ​which also means that families are more inclined to give their consent for their deceased relatives’ organs to be used.

In its first year, the scheme led to 70,000 additional sign-ups. The momentum continued, with 11.1 percent of all potential organ donors being registered in the five years after the scheme was introduced, compared to 7.7 percent before. According to a 2017 study, when presented with the decision to authorize the donation of their dead relative’s organs, 55 percent of families decided to donate after the priority scheme, compared to 45 percent before.

Do recessions benefit our health?

That is the topic of my latest Bloomberg column, here is one excerpt:

The human and economic costs of recessions are deep and well-documented. They can also have real health benefits, however, and seldom are they expressed so starkly as in this sentence in a new paper from the National Bureau of Economic Research: “The Great Recession provided one in twenty-five 55-year-olds with an extra year of life.”

…Overall, the paper notes, age-adjusted mortality in the US fell by 2.3% during the Great Recession. The finding, from professors at MIT, the University of Chicago and McMasters University, broadly tracks previous research showing that that mortality rates rise in good times and fall in hard times.

And:

One answer is related to air pollution, which is lower in recessions, typically because of reduced economic activity. The benefits of lower pollution levels persist long after the recession — at least 10 years, according to the researchers’ estimates. Air pollution reduction accounts for more than one-third of the mortality benefits from the Great Recession.

And all of this:

The data do provide some additional clues. Except for cancer, for example, all major causes of mortality fell during the Great Recession. Decreases in cardiovascular-related deaths accounted for about half the mortality gains during that time. Furthermore, the mortality benefits were concentrated among Americans without college degrees. You might think that some of these improved health outcomes were due to people losing their stressful, low-paying jobs, but unemployment can be pretty stressful too.

For a 55-year-old, according to the paper’s estimates, about one-quarter of the economic costs of the Great Recession were countered by these mortality gains. So the Great Recession was still a very bad event — just less bad than we used to think. That is especially true for less educated Americans, who were hit harder by unemployment but also reaped the mortality gains.

At the top end of the age distribution, Americans aged 65 and older didn’t lose much from the Great Recession, in part because so many were already retired or working only part-time (in some cases, they were ensconced in jobs they were not going to lose). The researchers estimate that those over age 60 were also better off, on net, from the Great Recession.

Worth a ponder.  Here is the original paper by Amy FinkelsteinMatthew J. NotowidigdoFrank Schilbach Jonathan Zhang.

Scientific Talent Leaks Out of Funding Gaps

Lack of speed kills:

We study how delays in NIH grant funding affect the career outcomes of research personnel. Using comprehensive earnings and tax records linked to university transaction data along with a difference-in-differences design, we find that a funding interruption of more than 30 days has a substantial effect on job placements for personnel who work in labs with a single NIH R01 research grant, including a 3 percentage point (40%) increase in the probability of not working in the US. Incorporating information from the full 2020 Decennial Census and data on publications, we find that about half of those induced into nonemployment appear to permanently leave the US and are 90% less likely to publish in a given year, with even larger impacts for trainees (postdocs and graduate students). Among personnel who continue to work in the US, we find that interrupted personnel earn 20% less than their continuously-funded peers, with the largest declines concentrated among trainees and other non-faculty personnel (such as staff and undergraduates). Overall, funding delays account for about 5% of US nonemployment in our data, indicating that they have a meaningful effect on the scientific labor force at the national level.

That is the abstract of a new paper by Wei Yang Tham, Joseph Staudt, Elisabeth Ruth Perlman, and Stephanie D. Cheng.  Here is my earlier piece, with Collison and Hsu, and what we learned doing Fast Grants.

Vaccine Induced Social Amnesia

Source: Clinique CME

NYT: In 2022, there were 941 reported cases of measles in the World Health Organization’s European region. Over just the first 10 months of last year, according to an alarming bulletin the W.H.O. issued in mid-December, there were more than 30,000.

This is the kind of spike — a 3,000 percent increase — that looks implausible in headlines….But as the year drew to a close, the European measles outbreak kept growing. Through December, case numbers in the region eventually reached over 42,000, and although the largest outbreaks were in countries most Americans regard as pretty remote (Kazakhstan, Kyrgyzstan and Russia), there is also a vicious surge in Britain, which may look plausibly to us as the canary in a coal mine. There, in just one of England’s nine regions, the West Midlands, 260 cases have been confirmed and dozens more suspected, in a country which, as a whole, recorded just two cases as recently as 2021.

As David Wallace-Wells explains, vaccination rates are still 90%+ and down only slightly but measles is so infectious that even amid an otherwise well-vaccinated population, it can sometimes find pockets of low vaccination populations and spread like wildfire.

Measles is an especially nasty infection because it can induce “immunological amnesia, thereby making individuals more susceptible to pathogens that they previously were able to resist.

Ironically, just as measles can induce immunological amnesia, vaccines can induce social amnesia about the severity of diseases, thereby making society more susceptible to pathogens that they previously were able to resist.