Category: Medicine
Will Uruguay legalize marijuana?
Members of Uruguay’s House of Representatives have passed a bill to legalise marijuana.
If it goes on to be approved by the Senate, Uruguay will become the first country to regulate the production, distribution and sale of marijuana.
The measure is backed by the government of President Jose Mujica, who says it will remove profits from drug dealers and divert users from harder drugs.
Under the bill, only the government would be allowed to sell marijuana.
There is more here, and reports indicate that approval for the bill is expected.
*The Great Escape*
The author is Angus Deaton and the subtitle is Health, Wealth, and the Origins of Inequality. It is a very good book, as you might expect. Here are two bits I found especially interesting:
In Sweden in 1751 — well before the modern mortality decline — it was riskier to be a newborn than to be an 80-year old.
And, somewhat more recently:
…until around 1900, adult life expectancy in Britain was actually higher than life expectancy at birth. In spite of having lived for 15 years, those teenagers could expect a longer future than when they were born.
The book’s home page is here.
The new Baptists and bootleggers?
Activists fighting to legalize marijuana in states across the country are running into an unlikely opponent: people who make a living in the medical marijuana industry. Politico calls it “Big Marijuana,” noting that those who form part of the billion-dollar industry are fighting hard to keep competitors out of the game. In its fight against full legalization, the medical marijuana sector has joined some unusual allies. The Medical Marijuana Caregivers of Maine, for example, joined law-enforcement groups and social conservatives to fight against a bill that would have legalized possession of small quantities, reports Politico.
Medical marijuana is good business not just for dispensaries but also the doctors who agree to prescribe the drug. Finding a doctor willing to recommend the drug “can take months,” reports Market Watch. In Massachusetts, for example, some 3,000 people are on the waiting list to see a doctor.
The link is here.
Off-label prescribing vs. RCT
Incidentally, another thing that’s fascinating to me is that, there’s a very funny saying when it comes to the ethical review of science, or an anecdote, which is that if a doctor wakes up in the morning and decides that, for the next 100 patients with cancer that he or she sees that have this condition, he’s going to treat them all with this new drug because he thinks that drug works, he can do that. He doesn’t need to get anyone’s permission. He can use any drug “off-label” he wants when, in his judgment, it is helpful to the patient. He’ll talk to the patient. He needs to get the patient’s consent. He can’t administer the drug without the patient knowing. But, he can say to the patient, “I recommend that you do this,” and he can make this recommendation to every one of the next 100 patients he sees.
If, on the other hand, the doctor is more humble, and more judicious, and says “you know, I’m not sure that this drug works, I’m going to only give it to half of the next 100 patients I see,” then he needs to get IRB approval, because that’s research. So even though he’s giving it to fewer patients, now there’s more review.
That is from Nicholas A. Christakis, via Jim Olds. The discussion is mostly about Big Data.
Does it matter if Muslim representatives are elected in India?
There is a new paper by Sonia R. Bhalotra, Guilhem Cassan, Irma Clots-Figueras, and Lakshmi Iyer which says yes it does matter:
This paper investigates whether the religious identity of state legislators in India influences development outcomes, both for citizens of their religious group and for the population as a whole. To allow for politician identity to be correlated with constituency level voter preferences or characteristics that make religion salient, we use quasi-random variation in legislator identity generated by close elections between Muslim and non-Muslim candidates. We find that increasing the political representation of Muslims improves health and education outcomes in the district from which the legislator is elected. We find no evidence of religious favoritism: Muslim children do not benefit more from Muslim political representation than children from other religious groups.
The NBER version is here, there is an ungated pdf here.
How Medicare payments are set
It’s never a bad idea to bring this point up yet again:
Reporters Peter Whoriskey and Dan Keating have opened Post readers’ eyes to the fact that Medicare pays for physician services — a $69.6 billion item in 2012 — according to an arcane and little-known price list, over which doctors themselves exercise considerable and less-than-totally-transparent influence.
Known as the Relative Value Update, the process consists of a 31-member committee of the American Medical Association (AMA) recommending what Medicare should pay for some 10,000 procedures — with the fees based in part on how long it takes to complete each one. This time-and-motion study often fails to take full account of changing technology and other factors affecting physician productivity, so anomalies result: For example, Medicare pays for a 15-minute colonoscopy as if it took 75 minutes.
Here is a bit more, here is the longer article.
By the way, there is also this new result:
In one of the study’s notable insights, Dr. [Joseph P.] Newhouse said, “we did not find any relation between the quality of care and spending, in either Medicare or the commercial insurance sector.”
That is from a new study of regional variation in Medicare expenditures. The study itself is here, and it seems to imply that regional discrepancies in Medicare expenditures cannot be easily rectified by rewarding the more cost-efficient regions. For one thing, cost variation among providers, within a region, is large, which makes it hard to apply incentives on a regional basis.
Penn State uses the stick to enforce medical exams
By November, faculty and their spouses or domestic partners covered by university health care must complete an online wellness profile and physical exam. They’re also required to complete a more invasive biometric screening, including a “full lipid profile” and glucose, body mass index and waist circumference measurements. (Mobile units from the university’s insurance company, Highmark, will visit campuses to perform these screenings.)
Employees and their beneficiaries who don’t meet those requirements must pay the monthly insurance surcharge [$100] beginning in January.
And if you don’t trust the employer, they have reassured us:
“It is important to note that screening results are confidential and will not be used to remove or reduce health care benefits, nor raise an individual’s health care premium,” a university announcement reads. “The results only are for individual health awareness, illness prevention and wellness promotion.”
Austerity and Irish health
From Cormac Ó Gráda:
Dermot and Brendan Walsh have just published a provocative comment in the British Medical Journal on the link between health and austerity [http://www.bmj.com/content/346/bmj.f4140/rr/651853].
Momentary relief from the deliberations on Anglo!
The comment reads:
Ireland is – after Greece – the country where the post 2008 structural adjustment programme, aka austerity, has been proportionately most severe. Yet there are few indications that this has had a significant adverse effect on basis health indicators.
The crude death rate in 2012 was 6.3 per 1,000 compared with 6.4 in pre-austerity 2007. The suicide rate in 2012 was 12.8 per 100, 000 in 2012 compared with 13.2 in 2007. Admission rates for depressive disorders fell to 117 per 100, 000 in 2012 from 138 in 2007. The percentage distribution of self-assessed health status did not change between 2007 and 2010 (the latest available year).
Overall there is a striking lack of evidence that the major austerity programme implemented since 2007, and the concomitant trebling of the unemployment rate, has had a significant deleterious effect on the health of the Irish population. This evidence needs to be given due weight in international assessments of the impact of economic policies on public health.
The link is here. According to The Irish Times, citing the OECD, “Spending on the health system fell by over 5 per cent a year in 2009-2011…” I should note that you will find significantly more negative results if you look at the experience of Greece with health care services. By the way, I read some of the recent book Why Austerity Kills but found the level of argumentation to be weak.
Drug Shortages are Killing
The shortages of injectable drugs that I have been writing about since 2011 (e.g. here and here) are continuing and they are extending to ordinary nutrients needed by premature babies:
Because of nationwide shortages, Washington hospitals are rationing, hoarding, and bartering critical nutrients premature babies and other patients need to survive.
..At the time of this writing—some shortages come and go by the week—Atticus’s hospital is low on intravenous calcium, zinc, lipids (fat), protein, magnesium, multivitamins, and sodium phosphate; it’s completely out of copper, selenium, chromium, potassium phosphate, vitamin A, and potassium acetate. And so are many other hospitals and pharmacies in the country, leading to complications usually seen only in the developing world, if ever.
The article in the Washingtonian covers problems with GMP regulations and the FDA, as I did earlier. The article also makes the following point. Many of these products, especially the simpler ones, are available in Europe but it is illegal to import them to the United States.
Many doctors are pinning their immediate hopes on Congress’s forcing the FDA to form a global pipeline to import an emergency supply. “I have friends in other countries who could get me some, but that would be illegal,” one doctor says. In fact, pharmacists note that the phosphorous Europe uses is a better product than that in the US because it’s organic and doesn’t interact with calcium in the PN, meaning more phosphorous could be included in the IV bag.
When Miguel Sáenz de Pipaón, a neonatologist at a prominent hospital in Madrid, arrived in the US for a research visit, he was stunned by the nutrition shortages.
“It’s crazy,” he says. “That doesn’t happen in Europe.” He noted that the US relies on a 25-year-old lipid emulsion, which is in shortage, while European hospitals use a newer version that’s readily available. Rather than import the newer emulsion, the US has left many patients without any lipids at all.
Hat tip: Kurt Schuler.
How does insurance eligibility affect labor supply?
There is a new paper by Craig Garthwaite, Tal Gross, and Matthew J. Notowidigdo, the abstract is this:
We study the effect of public health insurance eligibility on labor supply by exploiting the largest public health insurance disenrollment in the history of the United States. In 2005, approximately 170,000 Tennessee residents abruptly lost public health insurance coverage. Using both across- and within-state variation in exposure to the disenrollment, we estimate large increases in labor supply, primarily along the extensive margin. The increased employment is concentrated among individuals working at least 20 hours per week and receiving private, employer-provided health insurance. We explore the dynamic effects of the disenrollment and find an immediate increase in job search behavior and a steady rise in both employment and health insurance coverage following the disenrollment. Our results suggest a significant degree of “employment lock” – workers employed primarily in order to secure private health insurance coverage. The results also suggest that the Affordable Care Act – which similarly affects adults not traditionally eligible for public health insurance – may cause large reductions in the labor supply of low-income adults.
The NBER version of this piece is here, ungated here. Craig writes to me:
Applying our estimates to the ACA, this would mean a reduction in labor supply of about 0.3 to 0.6 percentage points (or about 500-900K people) just from this feature.
Is this a feature or a bug? Reihan adds comment.
Why isn’t health care employment slowing?
We’ve all heard a lot about the slowing of health care cost inflation. Yet, coming from Dan Diamond of The Advisory Board, here are some very interesting points of relevance to the topic:
“A lot of people have noted that health care spending has slowed,” Amitabh Chandra, an economist and the director of health policy research at the Harvard Kennedy School, told me last week.
“Many of us would like to think that this is a more permanent slowdown,” he added.
“[But] we see absolutely no slowdown in employment growth in health care. And if that is not slowing, then it’s very difficult to believe that there will be a sustained slowdown in health care spending.”
Health care gained more than 320,000 jobs in 2012—the sector’s strongest year in five years.
…”One hypothesis is that only lower-paying jobs in health are growing,” the Altarum Institute’s Ani Turner told me via email. But “we don’t think that’s true.” Altarum researchers have reviewed BLS data and found “stable growth” for the most highly paid health care workers—i.e., doctors and nurses—if somewhat lower growth for health care support roles.
And the University of Texas’s Richardson took a look at two other potential culprits: whether the wages paid to health care workers had fallen in recent years, or if their hours worked had declined. But neither scenario had come to pass; in fact, Richardson found that hourly wages had only climbed, while weekly hours worked have remained essentially flat.
The full article is here, and the entire discussion is of interest. You will note for instance that capital spending does seem to be down.
File under “The Puzzle Deepens.”
New Zealand Meow Meow
Instead of trying to ban new drugs as fast as they are
created, New Zealand has taken a different
approach, it will allow synthetic drugs to be sold so long
as they pass safety trials.
It’s the first nation
to take a dramatically different approach to psychoactive
substances like party pills and synthetic marijuana… [that] go by names like bath salts, spice or
meow-meow.
In a 119-to-1 vote on Thursday, the country’s parliament
passed the Psychoactive Substances Bill, establishing a framework
for testing, manufacturing and selling such recreational
drugs.
The law does not overturn existing bans
such as on marijuana although that issue is likely to be revisited.
File this sentence under the culture that is New Zealand:
The drug law enjoyed broad support although there
was debate over whether animal testing would be required in the
clinical tests.
Surgery price wars in Oklahoma City?
I don’t have deep background knowledge on this particular hospital, but here is a new and interesting article:
An Oklahoma City surgery center is offering a new kind of price transparency, posting guaranteed all-inclusive surgery prices online. The move is revolutionizing medical billing in Oklahoma and around the world.
Dr. Keith Smith and Dr. Steven Lantier launched Surgery Center of Oklahoma 15 years ago, founded on the simple principle of price honesty.
“What we’ve discovered is health care really doesn’t cost that much,” Dr. Smith said. “What people are being charged for is another matter altogether.”
Surgery Center of Oklahoma started posting their prices online about four years ago.
Click here to see the online prices at Surgery Center of Oklahoma.
The prices are all-inclusive quotes and they are guaranteed.
“When we first started we thought we were about half the price of the hospitals,” Dr. Lantier remembers. “Then we found out we’re less than half price. Then we find out we’re a sixth to an eighth of what their prices are. I can’t believe the average person can afford health care at these prices.”
Their goal was to start a price war and they did.
Their first out-of-town patients came from Canada; soon everyday Americans caught on.
Here is a bit more:
Dr. Smith said federal Medicare regulation would not allow for their online price menu.
They have avoided government regulation and control in that area by choosing not to accept Medicaid or Medicare payments.
I would like to know more about this example (maybe Cherokee Gothic can go buy something there), but the article is here and some further coverage is here. For the pointer I thank Jake Seliger and also Craig Fratrik and Timothy Miano.
Equip your robot with a Harris Tweed jacket
Robots are to be placed into the homes of people with dementia as part of a pilot on the Western Isles, but it is just one of many uses machines are being put to in Scotland amid a wider debate on robotics.
NHS Western Isles is the first health board in Scotland to try out Giraff.
The 1.5m (4ft 11in) tall, wheeled robots have a TV screen instead of a head.
A relative or carer can call up the Giraff with a computer from any location. Their face will appear on the screen allowing them to chat to the other person.
The operator can also drive the robot around the house to check that medication is being taken and that food is being eaten.
There is more here.
Repeal the employer mandate altogether
I agree with Ezra Klein, who writes:
Delaying Obamacare’s employer mandate is the right thing to do. Frankly, eliminating it — or at least utterly overhauling it — is probably the right thing to do. But the administration executing a regulatory end-run around Congress is not the right way to do it.
Ezra notes:
– By imposing a tax on employers for hiring people from low- and moderate-income families who would qualify for subsidies in the new health insurance exchanges, it would discourage firms from hiring such individuals and would favor the hiring — for the same jobs — of people who don’t qualify for subsidies (primarily people from families at higher income levels).
– It would provide an incentive for employers to convert full-time workers (i.e., workers employed at least 30 hours per week) to part-time workers.
– It would place significant new administrative burdens and costs on employers.
By tying the penalties to how many full-time workers an employer has, and how many of them qualify for subsidies, the mandate gives employers a reason to have fewer full-time workers, and fewer low-income workers.
We can only hope that repeal of this one part of the law is what the Obama Administration actually has in mind, though as Ezra notes Congress is not currently in a cooperative frame of mind. Still, this way it has a chance of serious reexamination after the 2014 elections.
Evan Soltas offers relevant comment on how this will change implementation in the short-run, namely that it puts more burden on the exchanges. Sarah Kliff comments on the politics, a very good post. Here is one good quotation from a source: “Politically, it won’t get easier a year from now, it will get harder,” he said. “You’ve given the employer community a sense of confidence that maybe they can kill this. If I were an employer, I would smell blood in the water.”
My view is you don’t serve up a delay and PR disaster like this, on such a sensitive political issue, unless you really wish to derail the entire provision.