Category: Medicine
Why a coach should be ambiguous
Remember how Mr. Miyagi taught The Karate Kid how to fight? Wax on/Wax off. Paint the fence. Don’t forget to breathe. A coach is the coach because he knows what the student needs to do to advance. A big problem for coaches is that the most precocious students also (naturally) think they know what they need to learn.
If Mr. Miyagi told Daniel that he needed endless repetition of certain specific hand movements to learn karate, Daniel would have rebelled and demanded to learn more and advance more quickly. Mr. Miyagi used ambiguity to evade conflict.
An artist with natural gift for expression needs to learn convention. But she may disagree with the teacher about how much time should be spent learning convention. If the teacher simply gives her exercises to do without explanation her decision to comply will be on the basis of an overall judgment of whether this teacher, on average, knows best. To instead say “You must learn conventions, here are some exercises for that” runs the risk that the student moderates the exercises in line with her own judgment about the importance of convention.
Thwarted body part markets in everything
The Chicago-based nonprofit faces “the same challenge any business would have, whether I’m selling Hostess Twinkies or cadavers,” says Stephen Burnett, a professor of management and strategy at Northwestern University’s Kellogg School of Management.
To stay ahead, the association wants to supply body parts to the FBI and launch new products, including its own plastinated bodies, says Mr. Dudek, 62, executive vice president since 2005. He draws on his entrepreneurial experience as a co-owner of an MRI center in the south suburbs, which he sold to join the association.
Originally known as the Demonstrator’s Society, the association has not changed its business plan since its founding in 1918. Bodies are donated, embalmed and transferred to institutions such as med schools, where dissection remains a rite of passage.
Reasons for donations vary. Some gifts are part of estate planning, while others are made by relatives who cannot afford funerals.
By law, bodies cannot be sold, although groups like the association can be paid for processing. Member med schools pay about $1,300 per cadaver; nonmembers pay $2,300.
Nationwide, there’s a shortage of cadavers, in part because of the rise in organ donation. Cadavers without their organs are not suitable for medical education, Mr. Dudek notes. The association needs about 425 bodies a year for its members but missed that mark in 2009 and has barely met it in three of the last six years.
And yet globalization and government may come to the rescue:
The Middle East, where the culture discourages body donations, could be a new market. Schools in Lebanon and Saudi Arabia have recently expressed interest, he says. Law enforcement agencies also are prospects. Anatomical Gift is close to signing a contract to supply the FBI’s K-9 unit, which uses body parts to train dogs to find crime victims, he says. Limbs cost $570, plus $335 for HIV and hepatitis testing, since they are not embalmed, Mr. Dudek says. An FBI spokeswoman declines to comment.
There is more here, and for the pointer I thank G. Patrick Lynch.
Sentences of interest
IBM is also working to program Watson so that it can pass the U.S. Medical Licensing Examination.
Here is more.
Facts about doctors
…new M.D.s per senior fell by about a third over the last three decades.
Much as I sometimes mistrust doctors, that is not good news. And I find it sad how infrequently this number is discussed. There is more from Bryan Caplan here. And get this:
New male M.D.s per person are down by over 45%.
That is a sign of rising female prominence when it comes to educational success, but there is no good reason why the flow of male doctors should be falling so rapidly; it’s not as if men suddenly have lost the ability to doctor.
The public funding of research and development
This is one of the best of all government programs (or it can be viewed as a collection of programs). Here is a good survey of the issue, by Brad Plumer, excerpt:
There’s a long, long list of world-changing innovations that can be traced back to federally funded R&D over the years. The Department of Energy’s research labs spawned digital recording technology, communications satellites, and water-purification techniques. Pentagon research laid the groundwork for the Internet and GPS. The current shale-gas fracking boom couldn’t have happened without microseismic imaging techniques that were developed at Sandia National Laboratories.
It also can be said that this is probably the worst side of the sequester.
The effects of pharmaceutical promotion
Here is a new paper by Dhaval M. Dave:
This review discusses the role of consumer-directed and physician-directed promotion in the pharmaceutical market, based on the classic conceptual framework of whether such promotion is “persuasive” and/or “informative”. Implications for public health and welfare partly depend on whether, and to what extent, advertising: 1) raises “selective” or brand-specific demand versus “primary” or industry-wide demand; 2) impacts drug costs; and 3) impacts competition. Empirical evidence from the literature bearing on these effects is surveyed. These studies show that pharmaceutical promotion has both informative and persuasive elements. Consumer advertising is more effective at enlarging the market, educating consumers, inducing physician contact, expanding drug treatment, and promoting adherence among existing users. Physician advertising is primarily persuasive in nature, effectively increasing selective brand demand. There is no strong evidence the drug promotion deters entry, and there is some suggestive evidence that it may even be mildly pro-competitive. There is also no strong evidence that either consumer- or provider-directed promotion substantially raises retail-level prices. While all of these effects point to welfare improvements as a result of pharmaceutical promotion, there is also evidence that consumer ads may induce overuse and overtreatment in certain cases. Market expansion, overtreatment and shifting brands for non-therapeutic reasons further raise the concern of a sub-optimal patient-drug match at least for some marginal patients. A comprehensive evaluation of the welfare effects of pharmaceutical promotion requires a balanced assessment of these benefits and costs.
You may recall my requesting a more balanced approach from Ben Goldacre. In terms of measuring and comparing actual costs and benefits, this goes well beyond the more negative (and I would say one-sided, though often quite on the mark) evidence in his book, entitled Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients. And you will notice that this paper is a survey, based upon a fairly broad published literature.
Is bipolar disorder more common in highly intelligent people?
Here is a new piece by Gale CR, Batty GD, McIntosh AM, Porteous DJ, Deary IJ, and Rasmussen F.:
Abstract
Anecdotal and biographical reports have long suggested that bipolar disorder is more common in people with exceptional cognitive or creative ability. Epidemiological evidence for such a link is sparse. We investigated the relationship between intelligence and subsequent risk of hospitalisation for bipolar disorder in a prospective cohort study of 1 049 607 Swedish men. Intelligence was measured on conscription for military service at a mean age of 18.3 years and data on psychiatric hospital admissions over a mean follow-up period of 22.6 years was obtained from national records. Risk of hospitalisation with any form of bipolar disorder fell in a stepwise manner as intelligence increased (P for linear trend <0.0001). However, when we restricted analyses to men with no psychiatric comorbidity, there was a ‘reversed-J’ shaped association: men with the lowest intelligence had the greatest risk of being admitted with pure bipolar disorder, but risk was also elevated among men with the highest intelligence (P for quadratic trend=0.03), primarily in those with the highest verbal (P for quadratic trend=0.009) or technical ability (P for quadratic trend <0.0001). At least in men, high intelligence may indeed be a risk factor for bipolar disorder, but only in the minority of cases who have the disorder in a pure form with no psychiatric comorbidity.
David Cutler and Nikhil Sahni on the health care cost curve
Technological change has also been a key driver of spending increases for some time. From pharmaceuticals to imaging to cardiac procedures, markets have been saturated with new and expensive services and products in recent decades. But the adoption of new technology seems to have slowed. Major parts of imaging growth are down, some cardiac procedures are being performed less frequently as studies show they are overused, and the number of new molecular entities approved by the Food and Drug Administration has not kept up with research and development spending.
To be sure, there are many new drugs and imaging devices on the market, especially in fields like oncology. But sales of these new technologies have been more disappointing than robust. The therapeutic prostate cancer vaccine Provenge was not the hit it was expected to be; Zaltrap, a therapy for some cancers and macular degeneration, had to halve its price because it was losing out to Avastin.
Efficiency efforts are finally taking hold in the health care community. Recent news reports about delivery system changes in large health care organizations, declining rates of hospital-acquired infections, and new emphasis on reducing readmissions are indicative of changes going on across the country. These efforts have been facilitated by the ACA and state efforts to limit Medicaid, total health care spending, or both (as in Arkansas, Massachusetts, and Oregon).
The first part is “the great stagnation to the rescue,” the second part is good news, and in the third part the reference to Massachusetts is some kind of Straussian satire. The article itself is here, and contains further analysis.
The initial pointer is from @JustinWolfers.
Economic agents ponder the collapse of the pooling equilibrium
Robert Pear reports:
“The new health care law created powerful incentives for smaller employers to self-insure,” said Deborah J. Chollet, a senior fellow at Mathematica Policy Research who has been studying the insurance industry for more than 25 years. “This trend could destabilize small-group insurance markets and erode protections provided by the Affordable Care Act.”
It is not clear how many companies have already self-insured in response to the law or are planning to do so. Federal and state officials do not keep comprehensive statistics on the practice.
Self-insurance was already growing before Mr. Obama signed the law in 2010, making it difficult to know whether the law is responsible for any recent changes. A study by the nonpartisan Employee Benefit Research Institute found that about 59 percent of private sector workers with health coverage were in self-insured plans in 2011, up from 41 percent in 1998.
And:
Large employers with hundreds or thousands of employees have historically been much more likely to insure themselves because they have cash to pay most claims directly.
Now, employee benefit consultants are promoting self-insurance for employers with as few as 10 or 20 employees.
And from the FT:
The penalty for not providing coverage is $2,000 per worker. According to the Kaiser Family Foundation, a non-partisan policy group, the average annual cost to employers of insurance is $4,664 for a single worker and $11,429 for a family.
(Do note that the worker will find the job less attractive without health insurance., so this may not translate into a net gain for the employer.)
Here is an update on the 50% premium that can be charged to smokers, assuming the repeal movement for that feature does not succeed.
And now let me stress that you should not expect salvation from the (stand-alone) private sector. DNA sequencing seems to be making real progress, which will make private solutions harder to sustain, a problem which Alex pioneered the analysis of.
Addendum: Here is a good Christensen, Flier, and Vijayaraghavan Op-Ed on ACOs and their problems.
Would Hayek have favored Obamacare?
In this video Nick Gillespie interviews Erik Angner and Erik is (with qualifications) positively inclined. A few points:
1. When Hayek wrote, health care costs were quite low as a percentage of gdp. The same can be said of early Friedman writings (it is startling how little attention Capitalism and Freedom, dating from 1962, pays to “the problems of old people”). It is not clear how views formed in that era should be extrapolated to the current day.
2. Angner-interpreting-Hayek draws a distinction between mandates — which are allowed — and price controls — which are verboten. Yet it is hard to have major government involvement in health care without price controls, or should I write “price controls,” in some manner or another. Third party payments cannot be made at any prices that suppliers might like. Single payer systems have to bargain over price. For that matter mandates have to put some limits on what suppliers can charge for the mandated good, including quality limits. The results may not literally be the same as legally mandated price maximums but a) it is hard for a health care-subsidizing government to avoid interfering with the price mechanism, and b) when viewed in these terms, it is not obvious why interfering with the price mechanism is worse per se than mandates or redistribution. Mandates and redistribution also interfere with the price mechanism, the former as shown by economic theorems about quantity-price duality and the latter once you think of an income as a price or the result of a set of prices.
3. To make it quite speculative, I believe Hayek — if fast-forwarded into the present — might favor a mix of forced savings into health savings accounts, cash transfers to the poor, and direct government provision of basic health care services for the very needy. Whether or not I am right, Hayek is far from laissez-faire on health care. But I doubt Hayek would have come close to supporting ACA. Most of all, I think he would have been horrified by the lack of legal generality and universality in the different categories of treatment, coverage, prices, subsidies, reimbursement rates, and so on. I think he would have seen this as a sign of our legal and philosophic barbarism, noting that I am not trying to put the predominance of blame on Obama here.
Health care cost control in Massachusetts, continuing the bad news string for ACA
Representatives from the state’s nonprofit health plans as well as national for-profit insurers doing business in Massachusetts estimated the “medical cost trend,” a key industry measure, will climb between 6 and 12 percent this year — higher than last year’s cost bump and more than double the 3.6 percent increase set as a target in a state law passed last year.
Here is more, and for the pointer I thank Jeffrey Flier.
Beware most measures of government consumption
Garett Jones reports:
Here’s one big area where I think we should change what we call one type of government spending: Medicare and Medicaid. Currently, these types of spending are counted as transfer payments (BEA PDF here) and so when we measure GDP they show up in C, consumer purchases. I think they should show up in G, government purchases. These medical purchases are so tightly controlled by the government that doctors–oops, “medical service providers”–have become and should be considered government contractors just like defense contractors or construction firms.
Sometimes you hear or read talk of “government consumption plunging,” but sometimes what is happening is that health care expenditures are crowding out other programs, which is not exactly the same thing as fiscal consolidation.
Will health insurance premia rise for young males?
I suspect the analysis cited in this article is an exaggeration, but it is even more than I thought the exaggeration would be:
The survey, fielded by the conservative American Action Forum and made available to POLITICO, found that if the law’s insurance rules were in force, the premium for a relatively bare-bones policy for a 27-year-old male nonsmoker on the individual market would be nearly 190 percent higher.
…Insurers have been reluctant to share their premium projections for a variety of reasons, but Holtz-Eakin, through a lawyer intermediary, was able to get aggregated, anonymous data under a nondisclosure agreement. On average, premiums for individual policies for young and healthy people and small businesses that employ them would jump 169 percent, the survey found.
Note that subsidies would cushion such price shocks for lower-income individuals and that the premia for older and less healthy people would fall, by twenty-two percent according to a comparable estimate (do not forget that a smaller percentage figure is being applied to a larger absolute number). From a distance, it is difficult to judge how realistic these projections are.
Still, I would think that the chance of younger individuals refusing to adhere to the mandate is higher than Massachusetts-linked projections have been indicating.
I would say that in recent times there has been a string of bad news about ACA and few new reported items of good news.
Addendum, from the comments, from Carl the Econ Guy:
The whole survey is here:
http://americanactionforum.org/sites/default/files/AAF_Premiums_and_ACA_Survey.pdf
Look at Table 1– where it says that the average premium for young healthy males will go from $2,000 to a little over $5,000. Yikes.
Department of Uh-Oh
Labor unions enthusiastically backed the Obama administration’s health-care overhaul when it was up for debate. Now that the law is rolling out, some are turning sour.
Union leaders say many of the law’s requirements will drive up the costs for their health-care plans and make unionized workers less competitive. Among other things, the law eliminates the caps on medical benefits and prescription drugs used as cost-containment measures in many health-care plans. It also allows children to stay on their parents’ plans until they turn 26.
To offset that, the nation’s largest labor groups want their lower-paid members to be able to get federal insurance subsidies while remaining on their plans. In the law, these subsidies were designed only for low-income workers without employer coverage as a way to help them buy private insurance.
…Contacted for this article, Obama administration officials said the issue is subject to regulations still being written…
Top officers at the International Brotherhood of Teamsters, the AFL-CIO and other large labor groups plan to keep pressing the Obama administration to expand the federal subsidies to these jointly run plans, warning that unionized employers may otherwise drop coverage. A handful of unions say they already have examined whether it makes sense to shift workers off their current plans and onto private coverage subsidized by the government. But dropping insurance altogether would undermine a central point of joining a union, labor leaders say.
…The Teamsters’ Mr. Hall said his union has no plans to eliminate workers’ insurance. Instead, he worries employers will have an incentive to drop coverage in collective bargaining if they can’t tap the subsidies.
All of a sudden, people are figuring this out. The article is here, and for the pointer I thank Craig Garthwaite.
Medical Self Defense
Americans have historically put great weight on the right of self-defense which is one reason why many people support the 2nd Amendment, as the Supreme Court noted explicitly in District of Columbia v. Heller. But what about medical self-defense? John Robertson argues:
A person can buy a handgun for self-defense but cannot pay for an organ donation to save her life because of the National Organ Transplantation Act’s (NOTA) total ban on paying “valuable consideration” for an organ donation. This article analyzes whether the need for an organ transplant, and thus the paid organ donations that might make them possible, falls within the constitutional protection of the life and liberty clauses of the 5th and 14th amendments. If so, government would have to show more than a rational basis to uphold NOTA’s ban on paid donations.
Unfortunately, the Supreme Court has rejected medical self-defense arguments for physician assisted suicide and let stand an appeals court ruling that patients do not have a right to access drugs which have not yet been permitted for sale by the FDA (fyi, I was part of an Amici Curiae brief for this case). Robertson argues, however, that these cases can be distinguished. Physician assisted-suicide doesn’t fall within a long-American tradition necessary to receive due-process rights and organ transplants are not untested or experimental. It’s a good argument although it’s disappointing that the medical self-defense principle must be unjustly delimited.
Hat tip: Law, Economic and Cycling.