Category: Medicine
*A Nation in Pain*
The author is Judy Foreman and the subtitle of this excellent book is Healing our Biggest Health Problem. Here is one excerpt:
In those not-so-old days when Jeffrey was born, as a preemie, many doctors mistakenly believed that babies’ nervous systems were too immature to process pain and that, therefore, babies didn’t feel pain at all. Or, doctors rationalized, if babies did somehow feel pain, it was no big deal because they probably wouldn’t remember it. Besides, since nobody knew for sure how dangerous anesthesia drugs might be in tiny babies, doctors figured that if surgery was necessary to save a child’s life, they’d better operate anyway — and comfort themselves with the hope that the child wouldn’t feel pain. As one scientific paper from those days intoned, “Pediatric patients seldom need medication for relief of pain. They tolerate discomfort well,”
That’s preposterous, obviously. But doctors had to have these self-protective beliefs for their own emotional survival, says Neil Schechter, a pediatric pain physician at Children’s Hospital in Boston. “Doctors were not sure how to do anesthesia in babies. In response, they had to believe that the babies couldn’t feel pain. They were too scared of the anesthetics.”
Here is part of the Amazon summary:
Out of 238 million American adults, 100 million live in chronic pain. And yet the press has paid more attention to the abuses of pain medications than the astoundingly widespread condition they are intended to treat. Ethically, the failure to manage pain better is tantamount to torture. When chronic pain is inadequately treated, it undermines the body and mind. Indeed, the risk of suicide for people in chronic pain is twice that of other people. Far more than just a symptom, writes author Judy Foreman, chronic pain can be a disease in its own right — the biggest health problem facing America today.
This book will make my best of the year list.
Korean markets in everything, prison meditation edition
In the middle of nowhere on the outskirts of Hongcheon, 58 miles northeast of Seoul, Kwon Yong-seok runs “Prison Inside Me,” a stress-reduction center with a penal theme. A meditation building, auditorium and management center sit on a 2-acre piece of land.
It is like this:
In June last year, the construction of the prison-like spiritual house was completed. It took a year and cost Mr. Kwon and his wife Roh Ji-hyang, head of a theater company, 2 billion won, or $19 million. Parts of the cost were covered by donations and loans from friends and relatives. Mr. Kwon says the goal of the facility, which has 28 solitary confinement cells, isn’t to make a profit.
On top of private meditation sessions, paying guests are helped to reflect on their lives and learn how to free themselves from what Mr. Kwon calls the “inner prison,” through meditation, spiritual classes and “healing” plays in a group session in the auditorium. A two-night stay costs 150,000 won or about $146.
But it may not succeed:
So far, it hasn’t been as easy for the couple to run the place as they had envisioned. They had to cut the length of stays to as little as two days because people aren’t willing to, or simply can’t, take time off. Also the facility had to make another big concession to modernity—allowing guests to check their smartphones at least once a day.
The full story is here, and for the pointer I thank Ben Smeal.
Points of view contrary to my own
1. Here is Timothy Lee on the Comcast merger.
2. Will Obamacare help you live longer? This result seems too rapid and too large to be attributable to improved access to health care, and out of line with other more general (non-policy) estimates.
Still, many people are touting this result. In any case we are committed to providing you with a broad range of perspectives, including those contrary to our own, so do read these. I am in the midst of travel and will not have a chance to read the health care study for a while.
Why Vampires Live So Long
NYTimes: Two teams of scientists published studies on Sunday showing that blood from young mice reverses aging in old mice, rejuvenating their muscles and brains. As ghoulish as the research may sound, experts said that it could lead to treatments for disorders like Alzheimer’s disease and heart disease.
The key papers are here and here and here. Some of the papers are pointing to a specific protein but the last paper suggests that simple transfusions also work and that raises a number of issues of public policy. As Derek Lowe notes:
Since blood plasma is given uncounted thousands of times a day in every medical center in the country, this route should have a pretty easy time of it from the FDA. But I’d guess that Alkahest is still going to have to identify specific aging-related disease states for its trials, because aging, just by itself, has no regulatory framework for treatment, since it’s not considered a disease per se.
…You also have to wonder what something like this would do to the current model of blood donation and banking, if it turns out that plasma from an 18-year-old is worth a great deal more than plasma from a fifty-year-old. I hope that the folks at the Red Cross are keeping up with the literature.
Rating the FDA by Division
In previous work, I have argued that asymmetric incentives make the FDA too risk averse with the result being excessive drug lag and drug loss. The FDA, however, is not a monolithic agency, it is divided into divisions which oversee different types of drugs. The divisions have different cultures, expectations histories and understandings. In my latest paper, written with Tufts researchers Joe DiMasi and Chris Milne, we put aside the question of global efficiency and ask a different question. How do the FDA divisions rate against one another? What we find is quite surprising: some of the FDA divisions appear to be much more productive than others. From the abstract:
After reviewing nearly 200 products accounting for 80 percent of new drug and biologic launches from 2004 to 2012, the authors find wide variation in division performance. In fact, the most productive divisions (Oncology and Antivirals) approve new drugs roughly twice as fast as the CDER average and three times faster than the least efficient divisions—without the benefit of greater resources, reduced complexity of task, or reduction in safety. The authors estimate that a modest narrowing of the CDER divisional productivity gap would reduce drug costs by nearly $900 million annually. The worth to patients, however, would be far greater if the agency could accelerate access to an additional generation of (about 25) drugs. Greater agency efficiency would be worth about $4 trillion in value to patients, from enhanced U.S. life expectancy. To reap such gains, this study encourages Congress and the FDA to more closely evaluate the agency’s most efficient drug review divisions, and apply the lessons learned across CDER. We also propose a number of reforms that the FDA and Congress should consider to improve efficiency, transparency, and consistency at the divisional level.
Andrew von Eschenbach a former Commissioner of the FDA and Director of the National Cancer Institute and now chairman of the Manhattan Institute’s Project FDA wrote a foreword to our paper. Eschenbach writes:
The authors of this report have taken a giant step…by assembling and analyzing a wide array of publicly available information about the relative performance of individual CDER divisions….Continuous, quality improvement measures routinely used by private industry could serve FDA leadership, sponsors, and patients by discerning factors that contribute to an optimal level of performance and, more important, disseminating such practices to ensure that all divisions achieve that performance. The payoff for such an effort could be enormous.
…Process improvement should not be a controversial proposal. An organization like the FDA—which is over a century old and which has maintained its current, basic organizational framework for decades—requires new tools to adapt to changing circumstances.
…I have enjoyed no greater privilege in my professional career than serving alongside the FDA’s talented staff. Today, the agency has more potential than ever to help the U.S. lead the world in advancing a biomedical revolution, one that will have an impact on every aspect of America’s economy and health-care system by improving health, increasing productivity, and reducing overall health-care costs.
…this report should be viewed as a positive, constructive contribution to a desperately needed dialogue on how to assist the agency in fulfilling this vital national goal.
Don’t put your money where your mouth is
Not a surprise to me but yikes nonetheless:
In the first comprehensive study of the DNA on dollar bills, researchers at New York University’s Dirty Money Project found that currency is a medium of exchange for hundreds of different kinds of bacteria as bank notes pass from hand to hand.
By analyzing genetic material on $1 bills, the NYU researchers identified 3,000 types of bacteria in all—many times more than in previous studies that examined samples under a microscope. Even so, they could identify only about 20% of the non-human DNA they found because so many microorganisms haven’t yet been cataloged in genetic data banks.
Easily the most abundant species they found is one that causes acne. Others were linked to gastric ulcers, pneumonia, food poisoning and staph infections, the scientists said. Some carried genes responsible for antibiotic resistance.
“It was quite amazing to us,” said Jane Carlton, director of genome sequencing at NYU’s Center for Genomics and Systems Biology where the university-funded work was performed. “We actually found that microbes grow on money.”
This was, by the way, a relatively frequent complaint in 19th century monetary writings, with the advent of banknotes.
The British may distribute mortality information to pensioners
British retirees may soon receive a novel kind of financial advice, courtesy of the state: They could be told when they are likely to die.
“People are living a lot longer, so we have to make sure they have up-to-date information,” the pensions minister, Steve Webb, said Thursday in an interview with the BBC.
“There’s no point being all British and coy about it,” he said. Gender, age and “perhaps asking one or two basic questions, like whether you’ve smoked or not,” Mr. Webb said, should be enough to determine how long, on average, someone is likely to live. Having an idea of life expectancy would help retirees with private pensions manage their finances more efficiently, he said.
There is more here.
The Socialization of Medicine
“We understand that we doctors should be and are stewards of the larger society as well as of the patient in our examination room,” said Dr. Lowell E. Schnipper, the chairman of a task force on value in cancer care at the American Society of Clinical Oncology.
In practical terms, new guidelines being developed by the medical groups could result in doctors choosing one drug over another for cost reasons or even deciding that a particular treatment — at the end of life, for example — is too expensive.
More from the NYTimes.
From the comments
This is from John B. Chilton:
For those who don’t click through this is what Tyler wrote:
“6. The exchanges will be mostly working by March 2014, but by then the risk pool will be dysfunctional. In the meantime, real net prices will creep up, if only through implicit rationing and restrictions on provider networks. The Obama administration will attempt to address this problem — unsuccessfully — through additional regulation.”
The simple answer to Christian’s query (“I’m curious how you stand now given current enrollment numbers and your previous prediction about a dysfunctional exchange.”) is that it’s not the enrollment numbers that matter, it’s the risk pool.
The jury’s out on the risk pool — lots of opinions out there on whether exchange premiums will go up for 2015.
Here is Ross Douthat on how will we know if Obamacare is working? It is the best post on this debate so far. He closes with this:
I’ll lay down this marker for the future: If, in 2023, the uninsured rate is where the C.B.O. currently projects or lower, health inflation’s five-year average is running below the post-World War II norm, and the trend in the age-adjusted mortality rate shows a positive alteration starting right about now, I will write a post (or send out a Singularity-wide transmission, maybe) entitled “I Was Wrong About Obamacare” — or, if he prefers, just “Ezra Klein Was Right.”
Markets in everything, positive pregnancy tests
The latest, uh, must-have appears to be positive pregnancy test results.
Women across the country are selling — and buying — them on Craigslist.
One post from Buffalo, New York, sums up the appeal for potential shoppers:
“Wanna get your boyfriend to finally pop the question? Play a trick on Mom, Dad or one of your friends? I really don’t care what you use it for.”
That particular test was going for the reasonable rate of $25 dollars. The tests in Texas seem to be slightly more expensive, at $30 a pop.
There is more here, via Marcela Veselková.
Department of Uh-Oh
A four-year slowdown in health spending growth could be coming to an end.
Americans used more medical care in 2013 as the economy recovered, new reports show. Federal data suggests that health care spending is now growing just as quickly as it was prior to the recession.
“We’re at the highest level of growth since the slowdown began,” Paul Hughes-Cromwick, a senior health economist at the Altarum Institute, which tracks health spending. “You have to go back seven years to see growth like this.”
There is more here, from Sarah Kliff. Note that is only from one quarter, however. Kevin Drum remains more sanguine.
Dept. of pure coincidence
The Census Bureau, the authoritative source of health insurance data for more than three decades, is changing its annual survey so thoroughly that it will be difficult to measure the effects of President Obama’s health care law in the next report, due this fall, census officials said.
The changes are intended to improve the accuracy of the survey, being conducted this month in interviews with tens of thousands of households around the country. But the new questions are so different that the findings will not be comparable, the officials said.
An internal Census Bureau document said that the new questionnaire included a “total revision to health insurance questions” and, in a test last year, produced lower estimates of the uninsured. Thus, officials said, it will be difficult to say how much of any change is attributable to the Affordable Care Act and how much to the use of a new survey instrument.
“We are expecting much lower numbers just because of the questions and how they are asked,” said Brett J. O’Hara, chief of the health statistics branch at the Census Bureau.
With the new questions, “it is likely that the Census Bureau will decide that there is a break in series for the health insurance estimates,” says another agency document describing the changes. This “break in trend” will complicate efforts to trace the impact of the Affordable Care Act, it said.
Obviously with a big new law you need new questions too, I suppose, plus the old questions ought not to hang around. You can read more here.
As a side note, I have been reading far too many blog posts about “numbers enrolled” as a metric of success for Obamacare. That has never been a good test of the serious criticisms (and defenses) of ACA.
I thank Megan and Garett for the pointers.
Addendum: You should read this update from Vox, though I am not satisfied with the Administration’s response.
What kind of doctor should I become?
Hi Professor Cowen,
I am a loyal MR reader and I wondered if you could comment on the following situation:
I am a 3rd year medical student, and for the purposes of this question, let’s assume I have equal interest and ability in the various medical specialties. In order to create the greatest good for the greatest number of people through my work in medicine (i.e., the highest return to society), what specialty should I pursue? I should add that, although I intend to practice in the U.S., I am open to devoting as much of my free time/vacation as possible to pro bono medical activities, and further, that I wish to do the interventions myself (instead, for example, or just making lots of money and then donating the proceeds to some other charitable activity). In attempting to answer this question, I’ve been looking at DALYs and QALYs associated with various medical interventions (e.g., cataract surgery). Am I going about answering this question the right way? Any thoughts?
An interesting corollary would be asking what job, in any field, has the highest return to society. Is there any literature on this?
The fundamental institutional failure to overcome is that many lives “out there” are pretty happy, and very much worth living, but those individuals do not have enough money to afford reasonable doctors. If you are seeking to maximize social welfare, look to step into some of these gaps.
But which gap in particular?
The second binding constraint, in my view, is that most people won’t in fact go through with their plan to do a lot of social good. That means you too. So you wish to seek out a form of do-gooding which is incentive-compatible over the long run, or in other words which is fun for you or rewarding in some other way. This second consideration is likely to prove decisive.
For instance you might decide the fight against dengue (just an example to make a point, not an actual net assessment) is the way to go, based on a narrow cost-benefit analysis. But it is hard as a field worker to really, fully protect yourself against dengue. And getting dengue can be very bad indeed. As you age, the pressures not to go into the field will mount. You might do more good by pledging your efforts to fight a malady which you can help fix without so much direct risk or exposure to yourself, let’s say infant mortality.
You will note a difference here between pledges of individual effort and pledges of money. A money pledger, thinking in game-theoretic Nash terms, will realize that effort pledgers will resist the fight against dengue. That is all the more reason why throwing money at the fight against dengue may bring high returns, namely that at the margin not enough is being done from the side of volunteer and quasi-volunteer labor. (In general this distinction creates a problem with talking up one kind of cause over another, namely that labor and money face differing incentives and should hear different messages of encouragement.)
You will note also that in a second best optimum, field workers will appear to be “consuming too many perks.” At the same time, donated funds should be trying to push field workers out of their comfort zones, at least on the margin.
I would add two final points. First, if you have a reasonable chance of being a research superstar, that may be the path to follow.
Second, if you are not already attached, spent time cultivating social circles (aid work, World Bank, vegetarians, etc.) where you are likely to meet a partner or spouse who will support a similar vision to help the world.
Addendum: David Henderson adds comment.
How do Olympic gold medals influence longevity?
I was intrigued by the new paper by Adam Leive, called “Dying to Win? Olympic Gold Medals and Longevity.” The main results are these:
This paper investigates how status affects health by comparing mortality between Gold medalists in Olympic Track and Field and other finalists. Due to the nature of Olympic competition, analyzing performance on a single day provides a way to cut through potential endogeneity between status and health. I first document that an athlete’s longevity is affected by whether he wins or loses and then detail mechanisms driving the results. Winning on a team confers a survival advantage, with evidence that higher mortality among losers may be due to poor performance relative to one’s teammates. However, winning an individual event is associated with an earlier death. By analyzing the best performances of each athlete before the Olympics, I demonstrate that an athlete’s performance relative to his expectations partly explains the earlier death of winners in individual events: on average, Olympic Gold medalists expected to win, but losers exceeded their expectations. Conversely, athletes considered “favorites” but who fail to win die earlier than other athletes who also lost. My results are robust to estimating a range of parametric and semi-parametric survival models that make different assumptions about unobserved heterogeneity. My central estimates imply lifespan differentials of a year or more between winners and losers. The findings point to the importance of expectations, relative performance, surprise, and disappointment in affecting health, which are not highlighted by standard models of health capital, but are consistent with reference-dependent utility. I also discuss potential implications for employment contracts in terms of a trade-off between ex post health and ex ante incentives for productivity.
The paper is here, and for the pointer I thank the excellent Kevin Lewis.
How are the benefits distributed from Medicare Advantage?
There is a new NBER Working Paper by Mark Duggan, Amanda Starc, and Boris Vabson, here is the abstract, with the bold emphasis added by me:
Governments contract with private firms to provide a wide range of services. While a large body of previous work has estimated the effects of that contracting, surprisingly little has investigated how those effects vary with the generosity of the contract. In this paper we examine this issue in the Medicare Advantage (MA) program, through which the federal government contracts with private insurers to coordinate and finance health care for more than 15 million Medicare recipients. To do this, we exploit a substantial policy-induced increase in MA reimbursement in metropolitan areas with a population of 250 thousand or more relative to MSAs just below this threshold. Our results demonstrate that the additional reimbursement leads more private firms to enter this market and to an increase in the share of Medicare recipients enrolled in MA plans. Our findings also reveal that only about one-fifth of the additional reimbursement is passed through to consumers in the form of better coverage. A somewhat larger share accrues to private insurers in the form of higher profits and we find suggestive evidence of a large impact on advertising expenditures. Our results have implications for a key feature of the Affordable Care Act that will reduce reimbursement to MA plans by $156 billion from 2013 to 2022.
There is an ungated version here (pdf).