Category: Medicine

The return of the house call

by  Tyler Cowen in

In the Netherlands, where else?:

In early March, the NVVE opened the world’s first euthanasia clinic. It’s called the Levenseindekliniek, the “end of life clinic.” It serves as a point of contact for all Dutch people who want to die but don’t have a primary care physician prepared to help them do so. The clinic has mobile euthanasia teams, each of which consists of a doctor and a nurse. When an individual qualifies for the program after passing a screening, one of the teams makes a house call to inject two drugs. One puts the patient into a deep sleep, while the other stops all breathing, leading to death.

The rest of the story is here.  And there is this:

The sweets were distributed two years ago as part of a promotional campaign. At the time, her organization was calling for Dutch pharmacies to be allowed to sell lethal drugs to individuals with a prescription. Printed on the wrappers is the word Laatstwilpil, or “last will pill.”

What is the real source of the medical adverse selection problem?

by  Tyler Cowen in

Ray Fisman reports on the job market paper of Nathaniel Hendren, an MIT student on the job market this year.  Here is an excerpt from Fisman’s piece:

…sufferers of heart disease and cancer have greater self-knowledge than healthy people in terms of what their likely medical care costs will be. The market for insurance unravels, in Hendren’s model, when patients have a clear view of their future health care costs and people who anticipate lower-cost futures self-select out of insurance coverage.

It’s not about knowing more about your state of health, it is about knowing more about how costly your treatment will be.

Is Medicare cost growth slowing down?

by  Tyler Cowen in

A lot is at stake here.  Kevin Drum has a good summary of some recent work:

Via Sarah Kliff, a pair of researchers have taken a look at per-capita Medicare spending and concluded that it’s on a long-term downward path which is likely to continue into the future. Their claim is pretty simple: Although Medicare’s sustainable growth rate formula has been overridden year after year (this is the infamous annual “doc fix”), they say that other attempts to rein in spending have actually been pretty effective. This suggests that the cost controls in Obamacare have a pretty good chance of being effective too. Their basic chart is below, and since we’re all about the value-added around here I’ve added a colorful red arrow to indicate the trajectory.

(Note that their calculations are based on potential GDP, not actual GDP. I’m not sure why, but I assume it’s to control for the effects of recessions and boom years.)

Now, this calculation is per beneficiary, which means that overall Medicare costs will still go up if the number of beneficiaries goes up — which it will for the next few decades as the baby boomer generation ages. There’s really nothing to be done about that, though. Demographic bills just have to be paid. Nonetheless, if we can manage to keep benefits per beneficiary stable compared to GDP we’ll be in pretty good shape.

While I would say “too soon to tell” (for me only the post-2005 data points mean very much vis-a-vis the original question), I would not dismiss such reports out of hand.

Charles Murray’s policy proposals

by  Tyler Cowen in

To narrow the class divide, that is.  I am almost completely in disagreement (how about more aid and opportunity, less attempted equalization?), the Op-Ed is here.  In the form of a list:

1. Apply the minimum wage to internships for the young, so privileged children cannot so easily receive this training.

2. Replace the SAT with specific subject tests.

3. Replace ethnic affirmative action with socioeconomic affirmative action.

4. Sue to challenge the constitutionality of a B.A. degree as a job requirement.

He does admit these proposals will not do so much good in absolute terms, but he nonetheless praises them for their symbolic value.

Medical markets in something

by  Tyler Cowen in

From John Goodman:

Can you buy health care the way you buy goods and services on eBay? Almost. A small, emerging online service called MediBid is letting providers bid to provide the care that patients need.

Patients must be able to pay cash. They fill out medical questionnaires; they can upload their medical records; and they can request the procedure they need. The patient’s identity is kept confidential until a transaction is consummated. MediBid-affiliated physicians and other medical providers respond by submitting competitive bids for the requested care.

Business at the site is growing.

Unemployment Insurance and Disability Applications

by  Alex Tabarrok in

More than 8.5 million workers are now collecting disability insurance, in other words almost 6% of the labor force is officially disabled. Perhaps not surprisingly, disability applications shot up just as unemployment benefits started to exhaust.

Applications are often denied so disability beneficiaries do not follow applications immediately. Denied applicants, however, often contest and apply again so eventually 50-60% of those who apply will typically enter the disability rolls and start to collect. Far fewer will ever exit the rolls, at least not by way of a job.

Since 1995 the number of disabled workers has doubled and expenditures have increased even faster than disabled workers, tripling since 1995. The increase in workers receiving disability insurance has come at the same time as the US working age population has become healthier. A large fraction of the increase in disability has come from increases in hard-to-verify back pain and mental problems (see Autor and Duggan and more recently Autor).

After the 2001 recession, disability applications also shot up and they never fell back to their old levels. We may be reaching a new, permanently higher, plateau.

Disabled workers do not count as unemployed, they have been bought out of the labor force.

The conservative critique of unemployment insurance used to be that it discouraged people from looking for work. The modern conservative response may be that it encourages people to not become disabled.

Department of Yikes

by  Tyler Cowen in

…his German counterpart [finance minister] suggested postponing Greek elections and installing [sic] a new government without political parties.

I do understand the financial motive here, but this is not a good idea!  It is even less of a good idea to say so in public.  Is the goal simply to irritate the Greeks so much that they leave the Eurozone on their own?  Twitter rumors are suggesting that Finland and the Netherlands are raising similar ideas, namely postponing elections and, it seems, simply ruling the country through its budget?  I am not sure how this is supposed to work, or to be received in Greece, or why it should be a good precedent for the European Union.  The FT story is here.

The medicine that is Dutch

by  Tyler Cowen in

It took a tall ladder and weeks of training, but an elephant at Amsterdam’s Artis Zoo has become the first of her species in Europe to be fitted with a contact lens.

Win Thida, a 45-year-old Asian elephant, suffered a scratched cornea during a tussle with another elephant. Her eye started watering and she had trouble keeping it open, so the zoo called in veterinarian Anne-Marie Verbruggen.

Verbruggen had experience fitting horses with contacts, but it was her first attempt on an elephant.

“The main difficulty was her height,” Verbruggen told the Irish Times. “Elephants can’t lie down for long before their immense weight impairs their breathing, so I used a ladder to get close enough. It wasn’t ideal, but it worked. She seemed happier straight away.”

The elephant had to be anaesthetized in a standing position, and she and Verbruggen trained daily for weeks to prepare her for the operation. The procedure took less than an hour. Protected by the lens, the elephant’s cornea should now be able to heal.

Here is (not much) more.

I have a longstanding sympathy for dirt

by  Tyler Cowen in

Kevin Outterson writes of “Hand Sanitizers as Agent Orange”:

Over at CommonHealth, Aayesha rounds up the literature on the limits of hand sanitizers, but fails to mention the collateral damage to the skin microbiome. Alcohol-based hand sanitizers kill many bacteria, viruses and fungi, but they don’t selectively target pathogens. They kill a wide swath of the microbial life on your hands, including little-understood non-pathogenic species. For an ecological analogy, think of using Agent Orange to kill a couple weeds.

A good introduction to the skin microbiome is a recent article in Nature Reviews Microbiology by Elizabeth A. Grice and Julia A. Segre (9, 244-253 (Apr. 2011)). From the abstract:

“The skin is the human body’s largest organ, colonized by a diverse milieu of microorganisms, most of which are harmless or even beneficial to their host. Colonization is driven by the ecology of the skin surface, which is highly variable depending on topographical location, endogenous host factors and exogenous environmental factors. The cutaneous innate and adaptive immune responses can modulate the skin microbiota, but the microbiota also functions in educating the immune system.”

As I’ve said before, our relationship with microbes should also be evaluated as an ecological issue. Completely germ-free environments are not necessarily the goal.

The culture that is Swiss?

by  Tyler Cowen in

The newly approved €20m (£17m) housing project is to be built next to the Swiss village of Wiedlisbach near Bern and will provide sheltered accommodation and care for 150 elderly dementia patients in 23 purpose-built 1950s-style houses. The homes will be deliberately designed to recreate the atmosphere of times past.

The scheme’s promoters said there will be no closed doors and residents will be free to move about. To reinforce an atmosphere of normality, the carers will dress as gardeners, hairdressers and shop assistants. The only catch is that Wiedlisbach’s inhabitants will not be allowed to leave the village.

There is more here, and the pointer is from @laurenzcollins.

*Life in the Sick-Room*

by  Tyler Cowen in

This neglected gem of a book was written by Harriet Martineau, best known for her 19th century tracts on political economy.  Now I learn she was a forerunner of behavioral economics, occupying a space somewhere between Burton’s Anatomy of Melancholy and the pain meditations of Dan Ariely, excerpt:

I have spoken of the relief afforded by visitations of severe pain.  These really the vital forces, and dismiss the temptation, by substituting torture for weariness — at times a welcome change.  The healthy are astonished at the good spirits of sufferers under tormenting complaints; and the most strait-laced preachers of fortitude and patience admit an occasional wonder that there is no suicide among that class of sufferers.  The truth is, however, that the influence of acute pain, when only occasional, and not extremely protracted, is vivifying and cheering on the whole.  The immediate anguish causes a temporary despair: but the reaction, when the pain departs, causes a relish of life such as the healthy and the gay hardly enjoy.  Though a slow death by a torturing disease is a lot unspeakably awful to meet, and even to contemplate, there can be no question to the experience, that illness in which severe pain sometimes occurs is less trying than some in which a different kind of suffering is not relieved by such a stimulus and its consequent sensations.

The Wikipedia page on Martineau is especially good.

ADA to Dental Practioniers: You Can’t Handle the Tooth!

by  Alex Tabarrok in

From an article at Governing.com:

…dental care is hard to come by in underserved areas of the country. Try finding a dentist in the remotest rural or deepest urban pockets of the land, and for blatantly economic reasons, they just aren’t there. That’s why states are looking to fix the problem by creating a so-called mid-level dental provider. Much like a nurse practitioner (NP) or physician assistant (PA) is to a doctor, this provider would be educated and licensed to perform basic dental services — routine checkups, cleanings, filling cavities and extracting teeth — under the supervision of a fully trained dentist.

…Yet in much the same way that the American Medical Association fought against the creation of NPs and PAs, the American Dental Association (ADA) and its state chapters are lobbying hard to thwart state legislatures as they work to create this new level of dental care providers, who are common and well liked in other parts of the world.

…“Publicly their main objection is safety issues,” Oswald says. “They tried to discredit the model, saying the therapists were not trained to the same level as dentists. In reality, all the research around the world shows that [mid-level providers] provide as good, if not better, care. Every time they stated safety as a factor, we asked for research, which they didn’t have.”

By the way, states with tougher licensing of dentists do not have better dentistry, but they do have higher prices. Almost thirty percent of the US workforce is now required to hold a license including shampoo specialists.

Hat tip: Carpe Diem