Category: Medicine

Portuguese drug decriminalization

Caitlin Elizabeth Hughes and Alex Stevens have written a new study:

The issue of decriminalizing illicit drugs is hotly debated, but is rarely subject to evidence-based analysis. This paper examines the case of Portugal, a nation that decriminalized the use and possession of all illicit drugs on 1 July 2001. Drawing upon independent evaluations and interviews conducted with 13 key stakeholders in 2007 and 2009, it critically analyses the criminal justice and health impacts against trends from neighbouring Spain and Italy. It concludes that contrary to predictions, the Portuguese decriminalization did not lead to major increases in drug use. Indeed, evidence indicates reductions in problematic use, drug-related harms and criminal justice overcrowding. The article discusses these developments in the context of drug law debates and criminological discussions on late modern governance.

CA Organ Donor Law

California has a new law creating a live donor registry for kidney transplants and requiring California drivers to say yay or nay on whether they want to be organ donors when they renew their drivers' licenses.  The law was passed with the prodding of Steve Jobs who last year had a liver transplant.

The live donor registry is very good. The required declaration is mixed but I hope it works.  I see it as follows.  The benefit is that if a potential donor has said yes to organ donation then next of kin almost always agree to their wishes so if more people positively affirm that is good.  The cost, however, is that now "no" really means "no" and next of kin will presumably agree to that as well.  Previously, next of kin might have said yes to non-signatories.  Let's use some back of the envelope figures:

100 potential donors
20 signed organ donor cards
80 do not sign but, among these, half the families say yes so 40.

Total: 60 donors.

So with declaration you need more than 60 to agree to be organ donors, i.e. a huge increase in those saying yes.  It could happen if what people say on surveys about supporting organ donation is true but I would have been much happier with even a small incentive to sign.  How about a free iPhone for signatories?  Or at least some more minutes!

See here for more on incentives and organ donation.

Addendum: Nudge blog has some helpful comment–the law appears to be closer to mandated ask than mandated choice.

Why is hospital food so nutritionally bad?

Mario Rizzo asks me:

Why is hospital cafeteria food so poor from a nutritional point of view? Fried chicken, preservative-filled cold cuts, cheese everywhere, etc. Keep in mind I am not talking about the food served patients who may have appetite problems. It is food they serve everyone else including doctors and nurses, many of whom know better.

You'll find some proximate answers here, referring to the institutional arrangements for supplying the food.  Here is a UK discussion.  Here are some signs of progress.  I would make a few more fundamental points:

1. Few people choose a hospital on the basis of the food or on the basis of the food their visitors can enjoy.  Furthermore the median American has bad taste in food and the elderly are less likely to enjoy ethnic food or trendy food.  You can't serve sushi.  They are likely to use the same food service contract for the patients and the visitors.

2. For the patients, some of the food is designed for the rapid injection of protein and carbohydrates.  For a terminally ill patient who is losing weight and wasting away, this may have some benefits.  Since healthier people tend to have very brief hospital stays, they can undo the effects of the fried chicken once they get out.  Many of the sicker patients in for longer stays have trouble tasting food properly at all.

3. Taxing hospital visitors is one way of capturing back some of the rents reaped by patients on third-party payment schemes.

4. I would be interested to know more about the insurance reimbursement rates for hospital food, but at the very least I suspect there is no higher reimbursement allowed for higher quality.  Combine third party payment with a flat price for rising quality and see what you get.  Furthermore, low quality food is another way the hospital raises its prices to inelastic demanders, again circumventing relatively sticky reimbursement rates from the third party financiers.  It's one sign that the net pressures are still in inflationary directions.

5. You can take the quality of the food as one indicator of the quality of other, harder-to-evaluate processes in the hospital.

One reason why fiscal reform is difficult

Joblessness and the accompanying loss of health benefits drove an additional 3.7 million people into the Medicaid program last year, the largest single-year increase since the early days of the government insurance plan, according to an annual survey by the Kaiser Family Foundation.

Enrollment in the program, which provides comprehensive coverage to the low-income uninsured, grew by 8.2 percent from December 2008 to December 2009, the second-largest rate of increase in the 10 years that Kaiser has conducted the survey. There were 48.5 million people on Medicaid at the end of 2009, or about one of every six Americans.

The article is here.  The dilemma is simple: variations in Medicaid coverage account for a lot of the variation in the health of state government finances.  Yet if states cut back on Medicaid in some manner, there will be more people on the more expensive subsidized exchanges, come the full onset of the Obama health plan.

Guess who is lobbying against marijuana legalization?

Yup, beer distributors and the police.  Ryan Grim of The Huffington Post does a very nice job on the politics:

The California Beer & Beverage Distributors is spending money in the
state to oppose a marijuana legalization proposition on the ballot in November,
according to records filed with the California Secretary of State. The beer sellers are the first
competitors of marijuana to officially enter the debate; backers of the
initiative are closely watching liquor and wine dealers and the pharmaceutical
industry to see if they enter the debate in the remaining weeks…

Public Safety First is largely funded by a different industry whose interests are threatened by the legalization of marijuana: law enforcement. Police forces are entitled to keep property seized as part of drug raids and the revenue stream that comes from waging the drug war has become a significant source of support for local law enforcement. Federal and state funding of the drug war is also a significant supplement to local forces' budgets.

Amusingly, the Teamsters and the teachers (!) are supporting legalization:

The Service Employees International Union, a major presence in California, has endorsed the proposition. The Teamsters in September made its first successful foray into organizing pot growers. The United Food and Commercial Workers is backing the initiative and organizing cannabis club employees in the Bay Area. The teachers union, citing the revenue that could be raised for the state, is also backing the initiative.

Very bad incentives in New York State

State institutions for the developmentally disabled generate so much federal Medicaid money that New York's other programs for people with intellectual disabilities would be threatened without them, state officials acknowledge in an internal document obtained by the Poughkeepsie Journal.

The article is here.  It gets worse:

The document, labeled "Confidential – Policy Advice," raises questions about the state's decision to keep 1,100 institutional beds at eight centers that were once slated to close.

And that is not all:

The Medicaid reimbursement rate for state institutions is $4,556 per person per day, the Poughkeepsie Journal has reported, three to four times higher than the cost of care.

Or this:

Put another way, just 1 percent of New York's developmentally disabled population – its 1,400 institutionalized people – generates about 40 percent of federal Medicaid money for the system, operated by the state Office for People With Developmental Disabilities.

This is one root of the problem:

The reason New York's rate is so much higher than the cost of care is a provision in the formula that, since the 1980s, allowed the state to keep two-thirds of federal payments for residents moved from institutions into community homes.

The Poughkeepsie Journal uncovered quite a story.  How does this sentence grab you?:

New York is well-known among disability researchers and providers for its ability to maximize Medicaid revenues, reaping more federal money for the developmentally disabled than any other state.

And does it put people to work?

New York's nine high-cost institutions are part of the reason, but a greater factor is the sheer size of the system, which serves 125,000 people including nearly 37,000 in 7,500 state and private group homes. The state even has a $27-million-a-year research center on developmental disabilities, and a huge bureaucracy to manage all that: 27,000 employees in 2009 earning an average of $42,000. This includes 278 people who made more than $100,000, according to an analysis of the state's salary database.

If we pursue an earlier story, and ask about the people living in the system, it gets truly scary:

Opened in 2001 without public input or review, the LIT [Local Intensive Treatment Unit, part of this system] serves what officials say are people who have had a brush with the law. Residents are classified by "offending behaviors," and, unlike those in two other units of what is now called the Wassaic campus of the Taconic Developmental Disabilities Service Office, they are not free to leave.

The Wassaic LIT and 10 other "intensive treatment" units – some with uncomfortable resemblance to prisons – mark a stark departure from the state's historically non-punitive approach to care of people with mental disabilities.

…In fact, numbers the state did provide show the LIT is populated mostly by people who have been transferred not from the criminal justice system but from other units here and across the state system.

To return to one of the original facts:

Every one of the unit's residents, among 1,400 residents in nine state institutions, generates $4,556 per day in state and federal Medicaid reimbursements.

Twelve percent of the residents are listed as being institutionalized for "elopement."  This guy offered an skeptical perspective on what is happening:

"I don't believe that that is the case, that these people are offenders," said Sidney Hirschfeld, director of the statewide Legal Service office.

He said a very small number had any involvement in the criminal justice system and was concerned that residents were being classified by offenses for which they were not charged, tried or convicted.

Need I relate stories such as this?

In one case, a mildly disabled woman in her 50s was kept in a unit so long – 15 years – that she developed aggressive "institutional behaviors" that became the justification to keep her there. A judge ordered her released, Shea said, but months later a community home still has not been found.

“Those situations are not unique,” Shea said. “Lengths of stay are 10 to 12 years.”

And here is another perspective, from inside the politics:

“Whatever they do there, my preference would be to obviously save jobs,” Euvrard said

For the pointer I thank the ever-vigilant Michelle Dawson.

The rule of law, or the rule of men (women)?

The Obama administration on Thursday told health insurers that it will track those who enact "unjustified" rate increases linked to the health overhaul and may block those companies from a new marketplace for insurance coverage.

Kathleen Sebelius, secretary of Health and Human Services, issued the warning in a letter to Karen Ignagni, the insurance industry's top lobbyist.

Ms. Sebelius said some insurers were notifying enrollees that their insurance premiums will increase next year as a result of the law's new benefits.

…"There will be zero tolerance for this type of misinformation and unjustified rate increases," Ms. Sebelius wrote. "We will not stand idly by as insurers blame their premium hikes and increased profits on the requirement that they provide consumers with basic protections."

Nowhere is it stated that these rate hikes are against the law (even if you think they should be), nor can this "misinformation" be against the law.  Here is further information, including a copy of the letter, which is worse than I had been expecting.

I suppose this is good news, sort of

A court in Tanzania has sentenced a Kenyan accused of trying to sell an albino to 17 years in jail and a fine of more than $50,000 (£41,200).

Albino body parts are valued highly in parts of East Africa and many albinos have been enslaved and/or murdered as a result.  It is believed that since 2007 there have been 53 albino killings in Tanzania.  The full story is here and I thank Ashok Hariharan for the pointer.

File under "Thwarted Markets in Everything."

The Paul Ryan debates

I haven't followed the numerical specifics of his plan (see Krugman, McArdle, and Ezra), which will never be voted on, so at this point I'm more interested in the general problem motivating the reform.  We all know that health care spending has to be restrained in some manner.  There are (at least) two approaches:

1. Have the federal government take a more active role in shutting down or limiting some reimbursements, based on efficacy studies ("death panels").

2. Turn some or all of Medicare into a fixed voucher program and let individuals choose which set of restrictions they will accept from private suppliers ("grandma bangs on HMO door").

As I understand Ryan's approach, he is putting a great deal of emphasis on #2, whereas most Democrats favor #1.

Which mix of #1 and #2 is best is one question; which mix people will accept politically is another.  A third issue is which mix is time consistent and a fourth is which prevents "rationed" people from simply popping up somewhere else in the public health system.  I would start with those distinctions and see which policy direction people need to be nudged in, relative to the path we are on now.  That probably means greater acceptance of both #1 and #2, to some extent.

I believe that #2 works fine for a lot of health care, especially the less controversial and less emotional areas of care, such as laser eye surgery.  Neither #1 nor #2 work especially well, or are especially popular, for end of life issues.

Whatever problems the Ryan plan may have (should we dismiss all ideas from people with overly optimistic forecasts?), I take his contribution to be a nudge in the direction of #2, given the current political equilibrium.  Overall I see this as a healthy nudge, even if you think that relying fully or even mainly on #2 is undesirable, infeasible, and time inconsistent.

Is there a genetic component to varying degrees of cooperativeness?

I have thought about this question and now I see a new paper (ungated here) on the topic:

Genes and culture are often thought of as opposite ends of the nature–nurture spectrum, but here we examine possible interactions. Genetic association studies suggest that variation within the genes of central neurotransmitter systems, particularly the serotonin (5-HTTLPR, MAOA-uVNTR) and opioid (OPRM1 A118G), are associated with individual differences in social sensitivity, which reflects the degree of emotional responsivity to social events and experiences. Here, we review recent work that has demonstrated a robust cross-national correlation between the relative frequency of variants in these genes and the relative degree of individualism–collectivism in each population, suggesting that collectivism may have developed and persisted in populations with a high proportion of putative social sensitivity alleles because it was more compatible with such groups. Consistent with this notion, there was a correlation between the relative proportion of these alleles and lifetime prevalence of major depression across nations. The relationship between allele frequency and depression was partially mediated by individualism–collectivism, suggesting that reduced levels of depression in populations with a high proportion of social sensitivity alleles is due to greater collectivism. These results indicate that genetic variation may interact with ecological and social factors to influence psychocultural differences.

Still, I can't see the evidence.  I don't see the case for causation.  Let's say something about a group's serotonin level made it more susceptible to social stress: couldn't that lead to either greater individualism or greater collectivism?  Is collectivism so calming and are social institutions so functional so as to respond to how stressed we feel from social interactions?  If I were a very stressed out person (I'm not), wouldn't I prefer to live in or construct the social institutions of Sweden, which in this context counts as individualistic? 

You might respond that the evolving alleles should be linked to earlier Swedish society and not Sweden today.  But then one needs to measure collectivism vs. individualism at that earlier point in time.  I wouldn't be surprised if China in the tenth century were "more individualistic" than Sweden in the age of the Vikings, and so on.

(By the way, Is "individualism vs. collectivism" the right spectrum?  We individualistic Americans seem especially apt at being trained to kill people and fire when ordered.  We also seem especially patriotic.)

If you pull out the strangely-placed Colombia from Figure 1 in the paper, it's basically a Europeans vs. Asians effect driving both the genetic contrasts and the collectivism vs. individualism contrasts.  We're left with two quite general contrasts and no theory connecting the two or much of a good reason to think they should be connected.

Don't we just have two data points here — "Asia" and "Europe" — and the split of the data into countries is a phony way to boost apparent statistical significance?

It's a broader question what effects higher serotonin levels have.  I've tried to read a few papers on this topic and I've seen high serotonin levels correlated with both anxiety and calm.  To be sure, this may reflect the inability of this non-specialist to see through to the best and best understood results, but still the relevance of serotonin to human behavior hardly seems like an open and shut question.  I'd sooner suggest that right now we don't understand serotonin very well, at least not as it shapes broader social interactions.

I thank RR for the relevant pointer.

Health care and revenue competition in Britain

Elite NHS foundation trusts are gearing up to lure private patients from home and abroad as health budgets are squeezed – a decision made possible after health secretary Andrew Lansley said he would abolish the cap limiting the proportion of total income hospitals can earn from the paying sick…

With a £20bn black hole opening up in NHS budgets, a group of top performing trusts are seeking to profit from paying patients and use the money to fund public healthcare in Britain.

Previously,

Labour's cap had meant most hospitals were unable to generate more than 2% from private income.

Here is more, although full details are not yet clear, it seems doctors will be much more in charge, in a decentralized manner.  Here's one opinion:

"What's to stop US healthcare companies coming over here to poach patients. Or GPs sending patients to India for cheap operations? Or English hospitals raiding Scotland for sick people?" said Alan Maynard, professor of health economics at the University of York. "It could be a real mess."

How long will it be before the entire NHS, as it was known, goes down as a collapsed model?  What exactly caused the collapse?  (I was surprised to read that Labour had tripled the budget since 1997.)  Will "the line" be that evil ideologues are dismantling a working system?  How will greater competition for patients alter our assessments of various national health care systems?  Is empowering doctors going to cut costs?  How much loyalty will patients, and voters, show to the old NHS model?

*The Fever*

The author is Sonia Shah and the subtitle is How Malaria has Ruled Humankind for 500,000 Years.  Excerpt:

The mosquito's immune system instinctively attacks the parasite, encapsulating the intruder in scabs and bombarding it with toxic chemicals.  To survive, the parasite must unleash armies of progeny in such massive numbers that fighting it off becomes more trouble than it's worth.  Male and female forms of the parasite, called gametocytes, then fuse, and the resulting parasites create cysts that cling to the walls of the bug's gut.  (The spasmodic waving of the male gametocyte's long tail, which precedes the act of fusing with the female — yes, this microbe reproduces sexually as well as asexually — is called exflagellation.)  Tens of thousands of slithering threads explode from the cysts and swarm up to the mosquito's salivary gland.  This is the form of parasite must take to infect human beings.  Malariologists call it the sporozoite.  When a mosquito starts a blood feed, some two dozen slivery sporozoites will escape into their next host.

It's an excellent book.  There is a short review and excerpt here.

Markets in everything Africa fact of the day

Desperate heroin users in a few African cities have begun engaging in a practice that is so dangerous it is almost unthinkable: they deliberately inject themselves with another addict’s blood, researchers say, in an effort to share the high or stave off the pangs of withdrawal.

The practice, called flashblood or sometimes flushblood, is not common, but has been reported in Dar es Salaam, Tanzania, on the island of Zanzibar and in Mombasa, Kenya.

It puts users at the highest possible risk of contracting AIDS and hepatitis.

Here is more, but perhaps that is all you need to know.  The pointer comes from Steve Silberman.