Category: Medicine

The Paul Ryan debates

by  Tyler Cowen in

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?

by  Tyler Cowen in

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

by  Tyler Cowen in

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*

by  Tyler Cowen in

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

by  Tyler Cowen in

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.

Robin Hanson receives ein Wunsch

by  Tyler Cowen in

German scientists are planning the country’s biggest biomedical study. The National Cohort will be an intensive investigation of the health, lifestyle and genetics of 200,000 people, at an estimated cost of €210m over 10 years.

…They intend to use the National Cohort “to investigate how chronic diseases are conditioned by lifestyle and environmental issues, as well as by genetic predisposition”.

“Technology has now advanced to the point at which we can use a population study to find and evaluate biomarkers and other tools for early detection of disease,” said Prof Kaaks.

These people will receive extensive medical examinations at the beginning and along the way.  Here is one example of what will be done:

The German scientists are keen, for example, to discover how exercise protects against disease. “Better quantitative estimates are required of how much protection there is to be had and how much physical activity is required to obtain it,” said Prof Kaaks. That means studying a very large number of participants whose activity can be assessed regularly over many years or even decades.

Germany has less variation in health care access than does the U.S., but still this is another variable which could be studied, given this data.

Optimizing Kidney Allocation: LYFT for LIFE

by  Alex Tabarrok in

Under the current system, kidneys are allocated to patients primarily based on the time that the patient has been on the waiting list and the quality of the match.  If we evaluate these criteria "locally" there's nothing obviously wrong but if we step back and think globally, that is think about what the ultimate goal of the transplant system should be, then the current system is deeply misguided.  Suppose that we want the transplant system to maximize total life expectancy or, as it is known in the literature, to maximize the life-years from transplant (LYFT).

The current system does not maximize life expectancy.  In the current system, a 60 year old patient can be given a 20 year old kidney–that's a waste because the life expectancy of the kidney is longer than that of the patient; it's like putting a new clutch in a car that is rusting away.  If we had 20 year-old kidneys to spare, this wouldn't be a big problem.  But we don't have 20-year old kidneys to spare, so we also give 20-year old patients 60-year old kidneys which means the kidney is likely to die early taking the patient along with it.  If we want to maximize total life expectancy, younger people should get younger kidneys.

Here is a simple example to illustrate the principle.  Suppose that the life expectancy of both patients and kidneys is 75 years of age so everyone dies when they are 75 or when their kidney is 75, whichever comes first.  Thus, if we allocate the 20 year old kidney to the 60 year old patient and vice-versa we gain a total of 30 years of life expectancy.

Kidney
Age		 Patient Age Life Years
20 60 15
60 20 15
30 years Total

But if we allocate the 60 year old kidney to the 60 year old patient and the 20 year old kidney to the 20 year old patient we more than double life expectancy to 70 years in total.

Kidney
Age		 Patient Age Life Years
60 60 15
20 20 55
70 years Total

It's not just age that matters, it turns out that the longer a patient has been on dialysis the less is their life expectancy after transplant (dialysis stresses the body so the sooner we get someone a transplant the better).  Although it may seem unfair, if we want to maximize total life expectancy we are doing the wrong thing by giving more points to patients who have been on the list longer.  

An optimized allocation system that took into account these considerations would increase total life
expectancy (modestly but significantly, about 11,500 extra life years) but it wouldn't benefit every individual.  Maximizing life expectancy would shift organs away from older people and people who have been on the waiting list a long time towards younger people.  As a result, some patients have argued that LYFT is unfair.  The Office of Civil Rights is even asking whether LYFT might violate age discrimination laws.  

But consider, would the older patients have objected to LYFT when they were younger?  If not, shouldn't their objections be discounted?  More formally, consider how people would vote behind a veil of ignorance.  By definition a LYFT approach maximizes total life expectancy, so without knowing the specifics of who you are or when you might need a transplant it's likely that behind a veil of ignorance just about everyone would favor LYFT.  Thus, in my view LYFT is a fair and ethical system. 

Here are previous MR posts on kidney transplant policy.

The next step in evolution?

by  Tyler Cowen in

This is not exactly my view, but Robin Hanson is always worth reading:

The next big change is likely whole brain emulations (i.e., ems), within a century or so. Profit-seeking investors may make trillions of copies of dozens of most suitable humans, and further select among trillions of ways to tweak each em.  This will allow enormous selection for the most adaptive em minds.  Adaptive behavior in the early em era has high work coordination, accepts more alien bodies and environments, has little interest in kids or hyper-stimuli, and accepts death, high trainee failure rates, long work hours, and near-subsistence wages.  Some of this may be achieved via genuine preference changes, but initially most will be achieved via strong delusory self-control.

There is much more in the post.

Health care policy in Rwanda

by  Tyler Cowen in

Also, the co-pays can be overwhelming. Even $5 for a Caesarean section can be too much for people as close to the edge as the Yankulijes, who live by growing beans and sweet potatoes and wear American castoffs (Mrs. Yankulije’s T-shirt read “Wolverines Football”).

Apparently there is 92 percent coverage, through a government plan, backed by NGOs, for a premium of $2 a year.  It is estimated that the total Rwandan health care bill, in a year, is $307 million.  The article is interesting throughout.  I liked this part:

“If people pay the $2 and then don’t get sick all year, they sometimes want their money back,” said Anja Fischer, an adviser to the Health Ministry from GTZ, the German government’s semi-independent aid agency.

FDA Overreach

by  Alex Tabarrok in

From the Washington Post:

The Food and Drug Administration on Friday ordered five companies that offer genome-sequencing tests to consumers, or that provide the scientific services for them, to prove the validity of such products.

The FDA said the tests, which scan a person's DNA for gene variants associated with specific diseases, are medical devices requiring the agency's approval.

The ability of genetic tests to predict diseases is currently limited; if the FDA were simply to require firms to acknowledge this point, say with a clear statement of probabilities, that would be one thing (although this task is better met by the FTC under advertising regulation).  But the FDA is brazenly overreaching in trying to regulate genetic tests as medical devices. First, there is no question that these tests are safe–safer than brushing your teeth!–and also effective in identifying genetic markers.  Thus, there is no medical reason whatsoever for regulation.

Moreover, genetic tests provide information, personal information about our bodies and our selves.  The FDA has no standing to interfere with the provision of such information.

Consider, I swab the inside of my cheek and send the sample to a firm. The idea that the FDA can rule on what the firm can and cannot tell me about my own genes is absurd–it's no different than the FDA trying to regulate what my doctor can tell me after a physical examination or what my optometrist can tell me after an eye examination (Please read the first line.  "G T A C C A…").

The idea that the FDA can regulate and control what individuals may learn about their own bodies is deeply offensive and, in my view, plainly unconstitutional.

Gattaca University

by  Alex Tabarrok in

From the NYTimes, Berkeley will give its students genetic tests. 

…this year’s incoming freshmen at the University of California, Berkeley, will get something quite different: a cotton swab on which they can, if they choose, send in a DNA sample.

The university said it would analyze the samples, from inside students’ cheeks, for three genes that help regulate the ability to metabolize alcohol, lactose and folates.

Those genes were chosen not because they indicate serious health risks but because students with certain genetic markers may be able to lead healthier lives by drinking less, avoiding dairy products or eating more leafy green vegetables.

Don't be surprised if this is soon canceled.

Draw the rational Bayesian inference here

by  Tyler Cowen in

Germany’s BaFin financial-services regulator said it will temporarily ban naked short selling and naked credit-default swaps of euro-government bonds starting at midnight. The ban also includes naked short selling of 10 banks and insurers.

I thank a loyal MR reader for the pointer, my apologies I have misplaced the email and I don't know your name.

Advertising and pharmaceutical prices

by  Tyler Cowen in

The classic Chicago School result was that advertising for eyeglasses lowered prices, due to increased competition.  It doesn't seem the same is true for pharmaceuticals, as we see from Dhaval Dave and Henry Saffer:

Expenditures on prescription drugs are one of the fastest growing components of national health care spending, rising by almost three-fold between 1995 and 2007. Coinciding with this growth in prescription drug expenditures has been a rapid rise in direct-to-consumer advertising (DTCA), made feasible by the Food and Drug Administration’s (FDA) clarification and relaxation of the rules governing broadcast advertising in 1997 and 1999. This study investigates the separate effects of broadcast and non-broadcast DTCA on price and demand, utilizing an extended time series of monthly records for all advertised and non-advertised drugs in four major therapeutic classes spanning 1994-2005, a period which enveloped the shifts in FDA guidelines and the large expansions in DTCA. Controlling for promotion aimed at physicians, results from fixed effects models suggest that broadcast DTCA positively impacts own-sales and price, with an estimated elasticity of 0.10 and 0.04 respectively. Relative to broadcast DTCA, non-broadcast DTCA has a smaller impact on sales (elasticity of 0.05) and price (elasticity of 0.02). Simulations suggest that the expansion in broadcast DTCA may be responsible for about 19 percent of the overall growth in prescription drug expenditures over the sample period, with over two-thirds of this impact being driven by an increase in demand as a result of the DTCA expansion and the remainder due to higher prices.

The paper is here (NBER gate).  Here is a simpler paper on advertising and prescription drug expenditures.  Here is a related paper on the advertising topic.  Here is another paper which generates higher prices from advertising.  Pharmaceuticals could be different from eyeglasses for a few reasons, one being weaker contestability in the market, due to patent protection, another being that consumers process information about health care differently.  This paper suggests that co-payments don't much help reduce inappropriate demands for pharmaceuticals.   

I thank Eric John Barker for the initial pointer.