There has been a lot of ink spilled over the rising cost of health care and in Why Are the Prices So D*mn High? Helland and I do not cover every theory and cannot satisfy every objection. Our goal is more modest. We can say that one major factor in rising health care costs is the rising price of skilled labor.
We argue that there is a direct, obvious, and measurable cause of higher costs in healthcare—namely, the price of skilled labor. No profession other than physicians has seen such large increases in incomes over the past 50 years. Figure 19 shows the real income of physicians from 1960 to 2016, indexed to 100 in 1960. Since 1960 the real income of physicians has increased by a factor of three. By comparison, barbers and bus drivers have seen essentially no increase in real incomes. Median incomes are up only modestly whereas mean incomes, which are pulled up by outliers, are up by only 50 percent.
Moreover, nurse incomes have risen in lock-step with those of physicians.
At the same time, we have hired more physicians and more nurses per capita. As Figure 20 shows since 1960 the number of physicians and the number of nurses has more than doubled.
With more physicians and more nurses each making more, it’s not surprising that the cost of medical care would increase.
Addendum: Other posts in this series.
Chernobyl, HBO’s taut 5-part mini-series, is excellent and it sticks close to the facts (although one female character played by Emily Watson is clearly made up). By all accounts, the series accurately represents life in the former Soviet Union and through a variety of means from color palette to casting and dialogue it does a remarkable job at capturing the political economy. One thing I learned (so far, it hasn’t all appeared yet) is that it could have been much, much worse but the Russians avoided the worst scenario with a combination of bravery, smarts and luck.
The number of cancer deaths from Chernobyl appears to be quite low. The WHO estimated an additional 9,335 deaths with about half of those coming from workers and nearby residents and other half more distant impacts, other estimates are higher. More recent analysis, however, suggests that Chernobyl and its aftermath had relatively small but significant effects across a large number of people. Here are two recent papers:
Chernobyl’s Subclinical Legacy: Prenatal Exposure to Radioactive Fallout and School Outcomes in Sweden by Almond, Edlund and Palme.
Abstract: We use prenatal exposure to Chernobyl fallout in Sweden as a natural experiment inducing variation in cognitive ability. Students born in regions of Sweden with higher fallout performed worse in secondary school, in mathematics in particular. Damage is accentuated within families (i.e., siblings comparison) and among children born to parents with low education. In contrast, we detect no corresponding damage to health outcomes. To the extent that parents responded to the cognitive endowment, we infer that parental investments reinforced the initial Chernobyl damage. From a public health perspective, our findings suggest that cognitive ability is compromised at radiation doses currently considered harmless.
and The long-run consequences of Chernobyl: Evidence on subjective well-being, mental health and welfare by Danzer and Danzer.
Abstract: This paper assesses the long-run toll taken by a large-scale technological disaster on welfare, well-being and mental health. We estimate the causal effect of the 1986 Chernobyl catastrophe after 20 years by linking geographic variation in radioactive fallout to respondents of a nationally representative survey in Ukraine according to their place of residence in 1986. We exclude individuals who were exposed to high levels of radiation—about 4% of the population. Instead, we focus on the remaining majority of Ukrainians who received subclinical radiation doses; we find large and persistent psychological effects of this nuclear disaster. Affected individuals exhibit poorer subjective well-being, higher depression rates and lower subjective survival probabilities; they rely more on governmental transfers as source of subsistence. We estimate the aggregate annual welfare loss at 2–6% of Ukraine’s GDP highlighting previously ignored externalities of large-scale catastrophes.
Hat tip: Jennifer Doleac and Wojtek Kopczuk.
Why have some prices increased since 1950 by a factor of four while other prices have decreased by a factor of four? Technology is making so many goods and services much cheaper than in the past–that seems to be the normal situation–so why do some industries seem not only to be not progressing but actually retrogessing? As Scott Alexander put it, why are some industries so weird?
Those are the questions that motivated my latest piece, a short book with Eric Helland just released by the Mercatus Center titled, Why are the Prices so D*mn High?
In approaching this question I had some ideas in mind. I assumed that regulation, bloat and bureaucracy, monopoly power and the Baumol effect would each explain some of what is going on. After looking at this in depth, however, my conclusion is that it’s almost all Baumol effect. That conclusion radically changes one’s evaluation of price increases and decreases over the long run and it changes what, if anything, one might try to do to address such price changes.
Next week I will examine some of the evidence that pushes me towards this verdict. I’ll also take a closer look at the Baumol effect, which is mistakenly called the cost disease.
Let’s note here, however, what we need to explain. For the most part, we don’t see quick, big changes in prices that then level off. That in itself is interesting since policy tends to be discontinuous. We might expect a big regulation, for example, to cause a big increase in prices as industries adjust but then growth should return to normal. Instead, what we see and need to explain is slow, steady rising relative prices that happens over decades. Indeed, in some cases, such as education, prices have been increasing faster than average for more than a century! Puzzle over that over the long weekend. More next week!
Addendum: Other posts in this series.
Very much a fun one, here is the audio and transcript, here is part of the opening summary:
Do we overrate the importance of doctors? What’s the importance of IQ versus EQ in the practice of medicine? What are the prospect for venture capital in biotech? How should medical training be changed? Why does he think the conventional wisdom about a problem tends to be wrong? Would immortality be boring? What would happen if we let parents genetically engineer their kids?
Tyler questions Emanuel on these topics and more, including the smartest thing his parents did while raising him, whether we have right to medical self-defense, healthcare in low- versus high-trust institutions, and much more.
Here is one excerpt:
COWEN: How can we improve medical education?
EMANUEL: Cut it down. Make it shorter.
COWEN: Cut it down? Why does that make it better? Or does it just make it cheaper?
EMANUEL: No, I think it will make it better. So, we have a lot of memorization, a lot of . . . So, let’s go back to the start. The four years of medical school: two years of preclinical in the classroom learning about biochemistry, genetics, anatomy, microbiology; and the two years of clinical time in the hospital, on the wards.
That dates from 1910. We haven’t really updated it much, except in this one way: we’ve cut down the preclinical time because — less of it — and it changes so fast, by the time you learn it in medical school, get out as a doctor, it’s out of date, A; and B, it’s more or less irrelevant to managing most patients…
And then, by the way, in med school, spending your time in a hospital is not the future. The future of American medicine is out of the hospital. So we need more rotations, more experiences for students out of the hospital.
No med school has made that big shift, and those are the shifts that are going to have to happen over the next 15 or so years.
COWEN: Is there a right to medical self-defense that should override FDA bans on drugs and medical devices? I want to try something that’s not approved —
EMANUEL: No. I don’t like that.
COWEN: I’m saying it’s my body. But why don’t you like it?
EMANUEL: No, no, no, no, no, no, no, no, no, Tyler.
COWEN: Now, you’ve written a much-misunderstood article about how hard you would try yourself to live past the age of 75. Would not the suspense of world and national history always keep you wanting a bit more extra time?
So, say I’m 75. I’ve decided I agree with you, but the NBA Finals aren’t over yet. I want to see game seven. I want the Mueller report to come out. Isn’t there always something?
And then, it’s kind of intransitivity of indifference. Every day there’s something, and you just keep on hanging on, even if one accepts your arguments in the abstract. Can you talk me out of that?
EMANUEL: No, no, Tyler, I think you’re exactly right. That’s why people do hang on. It’s because . . . you know, so I talked to my father, who — he says, “Zeke, you’re absolutely right. I’ve become slower, physically slower, mentally slower. My life” . . . what ends up happening is your life cones down, and you begin to overvalue certain small things. Like the NBA Finals. Like what’s in the Mueller report.
We all know, from any cosmic standpoint — even not a cosmic standpoint, just a 2,000-foot standpoint — most of those things are not irrelevant. It’s really cool to know.
You often ask — and this happens to me all the time. I teach undergraduates. Pretty smart undergraduates. Very smart undergraduates. MBA students, nurses, doctors, right? They have no understanding of history. So, whoever finishes in the NBA Finals, in five years, people have forgotten.
Recommended, interesting throughout.
People were outraged in 2014 when Facebook revealed that it had run “psychological experiments” on its users. Yet Facebook changes the way it operates on a daily basis and few complain. Indeed, every change in the way that Facebook operates is an A/B test in which one arm is never run, yet people object to A/B tests but not to either A or B for everyone. Why?
In an important and sad new paper Meyer et al. show in a series of 16 tests that unease with experiments is replicable and general. The authors, for example, ask 679 people in a survey to rate the appropriateness of three interventions designed to reduce hospital infections. The three interventions are:
Badge (A): The director decides that all doctors who perform this procedure will have the standard safety precautions printed on the back of their hospital ID badges.
Poster (B): The director decides that all rooms where this procedure is done will have a poster displaying the standard safety precautions.
- A/B: The director decides to run an experiment by randomly assigning patients to be treated by a doctor wearing the badge or in a room with the poster. After a year, the director will have all patients treated in whichever way turns out to have the highest survival rate.
It’s obvious to me that the A/B test is much better than either A or B and indeed the authors even put their thumb on the scales a bit because the A/B scenario specifically mentions the positive goal of learning. Yet, in multiple samples people consistently rate the A/B scenario as more inappropriate than either A or B (see Figure at right).
Why do people do this? One possibility is that survey respondents have some prejudgment about whether the Badge or Poster is the better approach and so those who think Badge is better rate the A/B test as inappropriate as do those who think Poster is better. To examine this possibility the authors ask about a doctor who prescribes all of his patients Drug A or all of them Drug B or who randomizes for a year between A and B and then chooses. Why anyone would think Drug A is better than Drug B or vice-versa is a mystery but once again the A/B experiment is judged more inappropriate than prescribing Drug A or Drug B to everyone.
Maybe people don’t like the idea that someone is rolling dice to decide on medical treatment. In another experiment the authors describe a situation where some Doctors prescribe Drug A and others prescribe Drug B but which drug a patient receives depends on which doctor is available at the time the patient walks into the clinic. Here no one is rolling dice and the effect is smaller but respondents continue to rate the A/B experiment as more inappropriate.
The lack of implied consent does bother people but only in the explicit A/B experiment and hardly ever in the implicit all A or all B experiments. The authors also show the effect persists in non-medical settings.
One factor which comes out of respondent comments is that the experiment forces people to reckon with the idea that even experts don’t know what the right thing to do is and that confession of ignorance bothers people. (This is also one reason why people may prefer pundits who always “know” the right thing to do even when they manifestly do not).
Surprisingly and depressingly, having a science degree does not solve the problem. In one sad experiment the authors run the test at an American HMO. Earlier surveys had found huge support for the idea that the HMO should engage in “continuous learning” and that “a learning health system is necessary to provide safe, effective, and beneficial patient-centered care”. Yet when push came to shove, exactly the same pattern of accepting A or B but not an A/B test was prevalent.
Unease with experiments appears to be general and deep. Widespread random experiments are a relatively new phenomena and the authors speculate that unease reflects lack of familiarity. But why is widespread use of random experiments new? In an earlier post, I wrote about ideas behind their time, ideas that could have come much earlier but didn’t. Random experiments could have come thousands of years earlier but didn’t. Thus, I think the authors have got the story backward. Random experiments generate unease not because they are new, they are new because they generate unease.
Our reluctance to conduct experiments burdens us with ignorance. Understanding and overcoming experiment-unease is an important area for experimental research. If we can overcome our unease.
Take that Adam Smith!:
Dr Lotay Tshering was one of Bhutan’s most highly regarded doctors before he entered politics last year, and while his prime ministerial duties occupy him during the week, on weekends he returns to the hospital as a way to let off steam.
“Some people play golf, some do archery, and I like to operate,” Tshering told AFP as he tended to patients one Saturday morning at Jigme Dorji Wangchuck national referral hospital, describing his moonlighting medical work as a “de-stresser”.
“I will continue doing this until I die and I miss not being able to be here every day,” he added. “Whenever I drive to work on weekdays, I wish I could turn left towards the hospital.”
Far from finding the two roles hard to juggle, Tshering said he had found that there was unexpected crossover between prime minister and surgeon. “At the hospital I scan and treat patients. In the government, I scan the health of policies and try to make them better,” he said. He has also put healthcare reform at the heart of his political agenda.
It’s well known that the opioid crisis started with prescription abuse but how much abuse was driven by patients who fooled their physicians and how much was driven by physicians who responded to monetary incentives with a nod and a wink? Molly Schnell provides some evidence which even a hard headed rationalist like myself found startling.
In August of 2010, Purdue Pharma replaced old OxyContin with a new, anti-abuse version of OxyContin. The new version was just as good at reducing pain as the old but it was more difficult to turn it into an injectable to produce a high. If physicians are altruists who balance treating their patient’s pain against their fear of patient addiction and downstream abuse then they should increase their prescriptions of new Oxy. From the point of view of health, the new Oxy is simply a better drug and with less abuse to worry about altruistic physicians should be more willing on the margin to prescribe Oxy to reduce pain. So what happened? Prescriptions for Oxy fell immediately and dramatically when the better version was released.
Now, to be fair to the physicians, patients who wanted to abuse Oxy stopped demanding it after the new version was released and physicians might not have realized how many of their prescriptions were being abused or sold on the secondary market. The aggregate data, which is a combination of supply and demand shifts, can mask individual physician behavior. Schnell, however, has data on the prescribing behavior of about 100,000 individual physicians who prescribed opioids.
Schnell finds that nearly a third of physicians behaved exactly as the altruism theory predicts. Namely, when new Oxy was released these altruistic physicians increased their prescriptions of Oxy and they maintained or reduced their prescriptions of other opioids. In fact, the median altruistic physician doubled their prescriptions of the new and improved Oxy. But almost 40% of physicians in Schnell’s sample behaved in a decidedly non-altruistic manner. Beginning in August of 2010, these non-altruistic physicians halved their prescriptions of new and improved Oxy and increased their prescriptions of other opioids. It’s difficult to see how attentive and altruistic physicians could decrease their demand for a better drug.
Schnell also finds that some parts of the country had fewer altruistic physicians and the consequences are evident in mortality statistics:
…. these differences in physician altruism across commuting zones translate into significant differences in mortality across locations…a one standard deviation increase in low-altruism physicians is associated with a 0.33 standard deviation increase in deaths involving drugs per capita. While this association is reduced conditional on observable commuting zone characteristics (including race, age, education, and income profiles), a significant and large association between the share of low-altruism physicians and drug-related mortality remains. Furthermore…this relationship persists even conditional on the number of opioid prescriptions, suggesting that the association is driven by the allocation of prescriptions introduced by low-altruism physicians rather than simply the quantity.
The less-altruistic physicians increased prescriptions for other opioids after new Oxy was introduced but perhaps even this was better than the non-prescription alternatives like heroin and street fentanyl. Indeed, Alpert, Powell and Pacula show that the introduction of improved Oxy led to more deaths because people switched to more dangerous, illegal alternatives. So was it a bad idea to introduce a better drug? Maybe, but if new Oxy had been introduced earlier perhaps fewer people would have been addicted, leading to less demand for illegal markets later. Thus, static and dynamic effects may differ. The economics of dual use goods is complicated.
The U.S. saving rate declined by 8 percent between 1980 and 2009. We document that the decline can be explained by rising health expenditures. Using exogenous variation in medical expenses generated by FDA drug approvals, we document that a 1 percentage point increase in health expenditure generated a decline in saving rate of 0.9 percentage points. We then estimate a model of household decisions to evaluate the mechanisms behind the decline. We find that the rise in health expenses and drop in saving rate are driven by progress in health technology, reduction in co‐payment rates, and improvements in income processes.
Philip Morris International, the tobacco company that sells Marlboro cigarettes, is getting into the life insurance business.
Called Reviti, the wholly owned subsidiary will initially sell life insurance in the U.K. with plans to expand into more markets overseas. Smokers will receive discounts if they stop, quit or switch to a possibly less carcinogenic product, like Philip Morris’ vaping devices.
On average, people who switch to e-cigarettes will receive a 2.5% discount on premiums, people who switch to Philip Morris’ heated tobacco product iQOS for three months will receive a 25% discount, and people who quit smoking for at least a year will receive a 50% discount, the company said. Premiums for a 20-year-old nonsmoker run about £5 ($6.47) per month for a life insurance policy that pays £150,000 ($194,125). The same premium would buy a £60,000 ($77,650) policy for a 40-year-old nonsmoker.
Here is more from Angelica LaVito, via Sheel.
Humans are living longer, better lives thanks to innovations in prescription drugs over the past three decades, according to several new studies by Frank Lichtenberg, the Courtney C. Brown Professor of Business.
Every year, according to Lichtenberg’s research, drugs launched since 1982 are adding 150 million life-years to the lifespans of people in 22 countries that he analyzed. He calculated the average pharmaceutical expenditure per life-year saved at $2,837 — a bargain, he says.
“According to most health economists and policymakers, if you could extend someone’s life by a year for less than $3,000, that is highly cost effective,” says Lichtenberg, who gathered new data for these studies to cast a never-before seen view of the econometrics of prescription drugs. “People might be surprised by how cost-effective drugs appear to be in general.”
…To tease out the answer, the professor gathered data on drug launches and the age-standardized premature mortality rate by country, disease, and year. Drawing on data from the World Health Organization, the United Nations, consulting company IQVIA, and French database Theriaque, Lichtenberg was able to identify the role that pharmaceutical innovation played in reducing the number of years of life lost due to 66 diseases in 27 countries. (“Years of life lost” is an estimate of the average years a person would have lived if he or she had not died prematurely.)
Between 1982 and 2015, for example, the US saw the launch of 719 new drugs, the most of any country in the sample; Israel had about half as many launches. By looking at the resultant change in each country between mortality and disease, Lichtenberg calculated that the years of life lost before the age of 85 in 2013 would have been 2.16 times as high if no new drugs had been launched after 1981. For a subset of 22 countries with more full data, the number of life-years gained in 2013 from drugs launched after 1981 was 148.7 million.
Or is it that there’s something wrong with culture, with the funding? Almost no grants go to younger scientists. When it’s scientists under age 40 that make […] of the most big discoveries, 2% of NIH grants go to scientists under age 40. That seems a little bit off. You have a peer-review process where anything heterodox can’t get funded. You have sort of a publish or perish dynamic where you have to do small, incremental things to publish lots of articles that don’t add up to anything ever…
And again, my sort of libertarian cut on what happened would be the history of was that we had a healthy, scientific world that was non-governmental. It was decentralized. It was idiosyncratic. Different people were doing different kinds of things. And in the 1930s, 1940s, it got centralized accelerated. The Manhattan Project…there was actually a way you could accelerate science temporarily by adding tons of money and centralizing…
So the centralization worked. But to use an ecological metaphor, it worked by creating a monoculture. And we’re now two generations in to where that monoculture has been just catastrophic.
That is from this taped dialogue between Peter and Bill Hurlbut, previously linked on MR.
Dozens of medical professionals in seven states were charged Wednesday with participating in the illegal prescribing of more than 32 million pain pills, including doctors who prosecutors said traded sex for prescriptions and a dentist who unnecessarily pulled teeth from patients to justify giving them opioids…
Another Alabama doctor allegedly prescribed opioids in high doses and charged a “concierge fee” of $600 per year to be one of his patients.
By Sari Horwitz and Scott Higham, there is more of interest at the link. For the pointer I thank Harrison Brown.
A recent study in Nature Communications shows that when stroke patients are surrounded by close connections like their immediate family, they are less likely to get to the hospital in time for treatment, compared to patients with looser social connections.
Amar Dhand is a neurologist at Harvard Medical School with a PhD in sociology from Oxford who studies the relationship between social connections and health. His team surveyed 175 stroke patients in Boston and St. Louis, and mapped their social networks against the time it took them to arrive at the hospital. The 67 patients who took more than six hours to arrive had both smaller and tighter-knit social networks than the 108 who arrived in under six hours…
“This is the biggest problem in stroke therapy today,” Dhand says. “The delay that is caused by patients and the caregivers. The social context is the largest part of the delay, hands down, in stroke patients arriving in hospital in time.” There’s a predictable sequence of events for stroke patients in close networks, he notes. Initially, a patient may delay telling their family about their symptoms, not wanting them to worry. “Secondly, they [the family] over-negotiate the symptoms, and perhaps even argue about them,” Dhand says. “Then they all validate each others opinion to watch and wait.”
He calls it an”echo chamber,” where family members, hoping for the best, minimize the gravity of the situation and conflate it with previous, less severe illnesses.
In contrast, when patients with only loose social networks have a stroke, there isn’t as much dithering. Patients who suffer strokes in a public place may be sent to the emergency room out of an abundance of caution by employees of the mall, store, or restaurant where they are afflicted. In some cases, an ambulance may be called by someone who doesn’t want the responsibility of caring for the sick person.
Here is the full article.
The FDA may be too conservative but it does subject new pharmaceuticals to real scientific tests for efficacy. In contrasts, many medical and surgical procedures have not been tested in randomized controlled trials. Moreover, dental care is far behind medical care in demanding scientific evidence of efficacy. A long-read in The Atlantic spends far too much time on a single case of egregious dental fraud but it’s larger point is correct:
Common dental procedures are not always as safe, effective, or durable as we are meant to believe. As a profession, dentistry has not yet applied the same level of self-scrutiny as medicine, or embraced as sweeping an emphasis on scientific evidence.
…Consider the maxim that everyone should visit the dentist twice a year for cleanings. We hear it so often, and from such a young age, that we’ve internalized it as truth. But this supposed commandment of oral health has no scientific grounding. Scholars have traced its origins to a few potential sources, including a toothpaste advertisement from the 1930s and an illustrated pamphlet from 1849 that follows the travails of a man with a severe toothache. Today, an increasing number of dentists acknowledge that adults with good oral hygiene need to see a dentist only once every 12 to 16 months.
The joke, of course, is that there’s no evidence for the 12 to 16 month rule either. Still give credit to Ferris Jabr for mentioning that the case for fluoridation is also weak by modern standards–questioning fluoridation has been a taboo in American society since anti-fluoridation activists were branded as far-right conspiracy theorists in the 1950s.
The Cochrane organization, a highly respected arbiter of evidence-based medicine, has conducted systematic reviews of oral-health studies since 1999….most of the Cochrane reviews reach one of two disheartening conclusions: Either the available evidence fails to confirm the purported benefits of a given dental intervention, or there is simply not enough research to say anything substantive one way or another.
Fluoridation of drinking water seems to help reduce tooth decay in children, but there is insufficient evidence that it does the same for adults. Some data suggest that regular flossing, in addition to brushing, mitigates gum disease, but there is only “weak, very unreliable” evidence that it combats plaque. As for common but invasive dental procedures, an increasing number of dentists question the tradition of prophylactic wisdom-teeth removal; often, the safer choice is to monitor unproblematic teeth for any worrying developments. Little medical evidence justifies the substitution of tooth-colored resins for typical metal amalgams to fill cavities. And what limited data we have don’t clearly indicate whether it’s better to repair a root-canaled tooth with a crown or a filling. When Cochrane researchers tried to determine whether faulty metal fillings should be repaired or replaced, they could not find a single study that met their standards.
Accounting for income endogeneity, our results suggested that being a current cannabis user may cost an individual over £5600 per year, in terms of lost wellbeing, while being a current user of other drugs may cost approximately £4000 per year. While acknowledging possible reverse causality, we estimated the annual population cost of drug use may be as high as £10.7bn in terms of lost wellbeing.