Category: Medicine

Market depletion and the income of doctors

Rural regions rule the doctor rankings: Alaska, Wyoming and Nebraska join the Dakotas in the top five states for physician pay, confounding the intuition hammered into our souls by more than a decade of covering economics. None of those are high-earning states overall, with the evergreen exception of Alaska. They’re also not high-cost: North and South Dakota rank 41st and 45th, respectively, in cost of living among the states and D.C.; only Alaska costs more than averageaccording to the Bureau of Economic Analysis.

Of course the highest-paid lawyers do not live in the Dakotas.  Do note this:

Rural America has about 20 percent of the U.S. population but about 10 percent of its doctors, according to our analysis of Census Bureau data. So the talented young physicians willing to hang their shingles in North Dakota don’t have to worry about rivals undercutting their prices. They can charge more for everything, from appendectomies to vasectomies.

Here is more from Andrew Van Dam.

Diego on gas station drugs

From my email:

The average gas station is now packed to the brim with drugs. This place had a Whip-it stand near the checkout, that I imagine is for recreational nitrous oxide users rather than whipped cream enjoyers, as well as a massive selection of kratom. ‘Whippets’ can cause irreversible brain damage and kratom has opiate-like effects, binding to the same receptors as morphine. There were also 3 stands near the checkout dedicated to weed-adjacent things including a mix of gummies, vapes, and flower bud containers. Unsure exactly what the weed-adjacent stuff was, some of it was Delta-8. Seems like a lot of these weed derivatives stemmed from the 2018 farm bill. The kratom proliferation has been insane. One of the main kratom brands, Botanic Tonics, sells super-popular small blue vials under the name ‘Feel Free’ that merely say ‘Plant-based herbal supplement’ on the front. Despite the FDA recently seizing $3M of kratom from Botanic Tonics as well as endless stories of addiction on the subreddit r/Quittingfeelfree, Botanic Tonics is an official sponsor of UT Austin and Florida State University and gives out free vials to students.

I do not personally have data on this question, but I thought this content was worth passing along.

AOC Gets on the Anti-FDA Bandwagon

At least when it comes to suncreen. As long-time readers will know, I have been complaining about FDA over-regulation of sunscreen for a decade! Maybe now that AOC is on the case things will change.

AOC’s sunscreen video is pretty good. One point she doesn’t stress is that requiring Americans to use more oily, less natural-feeling sunscreen can cause less use and thus more skin cancer. Even more important is the general issue of reciprocity or polycentric authority:

My rule is very simple. I don’t think the FDA is better than the EMA so if any drug or device is approved in Europe it ought to be available for purchase in the United States with a label saying “Approved by the EMA. Not approved by the FDA.” (By the way, we do have reciprocity type agreements with Canada and New Zealand for food so this would not be unprecedented.)

The Impact of Vaccines and Behavior on U.S. Cumulative Deaths from COVID-19

It is hard to think of a topic area where the Republican Party, the right-wing, and (many by no means all) MR commentators are so far off base.  Here are some new results from Andrew Atkeson:

…I find that vaccines saved 748,600 lives through June 2023. That is, without vaccines, cumulative mortality from COVID-19 would have been closer to 1.91 million over this time period. In answering the second question, I find that behavioral efforts to slow the transmission of the virus before vaccines became widely administered were critical to this positive impact of vaccines on cumulative mortality. For example, with a complete relaxation of these mitigation efforts, vaccines would have come too late to have saved a significant number of lives. Earlier deployment of vaccines would have saved many lives. I find that marginal changes in the strength of the behavioral response to COVID-19 deaths within the range of those responses estimated with the model have a significantly impact on cumulative COVID-19 mortality over this time period.

Here is the full paper.  By the way, in case you are wondering I did write some columns arguing we should reopen the schools (and I strongly encouraged my own institution, GMU, to reopen in the fall of 2020, when asked for advice.  Mercatus reopened once our landlord allowed us to.).  But I am glad that for instance normal NBA games with full crowds were not up and running in the usual manner in November of 2020.

Health Alert: Your Survival Odds May Increase When Surgeons Take a Break!

Another bit from my review in the WSJ of Random Acts of Medicine by Jena and Worsham:

The authors do not always endear themselves to their colleagues. In one intriguing study spanning a decade and involving 200,000 patients, a surprising revelation emerged. Patients who happened to have a heart attack during a week when hot-shot cardiac surgeons were away at national conferences were found more likely to survive. It sounds like a joke—stay away from hospitals because that’s where lots of people die—but the statistics are solid. The heart surgeons most likely to attend the national meetings also tend to be the go-getters, eager to cut and demonstrate their prowess in the operating theater. When these surgeons are away, mortality rates decrease by about 12.5%, a decrease “similar in magnitude to some of the best treatments we have available for heart attacks.” (Emphasis in the original). The president of the American Heart Association breezily dismissed the study’s findings, saying, “there’s nothing in this study that we see that would lead us to recommend a change in clinical practice.” Such dismissal in the face of significant evidence feels akin to malpractice.

There is now widespread recognition that too much medical care can be wasteful, but less recognition that it can also be harmful. Unfortunately, nearly all stakeholders, including patients, doctors, pharmaceutical firms and hospitals, are incentivized to spend and do more. Only insurance companies bear the burden of saying no. Given the inherent bias in our information sources toward positivity, it’s crucial to remain vigilant about instances where medical care has exceeded reasonable boundaries.

Left Digit Bias in Medicine

From my review in the WSJ of Random Acts of Medicine by Jena and Worsham:

You have probably heard of left-digit bias—the idea that $7.99 seems cheaper than $8, even though $8 is only negligibly different than $8.01. Left-digit bias is widely observed in pricing but the effect is more general. A car with 39,990 miles on the odometer, for instance, sells for more than a car with 40,005 miles (so be smart and buy the car with 40,005 miles). Could left-digit bias show up in medicine?

People who end up in the emergency room complaining of chest pains a few weeks before their 40th birthday are very similar to people who end up in the emergency room with chest pains a few weeks after their 40th birthday. But on a chart, the former are 39 years old and the latter are 40.

The big 40 is a heuristic among physicians for potential heart attack. Looking at more than five million patient records, the economist Stephen Coussens found that patients who were slightly over the age of 40 were almost 10% more likely to be tested for a heart attack than those just under 40. The difference shows up as a discontinuity, a jump up in the probability of being tested as patients cross their 40th birthday.

Messrs. Jena and Worsham show that similar discontinuities appear throughout medicine. Heart-attack patients just under the age of 80, for instance, are more likely to be given coronary artery bypass surgery than those just over 80. Kidneys from patients who die at age 69, just short of their 70th birthday, are more likely to be used for transplant than kidneys from patients just over 70, even though by all objective measures the kidneys are equally viable and valuable. Perhaps most tellingly, “children” just under the age of 18 are less likely to be prescribed opioids than “adults” slightly over the age of 18, even though these groups are statistically indistinguishable.

The point of these studies isn’t to titter or sigh at the peculiarities of human reasoning but to use these natural experiments to estimate the effect of medical procedures. If the only reason that near-18 and 18-year-olds are prescribed opioids differently is the semantics of “child” and “adult,” then we can use the discontinuity in prescriptions as a natural experiment—it’s as if prescribing around the age of 18 were randomly assigned. The authors find, for example, that compared to the just-under-18s, the just-over-18s were 12.6% more likely to later be diagnosed for an opioid-related adverse event such as an overdose. The greater rate of overdose is valuable information—but imagine the difficulty of trying to convince an Institutional Review Board that it would be ethical to randomly prescribe opioids to young people.

The Amy Finkelstein and Liran Einav health care plan

I am away from my review copy, so I am pleased that Matt Yglesias has offered ($) a good “standing on one foot” summary of the plan, as outlined in the new book We’ve Got You Covered: Rebooting American Health Care, by Amy Finkelstein and Liran Einav:

They call for:

  • A universal basic insurance system, covering both catastrophic and routine care but at a bare bones/no frills level of service.
  • A global budget, set by Congress, to determine how much money the basic plan has to spend on meeting the public’s basic needs, paired with expert panels to decide which services to cover.
  • An additive system of private top-up insurance that people could (and they anticipate mostly would) buy into to secure access to shorter wait times and more creature comforts.

The book offers a “think it through using first principles” approach, so perhaps the authors will be frustrated by my invocation of a “how has politics been going lately?” kind of response.  Nonetheless I see that Obamacare cost the Democrats dearly in more than one election, it had to be defanged (the mandate) to survive, it was supposed to be the new comprehensive framework that actually could pass (it did), and the most influential Americans just love their employer-provided private health insurance.

Whether you think those facts are good or bad, I take them as my starting point for health care reform.  This book does not.

I observe also that Obamacare passed, and American life expectancy fell.  I do not blame Obamacare for that, but I do notice it.  As a result, I have grown increasingly interested in “how can we boost biomedical scientific progress?” and increasingly less interested in “how can we reform health insurance coverage again?”  All the more because we seem to be living in a biomedical progress of science golden age.

One of the Democratic Party frustrations with conservatives during the ACA debates was witnessing them tolerate or even support Romney’s Massachusetts plan, but oppose Obamacare.  That I can understand.  One of the conservative frustrations with ACA was the fear that it would just be the first step in a never-ending, upward-ratcheting series of efforts to spend ever more on health insurance coverage, which has positive but only marginal implications for health itself.  After all, where exactly do the moral arguments for spending more on health insurance coverage stop?

Is there a politically feasible version of the Finkelstein and Einav plan that can spend less or the same?  Is there a politically feasible version of the plan period?  How much trust will there be in the promise that if I give up my private health insurance coverage, it will be replaced by something better?  How much trust should there be?

But again, the authors here have a very different perspective on the sector and how to do health care policy.

Australia fact of the day

Health officials have “virtually” eliminated HIV transmission in parts of Sydney that were once the centre of the Australian Aids epidemic, raising hopes of conquering a disease that has killed more than 40mn people.

HIV diagnoses in inner Sydney plunged 88 per cent from the 2008-12 average to just 11 cases last year, a decline on a scale never before recorded in a former Aids hotspot.

The results add to evidence that existing prevention strategies, including testing and pre-exposure drugs, are highly effective when implemented correctly.

“Rapid progress towards ending Aids is possible. If trends continue, several countries in several global regions will reach the [UN] goal of a 90 per cent HIV incidence reduction by 2030,” researchers said.

Here is the full FT story.  As I have been saying people, you are living in a new age of biomedical miracles.

Mental health and European economics departments

We study the mental health of graduate students and faculty at 14 Economics departments in Europe. Using clinically validated surveys sent out in the fall of 2021, we find that 34.7% of graduate students experience moderate to severe symptoms of depression or anxiety and 17.3% report suicidal or self-harm ideation in a two-week period. Only 19.2% of students with significant symptoms are in treatment. 15.8% of faculty members experience moderate to severe depression or anxiety symptoms, with prevalence higher among nontenure track (42.9%) and tenure track (31.4%) faculty than tenured (9.6%) faculty. We estimate that the COVID-19 pandemic accounts for about 74% of the higher prevalence of depression symptoms and 30% of the higher prevalence of anxiety symptoms in our European sample relative to a 2017 U.S. sample of economics graduate students. We also document issues in the work environment, including a high incidence of sexual harassment, and make recommendations for improvement.

That is from a new paper by Elisa Macchi, Clara Sievert, Valentin Bolotnyy, and Paul Barreira.

How the NSF Moved Faster than the NIH During COVID-19

The NSF is a much smaller organization than the NIH but during the pandemic it moved more quickly. Why? Maxwell Tabarrok explains:

The NSF relied on its special congressional authority to skip peer review to bootstrap its pandemic-related granting. Two pre-existing programs which use this authority enabled the NSF’s speedy response. The RAPID (Rapid Response Research) and EAGER (EArly-concept Grants for Exploratory Research) programs focus on “proposals having a severe urgency,” and “exploratory work in its early stages on untested, but potentially transformative, research ideas,” respectively. Both turn applications around quickly: while typical federal science grants take 9-12 months of review, RAPID and EAGER grants usually provide funding to researchers in less than a month.

…The NSF funded valuable research through its RAPID grants program, including the development of the first COVID-19 test to get FDA approval, the Johns Hopkins COVID-19 data dashboard, and both inhaled and micro-needle patch vaccines, the latter of which is currently being scaled up for use in HPV vaccines. These examples don’t conclusively show that the NSF avoided sacrificing quality control for speed, but they suggest that the NSF’s internal team of reviewers funded multiple effective projects that benefited from faster turnarounds. The benefits of speeding up these big successes when they were urgently needed outweighed the hypothetical costs of approving some below-average projects.

In crises generally, the success of a science funder is determined by its biggest wins, not by the average quality of the projects it approves. Science’s impact on the pandemic was dominated by a single technology: the mRNA vaccine. The next most important contributions, likely testing or pharmaceutical treatments, were less important than the vaccine, and the average COVID-19 research project may have had minimal impact. External peer review slows down the funding of all projects to make sure that low-quality research is not funded. This kind of bottom-end quality control is less important in a crisis environment. At crisis-response margins, it’s probably better for science funding agencies to anchor less on quality control and instead take more shots on goal.

The NIH, to be fair, also responded more rapidly than usual and it used some special “shark-tank” like programs to do so which also worked well.

Read the whole thing for more recommendations.

Against human-AI collaboration

From a new NBER working paper by Nikhil Agarwal, Alex Moehring, Pranav Rajpurkar, and Tobias Salz:

Radiologists do not fully capitalize on the potential gains from AI assistance because of large deviations from the benchmark Bayesian model with correct belief updating. The observed errors in belief updating can be explained by radiologists’ partially underweighting the AI’s information relative to their own and not accounting for the correlation between their own information and AI predictions. In light of these biases, we design a collaborative system between radiologists and AI. Our results demonstrate that, unless the documented mistakes can be corrected, the optimal solution involves assigning cases either to humans or to AI, but rarely to a human assisted by AI.

I am more optimistic in my views, noting there may well be contexts such as radiology where the collaborations fail.  I collaborate with Google’s AI all the time, and I am pretty sure that joint effort does better than either myself or “Google with no human” unaided.  Still, this is a cautionary note of some import, as many humans are not good enough to work well with AIs.

Intergenerational transmission of mental health problems

We estimate health associations across generations and dynasties using information on healthcare visits from administrative data for the entire Norwegian population. A parental mental health diagnosis is associated with a 9.3 percentage point (40%) higher probability of a mental health diagnosis of their adolescent child. Intensive margin physical and mental health associations are similar, and dynastic estimates account for about 40% of the intergenerational persistence. We also show that a policy targeting additional health resources for the young children of adults diagnosed with mental health conditions reduced the parent-child mental health association by about 40%.

That is from a new NBER working paper from Aline Bütikofer, Krzysztof Karbownik, and Fanny Landaud.

China estimate of the day

The paper’s title is “The Largest Insurance Expansion in History: Saving One Million Lives Per Year in China”:

The New Cooperative Medical Scheme (NCMS) rolled out in China from 2003-2008 provided insurance to 800 million rural Chinese. We combine aggregate mortality data with individual survey data, and identify the impact of the NCMS from program rollout and heterogeneity across areas in their rural share. We find that there was a significant decline in aggregate mortality, with the program saving more than one million lives per year at its peak, and explaining 78% of the entire increase in life expectancy in China over this period. We confirm these mortality effects using micro-data on mortality, other health outcomes, and utilization.

It is striking how few Westerns have even heard of this policy, one of the more important global events in recent years.  I do however wish to ask if this estimate is in accord with other, more general estimates from the literature.  The Amish, for instance, don’t see doctors so often and their life expectancy seems to be perfectly fineThe new paper is from Jonathan Gruber, Mengyun Li, and Junjian Yi.

The Birth-Weight Pollution Paradox

Maxim Massenkoff asks a very good question. If pollution reduces birth weight as much as the micro studies on pollution suggest, why aren’t birth weights very low in very polluted cities and countries? Figure 1, for example, shows birth weights in a variety of highly polluted world cities. The yellow dashed and blue lines show “predicted” birth weights extrapolated from the well-known Alexander and Schwandt “Volkswagen study” which looked at the effects of increased pollution in the United States. Despite the fact that every one of the highly-polluted cities is much more polluted than the most polluted US city, birth weight is not tremendously lower in these cities. Indeed, there is no obvious correlation between birth weight and pollution at all.

Similarly, US cities were more polluted in the past but were birth weights lower in the past? Figure 2 shows a number of US cities which were two to three times more polluted in 1972 (right side of diagram) than 2002 (left side of diagram). Yet, birth weights do not appear lower in the more polluted past and certainly do not follow the extrapolated birth weight-pollution predictions from the micro literature.

Massenkoff looks at a variety of possible explanations. One possibility, for example, is culling. Perhaps in highly polluted areas there are more miscarriages, still births or difficulty conceiving with the result that the observed sample of births is highly selected. There is some evidence that pollution increases miscarriages and stillbirths but these tend to be correlated with lower birth weight–a scarring effect rather than a culling effect. In addition, the effect of pollution on miscarriages and stillbirths also appears to be bigger on a micro level than on a macro level. That is, these rates aren’t massively higher in high pollution countries.

Another possibility is that pollution isn’t that bad and, in particular, not as bad as I have suggested. As a good Bayesian, I update, but for reasons I have given here, it’s not justifiable to update very much.

I assume, as I always do, that there are some overestimates in the micro literature for the usual reasons. But, more fundamentally, my best guess for the birth-weight pollution paradox is that weight is one of the easiest margins on which the body can adapt and compensate. Even in poor countries there are plenty of calories to go around and so it’s relatively easy for the body to adjust to higher pollution, on this margin. Indeed, weight is known as a variable that creates paradoxes!

Micro studies on weight and exercise, for example, show that exercise reduces weight. But looking across countries, societies, and time we don’t see big effects–indeed, calorie expenditure doesn’t vary much with exercise! Importantly, notice that the micro-estimates are correct. If you increase physical activity for the next 3 months, holding all else equal (which is possible for 3 months), you will lose weight. However, the micro estimates are difficult to extrapolate to permanent, long-run changes because there are complex, adaptive mechanisms governing weight, calorie consumption and energy expenditure.

The exercise paradox doesn’t mean that exercise isn’t good for you–the evidence on the benefits of exercise is extensive and credible. In the same way the birth-weight pollution paradox doesn’t mean that pollution isn’t harmful–the evidence on the costs of pollution is extensive and credible. In particular, it’s going to be much harder to adapt to pollution for heart disease, cancer, life expectancy and IQ than for weight. 

I am always impressed with papers that present big, obviously-true facts that most people have simply missed. Massenkoff is becoming a leader in this field.

Is “Lab Leak” now proven?

The WSJ ran a widely discussed article a few days ago, and many people have concluded that the Lab Leak hypothesis is now confirmed.  I’ve now read the piece, and I don’t see relevant new information in there.  The New York Times ran a rebuttal of sorts, with this as one key paragraph:

Recent news reports have unearthed new information about researchers from the Wuhan Institute of Virology who became sick in 2019. The news reports suggested that one of them could be patient zero. The information about the sick workers was first discovered at the end of the Trump administration. By August 2022, however, intelligence analysts had dismissed the evidence, saying it was not relevant. Intelligence officials determined that the sick workers could not tell them anything about whether a lab leak or natural transmission was more likely. Intelligence agencies view the information about the cases neutrally, arguing that they do not buttress the case for the lab leak or for natural transmission, according to officials briefed on the intelligence.

I read the London Times report, and didn’t see fundamentally new information in there either.

To be clear, I think the chance of Lab Leak being true is reasonably high, due to the accumulation of a lot of circumstantial evidence.  But I don’t think the new accounts are anything close to a slam-dunk, nor do they show that any of the researchers were “Patient Zero.”  That may well change as further information comes out, but so far it is a mistake to conclude that Lab Leak has been demonstrated to be true.

Addendum: As a side note, I am a little worried by how many people seem to be happy that Lab Leak hypothesis is (supposedly) confirmed.  I suppose it would mean you could feel vindicated in a certain kind of contempt for elites, both American and Chinese.  But under most normal views, the world where Lab Leak is true is a worse world than the world where Lab Leak is false.  So you should instead feel sad and upset if you think it is true, rather than happy or gleeful.  If you feel vindicated, it is a sign of a partial cognitive and emotive defect.

Second Addendum: This new national intelligence report doesn’t seem to confirm the Lab Leak take (though it doesn’t refute it either).  It pretty definitely downplays the import of the scientists getting sick.  Again, it is fine to not trust this report, but still a likely mistake to think new information has been coming out.  Here is a good WaPo look at where things stand.  Here are comments from Scott Sumner.