Category: Medicine
China’s Libertarian Medical City
You’ve likely heard of Prospera, the private city in Honduras established under the ZEDE (Zone for Employment and Economic Development) law, which has drawn global investment for medical innovation. The current Honduran government is trying to break its contracts and evict Prospera from 
Honduras. The libertarian concept of an autonomous medical hub, free to attract top talent, pharmaceuticals, medical devices, ideas, and technology from around the world is, however, gaining traction elsewhere—most notably and perhaps surprisngly in the Boao Hope Lecheng Medical Tourism Pilot Zone in Hainan, China.
Boao Hope City is a special medical zone supported by the local and national governments. Treatments in Boao Hope City do not have to be approved by the Chinese medical authorities as Boao Hope City is following the peer approval model I have long argued for:
Daxue: Medical institutions within the zone can import and use pharmaceuticals and medical devices already available in other countries as clinically urgent items before obtaining approval in China. This allows domestic patients to access innovative treatments without the need to travel abroad…. The medical products to be used in the pilot zone must possess a CE mark, an FDA license, or PMDA approval, which respectively indicate that they have been approved in the European Union, the US, and Japan for their safe and effective use.
Moreover, evidence on the new drugs and devices used within the zone can be used to support approval from the Chinese FDA–this seems to work similar to Bartley Madden’s dual track procedure.
Daxue: Since 2020, the National Medical Products Administration has introduced regulations on real-world evidence (RWE), with the pilot zone being the exclusive RWE pilot in China. This means that clinical data from licensed items used within the zone can be transformed into RWE for registration and approval in China. Consequently, medical institutions in the zone possess added leverage in negotiations with international pharmaceutical and medical device manufacturers seeking to enter the Chinese market.
… This process significantly reduces the time required for approval to just a few months, saving businesses three to five years compared to traditional registration methods. As of March 2024, 30 medical devices and drugs have been through this process, among which 13 have obtained approval for being sold in China.
The zone also uses peer-approval for imports of health food, has eliminated tariffs on imported drugs and devices and waived visa requirements for many medical tourists.
To be sure, it’s difficult to find information about Boao Hope medical zone beyond some news reports and press releases so take everything with a grain of salt. Nevertheless, the free city model is catching on. There are already 29 hospitals in the zone including international hospitals and hundreds of thousands of medical tourists a year. The medical zone is part of a larger free port project.
Prospera is ideally placed for a medical zone for North and South America. The Honduran government should look to China’s Boao Hope Medical Zone to see what Prospera could achieve for Honduras with support instead of oppositon.
Hat tip: MvH.
Do you want a Democratic or Republican doctor?
Political polarization is increasingly affecting policymaking, but how is it influencing professional decision-making? This paper studies the differences in medical practice between Republican and Democratic physicians over 1999-2019. It links physicians in the Medicare claims data with their campaign contributions to determine their partyalignment. In 1999, there were no partisan differences in medical expenditure perpatient. By 2019, Republican physicians are now spending 13% more, or $70 annually per patient. We analyze four potential sources of this partisan difference: practice characteristics (i.e., specialization and location), patient composition, preferences for financial gain, and beliefs about appropriate care. Even among physicians in the same specialty and location treating patients for the same condition, Republican physicians spend 6% more, especially on elective procedures. Using a movers design, we also find large partisan differences for treating the same patient. We find no evidence that these partisan differences are driven by profit incentives. Instead, the evidence points to diverging beliefs. Republican physicians adhere less to clinical guidelines, consistent with their reported beliefs in prior surveys. The timing of the divergence matches the politicization of evidence-based medicine in Congress. These results suggest that political polarization may lead to partisan differences in the beliefs and behavior of practitioners.
That is from the job market paper of Woojin Kim from UC Berkeley. I found this one of the most interesting job market papers of this year.
How Low Socioeconomic Status Hinders Organ Donation
Past studies find that lower socioeconomic status (SES) individuals are less likely to donate organs. Building on the extended self literature, we propose that this effect occurs in part because the body is more central to the sense of self of lower-SES individuals. We test our predictions across seven studies (N = 8,782) conducted in different countries (United States and Brazil) with qualitative, observational, and experimental data in controlled and field settings. Results show that lower-SES individuals ascribe a greater weight to their bodies in forming their self-concept, which reduces their willingness to donate organs.
That is from a new paper by Yan Vietes and Chiraag Mittal. Via the excellent Kevin Lewis.
The Health and Employment Effects of Employer Vaccination Mandates
Health care facilities considering mandating staff vaccination face a difficult tradeoff. While additional vaccination coverage will directly reduce disease transmission within the facility, the imposition of a mandate may also cause vaccine-hesitant staff to quit, which could harm patient care. To study this tradeoff, we leverage comprehensive administrative data covering virtually all US nursing homes, including payroll-based records on approximately 500 million daily nurse shifts and weekly data on COVID transmission and mortality at each facility. We use a difference-in-differences framework to estimate the impact of employer-imposed vaccine mandates at 581 nursing homes on disease spread, employment outcomes, and several patient care metrics. While mandates did slightly increase staff turnover, the effects were concentrated on staff working less than 20 hours per week, and resulted in a reduction of less than two minutes per patient-day. Furthermore, there is only limited evidence of lower levels of care at mandate facilities in typically-monitored conditions such as patient falls, pressure ulcers, or urinary tract infections. In contrast, implementing a vaccine mandate led to large increases in staff vaccinations at mandate facilities, which directly led to less transmission of and lower patient mortality from COVID. We estimate that vaccine mandates saved one patient life for every two facilities that enacted a mandate, a large effect given the typical facility has around 100 beds. Our results suggest that the health benefits of mandates far outweigh the costs in terms of reduced patient care from staff turnover.
Yup. For some of you, it is time to read it and weep. Here is the full paper by
Ethiopia fact of the day
More than 6.1 million malaria cases, and 1,038 deaths, have been recorded in the country this year through the end of September, compared with 4.5 million cases, and 469 deaths, for all of 2023. Worse, cases are likely to soar far higher in the next couple of months because peak malaria season, driven by seasonal rains, begins in September and runs through the end of the year.
“We’re backsliding so fast — we’ve gone back a decade,” said Fitsum Tadesse, the lead scientist overseeing the malaria program at the Armauer Hansen Research Institute in Addis Ababa, the capital of the country.
Here is more from the NYT.
Quantifying the Super-Villains
There is a new paper on this topic:
We investigate the effects of substantial Medicare price reductions in the medicaldevice industry, which amounted to a 61% decrease over 10 years for certain devicetypes. Analyzing over 20 years of administrative and proprietary data, we find theseprice cuts led to a 25% decline in new product introductions and a 75% decrease inpatent filings, indicating significant reductions in innovation activity. Manufacturersdecreased market entry and increased outsourcing to foreign producers, associatedwith higher rates of product defects. Our calculations suggest the value of lost inno-vation may fully offset the direct cost savings from the price cuts. We propose thatbetter-targeted pricing reforms could mitigate these negative effects. These findingsunderscore the need to balance cost containment with incentives for innovation andquality in policy design.
By Yunan Ji and Parker Rogers. Here is a summary tweet storm. Via Sam Hammond.
Iranian Kidney Donors
Iran is one of the few countries in the world to have eliminated the shortage of kidneys. A useful new paper looks at what donors are like,
First some background:
The adoption of a regulated market mechanism for kidney procurement in Iran started in 1988 in the absence of sufficient posthumous donations (Ghods and Savaj, 2006). The mechanism allows living unrelated Iranian individuals to donate kidneys to Iranian patients with end stage renal disease (ESRD) for financial gains. The program was successful in eliminating the renal transplant waiting list within a decade of its implementation (Mahdavi-Mazdeh, 2012). In addition, the Organ Transplant Act legalized brain-stem death donations in 2000. Both ESRD patients and potential kidney donors are referred to and registered with The Association for Supporting Renal Patients, a non-profit organization (NGO) which conducts a primary medical evaluation and facilitates the market exchange. Upon successful completion of the test, a formal consent is acquired and the potential donor and the recipient are introduced to each other. At this stage both the patient and the donor are referred to a nephrologist for further evaluation, cross-match, and angiography. If the patient-donor pair is compatible, in the next step the pair negotiate the terms and conditions of the exchange. All terms within the price-cap are guaranteed and enforceable by the NGO. The price-cap is frequently adjusted for inflation and during the course of our study was set at 180 million Iranian Rial (US$4700 in August 2017). However, the negotiation is private and the pair can agree any terms they wish. The donor also receives a “gift of altruism” and 1 year of insurance from the government through the Charity Foundation for Special Diseases. Transplant surgery is carried out free of charge in public university hospitals. The Iranian Ministry of Health and Medical Education introduced further procedural changes in July 2019. In particular, they established a center for organ transplant and procurement at the ministry which acts as the matching centre and provides oversight and overall control of the process.
Are the donors irrational, risk-loving, impatient? No, they are normal people making the best of sometimes limited opportunities:
The overall picture is of individuals who were in financial need, often unemployed but with a family to support and where alternatives sources of financial support were grim. However, despite their financial position, these individuals were typically patient and not especially prone to risk-taking. They were no less rational than the average, but those who ended up completing the process might be characterized as more altruistic than those who did not….More broadly our findings indicate that even in situations of extreme poverty we should not assume lower levels of rationality will be pervasive.
Given that donation saves lives and that kidney donation is not especially risky (much less risky than driving a motorcycle, for example) the tradeoff seems positive and well within ordinary bounds.
Turning to the US, here is Sally Satel on a proposed tax credit for kidney donation:
What if we could solve the organ donor shortage with a simple tax credit? That is the idea behind the End Kidney Deaths Act (EKDA) (HR 9275).
The bill, advanced by the Coalition to Modify NOTA (NOTA stands for the National Organ Transplant Act passed in 1984) would provide a $50,000 refundable tax credit—$10,000 per year for five years—to any living donor who gave a kidney to the next person on the waiting list. The tax credit would be a 10-year pilot program.
The credit would save 10,000 to perhaps as many as 100,000 lives over ten years.
FYI, I am a supporter of Modify NOTA (along with Al Roth, Steve Levitt, and Mario Macis, to name just a few of the economists, joined by surgeons, nephrologists and others).
Hat tip: Kevin Lewis.
Fluoride revisionism?
I am usually skeptical of such efforts, but Journal of Health Economics is quite a serious outlet:
Community water fluoridation has been named one of the 10 greatest public health achievements of the 20th century for its role in improving dental health. Fluoride has large negative effects at high doses, clear benefits at low levels, and an unclear optimal dosage level. I leverage county-level variation in the timing of fluoride adoption, combined with restricted U.S. Census data that link over 29 million individuals to their county of birth, to estimate the causal effects of childhood fluoride exposure. Children exposed to community water fluoridation from age zero to five are worse off as adults on indices of economic self-sufficiency (−1.9% of a SD) and physical ability and health (−1.2% of a SD). They are also significantly less likely to graduate high school (−1.5 percentage points) or serve in the military (−1.0 percentage points). These findings challenge existing conclusions about safe levels of fluoride exposure.
That new article is by Adam Roberts. Via the excellent Kevin Lewis.
Northern Ireland fact of the day
The NHS in Northern Ireland is the worst in the UK. During the quarter April/June 2021, over 349,000 people were waiting for a first appointment, 53 percent for over a year, an increase of 39,000 for the same period in 2020. Adjusted for population size, waiting lists in Northern Ireland are 100 times greater than those in England, a country 50 times its size.
That is from the truly excellent Perils and Prospects of a United Ireland, by Padraig O’Malley. Imagine a detailed, thoughtful 500 pp. book on political issues you probably don’t care all that much about — is there any better way to study politics and political reasoning? Every page of this book offers substance.
Elsewhere, of course, we are told that reluctance to give up their health care system is a major reason why Irish reunification is not more popular in the North, and that holds for Catholics too.
This one will make the best non-fiction of the year list.
Incentives matter, the demand curve slopes downward, mental health edition
Since 2000, pharmaceuticals for common psychiatric conditions aged out of patent protection. After generic entry, supply increases as more sellers enter the market, leading to lower prices – about 80-85% less! Cheaper prescriptions and more treatment are the stated goal of policies to improve affordability.
…Drug prices definitely fell during this period. For the SSRI sertraline, consumer cost per month dropped from ~35 dollars in the mid-2000s to ~6 dollars by the mid 2010s. Total Medicaid spending on antidepressants peaked in 2004 ($2 billion) then declined through 2018 ($750 million). Authors of that paper note that “generic drug prices steadily decreased over time” while utilization increased. From 2013 to 2018, both out-of-pocket costs and total expenditures per prescription fill went down for antidepressants and antipsychotics. For antipsychotics, generic drug claims grew 35% from 2016 to 2021.
According to the DEA, total dispensing of stimulants jumped 58% from 2012 to 2022; note how this follows the generic entry of long-acting Ritalin (methylphenidate) and Adderall (amphetamine) products. More recently, stimulant prices shot up amid shortages.
And:
By the mid 2010s, people with psychiatric conditions were better able to afford mental health care. Young adults, now on their parents insurance, saw declining out of pocket costs for behavioral health in particular. For people aged 18-25, “mental health treatment increased by 5.3 percentage points relative to a comparison group of similar people ages 26–35.” Even for employer plans, in-network prices and cost-sharing decreased from 2007 to 2017…
Here is the full essay by AffectiveMedicine. It has numerous other points of interest.
Model this
Doctors were given cases to diagnose, with half getting GPT-4 access to help. The control group got 73% right & the GPT-4 group 77%. No big difference.
But GPT-4 alone got 92%. The doctors didn’t want to listen to the AI.
Here is more from Ethan Mollick. And now the tweet is reposted with (minor) clarifications:
A preview of the coming problem of working with AI when it starts to match or exceed human capability: Doctors were given cases to diagnose, with half getting GPT-4 access to help. The control group got 73% score in diagnostic accuracy (a measure of diagnostic reasoning) & the GPT-4 group 77%. No big difference. But GPT-4 alone got 88%. The doctors didn’t change their opinions when working with AI.
A new schizophrenia drug
One of the most satisfying aspects of covering biotech as long as I have is the opportunity to report on the long arc of drug development, from start to finish. It’s not always pretty, and more often than not, it ends badly.
But KarXT, now Cobenfy, is one of those drug stories with a happy ending. I remember talking to Steven Paul in 2019 for a story about the phase 2 results, which were pretty remarkable. Paul was excited about what KarXT might mean for people with schizophrenia, but he was cautious because, as he warned me at the time, clinical trials for psychiatric conditions are extraordinarily difficult to replicate. Let’s wait to see what KarXT does in Ph3 trials, he said.
Now, we know.
It’s been cool to follow and report on the KarXT story all these years. From PureTech to Karuna to Bristol Myers Squibb, and now, to approval, where Cobenfy will have a meaningful impact on people living with schizophrenia.
That is from Adam Feuerstein, who also links to StatNews:
The drug, called Cobenfy, will be sold by Bristol Myers Squibb. It was developed by the biotech company Karuna Therapeutics, which Bristol acquired for $14 billion last year.
Supply is elastic, people. And we live in a (potential) golden age for biomedical advances.
On the price of Ozempic
That is the topic of my latest Bloomberg column, here is one excerpt:
As for consumer prices for the current obesity drugs, they are not as high as is often reported, once the various ways to get a discount are taken into account. Despite reports that the drugs cost $1,000 per month, the reality is more favorable. Even putting aside insurance coverage, readily available discounts can cut that price in half. Eli Lilly & Co. recently introduced online sales of Zepbound vials for $399 a month.
Lurking in the background are “compounded” versions of these drugs, which are pharmacy-produced copies, permitted by law when there is a shortage of the core drugs. These compounds do not undergo the same inspection processes as the brand names, and their safety and efficacy has been questioned. But they are easy to get and relatively cheap. This is an example of competition, however imperfect and in need of oversight, lowering prices — and in a less clumsy manner than a government price control.
Are we right now getting anything close to optimal price discrimination, or not?
“Despair” and Death in the United States
Increases in “deaths of despair” have been hypothesized to provide an important source of the adverse mortality experiences of some groups at the beginning of the 21st century. This study examines this possibility and uncovers the following primary findings. First, mental health deteriorated between 1993 and 2019 for all population subgroups examined. Second, these declines raised death rates and contributed to the adverse mortality trends experienced by prime-age non-Hispanic Whites and, to a lesser extent, Blacks from 1999-2019. However, worsening mental health is not the predominant explanation for them. Third, to extent these relationships support the general idea of “deaths of despair”, the specific causes comprising it should be both broader and different than previously recognized: still including drug mortality and possibly alcohol deaths but replacing suicides with fatalities from heart disease, lower respiratory causes, homicides, and conceivably cancer. Fourth, heterogeneity in the consequences of a given increase of poor mental health are generally more important than the sizes of the changes in poor mental health in explaining Black-White differences in the overall effects of mental health on mortality.
Sweden fact of the day
However, following the start of PhD studies, the use of psychiatric medication among PhD students increases substantially. This upward trend continues throughout the course of PhD studies, with estimates showing a 40 percent increase by the fifth year compared to pre-PhD levels. After the fifth year, which represents the average duration of PhD studies in our sample, we observe a notable decrease in the utilization of psychiatric medication.
Here is the article, via Jesse. Here are some relevant tweets. It doesn’t have to be causal to be interesting!