Tag Archives: Medicine

Why National Med?

People offer many noble rationales for public education, but the data suggest they were adopted to create patriotic citizens for war. I suspect a similar data analysis could show why so many nations have recently adopted national medical systems:

Even as Americans debate … Obama’s healthcare law and its promise of guaranteed health coverage, … many far less affluent nations are moving in the opposite direction – to provide medical insurance to all nations.

China … is on track to .. cover more than 90 percent of the nation’s residents. … Two decades ago, many former communist countries … dismantled their universal health-care systems amid a drive to set up free-market economies. but popular demand for insurance protection has fueled an effort in nearly all these countries to rebuild their systems. Similar pressure is coming from the citizens of fast-growing nations int Asia and Latin America. …

Some countries have set up public systems like those in Great Britain and Canada. But many others are relying on a mix of government and commercial insurance, as in the United States. …

In countries such as India, politicians have learned that one of the surest says to secure votes is to promise better access to health care.  … The Thai system, set up a decade ago, has survived years of political upheaval and a military coup. “No party dares touch it.” …

Columbia’s universal system, set up in 1993, has cost more than twice what as expected.  (Today’s Post, article by Levey, p. A11; link will go here when available)

My guess: for our distant ancestors, medicine was a way to show that they care about each other. So today there is a demand for medicine to be provided by units of organization toward which we, or they, want us to feel solidarity. But I’m not sure what are the most direct and proximate causes of such a need for solidarity.

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Consulate Care

Here’s another idea for medical reform: consulate care. Let countries like Sweden, France, etc. with approved national health care systems have bigger consulates, and open them up to paying customers for medical services. For example, you could sign up for Swedish Care, and when needed you’d go to their consulate to get medical care as if you were living in Sweden.

Now we might not approve consulate care for say North Korea or Uganda, but surely most developed nations are good enough. We don’t issue travel warnings suggesting people not travel to Sweden, for fear of getting sick there. So why not let folks travel to a Sweden nearby for their medical care?

Since most other nations spend far less than the US on medicine, consulate care should be a lot cheaper. And since those other nations seem to suffer no net health loss from their cheaper care, consulate care should be no less healthy.

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Med Media Mangle

The media holds medicine to a lower standard than it holds alternative medicine, such as say crystal healing. No way would an article in a major paper complain that we aren’t subsidizing crystals enough for poor folks, based on the observation that rich folks buy more crystals and rich folks are healthier. But for medicine, that sort of correlation is enough.

For example, this week the Post has not one but two long articles celebrating a new breast cancer study, which it says shows:

“Nearly five black women die needlessly per day from breast cancer” because they don’t have information about the importance of breast screening and they don’t have access to high quality care.

But in fact, the study shows only that across 25 US cities, the ratio of the black vs. white breast cancer death rates correlates (barely significantly) with median city income and a measure of city racial segregation. It is a huge leap to conclude from these correlations that black women don’t have enough info or care!

The very robust health-status correlation predicts more health for higher status folks, and thus more race-health disparity when there is a higher race-status disparity. It seem quite plausible that the race-status disparity is higher in cities where races are segregated and incomes are low.

More from the Post:

It would be nearly nine months before she told herself it was time to act. By then, the lump was the size of a small egg. … Doctors and advocates say the fear that kept her from acting quickly is all too common among black women. It is among the factors that contribute to a disturbing trend: Although they are less likely than white women to get breast cancer, black women are more likely to die from it. … Poverty and racial inequities are the primary factors driving the disparity, according to a study. … The study, which compared mortality rates between black and white women in the nation’s 25 largest cities, states that “nearly five black women die needlessly per day from breast cancer” because they don’t have information about the importance of breast screening and they don’t have access to high quality care. The authors … said genetics play only a small role in the disparity.

More from the study:

[In] the 25 largest cities in the US, … non-Hispanic Black : non-Hispanic White [breast cancer death] rate ratios (RRs) were calculated … Almost all the NHB rates were greater than almost all the NHW rates. … From among the 7 potential correlates, only median household income (r = 0.43, p = 0.037) and a measure of segregation (r = 0.42, p = 0.039) were significantly related to the RR.

Note that white women may seem to “get” more breast cancer because they are tested more often for it.

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Just A Flesh Wound

ARTHUR: You are indeed brave, Sir knight, but the fight is mine.
BLACK KNIGHT: Oh, had enough, eh?
ARTHUR: Look, you stupid bastard, you’ve got no arms left.
BLACK KNIGHT: Yes I have.
ARTHUR: Look!
BLACK KNIGHT: Just a flesh wound. (more)

In the US the top 5% of medical spenders spend an average of $40,682 a year each, and account for 49.5% of all spending. (The bottom half spend an average of $236.) Not too surprisingly, 60.3% of these people are age 55 or older. Perhaps more surprising, on their health self-rating, 28.9% of these folks say they are “good”, 19.9% “very good” and 7.5% “excellent”, for a total of 56.3% with self-rated health of “good” or better (source).

So, are these folks in serious denial, or is most of our medical spending on hardly sick folks?

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Doctors Dominate

We humans pretend to resist domination, but actually tend to submit, and are often consciously unaware of the contradiction. I recently posted on our relating this way to police. We also relate this way to doctors. For example, people are basically scared to post negative web reviews of doctors. No, they don’t consciously feel scared. They’ll talk about how busy they are or they don’t feel qualified to judge. Yet their usual arrogance lets them rate lots of other things they know little about. And they are scared for good reason: doctors do got out of their way to retaliate against negative reviews. Details:

The Web Is Awash in Reviews, but Not for Doctors. Here’s Why.

… It is puzzling that there is no such authoritative collection of reviews for physicians, the highest-stakes choice of service provider that most people make. Sure, various Web sites like HealthGrades and RateMDs have taken their shots, and Yelp and Angie’s List have made a go of it, too. But the listings are often sparse, with few contributors and little of substance. … Not enough people take the time to review their doctors. …

RateMDs now has reviews of more than 1,370,000 doctors in the United States and Canada. But getting in the faces of the previously untouchable professional class has inevitably led to legal threats. He says he gets about one each week over negative reviews and receives subpoenas every month or two for information that can help identify reviewers, who believe they are posting anonymously. …

Several years ago, a physician reputation management service called Medical Justice developed a sort of liability vaccine. Doctors would ask patients to sign an agreement promising not to post about the doctor online; in exchange, patients would get additional privacy protections…. Medical Justice has now turned 180 degrees and embraced the review sites. It helpfully supplies its client doctors with iPads that they can give to patients as they are leaving. Patients write a review, and Medical Justice makes sure that the comments are posted on a review site. Sound coercive? … p

Patients may be steering clear for a far more ordinary reason: if they live in a small town or are only one or two degrees of social separation from physicians or their family members, they may not want to create any awkwardness. … An Angie’s List customer who read my column about the service last week raised a related concern. She said she would never talk negatively about her doctors on the site because there were only two decent hospital systems where she lived and she didn’t want to end up blackballed by doctors at either. …

Others idolize their doctors … Insurance giant WellPoint, … has found that only roughly 20 percent of customers will switch to a generic drug or use a less expensive imaging center, even if there is no health risk. Why? Because their doctor told them so. It is exactly this sort of unquestioning mind-set that may cause such low participation (or disproportionately positive reviews) at many review sites. …

WellPoint tracks doctors’ communication skills, availability, office environment and trust, but it doesn’t yet provide information about medical outcomes. .. It pays many physicians more when they achieve better results. But it’s not ready to share all of its outcome data. .. “The unintended consequences would be if certain surgical specialists would not take on the most challenging, needy and difficult patients.” … the big health care law requires Medicare to share all sorts of such data about doctors starting Jan. 1, 2013, assuming legal challenges don’t get in the way. The A.M.A. has raised many concerns about “risk adjustments.” (more; HT Tyler)

Risk adjustment is an issue for most products, since most have variations in who uses them. Yet we let people rate other products and collect track records on experiences with them. But for docs, we allow risk adjustment as an excuse to avoid accountability. This is an old issue is health econ — the story has always been that of course giving consumers info is a good idea, but we’d have to wait to give patients info until we “solve” the risk adjustment problem, which never happens, and never will. Mark my words, we will long delay publication of doc track records.

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How Social Are Signals?

We are aware that do many things for show, and I often suggest that we do such “signaling” more often than we realize. But while I’m eager to see writings on signaling theories and their empirical support, I’ve come to suspect that most tend to be unrealistically asocial. Let me explain.

In the iconic signaling story, one person has a hidden feature, which they choose to show to one other person, via some visible action. For example, on Valentine’s day a man traditionally buys a gift, writes a poem, etc. to show a women the strength of his feelings for her. The bigger the gift, the bigger his feelings, supposedly.

In this iconic situation, only these two parties matters. And this allows for simple sharp predictions. For example, if the person watching can’t see the signal, or already knows about the feature, there is no point in signaling. And there is no point in taking an action A to show feature F if that feature is unrelated to willingness to do A.

In realistic signaling, however, third parties typically matter a lot more. For example, the man might want to signal that other women want him, or that he knows that other men want her. The woman might care less about what she infers from his signal, and more about being able to let slip details to her friends, to show them the kind of man she has. This inclusion of a wider social circle makes it harder to find simple sharp tests.

I’ve talked about how schooling could be such a more social signal, and how that could complicate empirical testing:

Firms want to impress customers, suppliers, investors, etc. with the quality of their employees, and hiring graduates from prestigious schools helps them signal such quality. Hiring such graduates can also help a manager to impress his bosses, potential employees, and sister divisions about the quality of his employees. … The fact that attending school seem to cause changes in students that employers are willing to pay for does not show that school isn’t all about signaling. (more)

Similarly, people often respond to my suggestion that medical care functions in large part to “show that you care” with the example of people buying medicine for themselves. “Surely that can’t be signaling,” they suggest. But consider that unattached women often buy themselves flowers or chocolates on Valentines day. As signals become more social, and involve wider circles, it gets harder to isolate situations where no signaling should happen.

By the way, one way to think about “status” is as the limit of very social signals. The more that an action or sign is generally seen as positive, without being very specific about what good features it indicates or who exactly cares about such features, the more that this action or sign looks like a signal of general social status.

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Don’t Torture Mom & Dad

A doc’s eloquent plea:

It’s typically the son or daughter who has been physically closest to an elderly parent’s pain who is the most willing to let go. Sometimes an estranged family member is “flying in next week to get all this straightened out.” This is usually the person who knows the least about her struggling parent’s health. … With unrealistic expectations of our ability to prolong life, with death as an unfamiliar and unnatural event, and without a realistic, tactile sense of how much a worn-out elderly patient is suffering, it’s easy for patients and families to keep insisting on more tests, more medications, more procedures. … When their loved one does die, family members can tell themselves, “We did everything we could for Mom.” … At a certain stage of life, aggressive medical treatment can become sanctioned torture. When a case such as this comes along, nurses, physicians and therapists sometimes feel conflicted and immoral. … A retired nurse once wrote to me: “I am so glad I don’t have to hurt old people any more.” (more; HT Amanda Budny)

Our urge to use medicine to show that we care costs more than just spending more for mostly useless treatment. It often literally tortures our loved ones.

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Me On Marketplace

I’m on today’s edition of the NPR radio show Marketplace Money (transcript; audio ~25:30 to 29:00):

The average dog owner spends $655 a year on health care, that’s up 50 percent from a decade ago. Cat owners are in for $644, up nearly 75 percent, close to how much our health care costs have risen by. And that’s a puzzle to economists, like Robin Hanson at George Mason University.

Robin Hanson: Everyone’s got a favorite villain or bugaboo about why human health care costs are increasing; it’s too much regulation, too much government involvement, too much third-party payment.

Too many malpractice lawsuits. None of these factors apply to pets. You can’t blame insurers for pushing up costs either. Pet insurance is rare; only 1 percent of pet owners in this country have it. The 99 percent are paying full freight.

Hanson: But in pet medicine, people put their money on the barrel head. And yet pet expenses are increasing nearly as fast as human expenses.

What gives? Hanson and other economists give two explanations. Explanation one: Love. We treat our pets like family. They eat our food, they sleep in our beds, they relax at the spa, they have Facebook accounts. Of course we’re going to pay for their health care. Take dogs.

Hanson: So we want to show loyalty to these dogs who are showing loyalty to us. One way to do that is to spend more on medicine for them.

Explanation two for the rising cost has nothing to do with your pets; it’s how we see ourselves.

Hanson: We compare ourselves to people around us. And we ask the doctor and they say well, lots of people do this, most people do this, and the bar has been raised on how much you need to spend on your pets to show you’re a caring pet owner.

In the interview I tried to pose the choice as supply vs. demand explanations, as I’ve done in my last two posts, but I guess they didn’t find as engaging.

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Dog vs. Cat Medicine

Yesterday I said that med spending increased faster for pets, vs. farm animals, suggests that med spending increases are due mainly to demand, not supply, effects. We spend more on pet medicine now more because we care more about pets now, or want to show we care, and less because doctors have invented new useful treatments.

Now consider dog vs. cat medicine. A 2007 source said that at one point annual med spending was $200 per dog and $81 per cat. (It was $92 per horse, $9 per bird. Today we spend $655 per dog; other current figures available here for only $3000. Sigh.) So we spent 2.5 times as much on dog med, vs. cat med. Yet dogs and cats have about the same lifespan (dogs, cats), and similar rates of medical problems:

50% of today’s cat owners never take their cats to a veterinarian for health care. … Because cats tend to keep their problems to themselves, … cats, on an average, are much sicker than dogs by the time they are brought to your veterinarian for treatment. (more)

I doubt we should blame this on cats. It seems more likely that cat owners pay less attention to cats, because they care less:

74 percent of the test sample like dogs a lot, while only 41 percent like cats a lot. … 15 percent of the adults questioned said they disliked cats a lot while the number who said they disliked dogs a lot was only 2 percent. … Dog people were 11 percent more conscientious than cat people. … Cat people were generally about 12 percent more neurotic. (more)

Yet there are more cats than dogs. Note also that both WebMD and wikipedia have pages devoted to dog lifespan; neither have such a page for cats. Dogs are famously more loyal than cats, and it seems plausible that dog owners thus feel more loyal to dogs, and more obligated to help when sick.

I tentatively conclude that we spend 2.5 times as much on dog vs. cat pet medicine mainly because we care more about dogs. This shows a huge demand effect on med spending.

Now consider that in our society many consider men more expendable than women. We send men to war, expect men to put themselves in harms way to protect women, and try to save “women and children first.” Women also go to the doctor a lot more often than men, even though men are on average sicker (they die faster). For 2008 US doctor office visits, here is the ratio of women to men by age:

All,  1.43; <15,  0.93; 15–24, 2.24; 25–44, 2.26; 45–64, 1.39; 65–74, 1.11; >75,  0.95. (more)

This also seems likely to be a demand effect – we spend more on female medicine mainly because we care more about women, or care more to show that we care about them.

Added 7p: That Marketplace show quotes similar numbers for dog and cat spending:

The average dog owner spends $655 a year on health care, that’s up 50 percent from a decade ago. Cat owners are in for $644, up nearly 75 percent.

So did we once to care more about dogs, and now care about the same?

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Farm vs Pet Medicine

We now spend a huge fraction of income on medicine. Today the US spends ~18% of GDP on medicine, while in 1940 we spent ~4%. Why the huge increase?

A supply explanation is that doctors have invented lots of new useful treatments. A demand explanation, in contrast, is that we want more medicine as we get richer, either because we care more about health, or about showing that we care.

One way to distinguish supply vs. demand explanations is to look at farm vs. pet animal medicine. Both kinds of animal medicine are treated similarly by most supply changes – new medical treatments help both kinds of animals. But most demand changes treat them differently – farm animals today aren’t that much more valuable than they were long ago, but we treat our pets as if they were far more valuable.

While I can’t find good historical data, what I do find suggests we’ve seen a huge switch in animal medicine, from a focus on food animals to a focus on pets. On recent pet med spending increases:

The average household in the U.S. spent $655 on routine doctor and surgical visits for dogs last year, up 47% from a decade ago, according to the American Pet Products Association. Expenditures for cats soared 73% over the same time frame—on pace with human health-care cost increases. Expenditures for people in the U.S. were up 76.7% between 1999 and 2009, according to the U. S. Centers for Medicare and Medicaid Services. (more)

On vets long ago:

Very early veterinarians were mainly concerned with the care of livestock and horses and mules. … Prior to World War II, very few people would consider paying more than a token amount for the medical care of their pets any more than the average person today would consider taking an injured chipmunk to the vet. (more)

On the focus of US vets in 2011:

Food animal exclusive 1.8%; Food animal predominant 6.0%; Mixed animal 6.8%; Companion animal predominant 9.7%; Companion animal exclusive 67.2%; Equine 6.0%. (more)

Thus much, perhaps most, of the rise in animal med spending is a demand effect. More careful data analysis might give a more precise estimate.

Now pets probably live to be older than farm animals, so a supply shock mainly relevant for older animals might explain an increase of pet med relative to farm animal med. But that seems pretty unlikely to be the main thing going on here.

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