Tag Archives: Medicine

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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Paying For Med Quality

Some hope to cut US med spending, and raise med quality, by paying more for higher quality outcomes. But this doesn’t work so well if the people you pay are also in charge of telling you the outcomes. Or if you must prove that their care caused bad outcomes, instead of being due to especially weak/sick patients. I have high hopes for a system that paid for med outcomes determined by independent third parties, where price competition for specific patients could deal with patient selection issues. But I’m pretty skeptical that the US govt will allow that:

Medicare has begun publishing the rates of complications as a step toward using them to set payment rates for thousands of hospitals. But leaders of a number of the nation’s prestigious teaching hospitals are objecting …

A central tenet of the 2010 federal health-care law will tie Medicare reimbursement to a variety of measures, including how patients rate their stays, readmission, mortality rates and how closely hospitals adhere to basic guidelines for care. … Officials at many of the hospitals listed as having high rates of complications say the measures are fundamentally skewed in ways that exaggerate problems at hospitals that treat many complicated cases or very sick patients. …

Hospital officials examined the cases that led Medicare to rate her hospital as having a high rate of accidental cuts and lacerations. They found most of those cuts had been intended by the surgeon, but erroneously billed to Medicare under the code for an accidental cut. … “These patient safety indicators, they’re not real­ly well risk-adjusted.” …

Medicare identified 190 of 3,330 hospitals as having very high levels. Of those, 82 were major teaching hospitals, … Cleveland Clinic, said the clinic’s high rates of accidental tears and lacerations and serious blood clots were because “people are careful at documenting, almost to a fault, things that are incidental to the case.” … Gregg Meyer … predicted that many hospitals will react to the publication of the patient safety data by instructing those who fill out the billing records to change what they include, or by lavishing staff attention on the areas flagged by Medicare even if they aren’t a real problem. (more)

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Brin Says Cryonics Selfish

Like Tyler, sf author David Brin says cryonics is selfish:

A majority of citizens today perceive cryonics enthusiasts as kooky. … I share some of this skepticism. … Wouldn’t any reasonable person — one worthy of revival — dedicate a lifetime’s accumulated resources to helping their children and posterity, instead of splurging it all on a chancy, self-important gamble for personal immortality?

Consider:

“Median total [US Medicare] expenditures in the last 6 months of life [in ’00 to ’06] were $22,407.” (More)
“Out-of-pocket medical expenditures … for the years 1998-2006 … in the last year of life is estimated to be $11,618 on average.” (more)

Since US medical spending has more than doubled since then, we must now spend over $50K per person on the last six months of life. And this spending seems to, if anything, reduce lifespan. In contrast, a ~$40K (30 + 10) cryonics procedure gives a chance of a whole new life, and increases the chance of others gaining the same benefit at a lower cost. So why don’t Cowen or Brin first complain about selfish end-of-life care?

Brin continues:

Some people who sign up for storage believe their bank accounts alone — set up to earn dividends until some future era — will suffice to make them worthy of being thawed, repaired, and given full corporeal citizenship in a coming age of wonders. Somehow, I wouldn’t give that bet anything like sure odds, no matter how many technological barriers future people overcome.

Let me get this straight. People who suffer ridicule and fierce conformity pressures to pay to take a chance to avoid death and help others avoid death, who actually end up being right, and who in addition save money that gets invested in the world economy to help it to grow faster and larger, in order to generously pay future folks to revive them, do not deserve to be revived?! Even if they are quite willing to work to pay their way upon revival? Future folk should instead steal their money and refuse to revive them?! Why doesn’t Brin suggest that we today kill old folks a few weeks early to save thousands in medical costs? How exactly are they deserving yet cryonics patients not?

Btw, a second person has finally taken their cryonics hour. Any more takers?

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All In Their Heads

A randomized insurance experiment found that on average people who thought they had a higher health risk bought more insurance. But they didn’t actually have higher risk:

[In] a large-scale randomized field experiment in Mexico … [in ’04 on] a voluntary health insurance option [=SP] … ‘high risk’ agents are, ceteris paribus, more likely to opt into SP—although the insured are not more ‘risky’ on average. That is, despite the absence of a positive raw correlation between agents’ insurance status and proxies of risk, this paper presents evidence of the systematic selection predicted by theory. In particular, individuals who rated their health as “bad or very bad” before SP became available are 6.9 percentage points more likely to sign up for SP than those in “good or very good” health (compared to an overall treatment effect of 29 percentage points).

Curiously, however, agents in the experiment sort only on pre-period medical expenditures and subjective well-being. There appears to be no selection on objective measures of health—possibly because individuals are less aware of the latter. … [Regarding] preventive care decline with insurance coverage, the effect of SP on the utilization of these services is negative and non-trivial in size. Given the positive price effect, such a decline is likely due to ex ante moral hazard. (more)

This supports the idea that medicine is less about health than health-related feelings. If medicine were more about the reassurance that comes from being taken care of medically (because medicine is a standard way for others to show that they care about us), it makes sense that we want more insurance when we feel more vulnerable to illness, but that sense of vulnerability would  have a lot more to do with the social assurances we desire than our state of health.

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Why Work Hour Limits?

Many laws discourage and limit work hours. Laws require holidays and vacations, limit hours per day and week, and require extra payment for work over these limits. And of course income taxes discourage work more generally. The standard economic explanation for these limits is to prevent inefficient signaling. People motivated to gain relative status, to show their extra dedication to success, and to appear more able, work extra hours, for a net social loss. Work hour limits can reduce such losses. (Academic articles here, here, here, here, here.)

This argument makes some sense, but it would make a lot more sense if we set broader and more consistent limits. Yet we don’t at all limit housework, and place few limits on self-employed work. Furthermore, high status occupations are especially exempt. Doctors, lawyers, managers, financiers, artists, writers, athletes, academics, and software engineers often work crazy hours. Yet the signaling argument would seem to apply nearly as well if not better to such high status work. Why are we so selective in our limits?

One explanation is a battle for relative status between professions and activities. Areas where work hours are limited produce less, and so look less impressive. Ambitious folks who want to show their high abilities then choose other areas, leading to an equilibrium were observers reasonably less respect folks who work in limited areas. On this story, work hour limits were set in manufacturing and manual labor in order to reduce the status of such activities.

A second related explanation is that each society is eager to look good to other societies. So each society prefers to encourage, not discourage, activities that are especially visible to outsiders. When outsiders evaluate societies more on the basis of their athletes than their shop technicians, societies naturally subsidize the former relative to the latter.

Another third explanation is that voters support limits on work hours in some jobs mainly as a way to defy and “stick it to” employers, who are seen as evil and in need of taking down. Firms who employ low status workers may themselves seem lower status and “exploitive,” and thus more acceptable targets of ire. Work hour limits serve as a quantity limit which raises wages and thus employer expenses. Any reduction of signaling losses is nice, but mainly a side effect.

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Why Boom Times Kill

It seems that the puzzle of why death rates rise in good economic times is nearly solved. There’s an effect of increased driving deaths from increased driving, but the main effect is that in good times nursing homes have to compete more for minimum wage nursing assistants. Apparently a one percentage point cut in the unemployment rate leads to three percent fewer nursing assistants, which increases the national death rate by a half percent (which cuts about three weeks of life per person):

We find that most of the additional deaths that occur during times of economic growth are among the elderly, particularly elderly women. … Cyclicality is especially strong for deaths occurring in nursing homes, and is stronger in states where a higher fraction of the elderly reside in nursing homes. … Staffing in skilled nursing facilities moves counter-cyclically.

A typical estimate suggests that a one-percentage point increase in a state’s unemployment rate leads to a 0.54% reduction in that state’s mortality rate. … Deaths by motor vehicle accidents are associated with the largest coefficient estimate. … It is likely that motor vehicle deaths fluctuate because people drive more during strong economic times. …

Approximately 80 percent of the averted respiratory deaths are among those over age 60. … Virtually all of the additional cardiovascular deaths are among those over age 65. … The correlation between changes in hospital employment and changes in aggregate employment is strongly negative (-0.90). … Nursing homes experience especially severe shortages of nursing aides when the economy is strong. … Between 70 to 90% of home health care agencies and nursing homes indicate shortages of direct care workers. …
Nursing home deaths are associated with an estimated [unemployment rate] coefficient that is an order of magnitude larger than the coefficient that is estimated among deaths taking place elsewhere. …

A one percentage point increase in the unemployment rate raises total full-time employment at skilled nursing facilities by approximately three percent. There is no statistically significant increase in the number of physicians, but there are significant increases in nurses, certified aides, and other occupations. (more)

A quick calculation says the US paid ~$13 billion for nursing assistant salaries in 2004, less than one percent of US medical spending (source). By cutting nursing assistants 3% when unemployment falls by 1% (and cutting three weeks off US lifespan), we save ~$400 million a year, or one part in 5000 of US medical spending.

Given how cheap they are, it seems inexcusable that we don’t raise wages on nursing assistants in boom times, to keep nursing homes fully staffed. Might this be due to a fixed government price that refuses to adapt to the business cycle?

Added 23Dec: See the comment here suggesting that med understaffing is chronic and makes a big difference.

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Japan’s Fat Tax

This has been going on for three years, yet I just learned of it:

In 2008, Japan’s Ministry of Health passed the ‘metabo’ law and declared war against obesity. …

Japanese people are normally envied for their lean physiques. In fact, the OECD ranks them, with only 3% population obesity, one of the least obese developed countries. … Comparing the time periods 1976-1980 and 1996-2000, prevalence of obese boys and girls increased from 6.1% and 7.1% to 11.1% and 10.2%. …

The law mandates that local governments and employers add a waist measurement test to the annual mandatory check up of 40-75 year olds. For men and women who fail the test and exceed the maximum allowed waist length of 33.5 and 35.4 inches, they are required to attend a combination of counseling sessions, monitoring through phone and email correspondence, and motivational support. …

Employers or local government … are required to ensure a minimum of 65% participation, with an overall goal to cut the country’s obesity rates by 25% by year 2015. Failure to meet these goals results in fines of almost 10% of current health payments. (more)

Even before Japanese lawmakers set the waistline limits last year, the International Diabetes Federation (IDF) amended its recommended guidelines for the Japanese. The new IDF standard is 90 centimeters (35.4 inches) for men and 80 centimeters (31.5 inches) for women. But the Japanese government has yet to modify its limits. (more; HT Melanie Meng Xue)

Two interesting patterns:

  1. Japanese waist limits are stricter on men, yet since men are taller health-based rules would be stricter on women.
  2. The thinnest rich nation (Japan) passed a big law to make itself thinner just as the biggest medical spending nation (USA) debated a big law (Obamacare) ensuring it would spend more on medicine.

My tentative explanations:

  1. Most societies find it easier to disrespect/mistreat/etc. low status men than low status women.
  2. National policy is more about reaffirming and supporting symbols of national pride than about addressing national needs. The USA is proud of its medicine and Japan is proud of its thinness.

Note that that if you want to regulate health it makes far more sense to regulate weight than medicine, since weight is far more related to health than medicine.

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