Wednesday, July 28, 2010

Blood supply

The safety of and the degree to which the blood supply can help individuals in need of transfusions in the United States is an issue that we hear about often.  We see the flyers for blood drives.  We often hear that there are chronic shortages of blood.  A piece in the Baltimore Sun points out that despite the concerns about shortages, not all blood in storage in hospitals just arrived.  In fact, it can be up to six weeks old.  Now there is concern that older blood may introduce risks for individuals who receive tranfusions.

Where is the economics here?  First, what does a shortage mean when at least some blood is around for six weeks and hospitals have protocols to use the oldest blood in storage so that none goes to waste?  A shortage may be for specific blood types (presumably less common ones) while others are in relatively strong supply.  The economic definition of shortage--a price at which the demand is greater than the supply--is difficult to interpret as so few consumers who need blood transfusions have any idea of the costs.

The economics is about how to use scarce resources.  What are the risks?  What are we willing to give up to reduce the risks?  And who will make those decisions?

If current studies establish that the risks of older blood for certain transfusions are real, would we be willing to risk wasting donated blood to assure safer transfusions?  If donors knew this, would they change their behavior?  Should price be involved in accessing safer blood?  How would we as a society or even medical professional agree on what the risk/benefit tradeoff should be?

From a cost-effectiveness point of view, if we look at the ways in which newer blood could change mortality or quality of life and compare that with the resources that might be wasted by discarding older blood donations, would we find this to be cost-effective?  It is almost certain that changes relative to the status quo in the United States would be more expensive even if they are more effective.  The persective (societal? patient? hospital? blood collection organization?) would also be crucial. 

Monday, July 19, 2010

What choices will we have with health reform in the United States?

An article in Saturday's New York Times described how some larger insurance companies are trying to figure out how to market plans that will offer a choice of lower premiums to have restricted choice of providers.  A comparison is made with the old limited choice discussion of the 1990's and early and health maintenance organizations.This is an interesting end result of the health care reform legislation.  Much of the conversation from the President during the debate in 2009 was about not being denied choice.  At this point, it all depends on what we think of as choice.

The choice in this case will be to pay more to get more choice of providers.  For those who want to pay more the choices of providers will be there.  For those who don't want to pay--or who don't have the resources to pay--they may only have options of plans with limited choices of providers.  Insurers have indicated that they are not seeking only to limit providers but to assure quality among the limited choice.

Research on earlier managed care plans suggested that the plans were good at containing costs in the short run but the plans did not necessarily limit the growth in costs.  Thus, having plans like these become more prevalent may be enough to save money for a while but may not change the eventual trajectory of costs. 

Is this the type of choice that the public thought it was going to receive?  Is encouraging insurers to figure out quality on behalf of their enrollees a likely solution for high quality care for patients in the long-run?  Do insurers have an incentive to compete on quality or on cost or both?  Can consumers recognize quality in an insurance plan?  Quality of medical care?  Is having plans that will limit choice and choose quality providers a likely solution for encouraging the provision of care that is cost-effective in the long-run?  Would another plan to align incentives of insurers and providers be more effective at controlling costs, providing high quality care, and encouraging the use of cost-effective procedures?  From whose perspective should the care be cost-effective, anyway?

These questions are not nececssarily easy to answer, but the general public in the United States will experience the consequences of the incentives that have been set for insurers and consumers in the coming years as the health care reform plan is implemented.

Tuesday, July 13, 2010

Sanitary habits and externalities

Last year I was at a meeting at the NIH campus and covered a sneeze with my upper arm. I was surprised when someone commented that they saw very few people do that.  I was very surprised that this would be true on the main campus of the National Institutes of Health.

Of course, we wouldn't expect people elsewhere to be any better.  A study from New Zealand highlighted in an article in the Baltimore Sun notes how few people made any attempt to cover a a sneeze or cough and how many of those who bothered to try actually did so with a bare hand.

Why would an economist be interested?  Both failing to cover a sneeze or cough and covering a sneeze or cough with a bare hand lead to externalities.  Different types of externalities but externalties nevertheless.

An uncovered sneeze or cough exposes others to the airborne viruses. A person who covers a sneeze or cough with a bare hand unfortunately does not keep the viruses to himself or herself but can spread them to doorknobs and other things touched.

The unfortunate thing from an economic point of view is that there is no easy way to provide alternative incentives--except perhaps social stigmatism.  However, if most people are doing this then it is not clear where the stigma would come from.

Perhaps the best we can hope for is better education about the risks and some way of internalizing the risks--at least to one's own family--and then a spillover from behavior toward one's own family to behavior to others.

If anyone could think of creative incentives that could be used in a cost-effective way to change this behavior, I'd be interested.

Tuesday, July 6, 2010

Side Effects of the Smallpox Vaccine

A piece in the New York Times this morning, described a risk from sexual contact with a member of the military who had been given the smallpox vaccination.  The smallpox vaccination does not use the smallpox virus--so no one has gotten smallpox.  The vaccination does use a virus called vaccinia.  The Centers for Disease Control has a website that discusses the vaccine and recommendations from 2001.  The website mentions a 1968 study suggesting that transmission to contacts results in 27 cases per million total vaccinations.  Not a major risk.  The piece in the New York Times mentioned a total of five known cases in the past twelve months from women who had sexual contact with a member of the military.  None of these cases were described (at least in the article) as passing it along to anyone else.  Vaccinia is described as not being a threat to an otherwise healthy individual but being a danger to those with a compromised immune system

How should this information affects our perception of the value of the vaccination?   This relatively small number of cases of infection (with none apparently leading to mortality) would probably not change the conclusion about the economic value of smallpox vaccination for members of the United States military.  The argument is not likely an easy economic argument in any case--the risk of smallpox as a terrorist weapon is not well defined for the general public.

Two things may be interesting to consider.  (1) Given the ongoing risk to contacts of vaccinated members of the military, would educating primary care providers about the potential for transmission be a cost-effective way of speeding up the process of diagnosis?  Possibly.  In the New York Times story mentioned at the start, the infected individual did need to see an infectious disease specialist to obtain a proper diagnosis.  (2) Whose perspective is of the most interest?  Certainly, the non-military contacts are important from society's perspective.  However, non-military contacts may not be as important from the point of view of the military.  Who makes the decisions?  Do they consider the economics?  And what perspective do they use when making these considerations?

All things to think about when there are risks to others in society from a vaccination program for the military for a threat to the military that is more than imagined but for which the general public has very limit information to assess the true level of the threat.    

Thursday, July 1, 2010

More on obesity

The Baltimore Sun carried an article with some interesting figures on obesity and parent's perceptions.  The figures presented note that the prevalence of obesity increased in 28 states last year and that eight states now have a prevalence of obesity over 30 percent (up from four last year) while more than two thirds of states have an obesity prevalence rate above 25 percent which no state had two decades ago.

Does this affect health care spending on a year by year basis?  Yes.

Does it affect health care spending over an entire lifetime?  Maybe.  People who are not obese may live longer and die from things that are more chronic so it is not entirely clear.

Are there important economic consequences to obesity?  Well, the costs mentioned above and potentially absenteeism or presenteeism at work.  Some jobs that may not be as easy or as safe as for non-obese individuals.  We could probably think of a few others.

What is most interesting in this article is near the middle.  Over one-third of children and teens are obese or overweight.  Yet, 84 percent of parents believe that their children are at a healthy weight--the issue may be with those who are only overweight and not obese.  Additionally, 80 percent of adults polled believe that childhood obesity is a problem.

For any method that we find to decrease the prevalence of obesity to be cost-effective (i.e. maybe cost saving, and if it is cost-increasing it brings enough additional health to make the extra spending worthwhile) is going to have to consider the difference between knowledge of the issue, perception about how a person or a person's family is affected by the issue, and related behavior.  Anyone wishing to study the potential cost-effectiveness of interventions will have to carefully consider whom to target; how to measure changes in knowledge, attitudes and behavior; how long to track the targeted population; and how to gather data on all the possible impacts of a healthy weight.