Shift work and health

Interesting article from the Baltimore Sun discussing issues about shift work and its health effects.  One big link is to obesity.  Obesity is linked to type II diabetes and to breast cancer in women.

What does this lead us to consider?  Well, do the men and women who perform shift work understand the risks?  Are they compensated for the risks?  (And should they be?)  Are there things that employers can do about some of the risks?  Are there things that employers should to do help employees  mitigate some of the risks?  What is the role for government as opposed to just leaving this to the market?

In general, as an economist, I would think that this type of issue could be worked out in the private sector--if everyone has all the information and understands the choices, then there should be a way for people who work night shifts to get paid more.  They may, already, to a degree although this was generally thought to be an issue of convenience  and what people liked.  It is not clear to what degree the new information would change existing relationships and how long it would take the new information to filter through the process of wage setting.

So, I would end up asking whether there may be some role for the government to try to accelerate the process of this information working its way through the system.  And, if so, what are the costs and health effects of such an activity.  Do they compare favorably?

Similarities and changes

This is the the next to the last week of the two classes I teach in the second term at the Johns Hopkins Bloomberg School of Public Health.  I have kept up one blog entry a week during this term, so we have two more blog entries before the term is over.  This morning, in scanning the CNN website, I cam across an interesting article that you can see if you click here.  This article caught my interest for several reasons.

First, and foremost, this I had recently been lecturing in my health economics class about health behaviors.  Along with that face, in the economic evaluation class that I teach online, we have discussed the cost-effectiveness of many health interventions, and behavior change interventions are one of the types of interventions that we can discuss.

Beyond that, I also find it interesting because I belong to a number of diverse social groups.  At least one of them is aimed at health behaviors--specifically running.  The organization called Back on My Feet draws people from the community to run with (mostly) men who are either homeless or in recovery.  The running allows the men to set goals and realize achievement.  There are a few additional services the men receive if they keep up with the running.  The intent is to get them focused on life in general.

The organization seems to work.  If you look at the men involved and the community volunteer runners there are not necessarily a whole lot of similarities in gender (the majority of community volunteer runners are female), weight or BMI.  Why does the organization work while the findings are that positive behaviors are generally easier to encourage/build when we are in similar rather than diverse groups?

I don't have any easy answers.  An obvious answer is self-selection.  The people who choose to run in Back on My Feet (both the men and the community volunteers) have chosen to participate and they know what they are getting themselves into.   The more interesting question is what about incentives or preference formation or constraints or resources suggests that we would do better making positive changes in our health behaviors in groups of individuals more similar to us.  And, on top of that, if we could actually put this fact to use, how would we determine whether it is cost-effective to purposefully form groups of similar individuals?  What if there was simply "open registration" and we didn't get enough of one type of individual--however we might define types?  Should we let people sort themselves or make a conscious effort to engineer certain combinations?

Never any easy answers when it comes to health and health behavior changes.  Most important thing, I think. is to have a goal and to have someone to help you to make yourself accountable for reaching thta goal--whoever it may be.

Consumers seeking information for their health

The Center for Studying Health System Change published an interesting report recently focusing on how much (or how little) people are seeking information about their health aside from asking their physician.  The report also focused on the sources of information, the degree to which different factors influenced the decision making process, and the degree to which the information sought helps individuals in maintaining their health and in deciding on courses of action.

In this age of information--books, magazines, television, the internet, friends, family, formal support groups, patient groups who share information online, etc.--it seems surprising that there would be fewer people seeking outside sources of information.  It may not be surprising that fewer people are looking to books magazines, and newspapers.  It is more surprising to me that the proportion of individuals looking to the internet had not changed very much.

The study also pointed out that individuals with lower education were less likely to seek information and older adults were less likely to see information.  What might that tell us?  Individuals with lower formal education may need the information more.  Individuals with lower formal education may be less able to use the information.  They may have less knowledge of where to find the information.  But with the availability of information is not clear why the quantity of information demanded (if we assume that individuals who are demanding information demand about the same and we are simply seeing fewer individuals accessing information) would have gone down.  Does it mean greater trust of physicians?  Does it mean that those with lower education (and possibly lower income) feel that they have fewer choices in the current economic environment and don't see the value in gaining information if they lack choice?  Does it mean that individuals with lower education (and possibly lower income) are simply worried about things other than their health care in the current economic environment?

For older adults, it is even more interesting to ask why they, as a group, are not engaging in information gathering.  Are they uncomfortable with new sources of information?  As the number of chronic conditions grows do people fell they are less able to make sense of information when there are multiple views?

No simple answers--and no simple ways of figuring out what to do about it.  Do we trust that if people wanted more information they would get it?  Do we try to provide more information?  Do we try to provide more education so that people will understand the information provided in the first place?  And what is the cost and the effect of such efforts?  Of all the ways that we might improve the health of the population, how does getting people more information rank compared with other alternatives?

Falls and injuries

Here is a link to an interesting story about loss of balance, falls, and injuries that can cost an average of $18,000: http://www.washingtonpost.com/national/health-science/consumer-reports-loss-of-balance-leaves-many-older-people-injured-in-falls/2011/09/16/gIQAEhCphN_story.html.

This is not something for which I have a whole lot of answers.  It is just important to realize what can affect falls.  As the quote in the article mentions there can be disease and specific treatments for diseases that have an influence on balance and falls.

As an economist, I wonder what influences a person's decision as to whether the try to prevent specific chronic conditions that may lead to a loss of balance, how individuals make decisions about treatments for these conditions, and how individuals make decisions about whether to adhere to the treatments.  In each case, an individual faces tradeoffs that are important to understand from an economic decision making point of view.  And in each case, the individual (with the help of their clinician) may have difficulty understanding the issues faced.

I also think about population level cost-effectiveness questions.  Especially when it comes to issues like whether or not promoting or funding yoga or Tai Chi classes is cost-effective.  Some evidence suggests that it may be.  But I think we have a lot to go.

As our population continues to have more chronic conditions with more treatments for more older people, we will be asking a lot more questions like these.

Distraction

Yesterday, I ran in the Third Annual Heather Hurd 5K. At the Harford Community College, the morning was crisp and beautiful—just right for a 5K run.  I haven’t seen my official time, but I think I ran 20:29 and placed second overall.  That was a lot of fun.  I’d been second in age group twice this year, but I haven’t been second in a run in a very long time. 

This run is organized by Heather Hurd’s parents.  Heather was the victim of  a distracted driver.  Her parents have also lobbied around the country to have stricter laws passed against distracted driving.  Our law in Maryland changed on October 1, thanks to the Hurds.  Making sure not to send texts while driving is something that most people agree on.  Making sure not to read emails or texts while driving is a foreign concept to many.  As I have shared information about my run with others, I have realized that many people didn’t even know about the law.  This law seems difficult to enforce, but it is now a primary offense with a $70 fine for the first offense and a higher fine ($110) the second time. 

As I think about this law, I have had to think hard about

1. (1) How to break myself of habits that would violate the law
2. (2) How much I appreciate the law as a runner/walker
3. (3) The importance of runners/walkers following similar rules

In thinking about how to break myself of the habit of reading emails while stopped (and occasionally while driving), I have now made a personal commitment to put my cell phone either in my glove compartment or even in my backpack while I drive.  Otherwise, I think that accessing it would be too tempting.  And, if I am going to run a 5K to raise awareness and hope that others will follow it, I should make sure to follow it myself.

In thinking about how I appreciate this law because as a runner, I have had several “too close for comfort” encounters with cars in the past two and one-half years of serious running.  Distracted driving can be dangerous for the drivers of the cars in which the distraction occurs, nearby pedestrians, and nearby drivers.

Finally, it is also critical for pedestrians and runners to abide by similar rules.  We have not outlawed distracted running and walking, but distracted pedestrians can be just as dangerous to themselves (and at least indirectly to others) by their actions as cars try to maneuver around them.

To extend it a bit further, also note that distractions from any task can make completing the task slower, harder, and produce less quality.  Perhaps avoiding distraction is an argument against multi-tasking in general.

Getting back to the focus on distracted driving, I realize that waiting 25 minutes (my normal commute time) to check emails again is not likely to cause anything to be late.  I sometimes feel the need to be productive in general, or to work or to be connected 24/7.  As I think about it, I can use all 24/7 of my life to be productive without having to be connected and responsive all 24/7.  Separating connection and productivity is critical moving forward.  Knowing how to balance them (and balance all the things that motivate me to even think about multi-tasking) is also key.

Interesting Study on Size and Status

Last week, the Johns Hopkins Bloomberg School of Public Health newsfeed pointed to an interesting column that was featured on the New York Times website.  The column is about how people associate the size of food portions with status.  The thought is that food is one thing that people have some control over so that when they are feeling otherwise powerless, they turn to eating bigger portions to gain some sense of power.

A couple of questions to ponder:

(1) Is this basic human nature or is it a part of American (or perhaps, more broadly, Western) culture?

(2) Is this something that can be changed?  The article suggests that it may be possible to change the perception of what holds status.

(3) Why is the size of the portion in our utility function at all?  In theory, wouldn't a rational utility function be based on satisfaction of biological needs?  Or is the fact that we have minds that can think and feel and experience emotion something that makes us so different and pushes us to include things in our utility functions other than just biological satisfaction?

(4) How expensive would it be to change the perception of what holds value at a societal level?  And, could it be cost-effective despite that expense given the large economic burden of obesity and related conditions?

(5) What is it that those who already feel in power actually seem to have very different  preferences--focusing on minimalism in a variety of ways?  Is it that power shapes preferences or preferences lead to power?  Or could it vary depending on where a person starts in life?

All of these issues could suggest something to us about how to approach trying to change the epidemic of obesity in the United States or could simply suggest how difficult the task of change is likely to be.

Medicare Premiums for 2012

An article was published in the New York Times last week indicating that premiums for Medicare Part B would be increasing by less than expected next year.  In fact, the premiums for Part B coverage would be going up by only $3.50 to $99.90 rather than the additional $6.70 up to an expected total of $106.60.  The article states that "Administration officials said the smaller increase showed their prudent management of the program..."  All I can say to that is maybe.

What else could be the cause?

Well, basic human behavior.  Premiums are a function of the probability of something happening to trigger a claim and the amount of the claim.  The amount of the claim the result of a basic demand relationship.  At the out of pocket price faced by individuals, what is the quantity of a particular service that they will choose to consumer to maximize their utility.  That is a function of preferences, health status, and income.

As you can see, a lot of things affect the premium other than just the cost saving plans put in place by the administration.  Without more data from a rigorous analysis it would be impossible to determine whether the cost saving measures imposed by the administration are truly the cause of smaller increases than expected.

And, even if they are the cause of smaller increases, we have to ask "what, if anything, is being given up?"  If we were to perform a cost-effectiveness analysis of the administrations plans would we find that we are spending less while getting equal or better health outcomes?  Or would we find, in contrast, that the health outcomes are worse?  And if they were worse, would we then find that they were just a little worse?  And, if we contrast this with the money saved (or at least not as much being spent) it would be acceptable.  Or would we find that the health care outcomes are sufficiently worse than expected that we would not feel we are getting a good deal on the savings.

In other words--what is the true root of the savings and is the health of our Medicare population suffering or not?  I would want a lot more data before concluding that what seems like sensible and favorable results of policy are as rosy as this article suggests is possible.

Mammograms

There was an interesting piece in the New York Times yesterday about mammograms (http://well.blogs.nytimes.com/2011/10/24/mammograms-role-as-savior-is-tested/?ref=health).  A key question for public health experts to address is what proportion of women who obtained a screening mammogram and for whom the screening mammogram detected the cancer had their clinical outcome changed by the detection.

Why wouldn't the clinical outcome be changed by detection?  The article states it quite well. Some cancers never would have amounted to anything.  They are very small growths that never would cause a problem. Yet, once they are detected on a mammogram, they are treated.  This is actually referred to as "overdiagnosis".

A second group is so aggressive that they can't be stopped.

A third group is more aggressive than the overdiagnosed group but not so aggressive that the screening really did anything.

It is described in the article as "only those that are aggressive enough to be potentially dangerous but that are found at just the right time to stop them from being dangerous" actually have their clinical course changed.

A difficulty is that we can't always tell which is which when the screening first occurs.  This does suggest that we use a lot of resources for (and have a lot of concerns about) mammograms that don't always live up to the expectations that patients have.

It creates an interesting set of resource-related questions.

Healthy Foods and Walmart

There is an interesting article in the New York Times today that talks about some new strategies on food sales that will be adopted by Walmart.  Walmart's stated goal is to work the improve the public's health after discussions with Michelle Obama.  What is Walmart's underlying goal?  I suspect that the underlying goal has not changed: maximize profits.

In light of that, we can use economics to evaluate the decisions that it has made.  First, it plans to reduce the price of more healthy foods.  What does this tell us?  Well, it may tell us that they are not pricing different types of foods to maximize profits at present.  That is not likely.  However, reduced prices can be associated with increased profits if there ius also a shift in the demand curve.  Walmart can lower the price and market the health foods to shift the demand curve and to make sure that the profits go up even after spending money on marketing.  Firms that are operating at a profit maximizing price cannot change price and expect to increase profits without also influencing the demand in some way.

Walmart has also said that change the recipes for its house brand products to reduce salt, sugar, and fat, and that it will pressure other food suppliers from which it buys to do the same.  If the threat is to keep the products that do not change off the shelves, then this may make a real difference.  It is similar to the way in medical care that large insurers can influence pharmaceutical companies by threatening to keep a product off a formulary.  When a retailer that buys a manufacturer's goods to sell can exclude the manufacturer from  a large share of the market, the retailer can exert a large amount of control over the manufacturer.  Thus, Walmart can use its power as the largest grocery seller to influence the market for food manufacturers.

This interesting interplay is a great example of how profit motivated firms can be influenced to do things for the good of consumers,  Some may argue that consumers should still have the right to purchase as unhealthy products as they would like.  For them, these changes may not be viewed as favorably.