An article published in the Journal of Sports Medicine and Physical Fitness and discussed in a Washington Post blog suggests that students who are more physically fit get better grades.  The article is quick to point out the better grades are not necessarily causally linked with physical fitness.  Let's consider why they may not be causally linked but also consider the impact on cost-effectiveness analyses of physical fitness interventions if the causal link is real.

First, why may they not be causally linked? Among adults, it is quite possible that those who are more physically fit have more "self-determination" or "drive" or a greater sense of "self-efficacy" in general. If true, that could imply that those who are more likely to take the time to become physically fit or maintain their physical fitness are also more likely to succeed in other areas.  Among students it could mean that those whose parents encourage doing well in school also encourage doing well in other things and also take the time to monitor and manage their children's physical well-being very closely.  So, there are plenty of reasons that these two concepts may be correlated but the relationship may not be causal.

But suppose for a moment, that the relationship is causal. Suppose that being more physically fit makes a person better able to concentrate and maintain their concentration.  Suppose that being more physically fit enables a person to learn better if they are also more socially and mentally healthy as well as physically healthy.  There are lots of possibilities here.  What, then, would we need to do to fully appreciate the value of physical fitness programs?

First, we would need to make sure that to the degree that improved physical fitness enhances fitness in other domains of health, this is recognized and incorporated into the results. In other words, the health related quality of life impacts of physical fitness may go well beyond making someone just more vital or decreasing obesity or the eventual risk od diabetes and other complications of a lack of fitness.

Second, we would need to establish a link as to how much fitness improves grades (or learning more generally) and how that translates into a person being more productive and what the economic value of that productivity might be.  In fact, the productivity could also have an impact on physical and mental health later in life.  So, the relationship could actually be part of a favorable feedback loop that could have a large economic value throughout life.  Failing to capture this feedback loop in any long term predictions of the impact of a childhood fitness campaign could great understate the campaign's value.

Of course, we have plenty of money being spent on fitness for kids already.  Perhaps we do not need more.  But as we continue to consider how to use the limited public dollars for both health and education, we might want to consider how these two interact and efficiencies that can be gained from thinking about the two together.  Failing to do so may lead to inefficient resource allocation.  But doing so is certainly no simple matter.  And going so will require more data and a fairly sophisticated modeling exercise to incorporate all the possible effects of fitness on education and vice versa.   

Cost-Effectiveness of Preventing Complications of Childbirth

Back on December 10, the Wall Street Journal had an article on the increasing incidence of complications at childbirth and commented on this could be related to the increase in age of the mother in many cases, obesity, and mothers having other chronic conditions.  Although the article was quick to point out that complications were not confined only to women with complicated health of their own and that otherwise perfectly healthy mothers could also have severe complications.

The article also pointed out that most safe birth initiatives in the past had focused on preventing harm to the infant.

What is interesting about this from a cost-effectiveness perspective is the question of whose benefits are counted.  In general, when it comes to birth we should count both the mother and the child.  And, not only would we want to count each of them, but we might also want to find a way to recognize that their health is closely intertwined.  For example, a mother losing a child could have a long-term effect on the mother's mental health.  And, if it affects her mental health it could also have an impact on her physical health.  The same might be said of an infant losing her mother.

When we see sophisticated cost-effectiveness analyses that calculate and use quality adjusted life years, we find that usually this focuses on a single target group.  In this case the mothers (if we are focusing on preventing or dealing with complications of birth) or the children (if we are focusing on the child's health immediately after delivery).  What we rarely see in the literature is the combination of the two.  And what we see even more rarely would be an explicit recognition of how the two are not just correlated but so closely interrelated.  A loss of health related quality of life or life years for one member of the mother-child pair is likely to have a critical impact on the other.  This is an interesting frontier to think about and to consider how acknowledging the impact on both members of a pair might make specific interventions looks like a better value as the impact is increased by considering the effects on two individuals.   

Looking at Statistics in Isolation Can Lead to the Wrong Conclusions

One aspect of public health is violence.  For example, at the Johns Hopkins Bloomberg School of Public Health we have a Center for Gun Policy and Research.  And, recently, there has been a lot of violence in the local news.  That, of course, is on top of numerous stories about gun violence nationally and internationally over the past several years.  So, it may seem like we should be looking for more ways to incentivize against violence and to find cost-effective solutions to preventing gun violence in particular and all types of violence in general.

In contrast, if we looked at the fact that the rate homicides appears to be going down, we might wonder, "Well, is there a problem with our perception of violence?  Maybe it is just lots of anecdotes and we don't need to look for more solutions or allocate more resources."

A piece in the Wall Street Journal recently entitled "In Medical Triumph, Homicides Fall Despite Soaring Gun Violence," (which is not available for free) they looked at this issue.  What the article reported on was an improvement in the survival after being shot in recent years.

Now, we could ask whether heroic treatment after gunshot wounds is cost-effective.  It is definitely expensive.  The trauma centers that have been set up to treat such patients (and that contribute to the much higher survival rate) have high fixed costs and high variable costs.  The WSJ article indicates that they deal with a great amount of uncompensated care in our current system and are reported to lead to losses for the hospitals at which they are located.  Thus, the demand for resources from society and resources that are taken away from the hospital are notable.  Importantly, I am not saying that we should not be saving lives.  Only that we need to be cognizant of the costs of saving the life and cognizant of the additional costs during any rehabilitation phase afterwards.

Then, once we are aware of the costs, we might ask whether the medical triumph is the most economically favorable way to decrease deaths from guns or whether we might be better off economically by trying to limit gun violence as a way to limit deaths rather than needing to treat those who do suffer gunshot wounds.

The contrasting inferences one might make based on different pieces of the data and even the contrasting steps one might take in structuring a cost-effectiveness analysis (e.g., comparing only prevention methods or only treatment methods or treatment with prevention) illustrate how important it is to try to assemble all relevant data before making a decision on further resource allocation and the need for and usefulness of economic evaluations.  

Pharmaceutical Cost-Effectiveness and Diet

I saw an interesting short piece in the Washington Post discussing the discovery that the number of drugs with important interactions with grapefruit has increased substantially since an initial report on the matter 20 years ago and particularly since 2008.

I will refer interested readers to the article for the details, but the short description of the issue is that grapefruit (but not all citrus fruit and not regular oranges) contain a chemical that interacts with some pharmaceutical products and substantially increases the bioavailability of the product.  In this case, more is not necessarily better.  In fact, more can be toxic, particularly to the kidneys.

This raises an interesting question that was probably not considered when any cost-effectiveness analysis related to the drugs is conducted.  Essentially, how does the cost-effectiveness change when you have this type of potential interaction.  It is not a typical drug-drug interaction.  It is not an adverse event due solely to the drug.  It is an event that is purely avoidable by properly reading the packaging or listening to a physician or pharmacist and then following up on what a person has been told.  Sounds simple enough.

I suppose if people were constantly have drug-grapefruit interactions, it would make the news and we would all become aware.  It is probably in the category of "things that sound scary but really are pretty rare" even though an article without additional information about the incidence of such events may make it sound very scary.

If this were a big issue, it would not seem too hard to provide better education at a fairly low cost and prevent events. If it is not a big issue, then while the increasing number of drugs that have this characteristic is interesting but probably not worth more than the short article that I saw.  I'd be intrigued to know more--such as whether anyone has personal knowledge of this issue for themselves or someone they know.

It does point to a larger issue of how we might evaluate the economic importance of better counseling about the interaction between drugs and diet more generally.  

Changing Medical Practice

In today's newsfeed from the Johns Hopkins Bloomberg School of Public Health there is a link to a blog entry about a study that asked medical care leaders why studies that seem to provide strong evidence of the relative effectiveness make such a small impact on the practice of medicine.  THe blog entry can be found here.

A key message from this blog entry seems to be--because the incentives don't point in the direction of adopting things that are less expensive.  The examples of studies with little impact tended to be things that would cost less money than the current approach to care.

We all hear from political leaders that we, in the United States, are spending too much on medical care.  We hear the same thing from business leaders.  We hear very similar things from insurance companies.  And, many individuals chime in with the same type of comment.

What we forget is two groups who aren't complaining--those who make the pharmaceutical products and devices on which we spend so much money and the physicians who prescribe their use.  Even with everyone else calling for reducing expenditures, the manufacturers do not have a strong incentive to save money.  The system right now pays in a way that bears at least some relationship to what is charged.  As such, companies that manufacture more expensive products that can be sold at a higher margin make more profits.

Physicians have only limited time to sort through the literature and to decide how to change their practice.  They listen to the way things are presented by manufacturers.  And they do not, at present, have to respond to incentives to provide care at a lower cost.

This is why I worry so much about the perspective of the cost-effectiveness or comparative effectiveness analyses.  The cost savings come from the societal perspective.  They may even characterize numerous other perspectives.  However, when all is said and done, if the economics don't work for the manufacturers and providers, change is unlikely to occur.  And, in a poor use of scarce resources, the manufacturer will spend money marketing (i.e., trying to convince people) that their products should continue to be used despite evidence to the contrary.

Unfortunately, that does not characterize an efficient system.  And changing the incentives in the first place may be much harder than changing practice patterns at any point.    

Flu Shots

First, an admission.  I have done research on flu shots.  I have helped a student of mine write a dissertation on the timing of flu shots.  However, neither I nor anyone in my family has ever had a flu shot.  Why was that our health economic decision?  We have never thought that the risk was all that large and we have never felt that the time costs were sufficiently low (even with minimal monetary costs) to warrant getting flu shots.

Now, to share an interesting piece of information.  In yesterday's Johns Hopkins Bloomberg School of Public Health news feed there was a link to a piece about a report on flu shot effectiveness.  The report that the blog had written about concluded that there was surprisingly little randomized trial evidence (the gold standard) of the effectiveness of flu shots--for almost any population and even for preventing excess transmission in hospital settings when hospital workers get vaccinated.  The blog points out the history of how we ended up with influenza vaccination being recommended for the older adult population and how difficult it would be to ever go back and rethink policy.  In short, the Surgeon General in 1960 made the recommendation and ever since then it has been considered unethical to withhold a recommended vaccine.  The author of the linked blog entry calls flu shots a sales job.

Here is where economics and ethics may come together.  Maybe if we could realize how many resources we may be over-utilizing, we could ask how it could be ethical to continue to use the resources without asking if it is efficient.  In other words, is a known inefficiency unethical?  Is a potential inefficiency unethical?  Is acting like a supposition is fact without high quality data on the facts unethical?  In any case, this would require some consultation with bioethicists and likely a new cost-effectiveness study based on the latest report showing the lack of data on the effectiveness of flu shots.  Then we could use that to motivate a new study.

It is not a common use of a cost-effectiveness study but it would be extremely useful in this case.   

Patients "Google" and Get More Out of Visits

Here is an interesting news piece about a study of patients "googling' to get information about their conditions before they go to a general practitioner and then feeling a set of more positive feelings about the experience of the visit with the general practitioner.

At first glance, I might have thought that patients googling would not help patient/provider relationships.  My intuition may have been that the process of obtaining information from the world wide web would have been seen as a substitute for positive patient/general practitioner interaction.  Instead, it seems to be complementary to and encouraging of positive interaction.

Patients have a choice--go to the general practitioner, invest their time in conversation with the GP, and come away with an experience that will guide their future health and well-being.  Alternatively, they can spend time before the visit gathering information (a use of a scarce resource), then engage in conversation with the general practitioner.  While my intuition may have been to think that patients would use the information as a substitute for interaction with the general practitioner.  What seems to happen is that the patients are taking the information and using the information to strengthen their interaction with their general practitioner.

This suggests that at least some patients see the value of the improved interaction with the physician as being more than the value of the time that it takes to search for information on the internet.  This suggests that the value of improved interaction must be substantial.

Of course, this is not just a patient issue. It is also a physician issue.  The physicians must believe that the information that patients bring to them is useful and does not interfere with the interaction.

The information from this new study may help patients and providers to plan better for more effective and more efficient interaction in the future.  

Obesity and the Public Interest

I am teaching a course on Coursera called "Principles of Obesity Economics" which is a mini-version of the online course that I typically teach at the Johns Hopkins School of Public Health each summer that is called "Obesity Economics".  The course has only been going for a day, but the preparation for it has actually demonstrated that as far as the "production of education" is concerned, there are interesting economies of scope from needing to prepare materials that are not interchangeable but that can be used with some variation in multiple settings.  But that is not the main point I want to make today.

When I typed in "Obesity Economics" as a search in google, I saw that several things with which my teaching is concerned and a blog entry at The Economist magazine.   In this entry, the author, discusses why American politics and culture makes it unlikely (in the author's opinion) that the United States will do anything that makes a serious impact on obesity in the next several decades.

That is an interesting conclusion in light of how much this gets talked about all the time.

The author concludes that the focus on individual rights to make decisions in their own self-interest and to focus only on their self-interest leads to high levels of obesity.  That is an interesting interpretation.  I am not sure I agree that this is the exact answer, but it is worth thinking about whether, from an economic perspective, there is reason to think that this might actually be the case.

Individual self-interest means that individuals maximize their own utility.  No one that I know wants to be obese.  Some people are more willing to accept it than others.  But does that necessarily mean that obesity should increase as much as it does.  That would suppose that people make poor decisions. Or that people don't have enough information to make decisions.  Or that people are given wrong information to make decisions.    Or that people don't look forward enough when making decisions.  Each of these might involve a government intervention.  Very little would necessarily need to be changed in terms of leaving individuals witha high degree of free choice of what they want to eat and when and how they want to use their energy and when.  Perhaps we could think a little harder about regulating business.  And perhaps that is truly the issue. Perhaps we do not need to be regulating or incentivizing individual behavior (although for all of America's focus on individual rights we still tend to think that we should not have to pay all of our own medical care costs so the responsibilities that come along with those rights don't necessarily seem to be taken as strongly). Perhaps we should regulate business more.  Although that does not seem to be a large part of American culture either.  And that may be the just as important a rate limiting factor to achieving goals having to do with weight control in the United States.

We would still have to justify it with a compelling public need or an example of a market failure, but the point of whom to target and how carefully to target them would seem to remain an open question.  

Hospitals Providing Formula

There is an interesting piece in the New York Times about hospitals ending the practice of sending formula home with mothers who are breastfeeding or ending the practice of sending mothers at home with formula at all.  There are a number of interesting economic questions here.

First, what is the role of a sample of formula in determining infant feeding practices.  This is particularly relevant for mothers who have decided to breastfeed at first.  On the one hand, it makes access to formula easier.  Less time required to obtain the first amount of formula that a mother will use to feed a child.  A lower price (zero beyond the hospital costs) than if the sample was not provided.  So, there is an economic logic to the idea that this might change mothers' behavior with respect to how they choose to feed their children.  Perhaps for any mothers who were truly at the margin about their decision to breastfeed, their decision might change.  Or, at the very least, their decision to stop breastfeeding might change to an earlier time than they had otherwise planned if the cost of switching to formula feeding is made lower than it would have been otherwise.

Even if the mother continues to breastfeed, one question would be how to measure the value of having the option of formula feeding readily available.  At least some mothers may assign a value to this even if they never choose to formula feed.  

Second, there is the question about whether it is acceptable to send formula home with mothers who are already formula feeding.  This does not seem like a question of promoting behavior change in this case.  Instead, the issue here is what brand the mother will choose.  Does the mother perceive the type of formula offered as an endorsement from the hospital.  In this case, is the hospital playing a role in essentially marketing a specific type of formula to the mothers.  If they are, is this a reasonable role for the hospital to play?

The biggest question overall may be whether the hospital has a role to play in shaping mothers' behavior rather than letting the mother make a choice for herself with the information she has available.  The hospital arguably has a role in providing information and helping the mother understand tradeoffs that she might need to make but what there is beyond that is uncertain.   

Non-Sedentary Economics

This week a study appeared on sedentary behavior and life expectancy.  The conclusions are that if sitting could be limited to less than 3 hours per day and watching television could be limited to less than 2 hours per day the life expectancy would increase.  The results were based on a meta-analysis, i.e, a study combining results from other studies, of five studies where people were asked about their behaviors like sitting and watching TV and then followed for some amount of time with mortality as an outcome.

A few thoughts on this issue.  First, the studies were not all US studies.  Is there reason to suspect that the effects of a sedentary lifestyle may not be the same everywhere?  Perhaps.  It may depend on the entire range of activities an individual undertakes.

Second, it is not clear whether the studies tested for any interaction terms.  The results have been interpreted as meaning that even people who exercise regularly are at risk if they also sit a lot or watch TV a lot.  The effects seem to be independent.  But what about a person who exercises regularly (perhaps even pretty hard) and also sits a lot.  Take myself.  Does running 25-45 miles per week (there is a lof of variation in my schedule depending on the temperatures, travel, vacation, work intensity, etc.) while sitting easily 8 hours a day at work, make a difference.  Perhaps the running has an independent effect (I sure hope it does). But do the two interact in more complex ways that are difficult to capture?  And how does sitting and working on a computer compare with watching TV? Or is watching different because one's body is more completely relaxed?  And what about those who multi-task rather than just "vegging out" in front of the TV?

Regardless of the study's limitations, (and the authors are up front about a number of others and no study is perfect), what if we take the results at face value?  First, is there a government role?  Is there a market failure for activity?  Is there a market failure with respect to TV watching?  Or are these just choices that people make that they should be allowed to make?  And what if people with jobs that are largely desk jobs want to change their behaviors?  what options do they have?  Is there any way to facilitate these individuals being productive while not sitting at work?  Is there suddenly going to be more of a market for the standing work desks?  And, if so, whose responsibility will it be to buy them?  The employer?  The employee?  Is there a place for government intervention here?


In the end, for me personally, there are a lot of tradeoffs and a lot of possible behaviors.  No easy answers. I'll just take my chances that my combination of activities, job responsibilities, food choices, and sleep quantities is right for me.  I suppose that is all most economists suggest--that people understand their choices, understand the implications of their choices, and are left as free as possible to make them.   

Income Inequality and Health

Some researchers hypothesize that there is a relationship between income inequality and health. The hypothesis suggests that in countries with less income inequality health outcomes will be better. This can provide an argument in favor of income redistribution from upper income individuals to lower income individuals. One interpretation would be higher taxes on higher income individuals with some type of extra support/benefits for lower income individuals.

Many of the studies that have supported this hypothesis have focused on cross-sectional data from multiple countries. One concern that other researchers raise is that when using this type of data, the countries with a great degree of income inequality also have more generous social support programs. In this case, it may not be the lower income inequality that actually results in better health outcomes. Instead, the argument may be in favor of more generous social programs--however we may find the resources for such programs Understanding what is only a correlation and contrasting that with causation is key.

One way to re-assess this question is to use panel data. A recent study by Dr. Mauricio Avendano at the London School of Economics tests this hypothesis. He used data over a number of years from the Organization on Economic Cooperation and Development (OECD). The data are advantageous for addressing the research question of interest to Dr. Avendano as he can look at how changes in income inequality over time within a country leads to any changes. He focused on infant mortality data. He did not find a strong relationship between income inequality and infant mortality.

So, does this completely rule out the possibility that programs leading to less income inequality will benefit health? No. But it does suggest that we should look harder for alternative hypotheses to explain what has been observed in cross sectional data and use this information to motivate policy. Policy that is based on correlations rather than causation is not likely to be efficient policy.

As with medicine, our focus in developing policies with respect to the economy and public health should be evidence based. This is simply one more study that suggests that the evidence to support specific programs that explicitly are aimed at reducing income inequality is not there. To clarify--it may be that the only way to find resources for more generous support programs would be to impose higher taxes on higher income individuals. That could result in less inequality in income that can be consumed. The key to the interpretation of Dr. Avendaon's finding is that while we could argue that reducing the income of high income individuals by a relatively small amount should not hurt them much while giving more resources to those with lower incomes should benefit them a lot may be true, there is nothing specifically about reducing income inequality itself that leads to better outcomes.

"My Disease Cost More Than Yours": It Really Depends on What is Counted

In the world of those who advocate for individuals who have a particular disease or condition, one thing that is often discussed is how much a disease costs.  In my casual observation as a scientist working with advocates, sometimes it seems like we get into a discusion of "My disease is bigger than your disease!"  Or, more appropriately, "My disease costs more than your disease and therefore deserves more attention."  Not quite like a schoolyard brawl. But definitely a sense of trying to get some attention based on the magnitude of the impact.

How do we measure the magnitude of the impact?  We often talk about direct costs (or how much we spend on medical care) and indirect costs (or measures having to do with productivity).  Sometimes, it is hard enough to measure the direct costs.  Who pays what?  How do we know how much they pay? IIs that is paid what it really costs?  How does the system (in the US or elsewhere) help to make it clear whether there is much of a relationship between what is paid and what it costs?

But that is the easy side.  Measuring lost productivity is even more complicated.  A key question that has been debated in the health economics community is whether to measure the value of the individual's time and the concept of potential productivity (often referred to as the "human capital approach") or whether to measure just the productivity lost by the firm (referred to as the "friction cost approach").

The conceptual model has been discussed in the literature extensively, but there is limited literature comparing estimates using the two approaches for the same disease with the same population.  A recent study by Paul Hanly and colleagues compared the estimates of the productivity cost of breast and prostate cancer using the two approaches.

It is at this point that we see that the numbers that are used by advocates greatly depend on what is being counted.  When counting all productivity costs over a lifetime, breast cancer has a far higher impact per person in Ireland than prostate cancer.  The breast cancer cases are younger, are likely earning more, and live longer with the impact of cancer.  However, with the friction cost approach, the two conditions are responsible for nearly identical productivity losses with prostate cancer having a slightly higher value.

In both cases, the wage is used rather than total compensation.  Total compensation includes things like employer sponsored health insurance premiums, payments to retirement accounts by the employer, etc.  Perhaps these are not issues in Ireland in the same way that they are in the United States, but they do need to be considered.

The next time you see that a given disease is costing a given country some enormous number of billions of dollars per year, be careful to stop and think "what is being counted," what should be counted, and how should we count it?  I find that I'm not ever sure of the answer to the last question.  And while the answer to the first one should be clear from reading a well-written scientific article, it may not be clear from reading a popular press interpretation.  Finally, the answer to the middle question may well depend on the policy context.  Let the user of results beware.  

Response Rates of Emergency Medical Services and Mortality

A recently published article looks at the association between reduced emergency medical system (EMS) response time and the mortality outcomes of patients.  You may be asking, "Well, why does it take a study to show that?"  It would seem logical and intuitive that faster response times are associated with better outcomes.  Many municipalities and others responsible for local EMS units have spent quite a bit of time and money trying to minimize response times.  If they did not lead to better outcomes why would we be doing such a thing?

In fact, there are many things in medical care where what is intuitive is what is done and there is not a strong evidence base to support the action.  There are many in the system who are trying to change this and move us to a more "evidence-based" medicine approach, but it takes a while.

How did this study address the question in a novel manner?  Sometimes, randomized trials are appropriate.  In this case it would be completely unethical to make it take longer to respond to some people at random.  The approach used is describe in the study's abstract which can be found here.  The author, Dr. Elizabeth Wilde, points out that some studies focusing on cardiac events have shown the expected relationship but that there was little evidence outside cardiac events and what evidence there was outside cardiac events suggested no relationship.  Why might there be no relationship when the data are analyzed?  That requires us to think about incentives and to think about who knows what.  If the caller indicates a dire emergency the dispatcher can (and has an incentive to) communicate this to the EMS unit.  This is a form of triage.  The researcher working with the data later has not idea how the dispatcher communicated with the EMS unit.  So, if the dispatcher consistently triages cases in ways that make the response times for more dire cases shorter, then those cases may do better than they would otherwise.  But if the original mortality rate for those cases was high, making it a little lower will just make it similar to the mortality rate for the ess severe cases that take longer.  Then, there will be no apparent relationship between the  time of response and the morality outcomes.

Dr. Wilde found a way to use some other data--the distance from the location of the person who called for EMS services to the nearest EMS unit--as a proxy for the response time.  People have used this type of proxy (or to use the technical term, instrumental) variable before--to show things like the effectiveness of more intense treatment for heart attacks. In that case, there was a similar concern about the severity of the condition being observable to the medical care provider but not the researcher.

In the end, Dr. Wilde found that a one minute increase in response time was associated with an 8% mortality increase one day after the incident and a 17% mortality increase 90 days after the incident.

So, now we have an evidence base for efforts to improve response time.  What is the most appropriate way to do that?  That is a separate economic, political, and normative question.  It could involve technology of locating individuals.  It could involve technology for traffic control?  It could involve enforcement of traffic rules.  Or it could involve a change in norms where people are more aware of the true costs of not moving out of the way of EMS vehicles as quickly as possible.

Regardless, the study by Dr. Wilde shows that every minute can be associated with increasing the potential to save more lives.  

Some less well known costs of obesity

I've commented many times on obesity over the past couple of years of writing in this blog space.  Here is a link to a Baltimore Sun piece about some less well known costs of obesity.

The key question is just which portion of these costs get captured in most economic evaluations of efforts to reduce obesity.  And, looking at which appears in the text, just how are we defining obesity.  The text of the article uses the term "mild obesity".  In the most recent reading I'd done on the topic, this was referred to as "overweight but not obese".  Yes, it is all a matter of semantics as it is the same BMI range-more than 25 and less than 30.  (I'm lucky enough to be just under 22.5 and still I try to be careful.)  But labeling does make a difference in how people interpret the information.  All the stuff that we used to say about "stick and stones may break my bones but names will never hurt me"--probably bogus.  Words matter.  Perceptions matter.  Perceptions affect behaviors and behaviors affect people's weight, health, and their notions of whether they can do much about it.

The costs that I have not seen before are things like the cost of extra airline fuel to carry passengers.  I'm not sure whether those numbers are literally just for the passengers' weight or also, presumably, for the extra clothing and perhaps even larger luggage.  Same goes for cars carrying people.  And, even more interestingly, if those change, then what about all the other effects such as how the increasing price of fuel will change the amount of money people have to spend for other things.

We can realistically only trace the effects so far.  The key is that the numbers of dollars and cents may be a bit bigger than we had previously anticipated.  

Medicare's Poor Incentivizing

Today's Johns Hopkins Bloomberg School of Public Health news feed provided a link to an article on what has been described as waste in the Medicare system.  The key is that as part of the health care reform legislation back in 2010, payments to most Medicare managed care plans were cut, but there was an incentive created to make bonus payments to plans that offer high quality care.

The concern now is that that the bonus payments have been given to plans with only mediocre quality care.  The plan has cost more than was intended as the bonuses have gone to many more plans than were expected.  It may seem patently obvious but giving bonuses to a large number of plans with so-so quality will not provide any incentive to provide care at the highest quality level.  That type of incentive might have been given by using the same amount of money (or perhaps even less) to provide a significant bonus to a smaller number of Medicare plans.

The Obama administration claims that it will not cancel the program as it is still expected to help to improve the quality of care being provided.

This is obviously highly questionable, and, if the newspaper story is correct, this is not likely to be a cost-effective way to improve the quality of care.

While the amount of money is small relative to the entire health care or Medicare budget is small, the principle is that making poor use of even small amounts of resources will sooner or later add up to poor uses of large amounts of resources.

Something to think about as we move forward with the implementation (or not) of the health care reform legislation from 2010. 

"Americans Still Not Exercising"

I put the title for this week's blog post in quotes as it is the exact title of the article that you can find by clicking here.  This is a short piece in the Baltimore Sun that came to my attention this morning thanks to the Johns Hopkins Bloomberg School of Public Health News Feed.  The title is pretty self-explanatory and the news "bite" is shorter than this blog entry will be.

First, let's acknowledge one thing.  The survey that says fewer people are active was conducted by...the Sporting Goods Manufacturers Association.  The fact that they have an incentive to tell people they are not sufficiently active so they can sell more goods is not lost on me.

Second, the change in the number of inactive adults over a one year period was a 1.6 percent increase--noticeable but not huge.  What is more noticeable is the 8 percent increase in a three year time period.  The article does not make clear whether that is adjusted for population growth or not, but 8 percent in three years is certainly more than could be accounted for by population growth.

Third, the piece says that Utah is the most active area.  Here, the article makes a distinction between regular exercise and complete non-participation.  I am not sure what it is about Utah, but it seems like a place that has great skiing, moderate temps for part of the year, and a lot of open space.  Since hiking and camping are activities listed, this may help to account for some of this difference.

Fourth, the piece comments that southern states are less active.  I'm not sure that could explain complete non-participation, but I could certainly see regular exercise being an issue for those who don't have a climate controlled place in which they can exercise.

Fifth, the article points out that hiking and camping are growing in popularity.  At least hiking is something that does not necessarily require organization, can be social as well as physical, does not require a gym membership, and can be done with little planning ahead.  It seems like a lot of forces in people's lives might push them toward this type of activity.

Finally, there is also the comment that yoga and boot camp classes are popular.  I don't participate in either regularly but I have done each at different points in time.  I would be very interested to know what brings more people to each of two very different activities.  I don't have a strong hypothesis about this one other than a general trendiness of each.

So, the brief news piece does not have all bad news, but does leave us to wonder what incentives or information could be used to move the 24 percent of US adults labeled as inactive (i.e., no participate in any of 119 possible activities) to do something.

Female Condom Distribution in Washington DC

The chair of the Department of Health Behavior and Society at the Johns Hopkins Bloomberg School of Public Health was a coauthor on a recent study that was featured in an article in the Washington Post.  The program that was funded consisted of the distribution of female condoms and a program to encourage women to feel comfortable talking about sexual health.

This article looks at the number of female condoms that were distributed, assumes the number that were actually used, and projects the number of HIV cases that were prevented.  Then, it used an assumption about the lifetime cost of HIV infection ($367,314) and projected the total savings associated with the program.  The lifetime savings were much greater than the cost of buying the female condoms, distributing them, and running the program to encourage women to feel more comfortable about discussing sexual health.

The analysis seems reasonable.  It is important to consider a few things for the economic implications of the study and what else we might expect to see in the long-run.

(1) Will the cost of female condoms change in the future?  Probably.  Of course there is general price inflation, but the key question is whether the relative price will change.  In general, the cost of items at a specific level of quality generally go down over time.

(2) Will the cost of managing HIV over a lifetime change?  Again, probably.  Here we must consider the combination of general price inflation versus relative inflation and the many changes that occur in the price of pharmaceutical products over time.

(3) Will the distribution of who is paying the medical care costs change over time?  This is rather unpredictable until the court case focusing on the Affordable Care Act is decided.

(4) Does the distribution of who is paying the medical care costs matter?  It probably does.  It was nice to have funds to obtain the female condoms to distribute for free.  However, will this continue?  If it does not is there any way to get those who will benefit from female condom use to pay for the condoms to distribute?  Who benefits?  The women--suggesting that a free market decision might work, although obviously we wouldn't need free distribution if the free market solution already worked.  Insurers--they benefit later.  A local public health department would not benefit as it does not pay for most (or perhaps any) of the care.

(5) Does the distribution of female condoms change people's sexual behavior other than getting at least some of them to use the female condoms?  Some worry that when individuals feel safer in having sex, those individuals will have sex more often with more partners.  Is this true? Perhaps, but not necessarily.

(6) Would simply trying to encourage people to avoid non-monogamous sex work?  Then, there would not be the cost of the condoms themselves and, for those who use the approach successfully, there is no failure.  There is, of course, a risk of failing to stick with it.  Whatever we as individuals may think of non-monogamous sex, evidence suggests this doesn't work.

So, would anything likely change the favorable economic outcome suggested by this analysis?  Probably not enough to change the conclusion that distribution of female condoms seems to save a lot of money at the societal level.  The key, politically, would seem to be to find a way to make sure that there is some way for those being asked to pay for the distribution to benefit from the savings.  

Affordable Care Act

I have not commented on the Affordable Care Act in a while.  With the Supreme Court case right now, I think it is worth commenting on again.

• Yesterday, I saw a public radio program's site asking for comments on mandated health care.  First things first--no one is mandating health care.  What is being mandated if it is considered constitutional is health insurance--that is not the same as health care.
• Just because people have health insurance doesn't mean that they will use care or use it to achieve any higher quality of health care services than they are now.  Yes, they will have reduced financial barriers.  But there are many more barriers that are non-financial.  Anyone who has ever wanted to see a new physician for a non-emergency reason has probably experienced a long wait.  For some people that is not a problem. For others, it might discourage them from seeking care.  And even if a person gets more care it doesn't inherently mean that it will be any more coordinated.
• While there are non-financial barriers, empirical research suggests that people who pay less for care when they need to use it use MORE care.  (In other words, medical care follows the same response to price that almost everything else does.)  Are there some people who will use less care or at least less expensive care because they get preventive care or have a chronic condition managed better and stay out of the hospital?  Of course.  But, at a population level it is quite possible that making care less expensive at the time people need it will end up leading to spending more on health care rather than less.
• I realize that people with pre-existing conditions would like to not have to worry about financing their health care expenditures.  That is true of all of us.  If insurers are no longer allowed to restrict the enrollment of people with pre-existing conditions, individuals with pre-existing conditions will be able to get financial protection that they could not get before. What will that do to premiums?  When individuals who are expected to spend more are added to the risk pool, the premiums will necessarily go up.  Now, that may be offset by health care providers not needing to charge some extra to make up for uninsured individuals, but there is no guarantee.
• Finally, with many more people with insurance who wish to consume a greater quantity of care, that will put more pressure on an already crowded health care system.  Without an increase in care providers, the waits that we already experience will grow longer.

So, is the net result good, bad, or otherwise?  Some people will obtain financial protection who did not have it before.  I am glad that is the case.  If they pay for it directly that will shift at least some of the financial responsibility for care.  There is an argument for fairness in that.  However, there is no guarantee that overall we will pay less as a society, that individuals with insurance will pay lower premiums, or that anyone will get higher quality care in a more timely way than we are now.  

Role of Government in Tanning Salons

As my last entry for my students in the School of Public Health third term course, I'd like them to think about tanning salons.  We are nearing spring with lots of opportunities for outdoor recreation for adults, for children, and for adults watching children (i.e., sports like baseball and lacrosse).  In any case, Idaho is apparently considering restrictions on the use of tanning salons by minors--and not even all the way up to 18, just up to 15.  You can find the story here.

What is interesting from an economist's point of view is the question--why do we need government regulation in this case?  Is it market power?  Probably not.  In most places where tanning salons spring up there are quite a few of them.  Monopolistic competition may be the best description of the market, but it certainly doesn't appear to be a concentrated market.

Is there a lack of information?  Maybe.  But the messages about sunscreen, skin cancer, etc., seem pretty wide spread.  That is true both in the US and Australia where I visited in January.  It seemed like you couldn't go more than one half hour without some type of public service commercial on television focusing on protecting oneself from skin cancer.

Is there a compelling need?  Maybe.  But on what basis?  Is there a disparity?  Is it to protect children?  If it is to protect children how does the government role fit with the parent role?  Why regulate for children and not adults?  Are there less direct measures that might result in a change in the use of tanning salons and now raise so much political controversy in a state that has historically placed a high value on personal freedom?

The question of personal freedom always leads to "freedom to do what?"  And that is a reasonable question.  Freedom to put oneself at risk for something?  If so, who pays for the consequences?  The article mentions motorcycle helmets--again, what is the risk and who pays?  Even for my beloved sport of running...if I put myself at risk for injury who should pay if I get injured?  What is the role of insurance--where those enrolled share risk--when people have some control over their own risk?  For example with running--what is the net risk?  Presumably lower for any disease related to cardiovascular health over time but a lot higher for sports-related injuries than my sedentary colleagues.  How shoudl we price that and at what level should we price it?  Me?  My employer?  Some other group?

There are no easy answers here--as usual.

Final question--the article comments on winners and losers from a policy like this.  Perhaps some entrepreneurs who expected to make more money on tanning salons are financial losers.  Perhaps younger teens who want use the tanning beds are "utility" losers.  But who would gain from this regulation--other than parents and public health experts with the utility of knowing their kids are at less risk (and there may even be some parents who agree with their teens' use of tanning salons).  Does anyone gain financially? 

Maryland State Law and CAM Providers

I am lucky enough to be able to afford to be treated by a massage therapist either before or after each REALLY long race that I run. (For me, I classify anything longer than a half marathon as a REALLY long race.) My practitioner brought the Maryland 2012 HB0238 and SB0337 to my attention. These are laws that involve the Nursing Board and who needs to be licensed. The synopsis of the bill on the state House website reads:

Exempting individuals who provide gratuitous care for specified individuals from the requirement that an individual must be licensed or certified before practicing specified health occupations; exempting individuals who respond to a disaster situation in the State from the requirement that an individual must be licensed before practicing registered nursing or licensed practical nursing under specified circumstances; authorizing the Board to grant specified licenses by endorsement; etc.

That seems to focus on exceptions to the rule of being licensed.

My practitioner is concerned about the language that refers to the licensed practical nurses. The language reads that a practitioner

"...in a team relationship an act that requires specialized knowledge, judgment, and skill based on principles of biological, physiological, behavioral, or sociological science to:

(1) Administer treatment or medication to an individual;

(2) Aid in the rehabilitation of an individual;

(3) Promote preventive measures in community health;

(4) Give counsel to an individual;

(5) Safeguard life and health;

(6) Teach or supervise; ..."

Now, these are specifically applied to licensed practical nurses in the language of the bill. However, practitioners like "breathworkers, midwives, doulas, herbalists, life coaches, sound/music therapists, art and poetry therapists, movement, dance, and eurythmy therapists, samyama healing practitioners, meditation teachers, acupuncturists, massage therapists, bodyworkers (reiki, zero balancing, rolfing, etc.) yoga therapists, ayurvedic consultants, counselors and other practitioners of alternative healing arts" might be interpreted as falling under this regulation and then be required to get new licensing that is controlled by the Nursing Board.

I don't know whether there is a hidden underlying intent here. However, consider the following:

(A) a history of conflict among health professions when it comes to scope of practice and control;

(B) an increasing number of nurse practitioners who have to compete for patients;

(C) people having to struggle with insurance and pay more out of pocket despite health care reform; and

(D) a growing number of non-medical providers interested in health and well being.

I think there might be an incentive for nurses (perhaps in collaboration with physicians) to limit the entry of others' into the market for providing services to maintain and improve health and there may be a close relationship between at least some nurses/physicians and both legislators and regulators within the executive branch. Perhaps there is an argument that consumers lack information about providers who are not regulated by the state's Nursing Board (or the equivalent for physicians) but it is not clear that there is a market failure here that needs regulating.

It's worth your consideration--regardless of what state you are in.   

Where to Give Birth

There was an interesting piece in the New York Times last week that caught my attention.  This article tells the story of residents of mainland China going to Hong Kong to give birth.  This demonstrates an interesting set of economic principles and just how health and other considerations are traded off in people's utility.

First, to go from one place to another to give birth is not always all that easy.  As my wife and I found out with our oldest--sometimes birth timing is unpredictable.  The lack of precision is both in terms of the date on which the birth will occur and how long the birth will take.  That could be an issue just for choosing a hospital across town other than the nearest hospital. Choosing to go to Hong Kong instead of mainland China would be even more complicated.

Second, the tradeoffs are interesting ones.  Apparently, the benefits of a birth in Hong Kong are sufficient for people to want to spent the resources to make the choice to plan for a birth in Hong Kong.  The benefits include higher quality medical care (according to the article) and certain benefits of citizenship.  These are traded off against cost, possible inconvenience, time issues, and really a possible threat to the health of the mother and child depending on just how long before the birth the mother is able to be in Hong Kong.

Third, it points to the degree to which individuals with higher income see both peri-natal care and the other benefits of a birth in Hong Kong as luxury goods.

Finally, it is interesting to think about what the appropriate response by authorities in Hong Kong should be.  Places to give birth in a modern setting are not things that can be easily added to the market quickly.  When there is a shortage being created how should the market respond?  How should the government respond?  And how should the residents of Hong Kong respond?  Additionally, if there are efforts now to build up the perinatal care capacity and at some later point residents of mainland China decide it is not worthwhile to come to Hong Kong to give birth, what woud that do to the market for services in the long-term?  This is an issue that the government of Hong Kong will have to consider carefully in order to provide sufficient services now without having an inefficient overabundance later as sometimes happens in health policy when change takes a long time and the market forces leading to differential demand sometimes change more quickly than the constructions of new facilities.

The Super Bowl and Measles

There was an interesting story from the Johns Hopkins Bloomberg School of Public Health newsfeed yesterday on the Super Bowl and measles.  I've provided a link to the Center for Disease Control and Prevention's (i.e., the CDC's) website on measles just so that people who have never really had to think about measles can find out a little more about what it is and what risks come with it.  The story (from PBS's News Hour) is interesting in illustrating the risks that come with large sporting events that attract people from all around the world.  As an economist, the main thing that I ask is how this reflects on the appropriate role of government.  In this case, even most economists I've met--despite their general lack of interest in government regulation--are willing to go along with the idea that the government has a role in mandating vaccination.

Why?  Well, the piece from PBS points out that the vaccination against measles is 95% effective.  If you could get nearly everyone vaccinated with something that is 95% effective, it will make the continued spread of a disease very unlikely.  And, in the United States, that was achieved.  Over the past decade more and more people have made a decision not to get vaccinated.  The issue here is that when nearly everyone else was vaccinated, a few unvaccinated people (as long as they were not traveling to parts of the world with insufficient vaccine coverage) would not likely get the measles and would not be a threat to others for whom either (a) the vaccination was not effective or (b) the vaccination was medically contra-indicated.

When many people choose not to get vaccinated the risk starts to increase.  And it is a risk for more than just the person who chose not to get vaccinated.  It is also a risk for the people in (a) and (b) above.  Given that 1-2 of 1000 children who get measles will die what we have to ask ourselves it this.  First, is there a role for government to make even a weak mandate for vaccination in this case because people should not be allowed to create risks for others at this level?  In other words, what is the minimum risk we can create for others that society is willing to try to regulate?  We regulate driving under the influence because it creates not just a risk for the driver but a risk for others as well.  Second, how much should the government strenuously enforce the regulation?  In other words, should the government allow parents to make a relatively weak objection to the vaccination and have their children unvaccinated.  In this case it gets really complicated.  We do mandate certain things about parenting.  The parent is making a decision not just for themselves but for another person.  And that person's susceptibility can then affect others.

No easy answers.  There almost never are.  

Insurance and Fitness

The JHSPH news service provided a link to an interesting article yesterday.  It is an interesting read with details about employers/insurers who are providing health insurance discounts/reimbursements to people who do exercise and (in some cases) penalizing people who do not.  It is an interesting story about how decision makers have acted to provide incentives to get fit or disincentives not to.

To a certain degree I really want to ask--why do we have to pay people to take care of themselves.  But perhaps that is just the part of me that has lived through what I felt like when my exercise was minimal for six year and since found joy again in exercise.  My preferences.  My time constraints.  My money.  I get to choose how to spend it and I have decided to spend a lot of time exercising--particularly since January 2010 when I decided to make marathon running part of my experience.  Not everyone shares my preferences.  Some people have less control over the schedules or have longer commutes.  And not everyone has the money for proper exercise gear.  Of course, it doesn't take all the distance I go or all the equipment I have.  But still, not everyone shares the same preferences.

Both the incentives and disincentives get at the same thing.  Encouraging people to be more active/fit.  My impression is that penalties (while perhaps perceived as being "mean") would get people's attention more than incentives.  This is suggested by prospect theory where even if the difference in spendable cash (that is not in health insurance premiums) for the fit and not fit is the same, it will get the not fit's attention more if they are paying a "higher" premium rather than if the fit individuals get a reward for their fitness.

Things like this have been tried in the past, although not necessarily directly as money.  There are many examples of small items for participation in wellness programs.  They never seemed to do a whole lot.  It is interesting to consider why people may be more responsive to such things now.  Is the dollar amount finally enough?  When income in general is feeling less certain, perhaps people are more price sensitive? If the economy recovered to the perceived wealth of the 1990's would be respond similarly?  Would habits developed now carry over to when the economy is better some day?

Also, it seems like the options discussed in the article all involved going to a facility.  For some, that may be just what they need to be active.  What allowance is there for the individual who is fit and exercises in a non-facility setting?  What about a person who gets a disutility from being at a gym?  That would be an interesting consumer sovereignty issue to consider and there may be simple technological solutions to document that a person is getting exercise in a location other than at a an affiliated facility.

It will be interesting to see how this proceeds as incentive and disincentive schemes like the ones described continue to be implemented.

Doctor's Weight and Obesity Diagnosis and Treatment

A recent study by one of our own JHSPH faculty found that physicians with a BMI of 25 or higher (i.e., overweight or obese) are less likely to diagnose obesity in their patients and less likely to discuss obesity with their patients.  One suggestion is that physicians think that there is nothing wrong with them and this leads them to conclude that there is nothing wrong with the patients.

Perhaps, let's put more of an economic twist on this.  Physicians will provide care until the marginal cost of providing more care is just equal to the marginal revenue from doing so.  We usually think in terms of monetary costs.  However, there are also psychological costs.  Perhaps physicians who are overweight themselves find a higher psychological cost of bringing up weight issues with their patients and this makes them less likely to undertake this type of care.

Which seems more likely?  Physicians thinking that they and their patients are okay?  Or ,physicians knowing that both they and their patients are not okay but choosing not to do something about it because they find it psychologically costly to tell someone else to do something that they have demonstrated that they do not do themselves.  And, how would we test which on is actually closer to the truth?  The policy recommendations may be much different depending on which explanation is correct.

Physician Induced Demand

In health economics text books ever since the first one I used by Paul Feldstein when I took my first health economics class in the 1989/90 academic year back at Penn State, the authors have discussed the topic of supplier induced demand.  This concept in health economics represents the idea that physicians can provide services for their patients that the patients don't really need.  Some of it is linked to the idea of defensive medicine (in other word, doing tests just to make sure that something can be ruled out--or ruled in--even if the likelihood of a result other than what is logically expected is extremely low).  But some of it is purely for the sake of the ability to make more money by practicing medicine.
In recent health economics texts, the situation was described as no longer being conducive to supplier induced demand given the degree to which patients were becoming more informed and the degree to which insurance companies were using information systems to track what was being billed and to attempt to control utilization.

While the story I'll share today is old, I stumbled on it in a blog, then found a link to a story from closer to the original event, and even a press release from the US Attorney's office.  Other than the fact that I don't tend to be teaching in June, I'm not sure how I had missed this for more than two years as an excellent example of modern day supplier induced demand.  A cardiologist doing stents that were proven, beyond a reasonable doubt (as per the US legal system), to be unnecessary.

This is interesting because it leads us to wonder what the market conditions were that allowed something like this to happen.  This is not a matter of simply performing a small extra test.  This was not prescribing unnecessary but otherwise not harmful antibiotics.  This was an example of taking advantage of the relationship that the physician had acting as an agent on the patient's behalf.  It is amazing that a procedure that can do so much good for patients who do need it was used in a way that was either (as the judge indicated) purely for greed or purely for ego.  Regardless, it shows some of the negative results that can occur in a market without regulation where one side has much more information than the other and a strong incentive to use it.  Also, it is important to recognize that this one example does not mean that this is occurring everywhere in the market, but it does make me wonder just how much of this is going on that, for whatever reason, continues to go undetected "under the radar screen".

Facts of Life and Rational Decision Making

A Washington Post blog entry caught my attention yesterday. The entry was titled, "Do teens know the facts of life?"  The fact that we would even have to address this question in the year 2012 is somewhat concerning.  A variety of beliefs exists about whether education about these matters is appropriate in the home, in the school, or in some type of faith-based education setting.  Regardless, the key is that there are many risks for teens that include pregnancy and all its consequences and sexually transmitted infections.  So, even if a parent or adult member of the community hopes the teens in whom they have an interest will remain abstinent until marriage, the teens still need information about the "facts of life" to make decisions about avoiding those risks.

In economics, we assume that people make rational decisions with complete information.  Or at least information that will give them the capacity to make a well reasoned decision.  While it could be debated whether anything related to teens in sexual relations is rational, the key is that we can't even expect teens to have an opportunity to make rational decisions if they don't have information (other than perhaps abstinence because they have been taught that is the right thing to do, though many teens are not known for doing the right thing in all cases).  The Washington Post blog is not written from an economic perspective but does point out that the most rational teens (among those who chose to have sex) may have been the ones who claimed not to use contraception because they would not have minded getting pregnant.  While we may go on to question whether the teens understood everything about pregnancy and raising a child, at least within the context of the decision about contraception, the choice seems rational.

I could certainly see where at least some may question whether we should try to use economics to think about teens and the facts of life.  However, while I realize that at the moment at which a teen would have to make a decision about contraception rationality may not be present, teens do make choices about whether to even put themselves in situations that may lead to such a moment.  If it is an appropriate societal role and use of societal resources to provide more information about the facts of life (and I realize even that is debatable), then we should think about how the information can be used best to improve the rationality of decision making for teens and which decisions are most likely to be affected by rationality.