Monday, February 27, 2012

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.

Thursday, February 23, 2012

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.  

Thursday, February 16, 2012

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.

Monday, February 6, 2012

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.