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.