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?