November 2007

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Some Friday Humor

November 30, 2007 in Miscellaneous | Permalink

The following list of phrases and their definitions might help you understand the mysterious language of science and medicine. These special phrases are also applicable to anyone working on a Ph.D. dissertation or academic paper anywhere!

“It has long been known” = I didn’t look up the original reference.

“A definite trend is evident” = These data are practically meaningless.

“While it has not been possible to provide definite answers to the questions” = An unsuccessful experiment, but I still hope to get it published.

“Three of the samples were chosen for detailed study” = The other results didn’t make any sense.

“Typical results are shown” = This is the prettiest graph.

“These results will be in a subsequent report” = I might get around to this sometime, if pushed/funded.

“In my experience” = once.

“In case after case” = twice.

“In a series of cases” = thrice.

“Correct within an order of magnitude” = Wrong.

“According to statistical analysis” = Rumor has it.

“A statistically oriented projection of the significance of these findings” = A wild guess.

“A careful analysis of obtainable data” = Three pages of notes were obliterated when I knocked over a glass of pop.

“It is clear that much additional work will be required before a complete understanding of this phenomenon occurs”= I don’t understand it.

“After additional study by my colleagues”= They don’t understand it either.

“A highly significant area for exploratory study” = A totally useless topic selected by my committee.

“It is hoped that this study will stimulate further investigation in this field” = I quit.

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Privacy

November 29, 2007 in Current Events, Healthcare IT | Permalink

I recently received an email from the Patient Privacy Rights organization. They are conducting a campaign to protect the privacy of individual’s prescription drug information. According to their website, a Newsday article reports the following:

Randee Lonergan filled her prescriptions at the same pharmacy for years. But a month ago she was shocked to find the pharmacy closed and all her family’s medical records sold to a nearby Target store in Levittown. Her information was sold legally because of a loophole in medical privacy law that allows pharmacies to “auction off” customer records – including prescriptions, information about medical conditions, Social Security numbers and insurance records – “to the highest bidder,” Sen. Charles Schumer said yesterday. The practice of selling off records, Schumer said, is a nationwide problem. Federal law requires doctors to let patients know when their medical history is being shared. But the law allows pharmacies to sell patient information to other pharmacies, Schumer said.

This sounds horrible. Patients should have a right to keep their medical information private. No one should be able to buy information that would tell them whether I take Zoloff for depression, Flomax for frequent urination, AZT to treat HIV or Viagra for erectile disfunction (see video).

I was about to sign the petition when I realized that sometimes I do want people to know what medications I am taking. One of the major benefits of electronic health records (EHR) is that emergency room doctors who I have never seem before can have instant access to my current medications and my allergies. EHR can help to provide a patient’s network of doctors with standardized information which can help in the treat of medical ailments.

How can we limit patient medical data to only the people and organizations that we want to have it? Would providing strict patient privacy protection make a standardized EHR impossible? Is it feasible to restrict access to medical records in a manner which protects patient privacy, but enhances medical care? These are complicated questions of which we need to find an answer.

Health Wonk Review is up

November 28, 2007 in Carnivals | Permalink

The latest edition of the Health Wonk Review is up at Roy Poses, MD.’s Health Care Renewal blog.

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Marriage and Obesity

November 28, 2007 in Obesity | Permalink

Are married people more likely to be obese than single individuals? More to the point, does being married cause obesity? Married individuals are generally older than never-married individuals and since age is correlated with obesity, there could be a spurious relationship between marriage and obesity.

One may think that married individuals are not on the “single’s market” and thus may not have a strong incentive to maintain an athletic physical appearance to attract mates. As stated in Sobal (1984), “We may hypothesize that as a marital relationship becomes solidified the partners may feel less need to maintain external appearances important in attracting a mate.” On the other hand, a paper by Rand, Kuldau and Robbins (JAMA 1982) found that individuals who had jejunoileal bypass surgery to decrease obesity had improved marriage relationships. Thus, those who value their marriage may wish to avoid being overweight to make the marriage experience more pleasurable.

If healthier individuals can more easily attract a mate, than it would be the case that married individuals will be less overweight than single individuals. Averett and Korenman (Int J Obesity 1999) found that obesity is associated with a lower probability of marriage. Gortmaker et al. (NEJM 1993) use the NLSY to conclude that individuals who where overweight in their adolescent years are 20% less likely to be married seven years later than a healthy-weighted individual. Cawley, Joyner and Sobal (Rationality and Society 2006) confirm that for adolescents “dating is less likely among heavier girls and boys and among shorter girls and boys.”

Sobal, Rauschenbach and Frongillo (Soc Sci Med 1992) categorizes the relationship between obesity as marriage through two distinct mechanisms: “marital selection” and “marital causation.” Non-overweight people are more likely to attract a mate, and thus “select” into marriage. However, if marriage “causes” weight gain–due to a more sedentary lifestyle, lower mate attraction incentive, childbirth, etc.–than a researcher may find that married individuals are more overweight on average.

The best way to control for these two conflicting effects is to use a panel data set. Cawley (JHR 2004) employs the 1979 NLSY, using lagged BMI as an instrument for current BMI and individual fixed effects to control for time-invariant individual characteristics. Other studies have used sibling weight (Avarett and Kroenman (JHR 1996), or spousal weight as an instrument for current BMI. Using data from the National Survey of Personal Health practices and consequences, the Sobal, Rauschenbach and Frongillo paper finds that “it appears that there is a relationship between fatness and marital status for men, with married men fatter and more obese.”

Nevertheless, more research is needed to refine the exact manner in which marriage affects obesity.

  • Averett S and Korenman S. 1996. “The Economic Reality of the Beauty Myth.” J Human Resources. 31(2): 304-330.
  • Averett S and Korenman S. 1999. “Black-white differences in social and economic consequences of obesity.” International Journal of Obesity. vol 23, pp. 166-173.
  • Cawley J. 2004. “The Impact of Obesity on Wages” J Human Resources. 39(2): 451-474.
  • Cawley J, Koyner K, Sobal J. 2006. ”Size Matters: The influence of adolescents’ weight and height on dating and sex.” Rationality and Society. Vol. 18, No. 1, 67-94.
  • Gortmaker SL, Must A, Perrin JM, Sobol AM, Dietz WH. 1993. “Social and Economic Consequences of Overweight in Adolescence and Young Adulthood.” NEJM. 329(14): 1008-1012.
  • Rand CS, Kuldau JM, Robbins L. 1982. “Surgery for Obesity and Marriage Quality.” 247(10): 1419-1422.
  • Sobal J. 1984. “Marriage, Obesity and Dieting.” Marriage and Family Review. 7:115-139.
  • Sobal J, Rauscehnbach BS, Frongillo EA. 1992. “Marital Status, Fatness and Obesity.” Social Science and Medicine. 35(7): 915-923.

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Swiss Healthcare System

November 27, 2007 in International Health Care Systems | 6 comments

Maggie Mahar has a interesting post discussing the Swiss health care system (“Herzlinger’s Meme on Switzerland and Consumer Driven Medicine“). The Swiss government mandates that all individuals purchase health insurance. While the insurance is subsidized by the government–and more heavily subsidized for poor Swiss individuals–most Swiss pay a large percentage of their insurance premiums. The government pays 25% of the premium while the individual pays the rest. Is having a “skin in the game” what is creating a more efficient health care system, where Switzerland has lower health care spending and better medical outcomes? Ms. Mahar doesn’t believe it (and neither do I):

But the truth is that Swiss patients have relatively little say over either the cost or the quality of the care they receive. Prices are regulated by the government, which also tries to make sure that consumers are getting value for their health care dollars by selecting which drugs, devices and tests insurance will cover. In fact, it is the very visible hand of a smart, largely efficient government that accounts for Switzerland’s relative success.

The key to consumer driven health plans (as recommended by Regina Herzlinger in the WSJ and JAMA 2004) is that 1) consumers–not employers–are the ones choosing their own health plans and 2) that consumers have adequate information regarding the quality of the plan.  The paradox of the Swiss system is that while the Swiss do decide their own plan and have quality information regarding their plan benefits, this quality information comes due to the fact that the government strictly regulates a minimum benefit.  This minimum benefit package on the one hand makes it easier for consumers to know what their health plan will cover, but on the other reduces the consumer’s health plan options and makes the health insurance system less “consumer-driven.”

Thanks to Joe Paduda for the link.

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Value-based pricing

November 27, 2007 in Academic Articles, International Health Care Systems, Pharmaceuticals | Permalink

In February of 2007, the UK’s Office of Fair Trading (OFT) recommended reform to Britain’s current Pharmaceutical Price Regulation Scheme (PPRS). The PPRS sets maximum and minimum profit levels from the sale of branded drugs to the NHS. The PPRS allows companies freedom to set prices as they please on new substances, but restricts subsequent prince increases. A system of price cuts has also been instituted as well, yet it is likely that firms take these future price cuts into account when making their original pricing decisions.

Reform

Are there any other options? Simeon Thornton (Health Econ 2007) argues that a value-based pricing (VBP) scheme would be superior. In VBP, the NHS would pay pharmaceutical companies based on the value of the pharmaceutical to the patient base. One question is how value is determined. Thornton proposes cost effectiveness studies, which in effect means that the government or academics will determine the price.

Pricing will also be allowed to vary by subgroup since people with certain diseases may benefit more from a disease than others. Also, incremental improvement will be encouraged since marginal improvements in treatment will receive higher payments.

This program does seem to be an improvement. It is dynamically efficient since pharmaceutical companies will be paid more for more cost effective treatments. Further, if it turns out patients do not like the medicine and no one takes it, then NHS will not be paying a lot for failed drugs. Also, after generics are available, the price will adjust downward.

In the static environment, the pharmaceutical company will capture all the consumer surplus since price will equal marginal benefit. However, as time passes and generics enter the market, a large consumer surplus will occur.

The major impediment of this reform is the problem of any centralized system: information. How will the NHS determine cost-effectiveness? Will it be impartial? Will the conclusions be manipulable by interested parties? These questions are easy to answer theoretically, but very difficult to predict empirically.

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Too fat to work

November 26, 2007 in Current Events, International Health Care Systems, Obesity | Permalink

The incapacity benefit system in the UK is intended to provide an income support for those unable to work.  Like any government program, many of the beneficiaries are in dire need of the money and are truly unable to work, but many other individuals who are able–but not inclined–to work have taken advantage of government largesse.  Liberals will highlight the fact that these programs help the needy while conservatives will generally retort with numerous examples of how individuals are able to take advantage of ‘the system.’

Last week, The Times of London reported (‘Too fat to work‘) that “Almost two thousand people who are too fat to work have been paid a total of £4.4 million in benefit.”  Should obese individuals receive a disability benefit?  If obesity is truly a disease, than one may say yes.  On the other hand, there is a seemingly simple cure for obesity–eat less and exercise more.  For those who are obese, however, accomplishing this physiological feat is not as simple as it sounds.  It is possible that the incapacity benefit may actually make the obese worse off.  Allowing the obese to collect an incapacity benefit may reduce an overweight individual’s incentive to lose weight in order to be able to work.

Any input on this subject would be greatly appreciated.

Thanks to my colleague Mike Ewens for the referral to the Times article.

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Sunlight is the best disinfectant

November 25, 2007 in Physician Compensation, Supply of Medical Services | Permalink

“On the biggest shopping weekend of the year, you’ll know the price of the big-screen TV and the Wii you’re about to buy – but you’ll likely be in the dark about the cost of any health care you need.”

Two Wisconsin state senators are trying to change this.  The Milwaukee Journal Sentinel (“…Health cost disclosure“) reports that “Sen. Jim Sullivan (D-Wauwatosa) and Rep. Steve Wieckert (R-Appleton) this week introduced a bill requiring health care providers and insurance companies to make available information about the cost of procedures or services to patients who ask for it.”

Here is one type of government intervention I support: the government is helping to reduce asymmetric information in the medical care market without fixing prices.  The bill would compel providers to state the cost of the 50 most common medical procedures.  These costs would be divided into 3 groups: the usual rate for the service (whatever that means); the rate paid by government programs; and the average rate for health plans.

Milwaukee pediatrician Carl Eisenberg, does note that the cost of a procedure can vary from patient to patient.  Nevertheless, the provider could charge a fee in which for some patients they lost money, but for some “easy” patients they made above average profits. 

There are other problems with the pricing structure.

Larry Rambo, chief executive officer for Humana’s Great Lakes region, said cost information might best come from an insurance company because it can encompass the “episode of care,” meaning all the costs that go into treatment.

“If you’re going in for knee surgery, you’re going to get a bill from the hospital, you’re going to get a bill from the surgeon, you’re going to get a bill from the anesthesiologist and you’re going to get a bill from the radiologist,” Rambo said.

Nevertheless, I am always in favor of more information.  As a supreme court jurist once wrote: “sunlight is the best disinfectant.”

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Thanksgiving Cavalcade of Risk

November 21, 2007 in Carnivals | Permalink

The Thanksgiving edition of the Cavalcade of Risk is up at Colorado Health Insurance Insider.

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Why are we Obese?

November 20, 2007 in HC Statistics, International Health Care Systems | 2 comments

The simple answer for this is that calorie intake is higher than the number of calories burned. But why are people getting fatter? In which countries are people the fattest?

This is the questioned tackle in a working paper by Sara Bleich and colleagues “Why is the Developed World Obese?” Obesity is a serious disease:

Excess body weight is the fifth most important risk factor contributing to the burden of disease in developed countries. Rising body mass index steadily increases the risks of type 2 diabetes, hypertension, cardiovascular disease, and some cancers.

Unsurprisingly, the U.S. has the highest rates of obesity throughout the data collected, but the rate of increase is very similar across all countries. Recent news reports (“Over 20m Chinese suffer diabetes“) even show that developing countries such as China are starting to experience higher rates of diabetes and obesity.

The main cause of increased obesity rates is increased food consumption. This is mostly due to decreasing real food prices over the past century. Another factor is the increased female labor force participation rate. One story to go along with this is that as more women work, families cook less and instead eat out more. If dining out occurs in high calorie restaurants and fast food establishments, calorie intake will increase.

The other facto influencing obesity is decreased activity. The main societal reason for a decrease in physical activity is the decrease in the number of active jobs. As the number of manual labor and manufacturing jobs has dwindled in the later half of the twentieth century, many more people are working at desk jobs where there is little physical activity. Further, increasing urbanization rates over time has also lead to decreased physical activity. Perhaps surprisingly, the number of cars per capita or the internet usage rate has no effect on obesity.

The authors claim that a junk food tax may help to decrease obesity and improve societal health. I am skeptical of this solution. Which foods will be categorized as junk foods? Who will decide this? I would guess there will be much lobbying by large food companies to have their products labeled as non-junk foods. Further, a junk food tax would hit the poor more heavily than the rich.

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