Antibiotic resistance

To deal with the rise of disease-resistant germs, ban antibiotic use on farms and give prizes for developing new antibiotics.

Outsourced to Ryan Cooper.

1. Yes, we should ban the routine use of antibiotics in farm animals.
2. And yes, the federal government should offer prizes for developing new antibiotics.

But I don’t believe for a second that there are no new antibiotics, or classes of antibiotics, left to discover.

Footnote I’d love to hear a libertarian analysis of the problem of factory farms breeding antibiotic-resistance disease organisms. Sounds like a case for regulation to me. But then I’m just a liberal.

Ross Douthat on health care cost containment and innovation

“Trickle-down” is not the only way to finance health-care innovation.

Ross Douthat’s essay against “Medicaid for all” – which boils down to opposition to any form of health-care cost control other than loading the cost on the patients – drew praise from, inter alia, Rich Yeselson:

Millian. You fairly explicated your interlocutors’ best arguments before astutely rebutting them. A model essay.

Agreed as to the format: when Douthat is finished, you know what he wants, why he wants it, and what the stakes are.  In particular, he is frank in saying that his preferred alternative would continue to create great financial stress for the non-rich when they get sick.

Douthat makes two strong points:

1. It’s easy to waste money on health care that could be better spent on something else.

2. The much-maligned U.S. healthcare system does, or at least pays for, a massive amount of health-care innovation; the competing systems spend less money in part by free-riding. Cost controls here could slow innovation worldwide, at a high price in avoidable suffering. (This is the drum Megan McArdle keeps pounding.)

To #1, I would reply that lots of consumer spending is “wasted;” see Robert Frank’s Luxury Fever.  Both the intra-personal hedonic treadmill and the interpersonal process of Veblenian competitive expenditure greatly reduce the marginal welfare gain of a dollar moved from health-care spending to something else consumers (have been persuaded by marketers that they) want. I don’t think we have any reason to think that the marginal healthcare dollar buys less happiness than the marginal dollar spent on anything else; the opposite might easily be the case.

#2 – innovation – is a much more troubling point for fans of cost containment. But it’s a convincing point only if there’s no alternative to unchecked spending on healthcare for the rich as a means of financing innovation. Right now the National Institutes of Health spend approximately 1% of total (public-plus-private) healthcare costs. It’s hard for me to believe that we couldn’t save 10% in healthcare costs, put half of that into more research – thus sextupling the research budget – and get back much more innovation than we’d lose. (And that’s ignoring the possibility that we might ask other rich countries to contribute something to the process.)

Is there any reason to think that patents are really the right way to finance the development of new pharmaceuticals, imaging devices, and medical equipment? Seems radically implausible to me, given prizes and publicly financed development of innovations which are then put into the public domain as alternatives.

Even if the rest of Douthat’s argument were more convincing than I find it, his casual acceptance of widespread financial stress as an acceptable side-effect of an approach whose benefits  – as he admits – are mostly speculative, strikes me as somewhat hard-hearted.  Increasing inequality has made financial stress much more common than it used to be, even in the face of rising GDP per capita. Financial stress is bad for health, and even for effective IQ. It seems to me that the presumption against financial-stress-increasing policy choices ought to be fairly overwhelming.

All of that said, Yeselson (and Chris Hayes) are right. It’s good to have a conservative writer whom it’s possible to engage in serious policy debate.



Community Reinvestment Comes to Health Care

I have no idea what the nonprofit community would do without Rick Cohen of the Nonprofit Quarterly: if there’s an issue affecting nonprofits he’ll have a fresh and useful perspective on it, and this article about the Community Health Needs Assessments required by the  Affordable Care Act is no exception.

What struck me most was Cohen’s point that CHNAs could do for health care what the Community Reinvestment Act did for real estate lending: make large institutions pay attention to the communities where they do business.  Whatever its weaknesses, CRA did make a serious dent in the once-common practice of red-lining, refusal to lend in poor neighborhoods, and we can expect CHNAs to make a similar change in the culture of nonprofit hospitals.  Simply providing an emergency room isn’t sufficient community service, and if a nonprofit hospital fails to grasp that it jeopardizes not only its Federal health-care dollars but the tax-favored status of the rest of its income.   We know that because the provision calls for enforcement by the IRS as well as the Department of Health and Human Services.

This sort of positive pressure from the legislature to improve community health services is far more effective than the purely negative pressure courts can supply by rejecting a hospital’s claim of charitable status (as in the Provena case in Illinois). Because the point isn’t to play “gotcha” with nonprofit hospitals—it’s to supply communities with the maximum benefit possible from the health care resources already available.

Once again the more you know about the Affordable Care Act, the better you like it.   And “Obamacare,” intended as an epithet, sounds more and more like a well-deserved tribute.

cross-posted with The Nonprofiteer:

It’s time to take your meds

Smartphones and paper ideas for helping us comply with our medication régimes.

It’s hard to keep to a medication régime. Most of us (75% according to one survey) fail to keep to them exactly, and many don’t stick to them even approximately. The health and financial costs of non-compliance are huge: for the latter, €100bn in the US annually according to the same source. [Update: For a moving example of the human costs, see Kathy’s comment below.] One good reason for keeping us expensively in hospital is that it’s often the only way of ensuring that we do take our pills.

Can anything be done about this? Continue reading “It’s time to take your meds”

The organ shortage

The way to fix it is to allow financial rewards for donors.

Zoe Pollock, posting on Andrew Sullivan’s blog, links to a paper that notes the shortage of organs for transplant: 114,000 recipients on waiting lists, 14,000 donors per year.

The two most promising alternatives are xenotransplantation, the replacement of a human organ with an animal one, or engineering human organs from scratch.

Actually, no. As Sally Satel keeps pointing out, the most promising alternative is allowing financial rewards for organ donors. That’s especially relevant to kidneys, where the donor can go on to live a perfectly normal life and where the savings to the government from not needing to do dialysis are in the tens of thousands of dollars per patient per year. That would allow for hefty payments while leaving the program still a net cost-saver.

The bioethical dogma that forbids payment for donation is just another version of “Right-to-Life” absolutism: it caters to the scruples of those sitting comfortably in their offices, with no skin in the game, at real cost to the lives of actual people. (Just imagine if each opponent of payment had to explain, in person, to five potential recipients and their families that he, personally, made the decision to let the patient die, in order to prevent “commodification” and preserve the moral freedom of donors to make altruistic choices.)

Time to get past it.

Food Trucks As a Model to Reduce Non-Emergent ER Care Use

(cross posted at freeforall)

Bill Gardner has a nice post on the use of Emergency Rooms (ER) for non-emergent care. Such use clogs the ER and is an expensive way to deliver basic care. However, many poor persons have no viable alternative. This is an old problem, and providing everyone with health insurance will not fix it. We need a care delivery innovation of some sort.

I have been considering investing in a food truck in Durham; the many food truck options in and around Durham, NC make me think that I have already missed the investment wave. However, my analysis has lead me to wonder if the food truck concept could be a useful way to address the use of ERs for non emergent care.

The best food trucks I have visited provide good quality food at a relatively low cost, typically by consistently providing a narrow range of fare, and showing up where the customers are when they want to eat.

In the same way, if Duke University Health System had an “ER on wheels” (or several) they could provide basic care at a lower cost than they do at the Duke ER, and could go to where the patients were. In fact, one set up just outside of the entrance to the ER might be the first place to start. After that, you could imagine a twitter-driven service in which The Duke ER trucks broadcast their locations; potential patients could tweet or facebook them and say “can you come near the intersection of X and Y street, I think my 10 month old may have an ear infection and I need to figure out if I have to call out sick from work tomorrow”. Patterns of use would emerge. Even if you assumed everyone using such an ER truck was uninsured (they wouldn’t be if competent care could be delivered quicker and cheaper than that at the ER), then it would be advantageous to Duke to undertake something like this so long as the cost was less than their cost of providing care to the uninsured in the ER.* And what patient wouldn’t want to avoid an hours-long wait in the ER?

You can definitely deliver health care via a truck or bus as Hangoverhaven is demonstrating in Las Vegas.

Our facility is open seven days a week from 8 am to 4pm. We have a shuttle that can come pick you up and drop you back off. We have a special WSOP package that is one bag of IV fluids, IV vitamins, and IV glutathione. Glutathione is an antioxidant that also supports mental function. I have been using it the last few weeks with clients and have noticed a significant difference. The WSOP package is priced at $99.

Continue reading “Food Trucks As a Model to Reduce Non-Emergent ER Care Use”

First, do no harm (medical research edition)

A plea for integrating the reduction of medical costs in major medical research programmes.

The National Institutes of Health explain the fundamental driver of the trend increase in health costs much better than I could:

In the past 40+ years, NIH funded research has successfully reduced the mortality and morbidity of once acute and lethal diseases and conditions by finding ways to improve treatment — even in later stages. These advances have moved what had been to acute to chronic diseases, to diseases that are chronic and manageable. These chronic diseases now form the largest component of health burden.

National Institutes of Health FY 2010 President’s Budget, page 3

A touch of hubris here – the NIH is much the biggest fish in the pond, but not the only one – but pardonable. In short: we die of things less, and live longer as permanent patients.

The great medical achievements of the NIH and its fellows worldwide are leading us (see my previous post) to an economic and social catastrophe. On current trends in medical costs, either all rich countries go broke sooner (USA) or later (rest of OECD), or we have extensive rationing of cutting-edge medicine by the market or the state, or we just leave the discoveries unused and settle for an iron rice bowl. (To be complete, or something turns up.) In homage to Jonathan Swift, who 300 years ago imagined the horrors of immortality without a stop to aging, let’s call this unsustainable situation a Struldbrug box. What’s the NIH plan for getting us out out of it?

Continue reading “First, do no harm (medical research edition)”

Those free riders in the sky

The rest of the world’s free-riding on American medical innovation is dwarfed by American free-riding on foreign medical education.

Matt Yglesias channels the CW on medical innovation:

Arguably the rest of the world gets by free-riding on American generosity. We provide the windfall profits that drive innovation and they offer payments much closer to marginal costs and save money.

Cry me a river.

According to the Migration Policy Institute, drawing on hard Census data:

In 2005, 15 percent of all US health-care workers were foreign born. … Of the 10 million persons engaged in health-care occupations ages 18 and above …1,454,883 were foreign born. … The foreign born accounted for 26.3 percent of 803,824 physicians and surgeons.

This army of professionals is very close in number to all the US armed forces put together: 1,445,000 in May 2009. The great majority of these doctors and nurses were educated at taxpayer expense in their countries of origin, which are mostly far poorer than the USA, like India and the Philippines. Not many Swedish or Japanese doctors choose to emigrate to greener pastures. The US health care system is a huge free rider on the developing world.

This regressive transfer of human capital far outweighs the hypothetical free riding on American medical and pharmaceutical innovation – usually overstated anyway.

The French Communist politician Jack Ralite was French Health Minister in 1981-83, during the swan song of the PCF in Mitterand’s early years. (The PCF ministers all quit government when Mitterand was forced into an economic policy U-turn in 1983.) Ralite tried to raise the number of medical students, but gave in to pressure from the professions. (Article in French).

Ralite understood basic capitalist economics better than John Boehner. If the US wants to cut bloated medical fees, it needs to tackle the Malthusian cartel that blocks the opening of new medical schools – and hoovers resources from the Indian poor.

Improving Health Care: The British Innovate

I am speaking at the U.K. Parliament next week about how to get better outcomes from addiction treatment. Like virtually all other forms of health care in the U.K. and U.S., addiction treatment is under pressure to deliver better outcomes without an increase in budget.

A number of projects (such as this one) have successfully improved aspects of the process of addiction treatment, e.g., reduced waiting times, increased use of evidence-based counseling methods and incentivized staff to retain patients longer in care. However, these process improvements have rarely translated into significant product improvements. That is, patients are seen more promptly, their treatment is better planned and organized, they stick around longer and they are more satisfied with their care, but their likelihood of recovering from addiction stays roughly the same.

In response to my recent post on hospital readmissions, some commenters suggested that psychiatric and addiction medicine are different than the rest of health care in that factors outside of treatment (e.g., housing, social class, family stress) rather than care quality explain most of the variance in how well patients do over time. But “hard medicine” is largely in the same boat: A study of Medicare’s quality of care measures for how hospitals dealt with heart attacks, chronic heart failure and pneumonia found that even dramatic differences in the quality of care during hospitalization relate only weakly to post-discharge death rates.

Many scholars committed to health care quality improvement would argue that it is hard to measure quality of care precisely and reliably, which leads to underestimates of the strength of the relationship between process and outcomes of care. They would also point out that the relationship between quality of care and outcome might be non-linear and hence go undetected in studies that employ conventional statistical approaches (e.g., correlations). For example, maybe genuinely lousy care damages health but given some baseline level of care adequacy, further improvements make little difference to outcome, creating the illusion that quality doesn’t matter in simple correlational studies. These are fair points and it would be foolhardy to give up on quality improvement just because the work is difficult.

But it would be equally foolhardy to not simultaneously try to improve the outcomes of health care in ways other than manipulating the process of care. The U.K. government has answered the challenge by leapfrogging questions about the process of addiction treatment to directly reward providers based on patient outcomes. “Payment by results” has been used in the NHS in a number of areas, but this is its first application to addiction treatment. In a small group of experimental areas around the country, addiction treatment providers will be paid based on their patients’ outcomes (e.g., drug use, employment, overall health and well-being) with the nature and process of care left up to the providers’ best judgment. There are a bevy of details to work out, including how to set the payment such that treatment programs will not shun hard-to-treat patients, but the basic concept has real promise.

Will it work? I don’t know, which is exactly why I am glad the experiment is being conducted. Bagehot is correct that boffins are ascendant in Whitehall these days, as two parties long out of power bruit the ideas they developed when they were in the political wilderness. The payment by results experiment in addiction treatment is among a number of demonstration projects that will put these new ideas to empirical test (The brainy Minister Oliver Letwin is a key player). Being experiments, some will generate negative results, but the spirit of innovation is encouraging given the pressing need to wring more health benefit out of every penny we invest in health care.

Worthwhile Ivy League stealth s*c**l*st initiative

An amateur report card on the progress of the US health IT plan.

(Long wonkish post for a quiet weekend)
During the election, the handover runup and the negotiation of the stimulus package, I posted various grumbles that the Obama team´s enthusiasm for health IT was creating a risk of a rerun of the British NHS near-fiasco. I thought I´d better check to see how things are going.

As far as I can see. the short answer is: pretty well. Here´s the website of the Office of the National Health Coordinator for Health Information Technology You can judge for yourself probably as well as I can. But since I went on record with criticisms, it´s only fair to retract them.

Longer report below the jump. Continue reading “Worthwhile Ivy League stealth s*c**l*st initiative”