Friday, October 15, 2010

How Many African Children is a Chilean Miner Worth?

The niche that I think is appropriate for this blog is that of utilitarian division of resources, focused primarily on US resources and the health and welfare of US citizens. Today I want to draw on the popular media circus of the day as an example of the question we should all ask all the time: how can we best spend our resources to maximize health and welfare?

I have yet to see the bill, but I read that it cost millions of dollars to rescue the 33 miners trapped in Chile, and much aid came from the US. I am going to make up numbers for the math I'm about to do to illustrate a point. Let's say that it cost $3.3 million to rescue the miners. That comes to $100,000 per person. These are Chilean men in the career of mining, so an expected lifespan of 70 would be optimistic. Let's say that the average age of the miners is 35. So, the rescue saved 35 years per person for $100,000 = $2,857.14 per life-year. That's pretty inexpensive in American terms. Heck, that's practically free compared to Avastin and mammograms. Based on the media, it seems that Americans are excited and happy about this rescue, so I doubt there are many who would begrudge the men this cost. What if the real cost of the rescue was $33 million? How would you feel then? There are over 40 million Americans who can't get any help paying for more life-years when they have problems.

Michael Moore, who I'm usually not impressed with, recently wrote a letter to President Obama pointing out that for two months of the cost of the war in Iraq we could dig wells that would provide Africans with clean drinking water. Many areas of Africa suffer from disease related to their water, and many people have to spend so much time getting water that is taken away from time they could be getting educated or working. I have not verified these claims, but they seem plausible, and I'm just trying to illustrate a concept. It seems that a well for 3000 people costs about $30,000. The Water Project says that $10 can give a person clean water for 10 years. Over 2 million children in the world die each year from a lack of clean water.

Let's say that giving these people clean water only lets them live 10 years longer on average because they then die from some other cause. We're looking at $1 per life year. It's almost unbelievably simple. So, a Chilean miner is worth thousands of African children.

Why isn't the US jumping up to save tens of thousands of Africans for the price of a handful of Chilean miners? Let's brainstorm.

1) The Africans are not as useful contributors to the American military-industrial complex.

2) Africans are black.

3) Africa is poorer than Chile.

4) A collapsed mine is an accident that happened to hard-working, blue-collar, Christian folk that Americans can relate to. Living in Africa is perceived as something an African can choose to stop doing. Nevermind that people with no money and no education really can't just up and move to a better place, and nevermind that the miners intentionally chose a dangerous job.

5) Let China do it.

6) There are only a handful of trapped miners, so we can save all of them and look like heroes. Even though we could save tens of thousands of Africans for the same price, there would be millions we did not save, so we wouldn't look as heroic.

7) Saving the miners was exciting and thrilling, with the constant danger of cave-in or other calamity, so it drew lots of attention and people who could capitalize on the attention. Building hundreds of wells is boring, so there would be no media circus out there to draw attention to participants.

This situation mimics the situation inside the US. We have poor, suffering people in America. We have the money to help millions of them easily and inexpensively. Instead, just enough of us are ignorant and hateful enough to say that these millions of people over here are less deserving of living healthy lives than that other handful of people over there. Just enough people lack compassion and humanity and intelligence that we as a country would rather waste billions of dollars on inefficiency and profits for the rich than give basic levels of care to our countrymen in need.

If you really care about life, maximize the life returns on resource investments. Let's spend our money where it will help the most.

Friday, March 26, 2010

Christian Health Collectives

This NPR article has been sitting in my browser so long that the newly passed reform bill may have made it obsolete, but I am finally motivated to discuss it. Only one collective is described. Members pay a modest annual fee to cover administrative expenses, then write monthly checks to other members as directed by the administrators. There is what appears to be a co-pay or per-need deductible of $300 (for lack of more specific terminology), and it is waived after a household pays it three times within 12 months for the remainder of the 12-month period. Members can voluntarily choose to help people whose needs exceed $100,000, or who have been injured in motor vehicle accidents.

This is an interesting experiment. It frighteningly mimics only basic catastrophic coverage, and payments are not assured. Pre-existing conditions are generally not covered, including most pregnancy costs. Is this a good idea?

It's easy to understand. There are about 30 pages of straightforward rules and instructions. There is one deductible rule. There is only one type of plan (not counting the two optional add-ons for motor vehicles and >$100,000 needs). The organization is compassionate. Membership in the collective is not exclusive of having other insurance, so the collective may end up being helpful to someone who is "underinsured".

With about 14,000 households spread across the United States, the collective lacks strong negotiating leverage to demand lower prices from care providers. Members who rely on the collective are self-pay patients, so they will be charged much more money than a large insurance company would be charged, increasing the burden to members via premiums (the premium to need ratio is less efficient for a small collective than a large insurance company, which is also why single-payer systems are so good at keeping costs low).

Payments are not assured, and would become less likely as needs increase. Small groups are more likely than larger groups to experience significant variance in needs from time to time. Large companies tend to have reserves that they can tap if there is a spike in health care consumption, but the collective is set up rigidly. The NPR article mentions that a vote of the membership is needed to increase premiums, reducing flexibility and security.

Health economics studies have consistently shown that people tend to gravitate towards plans with the lowest premiums, despite their risks or needs. Neuroeconomics has shown us that most people are terrible at making decisions when there is a lot of confusing information and a lot of choices, and they tend to focus on select pieces of information to the exclusion of other important factors. Keep that in mind: more choice is not necessarily better, and is often very bad, especially for the more ignorant and less intelligent who are also at higher risk for other problems in their lives. When shopping for health insurance, with all the many complicated plans, people tend to focus on premiums to make the decision easier. The collective has such a low premium (2/3 of what I pay for my bare bones plan) that it may attract people for whom joining is a terrible decision, and who are more likely to incur greater costs for the collective.

Finally, what are the effects of only including devout Christians? Very generally, when you ignore factors like church attendance, self-identified Christians are more likely to have health problems and engage in dangerous or criminal behaviors than atheists. Samaritan Ministries seems to have some decent safeguards up to protect itself, though. Members' pastors are involved in their membership, and the collective simply does not cover many things (substance abuse, STDs may be difficult) that are out of line with their stated values. I wonder if there are also impacts due to changes in the age composition of devout church-attenders. I wonder if the collective attracts a disproportionate number of elderly who use it to supplement Medicare, and how that affects the risks.

I like experimentation and innovation. I am curious to see how a project like this works over time. I also think it is very risky, and may need additional safeguards. Ideally, risk would be shared in a national plan that assures some basic levels of coverage to everyone, and collectives like this or private companies would sell supplemental plans.

Saturday, January 16, 2010

Grab Bag 2

Scorecards on state health care performance.
Not surprisingly, this shows that the south and Nevada are relatively bad at caring for their citizens. If the those states acted more like the best performing states, they would help a lot more of their people with better quality care at lower prices. They don't, though, because they have a predominant culture of blind belief in their superiority and refusal to engage in progressive change.

CT scans cause about 30,000 cancers per year, half of which will be fatal. This is not to say that we should never use CT scans. We do need to be more vigilant about the overprescription of tests and procedures, and this is a great example of that need. CT scans are typically overpriced and overprescribed because too many hospitals bought CT scanners by issuing debt and have to pay off those debts by increasing the prices to consumers and performing more tests than the population needs. Doctors with financial stakes in their clinics are especially prone to prescribing unnecessary tests and procedures because they profit from them. People will unnecessarily die early from expensively-treated cancer caused by unnecessary tests ordered for personal and hospital profit, as well as for the sake of defensive medicine. We need more oversight, more restrictions on the purchases of expensive equipment (some states restrict, but the outcomes are mixed because of the different standards used), and an absolute ban on doctors being in conflict-of-interest situations. "First, do no harm," right?

Speaking of defensive medicine, it is one component of the Congressional Budget Office's estimation that tort reform could effectively save America over $50,000,000,000 over ten years. The report suggests that the measures would also result in better health outcomes, perhaps due to a reduction in unnecessary tests and procedures that carry health consequences. Reform is of course heavily opposed by the deep, deep pockets of the lawyers who make piles of money no matter which side of the lawsuits they're on. Politicians are getting lobbied by the greedy lawyers who profit from the policies that hurt real people in our country.

Monday, December 21, 2009

Mammograms Revisited

Richard Thaler (coauthor of Nudge; I'll reference him often) wrote a piece for the NY Times about the current mammogram controversy. It's worth a read. He doesn't talk about "saving lives", he brings up the problems with prostate cancer treatment, and he provides some interesting numbers about the likelihood that breast cancer is not fatal and mammograms don't detect the types that are fatal, though not the expected life spans of women who are treated for breast cancer. I have a little commentary to add.

The stated false positive rate is 10% per test (which is huge for something with such serious consequences). For the math impaired, here's how that converts into the probability that women are likely to get a false positive over a decade. The simplest way to do this is to focus on the 90% chance that each test does not give a false positive. We use what is called the Multiplication Rule for Independent Events. For ten years, we multiply .9 (90%) by itself nine times: .9 * .9 * .9 * .9 * .9 * .9 * .9 * .9 * .9 * .9. This is more simply written as .9 ^ 10, and the product is about .35. So, there is a 35% over ten mammograms that a woman will not get a false positive, and a 65% chance that she will get a false positive. Of course, this assumes that there are no characteristics of a breast that would make it prone to false positives, which I imagine is unlikely. The 10% comes from aggregate data. I think it is more probable that women who produce false positives at age 40 are continuously more likely to do so each year than women who did not have false positives at age 40. Without the longitudinal data in front of me, I remain skeptical of the appropriateness of multiplying the false positive probabilities as though they are always independent events.

Thaler writes a little about the costs of all these mammograms in terms of unnecessary treatments that cause side effects, and the stress that women feel when diagnosed with breast cancer, but he avoids using dollar amounts to describe all the waste. What is missing is mention of opportunity costs. The cost of all the unnecessary procedures is not just the dollars exchanged for them, but also the other things we can not buy because our finite dollars were poorly allocated. I covered in my last post the idea that we could extend several times as many life years for Americans by taking the money spent on mammograms for women under 50 and spending on other endeavors, such as nutrition programs for children, or having nurses visit patients after operations to reduce treatment noncompliance complications. It is vital to consider opportunity costs. Mammograms for women under 50 don't just allocate $2 billion per year in exchange for a few thousand life years. They also cost us many thousands of other people's potential life years, and the unnecessary treatments and stress result in much lost work productivity. The practical net result, the way I see it, is that our system is effectively just killing other people early by insisting on giving mammograms to women under 50 who lack high risk indicators. Are women in their 40s more important than everyone else?

Many people have lost or almost lost loved ones to breast cancer. It is okay to feel empathy for them. If you are one of them, I feel empathy for you. That is not justification to ignore the data we have and allocate our limited resources on inferior practices. Emotions limit our perspectives and distract us from the ultimate goal of doing the most good we can with the resources we have. Please, let the cooler minds prevail and establish a system that gives America the greatest benefits it possibly can.

Autism Prevalence

A CDC report about autism has lead to some dramatic reactions. Here are some of my thoughts about this "1 in 100" "epidemic".

Summary, in case you want to skip the rest: Diagnosis got "better" for a while, but now I think we're overdiagnosing. There is really poor standardization in the medical field, and practically no oversight. Doctors refuse to let "bureaucrats" (epidemiologists, statisticians, and scientists, really) get in between them and their right to do whatever they feel like to their patients. New Jersey and Missouri have relatively high rates of ASD diagnoses because of nonstandard diagnosis practices. I expect the diagnosis rate to continue to increase, and that this is inefficient overall.

Firstly, remember that autism is not a disorder. There is a spectrum of severity of different features. To get an autism spectrum disorder (ASD) diagnosis, you don't need all the features, and they don't have to be severe. The primary feature involves impaired social interaction. Repetitive behaviors and sensory sensitivity are also common.

One big reason for the rise in the rate of autism diagnoses is that kids who would have otherwise been identified as mentally retarded are now being correctly classified. That is good because more helpful interventions can be assigned when diagnosis is accurate.

Unfortunately, another big reason for the rise is overdiagnosis. ASD is popular and famous. Neurotic parents whose kids aren't meeting expectations, who aren't the superstars the parents wanted, are looking for reasons and targets of blame and sources of hope. A lot of doctors just don't understand what they're doing, want to appease neurotic parents, practice defensive medicine, and benefit from making referrals to friends or businesses they have stakes in. The same nonsense that we see with ADHD and Bipolar diagnoses is happening with ASD. Little Billy likes to play by himself? ASD! Off to the occupational therapist! Little Billy has a slightly smaller vocabulary than his peers? ASD! Off to the speech therapist! Now, there are often cases in which some intervention would legitimately help a child, but interventions are expensive and different third-party payers have different diagnosis requirements for covering them. Well-meaning doctors commit a lot of insurance fraud, handing out inaccurate diagnoses in order to get a payer to pay for a useful intervention. This can be good for a client, but it is bad for our system. I generally see an enormous amount of money spent on small improvements.

The CDC report pertains to 8-year olds. There is generally a spike in diagnoses around age 8 because that is the transition to a developmental stage in which certain skills (reading and writing) are expected, as well as levels of self-regulation and interpersonal behavior. This is when school puts on more responsibility. Many learning disorders are suddenly noticed around this age. It makes sense for the CDC to use this age as it is likely to include cases caught late, though most autism should be recognized by age 3, when language is rapidly developing. A few teachers over the years increase the odds of recognizing problems.

What would be very interesting to look at is how many of these kids meet diagnostic criteria at age 12 or 18. There are a lot of reasons that kids develop skills and behaviors differently from each other, but a lot evens out the older they get. Many people carry around diagnoses like tattoos long after their natural developmental processes or interventions brought them into the normal range. All it takes is one doctor to use a label and a person who doesn't know better believes he's disabled for life, no matter what improvements are made. Anecdotally, I am familiar with a little girl who is almost three. She is quite a chatterbox now, but a doctor flagged her a year ago as having a low vocabulary. He offered the mother a referral to a therapist who would help the girl develop an average vocabulary for her age. Quite ridiculous and unnecessary and expensive. This was a doctor in New Jersey, by the way, which has the highest ASD rate in the country. Perhaps there is a medical culture in NJ that tends towards overdiagnosis. Perhaps their medical schools need to teach statistics better.

There is a lot of variance out there. People are different from each other. Every skill or characteristic of a person lies within a distribution. Half of people are below the average, and half above. There is a statistical term called "standard deviation" that describes how far from the average a person is relative to how widely people vary from each other in general. Most people are within 1 standard deviation of the average. There is precedent for saying that a person has a disorder when a characteristic of health or function is more than two standard deviations worse than average (a bit more than 2% of the population). Mental retardation is considered when a child's IQ is two standard deviations or more from the average. Many psychological tests flag problems when a person scores more than two standard deviations from the average on scales related to depression, anxiety, etc... But that alone should not be used to demark disorders or assign diagnoses. There has to be a convergence of information showing meaningful dysfunction.

Based on this precedent, we should not be surprised if the ASD diagnosis rate approaches 1 in 40. Kids who are socially awkward enough to rate as two standard deviations away from average on whatever metric someone makes up (there are a bunch of ASD symptom checklists out there, and they are not used well) would qualify for ASD. Asperger's and "high-functioning autism" are ballooning. We've gone past the point where formerly-mentally-retarded kids are being correctly identified with ASD, up to the point where formerly normal kids are being dragged into disorder land. They were probably called "weird" before, but is that something we need to fix? Is it really a problem?

I can't help but compare Asperger's to homosexuality. It was not long ago that homosexuality was considered a mental disorder. Now the legitimate medical community accepts homosexuals as healthy people who are just in a minority on a characteristic. We are surrounded by people who meet criteria for Asperger's, but they do well in academics, science, and technology. They are computer programmers and engineers and scientists and professors. Do we really need to say they are disordered because they're socially awkward and repetitive? Criteria C is redundant because criteria A necessarily involves social impairment. Are we really helping by imposing labels and interventions on these children?

Maybe. I don't know. I hope someone is recording a lot of data, and that there are enough "natural experiments" going on to eventually give us the answers. We definitely do need better standardization of diagnosis practices.

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Thursday, December 17, 2009

Prescription Information Availability

I got a little excited when I read that Congress might limit Big Pharma's ability to use doctors' prescription behaviors for their marketing. Of course, the proposed idea was quickly eliminated.

Pharmaceutical companies spend incredible amounts of money on marketing. Besides outright bribes to doctors with free food and paid speaking opportunities (averaging $3900 per targeted doctor), the marketers use information on which doctors are prescribing what and how often to custom-tailor their pitches. They can tell which of their sales techniques are most effective by looking at the spikes in prescriptions after each sales pitch. They know if a doctor was a waste of bribes, and they can focus their efforts on the ones who respond well to incentives.

The companies will claim that their behavior is to help keep doctors up to date on what works, but that is an outright lie. The marketers push the new, still under patent, expensive drugs over the cheaper drugs regardless of effects. Expensive drugs that do not work better are touted. There is no good reason that doctors should listen to the obviously biased salesmen of a drug instead of looking at peer-reviewed research articles in selective journals. There are problems even with those articles, but they are better.

I have attended drug rep presentations at medical facilities. They use anecdotes about outlier cases to hype up the drug, and lay out some lunch and branded office supplies. The MDs in the room didn't look at the fine print, which revealed to me the variance in the drugs effects (40% of participants for one drug got worse, and those who got "better" were still severely ill, so why use this expensive drug with lots of side effects?). A medical degree is no guarantee that a person is going to be careful or attentive, or even understands statistics, or keeps up to date with research. There is practically zero oversight of doctors in most settings because they run the show and they only listen to each other. Doctors are fallible and subject to manipulation. Smart hospitals have banned drug reps.

I am all for accurate and complete information about drugs being disseminated to prescribers. It should be done by unbiased parties, and be presented in a way that doctors can understand, comparing the risks and benefits of the drugs, and I would also include the costs. The PDR is obviously inadequate, and tends to just collect dust on a shelf. No drug marketing should be allowed, ever. Until that happens, let's keep prescription information from the marketers so they are less able to target unethical and mentally weak doctors.

Consumer Reports, an independent organization, may be a good resource. They have a free website about drugs. For example, recent 60-study analysis showed that $10/month Doxazosin is as effective as $246/month Flomax. Flomax is heavily advertised because it is new and expensive, not because it is more helpful.

Sunday, December 13, 2009

Rationing is Ethical

This is what I'm talking about. Allocate our finite resources in such a way that they bring our whole country the greatest benefits. It is completely detrimental and unsustainable to keep spending huge amounts of our resources at the end of life. I want my tax dollars and insurance premiums to result in the greatest possible increase in quality-adjusted life-years, though I understand the inherent subjectivity in determining how to measure or weigh "quality". Even ignoring quality and focusing on life-years would be a vast improvement over our current system. $80,000 of Avastin for a few more months of life? That money could lead to dozens or scores of extra life-years if spent elsewhere. If we, as a country, invested more in childhood nutrition, health education, and smoking cessation instead of pharmaceutical and biotech companies, we would have greater national health and longer, happier lives.