Health Wonk Review #21

Is there a happier day of the bi-week than HWR Day? Not for us health wonks. Here is this round of health policy blogging, complete with first-time hosting jitters.

R-E-S-P-E-C-T

Over at RDoctor.com, Aleksandr Kavokin interviews Kim McAllister, an ER/critical care nurse and host of Emergiblog, about the nursing profession and operating a web site devoted to that profession.

What Price, Scooters?

Bob Vineyard of InsureBlog wrestles with the inanities of administered pricing in Medicare. The most recent round of silliness? How much Medicare should pay for power wheelchairs and scooters. Seems that Medicare outlays for those geezer-pleasers jumped 28-fold in eight years. Medicare’s bureaucracy just reduced the amount it pays for the things, having gotten the impression that maybe they were paying too much. Gosh, do you think?

What Price, Biologics?

Sure, we want inexpensive biotech drugs. But some (read: biotech innovators) claim that biogenerics are impossible. David Williams of Health Business Blog has “a better idea than biogenerics.” Rather than allow biogenerics, Williams suggests slapping price controls on biotech drugs after an initial period of market exclusivity.

What Price, Medicare Private Plans?

In related news, the Century Foundation’s Leif Wellington Haase discusses the consequences of having Medicare pay private health plans based on the average senior’s expenses when plans have the ability to disproportionately enroll seniors with below-average expenses. It doesn’t take a genius to figure out that taxpayers end up paying more.

Haase concludes that Medicare should just give seniors the cash and let markets sort it out. No wait – that’s my conclusion.

Haase concludes that overpayments to Part D and Medicare Advantage plans should temper the enthusiasm of those who think that markets forces are doing wonders for Medicare. (Hey, that’s my conclusion too.) Haase also suggests that those overpayments “ought to be used for more benefits or for deficit reduction, not for drug company and insurer profits.”

Sine Qua Non of Controlling Health Spending

Speaking of things skewed, Ezra Klein rightly reminds us that we ain’t gonna make much of a dent in health expenditures until we restrain consumption among the 5 percent of patients who account for half of the spending. Klein deserves two cheers (hip! hip!) for noting that the rules surrounding health savings accounts (HSAs) are too restrictive to bring cost-consciousness to all such expenditures.

The host dangles that third cheer in front of Klein to see if he can be cajoled into acknowledging that, if widely adopted, HSAs could bring price sensitivity to more than 60 percent of medical expenditures by the non-elderly. Over at EconLog, Bryan Caplan offers another reason why Klein may be too pessimistic about the ability of HSAs to reduce above-the-deductible spending.

Save a Life, Buy an Organ

Every year, over 6,000 Americans die while waiting for an organ transplant because Congress prohibits payments to organ providers, thereby creating an artificial shortage. (Who says we don’t ration health care?) The always educational Healthcare Economist notes that support for payments to organ providers is bubbling up in some interesting places. You’ll never guess which country eliminated their waiting lists with a considerably more liberal organ procurement system than ours.

Is Health a Human Right?

The American Public Health Association made human rights the theme of its convention this year, and the Health Affairs blog is all over it. Parmeeth Atwal provides the background and interviews American Public Health Association president Georges Benjamin. Commenters include George Annas, Larry Gostin, and Sophie Gruskin.

Build Your Human Capital

Rita Schwab offers the following advice to those looking to excel in health care: attend some of the gazillion conferences put on by the industry every year. How to choose among them? Schwab has some ideas.

Cut to Cure? Or Ride It out?

Over at Workers’ Comp Insider, Jon Coppelman blogs a new study showing that patients who do not undergo surgery for a herniated disc eventually do just as well as those who do undergo surgery. The tradeoff is that they have to live with the pain a while longer.

But if the injury occurred on the job, workers’ comp provides an interesting twist: because comp pays as long as the injured worker is unable to work, that creates an incentive to forgo surgery and collect 2/3 of one’s salary while not working. Coppelman thinks insurers and employers would do well to steer clear of those costs – i.e., don’t start discouraging surgery.

How to Stand up to Your Rheumatologist

Add India’s to the list of health care sectors that aren’t following best-practice guidelines. Or so says Dr. Qaedjohar Dhariwal, an orthopedist writing at orthINDIA. Dr. Qaed lists “ten things any decent rheumatologist should be implementing in his practice” and advises that if your doc doesn’t make it past Thing Number One, “ditch him.”

The Hardest-Working Man in Health-Care-Blog Business

Matthew Holt, writing at Spot-on, thinks about what the Democrats might do if they had a Republican-like desire to reward their base, and how they’d need to create the political coalition to force through universal health care. Holt writes that a politically viable plan would have to (1) cover all the uninsured, (2) maintain the incomes and autonomy of doctors and hospitals, and somehow at the same time (3) convince employers and taxpayers that they won’t end up paying more. (Quoth Ned Flanders…)

As if that weren’t heavy lifting enough, over at The Health Care Blog Holt interviews Lonny Reisman, CEO of Active Health Management, a company that manages care using claims and lab data from insurers.

I’m not Going to Pay a Lot for This Procedure

Shahid Shah (a.k.a. The Healthcare IT Guy) gives a forum to Chini Krishnan, founder and CEO of Vimo.com, which hopes “to be the Lending Tree of healthcare and offer comparison shopping for surgical procedures, insurance, doctors, health savings accounts, and hospitals.” Krishnan expects that HSAs and other forms of consumer-directed health plans (CDHPs) will encourage the development of tools that help consumers make smarter decisions – and argues that CDHPs would have failed pre-Al Gore (read: before we had the internet).

One Spoonful at a Time

The title of this brief blurb comes from a New York Times Magazine article praised by Jon Schnaars at the Anxiety, Addiction and Depression Treatments blog. Schnaars provides links to that article and others on the struggle faced by families who are fighting anorexia.

Choose Your Enemies Wisely

Fard Johnmar, of Envisioning 2.0, takes a look at the recent flap between the American Heart Association and Pfizer over the release of data relating to Pfizer’s “good cholesterol” medication torcetrapib. Johnmar shows how this incident highlights the tension between numerous competing interests: medical societies vs. drug makers, medical societies vs. “outside” investors, medical societies vs. the SEC, small vs. large drug makers…

Duking It out in Denver

Speaking of industry bigwigs not getting along, Louise of the Colorado Health Insurance Insider laments the way that patients are getting jerked around in the spat between HCA and United HealthCare in Denver. Louise rightly questions whether those CEOs are really earning their seven- and eight-figure salaries – but did she call the U.S. health care sector a free market?

Shameless Self-Promotion

Finally, your humble host would be remiss were he not to plug the Cato Institute’s recent offerings on Indiana Gov. Mitch Daniels’ new health plan, a Health Affairs review of the Cato book Healthy Competition, and the ethics of the Born-Alive Infant Protection Act.

Next!

Health Wonk Review #22 is scheduled for December 14 and is to be hosted by Rita Schwab of MSSPNexus Blog. Get your entries in by Wednesday, December 13, at 9am EST.

Sen. Richard Lugar: Public Menace

Representatives of NATO are in Latvia this week to talk about the alliance. But no international gathering is safe from the careful eye of Sen. Richard Lugar (R-IN). On the eve of the NATO meeting, Lugar gave a speech at conference sponsored by the German Marshall Fund arguing that NATO must be capable of responding if producing states use energy “as a weapon” to cut supplies to NATO members.

Now, think about this for a minute. Lugar is implying that if A decides not to sell to B, then B has the right to shoot A in the head. If A decides to sell less to B than B might like, B is apparently also justified in shooting A in the head.

Sometimes, however, military retaliation might be a bit over the top – even for Sen. Lugar. In those cases, Sen. Lugar proposes that consumers diversify their sources of supply as a preventative measure. Apparently, this would never occur to market actors. This would only occur to United States Senators.

And now, let’s toast the new Democratic majority in the Senate ….

Global Warming? Let’s Hope So …

If the climate researchers at the Russian Academy of Sciences are right, global warming might turn out to be a blessing. Based on their analysis of solar cycles, scientists there are increasingly worried that a mini ice-age is around the corner. Warming might be the only thing standing between us and a glacial blitzkrieg due around 2055.

Just throwing that out there ….

Enviro Myth-Making about Easter Island

If you pay attention to the enviro press, you’ll find a lot of references these days to Jared Diamond, author of Collapse: How Societies Choose to Fail or Succeed. Time after time, we’re told, human societies have collapsed upon themselves because they didn’t pay enough attention to what they were doing to Mama Earth. Past is prologue, so if we don’t start paying attention to the Green doomsayers, we might as well kiss our butts goodbye.

But is it true? Take, for instance, the example of Easter Island, one of the main exhibits in this enviro show trial. Did the natives really go nuts strip-mining that island of resources? It turns out that the answer is no. According to a new study forthcoming in the Journal of Archaeological Science, the entire Diamond narrative is bunk:

Easter Island (Rapa Nui) has become the paragon for prehistoric human induced ecological catastrophe and cultural collapse. Today a popular narrative recounts an obsession with monumental statuary - a mania for moai - that led to the island’s ecological devastation and the collapse of the ancient civilization. Scholars offer this story as a parable for our own reckless destruction of the global environment.

In this paper, I critically examine the historical and popular narrative of human-induced environmental change, its causes and consequences, for Rapa Nui. I review new and emerging Rapa Nui evidence, compare ecological and palaeo-environmental data from the Hawaiian and other Pacific Islands, and offer some perspectives for the island’s prehistoric ecological transformation and its consequences. I argue here that a revised, later chronology for Rapa Nui calls into question aspects of the current model for the island’s ecological history. A critical examination of the paleo-environmental and archaeological records also reveals a more complex historical ecology for the island; one best explained by a synergy of impacts, rather than simply the reckless over-exploitation by prehistoric Polynesians. While my focus is on the palaeo-environmental record, it is essential to disentangle the related notion of prehistoric “ecocide” with the demographic collapse (i.e., post-contact genocide) that would come centuries later with European disease, slave-trading, and the other abuses heaped upon the Rapanui people. Contrary to the now popular narratives (e.g., Diamond, 1995 and Diamond, 2005), prehistoric deforestation did not cause population collapse, nor was it associated with it. Such an argument can be based only on facile assumptions and an uncritical faith in contradictory accounts from the island’s oral histories; but this is a critical subject worthy of detailed, continued examination (see Metraux, 1957, Peiser, 2005 and Rainbird, 2002).

There’s a reason people like me are deeply suspicious of virtually everything environmentalists have to say. After you run across this and similar vignettes hundreds of times over, you get to the point where you don’t believe a word these people say. They might be right here and there, but you’ll never know for sure unless you check it out for yourself.

Dasgupta vs. Stern

The academic criticisms of the Stern Review on the Economics of Climate Change keep pouring in. Prof. William Nordhaus’ trenchant critique is echoed by Prof. Partha Dasgupta, the Frank Ramsey professor of economics at Cambridge. Dasgupta, like Nordhaus, finds that the difference between Nicholas Stern’s calculations regarding the future costs associated with global warming and the far less alarmist calculations that characterize the academic literature has little to do with new facts about warming, better computer models, or anything of the kind. It’s all about discount rates.

Like Nordhaus, Dasgupta thinks that Stern’s moral admonition to treat generations the same across time is demonstrably ridiculous no matter how superficially attractive the idea might be at first blush. Assume, for instance, that we apply a 0.1% discount rate for future investment and assume a social rate of return on investment of 4% a year.

It is an easy calculation to show that the current generation in that model ought to save a full 97.5% of its GDP for the future! You should know that the aggregate savings ratio in the UK is currently about 15% of GDP. Should we accept the Review’s implied recommendations for this country’s overall savings? Of course not. A 97.5% savings rate is so patently absurd a figure that we must reject it out of hand. To accept it would be to claim that the current generation in the model economy ought literally to impoverish itself for the sake of future generations.

As economist Stephen Landsburg once famously wrote at Slate, anyone honestly concerned about equity would happily confiscate as much of the wealth from future generations that they could get their hands on. Anyway, read Dasgupta’s paper here.

Nordhaus vs. Stern

When the Stern Review on the Economics of Climate Change was released a few weeks back, I got a bevy of calls from reporters asking what I thought of it.  Of course, it’s hard to say anything intelligent about a 700+ page report that was released only hours earlier, so all I could do was quickly peruse the executive summary, speed-glance through the most pertinent sounding chapters, and opine like the wind.  While I thought I did a reasonable enough job summarizing the main issues at hand given the circumstances, the experience demonstrates a fundamental problem with journalism that is unlikely to ever go away.  To wit, reporters demand an immediate reaction when some new study or paper comes out, and the news cycle doesn’t last long enough to allow for particularly informed and/or careful review of many of these said studies or papers.  By the time that informed and careful response is ready, reporters have moved on to something else.  The deck is stacked in favor of the authors, who seldom have to defend against anything but superficial or relatively poorly-informed criticism in the popular press.

One of the things I was most interested in at the time was what economists who specialized in the economics of climate change had to say about the Stern Review.  The leading academic on this subject is William Nordhaus, an economist at Yale (another is Prof. Robert Mendelsohn at the same university.  Prof. Mendelsohn’s response to the Stern Review will be published in the next issue of Cato’s Regulation magazine).  When I emailed Prof. Nordhaus about the Stern Review, I got a rather short and vague reply.  Nicholas Stern is a good economist, Prof. Nordhaus said, and the report looked like a serious undertaking; the right questions were asked and the answers provided looked interesting.  Beyond that, little else.  Reporters I talked to told me this is what he had sent them as well.  Apparently, Nordhaus was not ready to jump into the discussion yet.

Reporters moved on, but Nordhaus did not.  Over the next several weeks, he apparently went to work on the document and by last week he was ready to offer up some thoughts.  Despite the fact that this highly credentialed economist finds that ”it is impossible for mortals outside the group that did the modeling to understand the detailed results of the Review,” his analysis is illuminating.  While no reporter is likely to write about Nordhaus’ take on Stern now, it is worth your time if you wonder whether an economic disaster of epic proportions really awaits us lest we do something drastic to reduce greenhouse gas emissions.  The answer; probably not.

The gist of the matter is this:  Academic economists who specialize in climate change generally agree that warming - if the “consensus” of scientific opinion as reported by the Intergovernmental Panel on Climate Change is correct - will only reduce global GDP by 0-3% per year and that those costs won’t be evident until well into the future.  The Stern Review, however, reports that losses may total as much as 20% of global GDP if warming is left unaddressed.  Why the disagreement?

While there are a number of issues in play, the main thing explaining the differing calculations is the extent to which future warming is discounted into the present.  Most economist use discount rates ranging from 3-5% when trying to put a price tag on future damages.  Stern argues that this is ethically indefensible - losses tomorrow, or even 200 years from tomorrow, are just as worth worrying about as losses today.  If you apply a 0.1% discount rate (Stern’s figure) rather than, say, a 5% discount rate (my suggestion, which matches the return on Treasury bills - or, put another way, the figure people apply themselves when considering the value of money today versus the value of money tomorrow) or a 3% discount rate (Nordhaus’s figure, although he is happy to confess that other figures are perfectly defensible), then you’re going to get a huge price tag for global warming.  Apply higher discount rates, and the price tag deflates to such an extent that it’s impossible to justify spending anything near what Stern wants us to spend to reduce greenhouse gas emissions.

Is Stern right to argue that we are morally required to treat losses to future generations in exactly the same manner that we treat losses to present generations?  Not necessarily:

Quite another ethical stance would be to hold that each generation should leave at least as much total societal capital (tangible, natural, human, and technological) as it inherited.  This would admit a wide array of social discount rates.  A third alternative would be a Rawlsian perspective that societies should maximize the economic well-being of the poorest generation.  Under this policy, current consumption would increase sharply to reflect likely future improvements in productivity.  Yet a fourth perspective would be a precautionary (minimax) principle in which societies maximize the minimum consumption along the riskiest path; this might involve stockpiling vaccines, grain, oil, and water in contemplation of possible plagues and famines.  Without choosing among these positions, it should be clear that alternative perspectives are possible.

Note that if you are an admirer of political philosopher John Rawls - as most of the Left most definitely is - then you should probably embrace the use of a high discount rate. 

Anyway, what if we use Stern’s discount rate regardless?  Nordhaus thinks it leads to palpably ridiculous policy prescriptions:

Suppose that scientists discover that a wrinkle in the climatic system will cause damages equal to 0.01 percent of [global] output starting in 2200 and continuing at that rate thereafter.  How large a one-time investment would be justified today to remove the wrinkle starting after two centuries?  The answer is that a payment of 15 percent of [the] world’s consumption today (approximately $7 trillion) would pass the [Stern] Review’s cost-benefit test.  This seems completely absurd.

Still happy with a near-zero discount rate?  What if we applied that philosophy in other policy arenas where the same issue arises - like, say, foreign policy?  Nordhaus echoes an argument I made myself several years ago:

While this feature of low discounting might appear benign in climate-change policy, we could imagine other areas where the implications could themselves be dangerous.  Imagine the preventative war strategies that might be devised with low social discount rates.  Countries might start wars today because of the possibility of nuclear proliferation a century ahead; or because of a potential adverse shift in the balance of power two centuries ahead; or because of speculative futuristic technologies three centuries ahead.  It is not clear how long the globe could long survive the calculations and machinations of zero-discount rate military powers.

Nordhaus’s commentary on Stern is only 21 pages double-spaced, and there’s more intellectual goodies therein.  Read it.  Learn it.  Live it.