The Incidental Economist

Michael Hiltzik’s article in the LA Times doesn’t pull any punches:

But you’d be hard-pressed to find a campaign against the ACA as narrow-minded and dishonest as the one mounted by medical device manufacturers.

This campaign has been largely a data-free zone:

The industry can’t cite a single objective study that supports its contentions that the tax will suppress innovation in the field and make U.S. manufacturers globally uncompetitive.

Worth reading the entire thing.

@koutterson

In this week’s JAMA Internal Medicine, “Comparative Effectiveness of Intensity-Modulated Radiotherapy and Conventional Conformal Radiotherapy in the Treatment of Prostate Cancer After Radical Prostatectomy“:

Importance  Comparative effectiveness research of prostate cancer therapies is needed because of the development and rapid clinical adoption of newer and costlier treatments without proven clinical benefit. Radiotherapy is indicated after prostatectomy in select patients who have adverse pathologic features and in those with recurrent disease.

Objectives  To examine the patterns of use of intensity-modulated radiotherapy (IMRT), a newer, more expensive technology that may reduce radiation dose to adjacent organs compared with the older conformal radiotherapy (CRT) in the postprostatectomy setting, and to compare disease control and morbidity outcomes of these treatments.

Design and Setting  Data from the Surveillance, Epidemiology, and End Results–Medicare–linked database were used to identify patients with a diagnosis of prostate cancer who had received radiotherapy within 3 years after prostatectomy.

Participants  Patients who received IMRT or CRT.

Main Outcomes and Measures  The outcomes of 457 IMRT and 557 CRT patients who received radiotherapy between 2002 and 2007 were compared using their claims through 2009. We used propensity score methods to balance baseline characteristics and estimate adjusted incidence rate ratios (RRs) and their 95% CIs for measured outcomes.

Some patients benefit from radiation therapy after a prostatectomy. But the original method, conformal radiotherapy (CRT) required a fairly large amount of radiation. Intensity-modulated radiotherapy was supposed to fix this. It cost a lot more, though. Nonetheless, it went from being non-existent in 2000 to more than 82% of radiation therapy in 2009.

Is it better though? Does it reduce morbidity and mortality? Wouldn’t it be nice to know?

That’s what this study did. It used existing data to look at what happened to patients who received each type of therapy for three years after their prostatectomies. What did they find? There were basically no difference in the adjusted number of events between IMRT and CRT for each 100 person years with respect to the diagnosis of gastrointestinal events (9.4 vs. 9.9), urinary incontinence (11.8 vs. 12.0), or erectile dysfunction (11.7 vs. 13.8). There was also no significant difference in treatment for recurrent disease.

So why are we paying so much more for IMRT? Why is it being used in more than 80% of cases?

@aaronecarroll

I’ve written about fluoridation in my books. Putting fluoride in the drinking water has been called one of the ten greatest public health achievements of the 20th century.  Cavities are still the most common chronic disease in kids 6 to 19 years of age. Still, battles rage to reverse this policy.

Sarah Kliff has a nice summary of the history of this fight. Go read.

@aaronecarroll

How would you debate a wing nut? Cass Sunstein has a very encouraging and interesting answer.

For a positive answer, consider an intriguing study by Philip Fernbach, a University of Colorado business school professor, and his colleagues. Their central finding is that if you ask people to explain exactly why they think as they do, they discover how much they don’t know — and they become more humble and therefore more moderate. [...]

Interestingly, Fernbach and his co-authors found no increase in moderation when they asked people not to “describe all the details you know” about the likely effects of the various proposals, but simply to say why they believe what they do. If you ask people to give reasons for their beliefs, they tend to act as their own lawyers or public relations managers, and they don’t move toward greater moderation. The lesson is subtle: What produces an increase in humility, and hence moderation, is a request for an explanation of the causal mechanisms that underlie people’s beliefs.

Interestingly, what we do on this blog — provide evidence — is not what the investigators suggest works. I don’t know if they tested this approach, but it is well-known that evidence is confirming but not convincing. If the Fernbach study is right, what one should be doing is a lot more listening and asking than telling.

Sunstein’s column is worth a full read. Before commenting, at least do that  much. If you disagree, I ask that you explain exactly why and how much you know about this subject. The published study is gated, but what appears to be an ungated working paper version is here (PDF). It’s in my pile.

@afrakt

I’ve seen it suggested in the comments on this blog and elsewhere that low take-up rates among those eligible for Medicaid suggests they do not find the program to be of value. I have not seen any strong evidence to support that view, but I’m happy to look at it if it is suggested to me. Meanwhile, there are other potential reasons for low take-up rates including cognitive limitations.

A new study by Ifedayo Kuye, Richard Frank, and Michael McWilliams examines the relationship between cognitive limitations and awareness of and enrollment into Medicare Part D’s low-income subsidy (LIS) program, which offers reduced premiums and cost sharing for Medicare’s drug benefit to beneficiaries with incomes below 135% of the federal poverty line and assets below $6600 if single or $9910 if married (2010 figures). The investigators’ source of data was the Health and Retirement Survey (HRS). (Yes, I have switched from Medicaid to Part D’s LIS. They are different and serve different populations. Acknowledged.)

To assess overall cognitive abilities, the HRS uses a validated survey instrument modeled after the Telephone Interview for Cognitive Status, an adaptation of the Mini-Mental State Examination for use over the telephone. Participants were asked to complete a series of tasks assessing orientation, attention, memory, word recognition and comprehension, and ability to count and perform simple arithmetic. Summary cognition scores could range from 0 (no tasks completed correctly) to 35 (all tasks completed correctly).

The chart below reports Part D enrollment, LIS awareness, and LIS application as a percentage of LIS-eligible beneficiaries, by quartile of cognition score. The paper includes other results by other cognitive metrics, but this suffices to make my point. Results are adjusted for age, sex, race, ethnicity, health status, chronic conditions, depressive symptoms, and difficulties with activities of daily living.

It could still be true that beneficiaries with lower cognitive skills find LIS benefits to be of less value relative to those with higher cognitive skills. Maybe the forgoing is evidence of revealed preference. This is an argument based on a market model in which consumers are reasonably, if not perfectly, well-informed about their choices. Does it seem likely to you that people with low cognitive skills are as well informed as their otherwise equivalent high cognitive skill counterparts?

Meanwhile, we have to acknowledge that only 25.5% of high cognitive skill beneficiaries eligible for the LIS enroll in it, which is just under half of those who are aware of it. Almost two-thirds of them enroll in Part D. A large proportion of beneficiaries are forgoing support for a benefit for which they are eligible and for which they are enrolled. Why? Is this revealed preference for, effectively, a lower income? Would a well-informed consumer behave that way? And these are respondents who scored high in cognition!

@afrakt

Fungal meningitis from improperly compounded products at NECC (NEJM article here) killed 55 people and infected more than 600 others (CDC data here). All of these products originated in Massachusetts, but all of the injuries occurred in other states. But Massachusetts felt some responsibility for the failures at NECC, as acknowledged by both Gov. Patrick and the Interim Commissioner of Public Health.  The DPH enacted emergency regulations on Nov. 1, 2012 and the Governor’s special commission delivered a comprehensive set of recommendations.  Both efforts informed the Governor’s proposed legislation in January 2013 and several bills pending in the Massachusetts House and Senate.

In the interim, the Governor boosted the budget for inspections at compounding pharmacies.  In a series of surprise inspections, just 4 out of 37 compounding pharmacies passed.  The Governor proposed an additional $1 million for pharmacy inspections next year.

So it comes as a surprise that the Governor’s requested budget was cut to zero by the Massachusetts Senate Ways & Means FY 2014 proposed budget (4510-0772).  Sen. Keenan has filed an amendment to restore about $600,000 for additional compounding pharmacy inspections (proposed amendment 513), but it is not clear whether that amendment will pass or whether that amount is sufficient. Action by the US Congress may take some time, so it is up to the states to police compounding pharmacies until we get federal legislation.

Prior TIE posts here.  I was an appointed member of the special commission.

@koutterson 

Sound Medicine is a radio show produced by the Indiana University School of Medicine and WFYI Public Radio. In the last few years, I’ve become their go-to guy on health policy. So, for those of you who would find your day brightened by the sound of my voice, enjoy the following:

Sound Medicine” health care policy analyst Aaron Carroll, M.D., M.S., weighs in on the actions employers are considering to reduce health care costs. Some companies have begun offering incentives like gym memberships to employees who lose weight; others have raised the cost of insurance for those who smoke. Some, like Honeywell, fine employees up to $1,000 for an elective procedure if they don’t seek a second opinion. According to Dr. Carroll, the companies are offering incentives in hopes of avoiding future costs caused by heart attacks from obesity, for instance, or smoking-related illnesses. But while losing weight or quitting smoking may reward the individual, the company may not save if the employee leaves in a few years, with the insurance savings lost to another employer.

Full audio after the jump

@aaronecarroll

Read the rest of this entry »

My post on Saturday about Axel Leijonhufvud’s paper reminded a reader (OK, it was my mom) of the 1956 paper in American Anthropologist titled “Body Ritual among the Nacirema,” by Horace Mitchell Miner.

Nacirema culture is characterized by a highly developed market economy which has evolved in a rich natural habitat. While much of the people’s time is devoted to economic pursuits, a large part of the fruits of these labors and a considerable portion of the day are spent in ritual activity. The focus of this activity is the human body, the appearance and health of which loom as a dominant concern in the ethos of the people. While such a concern is certainly not unusual, its ceremonial aspects and associated philosophy are unique.

More here.

@afrakt

Keith Humphreys is one of the nation’s top addiction services researchers. He leads an important center at the Stanford VA. During 2009 and 2010, he was Senior Policy Advisor at the White House Office of Drug Control Policy. While there, Keith helped craft provisions of the Affordable Care Act to expand coverage for substance abuse and mental health services for 62 million Americans.

I caught up with Keith for a Curbside Consult video conversation at healthinsurance.org. We touched on the politics of Medicare mental health parity, how ACA will change America’s treatment system, alcohol as the substance which sends more Americans to prison than any other, whether improved policies could reduce crime by individuals with severe mental illness. I hope that TIE readers will enjoy it.

@haroldpollack

From Life Among the Econ (ungated PDF), by Axel Leijonhufvud (1973):

The satire is worth a read. Despite its age it holds up well. I promise a smile, if not a laugh out loud. Hat tip to Harold Pollack on Twitter. Tyler Cowen blogged on it in 2007. Click through for a few quotes.

@afrakt