• The Cost Disease: Chapters 5-6, ctd.

    I wrote,

    The [quality-adjusted] life-year as a unit has not changed. Not ever.

    I believe this is wrong. It is my understanding that the quality-adjusting of life-years is a type of utility adjustment. The disutility (inconvenience, cost, life dissatisfaction) of a health condition can certainly change over time.

    Consider, for example, a low-extremity disability such that you cannot walk. If you, or someone like you, experienced such a disability 100 years ago, your change in quality of life would likely be different than if you experienced it today. Your relative disutility from that disability would probably be lower today than a century ago and, in part, for reasons having nothing to do with health care. I’ll give you two examples.

    First, the nature of the job market is different today than a century ago. There are many more jobs that don’t require use of one’s lower extremities today. I work in one. It’s the ubiquitous office job. All I really need to do my job is my brain, the vital organs that make it work, and a computer with an internet connection. Eyes help a lot, as do use of hands and arms. As much as I like them, my legs hardly matter for my work. Such jobs were not as common many decades ago. So, for access to work alone, were I a person with a lower extremity disability I’d be better off today.

    Second — and here I am speculating a bit — the difference in cost (including time cost) of a mile of transportation is not so different today between persons with and without a lower extremity disability. Assistive devices, public transportation (in some areas) and readily available motor vehicle modifications make it so. That’s not to say those don’t cost something.

    A century ago, I imagine the cost of a mile of transportation was much higher for someone who could not walk than for someone who could. A lot more transportation was by foot or by means that require use of lower extremities (horse, say). The relative disutility of life without use of legs for this reason was probably higher than it would be today.

    For these, and other reasons, the quality-adjusted life-year (QALY) of a lower extremity disability may be higher today than a century ago. Consequently, it is not true that QALYs don’t change over time.

    For all that, I am still not convinced that we can or should ignore quality-adjustment when considering productivity changes in the health sector. Baumol didn’t convince me. Can you?


    • I believe Baumol’s point is that even though quality may have improved, labor resources are still required and cannot be replaced by capital or other non-labor resources as it can in the manufacturing sector. For instance, take the extreme case, the quality of the music from a jazz quartet has also improved over time because of better instruments, speakers, etc. but 4 musicians are still required.

      • Sure, if you fixate on one specific delivery method (live, jazz quartet). Why isn’t this a units issue? Switch the units to an hour of listening to music and suddenly a lot of the quality is internalized. He even admits that the cost of live music is reduced by changes in transportation cost. But, fold in digital distribution and it’s a world of difference. Can we really ignore that? Why?

    • No, we cannot ignore quality but abstracting away from quality issues makes it easier to see his point about how difficult it is to substitute for labor in the production process when it comes to services. Once we consider quality issues, then the Baumol cost disease theory becomes an empirical issue. Hartwig (2008) provides a creative test not involving the measurement of medical care prices, which is difficult at best, and offers some empirical evidence for the cost disease theory. See http://www.sciencedirect.com/science/article/pii/S0167629607001105.

      • Agreed. But Baumol is making a stronger claim. He’s not just saying it’s hard to incorporate quality. He’s saying that even those who think it would be valuable to do so in principle are wrong. I think he’s taken the more difficult side of the debate on this, and he has not convinced me.

    • I’d assume that the quality of life would adjust over time for an individual. Read Oliver Sacks’s cases about people who lost their ability to see color, to smell, or other normal function. He wrote eloquently about an artist who lost his ability to see color. In black and white, his food looked disgusting. His wife’s face was the color of a rat — guess what that did to his love life.
      But over time he adjusted. What he saw was normal and while he had dreams in color, the lack of color in his normal environment ceased to bother him.

      I’d assume all losses of functionality would be the same.

      • I don’t know. I have gotten proficient at accommodating my disability (see comment below about opening revolving doors with my forehead) but in the past 10 years, I sill wake up every single morning wishing I had my leg back. My quality of life is significantly worse.

        Don’t confuse learning to live with a disability with non-diminished QOL.

    • Speculation never ends well — and in this instance, some research before making assumptions that a the cost for a mile of transport for someone with/without a lower limb disability is roughly equal would have been welcome.

      I might have agreed with you before I became disabled. But here are a few motes from my life:

      1. some physicists have shown that it takes 45% more effort to ambulate using crutches compared to “normal” walking. This alone should convince you that the “cost” is substantially higher. If not in time, than in effort.

      2. having lived in NYC for 10+ years with a lower limb disability, I can assure you that it “costs” me significantly more in both travel time and monetary costs than when I was able bodied. For example, many subways are not handicapped accessible. While I can get up and down stairs, it is extremely difficult. Consider my daily commute from Brooklyn to lower Manhattan: 1 set of stairs to descend into the station. 2 flights of stairs up followed by 2 more flights of stairs down to catch a transfer. 1 more LONG flight of stairs up to exit the subway at my destination. Arrive at office, confronted by revolving doors. Have you ever considered how hard it is to “open” revolving doors whilst on crutches? I have gotten very proficient at using my forehead to “push” the door open.

      My commute take 30 minutes longer compared to my able bodied coworker who lives at the same subway stop because of the stairs. Unfortunately, taking the bus (accessible, no stairs) takes even longer. Taking a cab every day is economically infeasible. The extra time I spend commuting also means less time for work and leisure. When I first became disabled, I was an hourly wage worker, and every minute I was not at work, was money that I lost. The additional 5 hours/week I spent commuting (30 min additional each way x 5 days a week) was equivalent to almost $250 in lost wages. You mention the dis-utility of being disabled, and how that might compared to 100 years ago. You forget that wages have steadily increased, so even a marginal dis-utility is manifest in much higher lost wage differential. Taking an extra hour to get somewhere 100 years ago probably didn’t cost you $50 in lost wages.

      3. After 3 years of appeals, I was finally recognized as permanently disabled by NYC DOT. This qualified me for disabled parking placard (let’s not even talk about how expensive it is to have a car in NYC) and access-a-ride. Access-a-ride is fantastic if you are unemployed, or if you want to wait up to 2 hours for a pickup/drop off.

      4. My commute could be drastically simplified if I could only afford to live in Manhattan. But shouldn’t that be part of the cost-equation, as well? I would be paying almost double in rent what I pay now to accommodate my disability. So while my commuting costs might be roughly equal to someone who was able bodied, my living costs would be drastically higher.

      5. Alternatively, I could live somewhere else where having a car would not be prohibitively expensive and logistically impossible (i.e. outside of NYC). But then you would have to consider the inefficiency that I am now forced to give up a good job, and one that I love to accommodate a missing lower leg.

      I know that case studies are never a substitute for a well designed trial, and I’m only one person, with one unique experience. But, being plugged into the disabled community has shown me that the daily frustrations, additional time and expense that just living my life costs is not unusual.