Something Not Unlike Research

Obesity is not a personality disorder

post by Bill Gardner

Jonathan Chait, commenting on the criticism that Governor Christie appears to lack discipline, because he is fat.

The American overclass prizes thinness... and the disgust privileged Americans feel toward fat people, who are more likely to be poor and middle-class, dresses itself up as medical advice... The premise here is that weight is a marker of personal discipline, and anybody who’s fat must simply be too lazy to take care of themselves. This conveniently fulfills the desire to categorize obesity as a character flaw, but ignores the extreme difficulty of sustained weight loss.

Chait is absolutely^3 right. Being heavy or obese is not a character flaw.

But even that argument is wrong if the premise is that it would be okay to be disgusted by obesity if it were a character flaw. Having a character flaw -- being narcissistic, being dependent, being anti-social -- should evoke our empathy, not our disgust.

What causes racial inequities in health?

post by Bill Gardner

The image is a recruitment letter from the Tuskegee experiment.

I am reading Angus Deaton's working paper, "What does the empirical evidence tell us about the injustice of health inequalities?" He notes the pronounced racial difference in health in the US.

In 2006, life expectancy at birth was 4.1 years less forAfrican Americans than for white Americans. There are also pronounced racial  differences in treatment patterns, for example for cardiovascular disease... or knee arthoplasty...

Why does this happen?

The conventional explanation for these inequalities, endorsed by a 2002 report of the National Academies of Sciences..., is that the encounter between healthcare providers and patients leads to poorer treatment of African Americans by largely white providers. 

If you accept this explanation for racial disparities in health care, then you may believe that the solution is to train culturally-competent health care providers, that is, providers who are able to interact effectively with persons from different cultures to deliver care.

Deaton does not dispute the cultural incompetence explanation, but

there is another, perhaps more obvious explanation, which is that African-Americans receive worse health care because the hospitals and clinics that serve them are of lower quality than the hospitals and clinics attended by other Americans. Hospitals in the US are run on something close to an apartheid basis, with few white patients in the hospitals that treat mostly African-Americans, and vice versa...; doctors and nurses are much less segregated, with many white doctors in “black” hospitals, and African-American doctors in “white” hospitals. 

That is, because we live in a largely segregated society, race is highly correlated with geography. This point does not seem to be widely recognized in the literature on health disparities. (A technical implication is that a regression analysis of disparities that does not account for the spatial clustering of data is likely to omit an important variable.) This clustering matters because

The “black” hospitals have worse outcomes, are less well-provisioned, their pharmacies have fewer drugs, and their providers are less well-qualified... In consequence, people who live in cities with large African American populations—both African-Americans and whites who live in those areas—have poorer health.

Both the "doctors are culturally incompetent" and "hospitals serving blacks are under-resourced" causes for health disparities would represent gross injustices. Both could be true. My sense, however, is that the medical establishment and many disparities researchers have attached themselves to the cultural competence explanation. It is the kind of problem that seems like it could be fixed by HR department training, or continuing medical education. Providing facilities and providers of equal quality to everyone, regardless of race or income, would be both expensive and -- shall we say -- politically difficult.

h/t to Mike Foster, for helping clarify these matters for me.

 

Where all the women are strong, all the men are good looking, and the doctors are below the average

post by Paul Kelleher

Aaron Carrol reports and comments on a recent survey of primary care physicians:

Could it be that doctors might practice more aggressively because when they do, they make more? Well, only 3% believed that financial considerations could influence their own practice. Most, however, thought that other physicians would be affected by such things.

In addition to reminding me of Garrison Keillor's tag line about Lake Woebegone, I am reminded of this passage from Robert Frank's "Why Is Cost-Benefit Analysis So Controversial?":

Yet a potentially more worrisome aspect of the consequentialist position remains, which is that people who view their ethical choices in cost-benefit terms must also construct their own estimates of the relevant costs and benefits. The obvious concern is that their estimates will be self-serving. More than 90 percent of all drivers, for example, feel sure they are better than average. More than 99 percent of high-school students think they are above average in terms of their ability to get along with others. Ninety-four percent of college professors believe they are more productive than their average colleague.

[I deleted my final joke here. Don't worry, you didn't miss anything.]

 

It's good to be the King. Isn't it?

post by Bill Gardner

From Angus Deaton, in a manuscript about the health gradient, the finding that social advantage is associated with better health. The health gradient is found in societies through out the world; which makes us believe that it is somehow baked into social life. But health and social advantage have not always been associated.

It is sometimes supposed that the gradient has always been with us, that rich people have always lived healthier and longer lives than poor people. That this supposition is generally false is vividly shown by Harris (2004, Figure 2) who compares the life expectancies at birth of the general population in England with that of ducal families. From the middle of the 16th to the middle of the 19th century, there was little obvious trend in general life expectancy. For the ducal families up to 1750, life expectancy was no higher than, and sometimes lower than, the life expectancy of the general population. However, during the century after 1750, the life prospects of the aristocrats pulled away from those of the general population, and by 1850–74, they had an advantage of about 20 years. After 1850, the modern increase in life expectancy became established in the general population. Johansson (2009) tells a similar story for the British royals compared to the general population, though the royals began with an even lower life expectancy at birth.

I suppose we could have learned this from Shakespeare. 

The health gradient is, in my view, the central injustice. It has not always been here, so perhaps we can make it go away again.

 

Do Physician Earnings in the U.S. Offset the Costs of Medical Education?

post by Paul Kelleher

In response to my post this morning on international comparisons in physician earnings, Brendan Saloner asked in comments: "What about the higher cost of graduate medical education and time spent in low paying residencies, in the United States? How is that factored in?"

This is an important question, but note that the answer is unlikely to dull the force of the finding I reported, namely that the ratio of physician earnings to high-earners' income is lower in the U.S. than in [the average of] non-U.S. OECD countries. Unlike most other OECD countries, medical training in the U.S. is not financed largely by the public sector. So one might expect U.S. physicians to demand relatively more compensation in order to offset the loans they take out. But, again, physicians in other countries tend to make more as a percentage of the average high earner than do physicians in the U.S.  

It is still true, of course, that physicians in the U.S. make more in absolute terms than those in other countries. But how much more, once medical education is factored in? A recent paper by Laugesen and Glied that I cited this morning addresses this issue (whether they address it adequately is for you social scientists to decide!):

If a physician [in the U.S.] practiced for thirty-five years (based on a present-value formula), the additional earnings, net of expenses, required to pay off this [average tuition] investment would amount to about $21,300 per year for a primary care physician and about $24,400 per year for an orthopedic surgeon.

Although the tuition cost of medical education in the United States borne by individuals is substantial, it cannot fully account for the observed differences between the earnings of US physicians and physicians in all other countries. The difference between annual net incomes, after practice expenses, of primary care physicians in the United States and in the second most costly country, the United Kingdom, is $27,000—somewhat more than the estimated $21,300 per year of practice required to recoup the average tuition investment in education. The difference between the annual net incomes of orthopedic surgeons in the United States and the United Kingdom is $118,000—nearly five times the estimated $24,400 difference in investment repayment costs.

According to the McKinsey report I also cited this morning, of the $643 billion dollars that the U.S. spent in 2006 beyond the spending that would be estimated by its wealth, $64 billion is accounted for by higher-than-expected physician compensation.  

What can academics learn from think tanks?

post by Bill Gardner

Judy Sebba of the University of Sussex has a useful post on getting research into policy. I wrote related posts here and here, as did Austin Frakt here and here. 

She notes that academic writing is often useless to decision makers. It can be impenetrably technical, or it can fail to offer clear outcomes or policy implications. Academics can learn from Think Tanks how to

synthesise, create or communicate information and give advice to the public and policy-makers...; [and] ...be far more ‘media savvy’ than academics [by working] with staff who have backgrounds in the communication industry...

If they do this, they can

link researchers and decision-makers or act as a ‘broker’ between them.

I made a similar point using this graph about the role of policy intellectuals in the research diffusion process.

Sebba notes, however, that

[Think tanks] do not subject their work to review by others and so the quality of their outputs are not assessed.

There is another problem with think tanks. Many are funded by stakeholders in the health industry, or they are closely tied to a political party, or both. Sometimes this results in 'analysis' that is just lightly disguised lobbying.

Partisan think tanks also risk being listened to only by the like-minded.   The graph below is a network analysis of linking patterns among conservative and liberal political blogs. The tight clustering suggests that many of these writers are simply echoing each other. 

So, what can academics learn from think tanks? Specifically, can they write timely articles with clear policy implications without getting caught in the webs of deep red or deep blue? Yes, I hope, if we can find ways to bring something like the accountability to the facts provided by peer review into academic blogging.

 

Do U.S. Physicians Earn More? Yes and No.

post by Paul Kelleher

Here is a Exhibit 14 from the McKinsey Global Institutes's Nov. 2008 report "Accounting For the Costs of U.S. Health Care":

This seems to suggest that there is something unusual about the U.S.: somehow physicians in America have a higher earnings-to-per capita GDP ratio than the OECD average. 

But this is just one metric one might use to compare U.S. physicians' earnings to those in other countries. Here is a table from a recent paper by David Cutler and Dan Ly:

 

The updated 2010 data used by Cutler/Ly still reveal a higher-than-trend ratio of U.S. physicians' earnings to per capita GDP. However, if one instead compares the ratio of earnings to the income of other high earners (i.e. income earners in the 95th to 99th percentile of the income distribution), the U.S. is actually below the non-U.S. OECD average. This is true both for specialists and general practitioners.

I was directed to the Cutler/Ly paper by a recent paper in Health Affairs by Miriam J. Laugesen and Sherry A. Glied, in which the authors argue that:

[T]he medical care delivery sector cannot be fully separated from the rest of the economy: Physicians everywhere are drawn from the peak of the educational distribution, and their earnings reflect the cost of drawing highly skilled people to the profession in an economy where the rewards for skilled individuals are higher than elsewhere.

ADDED LATER: To state it explicitly, Laugesen and Glied seem to be suggesting that instead of seeing the U.S. as the outlier (in terms of earnings/per capita GDP), you could see it as right there in the pack of all OECD countries (in terms of of earnings/high earners' incomes). The U.S.'s outlier status on the first score might then be a side-effect of (1) docs' salaries keeping up with high earners' as they do in all OECD countries and (2) the U.S.'s outlier status in income inequality.

Update: the cost of patients with multiple chronic conditions

Paul pointed out a statistic in an earlier post: "80% of Medicare dollars are spent on persons with five or more chronic conditions." I think he thought this was crazy, and I think he is right.  From the Agency for Health Research and Quality:

Expenses for people with one chronic condition were twice as great as for those without any chronic conditions. Spending for those with five or more chronic conditions was about 14 times greater than spending for those without any chronic conditions.¹⁴ Persons with five or more conditions also have high hospital expenditures. In New York State during 2002, of the 1.3 million different persons admitted to the hospital, the 27 percent with five or more chronic conditions accounted for 47 percent of all inpatient costs.¹⁵

So, the true situation is that people with multiple chronic conditions are much more expensive to care for than others, but they do not account for that great a percent of total Medicare spending.

The down side of writing fast... this was a 'fact' that was sufficiently implausible that I should have confirmed it. Live and learn.

Self-Rule and Mutual Concern

post by Paul Kelleher

In one of his first posts at his new philosophy-oriented blog, Will Wilkinson writes:

I like Bill [Glod]'s notion of freedom as self-rule, but I think specifying the meaning of "self-rule" is not at all easy, and does not obviously lead to what most of us would consider a "libertarian" conception of freedom. Of course, we're all constantly subject to the wills of others. People are constantly enjoining and entreating and wheedling and shaming and peer-pressuring and so forth. One doesn't want to say that self-rule or autonomy requires total immunity from the influence of others. And it's plainly circular to say the problem is being subject to an external will in a way that limits our freedom. But I think noting that helps us to see that the question is not really one of being subject to an external will or not, but of the way in which one is made subject to an external will.

I agree with Wilkinson that it is not wise to seek total freedom from the influence of others. In a modern economy, the state must play key roles to keep the wheels of economic prosperity turning. But I cannot support giving the state this power unless I am willing to let others exert control over me through political choices that determine how it will be used. What I can do, however, is demand that others take this influence they have over me seriously. Not only do I expect them to use it wisely--to forward only policies they think just and effective--but I also expect them to acknowledge the influence they have over my life and the special relationship that this creates between us. In trying to muddle through together the best we can, we make ourselves vulnerable to one another. I think this situation arguably gives rise to special duties of mutual concern. When you continue to cooperate with me even though I help to coerce you through support for laws that you may not fully agree with, I owe you something significant in return. What we give to one another is the sort of thing sports commentators refer to as "intangibles." It doesn't necessarily show up in a breakdown of national GDP, but it deserves special recognition nonetheless.*

I believe this approach to civic duty is in the same family as the outlook expressed in chapter 2 of Milton Friedman's Capitalism and Freedom. Consider the following passages:

[T]he organization of economic activity through voluntary exchange presumes that we have provided, through government, for the maintenance of law and order to prevent coercion of individual by another, the enforcement of contracts voluntarily entered into, the definition of the meaning of property rights, the interpretation and enforcement of such rights, and the provision of a monetary framework. (27)

[T]he characteristic feature of action through explicitly political channels is that it tends to require or to enforce substantial conformity...If we are to use some of our resources for such indivisible items, we must employ political channels to reconcile differences. The use of political channels, while inevitable, tends to strain the social cohesion essential for a stable society...Unanimity is, of course, an ideal...We must perforce accept something less. (23-4)

The notion of property...has become so much a part of us that we end to take it for granted, and fail to recognize the extent to which just what constitutes property and what rights the ownership of property confers are complex social creations rather than self-evident propositions...The [various forms of property] may perhaps emphasize the role of generally accepted social rules in the definition of property. It may suggest also that, in many cases, the existence of a well specified and generally accepted definition of property is far more important than just what the definition is. (26-7)

It is clear that Friedman acknowledges what John Rawls later termed "strains of commitment"--i.e. the fact that it can be difficult to continue one's cooperation under laws and policies one disagrees with or finds burdensome. And it is also clear that Friedman believes there's a role for the state that goes beyond the protection of some putative scheme of natural rights. This modern role leads to increased strains of commitment, since "Every extension of the range of issues for which explicit agreement is sought strains further the delicate threads that hold society together" (23-4). Given this situation, Friedman says it is most important that political channels deliver a decisive verdict on socially contested policies---at least then people will know what rules they are dealing with, and they can adjust to form rational plans.

I agree with Friedman that establishing rules of the game is of signal importance. But it should not overshadow the fact that social stability and economic prosperity depend on individuals' complying with the rules despite strains of commitment. Elsewhere Friedman refers to the "self-denying" character of normal political cooperation. I do not think it is a large jump from this outlook to one that says: when others give me their self-denying cooperation under laws I help to coercively impose upon them, I owe them something special in return. If that's right, then Friedman's stated view bears a family resemblance to a view on which these "intangibles" are the source of politically enforceable positive duties. For example, tax-financed social insurance programs may--may--be the proper vehicle by which our self-denying cooperation with one another is duly acknowledged and honored.

This variation on Friedman's outlook would take us beyond the libertarian's comfort zone of duties stemming from externalities. For my duty to support your medical care may have nothing to do with my causal relationship to your need, and everything to do with my social relationship to you. To use Wilkinson's phrase, this form of mutual concern may be what's required if we are to subject one another to an external will in the right way. 

*I am influenced here by the work of Richard W. Miller. For the most recent statement of his view, see chapter 2 of his Globalizing Justice. 

Getting it right and being on time

post by Bill Gardner

Austin Frakt responded to a recent post of mine on how to speed up the diffusion of research from the university to policy makers. In my post, I argued that to encourage researchers to communicate their results to decision makers and the public, we need more publications like Health Affairs that have as many as possible of the following attributes:

1. Writing that is conscise, data-driven, and policy-relevant.
2. Good editing and high production values.
3. Quality and prestige through peer review, providing academics with career incentives.
4. Authors and readers from every stratum of the policy discourse world, and every provider / stakeholder discipline (including patients!).
5. Excellent social media marketing to get articles into the discussion.
6. And it must not be the creature of any provider guild or health industry.

Austin agrees, but makes the following crucial observation

I’d add “timely.” Therefore, I would also rethink one of these items: peer-review (#3). To be sure, it’s a crucial element of primary publication of research results. But it takes a long time. Inserting it into a translational, dissemination process risks missing the window of opportunity for maximum impact and utility. Timing is everything.

This is an excellent point. I would say that policy discourse needs contributions from researchers at several velocities, including the very quick response that blogs provide. However, the faster you go, the harder it is to have peer review.

So, can we add timeliness to our web policy journal without sacrificing peer review? No. But let's keep in mind that peer review is not an end-in-itself. The goal is quality and having a reputation for quality (it is the latter that incentivizes academics). Peer review is just a means to those ends.

I have two suggestions. The core of the imagined web policy journal must be peer-reviewed publications so that it remains anchored in science. It could, however, also include some more timely outlets:

1. The journal could publish something like the Policy Forum in Science, and something like the OpEd page of The New York Times. These would be solicited pieces of < 1000 words that appeared perhaps weekly. This would require an editor who could anticipate issues that would be relevant, find authors who could respond on a fast turn around, and give those authors critical feedback to improve their pieces. 
2. The journal could sponsor one or more bloggers who would publish, for limited tenures, under the journal's brand. These pieces would appear without prior editing to achieve immediacy. However, the journal would maintain an editorial board that would be charged with monitoring the blogs and periodically rating their insight, accuracy, and objectivity. The board could replace bloggers who did not meet the journal's standards. 

These schemes would add a measure of review and selection to high velocity writing. Being a policy blogger for (say) Health Affairs would contribute more to an academic's reputation than publishing the same words under her own name. Moreover, having the imprimatur of a prestigious journal would greatly increase the visibility and impact of a blog. Conversely, having processes of article and blogger selection and pre- or post-publication review would help the journal insure that these more timely publications maintain its standards.