Something Not Unlike Research

Inequality? Oh we'd love to help, but...

post by Bill Gardner

Arnold Kling and Nick Schulz argue that the growth in US inequality derives from two factors:

• Technology that allows a few very able persons to achieve extraordinary things (think Sergey Brin), and
• Defective families and assortative mating based on ability that result in large groups of people at the bottom who lack the talent to produce much of value.

These are important causes of inequality. Kling and Schulz would do something about these things if they could, they really would, but 

there may be less that government can do than one might hope. Research from Heckman suggests that education is a relatively feeble remedy for the effects of family background (although Heckman believes that early intervention, in preschool or even before, shows promise). In order to make a dramatic impact on inequality, government would have to do something about the fundamental causes: technology and marriage patterns. However, putting a brake on technological progress seems hardly feasible or desirable. And forcing people to select mates at random rather than on the basis of similar backgrounds and tastes seems similarly unlikely. As much as inequality may be a problem, no real solution is in sight.

OMG, if the only alternatives are freezing technological progress or making people marry random partners (on second thought, this is the best explanation for my first marriage, and the kids turned out great anyway), then I guess there really is nothing to be done.

Or maybe we could try the following:

• We could give every mother good prenatal care, and institute programs to reduce premature delivery. 
• We could provide every child with universal, high-quality preschool education. Please, read Heckman for yourself. He isn't saying that early interventions "show promise." He's saying that "Early interventions promote schooling, reduce crime, foster workplace productivity, and reduce teenage pregnancy." 
• We could reform our criminal justice system. The US has 751 persons in prison per 100,000 population. Canada has 117. England's rate is 151; Germany's is 88; and Japan's is 63. Mexico has 204. The global median is 125. Are Americans really six times as violent and criminal as the rest of the world? The burden of US incarceration falls on the poor and above all on people of color. It destroys families. But it could be fixed.

America could do these things and it would still have considerable inequality. But these are solutions that would help and, contrary to Kling and Schulz, they are in plain sight.

Gender equity in the US and Canada

post by Bill Gardner

Aaron Carroll recounts an amazing incident (reported here by Carey Goldberg):

In 2007, Sophie Currier of Brookline, holder of M.D. and PhD degrees from Harvard, asked for extra time to take an all-day medical board exam. Her daughter was four months old at the time and exclusively breast-fed, and she needed more than the standard 45 minutes of total break time to pump her breast milk. The test’s overseers, the National Board of Medical Examiners, said no.

There are many things wrong with Canadian healthcare, but I would be deeply shocked if this happened here. The laws vary slightly across province, but mothers get a year's paid leave. Perhaps for this reason, there seem to many more female hospital CEOs and chiefs of medical departments here, compared to the US.

The point is that the problem may be bigger than just the need of physicians to haze their apprentices. The US should support parents with maternity and paternity leave rights comparable to those in Canada and Europe.

Do contemporary Republicans believe in public health?

post by Bill Gardner

Please do not misread the question. I am not asking whether modern Republicans want members of the public to be healthy. Of course they do.

What I am asking about is Public Health as a discipline and a social project. Do they believe that health has some of the characteristics of a public good? That is, do they believe that there are cases in which individuals making decisions in the market will not successfully coordinate their behavior to support the institutions that underlie public health? That we may need government for vaccination, sewers, monitoring of epidemics, monitoring of the safety of air and water, ..., on through public insurance? 

 

Public Health and individual liberty are in mild but real tension, and liberal societies find ways to balance utilitarian and libertarian concerns. I wonder, however, do the current group of candidates accept any government role in the promotion of public health?

I am particularly struck by Rep. Paul's comments about charity and health care in the video above. When you eat in a diner, it is not unusual to find a jar or a box below a homemade sign, asking for contributions to help pay for the cancer care of a child of a local family. It is heartwarming when you see that people do contribute. But it is also terrifying, as one knows full well that the contributions gathered this way won't even be a rounding error in the cost of the child's care. But mostly, like my Canadian and European friends, I am shocked that we put our neighbors through this. 

h/t to my friend Brian Wilcox, who posed this question and to Kaiser Healthcare News for the video.

 

Barbara Frum and 9/11

post by Bill Gardner

David Frum is one of the US political writers whom I most admire. He tweeted today about the anniversary of the death of his mother, who was a prominent radio journalist for the CBC. I looked up her Wikipedia entry, and was struck by the following,

She angered many in 1989 when she refused to acknowledge that the École Polytechnique massacre by a killer who proclaimed as he shot and stabbed women, "I hate feminists!" was an attack on women and feminism. "Why do we diminish it by suggesting that it was an act against just one group?" Frum said December 7, 1989 on The Journal.^[3]

I can't think of a better comment to frame our memories of 9/11.

Health care and accountability in Canada and the US

post by Bill Gardner

Paul posted yesterday on problems in getting doctors to routinely prescribe beta-blockers to patients who have suffered heart attacks. He quotes David Cutler's great book,

fans of the Canadian single-payer system should know that virtually the same share of people with a heart attack fail to receive beta-blockers in Canada as in the United States.

Not a surprise to me. We have only been working at our Canadian hospital for a couple of weeks, but it is quite clear that holding doctors accountable for meeting standards of care is just as serious a problem here as it is in the United States. 

There is a single payer in Canada (although it is the province, not the federal government). The provinces, however, just pay for the care. The hospitals and the doctors are independent contractors, and they and the patients make the decisions about care. There is no one from the government in the building giving orders.

But, you ask, why can't the party paying the bill demand improvements in care as part of the contract? I hope they can. However, a principal can only influence an agent to the degree that the principal can measure the agent's performance. That is just as big a challenge here as it is in the US.

Canadians need to control health care costs too

  My good friend Nils Finne raised a question in the comments to this post about how well Canadian are doing at controlling health care costs. The answer is: not well. The chart is made from data presented by Towers Watson. The vertical axis is the growth in national medical spending minus the general inflation rate for the country (or average of countries). Canadian cost growth has been greater than US or an advanced country average over the last five years.

Canada is, of course, increasing health care costs from a lower base level of spending compared to the US (but not compared to other advanced countries). As someone who has spent a career inside the US health system, things look lean here. Nevertheless, if these data are correct, these are truly dangerous rates of growth in cost. 

Canadian Patient-Oriented Research

post by Bill Gardner

Although the Canadian health system differs greatly from the US system, it faces many similar problems:

Canada faces a dual challenge in the research-to-practice continuum, often referred to as the two "Death Valleys" in the health care landscape. Valley 1 refers to the decreased capacity to translate the results of discoveries generated by basic biomedical research in the laboratory to the bedside or careside as well as to successfully commercialize health discoveries. This negatively impacts Canada's clinical research and knowledge base and its international competitiveness. Valley 2 refers to the limited capacity to synthesize, disseminate and integrate research results more broadly into clinical practice and health care decision-making. These two valleys must be bridged if Canada is to bring evidence to bear to enhance health outcomes and ensure a sustainable health care system.

In response, the Federal Health Minister, Leona Aglukkaq, has issued a new Strategy for Patient-Oriented Research. Among the key objectives:

• To strengthen organizational, regulatory and financial support for clinical studies in Canada and enhance patient and clinician engagement in these studies; and
• To improve processes for the early identification of best practices, expedite their development and harmonization into guidelines for patient care and support their adoption by clinicians, caregivers and patients.”

This similar to the strategy for comparative effectiveness research (CER) promoted by the US Patient-Centered Outcomes Research Institute (PCORI). Many conservatives oppose the PCORI, which was established as part of President Obama's Affordable Care Act. I've never understood why, but I urge them to reconsider their views on PCORI and CER. The Canadian strategy, after all, is the policy of the Conservative government of Prime Minister Stephen Harper.

US health care costs are higher because of administrative waste

post by Bill Gardner

The U.S. spends far more on health care than any other country in the world. For example, Canadians spent $3895 per capita in 2007, compared to $7290 in the U.S. There are many reasons why, but one disputed question is whether the U.S. has higher administrative costs than other developed countries. 

In Health Affairs (also summarized here) Morra and his colleagues report that physician practices in the U.S. spend far more time on administration than their Canadian peers. The chart reports the U.S. dollar value of the time spent by physicians and staff in the two countries. The U.S. physicians (blue bars) interact with multiple health plans on claims and billing, obtaining prior authorization for patient services, and dealing with pharmaceutical formularies. Canadians (red bars) deal primarily with a single provincial payer (Canadians can also hold supplemental private health care insurance).

The study also found that 

• Physician practices in the United States spent $82,975 per physician per year interacting with payers, compared with $22,205 in Ontario ( = $60,070 per physician per year extra cost in the United States). The cost of time spent by U.S. nurses and U.S. clerical staff were both greater than total Canadian costs.
• If U.S. physicians had administrative costs similar to those of Ontario physicians, their total savings would be approximately $27.6 billion per year.
• In the U.S., nurses and medical assistants spent 20.6 hours per physician per week on administrative tasks related to health plans, nearly 10 times the 2.5 hours spent by Canadian nursing staff. U.S. nursing staff spent more time in every category of interactions, most notably obtaining prior authorizations, which accounted for 13.1 hours per physician per week.

Please keep in mind that the study is considering only the administrative burden carried by clinicians and their staff. It does not include the hours of time spent by patients making sure that they have authorizations for care, checking bills against explanation of benefit forms, and searching for providers who take their insurance. These costs are also higher for U.S. patients, compared to Canadians.

There are significant problems in Canadian health care. Nevertheless, Canadians have better health at less cost than Americans. One important reason is that Canadian physicians and nurses spend more time on patients, and less time on paperwork.