K1 needs (?) expanders. This much we found out a month ago. The orthodontist also recommended the removal of 2 canines to facilitate the permanent teeth that were coming out.
There were two things we could have done, both of which I would have wanted to avoid.
1. Get a second opinion.
2. Go with the recommendation.
I don't see how either option can contribute to the reduction in health care costs (assuming dental is part of health care). Neither my spouse nor I had braces or orthondists and neither of us have perfect teeth and our feelings were - so what? But I had read an account of how at age 47 she decided to get braces and how her teeth bugged her through most of her life and really, who wants this for their kids.
So we went with #2. We went ahead with the extraction - not too bad - $290, and the expanders will cost $4000 over possibly 2 years or less (before braces). We're not quite sure how much of it insurance actually covers (yet) but one small contribution to the cost of escalating health care would be to remove insurance coverage of orthodontics except for injurious cases (e.g. plastic surgery for burn victims). It would certainly make us think harder about orthodontics.
Yet, with all the rising costs of obesity, as recounted by Mark Ambinder, the benefits of bariatric surgery is still unknown and hence not covered by insurance.
In the half century since surgeons began performing bariatric procedures, the surgery’s mortality rate has declined to half of 1 percent, and its long-term success rate—people who keep at least 50 percent of their excess body weight off for several years—has become exceptional. For reasons clinicians still don’t quite understand, the surgery seems to cure diabetes, sometimes instantly. The surgery does not work for everyone: some people who endure it will essentially regrow their stomachs and gain back the weight. Though the rate of minor complications can exceed 30 percent, the incidence of more-severe complications is less than 3 percent. But the procedure is still an equalizing force: for a honeymoon period, about six months to a year after surgery, it allows you to resist the environmental and physical pressures that intensify appetite and food addiction.
...For young adults who cross a certain weight threshold, bariatric surgery can be an effective preventive step. Its incidence among all adults doubled over six years, to 220,000 surgeries in 2008. And it seems to be increasingly prevalent among obese teenagers: one study suggests that from 2000 to 2003, the number of teens resorting to the procedure tripled. But it’s major surgery, and specialists aren’t comfortable doing it as a preventive measure. Moreover, many insurance companies (including mine) refuse to pay the $30,000 cost, reasoning that any economic benefit they would recoup is years down the road.
Showing posts with label Health Care. Show all posts
Showing posts with label Health Care. Show all posts
Tuesday, July 20, 2010
Monday, April 19, 2010
What if our randomized trial was incorrectly implemented
In an interesting article on estrogen in the NYT:
... the Women’s Health Initiative, or W.H.I. It was a federally financed examination of adult women’s health, extraordinary in scale and ambition, that started up in the early 1990s; one of its drug trials enrolled more than 16,000 women for a multiyear comparison of hormone pills versus placebos. On July 9, 2002, W.H.I. investigators announced that they had ended the trial three years early, because they were persuaded that it was dangerous to the hormone-taking participants to let them continue. ...
First of all, ... there are different forms of estrogenic molecules — ... estradiol. It’s [Estradiol] not the estrogen used in the W.H.I. study. Pharmaceutical estradiol like mine comes from plants whose molecules have been tweaked in labs until they are atom for atom identical to human estradiol, the most prominent of the estrogens premenopausal women produce naturally on their own. The W.H.I. estrogen, by contrast, was a concentrated soup of a pill that is manufactured from the urine of pregnant mares. ...
The progesterone he prescribed ... , like the estradiol, is a molecular replica of the progesterone women make naturally. It’s different from the progesteronelike synthetic hormone that was used for the W.H.I. study that ended in 2002. That medication was a formulation whose multisyllabic chemical name shortens to MPA and which has a problematic back story of its own: MPA takes care of the uterine-cancer risk, but there’s reason to suspect it may be a factor in promoting breast cancer. And it’s ingested as a pill, which means that like equine estrogens ... MPA metabolizes through the liver, possibly creating additional complications en route, before going about its business.
The biggest difference between me and the W.H.I. women, though, has to do with age and timing. I started on the patches while my own estrogen, pernicious though its spikes and plummets may have been, was still floating around at more or less full strength. The average age of the W.H.I. women was just over 63, though the study accepted women as young as 50. More significant, though, most of them were many years past their final menstrual period, which is the technical definition of menopause, when they began their trial hormones. The bulk of the group was at least 10 years past; factoring in the oldest women, the average number of years between the volunteers’ menopause and their start on the trial medications was 13.4.
The bottom line:
... one undiplomatic critic sum up the W.H.I. as “the wrong drugs, tested on the wrong population,”
Gelman's blog also discusses another randomized trial that did not fully answer the question on PSA screening. More here.
... the Women’s Health Initiative, or W.H.I. It was a federally financed examination of adult women’s health, extraordinary in scale and ambition, that started up in the early 1990s; one of its drug trials enrolled more than 16,000 women for a multiyear comparison of hormone pills versus placebos. On July 9, 2002, W.H.I. investigators announced that they had ended the trial three years early, because they were persuaded that it was dangerous to the hormone-taking participants to let them continue. ...
First of all, ... there are different forms of estrogenic molecules — ... estradiol. It’s [Estradiol] not the estrogen used in the W.H.I. study. Pharmaceutical estradiol like mine comes from plants whose molecules have been tweaked in labs until they are atom for atom identical to human estradiol, the most prominent of the estrogens premenopausal women produce naturally on their own. The W.H.I. estrogen, by contrast, was a concentrated soup of a pill that is manufactured from the urine of pregnant mares. ...
The progesterone he prescribed ... , like the estradiol, is a molecular replica of the progesterone women make naturally. It’s different from the progesteronelike synthetic hormone that was used for the W.H.I. study that ended in 2002. That medication was a formulation whose multisyllabic chemical name shortens to MPA and which has a problematic back story of its own: MPA takes care of the uterine-cancer risk, but there’s reason to suspect it may be a factor in promoting breast cancer. And it’s ingested as a pill, which means that like equine estrogens ... MPA metabolizes through the liver, possibly creating additional complications en route, before going about its business.
The biggest difference between me and the W.H.I. women, though, has to do with age and timing. I started on the patches while my own estrogen, pernicious though its spikes and plummets may have been, was still floating around at more or less full strength. The average age of the W.H.I. women was just over 63, though the study accepted women as young as 50. More significant, though, most of them were many years past their final menstrual period, which is the technical definition of menopause, when they began their trial hormones. The bulk of the group was at least 10 years past; factoring in the oldest women, the average number of years between the volunteers’ menopause and their start on the trial medications was 13.4.
The bottom line:
... one undiplomatic critic sum up the W.H.I. as “the wrong drugs, tested on the wrong population,”
Gelman's blog also discusses another randomized trial that did not fully answer the question on PSA screening. More here.
Tuesday, April 13, 2010
Is the Minute Clinic an alternative to the ER
The list of services and prices mean that we know what we're in for:
Services and Costs
Minor illness exam $62
Minor injury exam $62
Skin condition exam $62
Wellness & prevention $20-$95
Health conditionmonitoring $62-$97
Vaccinations $30-$112
Additional charges may apply.
Are they a viable alternative to the ER? I would think that in some cases, yes and the transparency might spur some competition or additional transparency in prices. Unlike David Goldhill I'm less certain that this will occur but the proof will be in the pudding (or time).
Services and Costs
Minor illness exam $62
Minor injury exam $62
Skin condition exam $62
Wellness & prevention $20-$95
Health conditionmonitoring $62-$97
Vaccinations $30-$112
Additional charges may apply.
Are they a viable alternative to the ER? I would think that in some cases, yes and the transparency might spur some competition or additional transparency in prices. Unlike David Goldhill I'm less certain that this will occur but the proof will be in the pudding (or time).
Thursday, December 31, 2009
Health care demand
Via Mankiw, the above chart is used to make the following claim:
The accompanying chart shows why we have a health care cost problem. Patients have little direct connection in paying for their care. Their role has fallen significantly. Meanwhile, the government's involvement has grown, as has that of the insurance industry.
Because so many Americans rely on an insurance policy or a government program to pay their health care bills, the internal governors that temper the rest of their purchases are turned off. When a visit to the doctor's office or a diagnostic test costs them a mere $10 or $20 co-payment out of pocket — or there is no charge at all — cost has little impact on their decision to see a doctor.
"By not knowing the full costs associated with health care, consumers demand more and 'overuse' it," Kenneth E. Thorpe explained a few years back in Health Affairs.
Americans would be more judicious in seeking health care — they would self-ration — if the right incentives were in place. An effective way to cut overuse and bring down costs would be to encourage through public policy the use of health savings accounts. If consumers used HSAs to pay the full amount for medical care at the point of service rather than letting employer-funded insurance or a government program pay the bills, the demand would fall.
There several issues that come to mind here:
1) If it were not profitable for the insurance companies to offer fixed co-payments then they would not do so. If we believe in the market then we should let insurance companies set the benefits: copayments and deductibles.
2) It is also true that perhaps the insurance companies are succumbing to political pressure to provide cheap medical care. If this were true then we would see insurance companies going out of business or withdrawing from the health insurance market over time. This is not happening (yet).
3) The reason why insurance companies offer these low copayments is to actually encourage the user to use health services. Why? Because if they do not and consumers postpone seeing the doctor the eventual cost of health may be larger than if they had seeked medical help early. There is no hard evidence of this (for now) except that since insurance companies are offering the low copayments then this is one rationale for them doing so.
4) For the same reason, HSAs will not work if instead of using the savings for routine medical care (e.g. checkups) consumers simply use it to avoid taxes and postpone health investments.
5) Economists may argue that insurance is just that - insurance. It should be used for something as predictable as annual physicals or dental care. These expenses ought to come out of the consumers pockets. This savings motive will also raise the personal saving rate of the economy as a whole. However, it is also true that some people tend to underestimate risks just as there are some who overestimate risks. The former group will postpone getting regular care until it becomes too late in which case the costs to the insurer may be high. On the other hand (as usual) there are those who go to the doctor for every possible scratch or itch.
How should we as a society balance these two forces? For those who believe in the market, we would let the market decide? Some insurers may opt to cover routine care and some may not. Eventualy, the weakest insurer will be weeded out. But this method may continue to increase health care costs overall.
If HSAs were mandated (would they?) and deducted the way Social Security contributions are held in a government entity and routine medical care was also mandated (so that a proportion of the savings are "confiscated" if not used for routine care - use it or lose it) then there may be some hope of containing health care costs via HSAs.
On a personal note I have noticed the following:
1) There were at least 2 occasions that had we not had insurance we would not have gone to the doctor for our kids. Once when there was an eye complaint and another was when there was a fever and in both occasions I would simply have waited. There was no harm to waiting (ex post since the doctor confirmed nothing serious) but it could have been possible that there was something serious.
2) However, even with insurance my last physical was about 4 years ago.
Thursday, May 1, 2008
What else is in our bodies? Or is this more unintended consequences?
In the wake of bisphenol (bpA) fear, I came across this National Geographic article "The Pollution Within". Writer David Ewing Duncan had himself tested at a price of $15,000 (paid for by NGS) for 320 chemicals and what he found surprised him.
My journalist-as-guinea-pig experiment is taking a disturbing turn. A Swedish chemist is on the phone, talking about flame retardants, chemicals added for safety to just about any product that can burn. Found in mattresses, carpets, the plastic casing of televisions, electronic circuit boards, and automobiles, flame retardants save hundreds of lives a year in the United States alone. These, however, are where they should not be: inside my body.
Where did this chemical (PBDE) could have come from? The writer thinks from airlines since he spends a lot of time flying and flame retardants are everywhere in planes for safety reasons.
I don't eat much fish, and the levels of mercury in my blood were modest. But I wondered what would happen if I gorged on large fish for a meal or two. So one afternoon I bought some halibut and swordfish at a fish market in the old Ferry Building on San Francisco Bay. Both were caught in the ocean just outside the Golden Gate, where they might have picked up mercury from the old mines. That night I ate the halibut with basil and a dash of soy sauce; I downed the swordfish for breakfast with eggs (cooked in my nonstick pan). Twenty-four hours later I had my blood drawn and retested. My level of mercury had more than doubled, from 5 micrograms per liter to a higher-than-recommended 12. ...
And that faint lavender scent as I shampoo my hair? Credit it to phthalates, molecules that dissolve fragrances, thicken lotions, and add flexibility to PVC, vinyl, and some intravenous tubes in hospitals. The dashboards of most cars are loaded with phthalates, and so is some plastic food wrap. Heat and wear can release phthalate molecules, and humans swallow them or absorb them through the skin. ...
As unsettling as my journey down chemical lane was, it left out thousands of compounds, among them pesticides, plastics, solvents, and a rocket-fuel ingredient called perchlorate that is polluting groundwater in many regions of the country. Nor was I tested for chemical cocktails—mixtures of chemicals that may do little harm on their own but act together to damage human cells. Mixed together, pesticides, PCBs, phthalates, and others "might have additive effects, or they might be antagonistic," says James Pirkle of the CDC, "or they may do nothing. We don't know."
My journalist-as-guinea-pig experiment is taking a disturbing turn. A Swedish chemist is on the phone, talking about flame retardants, chemicals added for safety to just about any product that can burn. Found in mattresses, carpets, the plastic casing of televisions, electronic circuit boards, and automobiles, flame retardants save hundreds of lives a year in the United States alone. These, however, are where they should not be: inside my body.
Where did this chemical (PBDE) could have come from? The writer thinks from airlines since he spends a lot of time flying and flame retardants are everywhere in planes for safety reasons.
I don't eat much fish, and the levels of mercury in my blood were modest. But I wondered what would happen if I gorged on large fish for a meal or two. So one afternoon I bought some halibut and swordfish at a fish market in the old Ferry Building on San Francisco Bay. Both were caught in the ocean just outside the Golden Gate, where they might have picked up mercury from the old mines. That night I ate the halibut with basil and a dash of soy sauce; I downed the swordfish for breakfast with eggs (cooked in my nonstick pan). Twenty-four hours later I had my blood drawn and retested. My level of mercury had more than doubled, from 5 micrograms per liter to a higher-than-recommended 12. ...
And that faint lavender scent as I shampoo my hair? Credit it to phthalates, molecules that dissolve fragrances, thicken lotions, and add flexibility to PVC, vinyl, and some intravenous tubes in hospitals. The dashboards of most cars are loaded with phthalates, and so is some plastic food wrap. Heat and wear can release phthalate molecules, and humans swallow them or absorb them through the skin. ...
As unsettling as my journey down chemical lane was, it left out thousands of compounds, among them pesticides, plastics, solvents, and a rocket-fuel ingredient called perchlorate that is polluting groundwater in many regions of the country. Nor was I tested for chemical cocktails—mixtures of chemicals that may do little harm on their own but act together to damage human cells. Mixed together, pesticides, PCBs, phthalates, and others "might have additive effects, or they might be antagonistic," says James Pirkle of the CDC, "or they may do nothing. We don't know."
Saturday, March 15, 2008
Drug development costs
The price of innovation: new estimates of drug development costs by Joseph DiMasi, Ronald Hansen and Henry Grabowski is an excellent introduction into the nitty gritty of estimating costs of R&D in the pharmaceutical industry especially for someone reading about this topic for the first time.
1. I was surprised to learn that some of the firms surveyed were unable to respond because of lack of data. It sounds as though the firms themselves do not have a clear idea as to what R&D development costs are. DiMasi et. al. estimate an average of $403 million (in 2000 dollars) and capitalizing the costs until drug approval doubles the estimate to $802 million (in 2000 dollars).
2. They don't quite answer why drug development costs have increased (7.4% over the inflation rate) so quickly but hints at two possiblities: a) Pharmaceutical companies are focusing more on chronic and degenerative diseases that are more complex and costly to test, and b) firms need to test the cost effectiveness of their drugs not against a placebo but against the current treatment alternatives which can require larger clinical trials.
3. Another possibility that they do not explore is the promised rewards of a blockbuster drug. The rewards can be so large that the pharmaceutical companies do not pay attention to the cost. (This is speculative of course since I'm not familiar with the field.)
1. I was surprised to learn that some of the firms surveyed were unable to respond because of lack of data. It sounds as though the firms themselves do not have a clear idea as to what R&D development costs are. DiMasi et. al. estimate an average of $403 million (in 2000 dollars) and capitalizing the costs until drug approval doubles the estimate to $802 million (in 2000 dollars).
2. They don't quite answer why drug development costs have increased (7.4% over the inflation rate) so quickly but hints at two possiblities: a) Pharmaceutical companies are focusing more on chronic and degenerative diseases that are more complex and costly to test, and b) firms need to test the cost effectiveness of their drugs not against a placebo but against the current treatment alternatives which can require larger clinical trials.
3. Another possibility that they do not explore is the promised rewards of a blockbuster drug. The rewards can be so large that the pharmaceutical companies do not pay attention to the cost. (This is speculative of course since I'm not familiar with the field.)
Tuesday, October 30, 2007
Is cleaning out ear wax an example of overconsumption of Medical Services?
When we were in Kuala Lumpur this past summer, K1 fell sick. We had thought it was a virus and after 3 days we decided to bring her to a local doctor who confirmed that it was indeed a virus. We mentioned that back in the states, the doctors usually order a complete blood count (CBC) at her annual checkup. The doctor was surprised and seemed to indicate that this was not normal practice in Malaysia. Is CBC at every annual checkup an example of overconsumption of medical services that drives up the cost of health care in the US? I haven't made up my mind. It's not that expensive and it's mostly covered by insurance. Our bill shows $49 before insurance.
Another related story is the following: My cousin who lives in Singapore has a 5 year old (I think) but for almost 2 years was incredibly worried because he was not talking. They went to see a specialist to try to figure out what was wrong. Eventually, hard as it was for me to believe, they found out that he could not hear and hence could not repeat anything back because his ears were full of wax. I was amazed to hear this because here in the US, during the annual checkups the pediatrician always looks in the kids ears to make sure they're clear. (K1 has a problem with impacted cerumen (which I'm guessing is ear wax) and always needs it cleaned out.) Having a doctor look into her ears doesn't cost us anything -- well, at least it's not itemized in the bill but is probably included as part of the checkup. Is checking ears an example of overconsumption of medical care? Here I would disagree.
It's dangerous to generalize about the quality of health care based on these incidents but it makes me wonder. I'm also not too partial to some of arguments of overconsumption because of generous insurance plans, for instance, noted here by Prof. Mankiw.. If there were overconsumption is it driven by the patient, the doctor or both? And if there were overconsumption but is still beneficial overall, why would insurance companies who are profit maximizing entities continue to insure that part of the medical care? I would expect that in equilibrium, if the overall costs of coverage are higher than the benefits then insurance companies would refuse coverage (as they already do for certain pre-existing conditions).
Another related story is the following: My cousin who lives in Singapore has a 5 year old (I think) but for almost 2 years was incredibly worried because he was not talking. They went to see a specialist to try to figure out what was wrong. Eventually, hard as it was for me to believe, they found out that he could not hear and hence could not repeat anything back because his ears were full of wax. I was amazed to hear this because here in the US, during the annual checkups the pediatrician always looks in the kids ears to make sure they're clear. (K1 has a problem with impacted cerumen (which I'm guessing is ear wax) and always needs it cleaned out.) Having a doctor look into her ears doesn't cost us anything -- well, at least it's not itemized in the bill but is probably included as part of the checkup. Is checking ears an example of overconsumption of medical care? Here I would disagree.
It's dangerous to generalize about the quality of health care based on these incidents but it makes me wonder. I'm also not too partial to some of arguments of overconsumption because of generous insurance plans, for instance, noted here by Prof. Mankiw.. If there were overconsumption is it driven by the patient, the doctor or both? And if there were overconsumption but is still beneficial overall, why would insurance companies who are profit maximizing entities continue to insure that part of the medical care? I would expect that in equilibrium, if the overall costs of coverage are higher than the benefits then insurance companies would refuse coverage (as they already do for certain pre-existing conditions).
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