Do No Harm

Kevin Lewis

October 30, 2009

"In a single night I had patients come in to our emergency department, most brought by ambulance, for the following complaints: I smoked marijuana and got dizzy; I got stung by a bee and it hurts; I got drunk and have a hangover; I sat out in the sun and got sunburn; I ate Mexican food and threw up; I picked my nose and it bled, but now it stopped; I just had sex and want to know if I'm pregnant. Since all my colleagues and I have worked our shifts while suffering from worse symptoms than these (well, not the marijuana, I hope), we have understandably lost some of our natural empathy for such patients...Our society has warped our perception of true risk. We are taught to fear vaccinations, mold, shark attacks, airplanes and breast implants when we really should worry about smoking, drug abuse, obesity, cars and basic hygiene...We demand unnecessary diagnostic testing, narcotics for bruises and sprains, antibiotics for our viruses (which do absolutely no good). And due to time constraints on physicians, fear of lawsuits and the pressure to keep patients satisfied, we usually get them. Yet the great secret of medicine is that almost everything we see will get better (or worse) no matter how we treat it." [Thomas Doyle (emergency physician), Pittsburgh Post-Gazette, October 11, 2009]


"Conservatives and Republicans need a better way to talk about cost-containment than the typical anti-comparative-effectiveness-research argument advanced (most recently) by Newt Gingrich in The Economist...Of course comparative-effectiveness reviews and cost-benefit analyses would limit medical innovation and enable rationing. And thank goodness. If we didn't limit medical innovation or ration medical care, we would spend 100 percent of GDP on medical care and there would be no money left over for shoes and ships and sealing wax, or food, education, and the internet. Another word for 'comparative-effectiveness research' or 'cost-effectiveness studies' is 'information.' Such research produces information that helps people limit medical innovation and ration medical care in the best possible way. Yet Gingrich took the bait. He pooh-poohs comparative-effectiveness research and even describes it as 'dangerous' - at the same time he assumes knowledge that only research can provide (e.g., 'smaller groups [of patients] may have responded best to drug X, Y, or Z')." [Michael Cannon, Cato, October 6, 2009]


Influence and Deterrence: How Obstetricians Respond to Litigation against Themselves and Their Colleagues

David Dranove & Yasutora Watanabe
American Law and Economics Review, forthcoming

The willingness of individuals to engage in a harmful act may be influenced by direct personal experiences and the experiences of others, which can inform individuals about the likely consequences of their actions. In this paper, we examine how obstetricians respond to litigation. It is contended that obstetricians respond to increases in litigiousness by performing more cesarean sections. Using micro data, we examine whether physicians perform more cesareans after they or their colleagues have been contacted about a lawsuit. We observe very small, short-lived increases in cesarean section rates. It does not appear that the recent sharp rise in cesarean section rates is in direct response to litigation.


Defensive Medicine and Obstetric Practices

Michael Frakes
Harvard Working Paper, September 2009

Using data on physician behavior from the 1979-2005 National Hospital Discharge Surveys (NHDS), I estimate the relationship between malpractice pressure, as identified by the adoption of non-economic damage caps and related tort reforms, and certain decisions faced by obstetricians during the delivery of a child. The NHDS data, supplemented with restricted geographic identifiers, provides inpatient discharge records from a broad enough span of states and covering a long enough period of time to allow for a defensive medicine analysis that draws on an extensive set of variations in relevant tort laws. Contrary to the conventional wisdom, I find no evidence to support the claim that malpractice pressure induces physicians to perform a substantially greater number of cesarean sections. Extending this analysis to certain additional measures, however, I do find some evidence consistent with positive defensive behavior among obstetricians. For instance, I estimate that the adoption of a non-economic damage cap is associated with a reduction in the utilization of episiotomies during vaginal deliveries, without a corresponding change in observed neonatal outcomes.


Association between political ideology and health in Europe

S. V. Subramanian, Tim Huijts & Jessica Perkins
European Journal of Public Health, October 2009, Pages 455-457

Studies have largely examined the association between political ideology and health at the aggregate/ecological level. Using individual-level data from 29 European countries, we investigated whether self-reports of political ideology and health are associated. In adjusted models, we found an inverse association between political ideology and self-rated poor health; for a unit increase in the political ideology scale (towards right) the odds ratio (OR) for reporting poor health decreased (OR 0.95, 95% confidence interval 0.94-0.96). Although political ideology per se is unlikely to have a causal link to health, it could be a marker for health-promoting latent attitudes, values and beliefs.


Paying a Premium on Your Premium? Consolidation in the U.S. Health Insurance Industry

Leemore Dafny, Mark Duggan & Subramaniam Ramanarayanan
NBER Working Paper, October 2009

We examine whether and to what extent consolidation in the U.S. health insurance industry is leading to higher employer-sponsored insurance premiums. We make use of a proprietary, panel dataset of employer-sponsored healthplans enrolling over 10 million Americans annually between 1998 and 2006 to explore the relationship between premium growth and changes in market concentration. We exploit the differential impact of a large national merger of two insurance firms across local markets to estimate the causal effect of concentration on market-level premiums. We estimate real premiums increased by 2 percentage points (in a typical market) due to the rise in concentration during our study period. We also find evidence that consolidation facilitates the exercise of monopsonistic power vis a vis physicians, whose absolute employment and relative earnings decline in its wake.


The Effect of Universal Health Insurance on Malpractice Claims: The Japanese Experience

Mark Ramseyer
Harvard Working Paper, September 2009

Japanese patients file relatively few medical malpractice claims. To date, scholars have tried to explain this phenomenon by identifying "faults" in the Japanese judicial system. They look in the wrong place. Largely, the faults they identify do not exist. To explore the reasons behind Japanese malpractice claiming patterns, I instead begin by identifying all malpractice suits that generated a published district court opinion between 1995 and 2004. I then combine the resulting micro-level dataset with aggregate data published by the courts, and publicly available information on the Japanese health care industry. I locate the explanation for the dearth in claims in the patterns of Japanese medical technology, and the reason for that technology in the national health insurance program. In order to contain the cost of its universal national health insurance plan, the Japanese government has radically suppressed the price it pays for the technologically most sophisticated procedures. Predictably as a result, Japanese doctors and hospitals have focused instead on more rudimentary - and more generously compensated - care. Yet, for reasons common to many societies, Japanese patients do not sue over rudimentary care. They sue the physicians who supply the most sophisticated care. Japanese patients bring relatively few malpractice suits because the government has (for reasons of cost) suppressed the volume of the services (namely, highly sophisticated services) that would otherwise generate the most malpractice claims.


Moral Hazard in a Mutual Health-Insurance System: German Knappschaften, 1867-1914

Timothy Guinnane & Jochen Streb
Yale Working Paper, September 2009

This paper studies moral hazard in a sickness-insurance fund that provided the model for social-insurance schemes around the world. The German Knappschaften were formed in the medieval period to provide sickness, accident, and death benefits for miners. By the mid-nineteenth century, participation in the Knappschaft was compulsory for workers in mines and related occupations, and the range and generosity of benefits had expanded considerably. Each Knappschaft was locally controlled and self-funded, and their admirers saw in them the ability to use local knowledge and good incentives to deliver benefits at low costs. The Knappschaft underlies Bismarck's sickness and accident insurance legislation (1883 and 1884), which in turn forms the basis of the German social-insurance system today and, indirectly, many social-insurance systems around the world. This paper focuses on a problem central to any insurance system, and one that plagued the Knappschaften as they grew larger in the later nineteenth century: the problem of moral hazard. Replacement pay for sick miners made it attractive, on the margin, for miners to invent or exaggerate conditions that made it impossible for them to work. Here we outline the moral hazard problem the Knappschaften faced as well as the internal mechanisms they devised to control it. We then use econometric models to demonstrate that those mechanisms were at best imperfect.


The Effect of Disability Insurance on Health Investment: Evidence from the Veterans Benefits Administration's Disability Compensation Program

Perry Singleton
Journal of Human Resources, Fall 2009, Pages 998-1022

I examine whether individuals respond to monetary incentives to detect latent medical conditions. The effect is identified by a policy that deemed diabetes associated with herbicide exposure a compensable disability under the Veterans Benefits Administration's Disability Compensation program. Since a diagnosis is a requisite for benefit eligibility, and nearly one-third of diabetics remain undiagnosed, the advent of disability insurance may have encouraged the detection of diabetes among the previously undiagnosed population. Evidence from the National Health Interview Survey suggests that the policy increased the prevalence of diagnosed diabetes by 3.1 percentage points among veterans.


Can States Lead the Way to Universal Coverage? The Effect of Health-Care Reform on the Uninsured

Ben Lennox Kail, Jill Quadagno & Marc Dixon
Social Science Quarterly, December 2009, Pages 1341-1360

Objective: This study assesses the impact of state policy reforms on health insurance coverage in the U.S. states considering three approaches to reform: consumer protection policies, policies relaxing regulation on insurance companies, and policies expanding public benefits.

Methods: Using data collected from several publicly available sources, we estimate state insurance coverage using fixed-effects pooled time-series regression from 1992 to 2005.

Results: We find that the only policies that had a positive effect on coverage were those expanding public benefits. None of the other state policy measures were associated with increased coverage and pricing restrictions actually were associated with reduced coverage.

Conclusion: We argue that a federal-state partnership offers an imperfect short-term strategy but that in the long run, states are incapable of assuming the burden of fully covering the uninsured.


Use of Intensive Care Services during Terminal Hospitalizations in England and the United States

Hannah Wunsch, Walter Linde-Zwirble, David Harrison, Amber Barnato, Kathryn Rowan & Derek Angus
American Journal of Respiratory and Critical Care Medicine, November 2009, Pages 875-880

Rationale: Despite broad concern regarding the provision and cost of health care at the end of life, country-specific patterns of care have rarely been compared.

Objectives: To assess the use of hospital and intensive care services during terminal hospitalizations in England and the United States, two populations with similar socioeconomic backgrounds and life expectancies.

Methods: Retrospective cohort study over a 1-year period (2001) using national (England) Hospital Episode Statistics, and regional (seven U.S. states) administrative discharge data as well as English and U.S. census data. We measured hospitalization rates and death rates during hospitalization with and without intensive care.

Measurements and Main Results: Age-adjusted acute hospitalization rates were 110.5 per 1,000 population in England versus 105.3 in the seven U.S. states, with the same mortality rate (0.9 per 1,000 population) in both countries. Of all deaths, 50.3% occurred in hospital in England and 36.6% in the United States, yet only 5.1% of all deaths in England involved intensive care, versus 17.2% in the United States, representing 10.1% of hospital deaths in England versus 47.1% in the United States. Greater intensive care use in the U.S. was most notable with older age; among decedents 85+ years, intensive care was used for 31.5% of medical deaths and 61.0% of surgical deaths in the United States versus 1.9 and 8.5% of deaths in England.

Conclusions: Despite similar overall hospitalization rates in England and the United States, there were marked differences in terminal hospitalizations, with far greater use of intensive care services in the United States, especially among medical patients and the elderly population.


Work Disability, Work and Justification Bias in Europe and the U.S.

Arie Kapteyn, James Smith & Arthur Van Soest
RAND Working Paper, August 2009

To analyze the effect of health on work, many studies use a simple self-assessed health measure based upon a question such as, 'Do you have an impairment or health problem limiting the kind or amount of work you can do?' A possible drawback of such a measure is the possibility that different groups of respondents may use different response scales. This is commonly referred to as 'differential item functioning' (DIF). A specific form of DIF is justification bias: to justify the fact that they don't work, non-working respondents may classify a given health problem as a more serious work limitation than working respondents. In this paper we use anchoring vignettes to identify justification bias and other forms of DIF across countries and socio-economic groups among older workers in the U.S. and Europe. Generally, we find differences in response scales across countries, partly related to social insurance generosity and employment protection. Furthermore, we find significant evidence of justification bias in the U.S. but not in Europe, suggesting differences in social norms concerning work.


Effects of U.S. States' Social Welfare Systems on Population Health

Ae-Sook Kim & Edward Jennings
Policy Studies Journal, November 2009, Pages 745-767

Social scientists have studied the welfare state extensively. Many studies seek to understand the determinants of the welfare state; however, a few have explored the social consequences of social welfare systems, especially on health outcomes of the population. Even though cross-national comparative studies support the thesis that the welfare state regime type, which represents different levels of commitment on social welfare, is closely linked to population health, there is little research to support this argument at a sub-national level. To fill the gap, this study explores the effects of the U.S. states' social welfare systems on health using age-adjusted mortality rates as a proxy for population health. By operationalizing social welfare systems as three dimensions-public expenditures, tax structures, and welfare program rules-we find that more generous education spending, progressive tax systems, and more lenient welfare program rules help to improve population health. The model corrects for first-order serial correlation using Prais-Winsten regression methods and is estimated with state and year-fixed effects.


Willingness-to-pay to avoid the time spent and discomfort associated with screening colonoscopy

Daniel Jonas, Louise Russell, Jon Chou & Michael Pignone
Health Economics, forthcoming

Background: The screening colonoscopy process requires a considerable amount of time and some discomfort for patients.

Objective: We sought to use willingness-to-pay (WTP) to value the time required and the discomfort associated with screening colonoscopy. In addition, we aimed to explore some of the differences between and potential uses of the WTP and the human capital methods.

Methods: Subjects completed a diary recording time and a questionnaire including WTP questions to value the time and discomfort associated with colonoscopy. We also valued the elapsed time reported in the diaries (but not the discomfort) using the human capital method.

Results: 110 subjects completed the study. Mean WTP to avoid the time and discomfort was $263. Human capital values for elapsed time were greater. Linear regressions showed that WTP was influenced most by the difficulty of the preparation, which added $147 to WTP (p=0.03).

Conclusions: WTP values to avoid the time and discomfort associated with the screening colonoscopy process were substantially lower than most of the human capital values for elapsed time alone. The human capital method may overestimate the value of time in situations that involve an irregular, episodic series of time intervals, such as preparation for or recovery after colonoscopy.

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