Tyler Cowen v. Ben Goldacre

Tyler Cowen reviews Ben Goldacre:

Goldacre’s policy recommendations would in general raise the costs of research and development, although they would  likely improve the accuracy of research results and reduce over-prescription and overuse of drugs.  It is quite possible they would lower the rate of return to pharmaceutical innovation, likely I would say.  These trade-offs are neglected, and, much as I admire many features of this book, I cannot help but, alas with trepidation, call some of its central features “Bad Science.”  Bad Economic Science.  The morality of the narrative and the Platonism of his vision distracts him from presenting the policy trade-offs clearly.

And Goldacre responds (in the comments):

The key argument of the book is that the results of clinical trials should not be withheld from doctors and patients. Industry spokespeople continue to deny that this happens at all, in the face of overwhelming evidence, in a testament to how easy they have found it to evade serious public discussion.

Sharing all trial results would not cost any more money, since the cost in a trial is in conducting it, rather than dissemination. The risk to industry is that doctors and providers of healthcare services would have a clearer picture of the absolute benefits of drugs, and of which is best, or most cost effective. So the downside would perhaps be that drugs might become more like commodities, as purchasers got better information.

I haven't read the book yet (though it's on my shortlist), but, for once, I think Goldacre has a stronger argument than Tyler here.  I'm sure that Goldacre probably could have moderated his tone a little bit, but if his book is, as he says, mostly about calling for greater transparency in pharmaceutical studies, then Tyler's response seems a bit weak.  Tyler basically seems to be saying that pharma companies should not have to publish their studies because they make a lot of money selling mediocre (but often unnecessary) drugs and the profits from these drugs allow them to create more drugs.  This seems akin to saying that it's okay for pharma companies to defraud the public because it's in the greater good.  It also seems to skew the incentives.  If a pharma company can turn a profit with either a mediocre product or a good one, there's not a whole lot of incentive to work extra hard to produce a good product. 

And as for Tyler's criticisms about tone, if your goal is to stir up public sentiment to push for reform, I'm not sure that moderation is the goal.  There is a place for moderate criticism and a place for outrage, and this book may fit the latter.  

Where is the best place to be born in 2013?

A View From The Cave has some thoughts about the Economist's index on where the best country to be born in 2013: 

According to the latest index from The Economist the answer is Switzerland followed by Australia, Norway, Sweden and Denmark. For those of you looking for the United States (16) and Britain (27) in the top ten. 

Of interest: 

Libertarian think tank the Cato Institute released its annual Economic Freedom of the World report which includes an index of countries ranked by economic freedom. It should come as no surprise that the index does not look favorably upon the United Sates who comes in ranked 18th in the world. There are some interesting points of similarity and divergence between the two indices  

Cato's 5 most economically free countries (Hong Kong, Singapore, New Zealand, Switzerland and Austria) are all in the top ten of the Economist's index. However, Mauritus and Bahrain, two nations considered to have high economic freedoms, do not make the list for The Economist. Also, Norway (3) and Sweden (4), are ranked 25 and 30 by the Cato Institute. 

I find that most interesting cases are the former communist countries: 

• Despite more than 30 years of spectacular growth, and more growth projected over the next two decades, China comes in at 49 out of 80, below every South American country other than Ecuador. 
• Despite a stifling lack of economic freedom, Cuba ranks 40th overall, ahead of several South American and Eastern European countries.  
• Russia ranks 71st out of 80, just ahead of Syria and below a number of countries with much lower GDP per capita. 

Will the ACA increase waiting lines for patients?

Brad DeLong has a question on ACA implementation:

What is your guess as to what will happen if the ACA works for access, works for quality, works for coverage--but the extra health-care workforce needed isn't there, and the lines start to get longer?

I have two thoughts: 

First, to answer the question directly: looking at the issue from a market-based standpoint, if his scenario comes true, I think the obvious answer would be that we need to graduate more doctors.  Doctors make a ton of money, meaning that there is probably an undersupply (although there are probably additional reasons) and there are loads of people who would like to be doctors, but can't get into medical school because there are not enough spots.

The problem, in my opinion, is that a lot of healthcare seems supply-sensitive, rather than demand-sensitive.  Which is to say that the more available doctors or hospital beds, the more doctors will prescribe more treatment, despite the fact that a lot of this treatment has very little effect on overall health outcomes.  It's possible that lines will start to get longer as a result of the ACA's provisions on access, quality and coverage, but it's possible that demand-side is a less significant factor than we believe it will be.  If nothing else, the studies on supply-sensitive care suggest that training more doctors would result in a spike in healthcare costs.

A better solution, as my doctor friend Dylan notes, is to expand the Nurse Practitioner workforce: "Non-urgent medical screening can be handled by NPs, and physicians can see sicker patients. Many clinics already do this. There's no reason a doctor has to perform a screening pap-smear for example." 

How to Make Aid Work: Don't give to local-decision-makers

The Economist cites a World Bank report warning that giving aid to local decision-makers is less useful than had been hoped:

Channelling development aid directly to local decision-makers sounds like a good plan. Empowering local groups like community clubs and school boards means decisions can reflect actual needs on the ground. It should mean fewer bureaucratic hands in the pot, too. But a new report by two World Bank economists warns against relying on decisions made at the most local level of government. Entrenched elites, bribery and fraud are as much of a problem in village life as they are in big emerging-market bureaucracies.

Also this:

The first problem is corruption. A study based in Madagascar, for example, found that central government was actually a relatively safe steward of development cash, with more of it siphoned off at local-government levels.

Why did homosexuality evolve?

Really interesting article from the Chronicle about why homosexuality may have evolved, despite being such a seeming weakness from an evolutionary perspective.  

The short answer is that we don't know, but several good theories are presented.  My two favorites are the "sexually antagonistic selection" theory and the "nonadaptive byproduct" theory.  

Here's the sexually antagonistic selection theory: 

What if one or more genes that predispose toward homosexuality (and with it, reduced reproductive output) in one sex actually work in the opposite manner in the other sex? I prefer the phrase "sexuallycomplementary selection": A fitness detriment when genes exist in one sex—say, gay males—could be more than compensated for by a fitness enhancement when they exist in another sex.

Anyone prefer any of the other theories?  I'm skeptical of the group selection and social prestige theories.  It seems like there would have to be a pretty enormous benefit conferred upon one's relatives to offset not having children of one's own.  

Breast cancer screenings

The Lancet reports on the findings of the independent UK Panel on Breast Cancer Screening:

The Panel found that routine breast screening leads to a 20% relative risk reduction compared with no screening. This means for every 235 women invited for screening, one breast cancer death will be prevented, representing 43 breast cancer deaths prevented per 10 000 women aged 50 years invited to screening for the next 20 years.

Additionally, the Panel found that some overdiagnosis occurs. 19% of breast cancers diagnosed in women invited for screening would not have caused any problem if left undiagnosed and untreated (a rate of 129 per 10 000 women). However, owing to the scarcity of reliable data in this area, more research is needed to accurately assess the magnitude of overdiagnosis. The Panel also considered how women feel about the available evidence: many women believe the balance of benefits to risks is worthwhile.

I'm not sure that this is conclusive, as the article's title suggests, but it seems like a strong evidence point in favor of continuing screenings in women 50 and above.

Marijuana Legalization

The New York Times looks at the significance of Colorado and Washington's new marijuana laws:

As soon as the laws are certified, it will be legal under Colorado and Washington law for adults 21 years and older to possess up to an ounce of marijuana. In Colorado, people will be able to grow as many as six plants. In Washington, users will have to buy their marijuana from state-licensed providers.

Bringing marijuana production under the control of state-licensed providers seems incredibly logical, both from a regulatory and a revenue-maximizing standpoint.  It also seems like the best way to reduce the illicit drug trade caused by the "War on Drugs" that has done so much harm in countries like Mexico and Guatemala.  The big question now is whether or not the Obama administration will allow it:

In a statement on Wednesday, a spokesman for the Drug Enforcement Agency said the Justice Department was reviewing the ballot measures and declined to comment directly on how officials would respond to them. But he said the agency’s enforcement of federal drug laws “remains unchanged.” The United States attorneys in Denver and Seattle responded with nearly identical statements, offering no clue on whether they would sue to block the measures from being put into effect.

It is a murky landscape now, one that potentially pits voters who supported President Obama and legalization against the president’s own Justice Department. In 2010, weeks before California voted on an unsuccessful initiative to legalize marijuana, Attorney General Eric H. Holder Jr. announced that authorities would still aggressively prosecute marijuana laws.

It would be a huge disappointment to see the Obama administration continue to enforce drug laws.

On a related note, Alex at MR has linked to a study showing that states with medical marijuana laws have seen  an 8-11 percent decrease in traffic fatalities.  If true, this is a significant development for public health and safety.

 

Links I liked

• Statistical analysis - coming to politics (and health policy?) next 
• How not to write a personal statement 
• The Borat of the Central African Republic
• Development in Bangladesh 

Longevity Project, the power of relationships

According to David Brooks' recent column, the capacity for intimate relationships might be linked not only to life success, but maybe to longer lives as well:

 Body type was useless as a predictor of how the men would fare in life. So was birth order or political affiliation. Even social class had a limited effect. But having a warm childhood was powerful. As George Vaillant, the study director, sums it up in “Triumphs of Experience,” his most recent summary of the research, “It was the capacity for intimate relationships that predicted flourishing in all aspects of these men’s lives.” 

Of the 31 men in the study incapable of establishing intimate bonds, only four are still alive. Of those who were better at forming relationships, more than a third are living.

The right to self-medicate?

Interesting argument presented by Alex at Marginal Revolution about the liberalization of prescription drugs:

Citizens have rights of self-medication for the same reasons that they have rights of informed consent. The prescription drug system has bad consequences and it privileges regulators’ and physicians’ judgements about a patient’s health over the patient’s judgement about her overall well-being. Most troublingly, the prescription drug system violates patients’ rights.

Instead, I propose that prohibitive pharmaceutical policies, which are a kind of strong paternalism, be replaced by nonprohibitive policies that enable patients to obtain whatever medicines they choose while promoting informed consumer choices by making expert advice readily available.

I'm not sure that I disagree with this argument, but I found it a bit shocking how lightly Ms. Flanagan shrugs off concerns over addiction.

Since addicts are autonomous and able to give informed consent for treatment, including their drug of choice, they ought to be given similar authority to access treatment, including their drug of choice. One way to mitigate the potential harm of addictive pharmaceuticals would be to designate some addictive drugs as "behind the counter" and enable addicts who do not wish to use addictive pharmaceuticals to precommit to not using by enrolling in a voluntary programme. 

I don't feel comfortable saying that, "well, there is a study saying that addicts are able to give informed consent; therefore we can dismiss concerns about increased access to highly addictive drugs leading to increased addiction rates."  This brings up an interesting argument about whether public health laws (and other laws, for that matter) should be designed for the lowest common denominator or the highest. I like a lot of libertarian ideas, but the place where the most hardcore libertarian ideas often lose me is when they seek to legislate for the highest common denominator, with little regard for the lowest.

Healthcare - the French system

French NHI is more generous than what a “Medicare for all” system would be like in the United States, and it shares a range of characteristics with which Americans are well acquainted—fee-for-service practice, a public–private mix in the financing and organization of health care services, cost sharing, and supplementary private insurance.

And yet it still costs significantly less than our healthcare system.  One big reason:

The number of nonphysician personnel per bed (in France's hospital system) is higher in public hospitals than in private hospitals; in the aggregate, it is 67% lower than in US hospitals

From the American Journal of Public Health's series comparing health systems.  The article is old, but nevertheless quite interesting.

Healthcare Price Databases

Kaiser reports on the trend in healthcare price databases.  According to the All Payer Claims Database Council's map, there are now nine states with such databases and several others that are on the verge of implementing their own.  

As the Kaiser article discusses, these databases are expected to help reduce some of the wild variations between the cost of different procedures: 

The price of a knee MRI in Colorado varies from $350 to $2,336...

The eight-fold range in MRI prices stands out, as does a four-fold difference in spending per health plan member between nearby counties. It ranges from a low of $1,000 per year in Hinsdale County to a high of just over $4,000 in Pitkin County. 

The databases themselves seem to vary in their degree of user friendliness, and publicizing their existence may be difficult.  Nevertheless, this innovation has the potential to significantly improve the functioning of our healthcare markets.  Ultimately, it may even be of more use than the ACA's much-touted health benefit exchanges.  

Escaping the tyranny of cultural choice

Dorian Lynskey's column on the tyranny of cultural choice rang a bit too true for me:

In the most heartfelt chapter of his book Retromania, the music critic Simon Reynolds admits to a strange nostalgia for the boredom of his youth. "Today's boredom is not hungry, a response to deprivation; it is a loss of cultural appetite, in response to the surfeit of claims on your attention and time." One of the many ways in which technology leaves the human brain gasping to keep up is in its provision of almost limitless choice, because time remains as limited as ever. "Life itself is a scarcity economy," writes Reynolds. "You only have so much time and energy."

Technology has birthed new versions of the bedside pile of books: the neglected links stacking up in my Twitter Favourites column; the high-minded Netflix queue compiled by a tired parent who has somehow mistaken himself for a film-studies undergraduate; the earnest documentaries waiting in silent accusation on my DVR, like an unused gym membership, until the day the device mercifully crashes. At the same time, the digital buffet can erode your ability to commit to one thing at a time. The main reason I don't own a Kindle or iPad is my suspicion that, without the firm anchor of a physical book, I will get restless and float away in a sea of options.

I've spent the past few years tweaking my media consumption so that I can capture all the most interesting knowledge (twitter, instapaper, google reader, evernote, etc...).  A few months ago, I finally got the formula right, to the point that I could now spend all day on the internet and never run out of interesting stuff to read, which is to say that I've gotten a little bit too good at capturing potentially interesting information.  My book list is impossibly long, and catching up with my twitter feed and my google reader often seem more like chores sometimes.  Finding a fun new article seems more exhausting than anything else.  So, after the reading this article, I decided that some new rules are in order.  Some ideas to experiment with over the next few weeks:

• Limit myself to two media consumption sessions per day, one the morning, one in the evening.  During those two sessions, I can check my twitter feed, go through my google reader feed and browse articles from my instapaper, but I'm not allowed to go back in time, so I will accept that anything that I don't feel like reading during those two session was not enough of a priority, and shall be remorselessly x-ed out of my browser.  If there was something that I was truly excited to read, but that I ran out of time for, I can save it to my instapaper.  
• Spend more time on books.  I spend too much time in front of a computer as it is.  Books require more mental discipline; I cannot just sit mindlessly in front of a book.  And they do not require me to sit in front of a computer, a position that is becoming bad for my back.  
• Find a non-computer-based hobby.  A musical instrument seems like the best bet.  
• Be more disciplined.  This, as ever, is probably the greatest struggle.  

Annual checkups and the overconsumption of healthcare

Naomi Freundlich has a terrific post on annual checkups:

It sounds like heresy, but recent evidence challenges the long-held belief that the annual physical is beneficial for healthy adults. Researchers at the Nordic Cochrane Center in Copenhagen wrote last week that although a regular check-up with multiple screening tests might seem to offer the advantage of catching problems like heart disease and cancer early, their review of studies involving some 180,000 adults actually found no benefit. People who had annual check-ups were no less likely to be admitted to the hospital, become disabled or miss work than those who did not have regular physicals. Even more surprising, they were no less likely to die from heart disease, cancer or any other illness.

The study's authors offer a compelling theory for why this might be the case:

In fact, subjecting healthy adults to this yearly battery of tests may do more harm than good. The authors write, “One possible harm from health checks is the diagnosis and treatment of conditions that were not destined to cause symptoms or death. Their diagnosis will, therefore, be superfluous and carry the risk of unnecessary treatment.”

I'm increasingly starting to believe that overconsumption of healthcare is a bigger issue than previously realized.

Looking at the minimal differences in longevity between rich and poor countries only strengthens this theory.  We spend much more on healthcare than many middle-income countries, but receive very similar results in life expectancy.  The U.S. spends $7,000/person on health; Mexico spends $800.  But U.S. life expectancy is only two years longer than Mexico's (78.2 in U.S. versus 76.2 in Mexico).  And that's despite the fact that violence and traffic accidents kills 7% of Mexico's population versus only 3% in the U.S.

Links I liked

Robin Hanson on the impatience of idealism
More from Ta-Nehisi Coates on language learning
Good news
Probably good news