School Lunches: The only place where a tater tot is the equivalent of a green, leafy vegetable

School lunches have never had a good reputation. Decrypting the true identity of "mystery meat", eating applesauce that is more reminiscent of paste than apples, or chewing green beans that have a questionably squishy texture... complaining about school lunches is a rite of passage for a lot of people. However, the complaint at this point in time isn't about texture or taste-- it's about nutritional content and the obesity epidemic that is occurring in the youngest populations.

Congress has been asked to make legislation that improves the quality of food that school children eat to make it more nutritious. Foods like pizza, french fries, and chicken nuggets appear regularly on school lunch menus and comprise a large part of the average American child's diet. This is problematic as these foods are correlated with higher body mass indexes (BMI)--which is also correlated with health problems in childhood, as well as in their later adult years. Cost has been the primary barrier to providing more healthful food--as it costs more to provide healthy foods than it does to provide less healthy foods (EX: fresh vegetables cost more than tater tots). Also- special interest groups (namely potato and salt industry) have a vested interest in making sure kids continue to eat their current school lunches which are often very high in white potatoes, white flour, and sugar (think: flavored milk). As of now, Congress has backed down on improving the quality of school lunches--and is remaining with the status quo.

The question is-- is this within the realm of what Congress should be doing? (Not that Congress always spends it's time on worthy things-- I remember them getting involved in some of the business with the baseball players who used steroids, and then lied about their usage...just saying). If the answer is yes-- then I think Congress should re-visit the cost-benefit analysis here.

What is the monetary benefit of improving the quality of school lunches? I'm not sure it's possible to determine how school lunches directly effect childhood obesity, but common sense tells me, if a child receives zero healthy meals per day, giving them 1 healthy meal per day at school would be an improvement. Also- this would expose them to healthy foods, which they may discover are actually pretty tasty--thus increasing the likelihood that the child will request mom or dad purchase these types of foods in the future.

Even if having more healthy foods results in very little weight loss in overweight or obese children-- it would still be a WIN on a population level. Imagine all children are on a standard deviation curve where the heaviest are in the right tail and the lowest weight children are in the left tail. If we shift those children in the right tail down the curve 1-2 pounds worth-- that results in less children in the overweight/ obese category (where there are well-known health risks that are very costly). Not having those kids suffer with the chronic conditions that occur due to excessive weight would obviously be good for the kids themselves--but would also be good for society from a cost perspective (and the reward would keep giving overtime--since overweight kids with health problems often turn into overweight adults with even more health problems).

In sum- it would be useful to know the relationship (or elasticity, in Economics-speak),between dollars spent on increasing healthy food for school lunches, and the percent reduction in children above the 85th BMI percentile (IE: the kids who are overweight or obese, by CDC standards). What an awesome experiment this would make! Obviously there would be lots of measurement challenges, and like any observational study, the results would show correlation-- not causation (if they show anything at all)... but it would still be a useful piece of information for Congress, schools, and the food industry to have.

Until then, if you have the resources, brown-bag lunches are looking like a pretty good option!

No cost birth control

An expert panel for the Institute of Medicine has recommended a number of medical services be given at no cost-- one of which is birth control. This raised concern (outrage?) in the pro-life and Catholic communities. Women's right's groups are ecstatic.

What we do know is that about half of all pregnancies are unintended. Women who do not want to be pregnant are less likely to get proper prenatal care and are more likely to have complications later on (low birth weight, delayed development/ development problems). So, we can deduce that for some women who do not want to be pregnant, it can have a distinctly negative impact on the resulting child.

Many women choose not to use birth control due to cost. By the law of demand, lowering the cost (to zero) of birth control more women can afford to take birth control-- thus we can reduce the number of unplanned pregnancies (and unhealthy pregnancies/ births).

Cost-Effectiveness of Meningitis Vaccine

Generally preventative medicines have a good shot at being cost-effective. They prevent hospitalizations, medical/ surgical procedures, additional medicines, etc. The trade-off is that vaccines need to be given to everyone who can get the vaccine for it to be effective. Like the flu vaccine ads say,"don't get it for you-- get it for ___ (insert name here)___" highlighting how getting a vaccine not only protects the person who gets it-- but also the all of the people who that person comes in comes in contact with.

What we don't want to see is the resources a vaccines saves in illness care for the small number of people who are infected, get made up for in the quantity of people having to get the vaccine (albeit, the vaccine is much less expensive than the medical treatment treating the disease). This is the case when the vaccine is very expensive and the disease the immunization protects against is relatively rare.

As a recent NPR piece highlighted, the bacterial meningitis may be in the position discussed. At first the vaccine was only given once and cost $100. Now ACIP (Advistory Committee on Immunization Practices) is recommending a booster-- which raises the cost to $189. NPR states that this would cost the government $387 million annually. All of this is estimated to prevent only 23 deaths per year. Is that okay? If all 23 deaths were people covered by government health care-- that would be more than $16 million per life saved. If you included what other non-government entities were spending on the vaccine- the cost would be even higher--since there are still only 23 deaths per year. Is that an acceptable amount to pay to save a life given the fact that there are budgetary constraints?

From the article:

....experts can't solve the fundamental problem of how to put a dollar value on preventing death or disease, says Mark Pauly, a health economist at the University of Pennsylvania.

"You do have a rough idea that if it's $1.98 per life saved that sounds like a good thing to do and if it's $198 million per life saved, that sounds like not a good thing to do," he says. "But where to draw the line is the part that any sensible person will run away screaming from trying to answer that question."

Excess spending on end of life care

Chris sent me this article- and it was pretty interesting!

This describes a problem well-known to those who know anything about health care expenditures. I remember a vague statistic from my Health Economics course-- it was something like a third of all personal health care expenditures are spent at the end of life, on average (don't quote me on that). While it may not be a third, I think we can safely say it's a disproportionate amount of money...

Given that I have a degree in the dismal science, I'm about to get all dismal on you-- but just think about this without thinking about the morbidity of it:

When you think about how you want to die, you probably don't envision your death dragging out over months and months while you whither away. However, by spending ourselves into the ground (or under it?) we do just that-- we pay for treatments that keep us alive for a marginal amount of time while we suffer.

As you're probably already thinking-- this is pretty tricky. Ideally you would know which disease would be your final, and you would know not to pursue any additional treatments that would prove to be fruitless-- as they would only drag out your suffering (which, it is assumed, is not your goal). Anyway- you would know to just stop, and enjoy your time on Earth doing the things you like to do and spending time with the people you love.

As far as spending goes-- yes, we'd like to reduce end-of-life expenditures (we'd like to reduce all types of expenditures really)... but the problem is that you never know when the "end" really is. This really just adds fuel to the cost-effectiveness fire- and makes it even more of an important and critical type of research. If we're not wasting time or resources of treatments that are just not effective or worth spending money on, we can theoretically give the best reasonable care, while still being fiscally responsible.

C-sections galore!

NPR ran a story on the air today describing the increased rates of Caesarean section births in developing nations. It is relatively well-known that C-sections have increased in popularity in developed countries like the US due to their convenience (working moms can schedule the C-section and plan maternity leave more easily, avoid the pain associated with a vaginal birth, retain bladder control by preserving the pelvic floor, rates of inducing births have increased which can cause the need for a C-section birth, etc.) Now we're starting to see this trend in developing countries as well-- but this is causing something of a problem.

Now that more women are opting into C-sections they're taking up more space in operating rooms that were once used only for women who truly needed them for medical reasons. The concern that arises now is whether wealthier women who can afford to pay for an elective C-section are taking operating room space away from women (poor or wealthy) who really need it.

Obviously this also starts raising questions about cost-effectiveness.... why are we paying for unnecessary medical procedures? I wouldn't say that a C-section is unnecessary if a women just prefers it (she should be able to obtain it if she's willing to pay for it and understands the risks involved...not that she's bearing the full cost of the procedure at all due to insurance--but that's a different conversation altogether), but I would say that it's unnecessary if the woman has been unnecessarily pushed into a C-section either due to convenience or revenue considerations coming from the hospital. C-sections are revenue makers. They generate twice as much revenue as a vaginal delivery.

It seems that we're getting a little heavy-handed with the C-Section ordering pen, but are we really considering the Economic implications? With such a great deal of geographic variation in C-section births, it's hard to make the argument that C-sections are needed at the high rates seen in some hospital systems. These C-sections are coming at a much greater cost than the vaginal deliveries, and also are more risky, and result in more readmissions--and in some cases lock women into delivering via C-section for subsequent children. All of these factors add up to much larger expenses in the end. It may be time to re-examine what determines the need for a C-section, and what does not, so that we can avoid unnecessary surgical procedures.

Also of interest

Methods of effectiveness research: Intro

I'm currently in the last semester of my Master's in Economics degree and am completing an independent study related to types of Economic analysis with respect to health care. Evidence-based medicine (EBM) is an "it" topic when discussing health care reform, or health care policy. While I'm not directly studying EBM this summer-- my topic is related as effectiveness research not only looks at which treatments are effective (like EBM), but also looks into quantifying and valuing the costs associated with the treatments--and attempting to make decisions related to which treatments/ procedures are worth their costs.

I'm looking at four types of analysis-- Cost of Illness studies, Cost-Benefit analysis, Cost-Effectiveness analysis, and Cost-Utility analysis. I'm also examining issues and practices that arise in the practice of these types of analysis--such as sensitivity analysis, discounting, and challenges associated with data collection and data interpretation.

Many of these topics have recently received a lot of attention from medical and academic communities--especially cost-effectiveness research. To understand why this has become so popular you have to understand where this type of research has come from. Cost-Benefit analysis is largely considered to be the gold standard form of analysis as far as Economists and other professionals are concerned. It's a very simple concept-- you subtract the benefits from the costs (in a common unit-- like dollars) and if the result is positive (ie: benefits > costs) then the decision is considered to be favorable. We do this everyday without noticing. For example, do the added calories from an extra Oreo outweigh how happy eating the extra Oreo is going to make you? If so, you will likely choose to put down the Oreo because the net benefit is going to be negative.

As far as health care is concerned, do the benefits of a twice yearly pap smear outweigh the costs associated with going to the OB-GYN for a pap? Maybe--maybe not. It depends on who you are (do you have a history of cervical cancer? how old are you? have you ever had an irregular pap?). What are the costs of going to the OB-GYN for a pap? Obviously the cost you pay to the office is a cost-- but what about what the insurance company pays? What about your lost productivity or wages at work due to the office visit? What about the emotional stress of receiving a pap twice a year? These are the types of problem you run into with Cost-Benefit analysis when you start trying to analyze these types of procedures. It's difficult to quantify costs-- but even more difficult to quantify benefits (ie: how much money is it worth to prevent cervical cancer?) For this reason, there has been a movement towards Cost-effectiveness analysis.

Cost-effectiveness analysis tries to get around the issue of having to put a dollar amount on benefits. Rather, benefits are measured in another form-- such as the number of cases of cervical cancer reduced due to an increase in screenings, or days of regular blood sugar when taking a new Diabetes medicine, or the % reduction in the size of tumor due to a new cancer treatment. Once the benefits are quantified in this form you can take the cost (which, granted, is still hard to quantify completely) and divide it by the measured benefits (ie: the number of cervical cancer cases avoided). This gives you what is known as an ICER-- incremental cost effectiveness ratio. When other ICERs are calculated (using the same units and same measures) they can be compared.

Cost-utility analysis, which is a form of cost-effectivenss analysis-- an is often just called cost-effectiveness analysis, takes the analysis one step further. Cost-utility analysis uses QALYs (quality adjusted life years) to value benefits rather than trying to directly measure an outcome.

Simply put:

As you can see, the numerator stays the same in all forms, but the denominator changes. Often times people prefer to avoid Cost-benefit analysis because of the difficulties associated with valuing benefits. Cost-effectiveness analysis and the ICER are useful, but sometimes ICERs can not be compared if the denominator isn't being measured in the same way (ie: for a Diabetes treatment: one researcher may measure days within a range of healthy blood sugar levels for a non-Diabetic person, while another researcher may measure days within a healthy blood sugar range for people are are healthy, or pre-Diabetic.) Another benefit associated with using QALY's is that QALYs take into account, not only mortality avoided, but also morbidity avoided due to a treatment. Researchers often like QALYs because of their ability to account for the increased quality of life people achieve after going through a treatment--something not accounted for when measuring a specific health outcome like days of healthy blood sugar. QALY's are, of course, not without their own problems as is described in "Cost-Utility anaysis: Use QALY's only with great caution". In this article, McGregor describes how mis-measuring (or not understanding what is being measured ) with regard to QALY's can limit how powerful the explanatory or comparative power of results of a Cost-Utility Analysis are.

So why does any of this even matter? It matters because no one is able to spend infinite dollars on health care. When there are scare resources, decisions have to be made. Using these forms of analysis we can make more informed decisions--which desperately needed by the federal and state governments as more and more of their money is going towards health care expenditures. We need to make purchasing health care more like purchasing a refrigerator. If you were going to purchase a fridge, you would research the models you were interested and determine which bells and whistles you wanted, and then research how much each model cost in one present day currency (as in 2010 dollars). From there you'd pick which one best fit your needs and your budget. We need to approach health care the same way-- determine what the costs are and which benefits we desire-- and then weigh each one in a standardized way to determine which treatments and procedures we want to (and can feasibly) support.

Information Problems

Asymmetric information is a topic discussed in introductory Economics courses that describes a situation where one party has more information than another. For example, if you are selling your car to a passerby on the street, you have more information about the car than the passerby does. You know that you took your car to your trusty mechanic every 4,000 miles for an oil change, and that whenever anything seemed remotely wrong with your car you got it checked out immediately. Perhaps you’re charging $ 8,000 for you 8 year old car. The passerby is thinking “that’s a pretty steep price for this car… it looks good, but how do I know if something isn’t wrong with it… there MUST be a reason (s)he’s getting rid of it”.

Alas—we have an information asymmetry.

There is no way the buyer can be certain of the quality of the car until they purchase it and drive it around for a few months. The seller can attempt to tell the buyer what a good car it is, but how can the buyer be sure they aren’t just getting scammed?

This story is applicable to the heath care industry as well. Let’s say you go to the doctor with a persistent sore throat and the doctor diagnoses you with some condition--something you can't even pronounce with confidence. “Oh no” you think to yourself, “that sounds serious". The doctor goes on to prescribe you an antibiotic and perhaps some other medicines that will make you more comfortable. The doctor is giving you directions on how to take your medications and what the side effects are, etc. You’re starting to feel a little out of the loop and you’re getting blown away by all of the foreign terminology and directions. At the end of the appointment the doctor asks “do you have any questions”? You think to yourself quietly for a moment… you’re not even sure you could come up with an educated question if you had to. Despite feeling overwhelmed you respond, “no”.

You’ve just been a victim of asymmetric information (and if this situation has never happened to you, surely you’ve taken your car to the shop before and have agreed to all sorts of repairs you weren’t really quite sure about). Doctors go through an intense amount of education—both in the books and in practice. We can’t expect for them to convey all of that knowledge to us when we visit their offices, but we really ought to be better consumers. You wouldn’t buy a new dishwasher without doing at least a little bit of research (at least you’ll compare Home Depot and Lowe’s). However, when you go to the doctor, often times you go in with very limited knowledge about prescription drugs or treatments your doctor may prescribe. If your doctor tells you that you need a test that will cost you (or your insurance company) $4000 at the hospital that you usually go to, are you going to call the other local hospitals to see if you can get the same test for less money? Maybe you think that the test will cost the same everywhere—surely these things have to be standardized—right?

Wrong. The variation in cost between hospitals can be astronomical. We’ll wait for another blog post before we discuss this in full—so for right now you’ll just have to believe me when I say that procedures don’t always cost the same at every hospital.

So, what is the problem here? The problem is simple—you don’t understand that product(s) you’re consuming, and you’re likely paying too much. The bigger problem is that, if you have health insurance, you (and your doctor) probably don’t care too much since you won’t be picking up the bill yourself. This results in overtreatment at increased costs. What’s worse is that, if you’re taking unnecessary medications (perhaps you get prescribed an antibiotic for a common cold) you may actually end up hurting yourself in the long run. I hypothesize, that if we were better, more informed, consumers of medicines we would save money, but more importantly we could be healthier. Every day people are harmed by drug interactions that could have been avoided. Doctors are people too—so they will make mistakes. The informed consumer can safeguard themselves from medical mistakes by asking questions and attempting to learn more about the medications and treatments their doctors prescribe.

What can you do? Next time you’re at the doctor try and think of questions to ask—even if they’re simple. Your doctor has a lot of knowledge—you just need to finagle it out of them.

Here are some questions to ask that I found on about.com:

1. What is the name of my medication?
2. What does my medication do?
3. How/ when should I take my medication?
4. How long should I take my medication for? (this is important—sometimes doctors are not inclined to remove you from medications, even when you may no longer need them)
5. What should I do if I feel better and I don’t want to finish my medication?
6. Does this medicine contain anything I’m allergic to—or will it react with any of my other medications and/or supplements or vitamins?
7. What food, drinks, or activities should I avoid when I take this medicine?
8. What are the side effects? Are they common?
9. Is there a generic version of this medicine?
10. Is it safe to use this medicine if I am pregnant or breastfeeding?
11. How soon will this medicine start working?
12. Will any tests be necessary while I’m taking this medication?
13. Most importantly (arguably): What risks are associated with this medicine and do they outweigh the benefits?