2. Production of Health FGS - Chapter 5

3. General Formulation HS = f (Health Care, Environment, Human Biology, Life Style) HS = f (HC, Env, HB, LS) If we’re concentrating on health care, Total Product: HS = f (HC, Env, HB, LS) Marginal Product: MP =  HS/  HC Average Product: AP = HS/HC (Excel Spreadsheet - Ch 5.xls)Ch 5.xls What are these?

5. Measures of Health Status Death rates (easiest to measure) Healthy days Morbidity rates It may be critical to distinguish between total and marginal contributions, since low marginals may accompany high totals. Think about longevity.

6. Total v. Marginal It is critical to distinguish between total and marginal contributions. It may turn out that although the total contribution may be substantial, the marginal contribution may be very small. Why do we care? Because many decisions are made at the margin. Additions to the amount spent, may not be “worth it.”

7. Marginal Products Under most conditions, marginal products are always going to be non-negative. Why? Can ΔH/Δx (where x = health care) be negative? Yes! 2 Possibilities

8. Iatrogenic (physician caused) disease Iatrogenic (physician caused) disease. All procedures have their risks. For example, in anesthesia, you kill someone a little bit -- You may do it too much. Suppose, that the more we do, the higher the risk. More care gives lower marginal product, higher risk.

9. Iatrogenic Picture Impacts of care –mgl product (+) –mgl risk (-) Net impact –mgl product - mgl risk. Health care, x Marginal impacts Mgl. Prod. Mgl. Risk Net impact = MP - MR Here, it’s positive.

10. Iatrogenic Picture Health care, x Marginal impacts Mgl. Prod. Mgl. Risk Net impact. Here, it’s negative. Why?

11. Examples of Iatrogenic (physician caused) disease Examples: smallpox vaccine is a prime example; Medical malpractice may be a another (i.e. the more done, the more possible mistakes).

12. Medicalization of Health Care Ivan Illich has argued that the medicalization (substituting medical for home care) of health care could effectively lead to less personal consumer effort to produce health. How would this work? Can you think of an example?

13. On the Historical Role of Medicine and Health Care McKeown focused on dramatic rise in population in England and Wales since 1750. It seems that world population rose and fell without any upward trend, up until that time. How does population increase? (Discuss) Increased births Decreased deaths Increased in-migration

14. Population Growth http://www.ciese.org/curriculum/popgrowthproj/worldpop.html

15. KEY !!! Decreased deaths due to: 1. airborne causes -- tuberculosis, bronchitis, pneumonia, and influenza 2. waterborne causes [Table 5.1].

17. Public Health If not medical care, than what? McKeown argues that it’s public health Immunization of populations Quarantines Sanitary standards for water and sewage Sanitary standards for food handling and treatment Key point, though is increased nutrition

18. Fogel - Increased Nutrition “Infectious disease creates a relationship between host and parasite. While control of the parasite is directly helpful in reducing disease incidence, the condition of the host helps to determine its resistance to disease. A person who is better housed, better rested, and... better fed, will be more resistant and less likely to die subsequent to exposure.” [FGS/4, Ch. 5]

19. Age GroupMales Females <142%35% 1-1916%26% 20-3944%42% 40-4954%69% 50-5938%28% 60-6926%17% 70-7920% 6% Fuchs -- Utah/Nevada Excess Death Rates (Nevada - Utah) How do we explain?

20. Neonate Mortality Table 5.3 looks at neonate mortality. Rate is the ratio of infant deaths aged 1 month or less per thousand live births. It fell 1964-1982 from 17.9 to 7.7. Corman, Joyce, and Grossman were able to estimate the contributions of specific types of medical care and specific types of neonate-related programs. WIC - Women, Infants and Children (improved nutrition program) is means tested, directed toward the poor. For whites - 25% of the reduction can be explained For blacks - 56% can be explained.

21. Bureau of Community Health Services Projects

22. Morbidity Mortality is useful because it is easy to measure. Morbidity refers to illness. What might we expect? If most diseases are either self-limiting, or irreversible, the possibilities for additional medical services to reverse morbidity are small. May work for some services (hypertension, periodontal disease), and not for others. That's about what is found.

23. Schooling - Two Different Theories Grossman - Educated people produce health more efficiently. Why? If so, it makes sense to transfer resources from medical care to education. Fuchs - Education is an investment with a long time horizon. So is health! Since individuals with low time discount rates, or “long time horizons” will tend to invest both in education and health, the two (health and education) will be correlated. No explicit link. This debate has been around for a while, and they’re still arguing about it.

24. MC Cutler Starts with a simple model: U = V(q) – C(q), where q = health output To maximize total utility Mgl. Value = Mgl. Cost Nothing profound here. What we’ve done thus far in all of our analyses today is Mgl cost. What about Mgl value? $ q TC TB MB q* Increasing MC Δs Decreasing MB Δs

25. Example Studies have shown that we’re willing to pay $300 (MC) for an air bag. What are MB? Air bag will save life of 1 in 10,000. So: MC for airbags ≤ MB for airbags $300 ≤ probability of dying * Value of life.0001 * Value of life Value of life ≥ $300/0.0001 = $3,000,000 Depending on how we discount it, this is worth about $100,000 per year.

26. Look at Cardiovascular Care Cutler asserts that “average 45 year old” will spend $30,000 in present value on CV care. Average person will live 3 years longer because of the medical advance? Is it worth it? Who is average? Turns out that average discounted benefit is $120,000. Yes, it is worth it! B/C=120/30 = 4!

27. But We want to look not only at marginal product  marginal costs, but at marginal valuation relative to marginal costs! Low marginal product, may mean increasing marginal costs, but it doesn’t mean that care is not valuable. $ Quantity of Care Mgl. Valuation Mgl. Costs Source: David M. Cutler Are the Benefits of Medicine Worth What We Pay for It? FIFTEENTH ANNUAL HERBERT LOURIE MEMORIAL LECTURE ON HEALTH POLICY, Syracuse University, 2004