Alastair Canaway’s journal round-up for 28th May 2018

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Information, education, and health behaviours: evidence from the MMR vaccine autism controversy. Health Economics [PubMed] Published 2nd May 2018

In 1998, Andrew Wakefield published (in the Lancet) his infamous and later retracted research purportedly linking the measles-mumps-rubella (MMR) vaccine and autism. Despite the thorough debunking and exposure of academic skulduggery, a noxious cloud of misinformation remained in the public mind, particularly in the US. This study examined several facets of the MMR fake news including: what impact did this have on vaccine uptake in the US (both MMR and other vaccines); how did state level variation in media coverage impact uptake; and what role did education play in subsequent decisions about whether to vaccinate or not. This study harnessed the National Immunization Survey from 1995 to 2006 to answer these questions. This is a yearly dataset of over 200,000 children aged between 19 to 35 months with detailed information on not just immunisation, but also maternal education, income and other sociodemographics. The NewsLibrary database was used to identify stories published in national and state media relating to vaccines and autism. Various regression methods were implemented to examine these data. The paper found that, unsurprisingly, for the year following the Wakefield publication the MMR vaccine take-up declined by between 1.1%-1.5% (notably less than 3% in the UK), likewise this fall in take-up spilled over into other vaccines take-up. The most interesting finding related to education: MMR take-up for children of college-educated mothers declined significantly compared to those without a degree. This can be explained by the education gradient where more-educated individuals absorb and respond to health information more quickly. However, in the US, this continued for many years beyond 2003 despite proliferation of research refuting the autism-MMR link. This contrasts to the UK where educational link closed soon after the findings were refuted, that is, in the UK, the educated responded to the new information refuting the MMR-Autism link. In the US, despite the research being debunked, MMR uptake was lower in the children of those with higher levels of education for many more years. The author speculates that this contrast to the UK may be a result of the media influencing parents’ decisions. Whilst the media buzz in the UK peaked in 2002, it had largely subsided by 2003. In the US however, the media attention was constant, if not increasing till 2006, and so this may have been the reason the link remained within the US. So, we have Andrew Wakefield and arguably fearmongering media to blame for causing a long-term reduction in MMR take-up in the US. Overall, an interesting study leaning on multiple datasets that could be of interest for those working with big data.

Can social care needs and well-being be explained by the EQ-5D? Analysis of the Health Survey for England. Value in Health Published 23rd May 2018

There is increasing discussion about integrating health and social care to provide a more integrated approach to fulfilling health and social care needs. This creates challenges for health economists and decision makers when allocating resources, particularly when comparing benefits from different sectors. NICE itself recognises that the EQ-5D may be inappropriate in some situations. With the likes of ASCOT, ICECAP and WEMWBS frequenting the health economics world this isn’t an unknown issue. To better understand the relationship between health and social care measures, this EuroQol Foundation funded study examined the relationship between social care needs as measured by the Barthel Index, well-being measured using WEMWBS and also the GGH-12, and the EQ-5D as the measure of health. Data was obtained through the Health Survey for England (HSE) and contained 3354 individuals aged over 65 years. Unsurprisingly the authors found that higher health and wellbeing scores were associated with an increased probability of no social care needs. Those who are healthier or at higher levels of wellbeing are less likely to need social care. Of all the instruments, it was the self-care and the pain/discomfort dimensions of the EQ-5D that were most strongly associated with the need for social care. No GHQ-12 dimensions were statistically significant, and for the WEMWBS only the ‘been feeling useful’ and ‘had energy to spare’ were statistically significantly associated with social care need. The authors also investigated various other associations between the measures with many unsurprising findings e.g. EQ-5D anxiety/depression dimension was negatively associated with wellbeing as measured using the GHQ-12. Although the findings are favourable for the EQ-5D in terms of it capturing to some extent social care needs, there is clearly still a gap whereby some outcomes are not necessarily captured. Considering this, the authors suggest that it might be appropriate to strap on an extra dimension to the EQ-5D (known as a ‘bolt on’) to better capture important ‘other’ dimensions, for example, to capture dignity or any other important social care outcomes. Of course, a significant limitation with this paper relates to the measures available in the data. Measures such as ASCOT and ICECAP have been developed and operationalised for economic evaluation with social care in mind, and a comparison against these would have been more informative.

The health benefits of a targeted cash transfer: the UK Winter Fuel Payment. Health Economics [PubMed] [RePEc] Published 9th May 2018

In the UK, each winter is accompanied by an increase in mortality, often known as ‘excess winter mortality’ (EWM). To combat this, the UK introduced the Winter Fuel Payment (WFP), the purpose of the WFP is an unconditional cash transfer to households containing an older person (those most vulnerable to EWM) above the female state pension age with the intent for this to used to help the elderly deal with the cost of keeping their dwelling warm. The purpose of this paper was to examine whether the WFP policy has improved the health of elderly people. The authors use the Health Surveys for England (HSE), the Scottish health Survey (SHeS) and the English Longitudinal Study of Ageing (ELSA) and employ a regression discontinuity design to estimate causal effects of the WFP. To measure impact (benefit) they focus on circulatory and respiratory illness as measured by: self-reports of chest infection, nurse measured hypertension, and two blood biomarkers for infection and inflammation. The authors found that for those living in a household receiving the payment there was a 6% point reduction (p<0.01) in the incidence of high levels of serum fibrinogen (biomarker) which are considered to be a marker of current infection and are associated with chronic pulmonary disease. For the other health outcomes, although positive, the estimated effects were less robust and not statistically significant. The authors investigated the impact of increasing the age of eligibility for the WFP (in line with the increase of women’s pension age). Their findings suggest there may be some health cost associated with the increase in age of eligibility for WFP. To surmise, the paper highlights that there may be some health benefits from the receipt of the WFP. What it doesn’t however consider is opportunity cost. With WFP costing about £2 billion per year, as a health economist, I can’t help but wonder if the money could have been better spent through other avenues.

Credits

 

Journal Club Briefing: Dolan and Kahneman (2008)

Today’s Journal Club Briefing comes from the Academic Unit of Health Economics at the University of Leeds. At their journal club on 2nd August 2017, they discussed Dolan and Kahneman’s 2008 article from The Economic Journal: ‘Interpretations of utility and their implications for the valuation of health‘. If you’ve discussed an article at a recent journal club meeting at your own institution and would like to write a briefing for the blog, get in touch.

Why this paper?

Dolan and Kahneman (2008) is a paper which was published nearly ten years ago, was written several years before that, and was not published in a health-related journal. It’s hence, at first sight, a slightly curious choice for a health economics journal club. However, it raises issues which are at the heart of health economics practice. The questions raised by this article have not as yet been answered, and don’t look likely to be answered anytime soon.

Summary

Experienced vs. decision utility

The article’s point of departure is the distinction between experienced utility and decision utility, often a source of fruitful research in behavioural economics. Experienced utility is utility in the Benthamite sense, meaning the hedonic experience in the current moment: the pleasure and/or pain felt by a person at any given point in time. Decision utility is utility as taught in undergraduate economics textbooks: an objective function which the individual dispassionately acts to maximise. In the neoclassical framework of said undergraduate textbooks, this is a distinction without a difference. The individual correctly forecasts the expected flow of experienced utility given the available information and her actions, forms a decision utility function from it and acts to maximise it.

However, Thaler and Sunstein wouldn’t have sold as many books if things were so simple. Many systematic and significant instances of divergences between experienced and decision utility have been well documented, and several people (including one of the authors of this paper) have won Nobel prizes for it. The one which this article focuses on is adaptation.

Adaptation

The authors summarise a large body of evidence that shows that individuals suffer a large loss of utility after a traumatic event (e.g. the loss of a limb or loss of function), but that for many conditions they will adapt to their new situation and recover much of their utility loss. After as little as a year, their valuation of their health is very similar to that of the general population. Furthermore, the authors precis various studies which show that individuals routinely underestimate drastically the amount of adaptation that would occur should such a traumatic event befall them.

This improvement over time in the health-related utility experienced by people with many conditions is partly due to hedonic adaptation – the internal scale of pleasure/pain re-calibrates to their new situation – and partly due to behavioural change, such as finding new pastimes to replace those ruled out by their condition. While the causes of adaptation are fascinating, the focus here is not on the mechanisms behind it, but rather on the consequences for measuring utility and the implications for resource allocation.

Health valuation and adaptation

The methods health economists use to evaluate the utility of being in a given health state, such as time trade-off, standard gamble or discrete choice experiments, will tend to elicit decision utility. They are based on choices between hypothetical states and so will not capture the changes in experienced utility due to adaptation. Thus valuations of health states from the general public will tend to be lower than the valuations from people actually living in the health state.

At first glance, the consequences for resource allocation may not appear to be particularly severe. It may lead to more resources being devoted to healthcare as a whole (at least for life-improving treatments – life-extending treatments are a different case), but the overall healthcare budget is in practice largely a political decision. However, it will not lead to distortions between treatments for alternative conditions.

Yet adaptation is not a universal phenomenon. There are conditions for which little or no adaptation is seen (for example unexplained pain), and when it occurs, it occurs at different speeds and to differing extents for different conditions. The authors show that valuations of conditions with a greater initial utility loss are lower than conditions with a lesser initial loss but a lower degree of adaptation, and thus will receive a greater level of resources, despite the sum of experienced utility being the same for both. The authors argue that this is unfair, and that health economists should update their practices to better capture experienced utility.

Public vs. patient preference

A common argument in favour of the status quo is that (in many countries at least) it is public resources which are being allocated, and thus it is public preferences which should be respected. It appears legitimate to allocate resources to assuage public fears of health states, even if those health states are worse in their imagination than in reality. The authors consider this argument and reply that, in this case, the instruments of health economists are still not fit for purpose. General measures of health states, such as EQ-5D, go out of their way to describe states in abstract terms and to separate them from causes, such as cancer, which may carry an emotional affect. It cannot be argued that public valuations are justified because resources should be allocated according to public fears if the measurement of valuation deliberately tries not to elicit those fears.

The argument that adaptation causes serious problems for valuing health and for allocation of health resources is a persuasive one. It is undoubtedly true that changes in utility over time, and other violations of the neoclassical economic paradigm such as reference dependence, do not presently receive sufficient attention in health economics and policy decisions in general.

Discussion

Which yardstick?

Despite the stimulating discussion and the overall brilliance of the paper, there are some elements which can be challenged. One of them is that throughout, the authors’ arguments and recommendations are made from the standpoint that the sum over time of the flow of experienced utility from a health state is to be used as the sole measure of value. This would consist in what one of the authors calls the day reconstruction method (DRM) which consists in rating a range of feelings including happiness, worry, and frustration.

Despite the acknowledgement of some philosophical difficulties, the sum of the flow of experienced utility is treated as if it is the only true yardstick with which to measure health, without a convincing justification and no discussion on the qualitative aspect of the measurement as opposed to a truly cardinal measure of health allowing ranking of individuals’ health states.

Public vs. private preferences revisited

The authors raise the question of whether current practice can be justified by a desire to soothe public fears, and dismiss it since the elicitation tools are not suitable. However, they do not address the question of whether allocating public resources according to the public’s (incorrect) fears of given diseases or health states could be a legitimate health policy aim. One could imagine, for example, a discrete choice experiment eliciting how much the general public dreads cancer over other diseases, and make an argument that the welfare of the public is improved by allocating resources based on these results. There are myriad problems with such an approach, of course, but there seem to be no fewer problems with alternative approaches.

Intertemporal welfare

Intertemporal welfare judgements are notoriously difficult once the exponential discounting framework is left. It seems just as legitimate to base valuations on the ex post judgement of individuals who have fully adjusted to a health state as on an integration of past feelings, most of which are now distant memories. Most people would agree that the time to value their experience of a marathon is after completing it, not during the twenty-fifth mile or at the start line.

Indeed, this appears to be the position tacitly taken elsewhere by Kahneman in his work on the peak-end rule. In Redelmeier et al. (2003), it was found that the retrospective rating of the pain of a colonoscopy was based almost exclusively on the peak intensity of pain and on the pain felt at the end. Thus procedures which were extended by an extra three minutes were remembered as less painful than standard procedures, even though the total pain experienced was greater. Furthermore, those who underwent the extended procedure were more likely to state they would undergo it again. It would seem strange, in this case, to judge them as worse off.

Schelling (1984) ends his superlative discussion of the problems of intertemporal decision making with the following thought experiment. Just as with valuing health, there are no easy answers.

[S]ome anesthetics block transmission of the nervous impulses that constitute pain; others have the characteristic that the patient responds to the pain as if feeling it fully but has utterly no recollection afterwards. One of these is sodium pentothal. In my imaginary experiment we wish to distinguish the effects of the drug from the effects of the unremembered pain, and we want a healthy control subject in parallel with some painful operations that will be performed with the help of this drug. For a handsome fee you will be knocked out for an hour or two, allowed to sleep it off, then tested before you go home. You do this regularly, and one afternoon you walk into the lab a little early and find the experimenters viewing some videotape. On the screen is an experimental subject writhing, and though the audio is turned down the shrieks are unmistakably those of a person in pain. When the pain stops the victim pleads, “Don’t ever do that again. Please.”

The person is you.

Do you care?

Do you walk into your booth, lie on the couch, and hold out your arm for today’s injection?

Should I let you?

Credits

No borders, no nations, no user charges

It was recently proposed that, here in the UK, foreigners should start having to pay towards their health care because of the apparent budgetary pressure from ‘health tourists’. Let’s be clear upfront; this isn’t a problem. If you believe the media, ‘health tourism’ costs the NHS around £30m per year. That’s less than 0.03% of the NHS budget. And the evidence suggests immigrants don’t use much health care anyway. Nevertheless, at some point in the future, this issue may really need addressing.

The case for treating everyone

The moral case seems obvious; everybody has an equal right to health care. If you think nobody has a right to health care, that’s fine too, but why should foreigners’ health be of less value? Economics, arguably, has a great cosmopolitan and egalitarian tradition. Most economists have been driven by their discipline to accept humans as being equal; even if they’re immigrants. This perspective, I suspect, extends to health economists in the UK.

The NHS constitution does not discriminate against foreigners, so it would presumably need changing if user charges for immigrants are introduced. It states that “public funds for healthcare will be devoted solely to the benefit of the people that the NHS serves“, but does not state who is included in “the people”. I’d like to think it includes anyone who happens to be within our borders at their time of need. Surely it should at least include NHS employees; many of whom are immigrants. If we decide not to treat foreigners for free it means that we do not value their health gains equal to ours. Indeed, the implication here is that any health care they receive is at the expense of a native. If this is the case then we health economists will need to adjust our cost-effectiveness analyses to shift any observed benefits for immigrants to the cost side of the equation.

I totally buy in to the moral case for open borders. It matters not to me whether you were born in England or not; nor does it matter to me whether or not you pay taxes. What’s more important to me is that you are willing to pay taxes, and I know plenty of born-and-bred Brits who would readily shirk their tax-paying responsibilities given the chance. For me an immigrant or a tourist has as much right to health care as an unemployed native. One cannot oppose treatment of immigrants on the grounds that they do not pay taxes without also opposing treatment for the unemployed. Case closed.

Moral arguments aside, plenty of services provided by the NHS also resemble public goods. The spread of infectious disease is an obvious risk of discouraging foreigners from seeking treatment. Furthermore, poor health may prevent or discourage immigrants from entering the labour market. It seems possible, if not likely, that charging immigrants a nominal fee for their health care would cost more than it saved. Hopefully we’ll see more evidence either way in the future.

The case against treating everyone

I can’t fathom a moral objection. Xenophobia might be to blame for the recent policy proposal, but I’ll leave it to others to try and figure out the moral arguments against treating everyone. Practically, however, and it pains me to say this, in the case of the NHS we could potentially have a problem. If a health care system is funded through national health insurance or taxation, the system can’t afford to insure the global population. Milton Friedman would probably agree on this point. The availability of welfare is likely to attract migrants who hope to receive it. Rational agents with health care needs would flock to the UK for treatment.

The budgetary pressure of ‘health tourists’, in the extreme, could dramatically reduce the average health expenditure per NHS patient. More care for ‘health tourists’ leads to less care for natives, and it seems difficult to justify reductions in the quality of care. Just to reiterate, this isn’t a problem right now. The tiny nugget of the budget that goes towards treating ‘health tourists’ does not jeopardise the quality of care provided by the NHS. I am speaking in hypothetical terms here of a situation which hopefully will never arise, but for which we should have a solution.

The solution

I don’t know. Obviously every country in the world should provide high quality universal health care that is free at the point of delivery; regardless of one’s nationality. This might happen some day. Let’s hope it does. In the meantime let’s stop legislating for problems that don’t yet exist.

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