Thursday, November 10, 2011

The future of health care today

From E. Klein:

The future of health care today:

In a New York Times op-ed today, M.I.T’s Frank Moss imagines a



high-tech health care future, where health care literally becomes part of our everyday life. “Inconspicuous wireless sensors worn on your body and placed in your home would continuously monitor your vital signs,” Moss speculates. “Wristbands would measure your levels of arousal, attention and anxiety.”


It’s worth pointing out that we’re actually not too far off: California-based CareMore is already pioneering what Moss suggests and has seen impressive results. The company, which caters to seniors in Medicare Advantage, monitors its patients remotely through wireless scales and blood pressure cuffs. If something seems off, the clinic knows because it’s getting continuous data from the wireless devices. The Atlantic magazine last month wrote about one CareMore patient, Ellen, to explain how this works:



One Wednesday morning last year, she got on her scale, as she does every morning. One hundred and forty-six pounds—wasn’t that a little high? Ellen felt vaguely troubled as she poured herself a bowl of oat bran.

Half an hour later, the phone rang. It was Sandra at the clinic. She too was concerned about Ellen’s weight, which had jumped three pounds since the previous day. Sandra knew this because Ellen’s scale had transmitted its reading to the clinic over a wireless connection.

Given that Ellen had a history of congestive heart failure, a three-pound weight gain in 24 hours was a potentially dangerous development, a sign of possible fluid buildup in the lungs and increasing pressure on an already stressed heart. Sandra wanted her to come in for an immediate visit: the clinic would provide a car to pick her up and bring her back home. Ellen’s treatment began that very morning and continued for two weeks until she was out of danger. Had the warning signs not been noticed and addressed so quickly, she might easily have suffered a long, painful, and expensive hospitalization.

This approach has done CareMore really well: Even with all the investments in monitoring, its costs are routinely 18 percent lower than industry averages. Hospital stays for CareMore patients are 24 percent less frequent and, when they happen, 38 percent shorter. The company could serve a good guidepost of what the future of health care should look like. The bigger hurdle is getting the rest of the system to catch up with it.




Thursday, November 3, 2011

More thesis ideas

* Use National Patient Registry data to answer questions like:
- What characterizes the group that receives most health care resources? (Age, gender, diagnoses)
- How much is spent on diagnoses related to alcohol and what characterizes this group?


* Examine the extent to which quality grading of articles by experts (eg. in systematic reviews) correspond with automatic grading based on an articles number of citations.

Wednesday, November 2, 2011

Ideas for master thesis

Here are some ideas for those who are thinking about topics for a master thesis:

We have a dataset in which the general population as well as MD have responded on different topics. You can have this dataset and look at different topics:

1. Attitudes towards sick leave among the general population and MDs
(Both groups have answered questions on this)

2. Attitudes towards paying for blood donation

Another topic, in which you have to collect some data, is:

3. What happened to the number of physician consultations when the copayment was eliminated for youths?


Friday, October 21, 2011

Small survey

Wednesday, October 19, 2011

The Senate acted to save potatoes from school nutrition rules

Random and fun helath care news from the US (Ezra Klein):

The Senate acted to save potatoes from school nutrition rules, reports Robert Pear: "The Senate stood up Tuesday for the humble white potato and rebuffed an effort by President Obama to limit its consumption by millions of schoolchildren around the country. The administration has proposed limiting the amount of potatoes and other starchy vegetables that can be served in school lunches to one cup per student per week, and banning them from school breakfasts. The Senate on Tuesday moved to block the proposal by adopting an amendment to the 2012 spending bill for the Agriculture Department. The amendment, approved by unanimous consent, prohibits the department from setting 'any maximum limits on the serving of vegetables in school meal programs.'"

Monday, October 17, 2011

Update on topics and exam

Anki - The flashcards (http://ankisrs.net/)
Go to the document in the link below and write your name next to the document you have signed up for. If you do not do so withing a week, somebody else will be allowed to take "your" chapter:
https://docs.google.com/document/d/19GwhIAghWFEhGcp6glq11_WsaM4LVHO8d5rG2OwkwhQ/edit?hl=en_US


About the exam
Some of you have asked about how much calculation you have to do, how much you neet to know about the things we do in class in addition to the topics in the book and so on. The short answer is: The exam will consists of several small questions asking you to define concepts and give examples. It will also consists of some questions involving calculations like we did in volumen-profit analysis (calculate break-even volumen and so on). Finally, the main part will be from the Drury book, but there may be one or two small questions about concepts we have covered in class. A list of the topics I expect you to know something about (with links) is listed below.


List of topics
Some of you have asked for a list of topics that are not in the Drury textbook. I have listed the topics below with some links and to more information. For the exam, you will be expected to know something about some of these concepts. It will not be a major part of the exam - concepts from the Drury book will cover that - but you may get some questions on the following: the concept of expected value, some of the mechanisms that create economies of scale and diseconomies of scale, and the problem of regression to the mean. I will update this list so you will always know the concepts that you are supposed to know.


Decision theory
(Define, Difference between expected value and expected utility, St. Petersburg paradox, Allais paradox, Net Present Value, Overconfidence, Bayes' Rule and screening)

System of Health Accounts 
(Importance ans use of health accounts, Boundary problems, Conversion problems, Quantification of problems)
The document itself is here: http://www.who.int/nha/sha_revision/sha_2011_final1.pdf

Economies and diseconomies of scale
(Average cost curve, mechanisms that create economies of scale, learning by doing, distribution of fixed costs, mechanisms that create diseconomies of scale, coordination costs, information costs, principal agent problems in hierarchies, chains of principal agent relationships)

Cost containment 
Lorenz curve, distribution of health cost among different groups, Atul Gawande, regression to the mean

Why projects often go over budget 
1. Political reasons
2. Technical reasons (Ths sum of most likely events is not always the most likely outcome)

Health care fraud
Examples of different kinds of fraud, estimating the size of fraud, fee-for-service vs. per capipta may lead to different frauds

Less relevant, but since I mentioned it in class:
Can you buy love? 
Here is a blog with lots of statistics about this and other things based on data from a net dating site (warning, not for the faint hearted): http://blog.okcupid.com/

Wednesday, October 5, 2011

Management and decision making 102: Bayes' theorem

Imagine yourself as the leader of a health agency and that you have to decide whether to go ahead with a large universal screening program e.g. screening for cancer. You have been told that the test used in the screening is 99% correct and that about 0.5% of the population has the disease.

Many people at this point simply conclude that the screening is a good thing: We will pick up a lot of cases at an early stage, they will get treatment and may even survive because the cancer was discovered early. You, however, are not most people. You try to think about this carefully.

First of all you might wonder about the cost of the screening and how many cases it discovers compared to the no universal screening case. Those with high risk migh go to the doctor anyway and so on, so the question is how many extra cases you will find and be able to cure. This is all true, but you also start to wonder about potential harmful effects.What about those who will get the message "you have cancer" because of mistakes in the test. Well, the test seems good, 99% certain, som maybe this is nothing to worry about?

Unfortunately, this is wrong. We can show this using an example as well as more formally using Bayes' Rule.

To illustrate the problem, imagine 1 000 000 people doing the test. Out of these, 5 000 have the disease and 995 000 do not have the disease. Given an accuracy of 99%, this implies that:
- Among the 5000 with the disease, 4950 will get the message "you have the disease" and 50 will get "you do not have the disease"
- Among the 995 000 who do not have the disease, 985 050 will be told "you do not have the disease" and 9950 will be told "you have the disease"

Altogether this means that 14 900 have been told that the have the disease (9950 + 4950). Out of these only 4950 really have the disease ie. 33.2% In other words, given the information in this example, when a person in the screening program is told "you have the disease" the probability of actually having the disease is only 33.2%

Why? The key problem is the fact that although the test itself seems accurate, the probability of not having the disease is very high. For every case the probability of making a mistake is small, but since there are so many cases, and since most of them are people who do not have the disease, even a small probability of making a mistake will result in many false alarms.

Formally we can use Bayes rule to calculate the probability of actually having a disease given a positive test. We want to know the probability of having the disease (A) given a positive test result (B): P(A|B). From basic probability theory we know:

P(AB) =  P(A) P(B|A)

That is, the probability that both A and B will happen can be found by multiplying the probability that A will happen and the probability that B will happen given that A has happened.

Similarly we know

P(BA) = P(B) P(A|B)

Since P(BA) = P(AB), we also have

P(B) P(A|B)= P(A) P(B|A)

Rearranged:

P(A|B)= P(A) P(B|A) / P(B)

This is called Bayes rule and it can be used to calculate the correct probability. Recall
P(A) : Probability that a person the disease = 0.005
P(-A) : Probability that a person does not have the disease = 0.995
P(B):  Probability that a person tests positive
P(B|A): Probability that a person tests positive given that she has the disease = 0.99
P(B|-A): Probability that a person tests positive given that she does not have the disease = 0.01


To work out the probability that a random person tests positive, remember that there are two ways of testing positive: Either you have the disease and test positive, or you do not have the disease and test positive.
Probabability of having the disease and testing positive: P(A) P(B|A) = 0.005 * 0.99
Probabability of not having the disease and testing positive: P(-A) P(B|-A) = 0.995 * 0.01
We then find

P(B) = P(A) P(B|A) + P(-A) P(B|-A)
P(B) = 0.005 * 0.99 + 0.995 * 0.01 = 0.0149

We then have all the information neede to use Bayes rule to calculate the probability of having the disease given a positive test:

P(A|B)= P(A) P(B|A) / P(B)

P(A|B) = 0.005 * 0.99 / 0.149 = 0.32

In short, knowing a three hundred year old mathematical rule, will enable you to make a better decision. You need not even know its precise formulation - all you have to remember is that the importance of considering not only the accuracy of the test (high), but also the base rate prevalence of the disease (low) and that the end result will be in between.




Tuesday, October 4, 2011

Relevant articles

The reading list mentions some articles. You have online access to some of these from the University of Oslo. Here are the full references:


Alanen J, Keski-Nisula L, Laurila J, Suramo I, Standertskjöld-Nordenstam CG, Brommels M (1998) Costs of plain-film radiography in an partially digitized radiology department: an activity based analysis. Acta Radiol 39: 200–207

Laurila J, Suramo I, Brommels M, Tolppanen EM, Koivukangas P, Lanning P, Standertskjöld-Nordenstam CG (2000) Activity-based costing in radiology: application in a pediatric radiological unit. Acta Radiol 41:189–195

Jonas Schreyögg & Oliver Tiemann & Reinhard Busse, 2006. "Cost accounting to determine prices: How well do prices reflect costs in the German DRG-system?," Health Care Management Science, Springer, vol. 9(3), pages 269-279.

J.A. Brickley and R.L. Van Horn (2002), Managerial incentives in nonprofit organizations. Journal of Law and Economics,  XLV  (2002), pp. 225–249.

Kuntz, C., and Antonio Vera. 2005. Transfer Pricing in Hospitals and Efficiency of Physicians: The Case of Anesthesia Services. Health Care Management Review 30(3): 262-269.


Management and decision theory 101: The basics and St Petersburg paradox

The theory
Should you invest in umbrellas or ice-cream? How should you choose between the two?

Some simply to go with their gut feeling. That may work sometimes, but it turns out that gut feeling is often wrong. Being led by your stomack or other bodily parts often lead to systematic mistakes and bad outcomes. To improve the way we make decisions, in life and in business, it is useful to explore both when gut feelings tend to lead us astray as well as what we should do to make better descisions.

How should one make the best possible decisions? Intuitively one should weight the costs and benefits of the two actions. The question is how one can do this in an uncertain world. Should you bring an umbrella or not when going out of the house? The decision depends on your beliefs about the weather, the hassle of carrying an umbrella and how bad you believe it is to be outside in the rain without an umbrella. All of this has to be estimated and somehow integrated into a single value in order to determine the best action.

Continue with the example and imagine that your subjective probability for rainy weather is p. To calculate the expected consequences of bringing an umbrella, you consider the two possible outcomes. If it rains you will avoid getting wet, if it does not rain you will look like a fool with an umbrelly on a sunny day. The higher the probability of rain, the more likely it is that you will experience the first outcome. In this way the probability of the outcome can serve as a weight. The more probable an outcome is, the more weight we should attach to it when calculating the expected consequence. So to make a rational decision we list all the possible outcomes from an action and weight the outcomes according to how probable they are. In short:

Expected consequence of an action = Sum of (probability * Value of outcome) for all outcomes of that action


St. Petersburg Paradox
This may sound obvious, but there are always surprises hidden in the details. To illustrate a potential problem, suppose you are offered a chance to play a game in which a coin is thrown until it lands heads up. If it lands heads up after the first throw, you get two dollars. If it takes two throws to get heads, you get four dollars. Three throws to gives you eight dollars and so on. In short, the money doubles for every time tails comes up and as soon as the coin comes heads up, you get that sum of money. Now, the question is how much you are willing to pay in order to be allowed to play this game.

Being rational, you start to calculate the expected value of playing the game. The outcomes are easy, you can  end up winning 2, 4, 8, 16 dollars and so on. The probabilities are also quite easy. The probability of getting heads on the first throw is 1/2. To win four dollars, the coin has to land with tails up on the first throw (p=1/2) and heads on the second throw (p=1/2). Each event has probability a half, so the probability for both to happen is 1/2*1/2 = 1/4. next, the third outcome - winning eight dollars - implies tails, tails, head or a probability of 1/2 * 1/2 * 1/2 = 1/8. If we go on we have:

Outcomes    (2   ,  4  ,  8  , 16   , 32   , ...)
Probabilities (1/2, 1/4, 1/8, 1/16, 1/32, ...)

Multiplying each outcome with the probability that it will happen, we then have (2 * 1/2) + (4*1/4) + 8 * 1/8 and so on:

Expected value of the gamble = 1 + 1 + 1 + 1 ...

Retunr to the question of how much you would be willing to pay to play the game. Since the expected value is infinite (1 + 1 + 1 forever), one might think that we should be willing to pay whatever we have available to play the game. In reality this is not what happens. Most people are only wiling to pay a dollar or two in order to play the game. Either the theory about how to make a good decision is wrong, or there is something wrong with the example!

As promised the interesting and surprising devil is in the details. The relevant outcome is not that you get a certain amount of money, but how much utility you get from that money. You do not care about the money in itself, only the utility it gives you. This small distinction is vitally important and it was first pointed out by the brilliant Bernoulli several hundred years ago: What we want to maximize when making a decision is not  expected value, but expected utility. Each outcome should be transformed into the utility we get from that outcome before we multiply it with its probability:

Expected value = Sum of (probability * outcome) for all outcomes of that action

Expected value = Sum of (probability * utility of outcome) for all outcomes of that action

In the case of the coin game, we then have

Expected utility of coin game = 1/2 * utility of (2 dollars) + 1/4 * utility (4 dollars) + 1/8 * utility (8 dollars)

How does this solve the problem? The basic problem when using the expected value, is that the sum became infinite because the growth of the money balanced the decrease in probability so we got an infinite sum of 1 + 1 + 1 + ... When using utilities, this is no longer the case. 4 dollars is twice as much money as 2, but the utility we get from four dollars is probably not twice as high as the utility we get from two. A billionaire is not a thousand times happier than a millionaire. This means thet the value of the outcome will not increase as much when we use utilities as outcome: the probabilities will decrease faster than the increase in the value of the outcomes and the sum no longer becomes infinite.

A rational decision
The lesson? Being rational implies, first of all, to consider all the possible actions, outcomes and their respective probabilities. The best decision is then the one that maximizes expected utility, defined as the sum of the utility of the outcomes associated with the action weighted by the probabilities of these outcomes.

This is, at least, the starting point!


Sunday, September 25, 2011

Organizational Diseconomies of scale - McAfee - 2005

Here is a paper on organizational diseconomies of scale (hierarchies and chains of principal agent relationships). This is not required reading, just for those who are interested:

Journal of Economics & Management StrategyOrganizational Diseconomies of scale - McAfee - 2005 - Journal of Economics & Management Strategy - Wiley Online Library:

'via Blog this'

Friday, September 16, 2011

Here is a book about fraud in the medical industry. Everything from overbilling, kickbacks, fake billing and many more examples. Estimated to cost somewhere between 3 and 10% of all health costs.

Lower Costs and Better Care for Neediest Patients : The New Yorker

In Camden, New Jersey, one per cent of patients account for a third of the cityHere is the article by Atul Gawande which I mentioned in class. He also briefly discusses the regression-to-the-mean problem.

Lower Costs and Better Care for Neediest Patients : The New Yorker:

'via Blog this'

Thursday, September 1, 2011

The difference between car repair and heart surgery


US health specialists argue that competition in the health market does not work. The main example: cardiac services. There is little price competition, high profit, too many interventions and not enough focus on alternative treatments. The solution: Pay for value, not volume, change incentives for physicians. In their own words:

... medicine is a highly dysfunctional market. There are many and sufficient reasons for this: getting your heart fixed is not the same as getting your car fixed. You can always take your car to a different mechanic, and, at worst, you can trade your failing car for a new one. A patient with 3-vessel coronary disease has fewer options. ... The study also suggests why this particular market works so poorly: “cardiac services contribute 25 percent to 40 percent of a hospital’s net revenues.” ... We pay too much for cardiac services, so we get too many of them.

Feel free to agree and disagree. More here: The Cost of Medicare: You Get What You Pay For | Care And Cost

Tuesday, August 30, 2011

Download audio of a special lecture


For those interested, here is the audio of a special lecture.  Hat tip to Fredrik Arneberg who sent the link.


Global lessons from 9/11 - implications for our societies and global health

Chair: Prof. Bernt Hagtvet
Richard Horton, chief editor The Lancet
Kristin Sandberg,  postdoc
Paul Fife, Director, Dept for Global Health, Education and Research, NORAD

    23. august 2011, Auditorium 2, Eilert Sundts hus  informasjon    

                                         

Thursday, August 25, 2011

Accounting and management 101, part 1

Books on accounting typically consists of endless pages of definitions and things that has to be memorized. Important yes, but it might be more motivating and fun to have a histrorical, critical and personal introduction. An approach in which we learn about the problems for which the distinction and terms was introduced before we have to memorize it. An approach in which we mention the people behind the ideas to make it more interesting. An approach in which we invite to debate by presenting conflicting views and encourage critical thinking instead of mindnumbing memorization. Now, hard work is still needed and we will have to memorize things, but it becomes much easier and fun to do this when we understand the need, when we can connect the ideas to persons and problems and when we have to think about weaknesses.

Take the case of double accounting. The historical background was the increasing size of trade, banking and companies in Rennaisanse Italy. An individual person or small trader knew how much money he had. The number of transactions was small enough that a simple system, or even no formal system, was needed. However, when a company becomes larger, you need a method to make sure that you keep track of money going in and out. Not only do you need a system for that, you would like to have a system that makes it easy to discover mistakens. Did we recive the goods we ordered and have we paid the bill?

Double accounting was an answer to this problem. It was first described, but not really invented, by a Franciscan friar, Luca Pacioli, in a book from 1492. The title of the book is a bit ambitious - "Everything about Arithmetic, Geometry, and Proportions." Not exactly a humble title, but maybe he was primary Italian and only secondary a friar. In any case, the point is that every transaction is listed twice because it represents something that comes in (credit) as well as something that goes out (debit). So, if you buy a new ship, your fixed asset account is credited with the value of the ship, but the price of the ship is a debit to the cash asset account.
Luca Pacioli

So what, you might complain. Why should we go through the tedious work of recording every transaction twice - as debit and credit in different accounts? Isn't this a waste of time? It may be if you are running a very small business, but if you are in charge of a larger company you need a method of accounting that reduces the chance of making accounting errors. To see this imagine you run a business and suddenly one day discover that you have enough cash to buy a new castle. Sounds good, but it would be a very bad idea if the reason you had so much cash was that you had forgotten some that some of it was income from merchandise that you had yet to pay. Such a mistake might be easy to make if the number of transactions is large, and doube accounting reduces this problem because it forces you to keep track of both credit and debit. It is a device to detect errors. Every day you check whether debits and credits sum to zero. Buying a ship increases fixed assets, but reduce cash assets (or increase liabilities if it is to be paid later). There is always a balance. If not, a mistake has been made, and error is detected, and you have to double check your accounts. As Pacioli argued:  A good merchant should not go to sleep at night until the debits equalled the credits!

There is of course, much more to accounting that this story, but it illustrates some main ideas. Accounting is not an end in itself. It is a tool to be used to make good decisions. Can I afford to make this investment? How much money do I have? How much of it is in liquid assets? Which investment will give the highest expected return? How much does the various steps in the production process cost and is it possible to cut some of the costs?

The usefulness ot accounting, and the purpose of learning it, depends on the extent it is able to answer these and other questions that we have. This means that it is not a fixed set of rules to be memorized, but someting that can be improved and criticised. This makes the theory of accunting much more interesting and creative area than most people believe - and introductions to the field should reflect this instead of just the dull stuff.

Victor Fuchs’ answer to the doctor’s dilemma

Here are some comments on Fuchs idea about how to combine the incentives to economize on resources at the same time that you want to give incentives to provide good health care.

Victor Fuchs’ answer to the doctor’s dilemma

Tuesday, August 23, 2011