Tuesday, June 13, 2017

Interview with Janet Currie: Health, Liability, Overtreatment

Jessie Romero interviews Janet Currie on a range of topics in "Interview: Janet Currie," Econ Focus: Federal Reserve Bank of Richmond, First Quarter 2017, pp. 23-36. Here are a few tidbits: 

Socioeconomic Status and Effects of Pollution
"There is a large environmental justice literature arguing that low-income and minority people are more likely to be exposed to a whole range of pollutants, and that turns out to be remarkably true for almost any pollutant I’ve looked at. A lot of that has to do with housing segregation; areas that have a lot of pollution are not very desirable to live in so they cost less, and people who don’t have a lot of money end up living there. It also seems to be the case, at least some of the time, that low-income people exposed to the same level of pollutants as higher-income people suffer more harm, because higher-income people can take measures to protect themselves. Think about air pollution. If I live in a polluted place but I have a relatively high income, maybe I have better-quality windows so I have less air coming in, or I can afford to have air purifiers, or I can afford to run my air conditioner. It could even be the case that lower-income people are more vulnerable to the effects of pollution in the first place. For example, someone who is malnourished is more likely to absorb lead than someone who is not malnourished. So people who are better nourished may be better able physiologically to protect themselves against the effects of pollutants."

Reform of Joint and Several Liability

"Joint and several liability, or JSL, is essentially the “deep pockets” rule: If multiple parties are found to be liable for the harm caused, the plaintiff can collect damages from one or all of the parties, regardless of how each one contributed to the harm. So people sue the deep pocket. A hospital is a good example. When Bentley MacLeod and I first started reading about tort cases related to malpractice during child delivery, one of the things that struck us as bizarre is that they often talked about the nurse: The nurse was sitting in the nurse’s station, she didn’t come when I called, she didn’t call the doctor. We wondered, why are they spending so much time talking about what the nurse did or didn’t do? Surely the doctor was the prime mover in deciding treatment? What we eventually realized was, the nurse is the employee of the hospital, whereas doctors are generally working as independent contractors; so if you want to blame the hospital — the deep pocket — you have to tie the nurse to the lawsuit. Most of the time, under JSL, the hospital gets sued and the doctor doesn’t. If the hospital pays, legally it can try to recover damages from the doctor, but they hardly ever do that. Essentially, under JSL, the doctors are working in a regime where they’re never going to get sued. JSL reform makes the payment of damages proportional to the contribution to the harm, which makes it more likely the doctor will be sued. And if the doctor is the decisionmaking agent, then in theory that should improve outcomes."
The Difference between Overprovision and Misallocation of Medical Care 
"Many people are concerned about overtreatment and excessive spending, but the problem is more subtle. Bentley, Jessica Van Parys, and I studied heart attack patients admitted to emergency rooms in Florida. We found large differences in how doctors allocated procedures across patients; some doctors were much less likely to use aggressive treatments with older or sicker patients who might have been deemed less appropriate candidates for the treatment. Young, male doctors who trained at a top-20 medical school were the most likely to treat all patients aggressively, regardless of how appropriate the patient seemed to be. In the case of heart attacks, it appears that all patients have better outcomes with more aggressive treatment, so treating only the “high-appropriateness” patients aggressively harms the “low-appropriateness” patients. Similarly, many people are concerned that U.S. doctors perform too many C-sections. But actually, in another paper, Bentley and I found that it looks like too many women with low-risk pregnancies receive C-sections, while not enough women with high-risk pregnancies receive C-sections. So the goal shouldn’t necessarily be to reduce the total number of C-sections but rather to reallocate them from low-risk to high-risk pregnancies."
A couple of add-ons here for interested readers: