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Does order matter when distributing resources? (Jun-03)

Should people with more severe health problems receive state funding for treatment before people with less severe health problems? See how your opinion compares with the opinions of others.

Imagine that you are a government official responsible for deciding how state money is spent on different medical treatments. Your budget is limited so you cannot afford to offer treatment to everyone who might benefit. Right now, you must choose to spend money on one of two treatments.

  • Treatment A treats a life threatening illness. It saves patients' lives and returns them to perfect health after treatment
  • Treatment B treats a different life threatening illness. It saves patients' lives but is not entirely effective and leaves them with paraplegia after treatment. These patients are entirely normal before their illness but after treatment will have paraplegia.

Suppose the state has enough money to offer Treatment A to 100 patients. How many patients would have to offered Treatment B so that you would have difficulty choosing which treatment to offer?

How do your answers compare?

The average person said that it would become difficult to decide which treatment to offer when 1000 people were offered Treatment B.

What if you had made another comparison before the one you just made?

In the study, some people were asked to make a comparison between saving the lives of otherwise-healthy people and saving the lives of people who already had paraplegia. After they made that comparison, they made the comparison you just completed. The average person in that group said it would take 126 people offered Treatment B to make the decision difficult. The differences are shown in the graph below

Why is this important?

The comparison you made is an example of a person tradeoff (PTO). The PTO is one method used to find out the utilities of different health conditions. These utilities are basically measures of the severities of the conditions. More severe conditions have a lower utility, and less severe conditions have a higher utility, on a scale of 0 to 1. Insurance companies, the government, and other organizations use these utilities as a way to decide which group to funnel money into for treatments.

On the surface, it seems like basing the money division on the severity of a condition is a good and fair method, since theoretically the people who are in the greatest need will be treated first. However, the PTO raises issues of fairness and equity that aren't accounted for in other utility elicitation methods like the time tradeoff (TTO) and rating scale (RS).

For example, when asked to decide how many people with paraplegia would have to be saved to equal saving 100 healthy people, many people say 100; that is, they think it is equally important to save the life of someone with paraplegia and a healthy person. Going by values obtained using the TTO or RS, an insurance company may conclude that 160 people with paraplegia (using a utility of .6) would have to be saved to make it equal to saving 100 healthy people. This would mean that less benefit would be gotten by saving someone with paraplegia, and thus they might not cover expenses for lifesaving treatments for people with paraplegia as much as they would for a healthy person. The PTO shows that many people would not agree with doing this, even though their own responses to other utility questions generated the policy in the first place.

For more information see:

Ubel PA, Richardson J, Baron J. Exploring the role of order effects in person trade-off elicitations. Health Policy, 61(2):189-199, 2002.

Is Bill Gates' time worth more than yours? (Jul-03)

Informal caregiving for relatives (parents, grandparents, spouses) can be time consuming. Can we attach dollar value to that time? Is everyone's time worth the same amount?

Imagine that your mother is suffering from moderate dementia and needs assistance with daily activities such as bathing and dressing. You are the only person available to care for her, as you are an only child and your father has passed away. On average, your mother will need about 2 to 3 hours of help per day, or 17 hours per week total.

Assuming that you provide 17 hours of care per week, that means you will provide about 900 hours of care each year. How much money would you say the time you devote to caregiving is worth each year?
 
Now imagine that Bill Gates, the world's richest person, is in the same situation as you. He has to provide 17 hours of care per week to his mother. How do you think the value of the time he spends giving care compares to the value of the time you spend giving care?
 
  • His is worth more
  • His is worth the same amount
  • His is worth less

How do your answers compare?

According to a study done to determine the costs of informal caregiving, the average value of the time spent giving care to someone with moderate dementia was about $7400. This was calculated using an average time of about 900 hours per year, at the mean wage for a home health aide in 1998 of $8.20 per hour.

What if the person you're caring for has less or more severe dementia?

As you might imagine, the cost of informal care differs depending on the severity of dementia. People with mild dementia don't need as much care (8.5 hours per week), and those with severe dementia need much more (41.5 hours per week). The amount of care needed directly impacts the estimated cost of care:

Dementia severity Hours of care per week Estimated cost of informal care
Mild 8.5 $3630
Moderate 17.4 $7420
Severe 41.5 $17,700
Why is this important?

As the Baby Boomer generation ages, the number of people needing informal care is going to increase dramatically. In order to make informed policy decisions regarding care for older people, the government will need an estimate of the value of informal care. A major obstacle to this is that there is no set way for making the estimates.

Earlier, you said that Bill Gate's caregiving time would be worth the same amount as yours. That implies that basing national estimates of caregiving costs on average wages would be the proper way to go about the calculations, since it means everyone's time is equally valuable.

However, some people think that not everyone's time is of equal value. In that case, using average wages to estimate the total cost of caregiving may not lead to an accurate representation. If one group of people is more likely to provide care than another group, then the average value of all caregivers' time may not be the same as the average of all peoples' time. This would possibly lead to an over- or underestimation of caregiving costs, depending on the value of the time of common groups of caregivers. Even without an agreed-upon estimation method, some valuable data can be generated.

The estimation method used in this study likely led to conservative figures, so the true costs of informal caregiving are probably higher than reported here. Even using this conservative method, the costs to society are staggering. The researchers estimated that the cost of informal caregiving for dementia alone in 1998 was $18.6 billion, which is almost two-thirds as much money as that actually spent on paid home care services for all conditions, not just dementia! That figure will grow considerably in the not-so-distant future when the Baby Boomers begin to need caregiving, whether formal or informal, and will likely have a large impact not just on health care systems, but on society as a whole as more and more people are called on to provide informal care.

For more information see:

Langa KM, et al. National estimates of the quantity and cost of informal caregiving for the elderly with dementia. Journal of General Internal Medicine. 16:770-778, 2001.

What is the price of life? (Aug-03)

Do you think that your life is worth more than the amount that the government usually uses as the maximum to spend to provide one year of life?

Imagine that you are a member of a government panel that is trying to decide how cost-effective a medical treatment must be in order for the government to cover the costs of the treatment. Suppose that a certain treatment could provide one additional year of life to an otherwise healthy person. What is the highest amount the government should be willing to pay per person for this treatment?

How do your answers compare?

For the past twenty years, the figure most often used as the maximum amount to spend to provide one year of life has been $50,000. This figure was originally proposed since it was the cost of a year of kidney dialysis, a lifesaving treatment that the U.S. government funds in Medicare.

Should the number be higher or lower than the current standard?

Conventional wisdom would suggest that the number be higher to take into account the inflation that has occurred in the years since the standard was developed. Current practices such as annual Pap smear screening for women with low risk for cervical cancer, which has a cost of $700,000 per year of life gained, also suggest that society is willing to pay more than the current standard for a year of life. The authors of the cited article recommend, based on current treatment practices and surveys of the general public, that the cost-effectiveness threshold should be revised to be around $200,000.

Should the number increase, decrease, or stay the same over time?

Again, it seems that the threshold amount should increase over time due to inflation. However, other factors come in to play that affect the value.

Since new technologies are emerging all the time, some of which will be deemed cost-effective, there will be more and more treatments to be offered in the future. Also, the rate of use of treatments is an important consideration, because even if a new treatment is more cost-effective than an old one, if it is used more often it will end up costing more to society overall. With more treatments becoming available and more people being given treatments, the threshold cost will probably have to decrease so that insurance companies and the government can keep up with the increasing availability and demand.

Why is this important?

Insurance companies and government health care entities face a continuing struggle when trying to determine which medical treatments to cover. Health care costs are increasing rapidly, so these groups will be facing even tougher decisions in the future. Establishing cost-effectiveness guidelines would be extremely helpful as an aid to making the decisions about treatment coverage. Evidence shows that the current threshold is probably not an accurate reflection of the desires of society or actual prescribing practices. It needs to be adjusted to become useful once again, and must be reevaluated periodically to make sure the value keeps up with trends in the health care market, rather than being left alone without question for two decades as is the current situation.

For more information see:

Ubel PA, Hirth RA, Chernew ME, Fendrick AM. What is the price of life and why doesn't it increase at the rate of inflation? Archives of Internal Medicine. 163:1637-1641, 2003.

Is your well-being influenced by the guy sitting next to you? (Nov-03)

Rating your satisfaction with your life may not be a completely personal decision. See how your satisfaction rating may be influenced by others.

When answering this question, imagine that there is someone in a wheelchair sitting next to you. They will also be answering this question, but you will not have to share your answers with each other.

How satisfied are you with your life in general?

Extremely satisfied 1       2       3       4       5       6       7       8       9       10 Not at all satisfied

How do you compare to the people surveyed?

You gave your life satisfaction a rating of 1, which means that you are extremely satisfied with your life. In a study done where people with a disabled person sitting next to them wrote down their life satisfaction on a questionnaire, they gave an average life satisfaction rating of 2.4, which means they were very satisfied with their lives.

What if you'd had to report your well-being to another person instead of writing it down?

In the study, half the people had to report their well-being in an interview with a confederate (a member of the research team who was posing as another participant). When the participants had to report in this way, and the confederate was not disabled, the participants rated their well-being as significantly better than those who reported by writing it on the questionnaire in the presence of a non-disabled confederate (2.0 vs. 3.4, lower score means higher well-being). The scores given when reporting to a disabled confederate elicited a well-being score that was no different than that when completing the questionnaire in the presence of a disabled confederate (2.3 vs. 2.4).

Mean life satisfaction ratings, lower score means higher satisfaction
Mode of rating well-being Disabled confederate Non-disabled Confederate
Interview (public) 2.3 2.0
Questionnaire (private) 2.4 3.4
What caused the difference in well-being scores?

When making judgments of well-being, people (at least in this study) tend to compare themselves to those around them. This effect is seen more when well-being was reported in an interview than when the score was privately written down, due to self-presentation concerns. A higher rating was given in public so as to appear to be better off than one may truly feel. Note that the effect was only seen in the case where the confederate was not disabled. While well-being ratings were better overall with a disabled confederate, there was no difference between the private and public ratings. Social comparison led to a better well-being judgment, but it appears that the participants were hesitant to rate themselves too highly in front of the disabled person for fear of making the disabled person feel worse.

Why is this important?

Subjective well-being is a commonly used measure in many areas of research. For example, it is used as one way to look at the effectiveness new surgeries or medications. The above studies show that SWB scores can vary depending on the conditions under which they are given. Someone may give a response of fairly high SWB if they are interviewed before leaving the hospital, surrounded by people more sick than they are. From this, it would appear as though their treatment worked great. But suppose that they are asked to complete a follow-up internet survey a week later. Since they do not have to respond to an actual person face-to-face, and without being surrounded by sick people, they may give a lower rating than previously. Is this because the treatment actually made their SWB worse over the longer term, or simply because a different method was used to get their response? The only way to really know would be to use the same methodology to get all their responses, which might not always be feasible. These are important considerations for researchers to keep in mind when analyzing results of their studies. Are the results they got the true SWB of their participants, or is it an artifact of how the study was done? And is there a way to know which measure is right, or are they both right which would lead to the conclusion that SWB is purely a momentary judgment based on a social context?

For more information see:

Strack F, Schwarz N, Chassein B, Kern D, Wagner D. Salience of comparison standards and the activation of social norms: Consequences for judgements of happiness and their communication. British Journal of Social Psychology. 29:303-314, 1990.

Bioethics Grand Rounds: Musical Event "When Death Comes Callin"

Wed, October 26, 2016, 12:00pm
Location: 
UH Ford Amphitheater & Lobby

When Death Comes Callin': Songs and Reflections About Death

Charlotte DeVries, Jeanne Mackey, Merilynne Rush, and friends offer a program of songs and brief readings reflecting various perspectives on death - humorous, sad, thoughtful, and quirky.

Lunch is provided on a first-come, first-served basis.

Check out the Ethics Path available to Michigan medical students through the Paths of Excellence (PoE) program. The ethics path provides opportunities for individualized, independent study, combined with field work with CBSSM, and a capstone project in the M4 year.

Click here for more information about the PoE program.

Research Topics: 
Sun, November 14, 2010

Raymond De Vries, Professor in the Center for Bioethics and Social Sciences in Medicine and the Departments of Medical Education and Obstetrics and Gynecology, authored a commentary in a Dutch national newspaper examining media misrepresentation of a recent article in the British Medical Journal about perinatal death in the Netherlands.  Dr. De Vries and colleague Lisa Kane Low, Director of Midwifery Education, will present at a conference, Knowledge in Business, sponsored by the Zuyd University in Maastricht.

Along with Ted A. Skolarus, M.D., M.P.H., CBSSM Co-Director, Angela Fagerlin authored a Viewpoint article titled "Rethinking Patient-Physician Communication of Biopsy Results -- The Waiting Game." In the article, they conclude, "Telemedicine approaches can potentially relieve much of the anxiety associated with in-person consultations while delivering bad news in a timely, compassionate, and patient-centered manner."

CBSSM Faculty, Brian Zikmund-Fisher, Tanner Caverly, and Jeffrey Kullgren were co-authors on a study published in JAMA Internal Medicine Article on Why Doctors Order Unnecessary Scans for Back Pain. Erika Sears, MD, MS was the lead author.

The study was highlighted in UMHS news release here.

Research Topics: 

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