This is the meta-subject of a new paper in PLoS ONE by myself and my buddy/co-author Brendan Maughan Brown. Here is the abstract, which mostly explains everything:
Objectives
We examined whether knowledge of the HIV-protective benefits of male circumcision (MC) led to risk compensating behavior in a traditionally circumcising population in South Africa. We extend the current literature by examining risk compensation among women, which has hitherto been unexplored.
Methods
We used data on Xhosa men and women from the 2009 Cape Area Panel Study. Respondents were asked if they had heard that MC reduces a man’s risk of contracting HIV, about their perceived risk of contracting HIV, and condom use. For each gender group we assessed whether risk perception and condom use differed by knowledge of the protective benefits of MC using bivariate and then multivariate models controlling for demographic characteristics, HIV knowledge/beliefs, and previous sexual behaviors. In a further check for confounding, we used data from the 2005 wave to assess whether individuals who would eventually become informed about the protective benefits of circumcision were already different in terms of HIV risk perception and condom use.
Results
34% of men (n = 453) and 27% of women (n = 690) had heard that circumcision reduces a man’s risk of HIV infection. Informed men perceived slightly higher risk of contracting HIV and were more likely to use condoms at last sex (p<0.10). Informed women perceived lower HIV risk (p<0.05), were less likely to use condoms both at last sex (p<0.10) and more generally (p<0.01), and more likely to forego condoms with partners of positive or unknown serostatus (p<0.01). The results were robust to covariate adjustment, excluding people living with HIV, and accounting for risk perceptions and condom use in 2005.
Basically, our results show that women react to information on circumcision's protective benefits in a manner consistent with risk compensation, which is a phenomenon where individuals undertake risky behaviors if they feel that they are protected from its consequences somehow. Why do women respond differently from men? We aren't sure, but we theorize that it could be related to (some combination of):
-Misinformation among women about the protective benefits of circumcision as far as male-to-female HIV transmission (circumcision has only been shown to impact female-to-male transmission).
-Lack of opportunities for women to discuss circumcision, sex, and HIV in public places.
-Higher prior probabilities of contract HIV in women (which means risk information will be more likely to shift beliefs about HIV on the margin - good ole' Bayes's Theorem)
-A sense of reduced need among women to have to negotiate condoms, which could be tricky in a world where there is imbalance in power across genders.
Some new research by other groups (more on this in a later post) provides evidence that the first of these could be at play. Watch this space for more, as we attempt to find some explanations!
Friday, August 10, 2012
Thursday, July 26, 2012
Does Expanding Medicaid Save Lives?
According to this recent paper by Ben Sommers, et al, in The New England Journal of Medicine, the answer is yes. Sommers and coauthors examine mortality before and after medicaid expansions in certain states, using the same before-after comparison in neighboring states as a control to account for general trends in mortality that would exist without Medicaid changes. They find expansions "were associated with a significant reduction in adjusted all-cause mortality (by 19.6 deaths per 100,000 adults, for a relative reduction of 6.1%; P=0.001)...Mortality reductions were greatest among older adults, nonwhites, and residents of poorer counties." They also find evidence of better self-reported health and reduced delays to getting care with Medicaid expansions.
This is a well done, timely piece. The recent Supreme Court ruling declared the provisions in the Affordable Care Act (ACA) decreeing mandatory Medicaid expansions to be unconstitutional. This has led some state governors to announce that they will not pursue such expansions. Some of this, of course, is dumb election year posturing: the ACA increases the Federal fund matching rate for Medicaid by a great deal, so governors will most likely buy in to the expansions because of these nice financial incentives. That said, this piece provides another angle to this whole debate, as failure to expand Medicaid may not just mean money left on the table, but people's lives as well.
This is a well done, timely piece. The recent Supreme Court ruling declared the provisions in the Affordable Care Act (ACA) decreeing mandatory Medicaid expansions to be unconstitutional. This has led some state governors to announce that they will not pursue such expansions. Some of this, of course, is dumb election year posturing: the ACA increases the Federal fund matching rate for Medicaid by a great deal, so governors will most likely buy in to the expansions because of these nice financial incentives. That said, this piece provides another angle to this whole debate, as failure to expand Medicaid may not just mean money left on the table, but people's lives as well.
Wednesday, July 18, 2012
Value Based Puchasing and Safety Net Hospitals
One of the mainstays of our current health care reform dialogue is promoting efficiency. The US health care system gets pretty good outcomes for its clients, but it comes at a great cost and with a lack of equity. Regarding cost, there has been a push to pay providers (doctors, clinics, hospitals, etc) for the quality of the services they render, not just for having rendered the service. Along these lines, with the new health care reform bill, Medicare will start paying hospitals based on performance as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). This is what is referred to as Value Based Purchasing (VBP).
En face, it sounds like a great idea. But are there potential downsides to VBP? An elegant new study by Paula Chatterjee and colleagues suggests that the answer might be yes. Paula, et al, look at how safety net hospitals, a group of providers that disproptionately take care of poor, vulnerable patients have performed on HCAHPS surveys, showing that these hospitals typically have fared work on the patient satisfaction aspect of this index. Strikingly, safety net hospitalis were 60% less likely to be at or above the median on a variety of patient experience measures when compared to other hospitals. Because the median is the key metric upon which the Medicare VBP algorithms are based, safety net hospitals will potentially stand to lose key Medicare dollars. As they are financially constrained as it is, this could potentially lead to a negative feedback loop, where safety net hospitals lack the funds to make the improvements necessary to perform better on VBP, thereby losing more funds, and so on.
This example highlights a few key points that are relevant for health care reform anywhere. First, certain kinds of incentives will create, or exacerbate existing, tradeoffs between making the system more equitable versus more efficient. In this case, the push for efficiency may potentially reduce available care options for the poor, which leads to worsening equity. Note that this could even lead to worsened efficiency, if the lack of immediate care for the poor leads to increased downstream costs (eg, more ED visits, or longer hospitalizations when an earlier, less costly, hospitalization would have done). Second, better designed incentives may actually help move to an equilibrium where this tradeoff is minimized. For example, a VBP system which allows safety net hospitals lead time in figuring out best practices (perhaps via learning from each other, or via some explicit "curriculum" or forum created by Medicare) may help them improve quality -which will certainly be equitable given their population- and stay solvent.
Ultimately, I think key for payment reform, which should be the explicit goal for Medicare and other health programs, is to perform the reachable alchemy of improving both equity and efficiency. I say "reachable" for a reason: everyone is aware that other OECD countries spend less and gain the same or more when it comes to health. At least on a less fundamental level (i.e, payment reform within our mish-mosh private system), we can aim to do the same.
En face, it sounds like a great idea. But are there potential downsides to VBP? An elegant new study by Paula Chatterjee and colleagues suggests that the answer might be yes. Paula, et al, look at how safety net hospitals, a group of providers that disproptionately take care of poor, vulnerable patients have performed on HCAHPS surveys, showing that these hospitals typically have fared work on the patient satisfaction aspect of this index. Strikingly, safety net hospitalis were 60% less likely to be at or above the median on a variety of patient experience measures when compared to other hospitals. Because the median is the key metric upon which the Medicare VBP algorithms are based, safety net hospitals will potentially stand to lose key Medicare dollars. As they are financially constrained as it is, this could potentially lead to a negative feedback loop, where safety net hospitals lack the funds to make the improvements necessary to perform better on VBP, thereby losing more funds, and so on.
This example highlights a few key points that are relevant for health care reform anywhere. First, certain kinds of incentives will create, or exacerbate existing, tradeoffs between making the system more equitable versus more efficient. In this case, the push for efficiency may potentially reduce available care options for the poor, which leads to worsening equity. Note that this could even lead to worsened efficiency, if the lack of immediate care for the poor leads to increased downstream costs (eg, more ED visits, or longer hospitalizations when an earlier, less costly, hospitalization would have done). Second, better designed incentives may actually help move to an equilibrium where this tradeoff is minimized. For example, a VBP system which allows safety net hospitals lead time in figuring out best practices (perhaps via learning from each other, or via some explicit "curriculum" or forum created by Medicare) may help them improve quality -which will certainly be equitable given their population- and stay solvent.
Ultimately, I think key for payment reform, which should be the explicit goal for Medicare and other health programs, is to perform the reachable alchemy of improving both equity and efficiency. I say "reachable" for a reason: everyone is aware that other OECD countries spend less and gain the same or more when it comes to health. At least on a less fundamental level (i.e, payment reform within our mish-mosh private system), we can aim to do the same.
Sunday, July 15, 2012
PEPFAR on the Mind
The July 31st issue of Health Affairs devotes itself to the President's Emergency Plan for AIDS Relief (PEPFAR) and explores the aid program from a number of interesting viewpoints. The highlights for me includes a piece by Harsha Thirumurthy and coauthors on the economic benefits of treating HIV and a wonderful piece of research by Karen Grepin examining the effects of PEPFAR aid on other domains on health care (she finds positive spillovers for certain maternal health services, but crowd-out for child vaccines). The article by John Donnelly discusses the origin of PEPFAR within the (W) Bush administration, which I am sure would make most send some positive vibes to this otherwise beleaguered president.
The articles on the future of PEPFAR (how the funding streams can be better targeted, how much funding is needed and for how much longer) are quite interesting, as well. Certainly, if you have a particular interest in PEPFAR, the whole issue is worth reading.
The articles on the future of PEPFAR (how the funding streams can be better targeted, how much funding is needed and for how much longer) are quite interesting, as well. Certainly, if you have a particular interest in PEPFAR, the whole issue is worth reading.
Tuesday, May 22, 2012
New Bond Trailer
Country? USA.
PGY? One.
Stethoscope? Littman.
Software? Stata.
Skyfall? Done.
Nope, my life is definitely not this interesting.
From the trailer, it's clear that "Skyfall" maintains the beautiful cinematography of "Quantum of Solace," which was perhaps the most visually stunning Bond movie ever made. Hopefully the plot in this one is a bit thicker.
PGY? One.
Stethoscope? Littman.
Software? Stata.
Skyfall? Done.
Nope, my life is definitely not this interesting.
From the trailer, it's clear that "Skyfall" maintains the beautiful cinematography of "Quantum of Solace," which was perhaps the most visually stunning Bond movie ever made. Hopefully the plot in this one is a bit thicker.
Thursday, May 17, 2012
Global Health Focus in This Week's JAMA
Some interesting new op-ed and research pieces on global health in the latest issue of JAMA. Perhaps the most interesting is this piece by Eran Bendavid and co-authors, who examine PEPFAR (The United States President's Emergency Plan for AIDS Relief) and its impact on all-cause mortality in Africa. This is important because some have argued that intense spending on HIV in this manner has crowded out spending on other important health problems. The authors use a differences-in-differences strategy (comparing mortality rates within countries before and after PEPFAR, with some areas getting funding and others not as much, holding context fixed factos across countries) and find that increased PEPFAR funding was associated with lower all cause mortality rates. (HT: Paula Chatterjee)
Monday, April 16, 2012
Poorly Conceived Incentives in Health Care: The AM Discharge
There's no shortage of examples of well-meaning, but ultimately failing, incentives in health care, but here is a recent one that I've come across as an intern. In the community hospital we all rotate through, interns are paid $5 dollars if they manage to discharge 2 patients by 10 AM. Early discharges are valued by hospitals because they help with turnover and flow: overcrowding in the emergency room is kept to a minimum if hospital beds are available in the morning. But discharges take time: as an intern, we have to round on all of our inpatients in the morning, any new patients we inherit from the overnight team, and write a bunch of orders and notes. Discharges require thought, often irritating paperwork and emails, and all of that crowds out time for these other tasks. Furthermore, discharging people only means that you'll get more new patients later. For most of us, that's usually exciting, but its easy to see how this may seem like a penalty for keeping the hospital's best interests in mind.
In most places I've worked, there are no incentives for residents to get people out by noon, other than to avoid having to be gently reminded (over and over) by case managers and nurses to get the work done. Obviously, since the (opportunity) costs far outweigh the benefits, I'm sure most interns and residents are not in real rush to discharge people when they could being doing other things for their patients (or themselves).
Enter the hospital where I am now. They've ostensibly addressed this incentive compatibility problem by offering a small financial incentive for a certain number of pre-10 AM discharges. However, I think their $5 scheme is doomed to fail for two reasons. First, $5 dollars is not much money and most of us value our time far more than that. Second, and likely worse, such small incentives may actually make us less likely to move people out the door. Indeed, a number of experimental studies in behavioral economics and psychology have shown that small monetary rewards may reduce effort, either by reminding us that we get paid less than our peers in other fields or by demeaning us (or the task) with the size of the offer. Several of the interns I've spoken to have interpreted the incentive scheme in the latter light.
So what is the right kind of incentive? There are several, likely more effective, options. One is to increase the cash value of the incentive: perhaps the intern or resident at the end of the month (or year, to reduce sampling error as far as the medical problems and sickness of the patient) gets $100 or more for getting the most people out by noon. Perhaps even better is to take the monetary aspect out of it, altogether. As physicians, many of us value the altruism that goes with the field. Why not make the hospital brass-resident relationship center around that aspect and reward the intern/resident who discharges most effectively with some kind of public, visible and worthy commendation that he/she is a good doctor (at least one valued by the hospital for his/her attention to patient care and the realities of health care delivery on a larger scale)?
In most places I've worked, there are no incentives for residents to get people out by noon, other than to avoid having to be gently reminded (over and over) by case managers and nurses to get the work done. Obviously, since the (opportunity) costs far outweigh the benefits, I'm sure most interns and residents are not in real rush to discharge people when they could being doing other things for their patients (or themselves).
Enter the hospital where I am now. They've ostensibly addressed this incentive compatibility problem by offering a small financial incentive for a certain number of pre-10 AM discharges. However, I think their $5 scheme is doomed to fail for two reasons. First, $5 dollars is not much money and most of us value our time far more than that. Second, and likely worse, such small incentives may actually make us less likely to move people out the door. Indeed, a number of experimental studies in behavioral economics and psychology have shown that small monetary rewards may reduce effort, either by reminding us that we get paid less than our peers in other fields or by demeaning us (or the task) with the size of the offer. Several of the interns I've spoken to have interpreted the incentive scheme in the latter light.
So what is the right kind of incentive? There are several, likely more effective, options. One is to increase the cash value of the incentive: perhaps the intern or resident at the end of the month (or year, to reduce sampling error as far as the medical problems and sickness of the patient) gets $100 or more for getting the most people out by noon. Perhaps even better is to take the monetary aspect out of it, altogether. As physicians, many of us value the altruism that goes with the field. Why not make the hospital brass-resident relationship center around that aspect and reward the intern/resident who discharges most effectively with some kind of public, visible and worthy commendation that he/she is a good doctor (at least one valued by the hospital for his/her attention to patient care and the realities of health care delivery on a larger scale)?
Saturday, April 14, 2012
Can Tax Breaks Help Decrease Organ Shortages?
Despite advances in organ procurement, immune suppression (to prevent the body from rejecting a transplant), and surgical techniques, organ shortages and wait list numbers continue to grow in the United States. Calls for instituting organ markets (including ones from prominent economists) notwithstanding, ethical concerns have made outright payments for organs a non-starter policy in the American context. However, policymakers have recognized that those who wish to donate organs, particularly living donors, may face enormous costs in the form of lost wages, health care costs and travel and lodging fees. As such, efforts have been made to reduce these financial barriers to donation: in the last decade, 16 states have now passed laws to provide tax deductions to living organ donors, with many other considering similar legislation.
Have these policies been effective in increasing donation rates? In a new paper in the American Journal of Transplantation, Erika Martin, Anitha Vijayan, Jason Wellen and I explore this question using data on living organ donations and transplants for each state between 2000-2010. Our research design basically compares the change in donation rates before and after the enactment of a tax policy in states that passed these laws against the change in same time period in those states that did not (the differences-in-differences design). We found no evidence that these laws were effective in appreciably closing the organ shortage. At most, they may have led to 5% increases in donation rates (the upper bound of our confidence intervals) - not too bad, but not the panacea.
Why is this the case? First off, tax deductions don't put that much money back in your pocket. For an upper middle class family of four, the value of a deduction amounts to $500-$900. Nothing to sneer at, but still below the estimated (opportunity) cost of making a donation. We argue that tax credits (which have a higher cash value) or grants may work better. Second, in doing the research we ended up talking to organ donation activists in many states, many of whom had no idea these policies were in place! It's possible that a lack of awareness led to our null finding, as well. Finally, while we don't elaborate on this in the paper, our Figure 1 shows that states that passed these laws experienced increasing donation rates relative to the other set of states prior to the passage of the laws. So it's possible that states that were progressive enough to pass tax deductions were already doing other things to bump up donation rates.
Finally, while tax deductions may not lead to new donors, they may be helping people who would donate anyway. For example, a living donor who is compensated for his/her private costs because of the tax policy, perhaps as a result in less financial distress, certainly would benefit from the policy. We don't really have the data to examine this "intensive margin." On this point, I wouldn't yet write tax policies off.
Have these policies been effective in increasing donation rates? In a new paper in the American Journal of Transplantation, Erika Martin, Anitha Vijayan, Jason Wellen and I explore this question using data on living organ donations and transplants for each state between 2000-2010. Our research design basically compares the change in donation rates before and after the enactment of a tax policy in states that passed these laws against the change in same time period in those states that did not (the differences-in-differences design). We found no evidence that these laws were effective in appreciably closing the organ shortage. At most, they may have led to 5% increases in donation rates (the upper bound of our confidence intervals) - not too bad, but not the panacea.
Why is this the case? First off, tax deductions don't put that much money back in your pocket. For an upper middle class family of four, the value of a deduction amounts to $500-$900. Nothing to sneer at, but still below the estimated (opportunity) cost of making a donation. We argue that tax credits (which have a higher cash value) or grants may work better. Second, in doing the research we ended up talking to organ donation activists in many states, many of whom had no idea these policies were in place! It's possible that a lack of awareness led to our null finding, as well. Finally, while we don't elaborate on this in the paper, our Figure 1 shows that states that passed these laws experienced increasing donation rates relative to the other set of states prior to the passage of the laws. So it's possible that states that were progressive enough to pass tax deductions were already doing other things to bump up donation rates.
Finally, while tax deductions may not lead to new donors, they may be helping people who would donate anyway. For example, a living donor who is compensated for his/her private costs because of the tax policy, perhaps as a result in less financial distress, certainly would benefit from the policy. We don't really have the data to examine this "intensive margin." On this point, I wouldn't yet write tax policies off.
Monday, March 26, 2012
Dear Rush Limbaugh: Oral Contraceptives Have Positive Labor Market Consequences!
Rush Limbaugh doesn't like oral contraception. At least, he doesn't think health insurers should have to pay it ('Dar He Blogs will keep this debate academic and avoid any "pot-kettle-black" type comments). I'm guessing he wasn't aware of a new study by Martha Bailey and co-authors illustrating the large, positive labor market effects "The Pill" has provided for women:
Decades of research on the U.S. gender gap in wages describes its correlates, but little is known about why women changed their career paths in the 1960s and 1970s. This paper explores the role of “the Pill” in altering women’s human capital investments and its ultimate implications for life-cycle wages. Using state-by-birth-cohort variation in legal access to contraception, we show that younger access to the Pill conferred an 8-percent hourly wage premium by age fifty. Our estimates imply that the Pill can account for 10 percent of the convergence of the gender gap in the 1980s and 30 percent in the 1990s.
Why would birth control pills enable women to earn more? By allowing more control over the reproductive cycle, this would reduce uncertainty in the timing of certain events, such as pursuing college, job training opportunities, and entering the workforce. One could easily imagine how providing women with relative certainty could lead to more investment in their "human capital" because it is now easier to do so and the returns become more predictable.
Another way oral contraceptives can help in the labor market has to do with absenteeism due to menstruation. In a really neat study, Andrea Ichino and Enrico Moretti show that work absences for young women follow a 28 day cycle, whereas those for women over the age of 45, and men of any age, do not. They suggest that this pattern is due to menstruation and go on to calculate that lost work days on the account of the cycle may explain 14% of the gender differential in earnings seen in their Italian dataset.
Decades of research on the U.S. gender gap in wages describes its correlates, but little is known about why women changed their career paths in the 1960s and 1970s. This paper explores the role of “the Pill” in altering women’s human capital investments and its ultimate implications for life-cycle wages. Using state-by-birth-cohort variation in legal access to contraception, we show that younger access to the Pill conferred an 8-percent hourly wage premium by age fifty. Our estimates imply that the Pill can account for 10 percent of the convergence of the gender gap in the 1980s and 30 percent in the 1990s.
Why would birth control pills enable women to earn more? By allowing more control over the reproductive cycle, this would reduce uncertainty in the timing of certain events, such as pursuing college, job training opportunities, and entering the workforce. One could easily imagine how providing women with relative certainty could lead to more investment in their "human capital" because it is now easier to do so and the returns become more predictable.
Another way oral contraceptives can help in the labor market has to do with absenteeism due to menstruation. In a really neat study, Andrea Ichino and Enrico Moretti show that work absences for young women follow a 28 day cycle, whereas those for women over the age of 45, and men of any age, do not. They suggest that this pattern is due to menstruation and go on to calculate that lost work days on the account of the cycle may explain 14% of the gender differential in earnings seen in their Italian dataset.
Thursday, March 22, 2012
Shortening Medical Training? Yes, Please!
Those who want to become a doctor in the United States stare at a very long road: 4 years of college, 4 years of medical school, 3-7 years of residency and, potentially, fellowship to finish it all off. (Some crazies additionally tack on another 1-5 years to do this in pursuing a joint degree, as well). But does it really require all this time to create a doctor well-equipped to fight disease in our current times?
None another than Ezekiel Emanuel and Victor Fuchs (one of the Founding Fathers of health economics) think that the answer is "no." In a recent piece in the Journal of the American Medical Association, they state that the current educational system for physicians is, in fact, wasteful. They point out that a physician today cannot credibly be the superhero, one-man-band of master clinician, penetrating researcher, community pillar, and public intellectual that she/he was expected to be up through the 1980s. The state that the complexity of medicine today requires a team based approach where doctors are relative specialists. Emanuel and Fuchs illustrate how physicians today are now more likely to take on the one (or two) of these archetypical roles that fit with their comparative strengths while letting other members of the larger team fulfill the other roles. In contrast to this new reality of medicine, our current system of medical education is wasteful because it still aims to produce one-man-band types.
So how can medical education be shortened? Emanuel and Fuchs suggest the following:
-Loosen requirements that undergraduate degrees be mandatory (there are plenty of six or seven year combined undergrad-MD programs that produce equally good doctors)
-Cut the pre-clinical years of medical school from 2 to 1.5 years (UPenn and Duke have shortened versions of the classroom years)
-Cut the clinical years from 24 to 15 months (Harvard is currently doing this, quite successfully I might add)
-Eliminate research requirements in residency and fellowship for those who do not want to do them (this, for example, would shave off 2 of the 7 years to become a general surgeon)
-Eliminate "leadership years" (for example, in internal medicine, the third year is to lead teams and has little value added in the education production function)
I am 100% behind this. Much of our current system persists because of historical considerations from nearly a century ago. In the same way that some of our antiquated mechanisms to finance health care (for example, employer sponsored health insurance) don't make much sense anymore, neither does making people spend a great deal of time in training where up to a third of it has little marginal benefit in turning people into good doctors.
If we are concerned with cost and efficiency in the health care system, we ought to paying as much attention to being efficient in how we train doctors as we are in figuring out how to pay them.
None another than Ezekiel Emanuel and Victor Fuchs (one of the Founding Fathers of health economics) think that the answer is "no." In a recent piece in the Journal of the American Medical Association, they state that the current educational system for physicians is, in fact, wasteful. They point out that a physician today cannot credibly be the superhero, one-man-band of master clinician, penetrating researcher, community pillar, and public intellectual that she/he was expected to be up through the 1980s. The state that the complexity of medicine today requires a team based approach where doctors are relative specialists. Emanuel and Fuchs illustrate how physicians today are now more likely to take on the one (or two) of these archetypical roles that fit with their comparative strengths while letting other members of the larger team fulfill the other roles. In contrast to this new reality of medicine, our current system of medical education is wasteful because it still aims to produce one-man-band types.
So how can medical education be shortened? Emanuel and Fuchs suggest the following:
-Loosen requirements that undergraduate degrees be mandatory (there are plenty of six or seven year combined undergrad-MD programs that produce equally good doctors)
-Cut the pre-clinical years of medical school from 2 to 1.5 years (UPenn and Duke have shortened versions of the classroom years)
-Cut the clinical years from 24 to 15 months (Harvard is currently doing this, quite successfully I might add)
-Eliminate research requirements in residency and fellowship for those who do not want to do them (this, for example, would shave off 2 of the 7 years to become a general surgeon)
-Eliminate "leadership years" (for example, in internal medicine, the third year is to lead teams and has little value added in the education production function)
I am 100% behind this. Much of our current system persists because of historical considerations from nearly a century ago. In the same way that some of our antiquated mechanisms to finance health care (for example, employer sponsored health insurance) don't make much sense anymore, neither does making people spend a great deal of time in training where up to a third of it has little marginal benefit in turning people into good doctors.
If we are concerned with cost and efficiency in the health care system, we ought to paying as much attention to being efficient in how we train doctors as we are in figuring out how to pay them.
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