Cayman Islands to have a Healthcare City

Reuters:

A renowned Indian heart surgeon has struck a deal to build a 2,000-bed healthcare city in the Cayman Islands to target American patients and insurers searching for deeply discounted medical care.

The British Caribbean territory agreed to the deal with Dr. Devi Shetty, a low-cost healthcare pioneer renowned as Mother Teresa's heart surgeon. The Caymans fulfilled its part of the bargain last week by passing legislation that caps medical negligence claims at U.S.$600,000.

The tiny, affluent territory west of Jamaica has 55,000 residents and is under pressure from Britain to diversify its economy and move away from its tax haven image.
...
U.S. insurers and employers are under pressure to reduce costs for high-tech procedures for heart, cancer, orthopedics, nuclear medicine and organ transplants, Shetty said. "It will be much easier for insurance companies to buy an air ticket and ask them to go to the Cayman Islands and get a heart bypass done and have a two-week beach holiday and come back at perhaps less than 50 percent of the cost," he said.
...
The average cost for a heart bypass is $144,000 in the United States, five times higher than neighboring Mexico at $27,000. Costa Rica charges $25,000 and Colombia $14,800 for the same procedure, the Medical Tourist Association said. Even with the higher cost of doing business in the Cayman Islands, Shetty estimates a heart bypass will cost less than $10,000.

Fat fairness (updated)

Fat rights lobbiests argue for fairness in pricing. By their logic car companies should sell obese people SUVs at a discount.

Is it enough to argue that you can't tell whether obesity is a pre-existing condition therefore it's not fair to charge the obese more for health insurance?

You can't tell whether my lack of productivity is due to a pre-existing condition. Pay me the same as everyone else. (Yes, I'm just kidding.)

Addendum added Oct 27. I've stumbled on this written on October 26th by the health economist Uwe E. Reinhardt:

It sounds like a great idea until one thinks about exactly how such an idea would be implemented in practice – especially in a country with a tort system such as ours. I wish both had given us their thoughts on that problem.

To take account of smoking in setting premiums is easy. Life insurers already do it, and even under community rating within mandated health insurance it would be relatively easy to charge higher premiums to smokers. I would favor it.

But consider obesity. Presumably an insurance company would somehow ascertain an applicant’s biomass and then somehow determine how much of any overweight is due to avoidable unhealthy behavior, and how much is rooted in genetic factors.
...
And even if that could be easily and cheaply done in practice, before long tort lawyers would bring class-action suits, citing the growing body of scientific literature suggesting that many behavior patterns — including unhealthy lifestyles — are rooted in very early cognitive development and subsequent education....

Add to that list environment factors beyond the individual's control, such as access to nearby grocery stores selling healthy foods at prices comparable to those in richer neighborhoods. See my essay at Daily Episcopalian.

Addendum 2, Oct 30. The technology could exist soon for your mobile phone to send your insurer information about your eating and exercise habits. Insurers could offer two kinds of policies, one where you consent to being monitored and another where you do not. Those who do not reveal themselves to be prone to unhealthy habits and would pay more. The insurer in this case is not insisting you reveal. They are only giving you the opportunity to reveal.

Oh, and isn't Reinhardt caught in an inconsistency between approving of charging higher premiums for smokers and not for those who have bad eating behavior? Arguably you can't help it that you like tobacco either. You may think, oh, but we know tobacco is bad for you and society frowns on it. But we're coming to that point with food abuse, too. Eat all you want, just don't base my premiums on how much you eat.

Woman too large for New Zealand

The Guardian

New Zealand has added another cruel cut to the myriad indignities visited upon those of larger girth: anyone with a dangerously high body mass index (BMI) is likely to be denied permission to emigrate there. Richie Trezise, 35, a Welsh submarine cable specialist, was initially rejected because of a BMI of 42 (25 or higher is regarded as overweight); he lost weight, but his wife Rowan, 33, has not found it so easy. For months she has tried to slim down enough to join her husband; if she can't do it by Christmas, he will have to give up his job and come home.

The government's reasoning is simple: it will take only immigrants of an "acceptable standard of health", ie those "unlikely to impose significant costs or demands on New Zealand's health or special education services" (a requirement that raises the even more controversial possibility of applicants being turned down for mental health reasons). Obese people are more likely to suffer from heart disease, diabetes, strokes and high blood pressure; ergo, obese people are not allowed.

The Sun has pictures.

New Zealand can't be blamed for Mrs. Trezise's weight. It can be blamed for causing its own citizens to be overweight. Its healthcare policy has weakened the incentive to stay fit.

Evidence? Obesity is an epidemic in New Zealand. As one news source points out,

The country's health care system cannot afford to open its doors to overweight immigrants, a spokesman for New Zealand's Fight the Obesity Epidemic explained to the Daily Mail.

Over half of New Zealand adults and nearly one-third of New Zealand children are already overweight or obese, according to the group. Those figures are expected to rise, as are the health problems associated with being overweight, such as high blood pressure and diabetes.

The UAE does not limit immigrants by weight, but then it doesn't let them participate in the health plan for citizens. Obesity among UAE nationals is a considered a social problem and is related to the high rate of diabetes.

Quote of the day

Greg Mankiw:

Given how overweight we Americans are compared with citizens of other countries, it is amazing that we live as long as we do. If we further standardized life expectancy by body-mass index, the U.S. lead in health outcomes would likely grow even larger.

Mankiw argues convincingly that it's not the fault of the US health care system that Americans are so unhealthy. See more here and here.

Mankiw points to this article in the Washington Post. An extract:

I was talking to Barry Nalebuff, a professor at Yale University and one the country's top game-theory economists. He has studied weight-loss incentives extensively. When I told him what my wife was paying me, he said: "It's not going to work. It's not big enough. Not even close." He had another idea: Take a picture of myself in a Speedo, and if I don't lose weight, he gets to hang the picture in my office. For extra motivation, he suggested I procure a similar picture of my wife, theorizing (correctly) that she wouldn't want my colleagues to see that much of her. "Then you'll really lose the weight," he said. He has done two nationally televised studies showing that this strategy works.

Nalebuff thinks the weight loss will happen only if there is something of importance being risked. When I told him that my wife might kill me under his proposed arrangement -- thereby defeating the purpose of me losing weight -- he suggested I enter into a contract in which I agree to pay him if I don't drop some pounds. "As much as people don't like to lose money, what they really don't like to lose is their own money," he said.

In fact, some of his Yale colleagues are in the final stages of launching a business based on this very concept.

Perhaps they could open a branch in the UAE. According to the Gulf News Treatment of diabetes is a big drain on national healthcare budget. Diabetes is caused by diet. Here's where healthcare policy comes in. When your government takes care of you if you don't take care of yourself, then incentives are screwed up. But it's very difficult for the government to refuse to take care of you, especially if it's a wealthy nation. Perhaps the UAE government should commit to giving a few billion dollars away to Darfur if it fails to stick to a policy of refusing to take care of people who don't take care of themselves.

Everything is connected

Item 1.

The NHS has traditionally depended on overseas doctors to help keep the health service running. The most recent figures show that almost 128,000 of the 277,000 doctors on the GMC register have been trained abroad.

Of these 1,985 are from Iraq and 184 from Jordan.

The skills gap has meant that, with the exception of consultants, doctors did not require a work permit until last year.

Ministers changed this only as the expansion in medical school places several years ago led to a boom in UK-trained doctors.

Item 2.

The latest crisis has come about because there were only 22,000 jobs for 30,000 junior doctors. The glut in applicants was caused by the introduction of a system where those who started training two years ago are competing for the same jobs as those who began three or four years ago.
...
the British Medical Association condemned the [NHS] system. Dr Faith Harries, a junior doctor, who has been offered no interview said: "I came out of medical school with £42,000 debt. I thought I was guaranteed a job in training in the UK — because I thought I would be able to pay it back. Now I am thinking of going abroad."

Price ceilings on healthy foods suggested

The Gulf News reports:

Healthy foods such as fruits and vegetables may soon be cheaper due to government efforts to control rising obesity in the society, experts said.

In the UAE, modifications to the Diet and Physical Activity Strategy (DIPAS) for Gulf countries include selling fruits and vegetables and other health foods at lower prices, and involving various government agencies and ministries.

Dr Huda Al Suwaidi, consultant in family medicine at the Health Ministry, told Gulf News that the initiative was important as unhealthy diet and lifestyle gave rise to many health problems in the region, including diabetes and cardiovascular disease.

She said the government would first seek voluntary participation from supermarkets.

"We might even get the Ministry of Finance to come up with legislation that would control the prices of vegetables and fruits, because it will be a way of getting people to eat more healthy food," she said.

She said the Health Ministry would lend its name in promoting supermarkets and cooperatives that take up the initiative voluntarily, as an incentive.

Introducing a price ceiling to lower the price of healthy foods would give consumers the incentive to seek to consume more healthy food, but it will also give suppliers less incentive to provide healthy foods. Consumers will end up consuming less, not more healthy food -- exactly the opposite of the good intentions of the Health Ministry.

If the ministry wants to spur consumption of healthy food it needs to either convince consumers to buy more at given prices, or subsidize healthy food in the marketplace.

The Gulf News article continues:

A Diet and Physical Activity Strategy also calls on the UAE to conduct a survey on social, demographical, economic and psychological factors influencing health in the UAE, which will be part of a global WHO and UN survey.

The survey could begin by the end of the year and will collect information on all age groups in the population, including their body mass index, blood sugar levels and cholesterol levels, as well as lifestyle.

About 70 per cent of men above 30 in the UAE are overweight and 30 per cent obese, while 78 per cent of women in the same age group are overweight and 50 per cent obese, according to 2005 WHO statistics. More than 20 per cent of schoolchildren aged 12 to 16 in the UAE are overweight, while 12 per cent are already obese.

Let's be honest and say what the article does not say directly. The population described here is not the UAE population, but the 20 percent who are nationals. A commenter at UAE community blog has marshalled the statistics and made this point very well. See also this excellent comment.

Because the government also provides health care to nationals it may well be that the government will save money by subsidizing health foods. Except of course that it would subsidizing healthy foods for the entire population of the UAE. Perhaps the government should stop subsidizing bad health habits -- which is what free health care does. Turn the savings over to nationals as a lump sum and let them decide what is in their best interest. It may be that it is in their best interest to take care of themselves.

The timing of the Dr Al Suwaidi's remarks are ironic given the recent announcement of an expansion in our unhealthy eating options in the UAE. On Thursday we learned a Krispy Kreme outlet opens tomorrow :

US doughnut and coffee chain Krispy Kreme will open its first UAE outlet in the Deira City Centre shopping mall tomorrow, the first of seven stores planned for the country this year. The North-Carolina-based food company, which is listed on the New York Stock Exchange, aims to roll out 100 stores throughout the Middle East in the next five years.

Unfamiliar with Krispy Kreme? -- here's some background. Nothing works like the profit motive.

The 52g original Krispy Kreme donut provides 10g of sugar and 200 calories (100 from fat). (For more on nutrition go here.)

Mmmm, donuts. If there is a Donuts Anonymous, I need to join.

Modern life is healthy :: New York Times

Those wacky microeconomists are looking in places where the average Joe would be surprised to find an economist (no, most of us have no expertise in stocks, bond and foreign exchange). So reports the New York Times.

New research from around the world has begun to reveal a picture of humans today that is so different from what it was in the past that scientists say they are startled. Over the past 100 years, says one researcher, Robert W. Fogel of the University of Chicago, humans in the industrialized world have undergone “a form of evolution that is unique not only to humankind, but unique among the 7,000 or so generations of humans who have ever inhabited the earth.”

The difference does not involve changes in genes, as far as is known, but changes in the human form. It shows up in several ways, from those that are well known and almost taken for granted, like greater heights and longer lives, to ones that are emerging only from comparisons of health records.

The biggest surprise emerging from the new studies is that many chronic ailments like heart disease, lung disease and arthritis are occurring an average of 10 to 25 years later than they used to. There is also less disability among older people today, according to a federal study that directly measures it. And that is not just because medical treatments like cataract surgery keep people functioning. Human bodies are simply not breaking down the way they did before.
. . .
Dr. Barker of Oregon Health and Science University is intrigued by the puzzle of who gets what illness, and when. “Why do some people get heart disease and strokes and others don’t?” he said. “It’s very clear that current ideas about adult lifestyles go only a small way toward explaining this. You can say that it’s genes if you want to cease thinking about it. Or you can say, When do people become vulnerable during development? Once you have that thought, it opens up a whole new world.”

It is a world that obsesses Dr. Barker. Animal studies and data that he and others have been gathering have convinced him that health in middle age can be determined in fetal life and in the first two years after birth.
. . .
But not everyone was convinced by what has come to be known as the Barker hypothesis, the idea that events very early in life affect health and well-being in middle and old age. One who looked askance was Douglas V. Almond, an economist at Columbia University.

Dr. Almond had a problem with the studies. They were not of randomly selected populations, he said, making it hard to know if other factors had contributed to the health effects. He wanted to see a rigorous test — a sickness or a deprivation that affected everyone, rich and poor, educated and not, and then went away. Then he realized there had been such an event: the 1918 flu.

The flu pandemic arrived in the United States in October 1918 and was gone by January 1919, afflicting a third of the pregnant women in the United States. What happened to their children? Dr. Almond asked.

He compared two populations: those whose mothers were pregnant during the flu epidemic and those whose mothers were pregnant shortly before or shortly after the epidemic.

To his astonishment, Dr. Almond found that the children of women who were pregnant during the influenza epidemic had more illness, especially diabetes, for which the incidence was 20 percent higher by age 61. They also got less education — they were 15 percent less likely to graduate from high school. The men’s incomes were 5 percent to 7 percent lower, and the families were more likely to receive public assistance.

The effects, Dr. Almond said, occurred in whites and nonwhites, in rich and poor, in men and women. He convinced himself, he said, that there was something to the Barker hypothesis.

If life in the womb and in the first two years has such a large impact, that bodes well for Jeffrey Sach's program of concentrating development aid on direct relief of extreme poverty: people will be able to lead much more productive lives. And, no, I have not lost track of the opposite direction of causality that Fogle points to: the Industrial revolution has allowed people to live longer with fewer disabilities.

Economic development even seems to be a cure for cancer:

“Suppose you were a survivor of typhoid or tuberculosis,” Dr. Fogel said. “What would that do to aging?” It turned out, he said, that the number of chronic illnesses at age 50 was much higher in that group. “Something is being undermined,” he said. “Even the cancer rates were higher. Ye gods. We never would have suspected that.”

Economics development in the last century has so improved lives that Fogel is suggesting the world's population carrying capacity is 50 billion.

Life for UAE nationals was quite harsh up until 40 or 50 years ago. The first two years of life for someone born here in 1960 was quite different for someone born here in 1980. Yes, we are seeing lots of childhood obesity. But is that extra weight due to a good start in life or to an unhealthy lifestyle? Moreover, even if it is the latter going back to the economy of the 1960s would be literally unhealthy.