Health technology assessment between our health care system and our health

In this contribution, I wish to explore the potential of health technology assessment and ethics for increasing our capacity to pre-empt the shortcomings and undesired consequences of modern health care while maintaining its benefits. Central is the presumption that in case of some health problems this cannot be done unless we explicitly reconsider some features of the modern health care system, especially those related to its strong reliance on scientific rationality and the strong role played by medical professionals. So as to both maintain the benefits of advanced health care and ensure that it produces less reason for concern, we need to reconsider our approach to rationality—and maybe even the way in which we build our health care system around that rationality. That is, we need to introduce an element of reflexivity. Two types of circumstances are being explored in which such reflexivity may prove worthwhile: controversies on side effects, and persistent problems encountered in optimising health care. Drawing on brief discussions of typical cases, we explore the potential of reflexive HTA and its methodical prerequisites. We conclude that ethicists may contribute to reflexive HTA, if they combine a hermeneutic—and often also participative—methodology with a solid understanding of the relation between the health problem under scrutiny and more general critique of the health care system. Insights from the areas of science and technology studies, as well as from social philosophy may be critical items in their tool kit.     

Deposit Insurance,Institutions, and Bank Interest Rates

Many recent institutional reforms of the financial system have relied on the introduction of an explicit scheme of deposit insurance. This instrument aims at two main targets, contributing to systemic stability and protecting depositors. However, it may also affect the interest rate spread in the banking system, which can be viewed as an indicator of either inefficiency or market power in this financial segment. This paper provides an empirical investigation of the effect of deposit insurance and other institutional and economic variables on bank interest rates across countries. We find that deposit insurance increases the lending–deposit spread in banking. The main effect seems to arise not from the deposit side though, but from an increase in the lending rate. We interpret this result as evidence of the presence of moral hazard problems related to this instrument. We also find that higher quality of institutions is associated with lower spreads, thus contributing to eroding sources of market power in the banking sector.     

A modified random-effect procedure for combining risk difference in sets of 2×2 tables from clinical trials

Summary Meta-analyses of sets of clinical trials often combine risk differences from several 2×2 tables according to a random-effects model. The DerSimonian-Laird random-effects procedure, widely used for estimating the populaton mean risk difference, weights the risk difference from each primary study inversely proportional to an estimate of its variance (the sum of the between-study variance and the conditional within-study variance). Because those weights are not independent of the risk differences, however, the procedure sometimes exhibits bias and unnatural behavior. The present paper proposes a modified weighting scheme that uses the unconditional within-study variance to avoid this source of bias. The modified procedure has variance closer to that available from weighting by ideal weights when such weights are known. We studied the modified procedure in extensive simulation experiments using situations whose parameters resemble those of actual studies in medical research. For comparison we also included two unbiased procedures, the unweighted mean and a sample-size-weighted mean; their relative variability depends on the extent of heterogeneity among the primary studies. An example illustrates the application of the procedures to actual data and the differences among the results. This research was supported by Grant HS 05936 from the Agency for Health Care Policy and Research to Harvard University.     

Generalized Laplacian approximations in Bayesian inference

This paper presents a new Laplacian approximation to the posterior density of η = g(θ). It has a simpler analytical form than that described by Leonard et al. (1989). The approximation derived by Leonard et al. requires a conditional information matrix R_η to be positive definite for every fixed η. However, in many cases, not all R_η are positive definite. In such cases, the computations of their approximations fail, since the approximation cannot be normalized. However, the new approximation may be modified so that the corresponding conditional information matrix can be made positive definite for every fixed η. In addition, a Bayesian procedure for contingency-table model checking is provided. An example of cross-classification between the educational level of a wife and fertility-planning status of couples is used for explanation. Various Laplacian approximations are computed and compared in this example and in an example of public school expenditures in the context of Bayesian analysis of the multiparameter Fisher-Behrens problem.     

Will taxpayers ever like taxes?: Responses to the U.S. Tax Reform Act of 1986

Major policy changes like the 1986 Tax Reform Act (TRA) in the United States provide natural experiments to study attitudinal and behavior responses to law. Surprisingly, public evaluations of the TRA became increasingly negative after passage, while general support for the tax system became more positive in response to the changes. To explain this puzzle, we propose a dynamic model of taxpayer attitudes that is consistent with the observed loose linkage between logically-connected concepts. We briefly review the political context, objectives and impacts of the 1986 Tax Reform Act, and present several studies testing the impact of self-interest, prior beliefs, and social discussion on changes in attitudes and behavior.Results suggest that the complexity of taxes and difficulty in knowing objective impacts weakens the role of self-interest in attitudinal changes, thereby strengthening the role of prior beliefs and discussion. Evaluations of tax laws are most responsive to more politically-oriented influences.     

Effects of Medicaid managed care policies on mental health service use among a national probability sample of children in the child welfare system

Children in the child welfare system are dependent upon Medicaid to finance services for their considerable mental health needs. This study examines the effects of Medicaid policies on mental health service use among a national probability sample of children in the child welfare system. Data for this study came from the National Survey of Child and Adolescent Well-Being, the Caring for Children in Child Welfare study, and the Area Resource File. Weighted multivariate logistic regression analyses were conducted to estimate effects of policy variables on children's use of mental health services, controlling for child-level covariates and county-level health resources. Children in counties with behavioral carve-outs under Medicaid managed care had lower odds of inpatient mental health service use. Medicaid managed care enrollment and variations in type of provider reimbursement did not affect use of mental health services. Older age, greater need for mental health services, and higher levels of caregiver education were associated with increased odds of service use. Restrictions on use of inpatient mental healthcare caused by behavioral carve-outs may disproportionately affect children in the child welfare system who have high rates of such use. Careful adoption of carve-outs is necessary to assure appropriate care for these children.     

The current state of the labor queue: National and regional Evidence

We employ vector autoregressive techniques to determine the current state of the labor queue. Unemployment rate differentials have narrowed in recent years, potentially due to a change in the queue ordering, though a tight labor market and a stable queue would yield similar results. We find no evidence that the queue ordering has changed, which brings into question the resiliency of gains made by minority groups. We employ the same techniques to reveal the state of the queue across geographic regions and find that substantial differences exist across regions, implying variation in the relative labor force status of demographic groups.     

Bayesian analysis of a marked point process: Application in seismic hazard assessment

Point processes are the stochastic models most suitable for describing physical phenomena that appear at irregularly spaced times, such as the earthquakes. These processes are uniquely characterized by their conditional intensity, that is, by the probability that an event will occur in the infinitesimal interval (t, t+Δt), given the history of the process up tot. The seismic phenomenon displays different behaviours on different time and size scales; in particular, the occurrence of destructive shocks over some centuries in a seismogenic region may be explained by the elastic rebound theory. This theory has inspired the so-called stress release models: their conditional intensity translates the idea that an earthquake produces a sudden decrease in the amount of strain accumulated gradually over time along a fault, and the subsequent event occurs when the stress exceeds the strength of the medium. This study has a double objective: the formulation of these models in the Bayesian framework, and the assignment to each event of a mark, that is its magnitude, modelled through a distribution that depends at timet on the stress level accumulated up to that instant. The resulting parameter space is constrained and dependent on the data, complicating Bayesian computation and analysis. We have resorted to Monte Carlo methods to solve these problems.     

Population constraints on pooled surveys in demographic hazard modeling

In non-experimental research, data on the same population process may be collected simultaneously by more than one instrument. For example, in the present application, two sample surveys and a population birth registration system all collect observations on first births by age and year, while the two surveys additionally collect information on women’s education. To make maximum use of the three data sources, the survey data are pooled and the population data introduced as constraints in a logistic regression equation. Reductions in standard errors about the age and birth-cohort parameters of the regression equation in the order of three-quarters are obtained by introducing the population data as constraints. A halving of the standard errors about the education parameters is achieved by pooling observations from the larger survey dataset with those from the smaller survey. The percentage reduction in the standard errors through imposing population constraints is independent of the total survey sample size.