APPLIED ECONOMICS FIRST EDITION怎么样

APPLIED ECONOMICS FIRST EDITION怎么样
APPLIED ECONOMICS FIRST EDITION怎么样

APPLIED ECONOMICS FIRST EDITION怎么样
几个重要的点 a. 第三方支付的确可以降低医疗的'price', 却只能抬高'cost'. b. 价格管制的确可以降低医疗的'price',但是下降的供给最终也要抬高'cost',最有名的就是我大NHS世界领先的手术等待时间. 这里面还有隐形的成本——等待手术的痛苦,病情恶化和误工——都不会体现在NHS的账簿上. 此外,在医疗价格被管制的国家,红包现象会很突出. 这些不会算进官方的医疗开支里,但确是实实在在的cost. c. 价格管制的供给破坏也可以体现在质量上,比如我大NHS旗下脏的出名的医院和世界落后水平的仪器. d. 照顾“弱势群体”,导致医疗纠纷多讼狱,直接导致了供应的紧缩,最终打回到弱势群体身上. 比如我大NHS每年要从第三世界国家招医生. 比如加州人找不到产科医生接生. e. 第三方支付的后果都说了很多了不重复. 美国第三方医疗支付是由税制引起的——'in-kind benefits'不便征税. f. 药品研发不愧为知识产权保护的经典案例,我服. g. FDA杀人这个大家也都见得多了. 我下面引得那一段FDA官员说的话特别revealing: In all our FDA history, we are unable to find a single instance where a Congressional committee investigated the failure of FDA to approve a new drug. But the times when hearings have been held to criticize our approval of a new drug have been so frequent that we have not been able to count them. The message to FDA staff could not be clearer. h. TS对买卖肾脏做了非常热情的辩护. 我服了. 见最后一段. In general, where the doctor is paid per patient visit, then a series of treatments that might have taken five visits to the doctor’s office can now take ten shorter visits— or more. Therefore political leaders can proclaim that price controls have succeeded because the cost per visit is now lower than it was in a free market, even though the total costs of treating a given illness have not declined and— typically— have risen. —— However,medicalcareisnotthesameashealthcare,even though the two are often equated. Many things that shorten human life— including homicide, drug overdoses and obesity— are more a result of individual choices rather than the state of medical care. There is relatively little that doctors can do about such things, which tend to be worse in the United States than in some other Western countries. —— When international comparisons of medical care, as such, are made the United States usually ranks higher than countries with government-run medical systems on such things as waiting times to see primary care physicians, waiting times to see specialists or have surgery, and cancer survival rates. In Canada, according to a provincial government website, 90 percent of Ontario patients needing hip replacements waited 336 days. In Britain, the wait is a year. —— Economic losses sustained by patients may also be considerable when the disease or disability prevents them from working. These costs do not appear among the statistics on the costs of medical care which are used when comparing such costs among different countries. —— In Canada, a 2004 study showed the median waiting time from receiving an appointment with a specialist to actually being treated was 15 weeks for ophthalmology and 24 weeks for orthopaedic surgery. This does not include the waiting time between being referred to a specialist by a general practitioner and actually getting an appointment with that specialist, these additional waiting times varying by province from 7 weeks in Manitoba to 12 weeks in Prince Edward Island. —— Official statistics do not capture these illegal financial costs, much less the even more important human costs of hasty diagnosis and treatments in abbreviated visits to doctors’ offices and the long time on waiting lists before even reaching a medical facility. Thus, in terms of publicly visible costs and benefits, a price-controlled medical system may be a political success. For years, the Soviet Union boasted of having the largest number of doctors and hospital beds of any country in the world— all the while concealing the fact that it also had rising rates of infant mortality and a declining life expectancy in its population as a whole, facts which came out only in its last years under Mikhail Gorbachev’s policy of glasnost or openness. —— Sometimes the opting out occurs earlier, when fewer people enter medical school after the rewards of being a doctor are reduced. More than one-third of the doctors in Britain, for example, were not trained in British medical schools but have been imported from many other countries, —— But the fact that only part of the costs are reimbursed by direct out-of-ocket payments from individual patients to doctors, hospitals, or pharmacies in no way indicates that the total cost of the particular medical treatment is any lower than before. When the public pays part of its medical costs in taxes that the government uses to subsidize medical treatment, or in premiums paid to health insurance companies, none of that lowers the total cost in the slightest. —— The particular system of private third-party payments for medical care in the United States, with health insurance provided by employers, was a fortuitous consequence of tax laws and wage controls during the Second World War— and had nothing to do with any special qualifications of employers to deal with medical care issues. Because employers were prevented by wage controls from raising pay rates to attract more workers during the labor shortages brought on by those controls, they resorted to increased “fringe benefits” to achieve the same results and these benefits were not taxed, so that their value to the workers exceeded their costs to the employers. Before the war, in 1940 only 10 percent of Americans had private health insurance but, a decade later, half did. —— Even if it is medically necessary for a given person to wear glasses, is keeping up with fashions also medically necessary? More to the point, would this same customer have bought eight or nine pairs of glasses with her own money? If not, then medical savings accounts have led to a misallocation of resources to buy things that are not worth what they cost, but which are purchased anyway because the government is helping to pay for them by exempting from taxes the income that goes into medical savings accounts. —— Because medical care is so often discussed in politics and in media as if there is a more or less fixed amount of “need” and the only question is how to pay for it, much attention has been focused on those who do not have any form of health insurance. But these financial arrangements are not ends in themselves. The real question is: How much medical care is available, whether or not particular individuals have health insurance? —— Third-party payments for medical care transfer the decision-making ability to determine how much medical care, and of what kind, each individual will receive. Given that economic resources of all sorts are scarce— that is, insufficient to provide everyone with enough to satisfy all desires— rationing is going to have to take place, whether for medical goods and services or for anything else, and whether those decisions are made by each person individually or by a government agency collectively for the population at large. —— It costs a jury nothing to “send a message” warning doctors to be more careful, and the particular doctor in the case at hand probably has insurance from a company that can pay a few million dollars easily out of its billions of dollars in assets. Only if the jurors think beyond stage one will they take into account the increased cost of medical treatment brought on by their awards and the future non-financial costs to pregnant women unable to find obstetricians in their area at the time of delivery and the lifelong costs to babies who may incur more or worse injuries or disabilities as a result. This is especially likely to be the end result in states where juries hand out multimillion-dollar awards readily, such as Nevada: Kimberly Maugaotega of Las Vegas is 13 weeks pregnant and hasn’t seen an obstetrician. When she learned she was expecting, the 33-year-old mother of two called the doctor who delivered her second child but was told he wasn’t taking any new pregnant patients. Dr. Shelby Wilbourn plans to leave Nevada because of soaring medical-malpractice insurance rates there. Ms. Maugaotega says she called 28 obstetricians but couldn’t find one who would take her. —— Since the cost of manufacturing a pharmaceutical drug is often a small fraction of its total costs, or of the price paid by the consumer, there are ample opportunities for politicians, journalists, and others to decry the “unconscionable,”“outrageous” or “obscene” profits made by charging two dollars a pill when the ingredients in the pill may cost only a quarter. By ingredients they mean physical ingredients, which are usually inexpensive, rather than the knowledge ingredient which is usually astronomically expensive because of years of research, with much trial and error, including many costly and failed attempts to create effective new medicines. —— Those who do not think beyond stage one focus on the money that can be “saved” by allowing Canadians to re-export back to the United States the American drugs they have bought at lower prices than Americans pay, thereby reducing the costs of medical care for the American government, individuals and medical organizations. Not only would there be direct savings by individuals and organizations importing American medicines from Canada, the pharmaceutical drug companies would then be under pressure to lower the prices they charge in the United States as well, after losing sales because of competition from the sales of their own medicines being imported back from Canada. None of this, however, deals with the crucial question for those who do think beyond stage one: Since the fixed costs have to be paid by somebody, if the development of new medicines is to continue, how can evasions of such payments of fixed costs fail to reduce the rate of investment and discovery of new medicines? —— Since pharmaceutical drugs can easily take a decade or more to be created, even if price controls caused all research and development of new drugs to come to a halt immediately, it would be long after the next election before people began to notice that no new medications were being created to deal with the ravages of still deadly diseases. These are virtually ideal political conditions for killing the goose that lays the golden egg. The short- run result would be visibly lower drug prices, making millions of voters happier, and the long-run consequences would be postponed until several elections later, by which time even those suffering needlessly from illnesses that new medications could have cured or prevented may see no connection between their own suffering and political decisions made years earlier. —— Depending on whether the anticipated additional sales would cover these additional costs— which can run into many millions of dollars— the company may or may not try to get the approval needed to permit advertising uses which medical science has already shown to be beneficial. A classic example is aspirin, which has long been approved as a medication for headaches but may be even more valuable in other uses which, until recent years, were not permitted to be advertised. —— Like other advertising, the advertising of pharmaceutical drugs is often thought of as adding to the costs which the consumer must pay for, driving up the price of the product. That would be true if advertising had no effect on sales and sales had no effect on economies of scale in production. But the obvious purpose of advertising is precisely to have an effect on sales— and there are huge economies of scale when there are high fixed costs, running into hundreds of millions of dollars, for producing a pharmaceutical drug and very low costs of actually manufacturing the drug. The larger the number of sales over which the huge fixed costs are spread, the lower those fixed costs are per unit of medication. Pharmaceutical drugs are a classic example of economies of scale. Yet many in politics and in the media speak as if it is axiomatic that advertising drives up the cost of medications. _ A former Commissioner of the Food and Drug Administration noted the institutional incentives and constraints: In all our FDA history, we are unable to find a single instance where a Congressional committee investigated the failure of FDA to approve a new drug. But the times when hearings have been held to criticize our approval of a new drug have been so frequent that we have not been able to count them. The message to FDA staff could not be clearer. —— More than 50,000 Americans were on waiting lists for kidneys, while only about 12,000 kidneys were available to be transplanted. Similar patterns are found in other countries. According to the British Journal of Medical Ethics, in Western Europe 40,000 people were on waiting lists for kidney transplants but only 10,000 kidneys were available— and nobody knows “how many people fail to make it onto the waiting lists and so disappear from the statistics.” Meanwhile, there are an estimated 700,000 patients on dialysis worldwide. —— The Economist magazine estimates that it would take less than one percent of healthy Americans from ages 19 to 65 to part with one kidney to eliminate the waiting list on which thousands of patients die each year. —— In any case, the costs of the organ purchases would not be the main costs of the organ transplant process. It has been estimated by an organ transplant specialist that the savings from reductions in the use of kidney dialysis by the use of kidney transplants could on net balance “reduce government expenditures significantly.” In short, price controls— in this case, making sales of organs illegal at any price— have relatively little effect on the total cost of an organ transplant, but can have serious effects in reducing the number of organs available to be transplanted. —— Since people on waiting lists for organ transplants are also in desperate circumstances, to have the options of both sets of people reduced, and their choices over- ridden, by people who are healthy and prosperous seems painfully ironic, as if the squeamishness of third parties should be decisive. Sometimes the argument is made that it is wrong to have a human organ reduced to the level of a “commodity,” as if avoiding a word is worth losing a life. —— A number of confusions plague discussions of the economics of medical care. A confusion between prices and costs has allowed politicians in various countries to be able to claim to be able to bring down the cost of health care, when in fact they only bring down the individual patient’s out-of-pocket costs paid to doctors, hospitals, and pharmacies. The costs themselves are not reduced in the slightest when additional money to pay for these costs is collected in taxes or insurance premiums and routed through either government or private bureaucracies.