Sunday, August 19, 2007

Perhaps Michael Moore Should Run a Taxi Service

I don't know which of the following statements is more surprising. From the AP:

A 35-year-old Canadian woman has given birth to rare identical quadruplets, officials at a Great Falls hospital said Thursday. Karen Jepp of Calgary, Alberta, delivered Autumn, Brooke, Calissa and Dahlia by Caesarian section Sunday afternoon at Benefis Healthcare, said Amy Astin, the hospital's director of community and government relations.

The four girls were breathing without ventilators and listed in good condition Thursday, she said.
Wonderful. And this part:

The Jepps drove 325 miles to Great Falls for the births because hospitals in Calgary were at capacity, Key said.

"The difficulty is that Calgary continues to grow at such a rapid rate. ... The population has increased a lot faster than the number of hospital beds," he said.
For those of you unclear on the geography, their trip looked something like this and would take about five hours at the posted speed limits. About halfway through the trip, they would pass through Lethbridge, which is home to Chinook Regional Hospital, which claims to offer a "high level neonatal intensive care unit." Not good enough? No beds there either? When they were in Lethbridge, they were about an hour away from Medicine Hat, home to this fine institution and its NICU, or two and a half hours plus a border crossing away from Great Falls. They chose the latter.

UPDATE (8/20): At the prompting of a commenter, I found that the doctor's statement about them driving the 325 miles is incorrect, and so too is my travelogue in the last paragraph of the original post (now italicized). Here is a report from the BBC that explains:
A medical team and space for the babies had been organised for the Jepp family at the Foothills Medical Centre in Calgary but several other babies were born unexpectedly early, filling the neonatal intensive care unit.

Health officials said they checked every other neonatal intensive care unit in Canada but none had space.

The Jepps, a nurse and a respiratory technician were flown 500km (310 miles) to the Montana hospital, the closest in the US, where the quadruplets were born on Sunday.

My apologies for the hasty and incorrect post, though this notion that "every other neonatal intensive care unit in Canada" had no space is more of an indictment of the system than my original remarks.


Jonah B. Gelbach said...

Wow, that is some story.

For what it's worth, though, clogged hospitals are not unique to Canada. I had to have an emergency appendectomy a little under 2 wks ago. I got to the hospital at noon (after seeing an offsite urgent-care doctor, who I mistakenly believed would be able to move me up the queue with a referral). Because they had no beds available in the ER, the nice ER intake folks made me wait--sitting up--for 7 hours.

After they finally took me to a bed in the ER trauma area, I waited nearly another hour for a doctor to do the 1-minute exam needed to discern that there was a 90% chance I had appendicitis. Interestingly, the exam was as best as I could tell identical to the one that the urgent-care doc did.

The surgery started at 2am (the surgeon insisted on a CT scan, given that I have a pre-existing condition, which decision I won't argue with).

So to recap, I presented at noon with an obvious case of appendicitis. Any doc looking at my chart would know that at a minimum they would be admitting me for observation to rule out appendicitis (that's the medical term, which I know because I had to go through it once years ago). Since they had no bed in the ER, they made me wait for seven hours with nothing but vitals checks every 2 hours. The end result was "emergency" surgery 14 hours after I presented.

Now, you might say that I just got unlucky and picked the wrong hospital (there are sth like 8 in Tucson, where I live). But, around hour 4 I asked the vital signs-checking nurse whether I would be better off going elsewhere. He told me that all hospitals in Tucson had the same situation that day.

And since then, at least a couple of people have told me similar and worse stories. Two of them had their appendixes burst while they were sitting--also for hours--in ER waiting rooms. It may be tempting to dismiss my case as minor--mine didn't rupture and as such I was never (yet) in any sort of grave danger--by comparison to a woman giving birth to quads. But those other people who told me their stories were conceivably in serious jeopardy.

So as long as we are using anecdotes to compare health care systems, let me just say that my recent experience in the US makes me think the "you-have-to-wait-there" criticism of other systems involves a certain amount of glass housing.

None of that is to say that my experience was necessarily typical, or that other systems, like Canada, are flawless. But our system seems to share some if not all of those flaws.

Jonah B. Gelbach said...

One other thing. After the ER doc finally examined me and made the call to admit me, a nurse mercifully gave me a few ccs of morphine.

Shortly thereafter, a nice man from the hospital finance department came to my gurney with a clipboard. He explained that my health insurance had a $250 copay for an admission and $750 for my annual deductible (none of which I'd used so far this year). I said, ok, figuring that's the way it goes. I thought it was nice of the nice man to come tell me these things so that I wouldn't be surprised when I got the bill.

And then the nice man asked me, very nicely, if there was any way I could pay some or all of the money upfront, right that moment. Of course I started to laugh--here I am, in pain for many hours, finally having been given some painkillers, and the finance guy comes to shake me down for cash while I'm doped up on morphine (great stuff, btw, though I recommend that if you get 4ccs, don't take it all at once).

So I start laughing, explaining the morphine bit. He looks surprised and says sth like "You look fine to me." Right. I'm fine. I'm just high on painkillers and waiting for "emergency" surgery, but why not conduct some business? I start to say I'll pay, but then in my dopey confusion (please hold back on the snarky comments), I can't explain to him where my credit card is (by now I'm wearing the hospital gown instead of my civvies). So I just mumble incoherently (again, no comments) for a while.

At this point he gets back to brass tacks and tells me that if I can pay the whole thing right then, he'll give me 10% off. He's *bargaining* with me! Well, I like a negotiation, even a drug-addled one. So I said I'd do it if he gave me 20% off. He gives me a very serious look and says he'll have to check with his supervisor. I tell him fine, my wife will be there soon (she'd had to go home to walk the dog) and he can discuss with her. End of the story is that I was in the CT scan machine when he came back, at which point he told my wife no dice on the 20% discount. So we paid 90%.

I bet you don't have that sort of interaction in too many other health care systems.

(As an aside, while I'm grateful to have insurance, my insurance policy's design seems pretty stupid to me. The $250 copay seems dumb, since I'm guessing that patient moral hazard is at most a minor problem with admissions decisions. And applying my entire annual copay to "emergency" surgery also is silly, since it's clearly not elective and since now all my care--including elective care--for the rest of the year comes with no deductible. Finally, no, I didn't have a choice over health insurance policies, because this is the only one the state of Florida, my previous employer, allows people to use once they move out of state, and my U of Arizona insurance doesn't take hold til Sep 1.)

Jonah B. Gelbach said...

And another thing. The AP story goes on to say

Two of the girls were to be transferred to a Calgary hospital later Thursday. The other two could be moved Friday if their conditions remain favorable, Key said.

They will likely remain hospitalized for four to six weeks, he said.

So whatever capacity problems there are in Calgary appear to have been short-lived. I wonder whether the real reason that the parents drove so far was to see specialists, or a doc they preferred for some other reason?

Finally, the article says that the parents refused to speak to the press. The person who says they drove to the US due to capacity issues was their US doc.

eightnine2718281828mu5 said...

Yes, this couple would have been much better off in the US; for example, my wife had trouble conceiving, and the only thing the HMO would cover were hormone shots. In addition, there was a gag order preventing the doctor from informing us that there were other alternatives.

After 3 years of bogus hormone treatments, we moved to Massachusetts, which had (gasp!) a state requirement that HMO's offer a broad array of reproductive services.

My wife had a diagnostic laparoscopy; the literature shows that this simple diagnostic procedure results in successful conception in 25% of the time.

We were one of the 25%.

So if any Canadian couples had shared our circumstances and lived in the US, the US HMO system could have certainly relieved them of the inconvenience of their 350 mile drive.

Tony Vallencourt said...

Of course, driving into the U.S. makes the children American citizens as well.

Darren said...

Unfortunately, nobody has yet pointed out that what Mr. Samwick has written is complete and utter nonsense. The Jepps did NOT drive to Montana. They were flown (at government expense, of course).

I know that it suits Mr. Samwick's prejudices to believe that socialized medicine would stick a 9 months pregnant woman carrying quads into a car and ask her to drive five hours.... but that's not how it is.

Darren said...

Spud: "If they delivered these quads in the ER, then you and I are paying for it via higher insurance premiums."

Bull****. The Calgary Health Region (ie Alberta govt) paid Montana, in full, for the births. $200k CDN.

Anonymous said...

Is this the quality of your research? You don't talk to the parents, but you believe the report of their US doctor without doing any further inquiry?

Perhaps they knew they had quints and had been told Great Falls was the place to go? Perhaps they wanted their kids to be US Citizens? Perhaps they didn't want to pay?

And of course, why does Michael Moore say there is bed capacity here? It's because 40% of the population doesn't have insurance. That is, the quotas occur before you even enter the waiting room.

I followed DeLong's link to get here.

Seriously, is this the state of your research?

Andrew Samwick said...


The article quotes the U.S. doctor as saying that "The Jepps drove 325 miles to Great Falls for the births because hospitals in Calgary were at capacity."

You are correct that they were flown to Great Falls. The doctor misspoke, and I will correct my post with new links.



Anonymous said...

As an economist, I know you're interested in efficiency and reducing wasted resources.

How many NICU beds should have a hospital have? The number of those beds are a function of what?

Lange said local physicians had been closely monitoring Jepp's pregnancy and were anticipating her newborns would require care at Foothills' neonatal intensive care unit.

But when Jepp began experiencing labour symptoms last Friday, the unit at Foothills was over capacity with several unexpected pre-term births.

Karen Jepp gave birth to her girls Sunday at the Benefis Hospital in Great Falls, Montana. They were flown south of the border because Foothills Medical Centre NICU in Calgary was over-capacity with the addition of three more preterm babies Friday.

Maybe you can do a survey of your city and see how many NICU beds are available at each hospital, and how many of them have four available on a moment's notice.

Darren said...

"You are correct that they were flown to Great Falls. The doctor misspoke, and I will correct my post with new links."

That is gracious of you, Mr. Samwick, but I'm not sure what the point of your new post will be. I understand that moving babies around from hospital to hospital in the US due to a shortage of intensive care neonatal beds is not exactly uncommon.. the equivalent act in Canada necessarily involves longer distances due to sparser population.... so what exactly do you think your anecdote will show?

Oh yeah... the Jepp's bill for all this? $0.00.

Sven said...

Avast! Deploy anecdotes!

Kathleen Schneiderwind is one patient who was desperate to get rid of the lightning bolts of pain shooting through her spinal cord. But she and her husband lost their health insurance when they retired, and the hip-resurfacing surgery doctors promised would help cost $30,000 in the United States.

Schneiderwind and her husband, both in their late 50s, didn't have that kind of money, and the thought of so much debt was scary. So they began searching for alternatives.

"We began to look at places outside the United States and traded e-mails with doctors in Turkey and India. It turns out that the doctors in Bombay were both more experienced in this particular surgery and would only charge a fraction of what we were going to have to pay at home," said Barry Schneiderwind by phone as he sat with his wife who was recovering at Wockhardt Hospital in Mumbai.

Roger Albin said...

Depending on where you are in the USA, ICU bed, including NICU bed, shortages are hardly unusual and patients bouncing around for open beds is common. At my large university medical Center, we frequently have to turn away requests for ICU transfers because we're at capacity. We also occasionally have post-op patients stacked up overnight in our recovery room and ER patients held overnight in trauma bays because of ICU bed shortages. What Samwick describes is a relatively routine occurrence in many parts of the USA.
One thing that is likely to be different in the USA and Canada is that American hospitals, including mine, will refuse to accept ICU transfers, even when beds are open, for insurance (translation; financial) reasons.

Lord said...

I can't say that it is much of an indictment since it means they are using their resources more efficiently than us, unless it was us you were indicting.

Darren said...

Yes. Note that this was a quad birth. It was necessarily to find a place that had, not one or two free spaces, but four. This is not a common need. I'm not sure why Montana has such facilities... I'd have to wonder at their utilization rate. Mr. Samick appears troubled that Canada does not have vast empty neonatal wards standing by in case of a quad birth like they do in Montana... I personally am not concerned... the people involved got the care they needed and it didn't cost them a dime. I'm really struggling to see any indictment here, unless... (OK, I'll stop there or this comment will get deleted).

Anonymous said...

Four years ago, my 4-day-old son had a seizure and stopped breathing. Taken by ambulance to Dartmouth-Hitchcock Medical Center, he spent 8 hours waiting for a bed in the NICU to open up. When it became clear that no NICU beds would be available, he was moved to the Pediatric ICU where he received excellent care. Intensive care capacity is very expensive and the U.S. medical system may have more spare capacity than the Canadian system, but as other commenters have pointed out, it is by no means an unlimited resource south of the border.

Darren said...

Andrew, I am still awaiting an explanation of why this is a particularly damning indictment of Canada's health care system.

The GM article suggests that "at least five" women have been sent to Montana this year. (and in fact, I would suspect that Montana's spare capacity is not unrelated to its proximity to Alberta and not indicative of what you would find in Alabama). Five women, out of a population of 1.75m women (with the highest birthrate in Canada), does not strike me as a horrifyingly large number. Canada is a large and sparsely populated country, long distance medivac is sometimes necessary.... who cares if it is over a border?

Granted, the US has more spare capacity than Canada. If per capita health spending in Canada were doubled (to equal that in the US), I betcha we'd have lots of spare capacity too.. and not a single uninsured person in sight.

Anonymous said...

They needed FOUR NICU beds, not just one NICU bed.

Are you sure no one in Canada had ANY beds? Or is it possible that no one had FOUR beds?

Perhaps they decided the kids should stay in the same neonatal care unit and not be sent all around town or province.

Anonymous said...

Dartmouth is not exactly a major city.

Ir your wife was in a similar situation and had to be helicoptered to a major hospital in Boston would your insurance pay for it?

You probably do not know the answer.
But I challenge you to check with your benefits manager and report the answer on your blog.

Anonymous said...

Brad DeLong referred to this article, and there's nice comment thread there (possibly redundant):

Summary - data is not the plural of anecdote (unless one is a right-wing econ prof, of course).

- Barry

Anonymous said...

Jonah B. Gelbach, I had a pretty obvious case of appendicitis when I was in 3rd grade and it still took 10 hours before surgery. And my father was on the faculty at the teaching hospital where I was admitted, so I imagine that I got preferable treatment at worst.

Jonah B. Gelbach said...

anonymous--given what I've heard from others, i'm not surprised.

regarding everyone else's discussion and criticism of andy, i'll say this:

1. andy linked to a story that turned out to have some factual errors pertaining to less-than-key facts of the original story's focus (which was on the unusual birth of identical quads).

2. andy chose to focus on the erroneous claims and make an issue out of them as a criticism of both the canadian health care system and michael moore.

3. when it was pointed out to andy that he had relied on erroneous reporting, he forthrightly apologized and posted an update that acknowledged the errors.

4. andy also contended that the corrected story contained information that was, to his thinking, even "more of an indictment of the system than [his] original remarks".

I don't happen to agree with Andy on that last point, or at least, I am not convinced that he is right. I think the points commenters have made about the rareness of this event and the finding of four beds in the same NICU are at least prima faciae compelling. Moreover I think the Canadian system looks good because of both the fact that there was a pre-arranged plan for the Jepps and then a very reasonable and apparently timely response by the system to the unexpected lack of capacity. So based on what I know, I'd probably draw different conclusions from Andy's given the updated information out there.

But in my book, those commenters who keep accusing Andy of dishonesty are being completely unfair. I don't agree with Andy's politics/policy preferences on plenty of things. But it seems to me that he's done exactly what honest people do: corrected his mistake and engaged others on the merits of the correct facts. The fact that people disagree with his argument doesn't justify the invective and guilt-by-preference insults that folks have been hurling his way.

Frankly I think those folks should be ashamed of themselves. Haven't we had enough years of substituting ad hominems for argument?

Andy, keep up the good blogging. You always make me think, even when I think you're wrong.

Elliott said...

1. The correction is at the bottom of the post and not the top.

2. Samwick has a history of dishonesty (infinite horizon estimates to make the soc. security deficit appear more dire) so benefit of the doubt is not warranted.

3. Samwick uses the update to reiterate rather than reevaluate his point that socialized medicine is bad. ("When the facts change, I change my mind. What do you do, sir?")

4. Samwick has not responded to any of the other criticisms of his argument.

I think this is sufficient to conclude bad faith on his part and more specifically a tendency toward dishonesty.

Elliott said...

With regards to point #1, I think that the importance of the error renders the post meaningless. In such a case, I have mostly seen corrections at the top or a completly new post acknowledging the error especially when the original post stretches to over a screenful.

With regards to point #2, the amount of uncertainty in the infinite horizon projections are so large that the only reason to use them is to mislead. I'm not a big fan of Annenberg, but your link indicates that is their take as well. That hotbed of iberal activism, the American Academy of Actuaries, has a similar opinion so your disdain for my standards seems a little hasty.

On point #3, this is precisely the point that Samwick has not addressed. The actual details of the story show that the availability of beds in the NICU was planned for, but actual events intervened. He has not preseented any data to suggest that the Montana trip was not the most economically efficient solution. He had a preformed opinion which he sticks to even though several commentors indicated that there is also a regional issue here (Calgary being one of the fastest growing areas in Canada).

Finally on the fourth point, I see that Samwick has replied directly 3 times in this thread and in none of them does he support his contention that this story represents a anecdote (not even data) that demonstrates the inferiority of the Canadian system. a. The Jepps didn't have to pay. b. A coordinated well-planned process put together a contingency plan without incident. c. the Great Falls, Montana hospital NICU has enormous excess capacity (cause or effect of the fact of twice the per capita US healthcare spending?)

Sorry, but nothing in your rebuttal suggests to me that characterization of Samwick as dishonest is inaccurate. What constantly comes through whether it be Delong or you is a respect for his professional work and his obvious superior intelligence and economics pedigree. Those things have nothing to do with his honesty. I'm sure you are similarly enamored of Mankiw.

Elliott said...

I bring up the use of infinite horizon estimates of the deficit that you are so fond of because it is the one irrefutable piece of evidence that you are either dishonest or incompetent. Since I am almost certain you are not incompetent, that leaves dishonest.

1. A statistics professor would ask why a simple mathematical equation is a question for him.

2. The use of truncated series is common. Why the discussion of long tails or fat tails other than the fact that we to the first order truncate most of our series.

3. The statistics professor if he wanted to get involved would probably look at the uncertainty in the underlying numbers in the projection, note the lack of any reasonable distribution and laugh his a** off. The next question by said statistics guru would be are you stupid or dishonest?

4. Let's say that the statistics professor didn't rupture something laughing at you, he might observe that the actual 20 year priors on the accuracy of your 10 year projections (let's not even talk about your longer ones) were so far off and in a systematic direction that you should probably update your model.

In short, your insistence on the use of infinite horizon projections especially when they do not differ in sign from the 75 year projection is simply a game of deception you use to justify your policy prescription. You can't generate enough concern from the suspect (but not totally useless) 75 year deficit so you resort to scare-mongering an infinite horizon estimate with payouts to people who haven't even been born.

In short, I focus on the social security infinite horizon deficit because it is a deliberate lie you will not ever concede designed solely to support your conclusion.

Andrew Samwick said...

Repeating my previous request:

Tell me your preferred measure of the unfunded obligations, and I'll use it if it's better.

Sarah said...

...this notion that "every other neonatal intensive care unit in Canada" had no space is more of an indictment of the system than my original remarks.

I see. More of an indictment of the Canadian system than 250 babies a year being turned away from a single NIC unit in New York is of ours? (The article is cited on Professor Thoma's blog, Economist's View.)

Or what about the 45% lower incidence of low birth weight babies requiring neonatal intensive care in Canada?

Let's see-- longer life expectancies, lower infant mortality, doctors deciding what you need instead of insurance companies, the ability to switch jobs freely without worrying about losing health coverage, no dragging your aching body halfway across town for bloodwork because the lab in the medical center you just left isn't covered by your insurance, no trying to make sense of what your elderly parents' supplementary health insurance has paid or failed to pay or trying to get reimbursed for the payment the doctor demanded up front. Oh-- and, of course, half the cost! Yup, that Canadian system is sure messed up.

Elliott said...

The deficit you quote is less than useless. Suggesting to you a "better" measure would be buying into your idea that your use of the infinite horizon number has any value other than going for the emotionally persuasive argument at the expense of logic. Engaging in a political economy discussion with infinite time horizon series is almost always misleading so the "better measure" is nothing; just stop using it. If you can find a "better measure" that does not have the same laughable problems then, be my guest, and use it, but as long as you stick to your infinite horizon crisis mongering, I remain disdainful and that disdain will extend to other areas you comment upon.

We (at least Congress) have shown ourselves able to act in a crisis in less than 4 years (the Greenspan Commission) and able to act incredibly stupidly and in damaging ways ignoring an obvious crisis 15-20 years out (Medicare part D). Therefore I would suggest you concentrate on measures that illuminate the discussion within those timeframes since I think that brackets any relevant discussion for policy purposes.

(Off topic) You will not be surprised then when I tell you that my preferred solution for social security is to do nothing. I am not so sanguine about Medicare or the general fund and think that our Canadian neighbors can teach us a lot.

MW said...

It's amazing how eager some of us are to leap to the conclusion that a Canadian-style system of care must be inferior to ours. We simply want and need to believe this, apparently. There will always be anecdotes "proving" the point, but anecdotes don't actually prove anything, as you know.

Jonah B. Gelbach said...


I'm a big fan of markets. But leaving aside the merits and demerits of the Canadian system -- and it has both -- the notion that "Americans enjoy on demand healthcare" is hard to square with most US residents' actual experience. Even among those insured with what our president calls gold-plated plans, access is quite far from "ondemand". And for the uninsured, of course, access is much worse. There are tradeoffs in any market characterized by severe informational imperfections. Our system happens to pile all sorts of additional bizarre third-party complications on top of those imperfections. It isn't exactly a model of allocative efficiency. Finally, I'm not sure what the use of the characterization "socialized medicine" really is, aside from as a (growingly less effective) political cudgel. Virtually all other wealthy market economies have what folks on the right would call "socialized medicine" if those plans were proposed here. So what?

Anonymous said...

I live in San Francisco and have Blue Cross health coverage from a major employer. A year ago I broke my hand, I went to an emergency clinic that is part of the University of California - San Francisco medical center. They gave me a cast and told me I should see a orthopedist in two weeks. When I tried to get an appointment with an orthopedist who was part of my preferred provider medical group, I was told there was a six week wait. Only by raising a huge stink was I able to get an appointment after two weeks. (Since breaks heal in six weeks you need to see an orthopedist after two weeks to make sure that the break is healing correctly.)

This isn't unusual. The wait for a dermatologist is two months and you are forced to see a different resident every time.

Now you might say just change preferred providers. Problem is that virtually every doctor in San
Francisco belongs to the same preferred provider. So I have a choice, a convenient doctor with long waits or an inconvenient doctor with shorter waits.

The key here is that it's not just Canadians who have to wait for health care.

Jonah B. Gelbach said...


I'm not going to bother addressing the nonsequitur part of your reply to me (e.g., public education, dental care). Congrats on so far being lucky enough not to have substantial chronic or acute medical costs. I've had both in recent years. So to use your apparent metric, MSAs must be bad -- since I'd be underwater in relative terms if I'd had one of them instead of my highly regulated insurance policy. In case you don't understand my point, by the way, it's that the absolutist pro-market position is just as silly as the absolutist anti-regulation/public-funding position.

Jonah B. Gelbach said...

just to clarify, that last sentence should have read "the absolutist pro-market position is just as silly as the absolutist pro-regulation/public-funding position."