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A New View on Tobacco Taxation

Economic viewpoints on tobacco taxation typically seek to correct for the externailities imposed upon citizens by tobacco smokers. This new analysis seeks to account for these externalities, plus those incurred by family members of smokers, and assumes that smokers do not accurately value their future health.

Previous exonomic studies have deduced that taxes which increase the price of cigarrettes by 10 percent ultimately reduce consmption by 1 to 3 percent. Besides generating revenue for local, state, and federal governments, tobacco taxes serve as disincentives to smoke and urge current smokers to quit. The economic theory behind such taxes is that they are designed to correct for the costs inflicted on society caused by smokers. According to economic theory, any personal harm incurred by a smoker upon himself or herself is a private decision which should not face tax implications.

Today, most smokers realize that their habit is unhealthy and poses potential future health problems. However, the decision to smoke a cigarrette is cotingent on the current benefit of smoking outweighing the foreseen costs of smoking-related disease. This principle is apparent in an analogy shared by almost all American consumers: using credit cards values cash (purchasing power) now versus a discounted amount of cash in the future (an amount reduced by interest payments). For smokers, the experience of a cigarette now exceeds the value of health costs in the future. The current author feels that smokers tend to discount the cost of smoking much more steeply in the near future compared to the distant future; this so-called hyperbolic discounting is likely a result of the addictive nature of nicotine.

Empirical evidence imforms that smokers tend to have a skewed perception of the value of health costs in the near future. This implied a tendency towards impatience in the near term. Another study which required smokers who were attempting to quit to deposit money into a bank account in stead of spending it on cigarrettes demonstrated a 38 percent increased quit rate compared to a similarly situated control group.

Face with such data, the author of this study suggests that tobacco taxes ought to account for some of the private costs of smoking (internalities) and not merely the externalities associated with smoking. While some economists may view this a readical viewpoint, at a minimum most could agree that tobacoo taxes should offet externalities incurred to society.

Based on present assumptions, the cost to society (including medical costs, sick leave, and life insurance costs) over the life of a 24-year old smoker averages out to $2.20 per pack. Expanding these externalities to household members yeilds an additional $5.44.

Data obtained from www.tobaccofreekids.org shows that the average tax rate on a pack of tobacco is only $1.34; this value fails to correct for the externalities on society and does not begin to account for externalities incurred on household members of smokers.

© Campaign for Tobacco Free Kids

Commentary

Tobacco cultivation dates back to pre-Columbian America were it was used ceremonially and sometimes as a trade item. Upon arrival of Europeans in America, tobacco became highly popularized and was a major cash crop of the Americas until the supremacy of cotton supplanted it.

In the modern world, the evils of tobacco as a contibutor to cancer, pulmonary, and cardiac disease has led to significant regulation and taxation. However, tax rates vary dramatically across the United States.

This current economic evaluation of tobacco taxes suggests that at a minimum – taxes (federal plus state and local) ought to add up to at least $2.20 per pack. It is conceivable, based on the eivdence presented, that tobacco taxes could be raised to a maximum of $7.64 per pack to account for externalities incurred upon household members and general society by smokers. While an outright ban on tobacco would seem unconsitiutional, lawmakers should continue to financially penalize those who smoke in order to recoup costs to society in lost productivity and death benefits.

AJPH. 2010; 100: 609-615.

by
Cedric K. Dark, MD, MPH

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A Randomized Trial of P4P

Pay-for-performance incentive programs are commonplace now among many health care payers. A new study out of California reports on the effect of the frequency of bonus payments on clinician quality improvement.

Pay-for-performance (P4P) initiatives rest on the premise that quality in patient care can be improved by providing incentives to clinicians to improve particular metrics (called process and outcome measures) relevant to patients’ health status. Prior research has clearly demonstrated that clinicians can improve tobacco cessation counseling rates and other measures that benefit patients as a result of incentive payments; other studies suggest that current P4P initiatives should put even more risk-reward into the hands of physicians.

The current study is a randomized, unblinded trial comparing the frequency of P4P bonus payments on the change in quality measures. The study investigates physicians practicing in multi-specialty groups in California. Both groups received quality report cards on a quarterly basis; this practice had been in effect prior to initiation of the study. Individual physicians (internists and family practice doctors) were randomized to receive bonus payments (up to $5,000 per year) either on a quarterly or annual basis.

One hundred twenty-four (124) physicians completed the study. Analysis of quality reporting data demonstrated a slow upward trend in composite quality scores in both groups. This trend was not statistically significant. Likewise, there was no statistical difference between the annual- and quarterly- bonus groups in terms of overall change in quality scores. The average bonus amount, which was $2,868, did not differ between the two groups.
The authors of this study correctly mention a major limitation; researchers were unable to conduct an additional comparison investigating the effect that the frequency of report cards for the clinicians might have on the change in bonus payments or overall quality scores. The review board approving this study deemed such a comparison unethical. However, quarterly report cards had been sent to these clinicians prior to the initiation of the study and therefore, it should be safe to assume that the observed results are accurate testimony to the ineffectiveness of the frequency of bonus payments to promote changes in quality.

Commentary
Reimbursement for medical care is often done based on the amount of service provided regardless of the quality of the service. A recent movement towards quality improvement has led to many pay-for-performance (P4P) initiatives across the United States and the world.

Multiple studies have shown that incentive payments to physicians can encourage doctors to improve of the quality of patient care as measured by various process measures (such as antibiotics before surgery) and outcome measures (such as rates of surgical site infections). This study suggests that quality is not necessarily affected by the frequency of bonus payment. Physicians tend to improve with adequate informational feedback despite waiting until the end of the year for financial feedback.

As the P4P movement continues forward, payers ought to consider these lessons:

  • bonus payments (and penalties) must be significant enough to effect change (some experts suggest upwards of 10% of total compensation)
  • feedback on quality must be frequent enough to allow clinicians to change practice patterns
  • payments may be made at any frequency without adversely affecting quality
  • process and outcome measures must be meaningful and achieve clinician buy-in
  • quality measures must be added, changed, and retired as necessary to remain meaningful
  • risk adjustment must be adequate to prevent adverse selection of patients by doctors

Health Services Research. Does the Frequency of Pay-for-Performance Payment Matter? Experience from a Randomized Trial. Online in advance of print.

by
Cedric K. Dark, MD, MPH

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Reflections from Haiti: Chaos to Camaraderie

Doctor Stanley Frencher recounts recent experiences of working in a field hospital in the earthquake-ravaged nation of Haiti. But in the end, he ponders is the health care system of Haiti all that different from his home of inner-city Detroit?


Amazing. Beautiful. Picturesque. Inspiring. Not words one would associate with the earthquake-ravaged disaster occurring in Haiti. In contemplating the idea of going there, I certainly faced questions of why now, what can you really do, shouldn’t trained professionals only go, and is it safe? While all of these questions were important, the main one I kept in mind was who better to go? I’ve been working with a local grassroots organization that has grown to national prominence on a message of working with existing infrastructures and providing culturally appropriate health messages to African American men in barbershops. Through that work, we have developed a myriad of partnerships that enabled us to garner needed supplies ($30,000 worth), travel to Santo Domingo, Dominican Republic and then work with a local NGO to arrive at the Dominican/Haitian border.

In the Dominican, Pastor Prophet and Dean, a family medicine doctor from Oregon, recruited us from Good Samaritan Hospital in Jimani to a Haitian Christian Mission just a few miles across the border. Upon arriving there, we were immediately inundated with surgical patients and limited facilities to treat them. Fortunately, a local field hospital had recently been established a few miles away and a nurse at the Mission helped us coordinate transfer of several surgical patients to that new facility.

The Love-a-Child Field Hospital, as it was called, was phenomenal. It sat at top a hillside with amazing panoramic views of Haiti. There could not have been a more tranquil place for victims of a disaster to recover both physically and emotionally. The Field Hospital was well-organized by emergency department trained staff with disaster preparedness expertise. We managed over 300 patients, most of whom required surgery. Operation Smile provided surgical oversight and supplies. The Field Hospital received daily shipments from various donors including 1,000 tents, a satellite dish for high-speed internet, and negative pressure tents that could be used to replace the classroom-style operatories where surgical procedures are performed. We still lacked basic things like sufficient food, trash bags, biohazard containers, and enough crutches for the dozens of amputees and patients with fractures. Nonetheless, the camp was nothing like any clinic I’ve ever experienced.

I had only planned to stay a short time and return after gathering actionable information for our partner organizations, but had decided I was going to stay when I lost my passport. After some wrangling I was able to board a C-130 military plane and traveled home with dozens of Haitian evacuees.

As we look to how we are to rebuild and reform our own healthcare system, we rarely look to circumstances and areas of the world such as Haiti for inspiration. Certainly in the short-term, the world will be bringing aid to Haiti. But is there an opportunity for the world and even the United States to learn something from this tragedy. Not simply about how to manage a disaster. And not merely the moral lesson of being a good neighbor. But rather, truly learn substantive lessons about how should a healthcare system be constructed to perform well under normal circumstances and in dire ones.

Our healthcare system is no more ready for a disaster than it is a flu pandemic. The tragic circumstances I observed in Haiti were the result of not only fallen buildings, broken limbs, infected wounds, and lost lives, but also a failed healthcare infrastructure. Haitians, unaffected by the earthquake, flooded makeshift clinics and field hospitals for chronic disease care—hypertension, diabetes, pregnancy, and prostate enlargement. The very same problems of limited access and poor quality that I encountered in Haiti occur here in the US everyday. Ironically, the populations who seem to suffer most in the US resemble that of Haiti—poor and of African descent. Certainly these are not the only populations suffering here, but it further begs that question: why can’t we, in a country so prosperous, do better than Haiti? Now, many will argue that we have the best healthcare in the world. And they are right. We have the best care for those who can access it. For those who can’t, they might as well be in Haiti.

I began by saying that this experience inspired me. It has. Working in austere conditions with limited resources taught me the value of clinical judgment and the true meaning of care for patients. Seeing the camaraderie of multinational volunteers who worked tirelessly to do whatever it takes to care for patients inspired me. Caring for the wounds of children who underwent amputations, often with limited anesthesia, changed me. I always empathized deeply with my patients, but I find myself even more uncompromising when it comes to the systems within which we physicians work to provide that care. It can no longer be acceptable that some patients can have access to the best care in the world while others settle for whatever is available. That’s simply not right. There will undoubtedly be lessons to be learned as Haiti is rebuilt and I am now working with several organizations to undercover and disseminate those strategic lessons. The rebuilding process in Haiti will inform our own redevelopment and the reformation of healthcare in the United States.

by

Stanley Frencher, Jr., MD, MPH

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