Nick Kristof Kills Babies

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The United States has the second highest rate of infant mortality in the industrialized world–tied with Malta and Slovakia. New York Times columnist Nick Kristof has dropped this factoid into his column on many occasions, and it has become Exhibit A amongst the chattering classes for the dysfunctional and callus state of the U.S. health care system, which refuses to spend enough to save even blameless preemies.

Today, Slate dissects the statistic and finds that the problem isn't too little money, it's too much. Infant mortality figures in the United States reflects a large number of premature births, and "modern medicine isn't good at preventing prematurity—just the opposite. Better and more affordable medical care actually has worsened the rate of prematurity, and likely the rate of infant mortality, by making fertility treatment widespread." This argument in response to Kristof's stats has gotten a lot of play, especially from a peeved James Taranto of the Wall Street Journal.

But the Slate piece adds another twist:

Today, neonatal intensive care is extremely lucrative, on average costing tens of thousands of dollars per preterm child. Neonatologists are among the highest paid pediatric subspecialists, and neonatal intensive-care units (NICUs, for short) are hospital cash cows—which is why the units are proliferating wildly nationwide. Yet in a startling 2002 New England Journal of Medicine study, David Goodman and his colleagues showed that the regional supply of neonatologists and NICUs bore no relation to actual need, implying that some doctors and hospitals set up shop simply because there was money to be made.

More disturbingly, areas with more beds and doctors don't have lower infant-mortality rates. The authors ominously suggest that "infants might be harmed by the availability of higher levels of resources." They argue that the availability of a NICU may mean that infants with less-serious illnesses may be admitted to one and then "subjected to more intensive diagnostic and therapeutic measures, with the attendant risks." Too many NICUs are also bad for babies because hospitals that handle a high volume of sick preemies have better outcomes. A 1996 study in the Journal of the American Medical Association confirmed this, concluding that concentrating high-risk deliveries in a smaller number of hospitals could reduce infant-death rates without increasing costs.

Conclusion: "Less money and less patient choice sound heretical—but, in this case, eminently sensible."

UPDATE: The first sentence had been corrected. The US has the second highest infant mortality numbers in the industrialized world. As one commenter delicately put it: "In other words, Mali and Rwanda are still a little worse off than the US."

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  1. It seems like the prices for neonatologists are so high because there is a scarcity. If there is such a scarcity, can neonatologists skew the numbers as much as Slate suggests? I assumed they were going to uncover some statistical flaw, like the US has a lot of premies because we have better prenatal care, and our lower miscarriage rate translates into a higher infant mortality rate, or something like that (just making that up). This seems like Slate’s usual eyebrow raising fare that turns out to be nothing.

  2. Anyone want to speculate why we have so many premature births in the first place? How about women putting off having children until the end of their classic childbearing years, necessitating the use of fertility drugs to get pregnant in the first place….

  3. Mcgcruiser,

    That could be a factor certainly.

    I also wonder if it’s because the state of the art in premature birth treatment is so advanced that what was once a ‘late term midcarriage’ is now a ‘premature birth’.

    This would also skew the mortality rates since a late term midcarriage wasn’t counted as a birth in the first place and so adding premature births (with the attendant lower survival rates than full term births) is skewing the sample.

    Question then is: if you limit the sample to full-term births (in all test countries) how does the outcome change?

    It may not be the quality of CARE so much as the character of the STATS that is changing.

  4. Mortality statistics are worthless outside of context. Some of the most advanced hospitals in the country have a similar problem–when you have the best facilities, they send you the really, really sick people. Much like how I shouldn’t be getting every deal I quote, hospitals that save every patient that enters the door probably aren’t allocationg their resources optimally on a macro sense

  5. They argue that the availability of a NICU may mean that infants with less-serious illnesses may be admitted to one and then “subjected to more intensive diagnostic and therapeutic measures, with the attendant risks.”

    Sounds like defensive medicine to me, a rational response to the incentives created by our malpractice system. Yeah, I’m looking at you, John Edwards.

    Neonatologists are among the highest paid pediatric subspecialists,

    They also have some of the highest malpractice premiums, in my experience somewhere north of $70K/year.

  6. I surprised Slate didn’t mention that at least part of the reason infant mortality rates are so high in the United States is that this country takes a more expansive definition of what constitutes a “birth” in the first place, compared with other countries. This practice is codified to some extent, and indirect evidence lies in stats on the share of infant mortality that occurs immediately after birth. In Europe, for example, this share is considerably lower than in the United States, which strongly suggests that what counts as “births” here are recorded as miscarriages elsewhere. The picture would be quite different if the rates of infant mortality were really different a few months out from birth, which is where’d we see any benefit from universal health care and the like. Turns out that’s not really the case.

  7. Katherine,

    You’re conclusion is wrong. It should be:

    “Concentrating neo-natal care at a few locations that specialize in such care proves, again, that division of labor works the best, even in medicine.”

  8. Katherine, was this sentence a joke? “The United States has the second highest rate of infant mortality in the world–tied with Malta and Slovakia.” Not only is that not in either of Kristof’s columns you linked to, it’s not on the Save the Children website either–and I even downloaded the major report on newborn mortality.

  9. This seems like a good illustration that the profit motive of the private sector doesn’t necessarily result in better health care outcomes. In fact, studies by the New England Journal of Medicine show just the opposite.

  10. Stop treating medicine like a market. The prices are fixed and so the only way to make more money is to increase volume. Thankfully, doctors do not mind working exceedingly long hours for no compensation and live free from market forces…

  11. They also have some of the highest malpractice premiums, in my experience somewhere north of $70K/year.

    Which they make back in what, 5 hours, billed to the insurer?

  12. Neonatologists are among the highest paid pediatric subspecialists,

    They also have some of the highest malpractice premiums, in my experience somewhere north of $70K/year.

    Traditionally, the specialties with the highest malpractice premiums have the highest rates of compensation. Anesthesiologists have a high risk biz because it’s relatively easy to get the dosage wrong, and when you do, it ends up brain damaging the patient, which means high tort awards because the lawsuit has to pay for the patient’s lifelong care. Similarly, when an obstetrician or neonatologist screws up, the patient is entitled to recover life long care which is in the millions. When a gerontologist screws up, the damages are much lower.

  13. “Katherine, was this sentence a joke? “The United States has the second highest rate of infant mortality in the world–tied with Malta and Slovakia.” Not only is that not in either of Kristof’s columns you linked to, it’s not on the Save the Children website either–and I even downloaded the major report on newborn mortality.”

    Yeah, it should read “The United States has the second highest rate of infant mortality in the industrialized world–tied with Malta and Slovakia.”

  14. Nicholas Kristof
    Is pissed off.
    And yet we have pedi-care
    To bankroll Medicare.

  15. Just for clarification: The US has the second-highest infant mortality rate from all industrialized nations, and not in the world. In other words, Mali and Rwanda are still a little worse off than the US.

  16. Chris S. is correct.
    On page 38 of the linked study is a bar graph showing the ranking of the 23 “industrialized” nations and indeed the US ranks near the bottom on it. Interestingly enough, on page 44 there is a ranking of countries based on “mother’s index”, “women’s index” and “children’s index” and the United States ranks (10, 13, 5) far outstripping both Cuba (27, 29, 32) and China (39,29,68), countries highly touted in Kristof’s articles for their superior infant survival rates.

  17. Thanks for the heads up. I’ve corrected the first sentence.

  18. They also have some of the highest malpractice premiums, in my experience somewhere north of $70K/year.

    Which they make back in what, 5 hours, billed to the insurer?

    Your average neonatologist makes around $225,000 a year. Thanks for asking.

    That means they probably work about five – six months a year for the government, and another couple of months for the insurance company.

    But go ahead, kick them again.

  19. A friend of mine years 20 years ago told me her doctor had told her she would have great difficulty carrying a child to term due to the three abortions she had in the past. Is there any statistical evidence to link this to increased prematurity.
    If it is a preemie and not a late term miscarriage, can’t the hospital make a sackful of money trying to treat the untreatable? Try to convince me it doesnt happen.
    If we had lower quality socialized medicine, would these problems arise?

    just foolin on the last one.

  20. Seems like should be a way of getting better, more fairly directly comparable statistics, by the people who track this stuff, to settle this controversy.

    I wonder whether either side really wants to.

    it seems like people prefer spin, to actually making suggestions for better statistical tracking. “Full term infant mortality” seems like it would be a good number to have here and pretty do-able.

  21. Out of religious convictions my wife and I don’t allow aminosentisis or anything similar because we would never abort the baby. I wonder if there is a higher rate of abortions for severe birth defects in other industrialized counties (which are mostly less religious). Unless you count these as “infant” mortality then it is a little unfair to compare the numbers.

  22. Your average neonatologist makes around $225,000 a year. Thanks for asking.

    That means they probably work about five – six months a year for the government, and another couple of months for the insurance company.

    If they *make* 225k isn’t that including the overhead? I mean presumably they also have office staff, records people, and pay for space at the hospital by the hour, which is none too cheap.

    So if they’re *grossing* 225k a year, then you’re telling me they make nothing, because after the 70k insurance bill they’re down to 155. Throw in all the overhead, and you’re telling me these guys make less than Taco Bell employees.

    If they’re *clearing* 225k, after they pay their overhead, then they are paid substantially better than the average lawyer, doctor or dentist. So I’m not weeping for them having a high insurance payment. Nobody made them go into neonatal care, and if the costs represent too high a barrier to entry into the market, then there are plenty of other things they are surely qualified to do.

  23. If they’re *clearing* 225k . . . other things they are surely qualified to do.

    Thanks, Worm. I wanted that counterpoint made, but was to surly to say it politely today.

  24. IW:

    Somebody who knows the field should chime in and correct me, but wouldn’t a doctor’s practice be organized as a corporation these days? That’s ignoring docs who are on staff at a hospital who don’t have a separate practice, in which case the institution deals with overhead.

    Many of the objections to the way stats are kept for premature birth can be found in the WSJ article by Taranto WSJ referenced above.

    Kevin

  25. kevrob,

    i don’t know how many NICU doctors are actual employees of the hospital, vs how many are corporate entities who set up shop within the hospital. Many of the doctors around where I live are independent entities, who use the facilities of the hospital, for which they pay an hourly fee (which includes all the equipment, staff, etc.). But they also keep offices nearby, in separate office parks, with their own admin staffs, where they meet patients for pre- and post-op visits.

    Most of these are surgeons who work on set schedules; I don’t know if there’s anything inherent in the nature of emergency care that would make that type of set-up a less viable business model for them. Maybe ER and ICU doctors are more likely to be employees, i don’t know.

    Also, in no way do I want to denigrate these folks; they do amazing, important work. They are entitled to make a large salary, because what they do is in high demand, as well as inherently valuable.

    But from a business perspective, none of that in itself gives them any greater latitude to bitch and moan about the costs of doing business, when they know going in that those costs will tend to be substantial. For some businesses, it’s insurance. For others it’s labor costs. For others, it’s regulatory compliance. Ask a guy who owns a factory how much he spends keeping on the good sides of the EPA and his state’s dept of environmental quality.

    At least in the case of the doctors, it’s another private company jacking up their costs; at least in theory, they could negotiate with different insurance carriers, perhaps finding one that could find a way to live on less than 3000% profit every quarter. But that would require actual competition in the insurance industry. Oops! Did I say that?

    Many business owners don’t get the option to find a better deal when their overhead is dictated by the government. The doctors should consider themselves lucky in that regard. (Then again, they may also have a lot of crap buried in the CFR or their state’s Admin Code to have to pay for too, in which case I extend my deepest sympathies to them).

  26. IW:

    I’m not an expert in medical business organization, but I’ve read, seen and heard a lot of local media reports to the effect that many private practices, especially medical groups, have been bought out by the larger HMOs and PPOs that operate in our area. Many docs who don’t exclusively work for hospitals are now employees. I dunno if they are strictly on salary, are independent contractors, or employee-owners of their groups.

    Kevin

  27. At least in the case of the doctors, it’s another private company jacking up their costs; at least in theory, they could negotiate with different insurance carriers, perhaps finding one that could find a way to live on less than 3000% profit every quarter. But that would require actual competition in the insurance industry. Oops! Did I say that?

    and there it is, in a nutshell.

  28. i don’t know how many NICU doctors are actual employees of the hospital,

    In all likelihood, none of them.

    I dunno if they are strictly on salary, are independent contractors, or employee-owners of their groups.

    Some of each.

    My only point on the cost of insurance v. their take-home (which is what the $225K average represents) is that a good chunk of the high bills everyone was bitching about above are the direct result of malpractice claims.

    Look at it this way: Get three neonatologists in a room, and they are probably supporting a lawyer and an insurance adjuster (not to mention a handful of government bureaucrats) as well as themselves.

  29. “…my wife and I don’t allow aminosentisis or anything similar because we would never abort the baby”

    I assume you would take full fiscal responsibility for the care of a severely handicaped child.

  30. “…my wife and I don’t allow aminosentisis or anything similar because we would never abort the baby”

    I assume you would take full fiscal responsibility for the care of a severely handicaped child.

    If they do, I respect their POV. If not, they are essentially forcing their POV on others.

  31. “I assume you would take full fiscal responsibility for the care of a severely handicaped child.”

    Of course, but what is your point? Should people be required to abort children they may not be able to provide for?

    Anyway, once a handicaped child turns 18 this is what SSI is for. I don’t what SS “insurance”, but I have it and pay for it and would use it if needed. If we could get rid of of SSI then chairty or privite dependent disablity insurance would cover that need.

  32. I assume you would take full fiscal responsibility for the care of a severely handicaped child.

    No, StupendousMan, you will and are. If you had any idea the number of low-functioning/high needs babies born in the NICU to people of zero… ZZZEEROOO financial means, I’ll bet all the way up to .50 cents you’d at least raise your eyebrows.

    This is not to mention some of the cost you’re bearing for Canadian mothers sent to U.S. hospitals because Canadian hospitals don’t have anywhere near the NICU facilities the U.S. has.

  33. “…Of course, but what is your point? Should people be required to abort children they may not be able to provide for? ”

    My point is the world is full of people who expect others to bear the burden of their beliefs.

    I don’t think people should be forced to have abortions but I shouldn’t be forced to support their kids. I also stomp on kittens and strangle puppies.

  34. RC Dean: Does the $225,000 include malpractice insurance, or would that be separate? Is malpractice insurance even mandatory? The reason that I am asking is that your post wreaks of a quickie wiki. You make it sound like insurance eats up 1/3 of their salary, and, at least in the field of OB/GYN, you couldn’t be further from the truth.

  35. Kristof never says “The United States has the second highest rate of infant mortality in the industrialized world–tied with Malta and Slovakia.” He says “The U.S. ranks 43rd in the world in infant mortality, according to the C.I.A.’s World Factbook.” and “According to the latest C.I.A. World Factbook, Cuba is one of 41 countries that have better infant mortality rates than the U.S.” This profound mis-attribution of Kristof’s remarks, as well as the initial sloppy failure to distinguish between industrialized countries and non should be an embarrassment for a source calling itself “Reason”.

    In both instances, Kristof cites the CIA world factbook, so any flaw resides in this government data source, not in Kristof.

    The Slate article doesn’t really dissect the problem; it just expresses a few alternative opinions.

    Perhaps the correct thing to do is to look at the SUM of stillbirths and infant deaths. This way, we catch the effects of expensive neonatal care turning stillbirths into post-natal deaths.

    Indeed, we find such statistics here: http://www.who.int/reproductive-health/docs/neonatal_perinatal_mortality/text.pdf

    Look at table A1.1 and sum columns 5+9 to get the sum of stillbirths plus neonatal deaths.

    For the USA, stillbirths plus neonatal deaths are 9 per 1000. Some other countries – Spain: 7, Switzerland: 6, Slovakia: 9, Sweden: 5, UK: 9, France: 8, Germany: 7, Italy: 6, Cuba 6 [if you trust Cuba’s reporting].

    The USA is still appears near the bottom compared to other industrialized countries.

  36. “I also stomp on kittens and strangle puppies”

    I have to draw the line at chokin the chicken

  37. some interesting facts behind international comparisons can be found at http://www.usnews.com/usnews/health/articles/060924/2healy.htm.

    “The United States counts all births as live if they show any sign of life, regardless of prematurity or size. This includes what many other countries report as stillbirths. In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. And some countries don’t reliably register babies who die within the first 24 hours of birth. Thus, the United States is sure to report higher infant mortality rates. For this very reason, the Organization for Economic Cooperation and Development, which collects the European numbers, warns of head-to-head comparisons by country. “

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