Sunlight and Protection Against Influenza.

Recent medical literature suggests that vitamin D supplementation protects against acute respiratory tract infection. Humans exposed to sunlight produce vitamin D directly. This paper investigates how differences in sunlight, as measured over several years across states and during the same calendar week, affect influenza incidence. We find that sunlight strongly protects against getting influenza. This relationship is driven almost entirely by the severe H1N1 epidemic in fall 2009. A 10% increase in relative sunlight decreases the influenza index in September or October by 1.1 points on a 10-point scale. A second, complementary study employs a separate data set to study flu incidence in counties in New York State. The results are strongly in accord.

Recollection Bias and Its Underpinnings: Lessons from Terrorism Risk Assessments.

Recollection bias is the phenomenon whereby people who observe a highly unexpected event hold current risk beliefs about a similar event that are no higher than their recollection of their prior beliefs. This article replicates and extends the authors' previous study of recollection bias in relation to individuals' perceptions of the risks of terrorism attacks. Over 60% of respondents in a national U.S. sample of over 900 adults believe that the current risk of a future terrorist attack by either an airplane or in a public setting is no higher than they recall having believed, respectively, before the 9/11 attack and before the Boston Marathon bombing. By contrast, a rational Bayesian model would update to a higher currently assessed risk of these previously uncontemplated events. Recollection bias is a persistent trait: individuals who exhibited this bias for the 9/11 attack exhibited it for the Boston Marathon bombing. Only one-fifth of respondents are free of any type of recollection bias. Recollection bias is negatively correlated with absolute levels of risk belief. Recollection bias in relation to highly unexpected terrorist events-the belief that perceived risks did not increase after the surprise occurrence-dampens support for a variety of anti-terrorism measures, controlling for the level of risk beliefs and demographic factors. Persistent recollection bias for both 9/11 and the Boston Marathon bombing is especially influential in diminishing support for protective policy measures, such as surveillance cameras in public places. Given that public attitudes influence policy, educating the public about risk is critical.

Artful paltering: The risks and rewards of using truthful statements to mislead others.

Paltering is the active use of truthful statements to convey a misleading impression. Across 2 pilot studies and 6 experiments, we identify paltering as a distinct form of deception. Paltering differs from lying by omission (the passive omission of relevant information) and lying by commission (the active use of false statements). Our findings reveal that paltering is common in negotiations and that many negotiators prefer to palter than to lie by commission. Paltering, however, may promote conflict fueled by self-serving interpretations; palterers focus on the veracity of their statements ("I told the truth"), whereas targets focus on the misleading impression palters convey ("I was misled"). We also find that targets perceive palters to be especially unethical when palters are used in response to direct questions as opposed to when they are unprompted. Taken together, we show that paltering is a common, but risky, negotiation tactic. Compared with negotiators who tell the truth, negotiators who palter are likely to claim additional value, but increase the likelihood of impasse and harm to their reputations. (PsycINFO Database Record

Medicare Advantage: what explains its robust health?

The Medicare Advantage (MA) program continues to grow and thrive, despite plan payment cuts imposed through the Affordable Care Act. What explains this surprising outcome (one that is strikingly different than the experience of MA plans in the late 1990s, when payment cuts led to dramatic shrinkage in enrollment and curtailment of plans)? This analysis argues that a combination of factors, including the way payment cuts were imposed, the plan offerings, the characteristics of beneficiaries, and the way they make choices together explain the program's current health. Understanding these factors is important for MA, Medicare, and, more generally, for participants in new payment models.

Climate sensitivity uncertainty: when is good news bad?

Climate change is real and dangerous. Exactly how bad it will get, however, is uncertain. Uncertainty is particularly relevant for estimates of one of the key parameters: equilibrium climate sensitivity--how eventual temperatures will react as atmospheric carbon dioxide concentrations double. Despite significant advances in climate science and increased confidence in the accuracy of the range itself, the 'likely' range has been 1.5-4.5°C for over three decades. In 2007, the Intergovernmental Panel on Climate Change (IPCC) narrowed it to 2-4.5°C, only to reverse its decision in 2013, reinstating the prior range. In addition, the 2013 IPCC report removed prior mention of 3°C as the 'best estimate'. We interpret the implications of the 2013 IPCC decision to lower the bottom of the range and excise a best estimate. Intuitively, it might seem that a lower bottom would be good news. Here we ask: when might apparently good news about climate sensitivity in fact be bad news in the sense that it lowers societal well-being? The lowered bottom value also implies higher uncertainty about the temperature increase, definitely bad news. Under reasonable assumptions, both the lowering of the lower bound and the removal of the 'best estimate' may well be bad news.

Better predictions, better allocations: scientific advances and adaptation to climate change.

Climate science initially aspired to improve understanding of what the future would bring, and thereby produce appropriate public policies and effective international climate agreements. If that hope is dashed, as now seems probable, effective policies for adapting to climate change become critical. Climate science assumes new responsibilities by helping to foster more appropriate adaptation measures, which might include shifting modes or locales of production. This theoretical article focuses on two broader tools: consumption smoothing in response to the risk of future losses, and physical adaptation measures to reduce potential damages. It shows that informative signals on the effects of climate change facilitate better decisions on the use of each tool, thereby increasing social welfare.

The relative weights of direct and indirect experiences in the formation of environmental risk beliefs.

Direct experiences, we find, influence environmental risk beliefs more than the indirect experiences derived from outcomes to others. This disparity could have a rational basis. Or it could be based on behavioral proclivities in accord with the well-established availability heuristic or the vested-interest heuristic, which we introduce in this article. Using original data from a large, nationally representative sample, this article examines the perception of, and responses to, morbidity risks from tap water. Direct experiences have a stronger and more consistent effect on different measures of risk belief. Direct experiences also boost the precautionary response of drinking bottled water and drinking filtered water, while indirect experiences do not. These results are consistent with the hypothesized neglect of indirect experiences in other risk contexts, such as climate change.

Social Class and (Un)Ethical Behavior: A Framework, With Evidence From a Large Population Sample.

Differences in ethical behavior between members of the upper and lower classes have been at the center of civic debates in recent years. In this article, we present a framework for understanding how class affects ethical standards and behaviors. We apply the framework using data from a large Dutch population sample. The data include objective measures of class, survey responses relating to ethical behavior, and results from an experiment designed to probe ethical choices. Ethical behavior proves to be affected by (a) moral values, (b) social orientation, and (c) the costs and benefits of taking various actions. Strong class differences emerge in each of these areas, leading to differences in behavior. Moreover, strong differences among different conceptions of class (wealth, education, etc.) produce additional variation. We argue that the relationship between class and ethical behavior is far from a simple pattern; it is a complex mosaic.

The challenge of degraded environments: how common biases impair effective policy.

Economic activity can damage natural systems and reduce the flow of ecosystem services. The harms can be substantial, as our case studies vividly illustrate. Most degraded landscapes have at least some potential to be reclaimed. However, uncertainty plagues decision making regarding degradation and reclamation, in relation to the extent of the damage, the success of reclamation, and how exposure will change in the future. We examine how a range of observed decision biases can lead to far-from-optimal policies regarding how much degradation to allow and when, as well as how and how much, to reclaim degraded sites. Despite our focus on degraded landscapes, we believe these are generic biases present in a wide range of risk situations. Our three case studies show these biases at work. The first two studies are of mining operations in the United States and Canada, and the third is of climate change.

The global challenge of antimicrobial resistance: insights from economic analysis.

The prevalence of antimicrobial resistance (AR) limits the therapeutic options for treatment of infections, and increases the social benefit from disease prevention. Like an environmental resource, antimicrobials require stewardship. The effectiveness of an antimicrobial agent is a global public good. We argue for greater use of economic analysis as an input to policy discussion about AR, including for understanding the incentives underlying health behaviors that spawn AR, and to supplement other methods of tracing the evolution of AR internationally. We also discuss integrating antimicrobial stewardship into global health governance.

Selection stories: understanding movement across health plans.

This study assesses the factors influencing the movement of people across health plans. We distinguish three types of cost-related transitions: adverse selection, the movement of the less healthy to more generous plans; adverse retention, the tendency for people to stay where they are when they get sick; and aging in place, enrollees' inertia in plan choice, leading plans with older enrollees to increase in relative cost over time. Using data from the Group Insurance Commission in Massachusetts, we show that adverse selection and aging in place are both quantitatively important. Either can materially impact equilibrium enrollments, especially when premiums to enrollees reflect these costs.

Generic script share and the price of brand-name drugs: the role of consumer choice.

Pharmaceutical expenditures have grown rapidly in recent decades, and now total nearly 10% of health care costs. Generic drug utilization has risen substantially alongside, from 19% of scripts in 1984 to 47% in 2001, thus tempering expenditure growth through significant direct dollar savings. However, generic drugs may lead to indirect savings as well if their use reduces the average price of those brand-name drugs that are still purchased. Prior work indicates that brand-name producers do not lower their prices in the face of generic competition, and our study confirms that finding. However, prior work is silent on how the mix of consumer choices between generic and brand-name drugs might affect the average price of those brand-name drugs that are purchased. We use a nationally representative panel of data on drug utilization and costs for the years 1996-2001 to examine how the share of an individual's prescriptions filled by generics (generic script share) affects his average out-of-pocket cost for brand-name drugs, and the net cost paid by the insurer. Our principal finding is that a higher generic script share lowers average brand-name prices to consumers, presumably because consumers are more likely to substitute generics when brand-name drugs would cost them more. This effect is substantial: a 10% increase in the consumer's generic script share is associated with a 15.6% decline in the average price paid for brand-name drugs by consumers. This implies that the potential cost savings to consumers from generic substitution are far greater than prior work suggests. In contrast, the percentage reduction in average brand costs to health plans is far smaller, and statistically insignificant.

Probabilities and preferences: what economics can teach doctors and patients making difficult treatment decisions.

Both for calculating probabilities and considering patient preferences, economics can provide useful analytic tools for those making decisions about risky treatments. For probabilities, integrated and absolute numbers should be preferred to partial and relative ones. Preferences become particularly important in cases where no treatment shows an equal or higher probability for all groups of better outcomes, or for cases where patients' values regarding outcomes can be expected to differ. Moreover, preferences can take account of more than just outcomes themselves; tradeoffs between the short- and long-term, as well as tolerance for risk and anxiety, may also be important.

Predictors of patient preferences and treatment choices for localized prostate cancer.

BACKGROUND: Little is known regarding how patients select treatment for localized prostate cancer. This study examined determinants of patients' preferences for health states related to prostate cancer, and assessed whether preferences and/or other factors predict treatment choices. METHODS: A survey of 167 patients with newly diagnosed localized prostate cancer was conducted in 4 academic medical practices from 2004 to 2007. The authors assessed demographic and health factors, and used a time-tradeoff method to elicit preferences in the form of quality-adjusted life years (QALYs) regarding health states related to prostate cancer. Linear regressions identified predictors of preferences (in QALYs) for erectile dysfunction (ED), urinary incontinence, rectal/bowel symptoms, and metastatic prostate cancer. Linear probability models identified predictors of treatment choice. RESULTS: Patient preferences were affected by a range of behavioral, demographic, and health factors. For example, sexually active men reported significantly lower QALYs for living with ED, and men with family members who died of cancer reported lower QALYs for metastatic disease. The strongest predictor of treatment was the type of physician seen (radiation oncology vs urology) at the time of the survey. Age and tumor grade also were found to be strongly predictive of treatment. In general, QALYs were not found to predict treatment choice. CONCLUSIONS: Patient preferences, as reported in QALYs, are shaped by reasonable behavioral and demographic influences. However, actual treatment choices appear to bear little relation to these patient preferences, and instead demonstrate a strong association with clinician specialty. More attention to variation in preferences among patients, as well as the use of decision-support technologies, may enable physicians to facilitate more optimal individualized treatment choices for patients with prostate cancer.

Custom-made versus ready-to-wear treatments: behavioral propensities in physicians' choices.

To customize treatments to individual patients entails costs of coordination and cognition. Thus, providers sometimes choose treatments based on norms for broad classes of patients. We develop behavioral hypotheses explaining when and why doctors customize to the particular patient, and when instead they employ "ready-to-wear" treatments. Our empirical studies examining length of office visits and physician prescribing behavior find evidence of norm-following behavior. Some such behavior, from our studies and from the literature, proves sensible; but other behavior seems far from optimal.

Decision analysis using individual patient preferences to determine optimal treatment for localized prostate cancer.

BACKGROUND: Selecting treatment for clinically localized prostate cancer remains an ongoing challenge. Previous decision analyses focused on a hypothetical patient with average preferences, but preferences differ for clinically similar patients, implying that their optimal therapies may also differ. METHODS: A decision model was constructed comparing 4 treatments for localized prostate cancer: 1) radical prostatectomy (RP); 2) external beam radiation (EB); 3) brachytherapy (BT); and 4) watchful waiting (WW). Published data were used regarding treatment success, side effects, and noncancer survival, and 156 men with prostate cancer were surveyed to elicit preferences in quality-adjusted life years (QALYs). The clinical scenarios were determined (age, tumor grade, and prostate-specific antigen [PSA]) for which variations in patient preferences led to different optimal treatments and those for which the optimal treatment was unaffected by preferences. RESULTS: Patient preferences were critical in determining treatment for low-risk cancers (Gleason score