In the midst of the uncertainty, Epic, a private electronic health record giant and a key purveyor of American health data, accelerated the deployment of a clinical prediction tool called the Deterioration Index. Built with a type of artificial intelligence called machine learning and in use at some hospitals prior to the pandemic, the index is designed to help physicians decide when to move a patient into or out of intensive care, and is influenced by factors like breathing rate and blood potassium level. Epic had been tinkering with the index for years but expanded its use during the pandemic. At hundreds of hospitals, including those in which we both work, a Deterioration Index score is prominently displayed on the chart of every patient admitted to the hospital.
The Deterioration Index is poised to upend a key cultural practice in medicine: triage. Loosely speaking, triage is an act of determining how sick a patient is at any given moment to prioritize treatment and limited resources. In the past, physicians have performed this task by rapidly interpreting a patient’s vital signs, physical exam findings, test results, and other data points, using heuristics learned through years of on-the-job medical training.
Ostensibly, the core assumption of the Deterioration Index is that traditional triage can be augmented, or perhaps replaced entirely, by machine learning and big data. Indeed, a study of 392 Covid-19 patients admitted to Michigan Medicine that the index was moderately successful at discriminating between low-risk patients and those who were at high-risk of being transferred to an ICU, getting placed on a ventilator, or dying while admitted to the hospital. But last year’s hurried rollout of the Deterioration Index also sets a worrisome precedent, and it illustrates the potential for such decision-support tools to propagate biases in medicine and change the ways in which doctors think about their patients.
Governments “don’t have to pay off their debt like a household does,” said Louise Sheiner, policy director for the Hutchins Center on Fiscal and Monetary Policy at the Brookings Institution. “They can just keep rolling it over. They’re never going to go out of business and have to pay all at once.”
State and local liabilities can also be likened to the federal government’s deficit and debt, Sheiner said in an interview with MarketWatch. Most economists think that as long as those numbers stay constant as a share of the economy, it’s not problematic.
In this paper we explore the fiscal sustainability of U.S. state and local government pensions plans. Specifically, we examine if under current benefit and funding policies state and local pension plans will ever become insolvent, and, if so, when. We then examine the fiscal cost of stabilizing pension debt as a share of the economy and examine the cost associated with delaying such stabilization into the future. We find that, despite the projected increase in the ratio of beneficiaries to workers as a result of population aging, state and local government pension benefit payments as a share of the economy are currently near their peak and will eventually decline significantly. This previously undocumented pattern reflects the significant reforms enacted by many plans which lower benefits for new hires and cost-of-living adjustments often set beneath the expected pace of inflation. Under low or moderate asset return assumptions, we find that few plans are likely to exhaust their assets over the next few decades. Nonetheless, under these asset returns plans are currently not sustainable as pension debt is set to rise indefinitely; plans will therefore need to take action to reach sustainability. But the required fiscal adjustments are generally moderate in size and in all cases are substantially lower than the adjustments required under the typical full prefunding benchmark. We also find generally modest returns, if any, to starting this stabilization process now versus a decade in the future. Of course, there is significant heterogeneity with some plans requiring very large increases to stabilize their pension debt.
Author(s): Jamie Lenney, Bank of England Byron Lutz, Federal Reserve Board of Governors Finn Schüle, Brown University Louise Sheiner, Brookings Institution