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September 12, 2007
Too Much Medicine?
As per usual, Robin Hanson's claims that we should cut the provision of medicine in half are, shall we say, a bit strong, but it is true that we've got enormous amounts of waste, and it's undoubtedly true that we should vastly enhance the amount of money we spend studying the effectiveness of treatments.
David Cutler's riposte, by contrast, seems quite on-point. Policy should focus on separating good care from bad care. There's no reason to go at this with a meat cleaver (unless you're Robin Hanson, and have made a career out of, um, "viewquakes," which sort of require you to make Shocking! Claims!) Also, if you are going to cut care, you'll want to do it on the supply side (i.e, with trained professionals helping decide where to slash spending), because all the available evidence shows that patients do not, themselves, know which care to cut, and when faced with higher medical bills, will just cut care indiscriminately.
Lastly, Hanson mentions that medicine is often used to "show that we care," which does not actually increase anyone's health. But medicine is also used to comfort. Take a patient with heart palpitations. Odds are they're just benign skipped beats. A doctor may even know those odds. But when your heart jumps, it's scary. So the doctor runs the set of tests that distinguish them from deadly arrhythmias. These tests are, in Hanson's telling, wasted medicine, as they do nothing to improve biological function and are very costly. But the assurances they offer do much to improve quality of life, which is, along with extending the length of life, rather the point of medicine.
There will always be some level of "wasted" medicine that isn't, at the moment of prescription, sure to be waste (i.e, a diagnostic that could find a deadly disease, but doesn't), and some amount of medicine that's used to calm fearful patients. Neither of those show up on yearly physicals, but nor are they necessarily wasted dollars if your metric is improving patients' quality of life.
September 12, 2007 in Health and Medicine | Permalink
Comments
I think you should integrate Robin's plan, and your thinking, and come up with a "the best way the government could spend the money it spends providing healthcare now." I think your statistic is that govenment pays for half of healthcare now; if it spent that on providing the most cost-effective care population-wide, you'd have England-level spending right there.
Posted by: SamChevre | Sep 12, 2007 12:09:32 PM
Can we settle there is a right to healthcare first before we settle how Conservatives can widdle down the right as wasteful? This ploy seems like deja vu. Can't figure out why.
Posted by: akaison | Sep 12, 2007 12:12:01 PM
"...But medicine is also used to comfort. Take a patient with heart palpitations..."
or take a patient such as myself, with unexplained fatigue and chest pains while exercising. The battery of tests run on my heart and lungs did not find anything and cost a lot: but I was awfully happy to know I wasn't about to die, at least not from a heart attack.
On a related note: how is it that society spends six to ten years training doctors to provide health care, then rewards them handsomely for their expertise: yet, once the market fairy appears, consumers (who may not have completed high school) are supposed to be able to 'direct' their own health care ?
For what value of 'direct' can this policy actually work ?
Airily assuming that the policy works, the next question arises - What is the market failure that makes doctors so expensive, when untrained consumers are able to effectively make the same decisions and determinations as said doctors, about their health care ?
Posted by: Doug K | Sep 12, 2007 2:31:38 PM
Also, if you are going to cut care, you'll want to do it on the supply side (i.e, with trained professionals helping decide where to slash spending), because all the available evidence shows that patients do not, themselves, know which care to cut, and when faced with higher medical bills, will just cut care indiscriminately.
Ezra,
2 points:
1. Practically speaking, its hard to imagine a policy implemented that would cut 25% of health care spending (meaning physician income and hospital revenues) that wouldn't require a reciprocal adjustment in compensation for remaining medical care-- which essentially does nothing from a cost perspective. Alternatively, if we are asking health professionals to make the cuts at the individual patient level rather than macro-level policy, the same dilemma exists-- are we really going to successfully get them to not recommend treatments, against their own financial interests? History gives a clear no. (For those who want to retort that we should move them to flat salary-- see above-- they'll want flat salary based on today's income, not the 25% reduction, which again accomplishes little on the cost issue. It may help retard future perverse incentives of fee-for-service (questionable IMO) but that's about future growth not a reduction in current spend.)
In short, there is no realistic scenario where health professionals, via policy (i.e. NICE-like system) or individually will help reduce costs.
2. Your own previously stated views on targeted cost-sharing disagrees with Cutler's premise above. Your point (and mine) is that if the cost-sharing is done discriminately, so will the consumers' care reductions. Do you no longer think this or were you just stating Cutler's view above?
Posted by: wisewon | Sep 12, 2007 2:31:42 PM
Remember, my argument is in context of a single payer system where the cost sharing levels are set by the government in consultation with experts. That's manipulating the demand side, to be sure, but it's quite close to what Cutler is suggesting.
Posted by: Ezra | Sep 12, 2007 3:00:20 PM
Doug K: wrote:
“On a related note: how is it that society spends six to ten years training doctors to provide health care, then rewards them handsomely for their expertise: yet, once the market fairy appears, consumers (who may not have completed high school) are supposed to be able to 'direct' their own health care ? “
This could be said of almost any product or service we buy. We do not know how they work but we seem to muddle through. I am a complete dolt when it comes to car repair so I usually get 3 estimates to fix a problem and go back if the fix did not work. Doctors may know medicine but we know before them if their last intervention worked.
"...But medicine is also used to comfort. Take a patient with heart palpitations..."
It is only on the margins that this sort of thing matters but the margins tend to grow if you let them until they are significant. I would feel better if the doctor just told me the odds. BTW I have heart palpitations.
BTW engineers seem to me to be generally to smarter than Doctors. Why is 4 years of post secondary education not enough education to be licensed to practice medicine? Why not a degree in medical engineering
Posted by: Floccina | Sep 12, 2007 3:22:01 PM
On the doctor vs patient directing care issue:
That's why I think the single biggest improvement we could make on the actual-cost-of-care front for basic care (not the cost of dealing with insurers issue) is the to re-think how you get into the medical system, along the lines the military does.
Have a problem? Here's your order:
First, see a "medic"--someone with the training of a paramedic and a good flowchart. He can treat you basically, or pass you up the chain. (You have poison ivy; use calamine lotion. You have a fever but it's not dangerous; rest and get plenty of fluids.) 10 minutes, $10.
Second, see a nurse (with a good flowchart); she can treat you basic+, or pass you up the chain. (You have a fever but no signs of anything else; take aspirin and rest. You have a sore throat; here's a prescription for penicillin. You asthma seems well-controlled; here's a refill prescription for your inhaler.) 5 minutes, $10.
Next see a doctor or nurse practitioner. 30 minutes, $75.
The point is to keep the people who don't need a doctor's help from taking up a doctor's time.
Posted by: SamChevre | Sep 12, 2007 3:41:48 PM
The problem that I see is this:
Since there is no incremental cost to the patient and none to the doctor they tend to demand treatment up until the point where in the doctor’s estimation the treatment has a 51% chance of improving health for the patient. And since we are all subject to some prejudice the doctor assumes that he will not make a mistake and so the 51% chance of improving things is probably like a 45% chance of improving things for the patient. The insurance company is not as motivated as one might think to decline treatment either because they know their competition will have to pay for the treatment and so they can raise their rates to cover it and their reputations can be damaged by denial of care.
This explains the resistance to evidence based medicine. I talked to a doctor about this and she said that she was taught evidence based medicine but that the customers (patients) will not stand for it. BTW When I told her that Robin Hanson had said that maybe 50% of the money was wasted, she replied, to my shock, “Everybody in the profession knows that”.
Further even beneficial medicine is not necessarily a good cost benefit. Maybe I would rather live shorter but better by spending my money on things other than healthcare. One might even prefer living 70 years on $40,000 per year than living 75 years with health insurance eating up $5,000/year leaving me with $35,000 per year.
So the question remains how do you reduce medical spending, I think that a plan where government provided insurance for all with a low deductible for the poor and huge deductible (like $200,000 for people making more than $100,000 per year) for the middleclass and rich might work.
Posted by: Floccina | Sep 12, 2007 3:51:34 PM
Rx of Pencillin for a sore throat- Which 9/10 is viral and does nothing but cause antibiotic resistance which drives up the cost for every one else. So your $10 visit could end up costing the individual thousands someday. Increasing quality and dumbing down medicine don't go hand in hand. It still amazes me everytime the cost of medicine is discussed it focuses on physician reimbursment, when its just a small overall percentage of out healthcare dollar that is spent.
Posted by: Dingo | Sep 12, 2007 4:36:34 PM
Colds are generally viral; persistent sore throat is not (unless it has changed since the last time I had one.)
So, either a doctor or a nurse can say:
"You have had a sore throat for 3 days? Ok, here's a prescription for penicillin."
Explain, please, why having a doctor with 10 years of training do this for $75, rather than a nurse with 3 years of training do it for $15, is better?
Posted by: SamChevre | Sep 12, 2007 4:47:21 PM
Floccina, while I'd agree that patients don't understand why a dcotor would refuse to do something they wanted, it's also the case that doctors may say they were taught "evidence based" medicine, but few really practice it, and it's not just about what patints want - it's about cautiousness, and distrust and iverthinking and tings that are, naturally, somewhat human foibles that come with taking care of people. My Doctor friend who's a Medical Director explained it to me with a thought exercise he uses at the local Medical School. He gives a class the case history of a patient who calls in with a common problem, and asks them to describe their treatment plan - what tests they'd order, what prescription they might use, whether to being the patient in, etc. His point is not that there's a right answer (there is), but that he gets a multitude of answers, from people who are trained in the same way from the same books about the same range of options and treatments. It was instructive to me about keeping in mind what a challenge "best practices" approaches are going to be with doctors, because most of them think what they do now is a "best practice."
I would add - aside from agreeing with wisewon that encouraging best practices that involve less care at lower billing will need some sort of financial incentive to work - that I think people should keep in mind that a lot of this determination of what's working is still in the early stages. Insurance companies and HMOs in many cases have more data than Medicare, which has only started in the last few years to measure outcomes, and then only some of the most basic conditions (diabetes, heart disease) where outcome measures are very well defined. And, one of the things that was going to be cut in the Democratic SCHIP bill was the funding to continue this research. Just some things to keep in mind.
Posted by: weboy | Sep 12, 2007 4:58:42 PM
Same reason that a Biology professor may know more about teaching biology than a junior Biology Student at a University.
Where did you say "persistent" sore throat? You said "sore throat"-cook book medicine, give them Penicillin. You get what you pay for and in those 7 years they may have actually learned how to get the correct diagnosis rather than rely on their "flowchart". We use midlevels more than any country does right now due to our incredible shortage of primary care physicians. They will continue to have to expand it as well to make any UHC feasible with the shortage that there is for physicians. Some demand nothing less than a physician others would be ok with your type of system. I know this I've never seen a nurse yet that can rod a femur or replace a knee.
Posted by: DIngo | Sep 12, 2007 5:04:32 PM
BTW engineers seem to me to be generally to smarter than Doctors. Why is 4 years of post secondary education not enough education to be licensed to practice medicine? Why not a degree in medical engineering
Go to medical school, and then maybe you'll have the answer to your questions.
Posted by: Pup, MD | Sep 12, 2007 6:10:30 PM
Funny that Ezra uses this example, we just used it today in medical school. A good doctor won't order tests merely for comfort. Unnecessary tests can in fact lead to more discomfort for a patient. In ordering tests, a physician must always remember the likelyhood of a false positive. The physician has to take into account the prevalence of the disease within the patient group to which the patient belongs.
For example, say this patient is a high school student. The incidence of heart disease within this group is very low. For the purposes of this example, we'll say it's 1%. If the tests Ezra refers to have a 90% chance of being positive if the patient has heart disease and a 95% chance of being negative if the patient does not. Statistics will tell the doc that, for any individual patient in this population, a positive test result means that there is an 85% that the patient does not have heart disease. If the patient were an older gentleman (and the incidence of heart disease in his group is 40%), there would be a 92.3% chance that a positive on the exact same test means that the patient has heart disease.
Its the doctor's job to know this. An unneccessary test could lead to an unneccessary proceedure. If you get a false positive, the next step might be a heart catheter, and that wouldn't do too much for the patient's comfort.
Posted by: Alejandro Gonzalez | Sep 12, 2007 6:22:11 PM
SamChevre:
1. Your proposed triage system (3:41 PM post) is already more or less how all urgent care clinics work. However, you've wildly underestimated the time and cost of even a simple visit. Even if you come in with just a scratch to get Bacitracin and a Band-Aid, it's going to take me more than 5 minutes to make sure there's nothing else wrong... and your proposed $10 per 5 minutes isn't going to cover costs unless I really can finish 12 patients every hour. Good way to make all the nurses drop dead.
2. Whatever you think "persistent sore throat" means, a sore throat for 3 days is hardly unusual for a viral infection. And someone who just wrote for penicillin without looking into any other symptoms, or looking at the patient's previous history, would be grossly negligent. (Much of the time penicillin isn't an appropriate first-line drug anyway. This isn't the 1950s.) And a nurse with "3 years training" is either still working on a degree, or has done an associate degree program and just barely started working.
Nothing personal, but you don't know as much as you think you know. Fortunately you're not running my clinic.
Posted by: Hob | Sep 12, 2007 8:25:04 PM
If an engineer fucks up and a bridge collapses, he doesnt get sued personally, its his company that takes the heat. The worst that happens to him is he could lose his job.
On the other hand, doctors are personally liable for every action they undertake. Thats part of the reason why docs are paid more.
Another reason is because designing a bridge or a rocket is fucking easy compared to healing people. Engineering projects are nothing more than a sum of the individual parts. We can easily take apart a bridge and build it back up again and you can never tell the difference. Thats obviously not possible with humans.
Posted by: joe blow | Sep 12, 2007 8:32:59 PM
I think it could be entirely part of the problem is that we have too much access to midlevels. Quicker access to specialty care could lower costs as well by eliminating unneccessary tests and time lost from work for unneeded and ineffectual treatments. With the complexities of healthcare today we need a higher level of training for each provider not lower. Problem is there are not nearly enough specialists or Primary Care Physicians for preventative medicine. I see people everyday that have thousands of dollars worth of tests done for their feet that I can tell in 30 seconds with a scalpel and a q tip whether they have osteomyelitis or not. Its a clinical diagnosis. Everyday patients walk in with a 1500 dollar MRI that I would never have ordered if I had seen them first.
Posted by: Dingo | Sep 12, 2007 8:47:05 PM
Remember, my argument is in context of a single payer system where the cost sharing levels are set by the government in consultation with experts. That's manipulating the demand side, to be sure, but it's quite close to what Cutler is suggesting.
Wait a minute... a month ago you wrote to me something along the lines of "when are you going to believe me when I say I'm not in favor of single-payer?"
What am I missing?
Posted by: wisewon | Sep 12, 2007 11:08:32 PM
"I would add - aside from agreeing with wisewon that encouraging best practices that involve less care at lower billing will need some sort of financial incentive to work - that I think people should keep in mind that a lot of this determination of what's working is still in the early stages."
Several people have made similar statements. That is pretty much what the HMO model was designed for. It gives physicians financial motivation to eliminate unnecessary spending, but it also puts physicians in an adversarial relationship with their patients. There really needs to be some way to educate and incentivize people not to demand excess care.
When I first started in medicine, I would only order appropriate tests and treatments as I had been taught in residency. It pissed people off, so now I try to walk the line between "reassurance" and "excess". It isn't easy. My present practice was inherited from a guy who was pretty dishonest. Some of his older patients are really unhappy with me since I don't do "routine" treadmills and "routine" ECGs with their "complete physicals", but I just can't bring myself to order those unless someone starts to shout at me (it's happened!) There aren't that many businesses where the seller is expected to say "No" to the buyer.
"Cancer" insurance plans that give people a rebate, usually $100, seem to be pretty successful at getting people to do appropriate screenings. Most people are pretty reasonable about making rational choices, but I'm not sure how to incentivize people to not demand antibiotics for viral upper respiratory infections.
Posted by: J Bean | Sep 13, 2007 1:06:16 AM
A hard problem is defining what "give comfort" means, and it changes over time. Take pain medication - for much of history, it was a bottle of booze. at best. For a time, opiates were cheap and plentiful. Now, pain specialist access in not so much being priced out of the market as being criminalized. At the same time, state-approved, lowend pain relief is trivially cheap.
Or take depression. For much of history, it was simply not recognized. Then it was stigmatized, and only treated in a semi-modern sense for the wealthy (being seriously depressed and poor could get you in to some eriously messed up situations, if you didn't have family to care for you. Now it seems that probably about a fifth of the people I know are on an SSRI, and seeing a therapist, (Granted, this is NYC), and SSRIs that are not under patent protection are dirt cheap - generic Zoloft (sertraline) is ~$8/month at Costco.
Contrast with unneeded antibiotics to make a patient feel like the doctor did something (still a big problem in some places, with serious implications for public health), or folks that, while perhaps not hypochondriacs, do overuse the medical resources at their disposal.
It seems to me that there are many, many shifting lines there in many, many different specialties. I have a hard time imagining a group of policy wonks coming up with reasonable guidelines that didn't make a lot of mistakes on both sides of the balance, no matter how well funded, dedicated, and plentiful.
Posted by: fishbane | Sep 13, 2007 3:45:43 AM
Ezra,
You're driving me nuts here. If the studies say that we can cut several hundred billion dollars without significant health costs by using a blunt instrument like higher copays/deductibles and reducing subsidies, then we could multiply the NIH budget by more than tenfold! That would allow us to launch numerous massive randomized studies to figure out what works and what doesn't, and to accelerate the development of new therapies that unambiguously work, like more powerful antibiotics or anti-retrovirals for HIV. We could get major improvements in public health infrastructure, providing preventive medicine for free. You could pay for universal coverage (copays for all except the poor).
Not to mention that we could put a tenth of the savings into global health (deworming, administering antibiotics, HIV prevention, oral rehydration therapy, malaria vaccine development, bed nets, etc) to save a hundred million lives or so.
To say that we're better off providing strong subsidies to use both harmful and helpful medical care, for no net health benefits, rather than spending on these other areas seems to be absolutely insane. Hundreds of millions of people die of cheaply preventable diseases worldwide, we spend only $28 billion on the NIH and federally-funded medical research while spending close to $2 trillion on health care. And we should retain the status quo because kabuki can make people happier (it doesn't even show up as placebo effect in the aggregate studies)? If you had the power to perform Hansonian cuts and put 10% of the savings back into medical research (including evaluating different types of care) or global health, would you do it? It seems that to refuse would be morally monstrous.
Posted by: Unknown Healer | Sep 18, 2007 10:02:48 PM
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