Are there any important differences between these medics and economists, who believe in free trade because of theory, despite the lack of empirical evidence that it is beneficial?

Was the placebo syrupy too? My recollections of cough medicine involve a decrease in coughing right after consumption–suggesting that either the consistency is what does it, or I’m easy to brainwash.

Now if we had a system where doctors are paid not by large insurance corporations but by their patients…

Yet the linked article:

• reports only on studies of over-the-counter cough medicines, not all cough medicines;
• reports only on studies of children, not all users of cough medicines; and
• reports only on coughing due to upper respiratory tract infection, not all causes.

You can do better.

For some reason, in treatment of hypertension (not post-MI), beta blockers, for seem to confer disproportionate benefit to white and young patients, while diuretics confer disproportionate benefit to African-American and elderly patients.

I’ve heard that blacks are more prone to low-renin hypertension than whites, though apparently the whole thing is controversial:

“It has been well documented that, as monotherapy or in the absence of a diuretic, {beta}-blockers, ACE inhibitors, and ARBs do not lower blood pressure to the same extent in African American patients that they do in white patients with hypertension. It has also been reported that, as monotherapy, thiazide diuretics and CCBs have greater blood pressure–lowering efficacy than do other drug classes in African Americans. However, studies reporting these types of data have certain common limitations: (1) they generally do not report SBP responses; (2) they generally reported response rates based on a reduction of 10 mm Hg or more from baseline DBP rather than achievement of target blood pressure; (3) individual agents cannot be used as a proxy for class effect; and (4) conclusions cannot be drawn regarding the best course of treatment for patients for whom antihypertensive treatment was not efficacious in these studies.”

With regards to the efficacy of diuretics, specifically thiazides, it’s not completely clear how they work.

Medicare has completely different policies for hospitals versus doctors and other fee-for-service providers. This site (and the links contained there) describes the determination of hospital reimbursement for patient treatments based on the patients’ diagnoses: http://www.cms.hhs.gov/AcuteInpatientPPS/.

This site describes the role of the Medicare Quality Improvement Organization: http://www.commonwealthfund.org/Content/Performance-Snapshots/Variations-in-Care/Quality-of-Care-and-Medicare-Spending-at-the-State-Level.aspx .

Acute-care hospitals are not governed by fee-for-service regulations, but rather are motivated by the fact that they will receive the amount determined to be appropriate for care of a certain disorder, with modifiers that may qualify for extra reimbursement. Among those modifiers are extra amounts for teaching hospitals based on several factors, including numbers of doctors in training. This is the main reason that such hospitals as Mass General may receive more money for the same service than Beth Israel, which has a smaller in-training force (your earlier post about these two institutions suggested the increased cost was because of patients’ willingness to pay for “prestige”). In the Medicare system, no matter what the patient is willing to pay, the price is fixed, and nothing higher can be collected. Voluntary over-payment is illegal. Medicare regulatory bodies can see the statistics of all participants, review the costs of the actual services performed, and assign what they consider to be a fair compensation nationwide or regionally. Hospitals that have high rates of complications and unnecessary services lose money (I should more accurately say “lose more money”, since all acute-care hospitals lose money on Medicare in-patients; it’s a part of the federal design).

Doctors are regulated by fee-for-service (Part B) rules. CPT codes for every imaginable service are published with the reimbursement for that service. Doctors who have excessive complaints or who are caught in fraudulent practices lose their permission to treat Medicare patients. The feds regulate the type of services allowed through the use of CPT coding: if there’s a CPT number, it’s considered a legitimate procedure/service. Unlisted services are considered on an individual basis, and frequently disallowed or priced so low that the physician has no financial incentive to perform the service. If the service is not approved by Medicare, the participating physician can perform it on a Medicare patient, but he cannot charge anyone at all. The physician can withdraw from participation with Medicare, and treat Medicare patients for cash (except in some states), but he cannot cherry-pick; his participation must be for all Medicare patients or no Medicare patients. Also regulated under fee-for-service rules are Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), and Hospices, and the like.

As the site about the Medicare Quality Improvement Organization describes, it is more a gatherer of info that influences general reimbursement trends, a recommender of quality practice policies, and a source of comparative performance among hospitals that can shame them into doing better, or award “attaboys”. Of course, a horrible provider can be excluded from the program.

While this long answer barely scratches the surface of your question, perhaps only those who have dealt extensively with Medicare can imagine how truly ridiculous and wasteful the system is.

In terms of antibiotics for common URIs, that are VIRAL, — most physicians know antibiotics only reduce symptoms by a day or two at best (if its bacterial) — if you have ever talked to a doctor you would know that some patients DEMAND antibiotics.

Further, studies can only answer questions that are capable of being asked about large numbers of homogeneous patients. Doctors often look closer at specific subgroups of patients where clinical experience leads them to favor a treatment that varies from what the big study says that the “average” patient should be getting. Yes, doctors often ignore valid evidence, but evidence is also not always as convincing to an expert as it may seem to a layman.

It’s certainly the case that most of that list is perfectly correct in criticizing clinical practice that doesn’t match up to good evidence but I felt like there’s also some nuance that people should be aware of.