The RAND experiment showed that people with more generous health insurance consumed a lot more health care than those with less generous insurance, but didn’t have much (or maybe anything) in the way of better health outcomes. The natural interpretation of this is that everyone, including those with less generous insurance, chooses to get all of the high-value treatments, and that the extra treatments consumed only by those with more generous insurance aren’t worth much.* If this was true, then Robin’s
Many of us have a chance to test our beliefs about healthcare.
Give up your health insurance and stop seeing doctors. You can save a significant amount of money that way just in copayments alone. And you can perhaps go to your employer and ask how much of a raise they'd give you in exchange for no health benefits. Something like 48 million americans spent some time uninsured last year, up from 46 million the year before. You could join them. If you're sure that health care does no good, it would be the right thing to do.
Then there's Alan Yeung's split:
"A better starting point would be to divide healthcare into public health, primary healthcare, emergency healthcare (accidents, injuries, etc.), care of chronic diseases (into which one should include old age), and care of major non-chronic conditions (heart disease, cancer, etc.)."
If you could get public health benefits and insurance just for emergency health care, and leave the rest....
The healthcare system of a nation doesn't have a whole lot of effect on the life expectancy of the population.http://www.nationalcenter.o..."More robust statistical analysis confirms that health care spending is not related to life expectancy. Studies of multiple countries using regression analysis found no significant relationship between life expectancy and the number of physicians and hospital beds per 100,000 population or health care expenditures as a percentage of GDP. Rather, life expectancy was associated with factors such as sanitation, clean water, income, and literacy rate.8"
Dear ShaneMaking it clear, since you may have not realised my point: no, I do not think you have to look for a MD every time you sneeze.Let us not loose the point of it all, and go back straight to it: The RAND experiment does not say that having no healthcare is better than having some. Read the study.Be a good sport and keep your good manners.
Cassio, you are nit picking this to death, and I really hope you're missing the point on purpose, since if you're not you are astoundingly dense. Here it is again, with training wheels, which you seem to require:
There are a huge number of things that someone might go to the doctor for, for which medical intervention is NOT required to stave off death. Since you are so passionate about strep, lets forget that, and go with a sinus infection, for instance, or blood poisoning, both of which I've had, without seeing a doctor, both of which didn't kill me. Or hay fever. Or back spasms. There are an infinity of other things just like these, for which medical intervention could have significantly improved my quality of life. Defining outcomes s.t. saying that this sort of health care has no effect on them is just absurd.
Dear Shane, the point remains the same: I do not think you have read anything on streptococal infection and its complications. Despite this, you do not consider yourself wrong. By the way, when the example for your conclusion is not valid, which seems to be the case, the conclusion itself has not been proven.
A couple of the comments above call into question the expert claim that the marginal and the infra-marginal treatments are really the same. And they may well not be. In fact, when I wrote the post, I thought that this was the most likely solution to the puzzle (the puzzle being the seemingly nonsensical result that if the marginal treatments didn't do any good, and the infra-marginal treaments are just like the marginal ones, then that must mean that the infra-marginal ones don't do any good either). But now Tomhs's diminishing marginal returns story seems more likely to be the correct answer. I'm not sure that the story is right, but it is convincing enough to me that I no longer regard the puzzle as a puzzle. Eliezer is right that this story only makes sense if the treatments are non-independent, but I would imagine that this condition is satisfied.
I wonder if part of the effect is from the use of health care on those with no possibility to benefit? I noticed that this showed up as a reason that t-PA (an anti-stroke treatment) actually appeared to kill people in actual clinical practice. It could be that patients and their families insist on "doing something" when the situation is hopeless.
As these treatments may be very expensive, this could introduce a large enough error into the estimates to hide a true beneficial effect.
In general, the therapies that seem to work well are also not terribly expensive. Antibiotics to cure syphilis are cheap and actually reduce overall costs (as insane people cost money one way or the other -- although you might hide the expense by putting it in other government bodies).
In the same sense, statins for the secondary prevention (given after one heart attack has already occurred) really do seem to be worth the current cost given net benefit (and will be a very cost-effective therapy once the drugs are off patent).
On the other hand, there is a lot less evidence for other (expensive) interventions -- see the whole controversy with drug-eluting stents. It's not clear to me that this (clever idea that was undertaken in good faith) is going to work out as a good idea from any point of view in the end.
What I never understand in these Overcoming Bias discussions of healthcare is that anything outside the US model of healthcare provision is ignored. Here in the UK, for example, we don't really have the consumer model for healthcare that you're describing, because you can't get a prescription or even a consultation with a specialist unless a GP believes it's necessary, and the GP has to follow strict guidelines set by NICE, the National Institute for Clinical Excellence, which makes national decisions about which treatments will and will not be available based on strict evidence-based marginal cost/benifit analysis. We don't have advertisements for prescription drugs on television. We don't have advertisements for hospitals at bus stops. What the studies you're quoting actually show is that the consumer model for healthcare is flawed, because consumers aren't good at predicting how effective treatments will be.The only analogious situation of healthcare as a consumer good, and marker of conspicuous consumption, in the UK is the 'alternative' healthcare sector, where middle-class people purchase expensive placebo treatments for themselves and their families and then talk about them at length at dinner parties.
It is known that private health institutions (hospitals) supply more expensive and sometimes unnecessary treatments to people with a more extensive health insurance. This is more because of economic concerns (greed?) than of health benefit.
Ever ask a barber how many "unnecessary" haircuts they provide?
This a very interesting point, and might be worth digging into. Seems it wouldn't be too hard either - take one of those studies that are eternally appearing about "disease X costs the economy Y billion dollars a year through sick days", and add level of insurance, money spent on care, and care outcomes (in terms of sick days) to the mix. Might be quite subtle to tease out the income levels (some of the working poor have less insurance but also less opportunity to be absent from work, not matter how terrible they feel - lawyers have good insurance but similarly tiny opportunity to be absent), but comparing across US states with different health systems might be helpful.
I believe the judgment regarding the 'necessity' of the additional care received was made by a panel of physicians. Were these the same physicians that provided the care? Regardless, a simple conclusion would be that medical professionals have a strong bias towards overestimating the efficacy and importance of the services they provide. Years of medical school focuses on the possible negative outcomes of underconsuming medical and the harm avoided through medical intervention- this would seem to create an environment that is highly conducive to overestimating the necessity and value one's field.
Ever ask a barber how many "unnecessary" haircuts they provide?
A person who pays full list price for a car will get better gas mileage than a person who pays less for the same exact car! Also, a car can run on sugar water, but only if the occupants really believe that the sugar water will work, so delete those sceptical thoughts from your mind or you'll be stranded at the side of the road. Just do what the car dealers tells you to do because they're the ones who conducted all this amazing research
Whoops, I did indeed mean "high glycemic." Thanks HL.
Re: strep throat: nonetheless, I don't think strep is terminal 100% of the time. If you like, choose some other non-terminal but distinctly miserable condition. The point remains the same, and I sure would like to see it addressed. (I suppose I could do the literature review myself, but in general I think when people post on some topic they should have read the paper about which they're making claims and suppositions, and be able to answer these sorts of questions.)
One possible explanation is that paying for medical care is good for you. There's a lot of research on placebos in general, and recent work shows that expensive placebos work better than cheap placebo: http://web.mit.edu/ariely/w...It is possible that paying a $10 copay makes a patient get better faster, even if the patient gets exactly identical medical care. As a result, we can't use price to the patient as a instrument for quantity. Price has an independent effect on health.Unfortunately, this idea is virtually impossible to test.
It's also difficult to divide treatments into marginal categories, because for some individuals in some situations (an MRI for someone with a minor concussion) a treatment is marginal and unlikely to result in a health benefit, while the same treatment in another situation (an MRI for someone with a brain tumor) is much more likely to result in a benefit.
It's easy to show that in some specific cases MRI is of only slight benefit, but you can't generalize that to a statement that MRI use should be forbidden since it's only of slight benefit.
Many of us have a chance to test our beliefs about healthcare.
Give up your health insurance and stop seeing doctors. You can save a significant amount of money that way just in copayments alone. And you can perhaps go to your employer and ask how much of a raise they'd give you in exchange for no health benefits. Something like 48 million americans spent some time uninsured last year, up from 46 million the year before. You could join them. If you're sure that health care does no good, it would be the right thing to do.
Then there's Alan Yeung's split:
"A better starting point would be to divide healthcare into public health, primary healthcare, emergency healthcare (accidents, injuries, etc.), care of chronic diseases (into which one should include old age), and care of major non-chronic conditions (heart disease, cancer, etc.)."
If you could get public health benefits and insurance just for emergency health care, and leave the rest....
The healthcare system of a nation doesn't have a whole lot of effect on the life expectancy of the population.http://www.nationalcenter.o..."More robust statistical analysis confirms that health care spending is not related to life expectancy. Studies of multiple countries using regression analysis found no significant relationship between life expectancy and the number of physicians and hospital beds per 100,000 population or health care expenditures as a percentage of GDP. Rather, life expectancy was associated with factors such as sanitation, clean water, income, and literacy rate.8"
Dear ShaneMaking it clear, since you may have not realised my point: no, I do not think you have to look for a MD every time you sneeze.Let us not loose the point of it all, and go back straight to it: The RAND experiment does not say that having no healthcare is better than having some. Read the study.Be a good sport and keep your good manners.
Acheman, what do you think is the best evidence about the health effectiveness of medicine in the UK?
Cassio, you are nit picking this to death, and I really hope you're missing the point on purpose, since if you're not you are astoundingly dense. Here it is again, with training wheels, which you seem to require:
There are a huge number of things that someone might go to the doctor for, for which medical intervention is NOT required to stave off death. Since you are so passionate about strep, lets forget that, and go with a sinus infection, for instance, or blood poisoning, both of which I've had, without seeing a doctor, both of which didn't kill me. Or hay fever. Or back spasms. There are an infinity of other things just like these, for which medical intervention could have significantly improved my quality of life. Defining outcomes s.t. saying that this sort of health care has no effect on them is just absurd.
I do hope you can wrap your head around this now.
Dear Shane, the point remains the same: I do not think you have read anything on streptococal infection and its complications. Despite this, you do not consider yourself wrong. By the way, when the example for your conclusion is not valid, which seems to be the case, the conclusion itself has not been proven.
A couple of the comments above call into question the expert claim that the marginal and the infra-marginal treatments are really the same. And they may well not be. In fact, when I wrote the post, I thought that this was the most likely solution to the puzzle (the puzzle being the seemingly nonsensical result that if the marginal treatments didn't do any good, and the infra-marginal treaments are just like the marginal ones, then that must mean that the infra-marginal ones don't do any good either). But now Tomhs's diminishing marginal returns story seems more likely to be the correct answer. I'm not sure that the story is right, but it is convincing enough to me that I no longer regard the puzzle as a puzzle. Eliezer is right that this story only makes sense if the treatments are non-independent, but I would imagine that this condition is satisfied.
I wonder if part of the effect is from the use of health care on those with no possibility to benefit? I noticed that this showed up as a reason that t-PA (an anti-stroke treatment) actually appeared to kill people in actual clinical practice. It could be that patients and their families insist on "doing something" when the situation is hopeless.
As these treatments may be very expensive, this could introduce a large enough error into the estimates to hide a true beneficial effect.
In general, the therapies that seem to work well are also not terribly expensive. Antibiotics to cure syphilis are cheap and actually reduce overall costs (as insane people cost money one way or the other -- although you might hide the expense by putting it in other government bodies).
In the same sense, statins for the secondary prevention (given after one heart attack has already occurred) really do seem to be worth the current cost given net benefit (and will be a very cost-effective therapy once the drugs are off patent).
On the other hand, there is a lot less evidence for other (expensive) interventions -- see the whole controversy with drug-eluting stents. It's not clear to me that this (clever idea that was undertaken in good faith) is going to work out as a good idea from any point of view in the end.
What I never understand in these Overcoming Bias discussions of healthcare is that anything outside the US model of healthcare provision is ignored. Here in the UK, for example, we don't really have the consumer model for healthcare that you're describing, because you can't get a prescription or even a consultation with a specialist unless a GP believes it's necessary, and the GP has to follow strict guidelines set by NICE, the National Institute for Clinical Excellence, which makes national decisions about which treatments will and will not be available based on strict evidence-based marginal cost/benifit analysis. We don't have advertisements for prescription drugs on television. We don't have advertisements for hospitals at bus stops. What the studies you're quoting actually show is that the consumer model for healthcare is flawed, because consumers aren't good at predicting how effective treatments will be.The only analogious situation of healthcare as a consumer good, and marker of conspicuous consumption, in the UK is the 'alternative' healthcare sector, where middle-class people purchase expensive placebo treatments for themselves and their families and then talk about them at length at dinner parties.
It is known that private health institutions (hospitals) supply more expensive and sometimes unnecessary treatments to people with a more extensive health insurance. This is more because of economic concerns (greed?) than of health benefit.
Ever ask a barber how many "unnecessary" haircuts they provide?
This a very interesting point, and might be worth digging into. Seems it wouldn't be too hard either - take one of those studies that are eternally appearing about "disease X costs the economy Y billion dollars a year through sick days", and add level of insurance, money spent on care, and care outcomes (in terms of sick days) to the mix. Might be quite subtle to tease out the income levels (some of the working poor have less insurance but also less opportunity to be absent from work, not matter how terrible they feel - lawyers have good insurance but similarly tiny opportunity to be absent), but comparing across US states with different health systems might be helpful.
I believe the judgment regarding the 'necessity' of the additional care received was made by a panel of physicians. Were these the same physicians that provided the care? Regardless, a simple conclusion would be that medical professionals have a strong bias towards overestimating the efficacy and importance of the services they provide. Years of medical school focuses on the possible negative outcomes of underconsuming medical and the harm avoided through medical intervention- this would seem to create an environment that is highly conducive to overestimating the necessity and value one's field.
Ever ask a barber how many "unnecessary" haircuts they provide?
A person who pays full list price for a car will get better gas mileage than a person who pays less for the same exact car! Also, a car can run on sugar water, but only if the occupants really believe that the sugar water will work, so delete those sceptical thoughts from your mind or you'll be stranded at the side of the road. Just do what the car dealers tells you to do because they're the ones who conducted all this amazing research
Whoops, I did indeed mean "high glycemic." Thanks HL.
Re: strep throat: nonetheless, I don't think strep is terminal 100% of the time. If you like, choose some other non-terminal but distinctly miserable condition. The point remains the same, and I sure would like to see it addressed. (I suppose I could do the literature review myself, but in general I think when people post on some topic they should have read the paper about which they're making claims and suppositions, and be able to answer these sorts of questions.)
One possible explanation is that paying for medical care is good for you. There's a lot of research on placebos in general, and recent work shows that expensive placebos work better than cheap placebo: http://web.mit.edu/ariely/w...It is possible that paying a $10 copay makes a patient get better faster, even if the patient gets exactly identical medical care. As a result, we can't use price to the patient as a instrument for quantity. Price has an independent effect on health.Unfortunately, this idea is virtually impossible to test.
It's also difficult to divide treatments into marginal categories, because for some individuals in some situations (an MRI for someone with a minor concussion) a treatment is marginal and unlikely to result in a health benefit, while the same treatment in another situation (an MRI for someone with a brain tumor) is much more likely to result in a benefit.
It's easy to show that in some specific cases MRI is of only slight benefit, but you can't generalize that to a statement that MRI use should be forbidden since it's only of slight benefit.