To me, the RAND Experiment seems clear evidence that medicine is a huge scandal. Readers of the medical literature, as well as readers of medical media coverage and students in health and medicine, have all been given the strong impression that in the aggregate, more medicine produces more health. This was the impression thirty years ago as much as today.
All you need to do is say that you don't see how it's possible (and give the reasons why you think it isn't possible). Saying "it's absurd" is essentially conflating opinion with fact. It's adding "something extra" that's not necessary, that's extraneous.
This is ubiquitous in the Internet, and in the long run doesn't add value.
Even "In my opinion it's absurd" is better, but still sub-optimal. You also need to account for arguing from personal ncredulity, however, and "I think it'd absurd" can run afoul of thst problem.
Either I've misunderstood your conclusions, or you're not making any sense at all.
You said: "To me, the RAND Experiment seems clear evidence that medicine is a huge scandal."
Medicine? The ENTIRE field of medicine? The basic idea of "This person is sick, we will perform action X and then he will feel better"? Or just most medicine as it is practiced today? Either way, I don't understand your conclusions.
The RAND experiment was not a test of "The effect of medicine on random people"; it is better described as a test of "The effect of giving free medicine to random people". That's a big difference.
Perhaps you notice this difference, considering your use of the word "more" in "[we] have all been given the strong impression that in the aggregate, more medicine produces more health." But I'm not precisely sure what you mean. "More" compared to what? Do you mean "more" compared to nothing, or "more" compared to what most people already have access to? That's an extremely important distinction. (And it still doesn't cover which *kinds* of medicine we might need more of vs. which kinds we have enough of, etc. etc.)
Let me draw an analogy with food. We all know that food is necessary to maintain one's health, right? We also know that, beyond a certain point, food is not helpful to one's health. (Eating 2000 Calories a day is much better than eating 500 Calories a day, but eating 8000 Calories at a day isn't any better than eating 2000 Calories a day)
Suppose we start with a group of randomly-selected people who all normally pay for their own food, and who all manage to purchase and eat the standard 2000 Calorie diet. Now divide the group in two, and give half of the group 2000 Calories worth of food everyday at no cost (the other half is the control group.) What will happen? Well the group with free food may eat a little more, but they won't be any healthier as a result. In the meantime they'll have extra pocket change to spend on movie tickets or whatever, since they won't need to budget as much (if anything) on food.
At the end of the study, both groups will have similar levels of health. Someone will then claim that "This experiment seems clear evidence that food is a huge scandal." and furthermore that "The food research literature must suffer from severe biases, such as fraud, funding bias, treatment selection bias, publication selection bias, leaky placebo effects, misapplied statistics, and so on."
An inaccurate conclusion, wouldn't you say? Or, if the speaker did reach the proper conclusion, then surely his wording is misleading. It *looks* like he's saying that there is no correlation at all between food and health, which is simply untrue.
If your original large group had been malnourished, then the giving of free food to half of them would have caused a great increase in health compared to the half that remained malnourished. It is only because the original large group already had sufficient food that the giving of free food had no net effect.
Similarly, I posit that the average American (at the time of the study) already had access to all the medicine that he could really make use of. Giving him additional free medicine thus had no net effect on his health. But if you had started with a large group of people with no medicinal access to speak of, then the group that received free medicine would have experienced a marked increase in health.
One vital note: The RAND experiment did NOT study people without any health insurance at all. Applying the food metaphor, this means that malnourished people were EXCLUDED from the study. In other words, the experiment proved that, among people who have basic access to healthcare, giving them free healthcare doesn't improve their health. It did NOT study anyone who had no access to healthcare to begin with and later received such access via governmental assistance.
The RAND study is helpful in deciding whether to give out free health care, and it tells us something about the effect of giving the average person *more* medicine than he already has access to. But it tells us next to nothing about the general effect of medicine in all cases. It doesn't invalidate the idea that sick people benefit from the application of medicine.
Do you see what I'm saying?
"what else but education and media biases can explain why this experiment, very expensive, well published, and the most important medical study ever, remains mostly unknown to medical students, professionals and the public? "
I have an explanation: The study doesn't prove what you (apparently) think it proves, and thus it is not nearly as important as you claim.
If a $100 million RAND experiment, Mk II, found that cutting health care expenditures by 30% had negligible health effects, this would suggest a great way to improve our knowledge of medicine: cut Medicare, Medicaid, and the tax subsidies to employer insurance and raise $500 billion to do truly gargantuan experiments and isolate helpful and harmful components of medicine.
In your original post, correct me if I'm wrong, you seemed frustrated with the state of healthcare in the United States and concluded that we must be performing many procedures which have net benefit zero.
All that I am saying, is why don't we try to find out which procedures have net benefit zero, or are harmful, and which are helpful.
Your original post spoke to the problem of bad information being used to make medical decisions. Why don't we try to improve our knowledge of medicine before we create a new system?
Joe, the purpose of developing a new better system is different and much more expensive than the purpose of testing the quality of the systems we have.
Yeah, but doesn't that put you down a slippery slope on which positive effects could get lost amongst negative ones. Each system proposed will have many factors and decisions made and at the end of the day, you probably won't be able to distinguish which of those factors or decisions helped or hurt the final outcome... which is something I assume we would like to know in attempting to create a better, more efficient healthcare system.
I am not so sure the problem is the system for choosing medicine, but rather the apparent holes in our knowledge regarding what helps and what hurts.
Shouldn't information on individual medicines allow for the configuration of an optimal system for choosing medicine.
"A new experiment could include several such systems for choosing which medicine is good enough to give patients, and see which regime actually works best. "
I think this is a great idea.... unfortunately, you are going to need a MUCH larger sample size. Any time you start looking at individual medicines, you are going to need a large population of people that actually received the medicine... your group of 10-20 thousand people will not have enough people receiving any one particular medicine to make the determination of "which medicine is good enough"... especially if you are going to account for multiple testing.
The new Michael Moore film 'Sicko' is getting rave reviews.See the BBC for a selection:http://news.bbc.co.uk/1/hi/...
I'll quote from the 'Variety' reviewhttp://www.variety.com/revi...
Quotes:
"Sicko," an affecting and entertaining dissection of the American health care industry, showing how it benefits the few at the expense of the many.
Employing his trademark personal narration and David vs. Goliath approach, Moore enlivens what is, in essence, a depressing subject by wrapping it in irony and injecting levity wherever possible: a graph shows America's position in global health care as No. 38 — just above Slovenia — and is followed by film footage of primitive operating conditions; and he offers a long list of health conditions that can deny a person insurance coverage, with the list scrolling into deep space accompanied by the "Stars Wars" theme.
Pic explores why American health care came to be exploited for profit in the private sector rather than being a government-paid, free-to-consumers service as are education, libraries, fire and police.
Pic starts by sketching a gamut of health-care horror stories from average Americans: those who can't afford insurance, those who are denied coverage for various, often ludicrous reasons, and those who believe themselves well-protected, but find that the moment they avail themselves of medical services their insurance provider uses obscure technical reasons to refuse coverage, retroactively deny claims and cancel insurance, or raise rates so astronomically that the patient is forced into the ranks of the nearly 50 million uninsured.
The congressional testimony of a former Humana medical director provides a devastatingly direct description of what she calls "the dirty work of managed care." Constantly told that she was not denying care to patients, rather simply denying them Humana's coverage, her career advanced as she saved her corporation money.----------------
Hal, the first RAND experiment included an HMO variation, where HMO administrators were a "feasible regime of quality control." Such administrators decided which medicine was good enough to give people.
Tyler Cowen responded to my petition saying he would like to see "How much healthier would we be if we retargeted expenditures to some commonly recommended areas, such as pre-natal care and prescription drugs?"
A new experiment could include several such systems for choosing which medicine is good enough to give patients, and see which regime actually works best.
I agree with the sentiment in the petition and signed it, but I was confused by the technical jargon in the final sentence:
"Whatever other purposes such an experiment pursues, it should try to make clear the aggregate health effects of variations in aggregate medical spending, variations induced by feasible regimes of quality control, including free patient choice induced by a varying aggregate price."
I think I understand the first part about aggregate spending: if we spend X% more on medicine, how much better health to do we get? But what about "variations induced by feasible regimes of quality control"? This seems to have something to do with the distinction between medicine as practiced in theory (in controlled studies, say) versus how it is practiced in the field. But the verb "induced" is tripping me up. And the last part: are we asking that the study specifically charge subjects different amounts and see how much medicine they are willing to buy? Why do we want to know that; is the point to distinguish whether medicine that people are willing to pay (more) for produces more health than "extra" medicine that comes cheap or free?
Overall I could benefit from some expansion of the logic behind how one might wish to see such a study constructed. I can see that it is not a trivial matter.
BillK,Are these "measures of quality, access, efficiency, equity" correlated with the measures of "outcomes"? Are these measures of outcomes even correlated with actual outcome? The article you link to talks about "potential years of life lost to diabetes." The gap between what the medical literature predicts for life expectancy and the real world dwarfs the gap between the US and Europe.
Do snakeoil products really have a negative impact on outcomes? Are they any less popular in Europe?
1) You have to distinguish between the theory of medicine and medical treatments (good) and medical practice as it is actually done in the US (poor).The problem in the US is not medical theory. The problem is improving the very variable experiences that customers receive. Some find it wonderful and life-saving, others have terrible experiences. Average = little overall benefit.
For examplehttp://www.sciencedaily.com...May 16, 2007US Continues To Lag On Health Care, According To New International Comparison
The U.S. health care system ranks last compared with five other nations on measures of quality, access, efficiency, equity, and outcomes, in the third edition of a Commonwealth Fund report analyzing international health policy surveys. While the U.S. did well on some preventive care measures, the nation ranked at the bottom on measures of safe care and coordinated care.
2) the second point is the huge scale of medical fraud in the US. Both via Medicare and self treatment by the general public, who will buy any snake oil or miracle cure that has a colourful advert.This impacts heavily on the poor outcome of those receiving so-called medical treatments.
On a scale of 1-10, I'd give you maybe a 3 for making that distinction clear...even in your original post.
"To me, the RAND Experiment seems clear evidence that medicine is a huge scandal."
"How else can we square the usual positive benefit found in medical publications with a net zero benefit? "
Can you perhaps reference a few articles in medical journals concerning your so-called "extra medicine"... and connect that with the "extra medicine" administered in the Rand study?
"True, but if you push the recommended mammogram age too early, then most of the positive mammograms will be false positives. This means that a whole lot of women will be subjected to both the (small) risks of the followup biopsy, and the (very large) stresses of hearing "maybe we need to look at this a bit closer...". These are the sort of tradeoffs that get made with EBM. "
I completely agree. But wouldn't you also agree that people who are at higher risk would be well-advised to start receiving routine mammograms earlier than others.
Sorry - wrong blog!
All you need to do is say that you don't see how it's possible (and give the reasons why you think it isn't possible). Saying "it's absurd" is essentially conflating opinion with fact. It's adding "something extra" that's not necessary, that's extraneous.
This is ubiquitous in the Internet, and in the long run doesn't add value.
Even "In my opinion it's absurd" is better, but still sub-optimal. You also need to account for arguing from personal ncredulity, however, and "I think it'd absurd" can run afoul of thst problem.
Either I've misunderstood your conclusions, or you're not making any sense at all.
You said: "To me, the RAND Experiment seems clear evidence that medicine is a huge scandal."
Medicine? The ENTIRE field of medicine? The basic idea of "This person is sick, we will perform action X and then he will feel better"? Or just most medicine as it is practiced today? Either way, I don't understand your conclusions.
The RAND experiment was not a test of "The effect of medicine on random people"; it is better described as a test of "The effect of giving free medicine to random people". That's a big difference.
Perhaps you notice this difference, considering your use of the word "more" in "[we] have all been given the strong impression that in the aggregate, more medicine produces more health." But I'm not precisely sure what you mean. "More" compared to what? Do you mean "more" compared to nothing, or "more" compared to what most people already have access to? That's an extremely important distinction. (And it still doesn't cover which *kinds* of medicine we might need more of vs. which kinds we have enough of, etc. etc.)
Let me draw an analogy with food. We all know that food is necessary to maintain one's health, right? We also know that, beyond a certain point, food is not helpful to one's health. (Eating 2000 Calories a day is much better than eating 500 Calories a day, but eating 8000 Calories at a day isn't any better than eating 2000 Calories a day)
Suppose we start with a group of randomly-selected people who all normally pay for their own food, and who all manage to purchase and eat the standard 2000 Calorie diet. Now divide the group in two, and give half of the group 2000 Calories worth of food everyday at no cost (the other half is the control group.) What will happen? Well the group with free food may eat a little more, but they won't be any healthier as a result. In the meantime they'll have extra pocket change to spend on movie tickets or whatever, since they won't need to budget as much (if anything) on food.
At the end of the study, both groups will have similar levels of health. Someone will then claim that "This experiment seems clear evidence that food is a huge scandal." and furthermore that "The food research literature must suffer from severe biases, such as fraud, funding bias, treatment selection bias, publication selection bias, leaky placebo effects, misapplied statistics, and so on."
An inaccurate conclusion, wouldn't you say? Or, if the speaker did reach the proper conclusion, then surely his wording is misleading. It *looks* like he's saying that there is no correlation at all between food and health, which is simply untrue.
If your original large group had been malnourished, then the giving of free food to half of them would have caused a great increase in health compared to the half that remained malnourished. It is only because the original large group already had sufficient food that the giving of free food had no net effect.
Similarly, I posit that the average American (at the time of the study) already had access to all the medicine that he could really make use of. Giving him additional free medicine thus had no net effect on his health. But if you had started with a large group of people with no medicinal access to speak of, then the group that received free medicine would have experienced a marked increase in health.
One vital note: The RAND experiment did NOT study people without any health insurance at all. Applying the food metaphor, this means that malnourished people were EXCLUDED from the study. In other words, the experiment proved that, among people who have basic access to healthcare, giving them free healthcare doesn't improve their health. It did NOT study anyone who had no access to healthcare to begin with and later received such access via governmental assistance.
The RAND study is helpful in deciding whether to give out free health care, and it tells us something about the effect of giving the average person *more* medicine than he already has access to. But it tells us next to nothing about the general effect of medicine in all cases. It doesn't invalidate the idea that sick people benefit from the application of medicine.
Do you see what I'm saying?
"what else but education and media biases can explain why this experiment, very expensive, well published, and the most important medical study ever, remains mostly unknown to medical students, professionals and the public? "
I have an explanation: The study doesn't prove what you (apparently) think it proves, and thus it is not nearly as important as you claim.
Joe,
If a $100 million RAND experiment, Mk II, found that cutting health care expenditures by 30% had negligible health effects, this would suggest a great way to improve our knowledge of medicine: cut Medicare, Medicaid, and the tax subsidies to employer insurance and raise $500 billion to do truly gargantuan experiments and isolate helpful and harmful components of medicine.
Robin,
In your original post, correct me if I'm wrong, you seemed frustrated with the state of healthcare in the United States and concluded that we must be performing many procedures which have net benefit zero.
All that I am saying, is why don't we try to find out which procedures have net benefit zero, or are harmful, and which are helpful.
Your original post spoke to the problem of bad information being used to make medical decisions. Why don't we try to improve our knowledge of medicine before we create a new system?
Joe, the purpose of developing a new better system is different and much more expensive than the purpose of testing the quality of the systems we have.
Yeah, but doesn't that put you down a slippery slope on which positive effects could get lost amongst negative ones. Each system proposed will have many factors and decisions made and at the end of the day, you probably won't be able to distinguish which of those factors or decisions helped or hurt the final outcome... which is something I assume we would like to know in attempting to create a better, more efficient healthcare system.
I am not so sure the problem is the system for choosing medicine, but rather the apparent holes in our knowledge regarding what helps and what hurts.
Shouldn't information on individual medicines allow for the configuration of an optimal system for choosing medicine.
Joe, an experiment could show that a certain system for choosing medicine did better on average without evaluating individual medicines.
"A new experiment could include several such systems for choosing which medicine is good enough to give patients, and see which regime actually works best. "
I think this is a great idea.... unfortunately, you are going to need a MUCH larger sample size. Any time you start looking at individual medicines, you are going to need a large population of people that actually received the medicine... your group of 10-20 thousand people will not have enough people receiving any one particular medicine to make the determination of "which medicine is good enough"... especially if you are going to account for multiple testing.
The new Michael Moore film 'Sicko' is getting rave reviews.See the BBC for a selection:http://news.bbc.co.uk/1/hi/...
I'll quote from the 'Variety' reviewhttp://www.variety.com/revi...
Quotes:
"Sicko," an affecting and entertaining dissection of the American health care industry, showing how it benefits the few at the expense of the many.
Employing his trademark personal narration and David vs. Goliath approach, Moore enlivens what is, in essence, a depressing subject by wrapping it in irony and injecting levity wherever possible: a graph shows America's position in global health care as No. 38 — just above Slovenia — and is followed by film footage of primitive operating conditions; and he offers a long list of health conditions that can deny a person insurance coverage, with the list scrolling into deep space accompanied by the "Stars Wars" theme.
Pic explores why American health care came to be exploited for profit in the private sector rather than being a government-paid, free-to-consumers service as are education, libraries, fire and police.
Pic starts by sketching a gamut of health-care horror stories from average Americans: those who can't afford insurance, those who are denied coverage for various, often ludicrous reasons, and those who believe themselves well-protected, but find that the moment they avail themselves of medical services their insurance provider uses obscure technical reasons to refuse coverage, retroactively deny claims and cancel insurance, or raise rates so astronomically that the patient is forced into the ranks of the nearly 50 million uninsured.
The congressional testimony of a former Humana medical director provides a devastatingly direct description of what she calls "the dirty work of managed care." Constantly told that she was not denying care to patients, rather simply denying them Humana's coverage, her career advanced as she saved her corporation money.----------------
Sounds like a film worth seeing.
BillK
Hal, the first RAND experiment included an HMO variation, where HMO administrators were a "feasible regime of quality control." Such administrators decided which medicine was good enough to give people.
Tyler Cowen responded to my petition saying he would like to see "How much healthier would we be if we retargeted expenditures to some commonly recommended areas, such as pre-natal care and prescription drugs?"
A new experiment could include several such systems for choosing which medicine is good enough to give patients, and see which regime actually works best.
I agree with the sentiment in the petition and signed it, but I was confused by the technical jargon in the final sentence:
"Whatever other purposes such an experiment pursues, it should try to make clear the aggregate health effects of variations in aggregate medical spending, variations induced by feasible regimes of quality control, including free patient choice induced by a varying aggregate price."
I think I understand the first part about aggregate spending: if we spend X% more on medicine, how much better health to do we get? But what about "variations induced by feasible regimes of quality control"? This seems to have something to do with the distinction between medicine as practiced in theory (in controlled studies, say) versus how it is practiced in the field. But the verb "induced" is tripping me up. And the last part: are we asking that the study specifically charge subjects different amounts and see how much medicine they are willing to buy? Why do we want to know that; is the point to distinguish whether medicine that people are willing to pay (more) for produces more health than "extra" medicine that comes cheap or free?
Overall I could benefit from some expansion of the logic behind how one might wish to see such a study constructed. I can see that it is not a trivial matter.
BillK,Are these "measures of quality, access, efficiency, equity" correlated with the measures of "outcomes"? Are these measures of outcomes even correlated with actual outcome? The article you link to talks about "potential years of life lost to diabetes." The gap between what the medical literature predicts for life expectancy and the real world dwarfs the gap between the US and Europe.
Do snakeoil products really have a negative impact on outcomes? Are they any less popular in Europe?
Two comments.
1) You have to distinguish between the theory of medicine and medical treatments (good) and medical practice as it is actually done in the US (poor).The problem in the US is not medical theory. The problem is improving the very variable experiences that customers receive. Some find it wonderful and life-saving, others have terrible experiences. Average = little overall benefit.
For examplehttp://www.sciencedaily.com...May 16, 2007US Continues To Lag On Health Care, According To New International Comparison
The U.S. health care system ranks last compared with five other nations on measures of quality, access, efficiency, equity, and outcomes, in the third edition of a Commonwealth Fund report analyzing international health policy surveys. While the U.S. did well on some preventive care measures, the nation ranked at the bottom on measures of safe care and coordinated care.
2) the second point is the huge scale of medical fraud in the US. Both via Medicare and self treatment by the general public, who will buy any snake oil or miracle cure that has a colourful advert.This impacts heavily on the poor outcome of those receiving so-called medical treatments.
Robin,
On a scale of 1-10, I'd give you maybe a 3 for making that distinction clear...even in your original post.
"To me, the RAND Experiment seems clear evidence that medicine is a huge scandal."
"How else can we square the usual positive benefit found in medical publications with a net zero benefit? "
Can you perhaps reference a few articles in medical journals concerning your so-called "extra medicine"... and connect that with the "extra medicine" administered in the Rand study?
"True, but if you push the recommended mammogram age too early, then most of the positive mammograms will be false positives. This means that a whole lot of women will be subjected to both the (small) risks of the followup biopsy, and the (very large) stresses of hearing "maybe we need to look at this a bit closer...". These are the sort of tradeoffs that get made with EBM. "
I completely agree. But wouldn't you also agree that people who are at higher risk would be well-advised to start receiving routine mammograms earlier than others.