An epidemic of unnecessary and unhelpful medical treatments(theatlantic.com)
theatlantic.com
An epidemic of unnecessary and unhelpful medical treatments
https://www.theatlantic.com/health/archive/2017/02/when-evidence-says-no-but-doctors-say-yes/517368/?single_page=true
121 comments
> but a potentially bigger issue with the act is that it transfers $3.5 billion of public health spending to medical research.
I would like to see much more public funding going towards medical research, with the stipulation that the results must be open and cannot be patented.
In mentioning this I just had an idea that I don't remember seeing before. I wonder if there should just be a sort of medical treatment lottery for pharma companies. They come up with a treatment, get a patent, and prove it works as normal. Instead of allowing the monopoly however, the FDA could buy out the patent and make it public domain. The pharma company gets a guaranteed and immediate profit (say 50% of the projected total profit over the life of the patent). Meanwhile any company can then produce the drug/device/etc. competing on the quality and price of the treatment, separate from the cost of the research that led to it.
I would like to see much more public funding going towards medical research, with the stipulation that the results must be open and cannot be patented.
In mentioning this I just had an idea that I don't remember seeing before. I wonder if there should just be a sort of medical treatment lottery for pharma companies. They come up with a treatment, get a patent, and prove it works as normal. Instead of allowing the monopoly however, the FDA could buy out the patent and make it public domain. The pharma company gets a guaranteed and immediate profit (say 50% of the projected total profit over the life of the patent). Meanwhile any company can then produce the drug/device/etc. competing on the quality and price of the treatment, separate from the cost of the research that led to it.
I think we should definitely experiment with how we incentivize research, but one of the problems with profit is that it's hard to quantify. Basically it's easy for companies to make profits disappear. I.e. Lookup Hollywood accounting.
I read once about a prize based on QALY gained (quality adjusted life years) over current best practices. One of the best parts about this is you could give it for unpatentable advanced like diet/exercise/herbs.
Lots of money is wasted trying to take an unpatentable ideas like intermittent fasting/curcumin and turn them into patentable drugs.
I read once about a prize based on QALY gained (quality adjusted life years) over current best practices. One of the best parts about this is you could give it for unpatentable advanced like diet/exercise/herbs.
Lots of money is wasted trying to take an unpatentable ideas like intermittent fasting/curcumin and turn them into patentable drugs.
There's nothing wrong with public funding of medical research.
Taking funds away from public health to do medical research is highly questionable.
Taking funds away from public health to do medical research is highly questionable.
One of the reasons this happens is conservative economic philosophy. Public health is carried out by the government, while drug sales are carried out by private corporations, and according to conservative economic philosophy, private corporations are better than the government.
The problem is conservative economic philosophy depends on letting a problem get bad enough that the typical customer becomes informed. How many people do you want to get MDR TB before people are sufficiently interested in the topic to become informed enough to make rational decisions in a well-developed market?
I'm not sure people realize how much the public health labs do that would simply never pay, yet saves lives: who's going to speciate and sequence rare, but highly contagious or virulent organisms (like MDR TB) isolated from some one homeless person, who, by virtue of their unfortunate circumstances, serves as a canary in the coalmine of the modern city.
I'm not sure people realize how much the public health labs do that would simply never pay, yet saves lives: who's going to speciate and sequence rare, but highly contagious or virulent organisms (like MDR TB) isolated from some one homeless person, who, by virtue of their unfortunate circumstances, serves as a canary in the coalmine of the modern city.
I agree and I wasn't clear enough about that. Moving funds from areas that provide clear tangible results to research that might produce results seems wrong.
The problem with awarding a prize is rather than the market awarding it, some person or persons has to make a judgement call on what prize amount to award. What if two companies come up with similar drugs, but one is slightly more efficacious? Do you just split the prize 70/30? Or 60/40? What if that split doesn't cover the R&D costs?
I can think of a number of ways it could go wrong.
I can think of a number of ways it could go wrong.
Adding to this article (I'm not a medical professional and not giving advice), the same inferior medical outcomes are attributed to most, if not all forms of back surgery. Physical therapy outperforms most or all back surgery with much fewer side effects, etc. This is covered extensively in the book How Doctors Think (https://www.amazon.com/How-Doctors-Think-Jerome-Groopman/dp/...) as well as articles like this Ars Technica one: https://arstechnica.com/science/2017/02/doctors-lower-back-p....
You see the same with exercise outperforming anti-depressants in most cases, again with much fewer side effects. (For example: https://www.theatlantic.com/health/archive/2014/03/for-depre...)
The kicker is that doctors will often refuse these same treatments when offered, which is not a good reflection on their efficacy (again covered in How Doctors Think). This is not an indictment of modern medicine (which is often very effective on acute care), just a recognition of the limitations.
The kicker is that doctors will often refuse these same treatments when offered, which is not a good reflection on their efficacy (again covered in How Doctors Think). This is not an indictment of modern medicine (which is often very effective on acute care), just a recognition of the limitations.
Exercise helped reduce my depression and anxiety, and I tried to cure it without medication for 2 years. Finally I gave in and went on a low dose of lexapro, in addition to my usual exercise and healthy diet, and I recovered within weeks. Completely changed my life. I know this is just my anecdote, but when natural remedies fail, don't be afraid of medicine.
It's probably worth giving some qualifiers on the grandparent comment. In short, the depressed population is bimodal with close to 2/3rds not responding to SSRIs and similar treatments satisfactorily and 1/3rd of people responding well. For the most part this is due to all of the different causes of depression being lumped in together. When the root cause of your depression is brain chemistry then you need the drugs, but if its secondary to environmental factors then it'll be less effective than lifestyle interventions.
This leads to people saying that those lifestyle interventions are more effective in general, but that's due to them being appropriate for more patients, while there's a smaller population for which these interventions won't work well. Good doctors/psychologists will identify which patients are which over time.
This leads to people saying that those lifestyle interventions are more effective in general, but that's due to them being appropriate for more patients, while there's a smaller population for which these interventions won't work well. Good doctors/psychologists will identify which patients are which over time.
I agree. If medical treatments make sense in specific cases, of course use them. And sometimes combination treatments are the best (as mentioned in this thread). But hopefully this is preceded by a talk about cost/benefit of all approaches and the weighted risks (including doing nothing), something that doesn't seem to be happening in a lot of cases in the US.
> but when natural remedies fail, don't be afraid of medicine.
SSRIs frequently create their own problems. They are sometimes effective because of their effect on the neuroactive steroids:
https://en.wikipedia.org/wiki/Neuroactive_steroid#Role_in_an...
Depressed people frequently have a metabolic problem, where they don't make enough ATP. This is caused by thyroid imbalances, poisoning with excess Omega-6 polyunsaturated oils, etc.
SSRIs frequently create their own problems. They are sometimes effective because of their effect on the neuroactive steroids:
https://en.wikipedia.org/wiki/Neuroactive_steroid#Role_in_an...
Depressed people frequently have a metabolic problem, where they don't make enough ATP. This is caused by thyroid imbalances, poisoning with excess Omega-6 polyunsaturated oils, etc.
I've been on anti-depressants since I was 17. I'm 30 now. Buproprion works best for me, to which I later added lamictal.
Prior to that, I'd been depressed since I could remember. In hindsight, I may have had mild aspergers like symptoms, mostly related to reading social cues. This wasn't "just growing up" despite shrinks for years telling me it was.
Finding the right anti-depressant changed my life for the better. Absolutely changed my life. After college, I went off them for a year just to see if I "needed them" any more. Within 6 months, I noticed my thoughts slip into old patterns of hopelessness, counterproductivity, loneliness, and general loops of existential pain, and this outlook effected everything and everyone around me. I do need them, it turns out.
So I wish people around me hadn't been so against drugs. In my case, they should have tried them earlier in treatment. That would have saved me some years of suffering.
Also, I tried prosac, lexapro, and effexor before buproprion. If I'd listened to the many drug critics, I'd have stopped looking after prosac (side effects there included sexual disfunction and mania). I notice no notable side effects with my current cocktail.
Also, I've exercised and been in good shape both pre and post taking anti-depressants. I feel better if I'm exercising than not, but it's not even in the same ballpark as what the drugs do for me. Everyone should exercise, not everyone benefits from anti-depressants. No exaggeration, I'd be dead without them.
Prior to that, I'd been depressed since I could remember. In hindsight, I may have had mild aspergers like symptoms, mostly related to reading social cues. This wasn't "just growing up" despite shrinks for years telling me it was.
Finding the right anti-depressant changed my life for the better. Absolutely changed my life. After college, I went off them for a year just to see if I "needed them" any more. Within 6 months, I noticed my thoughts slip into old patterns of hopelessness, counterproductivity, loneliness, and general loops of existential pain, and this outlook effected everything and everyone around me. I do need them, it turns out.
So I wish people around me hadn't been so against drugs. In my case, they should have tried them earlier in treatment. That would have saved me some years of suffering.
Also, I tried prosac, lexapro, and effexor before buproprion. If I'd listened to the many drug critics, I'd have stopped looking after prosac (side effects there included sexual disfunction and mania). I notice no notable side effects with my current cocktail.
Also, I've exercised and been in good shape both pre and post taking anti-depressants. I feel better if I'm exercising than not, but it's not even in the same ballpark as what the drugs do for me. Everyone should exercise, not everyone benefits from anti-depressants. No exaggeration, I'd be dead without them.
One of the mental hospitals gave my friend Wellbutrin. They took it away when they found her insufflating it. Thereafter they didn't care about her complaints of depression, and just forced her to take the suicide ideation pill ("anti-psychotic").
I guess Wellbutrin has mild stimulating properties. SSRI drugs were approved on the basis of fraudulent science. The MAOIs were reasonably effective, but caused high blood pressure when the patient also ate fine cheese.
I guess Wellbutrin has mild stimulating properties. SSRI drugs were approved on the basis of fraudulent science. The MAOIs were reasonably effective, but caused high blood pressure when the patient also ate fine cheese.
I've heard of people doing that with Wellbutrin, always struck me as strange -- it takes a couple weeks to notice any effects orally. A move of desperation, no doubt.
I will say some weird side effects have been cigarettes taste like shit and aren't addictive, cocaine doesn't work quite right, and MDMA doesn't work at all. Something about Wellbutrin binding strongly to the same receptors and blocking the others. Probably for the best though...
I will say some weird side effects have been cigarettes taste like shit and aren't addictive, cocaine doesn't work quite right, and MDMA doesn't work at all. Something about Wellbutrin binding strongly to the same receptors and blocking the others. Probably for the best though...
> A move of desperation, no doubt.
Certainly. Well-said, thanks.
> cigarettes taste like shit and aren't addictive
I learned from a hacker news comment that current thinking is that tobacco is addictive because of the combination of nicotine and chemicals that have an MAOI effect.
Certainly. Well-said, thanks.
> cigarettes taste like shit and aren't addictive
I learned from a hacker news comment that current thinking is that tobacco is addictive because of the combination of nicotine and chemicals that have an MAOI effect.
I'd be curious to learn more about what you know about this. Could we have a conversation? I'm a professor at WashU can you email me?
[email protected]
[email protected]
It seems that in a lot of cases of "unhelpful medical treatments" is a result of doctors forgetting the basics. If the doctor overlooks basics like lifestyle factors, electrolytes, vitamin deficiencies etc. then medications are of limited help in treating conditions like depression.
"the same inferior medical outcomes are attributed to most, if not all forms of back surgery."
I ran, not walked, to this thread without reading the article just to talk about back surgeries.
It is stupefying and outrageous that people allow themselves to get butchered up (yes, butchered up - go read about spinal fusions, etc.) for an outcome that could easily be achieved by merely walking a few miles a few days per week.
I ran, not walked, to this thread without reading the article just to talk about back surgeries.
It is stupefying and outrageous that people allow themselves to get butchered up (yes, butchered up - go read about spinal fusions, etc.) for an outcome that could easily be achieved by merely walking a few miles a few days per week.
Except when you are in a condition that you can barely walk more than 100 meters without having to stop giving the pain. Or when you try all kinds of physical interventions (physical therapy - pilates - yoga - quiropracty - osteopathy) that just makes you feel miserable in the end of the day.
Or that you are taking so much painkillers (from all ranges, up to opiates) that you just have the side effects and not the benefits.
Or that you are taking so much painkillers (from all ranges, up to opiates) that you just have the side effects and not the benefits.
This is only a problem in the US (aka "list of countries with private healthcare"). In Canada, we are actively trying to prevent any medical procedure possible because of the huge expense.
I just completed a huge app to educate and prevent diabetic foot amputations. It costs $70,000 to remove a foot and the government is really trying to cut down on these if they are preventable. Patient gets to keep their foot, government doesn't have to spend money - win win!
In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations? You don't get the $70k from the surgeries and you also don't get to subscribe them to a lifetime of therapy and prosthetics. Chop off more feet, I say!
I just completed a huge app to educate and prevent diabetic foot amputations. It costs $70,000 to remove a foot and the government is really trying to cut down on these if they are preventable. Patient gets to keep their foot, government doesn't have to spend money - win win!
In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations? You don't get the $70k from the surgeries and you also don't get to subscribe them to a lifetime of therapy and prosthetics. Chop off more feet, I say!
The article specifically addresses the fact that profit motive alone does not account for the prevalence unnecessary treatment.
Further, only about 20% of US hospitals are private, for-profit endeavors. Over 75% are not-for-profit or government. Of course, they are still affected bybthings like revenue, prestige, "performance" metrics, etc. But Canadian hospitals suffer from those same drivers.
I applaud the work you are doing, but I question your confidence that the US system is the only system with these issues.
I applaud the work you are doing, but I question your confidence that the US system is the only system with these issues.
Don't get confused by the label "non profit". Not for profit hospitals still make a lot of profit for their management. Their incentives are similar to for profit hospitals. The money just God to different people.
the issue is funding... it doesn't matter if the hospital is run as a non-profit, as long as they are funded by insurance claims then the incentive is to do more expensive treatment... paying for more equipment, doctors etc
publicly-funded health care has the opposite problem - constant pressure to reduce the budget
publicly-funded health care has the opposite problem - constant pressure to reduce the budget
Does the insurance company have an incentive to pay as much as possible?
IIRC, the ACA has stipulation that 80% of premiums must be spent on medical services, so...a larger spend -> increased premiums -> a larger 20% piece of pie they can keep.
That's true, the minimum MLR creates a distorsion to the incentives.
[Gross oversimplification] Nope - insurers are incentivized to pay as little as they can get away with. Which leads to healthcare providers being incentivized to bill the insurers as much as they can get away with. They'll meet somewhere in the middle.
There is different math for each system.
In the USA:
if riskFromTreatment <= riskFromNoTreatment: doTreatment
In most public systems:
if (treatmentCost <= someThresholdPerBenefit) && (riskFromTreatment <= riskFromNoTreatment): doTreatment
In practice, treatment outcomes are pretty similar, but more treatments are preformed in the USA system. Being a for-profit system is one cause, but so is the litigation culture. Not doing every possible treatment and test can lead to the physician being accused of being negligent.
In the USA:
if riskFromTreatment <= riskFromNoTreatment: doTreatment
In most public systems:
if (treatmentCost <= someThresholdPerBenefit) && (riskFromTreatment <= riskFromNoTreatment): doTreatment
In practice, treatment outcomes are pretty similar, but more treatments are preformed in the USA system. Being a for-profit system is one cause, but so is the litigation culture. Not doing every possible treatment and test can lead to the physician being accused of being negligent.
That's a bit of a strawman argument. In your math, you need to include the point that the article makes - that the American system always considers riskFromNoTreatment to be close to infinite. The risk is completely skewed on the American side, doctors are saying "EVERYTHING WILL KILL YOU TREAT IT NOW"!
That's an overbroad generalization. Not even close to all doctors constantly push for aggressive treatment of all medical conditions.
You have the US math wrong.
It is easier to sue for not treating than for over treating, and treating generates a profit. Therefore the default is excess treating EVEN THOUGH health outcomes are equivalent to worse.
(If you think this might be absurdly expensive, you are right. A glance at the costs and outcomes in the US vs other countries verifies this.)
if profitFromTreatment <= profitFromNoTreatment:
doTreatment
It is easier to sue for not treating than for over treating, and treating generates a profit. Therefore the default is excess treating EVEN THOUGH health outcomes are equivalent to worse.
(If you think this might be absurdly expensive, you are right. A glance at the costs and outcomes in the US vs other countries verifies this.)
I like the idea of more tests and data-driven medical decisions.
It would be nice if most of those tests were usually 'effective' (fairly accurate, or really cheep with rarely a false negative and a better confirmation test if warranted).
It would be nice if the goal was to /prove/ someone was healthy, just like how burn-in tests 'prove' that built systems function within the desired parameters.
It would be nice if most of those tests were usually 'effective' (fairly accurate, or really cheep with rarely a false negative and a better confirmation test if warranted).
It would be nice if the goal was to /prove/ someone was healthy, just like how burn-in tests 'prove' that built systems function within the desired parameters.
> In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations?
My Uncle died a few years ago when a tree fell on him while working in his back yard. While trying to stabilize him, a doctor put in a request to have a surgeon amputate his leg to prevent complications once he was stabilized. My uncle died that day, and a day later a surgeon and anesthesiologist came to amputate his leg. When he wasn't found in his hospital room, they went down to the morgue, amputated his leg there, and billed the insurance company for the procedure... including the cost of anesthetizing the dead man.
Ridiculous stories like this abound in the American system of healthcare.
My Uncle died a few years ago when a tree fell on him while working in his back yard. While trying to stabilize him, a doctor put in a request to have a surgeon amputate his leg to prevent complications once he was stabilized. My uncle died that day, and a day later a surgeon and anesthesiologist came to amputate his leg. When he wasn't found in his hospital room, they went down to the morgue, amputated his leg there, and billed the insurance company for the procedure... including the cost of anesthetizing the dead man.
Ridiculous stories like this abound in the American system of healthcare.
I don't believe that incident actually happened. While there are a few crooked doctors it's highly unlikely that 2 of them would commit easily detected criminal insurance fraud in a hospital setting for a relatively small surgery fee. Do you have any hard evidence?
Honestly it sounds like you either made this story up or you got the details completely wrong.
That simply isn't how it works in the US. There are specific standards of care for diabetes including annual foot exams. Insurance companies, and federal and state governments, require providers to report on those quality measures and penalize them for insufficient compliance.
https://www.qualitymeasures.ahrq.gov/summaries/summary/48831...
https://www.qualitymeasures.ahrq.gov/summaries/summary/48831...
>This is only a problem in the US (aka "list of countries with private healthcare").
This is complete nonsense and I'd like to see the source of this. Do you really think the state has any incentive to prevent health insurance and treatments from costing a lot? Spoiler alert: It doesn't. The state never has any incentive to save, it grows and grows. The more socialised and rigid your healthcare system, the more bloated it gets, and the more doctor and insurance mafia you get.
The strongest incentive to save is if the customer is free to decide. We see this time and time again. We do not have to force the people to save money, the market forces do a wonderful job all by themselves.
Now, what's got to happen is that patients inform themselves and diversify diagnosis. The crux of the problem is that patients seek advice from the exact same people who can make large financial gains if the patient opts for a certain treatment. Now, this is really just a beginner's mistake in negotiation and not something you can fix at the state level (since if you try to do that, the costs are socialised, but the poor judgement of the patient remains)
What needs to happen is that if doctors say "Don't inform yourself about your condition and don't read on the internet", get up, tell them to fuck off and get informed - like you would about every other service you like to buy. NEVER tolerate being taught ignorance. Nothing good comes out of ignorance, ever.
This is complete nonsense and I'd like to see the source of this. Do you really think the state has any incentive to prevent health insurance and treatments from costing a lot? Spoiler alert: It doesn't. The state never has any incentive to save, it grows and grows. The more socialised and rigid your healthcare system, the more bloated it gets, and the more doctor and insurance mafia you get.
The strongest incentive to save is if the customer is free to decide. We see this time and time again. We do not have to force the people to save money, the market forces do a wonderful job all by themselves.
Now, what's got to happen is that patients inform themselves and diversify diagnosis. The crux of the problem is that patients seek advice from the exact same people who can make large financial gains if the patient opts for a certain treatment. Now, this is really just a beginner's mistake in negotiation and not something you can fix at the state level (since if you try to do that, the costs are socialised, but the poor judgement of the patient remains)
What needs to happen is that if doctors say "Don't inform yourself about your condition and don't read on the internet", get up, tell them to fuck off and get informed - like you would about every other service you like to buy. NEVER tolerate being taught ignorance. Nothing good comes out of ignorance, ever.
> The more socialised and rigid your healthcare system, the more bloated it gets, and the more doctor and insurance mafia you get.
I'd like to see your source for this. Many reports have demonstrated that the US spends dramatically more on healthcare to get equal or worse results than the majority (almost all?) of developed countries. Those countries don't have one system, they have a variety - state run health care, state-paid health care, state heavily regulated health care...and they all work better than our system.
1) My understanding is that Medicaid/Medicare has consistently spent less money on overhead than private insurance.
2) Have you TRIED to get pricing information from a hospital? The market has done a terrible job.
3) Or, in simply talking to my doctor, if I need a second opinion from someone who has no incentive to mis-state the risks/benefits, AND is knowledgable enough to give me accurate opinions, exactly to whom should I turn? Or should I become a subject matter expert on every service in my life, so that I know that the non-FDA drugs I'm using actually work (which assumes that there is actual public evidence one way or the other in the absence of govt requirements), that the food I eat is safe, that my medical treatments are necessary and helpful....
> NEVER tolerate being taught ignorance.
Here, however, we are in agreement.
I'd like to see your source for this. Many reports have demonstrated that the US spends dramatically more on healthcare to get equal or worse results than the majority (almost all?) of developed countries. Those countries don't have one system, they have a variety - state run health care, state-paid health care, state heavily regulated health care...and they all work better than our system.
1) My understanding is that Medicaid/Medicare has consistently spent less money on overhead than private insurance.
2) Have you TRIED to get pricing information from a hospital? The market has done a terrible job.
3) Or, in simply talking to my doctor, if I need a second opinion from someone who has no incentive to mis-state the risks/benefits, AND is knowledgable enough to give me accurate opinions, exactly to whom should I turn? Or should I become a subject matter expert on every service in my life, so that I know that the non-FDA drugs I'm using actually work (which assumes that there is actual public evidence one way or the other in the absence of govt requirements), that the food I eat is safe, that my medical treatments are necessary and helpful....
> NEVER tolerate being taught ignorance.
Here, however, we are in agreement.
FWIW, I lived with someone who chopped diabetics' feet off for her living, and she always, always, always did her best to make that option a last resort, "the only alternative is total incapacitation" medical decision.
She would have loved to have an app like this.
So in my anecdotal experience at least, doctors are at least trying to do the right thing.
She would have loved to have an app like this.
So in my anecdotal experience at least, doctors are at least trying to do the right thing.
It would really hammer home your argument if you showed that outcomes for diabetes patients in the US were worse.
In the US, a hospital would be stupid to make an app like this
Perhaps, but in this example, shouldn't you be considering the insurance company as the entity with the motive to prevent expensive treatments?
Perhaps, but in this example, shouldn't you be considering the insurance company as the entity with the motive to prevent expensive treatments?
No, because the insurance company needs a reason to jack rates year-after-year. They need the number of diabetic foot amputations to increase so that they can justify increasing premiums.
That is an extremely ignorant statement and not at all reflective of how the medical insurance business actually works. In reality most large group buyers are self-insured now and the "insurance company" just administers claims and payments without bearing risk. So they have no financial incentive to increase the number of diabetic foot amputations.
Do you think insurance companies enjoy increasing rates for the sake of increasing rates?
If they're increasing rates because their costs have gone up, they're not making more profit. And other insurance companies that have done more to control costs are likely to start taking their customers over time.
If they're increasing rates because their costs have gone up, they're not making more profit. And other insurance companies that have done more to control costs are likely to start taking their customers over time.
> In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations? You don't get the $70k from the surgeries and you also don't get to subscribe them to a lifetime of therapy and prosthetics.
Isn't the prognosis something like 2 years after foot amputation for people with diabetes?
Better early treatment keeps them alive for longer and thus buying all the test strips and injecting pens plus needles plus etc.
Isn't the prognosis something like 2 years after foot amputation for people with diabetes?
Better early treatment keeps them alive for longer and thus buying all the test strips and injecting pens plus needles plus etc.
I may be mistaken, but I don't believe amputation cure the diabetic. They continue to have and manage the disease with the methods you mention.
It is difficult to make rational decisions when there is a political advantage to be had by misrepresenting the facts. Every system, whether private or socialized, medical or otherwise, has to decide to how allocate limited resources. When party leaders, along with popular media, can successfully label this "death panels," I don't see hope for a rational solution.
Insurance companies have the incentive, not hospitals themselves. There are plenty of US insurance companies that would pay for the app if it meant they could avoid paying $70K for a foot amputation.
Perhaps the problem is the socialized part of our system where you can get any prescription on Medicare for $5. That sure creates a lot of demand.
Sadly, the problem is not just excessive treatment, but also lack of them, for the exact same reason: medics seemly hate science.
Example: Thyroid disease diagnostic and treatment problems are so common, that there are organizations made solely to support thyroid patients, including having lawyers specialized in suing doctors to force them to start treatment...
The reason for that, is that although there is plenty of research showing that the 80s blood tests are too conservative (they only show positive to people that are usually too damaged beyond any repair), many doctors insist in using solely those tests, and ignore symptoms and newer blood tests.
This does have to do with pharmaceutic industry though, some of the organizations pushing for the 80s tests are all supported by pharma companies, and the same companies also have lobbists that try to get in the way of allowing research of treatments that would skip such companies, for example many patients only improve when using "alternative" but centuries old methods that were known to work for centuries, yet lobbists and pharma companies try to convince doctors and politicians that these ancient methods are "wrong because they are old", and don't allow even research to proceed properly, the leading manufacturer of thyroid medicine that works is in Thailand, because in most other countries their business is considered shady or sketchy.
Same thing happen in psychiatry, problems that are popular in the public mind are overdiagnosed, specially when they have expensive medication, yet when the problems aren't popular, psychiatrists refuse to treat sufferers. I found a strange case with ADHD: kids are being pumped full of meds due to the fact that they keep disrupting classrooms and ADHD is a "popular" disease with kids, but all adults I know that are actual sufferers from ADHD to the point of disrupting their adult lives, struggle to find treatment, with the usual excuse from doctors being that the meds are "too dangerous" (then why give it to the kids by the boatload?) or that people in their 20s seeking meds must be some kind of junkie looking to boost academic performance, nevermind if non-academic symptoms are there too.
Example: Thyroid disease diagnostic and treatment problems are so common, that there are organizations made solely to support thyroid patients, including having lawyers specialized in suing doctors to force them to start treatment...
The reason for that, is that although there is plenty of research showing that the 80s blood tests are too conservative (they only show positive to people that are usually too damaged beyond any repair), many doctors insist in using solely those tests, and ignore symptoms and newer blood tests.
This does have to do with pharmaceutic industry though, some of the organizations pushing for the 80s tests are all supported by pharma companies, and the same companies also have lobbists that try to get in the way of allowing research of treatments that would skip such companies, for example many patients only improve when using "alternative" but centuries old methods that were known to work for centuries, yet lobbists and pharma companies try to convince doctors and politicians that these ancient methods are "wrong because they are old", and don't allow even research to proceed properly, the leading manufacturer of thyroid medicine that works is in Thailand, because in most other countries their business is considered shady or sketchy.
Same thing happen in psychiatry, problems that are popular in the public mind are overdiagnosed, specially when they have expensive medication, yet when the problems aren't popular, psychiatrists refuse to treat sufferers. I found a strange case with ADHD: kids are being pumped full of meds due to the fact that they keep disrupting classrooms and ADHD is a "popular" disease with kids, but all adults I know that are actual sufferers from ADHD to the point of disrupting their adult lives, struggle to find treatment, with the usual excuse from doctors being that the meds are "too dangerous" (then why give it to the kids by the boatload?) or that people in their 20s seeking meds must be some kind of junkie looking to boost academic performance, nevermind if non-academic symptoms are there too.
Which specific thyroid organization sues doctors to force treatment? That seems highly unlikely. Refusal to provide treatment doesn't constitute malpractice.
These are the problems when arts and crafts with scientific elements are confused in the popular and professional imagination with science.
> but all adults I know that are actual sufferers from ADHD to the point of disrupting their adult lives, struggle to find treatment, with the usual excuse from doctors being that the meds are "too dangerous" (then why give it to the kids by the boatload?)
Not that I'm excusing this, but aren't most ADHD drugs powerful stimulants that are similar to street drugs? Adults would have the autonomy to abuse them, but most kids would not, and that might one way that they're "dangerous" for adults but not children.
Not that I'm excusing this, but aren't most ADHD drugs powerful stimulants that are similar to street drugs? Adults would have the autonomy to abuse them, but most kids would not, and that might one way that they're "dangerous" for adults but not children.
>The 21st Century Cures Act—a rare bipartisan bill, pushed by more than 1,400 lobbyists and signed into law in December—lowers evidentiary standards for new uses of drugs and for marketing and approval of some medical devices.
It shows again that we will not have sane healthcare system when there are thousands of lobbyist working to keep it insane.
It shows again that we will not have sane healthcare system when there are thousands of lobbyist working to keep it insane.
Here's a semi-random blog post with a handful of examples[1]. Generally speaking European countries are much quicker to approve most drugs and tend to have better health outcomes on average even though you can point to individual disasters like Thalidomide. But on the other hand beta blockers were available in Europe about a decade before they were in the US and would have saved about 10,000 lives a year during that time.
[1]http://www.advicegoddess.com/archives/2017/01/11/the_fda_pro...
[1]http://www.advicegoddess.com/archives/2017/01/11/the_fda_pro...
The article discusses beta-blockers.
The overall picture of beta-blockers is complex. For example, some beta-blockers have been shown clearly to reduce the chance of a stroke or heart attack in patients with heart failure. But the latest review of beta-blockers from the Cochrane Collaboration—an independent, international group of researchers that attempts to synthesize the best available research—reported that they “are not recommended as first line treatment for hypertension as compared to placebo due to their modest effect on stroke and no significant reduction in mortality or coronary heart disease.”
The overall picture of beta-blockers is complex. For example, some beta-blockers have been shown clearly to reduce the chance of a stroke or heart attack in patients with heart failure. But the latest review of beta-blockers from the Cochrane Collaboration—an independent, international group of researchers that attempts to synthesize the best available research—reported that they “are not recommended as first line treatment for hypertension as compared to placebo due to their modest effect on stroke and no significant reduction in mortality or coronary heart disease.”
Well, that'll teach me to post in Hacker News without reading all parts of an article.
Are you taking into account the recent studies of the effectiveness of beta blockers, which the OP article discusses?
"the latest review of beta-blockers ... reported that they 'are not recommended as first line treatment for hypertension as compared to placebo due to their modest effect on stroke and no significant reduction in mortality or coronary heart disease.'"
"the latest review of beta-blockers ... reported that they 'are not recommended as first line treatment for hypertension as compared to placebo due to their modest effect on stroke and no significant reduction in mortality or coronary heart disease.'"
What the article is talking about and what that bill seems to address are two separate issues. Whether you have high or low evidentiary standards for a new treatment is, under our current system and almost any system I've ever seen proposed, independent from whether doctors will end up completely correctly using those new systems. Doctors already have that responsibility and are already failing in that responsibility for a variety of complicated reasons, apparently, but it's easy to construct "solutions" that make it even worse. How do you out-expert the very people you've trained to be experts in the first place? That may not be unsolvable but it surely isn't a trivial problem to be fixed with some regulation here and some pamphlets there.
We've frequently discussed on HN the idea that sky-high evidentiary standards for new treatments may have passed the point where they are doing more harm than good. While I'm sure there are disagreeable details in the new bill, the broad strokes of the bill are things that the HN gestalt has at least been talking about for a while. It's not like it's a sudden out-of-the-blue idea that nobody's ever heard of before.
We've frequently discussed on HN the idea that sky-high evidentiary standards for new treatments may have passed the point where they are doing more harm than good. While I'm sure there are disagreeable details in the new bill, the broad strokes of the bill are things that the HN gestalt has at least been talking about for a while. It's not like it's a sudden out-of-the-blue idea that nobody's ever heard of before.
The term "sky-high" means the evidentiary standards are by definition harmful. One wouldn't describe them as sky-high if one thought they were reasonable. If one starts with the premise that existing standards are sky-high, then of course one will conclude they should be lowered.
I am obviously speaking about the end result of that debate and my personal opinion, which I won't try to hide. The debate itself was substantial, however, not merely word games.
Not to mention all the "patient advocacy groups" funded by the pharmaceutical industry: https://theintercept.com/2016/12/01/new-report-exposes-patie...
On the other hand, you had situations where people were smuggling drugs into the country for HIV treatment. Or you have drugs that we know are safe, and initial research shows a lot of promise, but are unavailable.
A patient with a serious condition should not be denied a possible treatment, as long as it's proven that it won't hurt him.
A patient with a serious condition should not be denied a possible treatment, as long as it's proven that it won't hurt him.
It'll make a great pejorative some day.
"No thanks, grandma. We don't want none of your 21st Century cures here."
"No thanks, grandma. We don't want none of your 21st Century cures here."
How exactly does it show that?
Because it was supported by many lobbyists? Or because it lowers evidentiary standards?
Because it was supported by many lobbyists? Or because it lowers evidentiary standards?
Surprised every time I'm in the US and see commercials for drugs and procedures that are administered by doctors being directed towards patients with the ending "ask your doctor about xyz".
I'm fairly sure this kind of thing ends up with patients asking/pressuring doctors for treatments they don't need.
I'm fairly sure this kind of thing ends up with patients asking/pressuring doctors for treatments they don't need.
Unsurprisingly, the FDA thought of this. They have concluded so far that drug ads are a net benefit for consumers.
> Other highlights of the surveys include:
> Most physicians agreed that because their patient saw a DTC ad, he or she asked thoughtful questions during the visit. About the same percentage of physicians thought the ad made their patients more aware of possible treatments.
> Many physicians thought that DTC ads made their patients more involved in their health care.
> Physicians thought the ads did not convey information about risks and benefits equally well. Seventy-eight percent of physicians believe their patients understand the possible benefits of the drug very well or somewhat, compared to 40 percent who believe their patients understand the possible risks, and 65 percent believe DTC ads confuse patients about the relative risks and benefits of prescription drugs. In addition, about 75 percent of physicians surveyed believed that DTC ads cause patients to think that the drug works better than it does, and many physicians felt some pressure to prescribe something when patients mentioned DTC ads.
> Eight percent of physicians said they felt very pressured to prescribe the specific brand-name drug when asked.
> DTC ads help patients have better discussions with their physicians and provide greater awareness of treatments. The study demonstrated that when a patient asked about a specific drug, 88 percent of the time they had the condition that the drug treated. And 80 percent of physicians believed their patients understood what condition the advertised drug treats.
> Doctors believe that patients understand that they need to consult a health care professional about appropriate treatment. Eighty-two percent responded either "very well" or "somewhat" when asked whether they believe that their patients understand that only a doctor can decide whether a drug is right for them.
https://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm14356...
Folks can argue that the FDA is biased in favor of drug companies at the expense of consumers, but then this would be a huge problem with the central mission of the FDA. It's not clear why we would trust it for approving drugs/treatment, but not trust it for considering the affects of adverisements.
> Other highlights of the surveys include:
> Most physicians agreed that because their patient saw a DTC ad, he or she asked thoughtful questions during the visit. About the same percentage of physicians thought the ad made their patients more aware of possible treatments.
> Many physicians thought that DTC ads made their patients more involved in their health care.
> Physicians thought the ads did not convey information about risks and benefits equally well. Seventy-eight percent of physicians believe their patients understand the possible benefits of the drug very well or somewhat, compared to 40 percent who believe their patients understand the possible risks, and 65 percent believe DTC ads confuse patients about the relative risks and benefits of prescription drugs. In addition, about 75 percent of physicians surveyed believed that DTC ads cause patients to think that the drug works better than it does, and many physicians felt some pressure to prescribe something when patients mentioned DTC ads.
> Eight percent of physicians said they felt very pressured to prescribe the specific brand-name drug when asked.
> DTC ads help patients have better discussions with their physicians and provide greater awareness of treatments. The study demonstrated that when a patient asked about a specific drug, 88 percent of the time they had the condition that the drug treated. And 80 percent of physicians believed their patients understood what condition the advertised drug treats.
> Doctors believe that patients understand that they need to consult a health care professional about appropriate treatment. Eighty-two percent responded either "very well" or "somewhat" when asked whether they believe that their patients understand that only a doctor can decide whether a drug is right for them.
https://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm14356...
Folks can argue that the FDA is biased in favor of drug companies at the expense of consumers, but then this would be a huge problem with the central mission of the FDA. It's not clear why we would trust it for approving drugs/treatment, but not trust it for considering the affects of adverisements.
If the ads help, is it reasonable then for the FDA to instead run ads based on the target demographic's most common diseases/ailments? Then they can talk to a doctor and the doctor can decide the best medicine.
For drugs that are off patent protection, yes. These would basically be public service announcement, which do exist, although some folks would like to see more. On the other hand, private philanthropic organizations also play this role to some extent, urging various screening, etc.
For things on patent protection, the argument would be that companies are better positioned than the government, for the same reason that most net-positive ads for non-medical goods are made privately.
For things on patent protection, the argument would be that companies are better positioned than the government, for the same reason that most net-positive ads for non-medical goods are made privately.
I find these utterly idiotic: you are telling patients about side effects of some drug with pretty pictures and a pleasant voice but only a doctor can prescribe them and you would assume understand the side effects and contraindications. What is the point? Other than obviously make drug companies more money.
That is the point. Drugs x, y, and z are all the market. They do the same thing with the same side-effects for the same cost. An ailment that the drug cures pops up in someone's life. When they go to the doctor, they can ask specifically for drug z, because they saw drug z in a commercial.
If our drugs, for all intents and purposes, are the exact same, then there is no point in a doctor prescribing drug x or y when the patient specifically asked for drug z.
If our drugs, for all intents and purposes, are the exact same, then there is no point in a doctor prescribing drug x or y when the patient specifically asked for drug z.
Any two drugs are most definitely not the same unless one is a generic of the other. And even then, because different manufacturers package drugs differently, this can slightly affect a compound's delivery.
Even when two drugs use the same mechanism of action (an agonist or antogist toward the same receptor active in the synthesis of a target protein), different generations of drugs often produce significantly different pharmacodynamic profiles of efficacy and toxicity that affect people differently. A good example are the diabetes drugs Actos vs Avandia -- same MoA (glitazones), but the latter has proven to be toxic.
Fact is, no two drugs are the same, unless they both do nothing.
Even when two drugs use the same mechanism of action (an agonist or antogist toward the same receptor active in the synthesis of a target protein), different generations of drugs often produce significantly different pharmacodynamic profiles of efficacy and toxicity that affect people differently. A good example are the diabetes drugs Actos vs Avandia -- same MoA (glitazones), but the latter has proven to be toxic.
Fact is, no two drugs are the same, unless they both do nothing.
> If our drugs, for all intents and purposes, are the exact same
This include the above. The point was that the drugs are the same in every way possible. Although this is most certainly not the case for drugs x, y and z, our example hinges on them being the same. Otherwise the doctor always should prescribe the best medication for the given situation.
This include the above. The point was that the drugs are the same in every way possible. Although this is most certainly not the case for drugs x, y and z, our example hinges on them being the same. Otherwise the doctor always should prescribe the best medication for the given situation.
If there are multiple treatments/drugs that achieve the same thing then the job of the SG is to recommend which to use. Usage of anything else should be viewed with a healthy amount of suspicion.
Because, as shocking and offensive as it may sound, not every doctor is 100% diligent about researching a patient's options.
They also may not have sufficient incentive to care about whether a non-life-threatening condition is actually cured.
They also may not have sufficient incentive to care about whether a non-life-threatening condition is actually cured.
Not everybody is going to tell their doctor that they're impotent or whatever unless they have some idea that there's a pill that cures that. People don't even necessarily have regular checkups if there's nothing they want a doctor to fix.
Is there a process or technology to avoid unnecessary medical treatment?
The article mentions how one patient googled his condition and sought a second opinion. I imagine that this direction is common among patients.
I am afraid that once I get old I will also be pushed to have unnecessary treatments.
The article mentions how one patient googled his condition and sought a second opinion. I imagine that this direction is common among patients.
I am afraid that once I get old I will also be pushed to have unnecessary treatments.
Yes, there's a range of products available now to many health systems that help with this exact problem. The category is called Clinical Decision Support. A CDS program may see a prescription or lab test deemed unnecessary by medical guidelines/evidence and warn the physician.
However, there's still a long ways to go in terms of UX, interoperability, adoption, etc.
However, there's still a long ways to go in terms of UX, interoperability, adoption, etc.
The ProPublica version of the article has a chart at the end showing an evaluation of the benefit vs risk of a treatment (search "A Different Way to Think About Medicine"):
https://www.propublica.org/article/when-evidence-says-no-but...
So one way to avoid unnecessary treatments is to seek out doctors who are willing to discuss treatments in similar terms. They may lack the information to build such a precise estimate, but they should still be willing to talk in a clear way about the risks and benefits of a given treatment.
https://www.propublica.org/article/when-evidence-says-no-but...
So one way to avoid unnecessary treatments is to seek out doctors who are willing to discuss treatments in similar terms. They may lack the information to build such a precise estimate, but they should still be willing to talk in a clear way about the risks and benefits of a given treatment.
I think you're describing "Number Needed to Treat" (NNT, or 'How many patients need to be treated with a drug or procedure for one patient to get the hoped-for benefit?'), which is described briefly just before the graphic you mention.
NNT is a great idea, but not as practically useful for individuals as for policymakers, IMHO. I suspect few primary care clinicians can discuss current and precise NNT figures. More likely they will rely on standard of care advice from the AMA or their subspecialty board that itself was shaped by NNTs.
NNT is a great idea, but not as practically useful for individuals as for policymakers, IMHO. I suspect few primary care clinicians can discuss current and precise NNT figures. More likely they will rely on standard of care advice from the AMA or their subspecialty board that itself was shaped by NNTs.
No, I was specifically talking about the sort of framework used in the graphic, where the outcome of a treatment may be beneficial, benign or harmful.
I'll repost my second paragraph too:
So one way to avoid unnecessary treatments is to seek out doctors who are willing to discuss treatments in similar terms. They may lack the information to build such a precise estimate, but they should still be willing to talk in a clear way about the risks and benefits of a given treatment.
Yes, it will be difficult for providers to have detailed information. They should still be open to discussing downsides and tradeoffs. It's a red flag if they hesitate to talk in terms of tradeoffs or to take the time to discuss the expected benefits and potential downsides.
I'll repost my second paragraph too:
So one way to avoid unnecessary treatments is to seek out doctors who are willing to discuss treatments in similar terms. They may lack the information to build such a precise estimate, but they should still be willing to talk in a clear way about the risks and benefits of a given treatment.
Yes, it will be difficult for providers to have detailed information. They should still be open to discussing downsides and tradeoffs. It's a red flag if they hesitate to talk in terms of tradeoffs or to take the time to discuss the expected benefits and potential downsides.
"Is there a process or technology to avoid unnecessary medical treatment?"
Yes - exercise and a simple diet.
Michael Pollan speaks of it in the 21st century and the greek philosophers spoke of it in the negative-fourth century.
And every thoughtful person in-between.
Go look - every philosopher you've ever heard of has taken some amount of time to pontificate about health and diet and has concluded the same thing.
Yes - exercise and a simple diet.
Michael Pollan speaks of it in the 21st century and the greek philosophers spoke of it in the negative-fourth century.
And every thoughtful person in-between.
Go look - every philosopher you've ever heard of has taken some amount of time to pontificate about health and diet and has concluded the same thing.
Sometimes medicine helps patients, sometimes the medical-industrial complex makes work for itself. I took a lot of medicaid patients to & from doctor appointments where nothing much was accomplished.
> In 2012, Brown had coauthored a paper that examined every randomized clinical trial that compared stent implantation with more conservative forms of treatment, and he found that stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all. In general, Brown says, “nobody that’s not having a heart attack needs a stent.” [...] Nonetheless, hundreds of thousands of stable patients receive stents annually, and one in 50 will suffer a serious complication or die as a result of the implantation procedure. [emphasis added]
(This comment recycled from the earlier submission of the propublica version this story: https://news.ycombinator.com/item?id=13705761 )
> In 2012, Brown had coauthored a paper that examined every randomized clinical trial that compared stent implantation with more conservative forms of treatment, and he found that stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all. In general, Brown says, “nobody that’s not having a heart attack needs a stent.” [...] Nonetheless, hundreds of thousands of stable patients receive stents annually, and one in 50 will suffer a serious complication or die as a result of the implantation procedure. [emphasis added]
(This comment recycled from the earlier submission of the propublica version this story: https://news.ycombinator.com/item?id=13705761 )
This is a very important issue. Doctors are over prescribing and jumping to unneeded surgeries. The question is, are they doing it out of fear of a malpractice lawsuit for denying a patient what they need or is it from kickbacks, incentives and the knowledge that the persons insurance will pay them?
Just because something works doesn't mean it's not a broken system.
Suprised that no one else has commented on this article.
Just because something works doesn't mean it's not a broken system.
Suprised that no one else has commented on this article.
> Suprised that no one else has commented on this article.
Didn't refresh
Didn't refresh
Three months later, his cholesterol had improved markedly, he had lost 15 pounds, and the chest pain never returned.
And it just goes to show you, that Dr. Brown might have saved the executive a stent procedure, but they are still promulgating the myth that cholesterol causes CHD. It's a side effect not the cause. There are plenty of people that have high cholesterol and don't have blocked arteries.
<sigh>
And it just goes to show you, that Dr. Brown might have saved the executive a stent procedure, but they are still promulgating the myth that cholesterol causes CHD. It's a side effect not the cause. There are plenty of people that have high cholesterol and don't have blocked arteries.
<sigh>
It's not a mere side effect.
If it were, treatment with anti-cholesterol drugs such as statins (the most used) or even a new class of drugs called PCSK9 inhibitors wouldn't have such a clear cause-and-effect on reducing cardiovascular events and mortality.
Since removing cholesterol from circulation reduces cardiovascular disease, you can view it as a cause and not as a mere marker of disease.
If it were, treatment with anti-cholesterol drugs such as statins (the most used) or even a new class of drugs called PCSK9 inhibitors wouldn't have such a clear cause-and-effect on reducing cardiovascular events and mortality.
Since removing cholesterol from circulation reduces cardiovascular disease, you can view it as a cause and not as a mere marker of disease.
If it were, treatment with anti-cholesterol drugs such as statins (the most used) or even a new class of drugs called PCSK9 inhibitors wouldn't have such a clear cause-and-effect on reducing cardiovascular events and mortality.
I've read that studies show it only has an effect for men > 50 yrs, but that the effect isn't due to reducing cholesterol.
I have notice a huge increase in the last 10 years in the number of researchers reporting no causal link between cholesterol and CHD.
On the first page of a Google search:
https://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines...
Evidence abounds that there is no link.
I've read that studies show it only has an effect for men > 50 yrs, but that the effect isn't due to reducing cholesterol.
I have notice a huge increase in the last 10 years in the number of researchers reporting no causal link between cholesterol and CHD.
On the first page of a Google search:
https://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines...
Evidence abounds that there is no link.
I have, according to my MRI, severe cervical stenosis. I also have carpal tunnel, which was diagnosed first. Based on my symptoms and the awful looking MRI, 4 highly regarded spine surgeons recommended a 2 level fusion right away. The 5th doctor, instead recommended carpal tunnel and ulnar nerve releases. My symptoms abated by 80+% and is something I can live with comfortably.
None of the 4 other doctors even considered dealing with my carpal tunnel first, which, combined with stenosis causes what's called a 'double crush' scenario. Only one surgeon recommended the least invasive and risky procedure for me! Even though a fusion in the future is likely, for now the risk - reward for such a procedure does not warrant immediate action.
I also think it's worth noting that that 5th doctor is the only female of the group. She was the only one that didn't seem gung-ho about the fusion. I'm not saying gender plays a role but...
None of the 4 other doctors even considered dealing with my carpal tunnel first, which, combined with stenosis causes what's called a 'double crush' scenario. Only one surgeon recommended the least invasive and risky procedure for me! Even though a fusion in the future is likely, for now the risk - reward for such a procedure does not warrant immediate action.
I also think it's worth noting that that 5th doctor is the only female of the group. She was the only one that didn't seem gung-ho about the fusion. I'm not saying gender plays a role but...
https://www.statnews.com/2016/12/19/patients-female-physicia...
>Public health researchers at Harvard found that elderly patients were less likely to die or be readmitted to the hospital within 30 days if treated by female doctors rather than male. The study doesn’t explain why this happens, but prior studies have found that female doctors tend to spend more time with patients, communicate better, and follow clinical guidelines more often than their male colleagues.
>Public health researchers at Harvard found that elderly patients were less likely to die or be readmitted to the hospital within 30 days if treated by female doctors rather than male. The study doesn’t explain why this happens, but prior studies have found that female doctors tend to spend more time with patients, communicate better, and follow clinical guidelines more often than their male colleagues.
The article gives an introductory example of a patient that was referred to two different cardiologists, both of whom wanted to do an angiogram. The article doesn't mention of course that the cardiologists get paid per angiogram performed. The remuneration per unit time for seeing the patient in clinic and carefully discussing the options and evidence is drastically less than just doing the angiogram. Some cardiologists will also have a target number of angiograms they need to perform every year specified by arrangements with the angiogram facility.
So although it is widely known that doing angiograms and inserting stens in patients with stable coronary artery disease is a waste of time, perverse incentives in a fee for service model result in these outcomes. As such it isn't a good example of evidence-free medicine. In Australian public hospitals, the cardiologists are paid the same salary regardless of whether they do zero or 1000 angiograms a year. They are very happy not to do unnecessary angiograms in line with the current evidence. If anything, this introductory example shows that a health system needs to be set up to facilitate and encourage evidence-based practice.
Otherwise this article rehashes many points about clinical trials and interpreting medical evidence, without a really coherent theme, except maybe to (yet again) criticise doctors.
Things have improved in the last 10 - 15 years. Clinical trials come under more scrutiny, trial pre-registration has become more common (although not strictly enforced), health systems gather more and more data about patient outcomes outside of clinical trials and manipulative marketing practices by pharmaceutical companies have been curtailed drastically.
In my opinion, the challenges for evidenced based medicine in the next decade are:
1. Getting some decent data about nutrition. There are really remarkably few useful things we can say about how nutrition relates to health.
2. Reducing unnecessary interventions towards the end of life in an ageing population. Healthcare and healthcare research is not well suited to de-escalating care.
3. Transitioning from a one-size-fits-all approach doing clinical trials in 1000s of undifferentiated patients, to collecting 1000s of data points about each individual patient (blood and metabolic variables, genome sequencing, immune profiling, microbiome etc) and using that data to get them healthy and keep them that way. Needless to say, the difficulties in doing this will make doing a randomised controlled trial look like a walk in the park.
4. Fighting pseudo-scientific diagnostic tests and treatments. Examples of this are everywhere - Theranos, gene therapy clinics in undisclosed locations in South America, quantified self services that have no proven health benefits, virtually every supplement ever sold, multivitamins...
5. Fighting the politicisation of health care. This is a very worrying trend that can easily render all our scientific efforts irrelevant - eg anti-vaxxers, far-right intolerance of harm minimisation measures like abortion and decriminalising drug use.
So although it is widely known that doing angiograms and inserting stens in patients with stable coronary artery disease is a waste of time, perverse incentives in a fee for service model result in these outcomes. As such it isn't a good example of evidence-free medicine. In Australian public hospitals, the cardiologists are paid the same salary regardless of whether they do zero or 1000 angiograms a year. They are very happy not to do unnecessary angiograms in line with the current evidence. If anything, this introductory example shows that a health system needs to be set up to facilitate and encourage evidence-based practice.
Otherwise this article rehashes many points about clinical trials and interpreting medical evidence, without a really coherent theme, except maybe to (yet again) criticise doctors.
Things have improved in the last 10 - 15 years. Clinical trials come under more scrutiny, trial pre-registration has become more common (although not strictly enforced), health systems gather more and more data about patient outcomes outside of clinical trials and manipulative marketing practices by pharmaceutical companies have been curtailed drastically.
In my opinion, the challenges for evidenced based medicine in the next decade are:
1. Getting some decent data about nutrition. There are really remarkably few useful things we can say about how nutrition relates to health.
2. Reducing unnecessary interventions towards the end of life in an ageing population. Healthcare and healthcare research is not well suited to de-escalating care.
3. Transitioning from a one-size-fits-all approach doing clinical trials in 1000s of undifferentiated patients, to collecting 1000s of data points about each individual patient (blood and metabolic variables, genome sequencing, immune profiling, microbiome etc) and using that data to get them healthy and keep them that way. Needless to say, the difficulties in doing this will make doing a randomised controlled trial look like a walk in the park.
4. Fighting pseudo-scientific diagnostic tests and treatments. Examples of this are everywhere - Theranos, gene therapy clinics in undisclosed locations in South America, quantified self services that have no proven health benefits, virtually every supplement ever sold, multivitamins...
5. Fighting the politicisation of health care. This is a very worrying trend that can easily render all our scientific efforts irrelevant - eg anti-vaxxers, far-right intolerance of harm minimisation measures like abortion and decriminalising drug use.
6. Studies on how to most effectively treat people with non-invasive treatments. "Take this pill once a day" has a far higher compliance rate than "exercise more."
I am thinking of the example mentioned in "The Power of Habit" where one group of knee surgery patients was given a brochure about post-surgery treatment, like PT, exercise, etc. The other was give the same brochure with blank pages to write out a specific plan for following the recommendations. Of course, the second group fared much better.
I am thinking of the example mentioned in "The Power of Habit" where one group of knee surgery patients was given a brochure about post-surgery treatment, like PT, exercise, etc. The other was give the same brochure with blank pages to write out a specific plan for following the recommendations. Of course, the second group fared much better.
The system is also rigged against cost-savings from small providers.
My wife is an ophthalmologist in private practice. Recently, we were looking at the economics of buying a laser to do a common treatment for patients with glaucoma, called a Selective Laser Trabeculoplasty (SLT).
Even with a decent understanding of medical reimbursement models in the United States, I was still kind of shocked by what I found.
The laser to perform the procedure costs about $30,000 to purchase.
The Medicare allowable for a physician performing the procedure in a standalone surgery center is about $315. There's really no reason that the procedure needs to be performed in a surgery center, and Medicare does let the physician bill about $30 more if they bought a laser for their office, and performed the procedure there. But, at an increase of $30/procedure, you'd have to be doing a ton of SLTs to make buying your own laser financially attractive vs. just using the local surgery center's.
Where things get crazy, is in terms of facility fees.
If a physician performs an SLT procedure at an ambulatory surgery center, the physician's medicare allowable is about $315, and the surgery center can bill a separate facility fee of about $290, making the total procedure cost medicare just over $600.
If my wife's practice were bought by a hospital tomorrow, and they brought an SLT into her office, every time she performed an SLT in the exact same office that was now hospital owned, they'd be able to bill the $315 physician fee, plus a "hospital outpatient department" (HOPD) facility fee of $443, bringing the total cost of the procedure to over $750.
So, to recap the total costs to medicare:
Physician does the procedure in their privately owned medical practice: $345
Physician does the procedure in a surgery center: $600
Physician does the procedure in a hospital-owned medical practice: $750
You want to know why independent medical providers are getting bought up by hospitals and large health systems at an alarming rate? That's why. Because for doing the exact same thing, they get paid by medicare and private insurance companies (whose rates are largely based off of medicare reimbursement rates) 2x what a provider can on their own.
You hear a lot in the healthcare market about the efficiencies of scale, and how large integrated healthcare organizations are doing amazing things. You don't hear a lot about the potential for independent practitioners to reduce costs, but it's absolutely there, and largely ignored.
That said, medicare is (or at least was under the ACA) moving toward a "pay for performance" model, where instead of getting paid more for doing more angiograms, cardiologists will get paid more for keeping their patients from needing angiograms in the first place. There are still plenty of issues, but I think broadly that's the right direction for healthcare reimbursement to be going.
My wife is an ophthalmologist in private practice. Recently, we were looking at the economics of buying a laser to do a common treatment for patients with glaucoma, called a Selective Laser Trabeculoplasty (SLT).
Even with a decent understanding of medical reimbursement models in the United States, I was still kind of shocked by what I found.
The laser to perform the procedure costs about $30,000 to purchase.
The Medicare allowable for a physician performing the procedure in a standalone surgery center is about $315. There's really no reason that the procedure needs to be performed in a surgery center, and Medicare does let the physician bill about $30 more if they bought a laser for their office, and performed the procedure there. But, at an increase of $30/procedure, you'd have to be doing a ton of SLTs to make buying your own laser financially attractive vs. just using the local surgery center's.
Where things get crazy, is in terms of facility fees.
If a physician performs an SLT procedure at an ambulatory surgery center, the physician's medicare allowable is about $315, and the surgery center can bill a separate facility fee of about $290, making the total procedure cost medicare just over $600.
If my wife's practice were bought by a hospital tomorrow, and they brought an SLT into her office, every time she performed an SLT in the exact same office that was now hospital owned, they'd be able to bill the $315 physician fee, plus a "hospital outpatient department" (HOPD) facility fee of $443, bringing the total cost of the procedure to over $750.
So, to recap the total costs to medicare:
Physician does the procedure in their privately owned medical practice: $345
Physician does the procedure in a surgery center: $600
Physician does the procedure in a hospital-owned medical practice: $750
You want to know why independent medical providers are getting bought up by hospitals and large health systems at an alarming rate? That's why. Because for doing the exact same thing, they get paid by medicare and private insurance companies (whose rates are largely based off of medicare reimbursement rates) 2x what a provider can on their own.
You hear a lot in the healthcare market about the efficiencies of scale, and how large integrated healthcare organizations are doing amazing things. You don't hear a lot about the potential for independent practitioners to reduce costs, but it's absolutely there, and largely ignored.
That said, medicare is (or at least was under the ACA) moving toward a "pay for performance" model, where instead of getting paid more for doing more angiograms, cardiologists will get paid more for keeping their patients from needing angiograms in the first place. There are still plenty of issues, but I think broadly that's the right direction for healthcare reimbursement to be going.
Does anyone know what the problem is that the 21st Century Cures Act is solving? The claim was made that treatments are being withheld pending FDA approval. Is it illegal to use FDA-unapproved drugs, or is it that insurance is not covering unproven treatments?
A big part of the 21st Century Cures Act is to incentivize new antibiotics. Right now the FDA requires the same standards for antibiotics as for other drugs.
That can be a problem if you are trying to test a new antibiotic for a very rare drug resistant strain. You need 100 patients in your trial to hit statistical significance, but only 50 cases happen in the US each year.
So you run a smaller trial, get the best data you can and the FDA gives you conditional approval. You agree to a patient registry to collect post approval data where in time you get full FDA approval.
That can be a problem if you are trying to test a new antibiotic for a very rare drug resistant strain. You need 100 patients in your trial to hit statistical significance, but only 50 cases happen in the US each year.
So you run a smaller trial, get the best data you can and the FDA gives you conditional approval. You agree to a patient registry to collect post approval data where in time you get full FDA approval.
It's not illegal to take them, but yes I doubt insurance will cover unapproved treatments. Also, while it's not directly illegal for a doctor to prescribe an unapproved drug, I think it would open them up to malpractice lawsuits, and it just seems like a bad idea in general. Here's a doctor's blog post about this issue: http://thehealthcareblog.com/blog/2013/08/26/should-a-doctor...
Thanks for sharing the article. Layman's perspective, but it seems like the problem in the USA is not the FDA regulation process, but the drug prescription process. If I, a functional adult, have done the research and weighed the risks and decided I want to purchase a specific drug or treatment, why should I need a doctor to "co-sign the loan" for me? We're coupling doctors' financial risks to patients' health risks when the decision making factors are significantly different.
If prescriptions were not necessary, drug advertising would be even more heavily targeted at average consumers, addiction problems would be more widespread, and anyone could operate a doctor's office without a license or proper education. You should have the right to put whatever you want into your body, but drug companies and pharmacies should not have the right to sell whatever they want to you.
Fundamentally, you have not "done the research and weighed the risks" unless you went to medical school.
Fundamentally, you have not "done the research and weighed the risks" unless you went to medical school.
I disagree that medical school makes anyone more of an expert on my body than me. Not to discount years of experience and training physicians have, but it's just one leg of the stool. By over-weighting it, you become just another patient who is not staying informed and involved with their own treatment. Doctors know a lot, but you can ask any doctor if they know everything about the human body, and they'll sure tell you they don't.
I think sensible people can choose to procure FDA approved treatments through conventional providers. It's a jump to assume that, just because alternative treatments are available, everybody will be lining up to purchase them.
I think sensible people can choose to procure FDA approved treatments through conventional providers. It's a jump to assume that, just because alternative treatments are available, everybody will be lining up to purchase them.
I'm not talking about alternative treatments. If prescriptions are not necessary, anyone can buy opiates without understanding the risks of addiction. Anyone can open a doctor's office, charge half as much as a real doctor, and recommend whatever drugs they feel like. Anyone can buy some heart medication they saw on TV because they've been having chest pains.
Doctors absolutely know more about your body than you do. Obviously they don't know everything, and patients should be active and involved, but that doesn't mean you can cut out the doctor because you read a few papers. Letting drug companies sell anything to anybody would be immensely damaging to society.
Doctors absolutely know more about your body than you do. Obviously they don't know everything, and patients should be active and involved, but that doesn't mean you can cut out the doctor because you read a few papers. Letting drug companies sell anything to anybody would be immensely damaging to society.
I agree doctors know a lot, but they are human. Most specialize in a narrow subset, and that is the lens through which they will treat you. That's not always a bad thing, but I will respectfully disagree and say that I know more about my own body than a doctor I'm meeting for the first time (i.e. most specialists).
Legalization of drugs, including opiates, has been successful (or at least not disastrous) in many societies. What makes you think it would be a disaster here?
Also, it's a straw man to argue that random people would be opening up doctor's offices. I'm not advocating that we remove the MD from anybody's name.
Legalization of drugs, including opiates, has been successful (or at least not disastrous) in many societies. What makes you think it would be a disaster here?
Also, it's a straw man to argue that random people would be opening up doctor's offices. I'm not advocating that we remove the MD from anybody's name.
Legalization of drugs is "successful" in that it's a lot better than jailing people, but addiction is still a huge problem for society. If someone really wants to get high, there's not much we can do to stop them, and that's an acceptable consequence of drug legalization. But what we can stop is someone in a lot of pain who buys way too much Oxycodone and gets addicted because they didn't understand the risks. Right now, they'd have to go see a doctor first, who could prescribe an appropriate amount and/or recommend less dangerous treatment options.
When I talk about unlicensed doctor's offices, I don't mean someone posing as an MD, I mean a well-meaning individual opening a cheap clinic and offering medical advice for non-emergency issues. Or maybe more likely, WebMD adding links to order drugs on their results pages. Why go to the doctor if you can just look up your symptoms in 5 minutes and have pills arrive at your door the next day?
When I talk about unlicensed doctor's offices, I don't mean someone posing as an MD, I mean a well-meaning individual opening a cheap clinic and offering medical advice for non-emergency issues. Or maybe more likely, WebMD adding links to order drugs on their results pages. Why go to the doctor if you can just look up your symptoms in 5 minutes and have pills arrive at your door the next day?
> but addiction is still a huge problem for society. If someone really wants to get high, there's not much we can do to stop them, and that's an acceptable consequence of drug legalization. But what we can stop is someone in a lot of pain who buys way too much Oxycodone and gets addicted because they didn't understand the risks.
But what part of the pain management patients actively abuse their meds. It's a real issue, but is it a commonplace issue where we absolutely have to devout resources to solving it?
But what part of the pain management patients actively abuse their meds. It's a real issue, but is it a commonplace issue where we absolutely have to devout resources to solving it?
Yes, there's a reason it's called an epidemic: https://www.hhs.gov/sites/default/files/Factsheet-opioids-06...
Imagine the numbers if patients didn't need a prescription and didn't need to talk to a doctor about safe usage.
Imagine the numbers if patients didn't need a prescription and didn't need to talk to a doctor about safe usage.
Doctors over prescribing this is exactly the problem.
I agree painkillers like oxycodone are a huge problem, but ironically, this is exactly because doctors are over prescribing them. If people had access to options like medical marijuana, I think we'd actually see less prescription drug abuse.
And why not allow the OTC treatments and clinics you describe? They may not (probably should not) be covered by medical insurance, but I see no reason not to allow someone to open up a medical advice clinic of their own volition. Is that even illegal today?
And why not allow the OTC treatments and clinics you describe? They may not (probably should not) be covered by medical insurance, but I see no reason not to allow someone to open up a medical advice clinic of their own volition. Is that even illegal today?
> Anyone can open a doctor's office, charge half as much as a real doctor, and recommend whatever drugs they feel like.
Yeah, medical licensing does nothing to prevent that.
Yeah, medical licensing does nothing to prevent that.
Yes, but prescriptions do. Anyone can "recommend" vicodin right now, but it's hard to get some without a prescription from a real licensed doctor.
That definitely seems different than "withholding" treatments as described in the article. If you want to use an unapproved drug, you can do so, it's just not going to be paid for by our shared insurance system. Makes total sense to me.
I'm not arguing, just wondering what exactly is the problem that this act is trying to solve.
I'm not arguing, just wondering what exactly is the problem that this act is trying to solve.
The problem is mostly on the side of drug and medical device companies. They spend lots of money on research and development and they want an easier and faster return on their investment. There are also problems for patients, when someone hears about a promising new treatment for their serious condition, but it's going to take several years to get through FDA approval.
> If you want to use an unapproved drug, you can do so
This is not true in general. Where do you get it? A doctor won't prescribe it, you can't get it from a pharmacy without a prescription, you certainly can't just order it directly from the drug company. Sometimes it might be more easily available in another country, but that won't always be the case.
> If you want to use an unapproved drug, you can do so
This is not true in general. Where do you get it? A doctor won't prescribe it, you can't get it from a pharmacy without a prescription, you certainly can't just order it directly from the drug company. Sometimes it might be more easily available in another country, but that won't always be the case.
You're right. My other comment was hopefully more informed thanks to the article you posted.
Check the story of AIDS treatment in 1980s - there were drugs available on other markets that essentially brought patients to life, but they had to be literally smuggled into US.
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> Steven Galson [...] has called the strengthened approval process created in 1962 the FDA’s “biggest contribution to health.” Before that, he said, “many marketed drugs were ineffective for their labeled uses.”
Sam Peltzman in "Regulation of Pharmaceutical Innovation" provides statistical evidence that the "safe and effective" 1962 Amendments reduced the development of new effective treatments as well as new ineffective ones, for a net decrease in positive results.
Sam Peltzman in "Regulation of Pharmaceutical Innovation" provides statistical evidence that the "safe and effective" 1962 Amendments reduced the development of new effective treatments as well as new ineffective ones, for a net decrease in positive results.
This is an excellent and disturbing article. However, something very important was missed.
Let me start by saying that I think that whenever we have a problem in this country, one of the things we should do is look at how other countries handle it to see if there is anything useful we could learn.
That being the case, we need to know how other countries handle the over-treatment problem. Are there studies on this? Perhaps the authors could write a follow-up article.
Let me start by saying that I think that whenever we have a problem in this country, one of the things we should do is look at how other countries handle it to see if there is anything useful we could learn.
That being the case, we need to know how other countries handle the over-treatment problem. Are there studies on this? Perhaps the authors could write a follow-up article.
Speaking from my personal experience…
My way of life dictates adequate exercise, healthy diet and normal sleep patterns.
I come from a family of strict vegans. No, I’m not here to promote either veganism or non-veganism. I’m in my early 40’s and have been exercising since I was a teenager. My routine includes running, cycling, strengthening exercises, lifting light weights, and I do one or two of these a couple times a week. IMO, any and all physical activity is a form of exercise. Usually, my day starts in the early hours. And, as I’m getting older, my endurance levels have been getting significantly better now than during my schooldays, 20’s, or 30’s and with regard to my work I’m getting more productive, too.
I also think that those who are not predisposed to any genetic conditions are in a league of their own. Even those who inherit a predisposition can benefit from delayed onset of a condition by practicing a healthy lifestyle. I’m not a medical professional, so my assumptions may or may not carry any weight.
All I’m trying to do is keep such treatments as are being discussed here at bay and I will keep at it as long as I possibly can :)
My way of life dictates adequate exercise, healthy diet and normal sleep patterns.
I come from a family of strict vegans. No, I’m not here to promote either veganism or non-veganism. I’m in my early 40’s and have been exercising since I was a teenager. My routine includes running, cycling, strengthening exercises, lifting light weights, and I do one or two of these a couple times a week. IMO, any and all physical activity is a form of exercise. Usually, my day starts in the early hours. And, as I’m getting older, my endurance levels have been getting significantly better now than during my schooldays, 20’s, or 30’s and with regard to my work I’m getting more productive, too.
I also think that those who are not predisposed to any genetic conditions are in a league of their own. Even those who inherit a predisposition can benefit from delayed onset of a condition by practicing a healthy lifestyle. I’m not a medical professional, so my assumptions may or may not carry any weight.
All I’m trying to do is keep such treatments as are being discussed here at bay and I will keep at it as long as I possibly can :)
Is this a correlating effect with the fact that a large number of published scientific results are botched? If researchers are not allowed to do good science they are no more progressive than the augur reading from the entrails of a fish.
It isn't just poorly done research. In many cases it is simply difficult to design a study that can reasonably evaluate a treatment. The article discusses a cancer vaccine at length, pointing out that the ethics of providing known effective treatment basically obliterate the ability to evaluate the vaccine.
It's concerning that the vaccine was approved despite the problems with the study, but they also can't have people agreeing to die in order to increase the statistical power of their results.
It's concerning that the vaccine was approved despite the problems with the study, but they also can't have people agreeing to die in order to increase the statistical power of their results.
You make it sound like the entrails of the fish do not have anything to tell you...
A sibling comment mentions that lobbyists worked to get the 21st Century Cures Act passed, but a potentially bigger issue with the act is that it transfers $3.5 billion of public health spending to medical research.