8 ms·

Our main problem in health policy is overemphasis on medicine (2007)

53 points by orborde 5y ago

tom_bombadil 5y ago
> "The right says governments produce a much inferior baby" Too many Cesarean sections over centuries will yield more narrow female hips. You will like small butts, and you will lie. [0] Russians expose their newborns to the cold on purpose, to build immune systems so as to not eventually need as much "Big Pharma". [1] [0] https://www.youtube.com/watch?v=X53ZSxkQ3Ho https://www.youtube.com/watch?v=X53ZSxkQ3Ho [1] https://www.reddit.com/r/interestingasfuck/comments/qinla7/babys_were_left_to_sleep_out_in_the_cold_to/?utm_source=share&utm_medium=web2x&context=3 https://www.reddit.com/r/interestingasfuck/comments/qinla7/b...
- deleted 5y ago
  [deleted]
ABeeSea 5y ago
This is a 14 year old article (pre ACA) from an associate professor in economics who doesn’t have a degree in economics. Sigh
- dang 5y ago
  Those aren't good reasons to reject an article. Would you mind reviewing the site guidelines? Note that they include: "Please don't post shallow dismissals, especially of other people's work. A good critical comment teaches us something." Also: "Don't be snarky." Older articles and historical material are always welcome on HN, if they're interesting. Often they're more interesting than the latest $thing about $current-hot-topic. As for which credentials professors do or don't have, that seems irrelevant to whether or not the article can be the basis for a substantive, interesting discussion, which is what we care about here. The main reason to consider this article offtopic for HN would be that it's on a classic flamewar topic. However, those aren't automatically bad. It depends, again, whether the article contains enough interesting information be different (https://hn.algolia.com/?dateRange=all&page=0&prefix=false&sort=byDate&type=comment&query=diffs%20by:dang https://hn.algolia.com/?dateRange=all&page=0&prefix=false&so...), and can sustain an interesting discussion. After skimming it a bit, I think it probably clears that bar. I've changed the title from the original, though (because it's provocative and therefore flamebaity) to a representative sentence from the article body, which says what the article is about. Of course it's still up to HN users to focus on the interesting parts and discuss them thoughtfully, rather than use it as a diving board to spring into pits of hellfire from. https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html
  - NoPie 5y ago
    14 years old article is a good reason to take note of it as it shows it is not just some fad but important long-term issue. I don't think the issue itself is controversial. I was taught at university that our life expectancy is determined roughly speaking one third by our genes, one third by our lifestyle and one third by healthcare. And then it became apparent that most healthcare interventions (childhood vaccinations, antibiotics, most medicines) that have a big effect are relatively cheap. The most costly interventions have the least effect. We could easily cut the health budget in half with only a marginal decrease of actual outcomes. But it would be very hard to do due to politics, the structure of incentives etc. But we really need to critically examine and educate people that expecting more and more from healthcare despite progress in this field can only lead to diminishing results. We cannot change our genes (yet) but we need to think more about our lifestyle (obesity, drug and alcohol use) which could provide considerable potential as well.
    - dang 5y ago
      (The classic flamewar topic I was referring to is the U.S. healthcare system)
    - nradov 5y ago
      I generally agree but public sanitation measures including water purification, food inspection, garbage disposal, and sewers also have a huge impact on average life expectancy. Maybe even more than healthcare. In other words, vaccines are wonderful but if I had to pick between vaccines and clean water I'd take clean water every time.
      - redis_mlc 5y ago
        I'd agree. My theory is that the reason life span is 20 years less in the developing world is solely due to water treatment issues, resulting in wide-spread hepatitis. By 60, most people look (and feel) 80 there.
- orborde 5y ago
  What specifically has changed since this essay set was published that would render it moot? If "the ACA", what specific ACA policies?
jt2190 5y ago
(2007)
- dang 5y ago
  Added above. Thanks!
orborde 5y ago
(OP here) This essay set may superficially appear to be another repetitive salvo in the interminable US healthcare political conflict, but I recommend reading a bit deeper. I think the perspective these essays offer (that, at the margin, medical spending doesn't affect people's wellspan much, at least not in the US) is both quite important and underrepresented in most discussions of healthcare.
- isoblvck 5y ago
  medicare for all. done.
- lambdaba 5y ago
  I mean, why would we expect it too? Spending is about profits accumulating somewhere, so why would that have anything to do with optimizing healthspan? Note, I'm vehemently critical of the modern medical establishment, and a health loon myself (by necessity, was hit with a though illness early on in my life).
dadjoker 5y ago
[flagged]
- umvi 5y ago
  "An ounce of prevention is worth a pound of cure" - old proverb
- tux3 5y ago
  Fit, healthy, people are dying left and right. There are risk factors, but don't start thinking you're invicible for not having them. The adaptive immune system is slow, vaccines prime it to react faster with more specific antibodies. Dying of pneumonia does not feel good. It makes grown men cry and beg. Strongly recommend against.
  - lambdaba 5y ago
    But those "fit, healthy" (the genuinely so, I'm not sure I even agree with the characterization for many of the mediatized cases), are OUTLIERS. Yes, you are never invincible, but it's 100% correct to characterize Covid as a disease of the metabolically dysfunctional. Sadly, this is a HUGE percentage of the population of the world nowadays, which seems to be the point of the article (disclaimer: in true HN tradition, I haven't read it) Traditionnal post-downvote comment: Covid affects those: - on immunosuppressant medication most often for a PREVENTABLE "lifestyle" disease - otherwise negatively affected by said disease, particularly in the vascular system, we know that Covid kills most those that have hypertension, long-term vascular damage from chronically-elevated blood sugar, etc. - nutritional deficient / malnourished (low vitamin D, absence of sunlight, etc. etc.); this is also very common
    - whoopdedo 5y ago
      > this is a HUGE percentage of the population of the world nowadays, And thus make up a sizeable amount of COVID patients. I see nothing noteworthy here. Having a preexisting condition makes you suffer more when you contract an infectious disease. I'd expect the same things you said could be repeated for influenza, pneumonia, or anything else. For that matter, how much worse do obese patients fare when recovering from a broken leg? Are fractures then a disease of the metabolically dysfunctional, as you put it?
paulpauper 5y ago
A lot of $ is spent on medicine because medicine works. Alternatives such as diet, exercise either are spotty in efficacy or do not work. Medicine offers a quick fix and in some cases the only fix. Someone who has cancer will need to be treated with medicine, not diet.
- lambdaba 5y ago
  this is such a strange comment for me, and I beg people not to reflexively downvote and instead join in for a discussion, but I'm part / have been part of communities where people ROUTINELY achieve remission from disease the medical establishment deems incurable I can go in further details if people ask, but lifestyle intervention has DRAMATIC results for many people, myself included, and results not provided by drugs or any commonly available medical intervention Let me give you an example, RE: cancer and diet, look up "Andrew Scarborough brain cancer" and you'll find a detailed account of someone treating incurable brain cancer with diet and lifestyle; and this is someone working in the medical field (actually, precisely in oncology)
  - danachow 5y ago
    > and this is someone working in the medical field Well, yes, even a crackpot can claim to be working in the field. This in no way supports your claim of “routine” cures through diet. There is no evidence that a fucking keto diet will cure cancer* and it doesn’t pass any sniff test as at the end of the day your body still runs on glucose. This is pretty much an insult to anyone not fortunate enough for their cancer to go spontaneously into remission - and looking at the loon you posted, both he and a family member had some amount of treatment before diet, confounding any claim that diet was responsible for remission. * whether such a diet can have some survivability benefits or some better or worse outcome is an open question, which has nothing to do with your crackpot claims.
    - lambdaba 5y ago
      I am only replying to your incendiary comment to say that your characterization is insulting and wrong, "fucking keto diet"(s) are having results for many people, whether you like it or not Others, please research this person further, he's not a "loon" / "crackpot" just a regular smart young person who also happens to be a cancer researcher. BTW, keto also cures epilepsy, and that's known since the early 20th century, is that also triggering to you?
Animats 5y ago
Bring back fat-shaming!
wkd415 5y ago
Duh.
colinmhayes 5y ago
This is why we need medical payments to be capitated, not fee for service. The way medical care currently works has horrible incentives. Medical providers have an incredible informational advantage so patients just do whatever their doctor tells them. Since doctors get paid for doing things they routinely tell people to do things that are proven to have little efficacy. Medical providers should instead be paid per patient they cover. Especially now that hospitals are so consolidated it's relatively easy to tell if health outcomes are better or worse than average over the group of patients they cover. By punishing providers for achieving bad outcomes and sharing the savings they obtain by cutting waste we can drastically reduce healthcare costs. Medicare and Kaiser permanente are leading the charge with this style of insurance and have already shown it to be cost effective while not reducing the quality of outcomes.
- michaelbuckbee 5y ago
  This is tricky to implement as it introduces other perverse incentives: namely that health care providers stop treating very sick people. You see this in some cases with surgeons already that have a very high success rate. They'll only opt for surgery if it's a relatively minor need, but if it's complicated or there are potentially complicating issues they'll pass.
  - colinmhayes 5y ago
    Outcomes for very sick people being worse is taken into account so providers aren't punished if their success rate is lower for those patients. We have all the data we need to know what the outcomes should be for a provider over the course of a year. Anyway, providers have to precommit to their pool of patients, so it's not like they can just pick the lucky ones. Capitation is admittedly a much more complicated way to administer health care, but fixing the incentives is absolutely worth the pain we may face in the short term. Which we might not considering how well these programs have been shown to work.
    - RSZC 5y ago
      Huh, I didn't expect to come across something I have such direct knowledge of. I used to work with this data directly - I worked with MACPAC to prepare reports for the CBO on the efficacy of pay-per-performance programs, especially as it pertained to the possibility of switching Medicaid from a fee-for-service model to a pay-for-performance model. (6-9 years ago) I just wanted to chime in on this one quote: > We have all the data we need to know what the outcomes should be for a provider over the course of a year. The data here is exceedingly low quality, especially for Medicaid. Medicare is in a better state due to being centrally administered. We do *not* have all the data we need to make pay-for-performance more than an extremely rudimentary approach. Is that rudimentary approach still better than fee-for-service? Maybe - that's a complicated question I let the public health PHDs write very long reports on.
deleted 5y ago
[deleted]
JuettnerDistrib 5y ago
One thing this article misses are medical procedures that improve the quality of life, but have no bearing on life expectancy. For example, if you knock out your front row of teeth, not only do you look weird to people (a pirate), but also you can no longer easily bite into a hamburger, and your speech is impacted. You will have trouble pronouncing words that contain 'v', 'th', or 'f'. Getting implants is not going to increase your life expectancy, unless you live in a society devoid of knives (our external teeth). But the increase in quality of life is often worth it. That being said, in the US dentists seem to take way too many X-rays. They take X-rays before the doctor even sees you. Then the doctor tells you what you could have told them. Source: personal experience.

53 points by orborde 5y ago

> "The right says governments produce a much inferior baby" Too many Cesarean sections over centuries will yield more narrow female hips. You will like small butts, and you will lie. [0] Russians expose their newborns to the cold on purpose, to build immune systems so as to not eventually need as much "Big Pharma". [1] [0] https://www.youtube.com/watch?v=X53ZSxkQ3Ho https://www.youtube.com/watch?v=X53ZSxkQ3Ho [1] https://www.reddit.com/r/interestingasfuck/comments/qinla7/babys_were_left_to_sleep_out_in_the_cold_to/?utm_source=share&utm_medium=web2x&context=3 https://www.reddit.com/r/interestingasfuck/comments/qinla7/b...

deleted 5y ago
[deleted]

ABeeSea 5y ago

This is a 14 year old article (pre ACA) from an associate professor in economics who doesn’t have a degree in economics. Sigh

dang 5y ago
Those aren't good reasons to reject an article. Would you mind reviewing the site guidelines? Note that they include: "Please don't post shallow dismissals, especially of other people's work. A good critical comment teaches us something." Also: "Don't be snarky." Older articles and historical material are always welcome on HN, if they're interesting. Often they're more interesting than the latest $thing about $current-hot-topic. As for which credentials professors do or don't have, that seems irrelevant to whether or not the article can be the basis for a substantive, interesting discussion, which is what we care about here. The main reason to consider this article offtopic for HN would be that it's on a classic flamewar topic. However, those aren't automatically bad. It depends, again, whether the article contains enough interesting information be different (https://hn.algolia.com/?dateRange=all&page=0&prefix=false&sort=byDate&type=comment&query=diffs%20by:dang https://hn.algolia.com/?dateRange=all&page=0&prefix=false&so...), and can sustain an interesting discussion. After skimming it a bit, I think it probably clears that bar. I've changed the title from the original, though (because it's provocative and therefore flamebaity) to a representative sentence from the article body, which says what the article is about. Of course it's still up to HN users to focus on the interesting parts and discuss them thoughtfully, rather than use it as a diving board to spring into pits of hellfire from. https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html
- NoPie 5y ago
  14 years old article is a good reason to take note of it as it shows it is not just some fad but important long-term issue. I don't think the issue itself is controversial. I was taught at university that our life expectancy is determined roughly speaking one third by our genes, one third by our lifestyle and one third by healthcare. And then it became apparent that most healthcare interventions (childhood vaccinations, antibiotics, most medicines) that have a big effect are relatively cheap. The most costly interventions have the least effect. We could easily cut the health budget in half with only a marginal decrease of actual outcomes. But it would be very hard to do due to politics, the structure of incentives etc. But we really need to critically examine and educate people that expecting more and more from healthcare despite progress in this field can only lead to diminishing results. We cannot change our genes (yet) but we need to think more about our lifestyle (obesity, drug and alcohol use) which could provide considerable potential as well.
  - dang 5y ago
    (The classic flamewar topic I was referring to is the U.S. healthcare system)
  - nradov 5y ago
    I generally agree but public sanitation measures including water purification, food inspection, garbage disposal, and sewers also have a huge impact on average life expectancy. Maybe even more than healthcare. In other words, vaccines are wonderful but if I had to pick between vaccines and clean water I'd take clean water every time.
    - redis_mlc 5y ago
      I'd agree. My theory is that the reason life span is 20 years less in the developing world is solely due to water treatment issues, resulting in wide-spread hepatitis. By 60, most people look (and feel) 80 there.
orborde 5y ago
What specifically has changed since this essay set was published that would render it moot? If "the ACA", what specific ACA policies?

jt2190 5y ago

(2007)

dang 5y ago
Added above. Thanks!

orborde 5y ago

(OP here) This essay set may superficially appear to be another repetitive salvo in the interminable US healthcare political conflict, but I recommend reading a bit deeper. I think the perspective these essays offer (that, at the margin, medical spending doesn't affect people's wellspan much, at least not in the US) is both quite important and underrepresented in most discussions of healthcare.

isoblvck 5y ago
medicare for all. done.
lambdaba 5y ago
I mean, why would we expect it too? Spending is about profits accumulating somewhere, so why would that have anything to do with optimizing healthspan? Note, I'm vehemently critical of the modern medical establishment, and a health loon myself (by necessity, was hit with a though illness early on in my life).

dadjoker 5y ago

[flagged]

umvi 5y ago
"An ounce of prevention is worth a pound of cure" - old proverb
tux3 5y ago
Fit, healthy, people are dying left and right. There are risk factors, but don't start thinking you're invicible for not having them. The adaptive immune system is slow, vaccines prime it to react faster with more specific antibodies. Dying of pneumonia does not feel good. It makes grown men cry and beg. Strongly recommend against.
- lambdaba 5y ago
  But those "fit, healthy" (the genuinely so, I'm not sure I even agree with the characterization for many of the mediatized cases), are OUTLIERS. Yes, you are never invincible, but it's 100% correct to characterize Covid as a disease of the metabolically dysfunctional. Sadly, this is a HUGE percentage of the population of the world nowadays, which seems to be the point of the article (disclaimer: in true HN tradition, I haven't read it) Traditionnal post-downvote comment: Covid affects those: - on immunosuppressant medication most often for a PREVENTABLE "lifestyle" disease - otherwise negatively affected by said disease, particularly in the vascular system, we know that Covid kills most those that have hypertension, long-term vascular damage from chronically-elevated blood sugar, etc. - nutritional deficient / malnourished (low vitamin D, absence of sunlight, etc. etc.); this is also very common
  - whoopdedo 5y ago
    > this is a HUGE percentage of the population of the world nowadays, And thus make up a sizeable amount of COVID patients. I see nothing noteworthy here. Having a preexisting condition makes you suffer more when you contract an infectious disease. I'd expect the same things you said could be repeated for influenza, pneumonia, or anything else. For that matter, how much worse do obese patients fare when recovering from a broken leg? Are fractures then a disease of the metabolically dysfunctional, as you put it?

paulpauper 5y ago

A lot of $ is spent on medicine because medicine works. Alternatives such as diet, exercise either are spotty in efficacy or do not work. Medicine offers a quick fix and in some cases the only fix. Someone who has cancer will need to be treated with medicine, not diet.

lambdaba 5y ago
this is such a strange comment for me, and I beg people not to reflexively downvote and instead join in for a discussion, but I'm part / have been part of communities where people ROUTINELY achieve remission from disease the medical establishment deems incurable I can go in further details if people ask, but lifestyle intervention has DRAMATIC results for many people, myself included, and results not provided by drugs or any commonly available medical intervention Let me give you an example, RE: cancer and diet, look up "Andrew Scarborough brain cancer" and you'll find a detailed account of someone treating incurable brain cancer with diet and lifestyle; and this is someone working in the medical field (actually, precisely in oncology)
- danachow 5y ago
  > and this is someone working in the medical field Well, yes, even a crackpot can claim to be working in the field. This in no way supports your claim of “routine” cures through diet. There is no evidence that a fucking keto diet will cure cancer* and it doesn’t pass any sniff test as at the end of the day your body still runs on glucose. This is pretty much an insult to anyone not fortunate enough for their cancer to go spontaneously into remission - and looking at the loon you posted, both he and a family member had some amount of treatment before diet, confounding any claim that diet was responsible for remission. * whether such a diet can have some survivability benefits or some better or worse outcome is an open question, which has nothing to do with your crackpot claims.
  - lambdaba 5y ago
    I am only replying to your incendiary comment to say that your characterization is insulting and wrong, "fucking keto diet"(s) are having results for many people, whether you like it or not Others, please research this person further, he's not a "loon" / "crackpot" just a regular smart young person who also happens to be a cancer researcher. BTW, keto also cures epilepsy, and that's known since the early 20th century, is that also triggering to you?

Animats 5y ago

Bring back fat-shaming!

wkd415 5y ago

Duh.

colinmhayes 5y ago

This is why we need medical payments to be capitated, not fee for service. The way medical care currently works has horrible incentives. Medical providers have an incredible informational advantage so patients just do whatever their doctor tells them. Since doctors get paid for doing things they routinely tell people to do things that are proven to have little efficacy. Medical providers should instead be paid per patient they cover. Especially now that hospitals are so consolidated it's relatively easy to tell if health outcomes are better or worse than average over the group of patients they cover. By punishing providers for achieving bad outcomes and sharing the savings they obtain by cutting waste we can drastically reduce healthcare costs. Medicare and Kaiser permanente are leading the charge with this style of insurance and have already shown it to be cost effective while not reducing the quality of outcomes.

michaelbuckbee 5y ago
This is tricky to implement as it introduces other perverse incentives: namely that health care providers stop treating very sick people. You see this in some cases with surgeons already that have a very high success rate. They'll only opt for surgery if it's a relatively minor need, but if it's complicated or there are potentially complicating issues they'll pass.
- colinmhayes 5y ago
  Outcomes for very sick people being worse is taken into account so providers aren't punished if their success rate is lower for those patients. We have all the data we need to know what the outcomes should be for a provider over the course of a year. Anyway, providers have to precommit to their pool of patients, so it's not like they can just pick the lucky ones. Capitation is admittedly a much more complicated way to administer health care, but fixing the incentives is absolutely worth the pain we may face in the short term. Which we might not considering how well these programs have been shown to work.
  - RSZC 5y ago
    Huh, I didn't expect to come across something I have such direct knowledge of. I used to work with this data directly - I worked with MACPAC to prepare reports for the CBO on the efficacy of pay-per-performance programs, especially as it pertained to the possibility of switching Medicaid from a fee-for-service model to a pay-for-performance model. (6-9 years ago) I just wanted to chime in on this one quote: > We have all the data we need to know what the outcomes should be for a provider over the course of a year. The data here is exceedingly low quality, especially for Medicaid. Medicare is in a better state due to being centrally administered. We do *not* have all the data we need to make pay-for-performance more than an extremely rudimentary approach. Is that rudimentary approach still better than fee-for-service? Maybe - that's a complicated question I let the public health PHDs write very long reports on.

deleted 5y ago

[deleted]

JuettnerDistrib 5y ago

One thing this article misses are medical procedures that improve the quality of life, but have no bearing on life expectancy. For example, if you knock out your front row of teeth, not only do you look weird to people (a pirate), but also you can no longer easily bite into a hamburger, and your speech is impacted. You will have trouble pronouncing words that contain 'v', 'th', or 'f'. Getting implants is not going to increase your life expectancy, unless you live in a society devoid of knives (our external teeth). But the increase in quality of life is often worth it. That being said, in the US dentists seem to take way too many X-rays. They take X-rays before the doctor even sees you. Then the doctor tells you what you could have told them. Source: personal experience.