Articles

131 thoughts on ““How do you feel about Evidence-Based Medicine?”

  1. @BillyJoe, that is extraordinarily disingenuous. You are truly grasping at straws. Let me first address the “one issue” you have with one paragraph that I wrote that explained my personal feelings towards prostate cancer.

    If you simply read the entire paragraph that you quoted from me, you will see that I wrote I have a positive family history of prostate cancer. My father was recently diagnosed and treated. It must be rather embarrassing for you that the “whole thing that started this discussion” is something that you simply failed to read.

    Here is the initial post that you wrote which is what I first read and what actually started this discussion:

    I have been interested in the evidence base for PSA testing for prostate cancer ever since my father was diagnosed with that disease. I often come across comments made by medical practitioners which make it clear that they base their decision to promote the test amongst their patients as a result of a single experience they have had – for example a patient who asked for the test to be done, was diagnosed with prostate cancer, had a prostatectomy…and is still alive! This apparently trumps the systematic reviews based on tens of thousands of patients that conclude that PSA testing cannot be recommended.

    In this post, you are using your personal experience (anecdotes) to essentially condemn “medical practitioners.” You seem to assume that doctors are clueless regarding the evidence basis of PSA screening and that we all just screen everybody because of a single success story. In reality, any doctor who is unaware of the reccomendations behind PSA screening is simply out of date. PSA screening is discussed ad nauseum in almost every single piece of medical literature you read, and is one of the most discussed topics. Perhaps in Australia because they are all so busy chasing down kangaroos they are too busy to read one of thousands of publications that are available to PCPs? (That’s a lame joke. @mousethatroared please don’t ask for peer-reviewed evidence that states Australian doctors chase kangaroos at a rate statistically significantly higher than the rest of the world.)

    I then replied to your post giving the textbook answer for what is correct, ethical, and appropriate for prostate screening. If you read (most? all?) recommendations for PSA screening, they always involve a component of what the patient is comfortable with. That lead to my statement that you seem to have such a problem with. As I already pointed out, you completely failed to read that I wrote I have a positive family history of prostate cancer, which makes me high risk. Further, my father’s prostate cancer was considerably fast growing, and had a rather high Gleason score, but thankfully no metastases. So, my statement that I will have a PSA in the future, and if it’s elevated, I will undergo biopsy, is absolutely based in science and in line with recommendations.

    As for my statement about utilizing the robotic procedure, I wrote that because that is currently the recommended surgical procedure from the urologists at MD Anderson (MD Anderson is one of the top cancer treatment facilities in the USA.) Let me save you the trouble of pointing out the appeal to authority. In some cases, you simply have to defer to the authority. I do not treat cancer, and I do not do surgery. If I go to one of the best cancer treatment facilities, and the team there would prefer to do the robotic procedure over the traditional approach, then you’re damn right I’m going to follow their advice. You need to keep in mind that there is a (huge) element of skill in surgery. The “best approach” in incompetent hands is infinitely more deadly than a “worse approach” in expert hands. Therefore, if my caregiver at one of the top cancer hospitals prefers a certain procedure, then I will listen. To consider a flawed argument from a zero-experience internet researcher, in this case, is laughable.

    The funny thing is that I’m still at least a decade away from actually pursuing a PSA. By then, who knows what kind of screening tests and surgeries we will have for prostate cancer.

    You then wrote, in response to someone else:

    I’m not sure what point you are trying to make here. Of course there is nothing wrong with a patient requesting a PSA test. But what IS wrong is the doctor not explaining to that patient why PSA tests are not recommended. He probably should refuse to order the test but, if the patient insists, there is probably no way to avoid it. If the patient did turn out to have prostate cancer, the doctor would be “in deep s**t” if he outright refused to order the test. In Australia, it is the media that is driving the push for PSA testing using testimonials of celebrities who have developed prostate cancer to urge men to attend their GPs to have it done.

    You are correct that there is nothing wrong with a patient requesting a PSA. However, your use of “not recommended” is very wishy-washy. In some contexts I interpret your “not recommended” as “recommended against”, which is absolutely wrong. This interpretation is supported by your sentences that follow it. You then wrote that a doctor probably should refuse to order the test. This is absolutely wrong. If you refuse to order a PSA after explaining the risks and benefits then you have compromised the patient-doctor relationship. That is a complete failure as a doctor, and this exemplifies my point about non-doctor internet researchers preaching about how doctors “should” act. The truth is you are simply clueless. That is not an attack on your intelligence, it’s just that you do not have an understanding of medicine. I wouldn’t go around telling structural engineers how they “should” build a bridge. You further go on to conspire that doctors should only do a PSA to avoid being in trouble if the patient ended up having prostate cancer. Your statement about Australia celebrity testimonials is irrelevant, although I had some fun thinking in an Australian accent and making up a commercial about PSA screening (“Oy! You got to have a finger up yar bum and get the PSA! I had the cancer, mate, you may too!”)

    You were consistently and demonstrably wrong. You then proceeded to hyperfocus on one statement that I made which merely reflected my personal beliefs on how I would personally pursue treatment if I indeed have an elevated PSA in the future. You selectively quoted me, which suspiciously left off the part where I wrote I indeed have a family history, which completely crushes your attack on me.

    Shame on you. I am finished with you.

  2. * Excuse me, I made a mistake. I identified my family history in a subsequent post, not the one you quoted repeatedly:

    As to your question of me saying that I would happily remove my own prostate cancer: my statement is absolutely in line with what is ethical and in line with recommendations. My personal attitude towards cancer is that I do not want it, and I could not live knowing that I have prostate cancer actively growing inside of me. I am in my 30s, and I am absolutely healthy. I have no sudden or early death in my family, but I do have a family history of prostate cancer and multiple myeloma (one in each parent, both “in remission” by state of the art medical treatment.) I am not riddled with other diseases that lowers my life expectancy. I will undergo regular PSA testing and if mine is elevated, I will undergo biopsy, and if a significant Gleason score is found, I will have my prostate removed. I obviously know that prostate cancer usually doesn’t kill males (please re-read my previous post), but do not forget that prostate cancer is the second leading cause of cancer death in men (at least in the USA.)

  3. pmoran says:

    SH: “I was writing, correctly, that PSA screening should be discussed with and offered to patients based on their personal beliefs, risk factors, and co-morbidities. Nobody recommended pan-screening. “

    It is still not clear how what you describe in the first sentence above differs from what you would be doing if you were to wholeheartedly endorse PSA “pan-”screening. You would still be having to seek informed consent.

    Much of what you say suggests a positive attitude towards screening, or at least for your own brand of selective screening, despite the fact that we cannot yet identify any subgroup of prostate cancer sufferers where screening has clear benefits and that the practice of medicine in an important and potentially very harmful area would be coming to rely more upon patient whim than anything else. It is only right to be thinking critically about how what we are doing. .

    Remember that when we brought in mammographic screening we had strong evidence that breast cancer mortality could be reduced by 30% or more. We have nothing comparable to lay on the table for those risking impotence or incontinence from the treatment of a test finding.

  4. The quoted sentence is precisely in line with the recommendations from nearly every major medical organization. Please don’t be a pedant.

  5. BillyJoe says:

    Skeptical Health,

    Thanks for acknowledging that you didn’t mention the history of prostate cancer in the post I responded to. And, to be honest, I didn’t pick that up in your subsequent post.

    However, that is neither here nor there.
    As I stated in my last post:
    “Even then [if you have a family history of prostate cancer], you would need to consider the evidence that treatment of prostate cancer offers a “small to no reduction in prostate cancer-specific mortality” in exchange for a very high risk of ongoing morbidity (impotence and incontinence).”
    To be clear, this conclusion does not change if you have a family history of prostate cancer.

    And I think you should stop with the ad hominems.
    You would be surprised how much I have looked into the question of PSA screening over the years since my father was diagnosed with prostate cancer. Prior to that I had exchanges with a medical specialist who posts on the JREF forum who corrected me on a nuanced point about the conclusions of a clinical trial that I was misinterpreting. She subsequently set me on the path to learning how to properly interpret them and how to evaluate them for methodological flaws.

    Finally, despite much provocation, I have not attacked you. I have merely demonstrated the lack of scepticism in your approach to PSA testing. I think what you have failed to do is to distinguish what the evidence says about PSA testing (not recommended) and the practicalities of dealing with patients who come requesting a PSA test.

    Anyway, you are stuck in a rut here, so I won’t pursue this any further.

  6. You are absolutely wrong. What I have stated about dealing with patients who request PSA screening is absolutely correct and in-line with what the evidence shows. Send your anonymous “specialist” from the JREF forums here and I will happily correct her flawed understanding of PSA screening. No comment about how your absolutely wrong advice on how doctors “should” act is completely unethical and inappropriate? (Not to mention completely unscientific?)

  7. BillyJoe says:

    SH,

    You simply keep misunderstanding what I am saying.

    I clearly stated that the medical specialist led me on a path to learning how to evaluate and interpret clincal trials. Nothing specifically to do with PSA testing. I merely used that knowledge to assess clinical trials involving the assessment of PSA screening for prostate cancer.

    And I have already agreed with you – several times now – on the practicalities of dealing with a patient who presents for a PSA test. I even stated that the RACGP takes that line as well. What you seem to completely miss is that the assessment of the scientific evidence for PSA testing is a separate issue.

    I will say it again: On the evidence that treatment of prostate cancer offers a small to no reduction in prostate cancer-specific mortality in exchange for a very high risk of ongoing morbidity (impotence and incontinence), PSA testing is not recommended.

    How you then deal with a patient who presents for a PSA test, is then a separate issue on which we all agree.

  8. I think the one thing we can all agree on is that hopefully we can learn better ways to identify aggressive prostate cancers so that we can improve our ability to diagnose aggressive prostate cancers early. Ie, some biochemical marker that signals a truly aggressive prostate cancer.

    I do not know much, if anything, about where we get the money for cancer research (obviously tax dollars, private funding, etc). I just read that the National Cancer Institute gets around 5 billion dollars per year for cancer research, and it looked like about 300 million went to prostate cancer. For fun, I saw that NASA’s yearly budget is about 18 billion dollars, the new fighter jet has cost about 400 billion and may cost up to a trillion dollars. The war in Iraq was costing about 720 million dollars per day, so 8 to 9 days of the war consumed as much money as a years worth of cancer research.

    I sure wish we’d put a little more money towards fighting the 1st and 2nd leading causes of death in the USA.

  9. JMB says:

    ” Bodies like the USPSTF should be in the business of informing about optimum measures, not of judging whether society can afford specific measures.”

    I agree. In fact the traditional operation of the USPSTF was to prepare a recommendation of whether the screening was effective in reducing morbidity and mortality, and the cost per year of life saved. Another committee of CMS, chaired by a high profile presidential appointee (the head of CMS), would then decide whether medicare/medicaid would reimburse for the screening. However, beginning in 2009, the USPSTF introduced a new decision method, the efficient frontier analysis, and began choosing the most efficient screening protocol, instead of the most effective screening protocol (effective is that protocol which maximizes the number of years of life saved).

    “It’s only been recently that overdiagnosis and overtreatment have become major concerns. ”

    I agree. However, figures for overdiagnosis and overtreatment are a derivative of data that has always been considered in decisions of treatment for breast cancer. When a patient has biopsy proven breast ca following screening, and treatment options are provided for the patient, the quoted figure for percent survival quoted with the option of no treatment would represent the percent of over-diagnosis (and possibly over-treatment if the patient selects treatment options). The figure quoted by many published authors includes patients diagnosed with multiple stages of breast cancer that died from other causes (heart attack, stroke, motor vehicle accidents) before they died from complications of breast CA. Sometimes those figures include those cases of breast cancer who died in spite of best efforts of treatment (do we deny patients with stage 3 or 4 breast cancer treatment because it is over-diagnosis and over-treatment?).

    So before “recently”, the issue of over-diagnosis and over-treatment was presented in the decision about treatment options. The patient could choose the no treatment option, being informed of the percentage of patients would would survive based on the individual factors of tumor type, tumor aggressiveness, tumor size, and nodal involvement. If the patient chose the no treatment option and survived, they were over-diagnosed.

    Now many are trying to shift that decision one step forward into the screening process, when we have no information about the individual tumor, just population averages. Is that justified? If we give up the goal of minimizing breast cancer mortality, and replace it with a goal of more efficiency, it may be justified.

    I would argue that so long as we can show in multiple RCTs that there is a reduction in mortality, offering that screening strategy to the patient for the most effective reduction of breast cancer mortality is justified (providing information about the expected benefits and risks). When we detect a tumor, and obtain further information pertinent to whether it is likely to be an over-diagnosis or over-treatment, then we include that information for the patient in their decision. We should provide information about the risk of over-diagnosis and over-treatment to the patient, but the figures quoted should be based on the excess number of cases detected in the screening group after 15 years of follow up. The sequential decisions based on the best available information at each stage will achieve the best optimum decision in the Bayes strategy.

    We physicians tend to think over-diagnosis and over-treatment refers to breast cancers that are minimal and/or noninvasive. However, some authors have quoted figures from population studies that include cancers that are Stage 2, 3, and even 4. We cannot see into a crystal ball and predict absolutely when and how a patient will die (with a possible exception for some patients in an ICU scenario at imminent risk of death). However, we can maximize the use of available information to make strategies the will maximize the best outcomes for the patient, and let the patient decide if the risks are worth the benefit. We don’t have to bury our head in the sand and not do screening because of concerns about over-diagnosis and over-treatment that are nebulous before we characterize the tumor. The RCTs will give us the expected mortality rate reduction, and the excess number of breast cancer cases detected in the screened group. Those are the statistics we should pay attention to in deciding to offer screening.

    Prostate screening issues are fundamentally different than breast cancer screening issues. The meta-analysis of RCTs of breast cancer screening support that there is an expected mortality reduction. The meta-analysis of prostate cancer screening does not support a reduction of prostate cancer mortality.

  10. BlindedByScience2020 says:

    This alternative medicine thing has become a really huge problem. It’s actually way worse than I thought. I recently decided to change primary care physicians. It turns out that finding a new doctor that embraces science based medicine is much easier said than done. Almost every medical professional that comes up in a search offers some sort of alternative product or philosophy. Either they believe it themselves, or they perhaps feel obligated to offer it because that’s what people want and they know they won’t get any patients if they don’t. It’s really starting to get out of control.

  11. nybgrus says:

    I just finished a week of doing OBGYN clinic and my attending was prescribing black cohosh to patients for menopausal symptoms. I played (half) dumb and said, “I think I remember reading about that stuff and it didn’t seem like there was any evidence that it actually worked.” She responded by saying, “No the evidence doesn’t seem to show it does, but it seems to for some women, and for those that just don’t want hormonal therapy I offer to them. If it makes them feel better than it has worked.” And I said, “But weren’t there some kind of side effects with it? Maybe it is something else, but I remember reading it had bad effects on the liver.” And she said, “No, this is herbal stuff and it is really pretty benign.”

    Face palm.

    I also noted that her undergrad degree was a BA in Romance Languages. I asked her what prompted her to change direction like that (a genuine question). She said that she always wanted to do medical school, but went with her advisors advice about “doing whatever undergrad sounded like fun” and doing the min pre-reqs and the MCAT since that is all you needed to get in.

    I really think med schools need to re-evaluate their “any bachelors + the min science classes” stance on eligibility.

    1. Harriet Hall says:

      @nybgrus,
      “med schools need to re-evaluate their “any bachelors + the min science classes” stance on eligibility.”

      Oh dear! I must defend my pre-med education. I too was a Romance Languages student. I got a magna cum laude BA in Spanish Language and Literature, which involved a junior year at the University of Madrid with an invaluable exposure to another culture. I won the department award and was elected to Phi Beta Kappa. I had planned on med school all along, and switched from my initial chemistry pre-med major for a number of reasons. I think you respect me enough to realize my major didn’t do me any harm. I think a well-rounded background is at least as likely to produce a thoughtful, caring physician as a straight nerdly science track. And I’m afraid my real understanding and appreciation of science developed after medical school, not in pre-med or med school classes.

  12. Yeah :) I have to agree with Dr. Hall. The med school pre-reqs do a decent enough job of giving you a basic understanding of science. And I definitely saw colleagues who majored in things like psychology not understand things like 2 alleles forming a genotype (my jaw dropped when one tried to explain something to me…) Sure, I would believe that someone who majored in biology or similar field would be more inclined to be scientifically-minded, but it’s certainly not a guarantee. Let’s be honest, college is pretty damn easy, so the bulk of people graduating with these degrees likely don’t know their ass from the elbow. My undergrad, which was at an honestly barely decent college, was very frustrating. You could study for a week for an exam and make a 98-100. Or you could study for 2 hours and do bonus work and get a 90. (You know what I mean.) I hated bonus work. Why should someone pass a class because they did busy work instead of learning the material?

    I almost think that medical schools should encourage students to pursue a degree outside of biology/pre-med. The number of students that get in to medical school is small, and when they fail to matriculate they are stuck with a pile of student loan debt and a degree that you really can’t do much with besides pursue further education. I seem to remember one girl who got almost straight As, but got a 16 on the MCAT. She’s now a med-tech. It cost her a couple of extra years of college.

    But then again, I’m of the opinion that some of college is a waste of time, and it’s pretty bad that students take entire semesters of worthless classes, while paying for them with student loans, and having to pay living expenses, etc, just to complete a “4 year degree.” I understand the necessity of being “well rounded”, but crap man, that’s a lot of money to pay back! There are more than enough stories of people who spent $60,000 on a degree in medieval literature that are now cleaning houses for a living. But then again, the student should be responsible for themselves and know that they are pursuing a degree that has limited income/employment potential. I guess if we remember the chiropractic thread its similar to them, $100,000 for a degree that is completely useless.

    The strangest thing is all of the woo schools require introductory science classes, which seems completely contradictory to what they are teaching. A friend of my wife, who I alienated after they invited us for dinner one night and he started attacking “Western” medicine (if you think I’m a dick on these forums, I can be just as verbally cutting in real life, he still can’t look me in the eyes), was a massage therapist and is now going to acupuncture school. He was required to take the first pair of biology classes, along with other classes, before applying. Those classes certainly did not help him think critically, or to understand that there are no such things as meridians in the body, or any such non-sense. Likewise, massage school students, chiropractors, naturopaths, etc, all take high-school level anatomy & physiology, and it never seems to strike a chord with them that these mythical pathways they believe they are manipulating are never taught in these classes, nor or they in any respectable textbook.

    I’m almost embarrassed to admit this: my wife is obsessed with nutrition, and it’s great because she has started creating some absolutely delicious meals that are healthy, and are diets are as good as they can be now. She wants some sort of nutrition certification, which really doesn’t exist. She already has a career, so going back to college to become a dietician is out. She just wanted something with structure to keep her reading on the topic. She signed up with one of those online nutrition schools. We looked hard for the one that seemed to have the least woo in it. We settled, and the first 2-3 semesters were great. Sure, some of the books had some crap in them, but she was learning basic biology, nutrition, etc. She is now in the 4th semester, and received her books in the mail. Sadly, half the books this semester were written by the “founder” of the school (here: http://www.rowlandpub.com/ ), and they include gems like “Thyroid hormone testing is completely inaccurate. The best way to diagnose hypothyroidism is to take 4 body temperatures in a 24 hour period. If they are below 98.6 then you are hypothyroid” and “Allergy scratch tests are completely inaccurate. Applied kinesiology is accepted as the most accurate diagnostic technique.” Oh it makes my head spin. Luckily my wife isn’t an idiot, and is just suffering through these retarded books because she’s enjoying the program, and yes, she understands that the certificate she gets at the end is useless.

    So, who knows. Education is important, but it really seems like the individual is important too.

  13. Chris says:

    SkepticalHealth, you should enjoy these videos: Frugal Dietitian Channel.

  14. nybgrus says:

    I had planned on med school all along, and switched from my initial chemistry pre-med major for a number of reasons. I think you respect me enough to realize my major didn’t do me any harm.

    Of course I do, Dr. Hall. Please forgive the brusqueness of my post – it was at 5 this morning whilst scrambling to slug a coffee before heading out for a run before surgery.

    I didn’t mean to imply that the degree necessarily harms one’s ability to think critically and scientifically (though in the case of my BA in which I also graduate magna cum laude, it sure did!) I was merely trying to say that we need to find a way to get people – at least in med school – to be more critically thinking. I won’t try and lie by saying that is all I meant – I did intend to imply that a science degree should be necessary for admission to med school… but I meant it from the perspective that said science degree has a higher chance of producing a scientifically minded critical thinker.

    I will say, however, that in today’s day and age, with so much information being flung at you it is very easy to go all the way to being an attending without ever getting a grasp of the fundamental scientific underpinnings of science in the practice of medicine. In fact, it is often encouraged these days. I won’t waste space by naming all the MDs who would fit that bill with whome we are all familiar.

    I don’t know what the solution is – and I certainly fully acknowledge that any undergrad degree can yield critical thinkers and excellent physicians. But when I look at a colleague of mine who has a background in journalism and the min science classes and she has not the foggiest how ATP, ADP, AMP, cAMP, and adenosine relate to each other I wonder when she will ever find the time. We don’t have much as it is and medical school itself is not geared to make you a critical thinker. It is geared to make you remember a lot of algorithms and facts that you can regurgitate on command. I can fill this blog with stories of my classmates that demonstrate this point – heck, one today literally had her jaw drop when I said it is reasonable for Cochrane to take a stance on homeopathy and that we shouldn’t fund studies of magic (yes, I said magic). She said, “Well maybe it would work… and if people want to keep using it shouldn’t we respect that?” No, it won’t work, and no bad ideas don’t deserve respect.

    Sorry, now I am rambling. I’ll close by just saying that my point was that however we do it, we need to generate more critically thinking, scientifically literate undergrads since med school will more often than not worsen someone’s proclivity for laxity in thought and poor application of science. I think the easiest way would be to require science undergraduate degrees, but I’ll readily agree there are many other options.

  15. kathy says:

    One can teach people how to think critically, but how can you make them want to? Especially if their society encourages them to be conformist freethinkers. All the cosiness of a mental couch-potato, chomping pre-packaged cognative junk food, but because that junk food is labelled “Born Free! … Think out the Box!! … No more Slavery to Big Pharm/Meds!!!” they think they are really original deep thinkers.

    I’m thinking of my students now, I teach them how to think for themselves and knock me over! they turn it all into just another course to be passed {deep sigh}.

  16. nybgrus says:

    Sorry to be a necromancer here, but PZ Myers just had an interesting post regarding PSA testing and prostate cancer (and I stayed out of the BJ/SH debate merey because I didn’t have enough desire to warrant the time):

    UC Davis was sponsoring a public seminar on prostate cancer; specifically, they were actively promoting the prostate specific antigen (PSA) test. One professor, Michael Wilkes, objected — the PSA test is now discouraged as worse than useless. Wilkes is a specialist in prostate cancer; he knew this. Heck, I knew this, and my local MD knows this. He explained to the department that was sponsoring the seminar that it was wrong…

    Dr. Wilkes wrote an editorial that is linked to and quoted as well that is worth reading.

  17. nybgrus says:

    merey = merely*

  18. Jurjen S. says:

    Re: fledarmus1′s observation that: “If there really was some negotiation between buyer and seller, that would be a different story,” as well as Mousethatroared’s counterpoint, I’d say the fledarmus is on the right track, but where the disconnect is not in health insurance per se, but in health care. As The Economist put it,

    For most Americans, buying a procedure is akin to choosing a house blindfolded, signing a mortgage in Aramaic, then discovering the price later.

    “Consumer-driven” insurance plans have run into trouble in that the employees covered by them, and required to spend a certain amount before insurance kicks in, have found it next to impossible to get clear answers as to how much treatments and procedures actually cost, because prices are negotiated between health care providers and insurers, and both parties in those negotiations will not share the results of those negotiations with others. For the same procedure, one hospital may charge 125-150% of what another hospital in the same city charges, and only the insurers know beforehand what the price will be.

    Frankly, I think many Americans would be quite happy if health insurance worked more like car insurance: rather than have every bit of routine maintenance, minor repair, even merely consulting with your mechanic require reams of paperwork involving the insurer, they’d rather reserve the insurance for calamities and pay for routine and minor stuff out of pocket, rather than have their insurer interpose himself in every transaction.

  19. Scott says:

    @ Jurjen S:

    An important distinction is that your car insurance company doesn’t care whether you change the oil – they’re not on the hook to pay for the damage if you don’t and the engine seizes. A health insurer, OTOH, cares very much about encouraging you to get stuff dealt with while it’s still “routine and minor” so they have good reason to cover it for you.

    This is one of the reasons I like the idea of moving away from a “pay by procedure” paradigm to “pay by patient, condition, and result.” That does a decent job of aligning the provider’s incentives with cost-effectively fulfilling the patient’s needs.

    It’s not a magic bullet, it will probably have unintended consequences, and it will be hard to get from here to there, but IMO it’s an important and useful part of the puzzle.

  20. nybgrus says:

    “pay by patient, condition, and result.”

    A lot of coverage has moved that way – in particular Medicare and Medicaid. The problems that arise there is that guidelines become a bit too rigid and thus time and money are lost on patients that could be skipped ahead of pointless tests and procedures before moving to more specialized tests and physicians. The bigger issue is that many times doctors and hospitals become penalized for patients that are more complex than the mold allows and patients that are simply non-adherent to treatments.

    In many cases if a patient returns to care for any reason within 30 days of initial treatment, the hospital and doctor are not reimbursed for initial care. This is to motivate the system to help the patient become more adherent and knowledgeable and to avoid collecting payment for shoddy service repeatedly on the same patient. The downside is that in many cases there is simply nothing more the system could have done and thus gets double penalized since initial payment is rescinded and the subsequent treatment is out of pocket for the hospital and doctor.

    The other scenario is a patient that codes for one illness which is capped at a certain reimbursement but is simply more complicated than that and costs more to care for. Time spent counseling is poorly reimbursed, if at all, so it becomes much more economical to throw a bunch of tests at someone and kick them to the curb and hope for the best.

    The further consequence of this is that doctors become very adept at finding ways to up-code and cover extra care, sometimes beyond what is really necessary and ultimately subverts the system.

    I agree that this sort of direction is probably the better way to go, but it requires intellectual honesty from all parties and more focus on the science involved rather than political gestures.

  21. evilrobotxoxo says:

    @Jurjen: this is getting quite off-topic, but I think there is another more serious problem with market-based healthcare systems, which is that there is minimal elasticity of demand. In other words, if a person needs a surgery, they need a surgery, and they’ll get it no matter how much it costs. It’s not like going to the movies, where low ticket prices lead to increased sales and high ticket prices lead to decreased sales. The amount of health care people need is relatively constant regardless of price, so it’s not obvious that a free market model will optimize prices successfully. Another problem is that free markets assume that the consumer is well-informed about the choices, which in the case of medical care is simply not true (hence the need for doctors to parse the evidence and make recommendations).

    On the question of whether or not people would be happy if health insurance worked like car insurance, I’m not sure whether or not it would lead to increased happiness, but I do know that a system like that would be less effective from a purely medical perspective. The reason why is because one of the largest problems across all of medicine is patient nonadherence to treatment recommendations. People don’t like taking their blood pressure meds, their diabetes meds, their asthma meds, etc., and then they rack up exorbitant medical bills when they get admitted to the hospital for catastrophic events that are often preventable. Not everybody does this, but the people who do are responsible for a grossly disproportionate amount of health care spending. The problem is that the system you’re describing, or really any catastrophe-only insurance model of health care reimbursement, encourages this type of behavior. A better and cheaper system would be the opposite, where people don’t pay out-of-pocket for preventive care but actually get paid (e.g. an iPad raffle or free movie tickets) for showing up to appointments and meeting health goals such as weight loss, smoking cessation, controlling hypertension and diabetes, etc.

  22. nybgrus says:

    kudos evilrobotoxxx. I have been trying to explain these concepts to my very libertarian and very “free market capitalist” friend for over a year now. He is firmly convinced that free market forces can and will fix anything, including health care, and almost as convinced that no government is better than heaps of it.

  23. BillyJoe says:

    MSdragonslayer,

    Well, that was a long post and a lot of questions.
    But you could have saved your time by reading the comments. ;)

  24. BillyJoe says:

    ..oops, wrong thread.

  25. mousethatroared says:

    Gotta agree with evilrobotxoxo that the decisions are to complex for the laymen to find saving. For instance, a while back a friend sent a link to an article about how children’s hospital’s charged more in a side by side comparison of standard procedures than standard hospitals. The article’s position was that the children’s hospitals were charging more because parent’s were responding to the prestige factor and choosing children’s hospital’s over standard hospital.

    So the cost of a CAT scan at the children’s hospital was more than the cost of the CAT scan at a standard hospital. People should use the standard hospital and save money, right? Except when my son needed a CAT scan we were told that he would probably need sedation to remain still and get a good picture. Luckily, the children’s hospital had a high speed (expensive) CAT scan machine, so no sedation was needed. How does a laymen find out about these differences, much less weigh the risk of sedation against additional cost.

    Same thing for for the multiple naseoendoscopies my son needed. Maybe the children’s hospital was more expensive, but they also had the equipment specialized to children and specialists experienced in working with children, How do you weigh extra cost against the risk of having your son or daughter go into a panic attack every time you go to the doctor because the person who did their naseoendoscopies was used to doing them on 40+ yo men who will sit still through some discomfort. Does that anxiety result in a lower quality of life or the use of sedation for future procedures with the additional risks and costs?

    I could go on and on and probably already have.

Comments are closed.