Our main problem in health policy is overemphasis on medicine (2007) | Hacker News Reader

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

cato-unbound.org

53 pointsorborde76 comments

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.

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.

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.

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.

you're not fixing the distortive incentives with this scheme, just transforming them. 'capitation' incentivizes hoarding of patients, most obviously by incentivizing the minimization of treatment times and associated costs but also through outright fraud (by falsifying records, etc.). so you're essentially trying to maximize patient outcomes by capping costs, which is a terrible proxy metric all around.

to actually improve healthcare, we'd need to increase spending per person (by an order of magnitude or more, using more team-based medical care rather than 1-on-1), for not only direct care costs, but also research and development. what we absolutely need none of is deadweight losses, like profit-maximizing medical administration, big pharma, and the whole medical insurance industry. medical 'insurance' has become a complete misnomer, as it no longer serves to mitigate the distasterous effects of low probability, high impact events, but as a socialization of routine medical care, which is not insurance at all.

The healthcare industry is gradually shifting from a fee-for-service model to a value-based-care model. This will take a long and we'll probably always have a hybrid model with varying levels of financial risk spread across insurers, providers, patients, and government.

As an incremental step forward bundled payments are a good approach. For common interventions like a hip replacement the insurer gives the provider a single lump sum for everything instead of having separate line items for surgery, anesthesia, medical device, antibiotics, hospital stay, physical therapy, etc.

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.

(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.

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).

medicare for all. done.

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.

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)

> 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.

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?

Had to login just to counter the epilepsy part of this comment, though I think it applies to the rest of the topic wrt cancer as well. Keto diets can, in some cases, help epilepsy patients, particularly those with certain seizure types or genetic basis. But, like with cancer, epilepsy is complicated both in presentation and cause and to pretend that keto is any way a cure for epilepsy outside of a small minority of patients isn't true. See https://www.epilepsy.com/learn/treating-seizures-and-epileps... for high level overview.

It sometimes is enough, sometimes not. But it does have SOME undisputed efficacy and it's an area of legitimate research.

Lol "sometimes is enough, sometimes not" is a bit of a backpedal from definitively putting cancer into remission.

If it's an area of legitimate research for cancer treatment, then why do you lead with a reference to an individual crackpot - instead of even a poorly designed peer-reviewed study in a low impact forum.

Of the millions of possibilities, why do you assume that it was the keto diet of this individual that lead to their remission? Do you lack the imagination that it would likely be something else?

I was referring to epilepsy.

I will not get into further arguments with you re: the "crackpot", insult. Have a nice day.

Also, re: this caricature you make of these "keto" diet cancer plans, it's not true that the "body still runs on glucose", in fact only 25 grams of glucose are manufactured by the liver per day in the absence of dietary carbohydrates. And I don't claim to know the mechanisms, but I know FOR SURE that human beings (and no other animal for that matter) evolved to live on candy bars and sugar water, and that replacing one's diet with something species-appropriate and nutritionally replete is bound to have some effect.

To elaborate: red blood cells are the only part of the body that absolutely must use glucose, and they're not incredibly metabolically active.

Thanks, I didn't know. It's weird to see this misinformation about glucose being the primary fuel for human bodies while it's quite obvious human biology is optimized for fat burning. Glucose is just dealt with in priority because it's only safe in a tight band, and chronically elevated glucose in particular is disastrous to blood vessels. Humans should spend a decent amount of time in fat burning mode with periods of fasting and adequate magnesium intake and exercise for optimal vascular health.

Because it’s not misinformation - the body absolutely needs glucose homeostasis to survive - if you don’t eat carbs it will make it out of protein. The body has numerous mechanisms and basically dedicated organs for the conversion, metabolism, storage, and production of glucose. The whole Krebs cycle is built around the processing of byproducts of glucose - so you’re utterly full of shit that it’s “only safe in a tight band”. That the body can additionally use fatty acids in the form of ketone bodies as a stopgap is a testament to adaptability - but even people on keto require a homeostasis of a close to normal level of blood glucose. And how do they get this? Through the metabolism of proteins which can be amazingly converted to the glucose the body needs to survive.

This is high school level biology, and easily reviewed with 10 minutes on Wikipedia.

I did not say the body can't deal with glucose and as you point out, produce it on demand. What I meant by "in a tight band" was the chronically elevated glucose is damaging to organs as evidenced by what happens in advanced diabetes.

And the body doesn't need dietary carbohydrates, which was my point. It does absolutely need both proteins and fats without which starvation occurs.

I said the body runs on glucose (ie it is essential for survival) - you claimed that was misinformation (which it isn’t) - I said nothing about dietary carbohydrates.

Blood glucose levels for those on even the extreme keto diets will be regulated in the same range (60-90 mg/dl) as someone on a more conventional diet that does not have impaired glucose metabolism.

People with Type 1 diabetes still need insulin even if they are on a keto diet.

You said "at the end of the day your body still runs on glucose" which is NOT true on a ketogenic diet, as a mere 25 grams are manufactured by the liver as needed for (apparently) red blood cells.

Yes, I agree that ketogenic dieters still have glucose, obviously, my point was about CHRONICALLY ELEVATED glucose being deleterious for blood vessel health, which is widely known and, again, cause of the necrosis seen in late-stage diabetes.

I know of at least one T1 diabetic that is OFF INSULIN on a ketogenic (carnivore) diet.

Glucose is produced constantly by numerous cells in the body, and that is an essential function - regardless of diet.

> I know of at least one T1 diabetic that is OFF INSULIN on a ketogenic (carnivore) diet.

No, you do not. Fully progressed Type 1 or LADA diabetics need insulin to live or they need a pancreas transplant. There are some other experimental avenues - but they have nothing to do with diet because the key issue with T1DM is autoimmune destruction of the pancreas and insulin is essential.

You clearly do not have beyond a grade school understanding of biology. You may convince others that are similarly ignorant of the basics, but that would not be me.

Here's one example from a search: https://revero.com/vlad-manages-type-1-diabetes-carnivore-di...

And here's a person I know from Twitter: https://twitter.com/furniss_jon

I found an article by this person about it https://blogs.meterbolic.org/blog/taking-control-of-type-1-d...

Note that I'm not sure about his status at the moment because he's experimenting with a lot of stuff, and I'm aware of the beta cell issue, but it seems to be more complex than that. Perhaps it can only be arrested in a subset of people who somehow retained a baseline of insulin production.

Re: glucose, I'm not disputing glucose is always necessary, just not dietary glucose and only about 25 grams per day. Humans seem to be extraordinary at using fat for energy.

I read the blog post once and concluded this poor chap was confusing type 1 and type 2 diabetes - because really the first paragraph is silly - that testimonial is classic for type 2 diabetes.

I’m still a bit skeptical this dude actually has true type 1 diabetes, when it fits more likely that it is LADA, latent autoimmune diabetes of adulthood - maybe look it up.

But in any event, everything I could find is that this guy is still using insulin. So that doesn’t really change anything - he’s still insulin dependent - and he “hopes” that it can be reversed. But why? Not based on anything logical I can see. He reduced his insulin requirements - by reducing his dietary carbohydrate intake - well duh that is a mainstay of diabetes management for years - you don’t have to go full blown keto to realize decreasing insulin requirements with lower dietary carbs.

So your example doesn’t even demonstrate your point. And even if it did, your fundamental line of reasoning is flawed - you keep bringing up examples - these people might as well be medical outliers - this has no generalizability and you don’t have any justification to even suspect that their diet had any effect on their health outcomes.

Edit: also please read the comments carefully on “vlads” post - lol he’s been diagnosed type 1 at age 40 - more likely it’s lada. And he’s only been diagnosed 2 months - yeah maybe he still has some functioning islet cells left - look where he is in 2 to 3 years. I appreciate the commenters that basically call him out on his bullshit.

Yes the speculation is a zero carb diet will arrest type 1 if caught early.

Anyway we can perhaps at least agree that t2 diabetes is resolved by a low-carb diet and my initial point was just to say that blood vessel health is negatively impacted by abnormally elevated blood glucose, nothing more.

Third point, and I'm going to end it here: I myself suffered from Multiple Sclerosis when I was younger; it was retrospectively very easy to correlate, at least in a large part, with diet and lifestyle. The changes I had to make to be in remission were DRAMATIC but worth it. I don't think I would've been insulted to read about people in similar situations experiencing remission from lifestyle adjustments, in fact, I would have been extatic to find out I'm not condemned to slowly drift into being eventually wheelchair-bound, as my doctors were predicting.

Diet and exercise will work much better to prevent obesity than any medicine on market. It is just that long-term adherence to these things is very much determined by culture and will be much harder for Americans compared to Japanese, for example.

There are new discoveries in diabetes medicines recently but again, you will do much better by not getting diabetes in the first place.

The same goes for smoking which can cause, for example, lung cancer. Roughly speaking, once you get diagnosed with lung cancer you only have 40% chance living more than 1 year. Costly novel medicines often prolong the life by few months only.

We really need better health economy education for everyone.

I mean, it's not complicated, when we allowed the tobacco industry to manipulate people for profits while hiding the disastrous health consequence of their products, people got ill in larger numbers

It's the same for the processed food industry. It's time will come, soon, too, as healthcare systems everywhere are failing because of it.

all the nutrition info is on the labels yet people knowingly overeat. different type of problem.

I don't think people think much beyond calories wrt to overeating. I know my mentality was once "calories can come from anywhere, can always take a multivitamin to cover deficiencies", which I now find, to put it gently, silly.

Not "diet and exercise", just diet. Exercise doesn't contribute more than ~10% to weight loss (it helps for many other things but not that) - and if you're having trouble with the diet then it makes it more difficult because you get hungry, which sometimes cancels the entire thing out.

IME exercise (combined with appropriate diet, mind you), actually reduces food intake for me. Or at least, makes it so I eat less net calories after removing the expenditure. But otherwise agreed, diet is the foundation.

Well, the idea is probably not to gain weight in the first place. Once you gain weight it is very hard to lose it. Many people manage naturally to keep perfect BMI by eating healthy diet and having enough exercise or by just moving around. Exercise will have more health benefits than just keeping your body weight low.

The efficacy of cancer prevention via fitness, diet and lifestyle far exceed the efficacy of cancer treatment by medicine.

(2007)

Added above. Thanks!

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