Is More Medicine Better? (Cato Unbound)
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Last annotated on September 6, 2016
Hanson points to a spate of studies — especially the huge RAND health insurance experiment — to show that “in the aggregate, variations in medical spending usually show no statistically significant medical effect on health.”Read more at location 74
letters. (Send them to wwilkinson@cato.org.) Lead Essay CutRead more at location 88
Note: i medici salvano tante vite quante ne uccidono: non esiste correlazione, né a livello nazionale né a livello internaxionale, tra spesa sanitaria e speranza di vita altri fattori che contano di più: fumo rural living dieta temperatura ambiente esercizi reddito l evidenza errori medici dove funziona: pronto soccorso immunità e cure neonatali lì ha senso investire ma la spesa aggregata deve calare xché l illusione ottica persiste (placebo pub bias show caring) Edit
Cut Medicine in Half Car inspections and repairs take a small fraction of our total spending on cars, gas, roads, and parking. But imagine that we were so terrified of accidents due to faulty cars that we spent most of our automotive budget having our cars inspected and adjusted every week by Ph.D. car experts. Obsessed by the fear of not finding a defect that might cause an accident, imagine we made sure inspections were heavily regulated and subsidized by government.Read more at location 88
Then let me speak plainly: our main problem in health policy is a huge overemphasis on medicine.Read more at location 102
But health policy experts know that we see at best only weak aggregate relations between health and medicine, in contrast to apparently strong aggregate relations between health and many other factors, such as exercise, diet, sleep, smoking, pollution, climate, and social status.Read more at location 103
Children are told that medicine is the reason we live longer than our ancestors, and our media tell us constantly of promising medical advances.Read more at location 110
In contrast, few doctors know that historians think medicine has played at best a minor role in our increased lifespans over the centuries. And only a few health policy experts now know about the dozens of studies of the aggregate health effects of medicine. Worse, these studies can seem muddled, with some showing positive, some showing negative, and some showing neutral effects of medicine on health.Read more at location 112
In the aggregate, variations in medical spending usually show no statistically significant medical effect on health.Read more at location 116
By “variations” I mean the large changes in medical spending often induced by observable disturbances, such as changing culture or prices, and by “aggregate” I mean studies of the health effect on an entire population of disturbances that affect a broad range of medical treatments.Read more at location 120
Note that a muddled appearance of differing studies showing differing effects is to be expected. After all, even if medicine has little effect, random statistical error and biases toward presenting and publishing expected results will ensure that many published studies suggest positive medical benefits.Read more at location 123
(A general review is found in Fuchs, Health Affairs, 2004 . A contrarian review is Hadley, Medical Care Research and Review, 2003.) The first study known to me was by Auster, Leveson, & Sarachek, Journal of Human Resources, in 1969Read more at location 125
a Fisher et. al. Health Services Research 2000 study, and a related Skinner and Wennberg 1998 study,Read more at location 139
1998 Lantz, et al. study in the Journal of the American Medical AssociationRead more at location 148
large and significant lifespan effects: a three year loss for smoking, a six year gain for rural living, a ten year loss for being underweight, and about fifteen year losses each for low income and low physical activity (in addition to the usual effects of age and gender).Read more at location 150
discussion of the health effects of medical spending variations usually turns eventually to our clearest evidence on the subject: the RAND health insurance experiment.Read more at location 155
Let us now summarize and interpret these results. Medicine is composed of a great many specific activities. Presumably some of these activities help patients, some hurt patients, and some are neutral. (Don’t believe medicine can hurt? Consider the high rate of medical errors, and see the Fisher & Welch Journal of American Medical Association 1999 theory article.)Read more at location 183
I thus claim: we could cut U.S. medical spending in half without substantial net health costs.Read more at location 196
How should we cut medical spending? There are many possibilities, and I may prefer some possibilities to others. But I do not want such preferences to distract from the main point: most any way to implement such a cut would likely give big gains.Read more at location 198
Yes, I know, these are not politically realistic proposals. But at least health policy experts should publicly contradict those who overemphasize medicine,Read more at location 202
If health policy experts hesitate on my proposals due to doubts about how much we can rely on the RAND experiment and correlation studies, then they should at the very least immediately and fully support channeling available funding into repeating the RAND experiment today,Read more at location 205
Do you have little voice in health policy or research? Then at least you can change your own medical behavior: if you would not pay for medicine out of your own pocket, then don’t bother to go when others offer to pay; the RAND experiment strongly suggests that on average such medicine is as likely to hurt as to help.Read more at location 210
What about studies suggesting larger benefits in particular areas, e.g., immunization, infant care, and emergency care? Yes, there are categories of medicine where larger benefits seem plausible, and where empirical studies support such claims. (See, for example, Filmer & Pritchett Social Science and Medicine 1999 and Joseph Doyle 2007.)Read more at location 213
What about health and innovation externalities? Your health may give positive benefits to others, but most medicine on the margin seems to have little to do with health.Read more at location 223
What if everything has changed recently? Overreliance on medicine seems to be quite ancient and widespread; historians suggest that until recently our ancestors would have been better off avoiding doctors.Read more at location 230
How could we be this wrong about medicine? If you wonder how the usual medical literature could give such a misleading impression of aggregate medical effects on health, I will point to funding and publication selection biases, statistical tests ignoring data mining, leaky placebo effects, differences between lab and field environments, and the fact that most treatments today have no studies.Read more at location 236
I’ll point you to my forthcoming Medical Hypotheses article, wherein I suggest humans long ago evolved a tendency to use medicine to “show that we care,” rather than just to get healthy. Briefly, the idea is that our ancestors showed loyalty by taking care of sick allies, and that, for such signals, how much one spends matters more than how effective is the care, and commonly-observed clues of quality matter more than private clues.Read more at location 241
half could still be a good idea. Response Essays UseRead more at location 249
The most important reason why medical costs increase over time is because we develop new ways of treating patients and provide that care to ever more people. Consider the most expensive part of medical care: care for people with cardiovascular disease. In 1950, a person with a heart attack received bed rest and morphine (to dull the pain). That was how Dwight Eisenhower was treated when he had a heart attack in 1955. This therapy is not very expensive, but it is also not very effective. Today, such a person receives clot-busting drugs and other medications, and intensive interventions such as bypass surgery or angioplasty. These technologies are certainly costly. Spending in the few months after a heart attack is about $25,000 per patient. And yet the care provides enormous benefits. Mortality in the aftermath of a heart attack has fallen by three-quarters since the 1950s. Read more at location 276
Virtually every study of medical innovation suggests that changes in the nature of medical care over time are clearly worth the cost.Read more at location 283
Reconciling this finding with the fact that there is a lot of waste is not hard conceptually. Read more at location 290
The problem in medical care is how to separate the good from the bad. Read more at location 292
He is certainly correct that the role of medicine has been overstated.Read more at location 317
The HIE is more than three decades old, and in that time period many new therapies have emerged.Read more at location 330
There is a lot of waste in the system, as the evidence cited by Hanson and others makes clear.Read more at location 336
let’s give them the tools they need. The Conversation LetRead more at location 413
Note: riassunto delle posizioni tesi: chi si oppone dice che i tagli potrebbero interessare la sanità utile. nn siamo d accordo su come agire. ma xchè non agiamo su dove c è accordo: i tagli non provocherebbero danni alla salute risparmiando risorse ipotesi di critica attesa: stidi fallaci effetto maschera opportunità politica parallelo studi e incremento prezzi moralità intenzionale Edit
So far, no commenter on my essay seems willing to let go of the nut of effective medicine, held in the gourd of the second half of medical spending.Read more at location 415
I challenged health policy experts to “publicly agree or disagree” that “it has long been nearly a consensus” that since “variations in local medical culture … [and] prices” produce spending variations with little apparent relation to aggregate health,Read more at location 422
Cutler seems at first to agree, saying “if the high spending areas were brought to the level of the lower spending areas … we could save 25 to 30 percent of Medicare spending.” But then he says higher prices are “wrong” because they do not “separate the good from the bad” as “consumers appear to cut back indiscriminately,” such as stopping drugs. Instead Cutler wants “carefully targeted evaluations” of better “supply side policies.” Goldman agrees “the role of medicine has been overstated,” but also rejects higher prices because it “isn’t enough” to eliminate waste, as patients are “as likely to reduce appropriate as inappropriate care.” Instead, “we should be spending a lot less in some areas, but also spending a lot more elsewhere.” Garber says my “diagnosis … is not particularly controversial” but rejects “policies that would heedlessly cut high-value benefits along with the low-value marginal benefits.”Read more at location 425
Shannon Browlee’s Overtreated, published today, argues “between 20 and 30 cents on every health care dollar we spend goes towards useless treatments and hospitalizations.” Yet even she will not support crude price increases or spending capsRead more at location 436
Bloggers Matt Yglesias and Ezra Klein reject higher prices because “patients … will just cut care indiscriminately.” Tyler Cowen similarly shrugs “I’m not sure what mechanism will get rid of the bad half” of spending. (Arnold Kling, Bryan Caplan, and Seth Roberts seem more sympathetic, but take no explicit position.)Read more at location 438
I’m all for finding better ways to favor helpful over harmful medicine, but since we have no consensus on how to do this, why must this distant possibility stop us from publicizing and acting now on our consensus that we expect little net health harm from crude cuts?Read more at location 445
Critics seem to me to suffer a “leave no man behind” obsession that makes the best the enemy of the good.Read more at location 447
But apparently I stand alone; what am I missing? Help me see your reasoning. Please, pick one or add another:Read more at location 452
Do you claim aggregate studies on balance do show spending increases from observed disturbances,Read more at location 454
Do you claim the existence of identifiable treatments with positive benefits, which are cut when spending is cut, shows that aggregate spending variations do give substantial aggregate health gains?Read more at location 456
Do you claim that implementing simple crude policies like price increases or spending caps today would make it much harder to implement other policies later,Read more at location 462
Do you argue that it is immoral to ever “leave a man behind” to disease, even if this tends to hurt as many in the attempt as it helps?Read more at location 464
If we cut half — without knowing what to cut — we will likely cut half the value.Read more at location 473
Do you claim the existence of identifiable treatments with positive benefits, which are cut when spending is cut, shows that aggregate spending variations do give substantial aggregate health gains? My response is yes.Read more at location 478
Per capita income in the United States is 30 percent higher than in Sweden, and yet Americans are no happier than Swedes; indeed, Swedes report greater levels of happiness. Based on these data, can one conclude that cutting income in the United States by 30 percent across the board would leave Americans unaffected?Read more at location 546
don’t do ourselves any favors by pretending it is easy. StillRead more at location 558
David, in this case you seem to be suggesting that aggregate happiness studies are missing adequate controls, i.e., you suggest that happiness studies which controlled for income equality and social goods would in fact show that aggregate variations in GDP are substantially related to aggregate variations in happiness. This is exactly the kind of specific critique that I request for aggregate studies on medicine and health.Read more at location 571
health insurance premiums above the cost of this limited plan? Yes,Read more at location 589
Dana gives an example of “what is missing from aggregate studies”:Read more at location 595
Well, yes, any industry must pay transition costs to switch from less to more efficient technologies,Read more at location 598
Maybe people in Miami prefer surgery, and people in Minnesota prefer medical management.Read more at location 606
In this situation I predict most health policy experts would clearly and publicly say that we should act now to promote, e.g., child car seats orRead more at location 617
When asked what reasons they have for doubting that existing aggregate studies suggest crude medical cuts will not hurt health, the three commentators here at Cato Unbound do not point to the same reasons.Read more at location 625
David Cutler suggests aggregate studies are missing important controls (which he does not identify). Alan Garber dismisses simple cuts as politically infeasible, but does seem willing to endorse lower tax-based subsidies. Dana Goldman first points to “the existence of identifiable treatments with positive benefits, which are cut when spending is cut.” Instead of responding to questions about this, he switches to suggesting high spending region doctors have invested more in learning expensive treatments, and when questioned about this he switches to unmeasured differing preferences; “Maybe people in Miami prefer surgery, and people in Minnesota prefer medical management.”Read more at location 627
If aggregate studies had suggested medical spending helps health a lot, I can’t imagine health policy experts being nearly as reluctant to endorse simple crude spending increases. This seems a double-standard.Read more at location 631
