Just had a recent physical - I got a low value for a test and it kicked off more tests, a visit to a specialist, more tests and no conclusion besides 'let's wait and see' which I could have done without draining my HSA. If the price of care was reasonable, sure, let's be proactive but because PCPs don't really seem to do anything but refer you to a specialist and any visit to a specialist + tests will immediately trigger thousands of dollars in bills, even if you're insured you're going be paying your deductible plus like 10-30% after that.
I got a random lab bill for like $650 (discounted from $2500) and in the follow up visit everyone agreed that was high but no could explain why it was that expensive - medicare's fee schedule has the same code costing $90. Until we stop this madness of providers basically charging whatever opaque negotiated random amount they want to insurers who then pass that down to charge payers after collecting a % the prices are just going to continue to go up and the broken medical system will stay fucked - with the consequence that the economics aren't going to make sense to seek proactive care.
The issue isn't really that they're expensive - they are, they shouldn't be. Proactive access to care is good.
The article kind of hints at this, but it comes down to Bayes theorem [1]. The general population has a relatively low incidence of disease, so even tests that are fairly reliable in a population with a high incidence of disease become super inaccurate when applied to the general population.
Worse, false positives generally - especially in the US, due to high financial liability risk - end up involving expensive, invasive medical follow-up tests, and the probability of a false positive multiplied by the risk of the exploratory procedures outweighs a later diagnosis.
No wonder annual physicals don't do much good.
High-risk people should get periodic tests for the things they're at risk of, and people should be in a position to report issues they discover in the course of their lives. However testing otherwise-healthy people for things they probably don't have isn't likely to yield good results no matter how good the test. It's just math.
I had a similar mindset as you describe here - but I no longer agree after experiencing long covid. My experience with long covid was made easier because of historical lab data from bloodwork tests that were taken pre-covid when I was a healthy 30 y/o white male. After suffering for months from (what I now know was) long covid, I went in for a checkup for some help.
The blood test comparison of healthy me to sick me was invaluable, because the healthy tests established a baseline of my system at peak condition.
Periodic baseline tests are The Correct Answer™. To establish individual patient normals.
Can't manage what we don't measure.
Attention should focus on what's changed. Instead of playing 20 Questions for each new problem. [1]
High LDL? Well, it's always been high, and stable. We don't have to treat it.
Bone spurs (on spine)? Well, most everyone has them and they're not bothering you.
Oh, new sciatica symptoms? Hmmm, looks like you've got a new bone spur which may be impinging. Let's try some PT, get you a standup desk for work, and reassess in 6 months.
Etc.
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Concern trolls claim more testing begets false negatives, begetting unnecessary treatment, which has its own risks.
Fine. Change healthcare from transactional to relational. Change from our current fee-for-service to continuity-of-care (or capitation, prevention, whatever we end up calling it).
Like u/JumpCrisscross says elsethread, only treat anomalous results per new symptoms.
I believe periodic baselines with regular checkups would reduce testing and unnecessary treatments, overall.
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[1] Monitoring, logging, anomaly detection, and RCA... Starting to sound suspiciously like engineering and operations. Of course, some orgs treat each incident as unforeseen one-offs, aka The Condi Rice Defense™. But high functioning teams plan ahead.
> High LDL? Well, it's always been high, and stable. We don't have to treat it.
Only if you particularly want to die of a major adverse cardiovascular event[0], then we don’t have to treat it. Note that treatment begins with lifestyle interventions and not necessarily pharmaceuticals.
We have reference ranges with lab tests for a reason. There is no such thing as a “normal” high LDL and there is growing evidence that statin therapy is beneficial even in those without other cardiovascular risk factors.
Again keeping in mind that lifestyle interventions are the first step. Dismissing dyslipidemia as “stable” is flatly incorrect.
N.B. This evidence synthesis is outdated now but presents the risks in an accessible format, interval evidence is even more supportive of intervention.
Number Needed to Treat (NNT) seems like a great idea. Will learn more. Thanks.
The risk of cherry picking examples is they'd distract from my thesis. So I used two from my own life. I am fail. (Also, I have mo medical training and cannot advise others.)
As for LDL, mine is borderline, I'm very worried, it's unchanged by statins or diet, and I guess the plan is to monitor it. Further, the more I read about cholesterol, the more confused I get. It seems to be a topic in a state of flux. I'm currently eating buckets of fiber (oatmeal, beans, etc) and misc fish & krill oil, and recently added cocoa butter. Next I'll prob try that Fire In a Bottle stuff (some kind of tea extract).
I think statins make sense for most patients. A cardiologist friend says everyone in their practice start statins preventatively by age 40 (?). And they'd know best, right?
> Number Needed to Treat (NNT) seems like a great idea. Will learn more. Thanks.
No problem, NNT and NNH are the most important measures we look at when deciding on interventions on a population level and easily understandable. "https://thennt.com" is a high quality resource intended for physicians but is fairly accessible to an educated reader and covers many common interventions one may face.
A lot of proposals have sounded great during my medical practice until the numbers come back with a NNT of 100,000 and NNH of 1000.
> Further, the more I read about cholesterol, the more confused I get. It seems to be a topic in a state of flux.
We used to have "LDL target < 2" when I was in training but my understanding is the general consensus amongst experts (and some recent evidence, but not enough to make a general recommendation) points to a stochastic relationship rather than a deterministic one/specific threshold with continued benefit scaling to 0 (found looking at hunter-gatherer indigenous populations).
> I think statins make sense for most patients. A cardiologist friend says everyone in their practice start statins preventatively by age 40 (?).
This is beyond my scope of practice (i.e. don't take this as medical advice) but anecdotally I also recently asked a cardiologist I greatly respect about a family member and his response was similar to what you were told, he started statins himself in his late 30s as male with "normal" cholesterol and no risk factors although the evidence is not yet there to support such liberal use and the guidelines don't recommend this (yet).
Beyond cholesterol reduction statins coincidentally also have plaque stabilizing effects that reduce the risk of MACE.
Given that there is next to zero harm with statin therapy and they're cheap, it seems like a reasonable intervention en masse in my non-domain expert opinion. The diabetes risk was overstated in earlier literature but we have better data now that their use is so widespread, myopathy is a self-limiting nothingburger that goes away when you stop/switch agents.
Personally, I'm planning start a statin soon as well regardless of my LDL levels (typical disclaimer of this is not evidence-based and a personal decision, discuss with your physician etc).
> And they'd know best, right?
Either endocrinology or cardiology would be good experts to ask as they live in this world. I would/did trust a cardiologist when I needed expert opinion on this personally.
> The risk of cherry picking examples is they'd distract from my thesis.
I mostly wanted to address the LDL as that has a strong body of evidence behind it.
The issue with your thesis otherwise is that most tests have no relevance without appropriate clinical context and if they won't change management what's the point?
Consider radiology which is the land of meaningless incidentals, the issue we often face is "oh great, there's an incidental adrenal adenoma on this appendicitis scan that's probably nothing but could theoretically be an adrenal cancer what the hell do we do now?".
A single baseline would often be nice in the sense of if a patient did develop a non-adrenal cancer I could look back and say "oh this was there before, it's not metastatic" but there isn't enough evidence to support this statement considering the potentially life-threatening harms from over-investigating benign findings with biopsies/surgery. This has been the main criticism of whole-body screening MRI but the literature is just starting to come out.
Thanks again. I'll consult my primary about restarting statins.
I forgot to mention a huge reason I support regular baselines of some sort: eldercare.
In the case of our mom, now 85yo, it would have been really useful to have done cognitive assessments and bone density and maybe image likely arthritic joints when she was 65.
Divining when, which, and how much brain pills to give her has been pure guesswork.
And deciphering her chronic back pain has also gone poorly. Resulting in a lot of trial and error. With no real improvement. IMHO. (Experiencing chronic pain myself, I know it's wicked hard to treat.)
Ditto the 3 other elders us siblings have been responsible for. We were just guessing how to best care for them. We didn't know their rate of decline, so weighing risk/benefit was just guesswork. So maddening and wasteful. It really felt cruel and inhumane.
Maybe having better medical history, perhaps in the form of baseline assessments, would have helped.
Hopefully the research you mentioned will help future care givers make better decisions.
Thanks for the informative, thoughtful replies. Peace.
Having baselines is fine, but they don't have to be annual and they certainly don't need to trigger a barrage of tests which are unnecessary at best and potentially harmful at worst.
In somewhere this is where authority fallacy comes into play
People need to push back and ask questions not just accept everything the doctor says at face value..
If I take my car in for routine maintenance and the mechanic comes back with 1000 things they want to do I am not prone to just say "sure do what ever you think is best, you are the expert"
Except physicians don’t practice independently like a mechanic and we answer to several authorities (licensing boards, specialty colleges, hospital M&M and MAC). We follow evidence-based guidelines that have looked at various outcome measures.
It would be malpractice and I would be sanctioned if I were to willfully ignore validated guidelines without strong medical evidence to support me.
It’s a good thing to ask questions but “pushback” suggests an adversarial approach. If you feel like your physician is attempting to fleece you find a different one, in my experience most of us aren’t like that. Physician-patient trust is critical.
If you’re unsure of where to look a good starting point is an academic-affiliated practice which will have more oversight and reimbursement structures that don’t align with over billing.
You point to "several authorities" as meaning the relationship between doctor and consumer should be less adversarial as the doctor then to the mechanic and consumer. as the doctor would have sanctions if they go against that authority, that orthodoxy
to me however that means my personal care is not the only concern, with the mechanic the motives and incentives are clear. With the Doctor they hidden with a split set of masters and at the end of the day the patient is not the primary concern or factor, the Licensing board is, the insurance company is, the government regulators are, but not the patient.
These over lapping authorities you think make the system less adversarial to me makes it more adversarial, as now I have to ensure the motives of your decision making is about me, the patient, and not the government authority that told you what you have to do... not the licensing board, not the insurance company, etc.
See COVID response as a recent example of this, but history is fraught with other examples where patient care suffered under the weight of authority.
this is with out going into the pure corruption that influence many health policies from diet to drugs... Making it less "evidence-based" then I think you are asserting.
I mentioned these as you said “do whatever you think is best” and to contrast with the workflow of a mechanic. I’m not doing whatever I think is best I’m doing what the body of evidence thinks is best, adjusting to specific patient circumstances.
As an aside the “agenda” of these authorities is to ensure we practice safely (i.e. evidence based medicine) in the interest of patient care and not based off our own personal gain or thoughts (as you posited with the mechanic analogy). An example of a sanctionable offense is performing an unnecessary procedure because it pays well, like in your mechanic example.
Where there is no compelling evidence, or when there are unique patient circumstances, I practice with more latitude (e.g. I commonly biopsy lesions that don’t need one when it’s causing patient anxiety and the risks are low, despite not adhering to guidelines, and have no fear of being sanctioned as it is justifiable as reducing anxiety/for the patient’s mental wellness. What I can’t do and will be sanctioned is if I unnecessarily biopsy a benign incidental lesion for the $90).
With respects to insurance and pharmaceuticals I couldn’t care less what their interests are. As part of my job I fight with them routinely and we take industry funded evidence with a grain of salt.
The primary guiding interest in any patient encounter is unequivocally the patient’s health. We are explicitly instructed (and obligated) to disregard systems-level issues and concerns in patient encounters.
COVID is a perfect example of why science-based medicine doesn’t work as the response was not evidence based at all, largely because it’s impossible to acquire evidence during a pandemic.
As someone who was critical of the response, you’re right that the authorities limited us (not that I practice primary care) but that period of time was the medical equivalent of martial law. This has been the only period in my lifetime where medical practice was dictated by an authority to such a degree.
Mistakes will happen in exceptional circumstances, most medical encounters are not exceptional. We are also all human.
Pointing out rare exceptions doesn’t disprove the validity of evidence-based medicine or provide evidence of its corruption.
FWIW, I think you're coming from a position of good faith and you do want to see doctors do all they can for the patient's health.
That being said, the structure of medical practice in the US leads to mediocre and expensive outcomes for patients because no one cares to address systemic issues because no one is incentivized to.
> We are explicitly instructed (and obligated) to disregard systems-level issues and concerns in patient encounters.
That's a problem isn't it? Since we're on HackerNews, if I have an application that has a performance issue due to a slow disk, should I just throw my hands in the air and say "I have to disregard systems-level issues and focus on delivering features"? I hope I and my management can cut through the org chart to align on addressing the root cause which is getting a faster disk.
Another anecdote: my uncle was a doctor in South America and he is appalled whenever he sees doctors in the US. Doctors in the US do not care to learn anything about you beyond your symptoms, vital signs, and blood work. They see you like a car engine and follow a cause and effect flow-chart to decide on a treatment. In South America, he would spend time trying to understand the patient's living conditions, his occupation, stressors, hobbies, etc. to understand if the patient's self-identified symptoms are consistent with other patients with similar backgrounds. Seeing each patient took more time, but he and his patients were much more satisfied with the exchange than in the US. The lesson he learned there is that in the US there are too many invisible hands in the room guiding the doctor's hand, leading to an outcome where the patient's health is just as important as the insurance's health, the doctor's (financial) health's, the hospital's health, and the government's political health.
I think there is a very important distinction to be made. An individual doctor-patient relationship may not be concerned with systemic issues, but that doesn’t mean the overall healthcare system ignores systemic issues. If a patient goes in for care, they deserve to have their symptoms and underlying disease treated, irrespective of the physicians ability to make systemic change.
However, I will say some healthcare systems do try to get to the root causes. Once upon a time, I worked for a healthcare system in a “process engineer” role, for a lack of a better term. There was a team of us, and the whole point was to take a systemic look at healthcare outcomes so we could mitigate root causes that led to less than optimal patient outcomes/quality of care.
> because no one cares to address systemic issues because no one is incentivized to.
I'm not sure that's true having practiced both in the US and Canada which are both very similar. Speaking to my own specialty (radiology) there are several academics working to build evidence to reduce unnecessary and expensive follow-ups that seem to have low clinical utility.
I'll give you an example, current follow-up regimens for pancreatic cysts are unnecessarily long and expensive with very high probability although all societal guidelines (US and international, with the US version actually the shortest) have very long and expensive follow-up recommendations based on limited evidence from Japan and expert opinions.
When I report a pancreatic MRI although I don't personally want to I still recommend "follow-up in one year per ACR guidelines" as that is currently the standard of care and in the chance that I'm wrong (no compelling evidence on either side at this point but the status quo is to follow-up) the outcome (pancreatic cancer) is devastating.
Simultaneously, several groups (including myself) are looking at long-term evolution of these cysts so we can one day stop doing these probably unnecessary studies with confidence. This is despite the fact that I can bill $130 for a "stable pancreatic cyst" MRI that takes me 2 minutes to report.
Within my own specialty the same thing has been done for breast masses, liver lesions, ovarian masses and renal masses within recent memory and we have dramatically reduced investigations at financial cost to ourselves in the interest of patient care.
> That's a problem isn't it? Since we're on HackerNews, if I have an application that has a performance issue due to a slow disk, should I just throw my hands in the air and say "I have to disregard systems-level issues and focus on delivering features"? I hope I and my management can cut through the org chart to align on addressing the root cause which is getting a faster disk.
There's a time and place to fix systems-level issues (which are very hard to objectively evaluate and obtain evidence for fixes), during a specific patient encounter is not one of them.
Inertia in healthcare is real but we also have to remain cognizant that the consequences of mistakes/poor decisions are far more significant than in most other areas of life.
> Another anecdote...
Primary care is broken in the US and Canada (can't speak to elsewhere) due to several issues, the funding model being one of them which greatly limits how much time a GP can spend with a patient while still eating/being able to sustain a practice. Hospital-based specialty care is a lot better on average as we have more resources.
> he would spend time trying to understand the patient's living conditions, his occupation, stressors, hobbies, etc
For example we do this in oncology where I mostly reside professionally. Treatment decisions are influenced by these factors and every cancer center I've worked in has allied health professionals as part of the team to also help evaluate these factors.
> The lesson he learned there is that in the US there are too many invisible hands in the room guiding the doctor's hand, leading to an outcome where the patient's health is just as important as the insurance's health, the doctor's (financial) health's, the hospital's health, and the government's political health.
The issues you describe are most prominent in private practice environments which are very heterogeneous and there are definitely toxic physician groups that optimize billing, but I wouldn't say the system as a whole does not care. I suggested somewhere that patients try to find academic-affiliated practices (ironically my clinical work is private practice) if they are unhappy with their care as these groups have far less financial considerations and are generically speaking a better choice.
Overall I'd say the system is far from perfect and there are many inefficiencies but the majority of physicians I've worked with do in fact care about patients more than financial incentives. There is no easy fix for these very complex issues.
Thanks for the detailed reply, I sense then there are at least 3 kinds of health related interactions we’re talking about: 1) PCP visits which have wide variance in quality 2) non-hospitalized specialist visits where it’s unclear if the cost is justified 3) hospitalized care.
Most people don’t experience 3 until there is a serious enough problem, but when they do their care is far better than anywhere else in the world.
I don't know in which country you practice but here in Switzerland no board will ever give a decision of malpractice short of the doctor sticking a pitchfork in your eye. Theory is all nice but current practice makes this medical responsibility a joke.
Sounds like you're over it now, any idea what helped? I also developed long covid as a healthy 30 y/o white male, but haven't been able to kick it after 8 months.
Might be pure coincidence but my wife shook her long covid symptoms when the first vaccines appeared. They had diagnosed inflammation of the small passages of the lung and she had real shortness of breath. Inhalers of various kinds didn’t seem to help. Bad when things can be diagnosed by zoom or a phone call with good sound reproduction. Fortunately it’s not recurred.
brain fog, no smell, and reduced lung capacity. elevated liver enzymes in the bloodwork showed i wasnt crazy. oh, i should mention probiotics helped out too, along with the vaccine.
> asking for info, not doubting anything!
sure, just hesitant to answer because im not looking for a debate on this stuff anymore, got enough of that in my day-to-day while i was symptomatic. after the last 3 years i just want to put it all behind me and get everything back to normal.
Curious how blood tests helped you in this situation? I not only had extensive blood tests prior to getting sick but also had a sleep study and extensive psychological testing, none of which were consequential in my eventual long covid diagnosis
It helps eliminate benign anomalous results in emergencies. I have a low neutrophil count. It is totally uneventful. Having that baseline means if I’m sick and have the works run, doctors need not start treating my neutropenia—that wasn’t caused by whatever is going on.
More broadly, catching a vitamin D deficiency and allergy early probably saved some years of life and definitely improved my quality of life.
Some doctors are test happy. Most are not. Finding the right fit is part of being a human in the midst of modern healthcare.
Most medical diagnosis goes like this: you see a symptom, this could be caused by a dozen entirely different problems. A few of them can be easily ticked off by absence of some very clear flags in the lab result list. Others only have indicators that are much less clear, that are shared with a whole bunch of other outside-the-norm conditions, many of them perfectly fine. If you have a backlog, if instead of a list of current measurements you have a matrix of current and previous measurements, you can narrow it down much more.
Not really, very few diagnoses benefit from such historical data.
Any lab value flagged as abnormal is typically >95%ile meriting some form of further investigation (whether that’s continued follow up/repeat blood work or a different test depends on what we’re talking about).
The tests that could be physiologic for a patient outside of reference ranges (e.g. mild LFT elevations) will often just get repeated to establish stability as you propose. There isn’t a compelling argument to do this prospectively before symptoms start.
My wife's hemoglobin comes back high. It always comes back high. That's just her, it doesn't mean something's gone wrong. Some out-of-range values are meaningful (like cholesterol) by themselves, but in many cases if they're out of range but the patient is healthy it's simply something to note as normal for that patient.
Mid forties, my insurance only covers preventative blood work every 3 years or something like that. I guess that can be based on having a normal/good workup the previous time.
> High-risk people should get periodic tests for the things they're at risk of, and people should be in a position to report issues they discover in the course of their lives.
How do you know if you’re at high risk for something? This assumes a medically literate and motivated person will seek care based on … what? Realizing that grandpa, great-grandpa and dad all didn’t live past their 60’s? High cholesterol and hypertension can be “silent killers” - how do you know to check for them?
For what it's worth hypertension is a good example of a bad test - or a routinely poorly executed one, anyways.
According to the AHA, blood pressure is supposed to be taken with feet flat on the floor, relaxed, and quiet for five whole minutes before, on an empty bladder, without caffeine and not having exercised within 30 minutes. I can count on zero hands the number of times I've had my blood pressure measured in accordance with this procedure in a doctor's office during a check-up. [1] It's a highly variable thing that can spike instantaneously and take a long period of time to return to normal without issue.
Which is probably part of why 30% of people who get their blood pressure taken in a doctor's office will register a higher than normal blood pressure principally only in the doctor's office. This is called 'white-coat hypertension' and doctors and researchers are pretty split on whether or not this represents an actual problem. With that in mind, it makes this a pretty worthless test in the context of an annual physical.
The optimal way to make a hypertension determination is a 24-hour continuous blood pressure monitoring cuff. You should take your blood pressure at home, on your own time, in a relaxed environment and if you see a consistently elevated reading, only then reach out to your doctor and set up an appointment to confirm with a 24h test.
It is not worthless. After getting a series of higher test results my doctor suggested a 24h test snd only then diagnosed mild hypertension.
Baseline blood measurements can also be invaluable. When getting sick you don‘t want to go down rabbit holes.
The US has a comparatively high hurdle to access to doctors. When doctors see patients they need to assume it is bad (liability another factor) driving costs up. Also people are not used to reach out to doctors letting them hesitate when they should not - regular contact can help here.
Every year major bloodwork and investigations may not be worth it but seeing your doctor regularly, being able to communicate effectively, doctor having a baseline of you as a person and some bloodwork too makes other countries a lot more efficient in providing health care.
I addition to the not-waiting-five-minutes part not being observed, I’ve heard from medical assistants that automated blood pressure cuffs always read high and that “good” doctors don’t trust them. In fact, when I go to the cardiologist, they seem to always use the non-automated method. However, every ER, urgent care, PCP, etc. seems to use the automated method.
Weird because the automated one I have at home reads normal but my PCP's always shows high. The difference is that I do mine after being still and quiet for 5 minutes while they rush me into the office, ask me a ton of questions and immediately read my blood pressure while I sit on that bed thing with no back support
I highly doubt that, the situation in which it's measured (no back or foot support while talking) is literally against the AHA and other guidelines for BP measurement. When I replicate it at home, it's the same and higher but if I wait and use a proper chair and don't talk then it's fine
I’m not disagreeing with your (accurate) description of proper technique at all, or that incorrect technique can result in falsely elevated office BP (due to expected physiologic responses).
I just meant it may also be a factor in elevated office BP measurements even if done properly, hence “potential contributor”.
If you have multiple documented normotensive measurements on your home BP monitor that’s more reliable than even proper technique in a medical setting to be honest.
The hierarchy of BP measurement accuracy is:
24 hour ambulatory measurement > multiple home patient measurements > in-office automated BP cuff (with proper technique) > in-office BP measurement with auscultation (not sure why this was suggested as more accurate to the commenter you replied to).
> Which is probably part of why 30% of people who get their blood pressure taken in a doctor's office will register a higher than normal blood pressure principally only in the doctor's office. This is called 'white-coat hypertension' and doctors and researchers are pretty split on whether or not this represents an actual problem. With that in mind, it makes this a pretty worthless test in the context of an annual physical.
My favorite conspiracy theory is that this is why we always have to wait so long after we're in the exam room but before the nurse comes in to take BP. My BP monitor's instructions say to sit calmly for 15 minutes for an accurate reading and I think that's what they're doing.
Meanwhile, since the kids are so hyper it's not even worth trying the delay tactic so the pediatricians come in much faster.
No physician should (and I expect would) diagnose hypertension on a single office-based blood pressure measurement. We suspect it based on the office measurement and then confirm.
I last worked in primary care back in 2016 but even back then we would either do multiple visits or ask the patient to check multiple times at a pharmacy (or at home if they could afford a cuff).
24 hour ABPM is the preferred method for diagnosis as you stated but has limited (albeit growing) availability today.
Fortunately consumer health-tech advancements has resulted in cheaper accurate BP cuffs but this is a recent-ish phenomenon.
Is there a form of passive blood pressure wearable? I am trying to find a way for my mom to track her BP throughout the day after meals etc. she does this with a libre for blood sugar
The general consensus from MDs that I’ve heard is that the non-FDA approved ones have way too much variance to be useful. They just aren’t very accurate.
I suppose considering your family history or having your DNA analyzed is one way. But the more direct way is to consider your own medical history. Chronic diseases may coincide with risk for other ailments and you get regular checkups for those. If you had a heart attack, you have a yearly visit with a cardiologist. Etc.
This is a more specific version of the base rate fallacy, called the false-positive paradox. It's illustrated by a simple example.
Suppose you have a test looking for an extremely rare genetic condition (say, 1 in 1 billion people have it). That means that the test needs to be extremely accurate (in this case, accuracy of .999999999) to avoid having so many false positives that it's worse than a coin flip about whether you have the condition or not. Therefore, in most cases you would be better off making a fake test that just says "no" every time.
It's true that there are other options. However, in the real world that might not help, because sometimes the erroneous circumstances which cause the test to be inaccurate will continue to persist.
For example, genetic parental tests are very accurate... unless the parent being tested has chimerism, in which case you'll get the very confusing result that the child isn't your own, even under repeated testing.
> people should be in a position to report issues they discover in the course of their lives
What does this mean? Which issues? How many thousands of diseases are there?
I have a friend who has low level of energy, everyone was calling him lazy his entire life. He thought thats just how life is. He cannot compare how it feel to be him with how it feel to be someone else.
I convinced him to see a doctor about this at the age of 25. First doctor didnt take him seriously, didnt want to do any tests. The complains are very non-spesific. maybe you are lazy, maybe you are depressed.
After weeks of fighting the medical system he discovered that he had a digestive issue, which led to low level of iron and low level of enegy. His entire life he was suffering from an easily treatable problem.
Imagine he treated this at the age of 12, how many sports did he miss out on, how much academic achievement was missed, maybe his career and life trajectory would be different.
A friend of mine struggled with back pain for 3 years. He coupst find the cause. It got so bad, he thought he'd become disabled. He left UK and went back to Romania to have support of his family. Suffenly in Romania he started getting better. Turned out it was vitamin D defficiency.
I started taking Vitamin D agressively, 2,000 units daily, 5 times the recommended amount by the NHS. After taking it for 6 months I went private and did a first vitamin D test in my life - my level is 1/3 of normal.
So how doea one know what is normal, if most people gp their entire life without ever doing a full blood test
Not always. It depends on the performance characteristics of the test, i.e. the sensitivity and specificity. Tests with high sensitivity and low specificity often reveal indeterminate results that, in an effort to gain more certainty, expose the patient to significant procedural risk.
Bayes' theorem is not enough, I think you have to weight how expensive is the test, what are the consequences of false positives and true positives.
For example a low price test with almost zero both false positive and negative rate whose associate treatment has low cost and risk and that can save life of patients seems to me a test that should be applied to anyone at risk.
Bayes incorporates the false positive rate. In fact, using the posterior is exactly the point. It's just noting that the diagnostic power of many tests is not very high if the prior probability of the disease is low. All the points you make don't change that.
From a practical point of view, if the prior probability of the disease is low but the disease is mortal and there is a $0.1 test and $0.2 pill that cure the disease without having negative effects, I think that you should take the test and if positive take the pill. Knowing the posterior probability is not enough to decide what to do, you have to know what are the tools and trade-offs.
Ok, but then I'd like to see Bayes theorem being actually applied for different cases, instead of just hand-waving the issue away for all cases. Also, for some false positives there is no problem, e.g. vitamin D deficiency, where you can just take extra vitamins without much risk.
I'm not sure how they can be cheaper. The bill for a checkup pays the nurse and the doctor for their time. Claims about some greedy capitalist coming in and taking massive profit margins can be discarded by pointing out that non-profit hospitals do not charge substantially different rates for identical checkup services.
The way to make a checkup cost less is to pay doctors and nurses less. There are no pharmaceuticals, no surgeries, no complicated specialist medical equipment, and no expensive labwork involved in the price.
Society generally doesn't agree with the notion that doctors and nurses should be paid less. Therefore, checkups are more or less priced appropriately. Paying high skilled labor for their advice simply costs a lot of money. Ask any dev contractor here on HN.
The Direct Primary Care model shows that the overheads for healthcare are definitely a very large contributing factor to high costs and poor patient experiences. Cutting out the insurance company and related overheads from the medical practice, lab tests, and pharmacy creates an incredible experience for the patient at a very reasonable cost. I was and continue to be baffled at the attention I receive under a DPC physician, as well as how low the associated non-subscription costs are (effectively zero with the elimination of urgent care and expensive tests). The doctors and staff at the DPC practice are all happy and stress-free. Our system is definitely broken.
There is a lot more to it than that. At a bare minimum, you are also paying for the office rent, the administrative cost of billing through insurance, the administrative cost of the insurer, malpractice insurance, and the price of the doctor’s education.
All of these factors (except maybe rent) are higher or even unique to healthcare in the US. Capitalism isn’t even to blame for most of these. A free market would have price transparency, and would incentivize direct billing over billing through insurance due to lower overhead. Just because it’s the USA doesn’t mean it’s capitalism. That said, nationalized healthcare also seems to be able to solve some these problems through collective bargaining on drug prices, and reducing the billing overhead.
I would urge you to do some more research. Over testing is well known to cause higher rates of unnecessary medical procedures. There are many ways it can break down. For instance, the test may false positive consistently if an individual has some other factor such as mediation, virus, or bacteria that confound the test. Tests are also only validated under certain criteria. For instance if the clinical trial only tested people who presented with certain symptoms, the efficacy of the test may be completely different on the general public.
Running the tests again only works if the false positive rate is just due to noise. I.e. if the occurrence of a false positive is uncorrelated between re-tests.
I guess most real false positives aren't due to noise, but due to the test triggering on something unrelated and rare. In that case re-testing will yield the same result.
This isn't what happens. A huge volume of the people that come in to US hospitals are chronically ill people with no money and very commonly no regard for their own health. Quite often they are also disrespectful and combative to hospital staff. The system pays for their extended care and the healthy majority pays huge premiums to subsidize their care. The vast majority will be paying premiums vastly out of proportion to what they will use.
This sounds like a delusionally extreme take, as if there is no in-between or nuance. You're either a victimized superhuman who never gets ill or a chronically ill scumbag with no regard for your health? Hardly realistic at all.
>> medicare's fee schedule has the same code costing $90.
People would be upset if the gas stations charged different prices after they review your auto insurance policy. With healthcare, they look at our policy and make up price numbers.
Maybe this violates anti-trust laws. The State attorney generals don't seem interested in pursuing such discriminatory pricing.
> Who can manage an international trip each time they need medical help?
> Not everyone can afford the delay, the time, the money or the inconvenience.
If you have no symptoms and it's follow up for a routine screening test, you can probably afford the delay. The time is certainly an issue, although if you can get any needed subsequent tests and care immediately internationally, it might be less time overall. The money could work out in favor of international travel, depending on the details; almost certainly less all things included, but not necessarily less if you're only counting money that comes directly out of your pocket.
The real question is when does it become legal for insurers to send you overseas for care, and when does it become legal for medicare and medicaid to do it.
Private medical care is in most circumstances illegal in Canada and they have large enough wait lists that people are dying in large numbers waiting for medical care. Medical tourism to Canada is a non-starter for Yanks.
> “Canada is the only country in the world where it is illegal to obtain private health insurance when there are long wait-lists. That surely says something,” said Dr. Brian Day, medical director of Cambie Surgery Centre in Vancouver and past president of the Canadian Medical Association (CMA).
…
> He launched a legal challenge to the B.C. Medicare Protection Act, saying wait times in the public health system are too long and stopping patients from paying for those services outside the public system violates their rights.
> In July, the B.C. Court of Appeal dismissed the Vancouver surgeon’s challenge.
> However, in their ruling, the judges accepted that the act’s provisions “deprived some patients’ right to security of the person by preventing them from accessing private care when the public system had failed to provide timely medical treatment.”
> Private medical care is in most circumstances illegal in Canada and they have large enough wait lists that people are dying in large numbers waiting for medical care. Medical tourism to Canada is a non-starter for Yanks.
Can you cite a source for people dying in "large" numbers waiting for medical care in Canada?
Canadians live longer, and they spend about half as much on healthcare per person.
If Canadians are dying in large numbers waiting for care, something pretty grim is going on south of the border to make the stats worse in the US.
The bottom link is to commentary on the Supreme Court’s recent ruling in the case, and the criticism of a more privatised system is interesting.
“The entire premise underlying the Canada Health Act is that people ought to be able to access health-care services based on need, rather than ability to pay…
It's pretty clear that having physician's practice both in and outside of the public system, if anything, results in longer wait times for patients in the public system, not the other way around…
The people most likely to need urgent surgery are often the least able to pay out of pocket.”
Notably, the legal action was brought by someone with very vested interests.
There's no reason to assume that government care supply would rise to meet demand. If private pay is allowed, and medical school enrollment is not artificially constrained, supply can rise to meet demand at a low price.
What is the reason for the wait times, though? If it's availability of doctors, I don't see how paying for private insurance magically makes doctors less busy and able to see you. And if that does work, then it just means that the mostly-unavailable doctors are prioritizing people who can pay them more, which isn't exactly a great outcome either. Or am I missing something?
This is how it happens in Spain: public doctors work from 8:00 to 15:00, with long queues. The same doctor has a private office from 16:00 to 20:00, where the queue is almost zero.
There are some doctors that works exclusively public or private.
It may be that the service provider (in this case, a doctor) realises that to price too many people out would be an optimisation that ignores that not all kinds of suffering are equal e.g. yes, optimise the pricing of Playstations and flight tickets and some people will miss out and feel bad, but the suffering of those priced out of a medical procedure is worse.
On the other hand, if we allowed a freer market in medicine (anywhere, no particular target country in mind), seeing doctors make more money treating something should spur on new trainees, thus more doctors in that specialism, and hence price drops and improvements in waiting times and possibly techniques, but that would require that freer market that so many seem against.
Doctors are a finite resource. Ultimately you have to ration that resource.
You can do it based on social status and wealth (America) or on medical necessity.
Obviously this is HN were people have money so they are upset if they are put on a waiting list.
We don't hear much about the people from trailer parks getting million dollar cancer treatments thanks to the public healthcare system.
Partly because other professions, like banking, attract greater remuneration. It's also why you'll notice that many new doctors (in the US) choose the ROAD, for many reasons[1], but this one stands out:
> The amounts of money that can be made in dermatology and plastic surgery are a temptation that many people cannot resist
If you want more doctors, and more doctors in things like primary care, then offer incentives. Money is a good one. You may also ask if plastic surgery is still an expense that only a wealthy elite can access, as it was in the past, or if it's become quite commonplace, and then, since it has, why. Could it be that the usual processes that other capitalist goods follow also work in healthcare?
The other side of that is training enough doctors. I think it would be a good question to ask why so few are trained, and I wouldn't be surprised if one of the reasons is that the guild itself, as all guilds do, limits the number of new entrants. That's speculation on my part.
> Obviously this is HN were people have money so they are upset if they are put on a waiting list.
I thought that everybody gets upset if they're put on a (long) waiting list so I'm not sure what need the ad hominem in your comment serves.
> that would require that freer market that so many seem against.
I’m not sure that medicine could ever be a poster child for the free market. It’s tightly regulated for good reason. Is there anywhere that has free market medicine? I’d like to read about it, but wouldn’t want to use such a system.
You think the kind of regulations that are being discussed in this thread are good things? They don’t seem to benefit anyone but insurance companies. Tell me, why shouldn’t you be able to walk into a doctor’s office and they be able to tell you how much a test costs? I wonder what regulation makes that impossible and what intended good it is supposed to make possible.
> Tell me, why shouldn’t you be able to walk into a doctor’s office and they be able to tell you how much a test costs?
I can. I live in New Zealand.
Medical practice here is plenty regulated and complying with these regulations is a meaningful percentage of my day job. Not all of it is worthwhile, lots is.
No, that's anarchy. A free market is one where market forces are allowed to work. A market captured by monopolists and anti-competitive agreements is not free at all.
Take a small market store selling product A and product B. Whichever sells more at a given price wins more profit, great. Free market forces are at work. But then (anything goes, after all) the manufacture for A comes in and says to the store owner: if you sell product B we'll firebomb your market and kill your dog. So then the small market stops selling product B. Now, the small market only sells product A and at a huge markup.
Is product A actually better? Does the consumer win?
Regulations are necessary so the manufacture of A can't do that and make sure that the market is actually free.
That's a well-regulated market not a free market. I completely agree that regulation is needed, and better by the people than by the biggest bully in the market.
>Private medical care is in most circumstances illegal in Canada
That's not quite right.
As I understand it, private clinics themselves are fine: the very next sentence of your article explains that the doctor in question runs his own private clinic.
Instead, the issue is how you pay for services rendered by those clinics since BC's Medicare Protection Act restricts insurance policies that would cover them.
More or less correct, healthcare in Canada is mostly “private” with a single public payer on a provincial level. One other difference is that hospitals are owned and run by the government (with slight variation between provinces) so they don’t bill the government and are instead given large annual budgets with some incentive based payments.
Imagine the US system with Medicare as a single payer setting rates and HHS owning all of the hospitals.
Physicians (for the most part) bill the government on a fee for service basis and most do so through a medical professional corporation that only physicians and certain family members are allowed to be shareholders in.
It is illegal to charge for services insured by the government. It is not illegal to charge for uninsured services (for example some knee arthritis injections) or those not insured (e.g. visiting Americans).
I knew Dr. Day professionally, he has run an ambulatory surgical center (different from a private clinic, all freestanding clinics are “private” in Canada) for several years now and the issue with his practice is they are providing insured services (like joint replacements) charged directly to the patients. Although technically illegal, the BC government has let this happen due to long wait times and lack of political will in their voter base but this recently gone to the legal system.
If our (US) medical system is so broken that your best option is to travel thousands of miles to a different medical system for care, that's a sign that things need serious change. Medical tourism is the equivalent of treating a symptom but leaving the root cause untreated.
* you can't get paid by insurance unless you have payment authorization from the patient on an estimate that is within 30% of the actual price (exceptions for emergency care).
* a requirement that all provider participate in an digital marketplace where patents and providers can get immediate quotes for labs/procedures and you get a list of local options+prices.
* anti-trust break up of healthcare cartels
* some price cap like 200% of medicare negotiated rates as a backstop for these really crazy outlier bills.
Your test is consistent with condition A. Its prevalence in the general population is B/1000 people. We can do a follow-up test that involves B, C, D, will cost $E and in cases like yours confirm condition A in F% of cases. Or we can wait and see; we'll redo the test in G time out if you present with other signs and symptoms H, I, J. Other possible causes for the test result are K, L, M. How could you like to proceed?
I have a PhD in this stuff and I'm not sure I'd want to be making those sorts of decisions, especially for myself or a loved one.
In your example, suppose I do have A (or K, L, or M). If I wait, how will that affect the costs and prognosis? Or if I go ahead with the test, what are the possible side effects (e.g., for a biopsy) and what would managing them cost? Even if you're confident that you have—and understand—all the relevant information, you're also often making these decisions in an emotionally-charged situation.
But it’s hospitals/labs which are as bad or much worse in this regard. “Greedy” pharmaceutical companies are just a boogeyman, insurance companies, hospital admin and doctors are just fine with charging “random”/arbitrary fees based on clients perceived ability to pay and not in anyway related to actual costs.
Of course not. It just seems that they might actually be the most transparent segment of this entire system which makes more visible.
And well… from the society’s perspective high/very-high prices for new drugs for a decade or so (20 years seems too long though) might be a good deal if it results in very high investment into R&D.
See my nearby comment on Direct Primary Care. It is possible to partially opt out of the system, and fortunately it is the part of the system that you touch most often (or should be anyway).
> PCPs don't really seem to do anything but refer you to a specialist and any visit to a specialist
(Yet another, I live in the US, therefore everyone else does moment)
This is one of the things that surprised me the most in the US. Doctors seem afraid to draw any reasonable conclusion and are more like salesmen. I'm sure the fact that you can sue for pretty much everything plays a role in them not being more confident.
I hope that testing gets cheaper and more data gets public so we can eventually have AI doing the medical scoring and with it routing/prioritizing patients.
I live in the US and have run into both kinds of doctor. If you end up with one that does nothing and only refers you to specialists, it's worth trying other doctors. There are definitely nerdy doctors that know a lot more and are more willing to get their hands dirty.
Ultimately, even the nerd doctors will send you to a specialist if you need it.
I like my current doctor a lot. He runs his own independent practice and is just generally really cool.
In much of the US finding a PCP who is accepting new patients is hard. And the ones that are accepting new patients are unlikely to be one of the good noes.
Plus, new patient appointments are a 6-9 month wait where I am (suburban California) so it could take over 2 years to try 3 Primary care doctors.
We just got a doctor appointment now after scheduling in September. Went into the office and the receptionist explained “oh, sorry, Doctor X is busy and can’t make his appointment. Next available is in July.”
It’s always funny when people say “universal healthcare will have long wait times for doctors like in Europe!!” This is is currently happening in the USA.
> universal healthcare will have long wait times for doctors like in Europe!!
I don't know about that. The missus had a problem, had to see a specialist, they first said next slot is in 1.5 months, then she read her blood test over the phone and they scheduled her in like 3-4 days. TBH that wasn't funny at all, the 1.5 months appointment would have looked ... healthier.
Eastern Europe where the universal health care isn't considered great.
[Posting as throwaway because the missus can be identified by my HN nick]
Same experience with me in the Bay Area. Wait times where 2-3 months for anything reasonably close (within 45 minutes driving). Ended up paying for one medical.
"Doctor's surgery" is what we'd call the doctor's office in the US, right?
In terms of walk-in, there's "urgent care" and similar things. And of course the emergency room if the need is severe. Telehealth was vastly expanded during the pandemic and has stuck around to a significant degree.
In addition to urgent care clinics, every doctor I've had holds a few appointment slots open for same-day or next-day visits. I just have to call them when they open.
Just checking my doctor's group, they have multiple appointments available for new or existing patients in all 7 of their locations around Austin as early as Tuesday - and that's probably only because Monday is a holiday. The only caveat is that you have to accept whichever doctor is available, rather than selecting you PCP.
I know it's a big country with a lot of variability of experience, but this has been the case everywhere I've lived.
Yea, we basically use urgent care for everything, since it seems very few in-network doctors want any more patients, and the ones who do have no availability for months. So we're in this weird position where we have no "primary care doctor".
Growing up in the sticks, I had a primary care doc who, in retrospect, tried to treat things he should have referred out to specialists. The result was at least one early death in my family, another close call, and avoidable permanent disability.
It's not common to sue for anything really. Most people don't ever sue anyway, but a small amount of people sue a lot, backed up by the armies of attorneys that advertise on daytime tv and bill boards. My wife works in liability defense and it is common that most plaintiffs have been involved in other lawsuits. Car wrecks, slip and fall, wrongful terminations, plaintiffs will often have 2 or 3 ongoing cases. They are all generally bullshit but will settle out for between 20-40k after a year or two of depositions and back and forth.
One interesting thing though is that pain and suffering is typically calculated at 2x medical costs. So those crazy high bills work in your favor when you are suing someone.
You can likely get labs and imaging for significantly less by going to specific stand alone lab/imaging facilities.
Health care groups tend to refer you to onsite services and/or specific companies they have relationships with.
It is a pain though because you have to call around to get prices.
Generally, the places with the lowest cash prices will also be the places that are least expensive after you've reached your deductible, but it's good to confirm with your insurance.
Medicare's fee schedule is almost always lower than what you can get, even with all cash, because the US government can set the rates they pay to some degree. It's up to doctor's/medical groups if they'll accept that or just stop taking Medicare completely.
Specialists are great, but it would be so much better if healthcare systems did a better job at properly looping back in the patient's primary care / family doctor in on important health decisions. Primary care physicians, when not stifled by the system, have a remarkable ability to keep track of a patient's health over the course of several years and provide a balanced, realistic view of what might be needed. The way that PCP visitations have become shorter and shorter in a more overworked and hectic environment has done a great disservice to patients.
I think that's basically a fantasy. My experience with primary care physicians is that they barely remember who I am, and they frequently move on to other practices. It's not uncommon to see a new person each time.
On my latest attempt to make an appointment they said that I am no longer a patient because I didn't come in during COVID, and that I would have to wait to get back in.
I decided I'd just go without until something bad happens. So far so good.
Yep, this is what the system has created. There's little incentive to stay within that career path, and nobody is helped by the fact that healthcare administrators and staff shortages are forcing doctors into 3 minute visitations that establish little to no connection with patients. It leads to so many "my doctors are idiots who couldn't figure out my condition" situations that are rarely caused by lack of education (not that there aren't any closed-minded doctors), but by lack of cohesiveness of the entire system. Healthcare urgently needs to go back to being a continuous process, not a series of tech support tickets.
The behavior you're describing is clearly an effort to economize use of doctors time. Since there is a cartel controlling salaries hospitals are doing everything legally possible to maximize their usage and shift work to cheaper labor.
Lookup direct pay family doctor office in your area. I pay about 80 bucks a month for doctor I can call, text, spend 30 minutes of I visit. She have arrangement with testing lab with really tiny costs for tests, x-ray, etc. And because of direct relationship, she indeed can track my health over the years.
I still have high deductible insurance to cover something serious, but otherwise pay cash for routine stuff.
It's like that for most employed physician practices and a large number of group practices but if you can find a solo practice (i.e. a practice with one doctor and maybe one or more NPs), odds are they will be pretty decent.
I had an abnormal value. Doctors kept telling me to ignore it. Despite me having a lot of issues.
2 years of battling to get tests done. End up having 3 uncommon conditions. One of which was going to kill me without urgent treatment. Drastic quality of life improvement from proper treatment.
Spent years being told I was a hypochondriac for insisting something wasn’t right. That everything I was experiencing was just anxiety.
That lab really gouged you and your insurance provider. I use CPL and I don’t recall ever paying more than 200 for custom bloodwork, not going through insurance either. My insurance prefers LabCorp but their assays are questionable at best.
> any visit to a specialist + tests will immediately trigger thousands of dollars in bills, even if you're insured you're going be paying your deductible plus like 10-30% after that.
A half-lifetime of experiencing and observing modern medicine, in good faith, has taught me that participating in the medical system while not in need of emergency care is risking one's health and life.
Assuming that one doesn't engage in risky behavior, the smartest path is to avoid the medical system altogether. That doesn't mean "seek alternative medicine". It's just what I said.
The Medical system doesn't highlight its failures. It obscures them, and only speaks in bullshit PR terms. Its failures (premature suffering and death) are almost always attributed to causes other than the malpractice that caused them. Even families are hoodwinked.
Laugh at anyone quoting "evidence" without citing it for critique. The medical profession hasn't had broadly-intact scientific integrity for decades.
Much of medicine is charlatanism for billing. Doctors know this though most won't admit it. The consequences range from annoyance, to minor malfunction, to catastrophic.
Having kids has shown me how much of medicine is about incentive alignment, rather than doing no harm. Every time one of my kids gets an ear infection, pinkeye, or a sore throat, my daycare requires a doctor’s note and antibiotics to be given before they are allowed back in daycare. The urgent care doctors always prescribe antibiotics, even though the most likely cause is viral and most bacterial infections resolve within 3-5 days with or without antibiotics. I had one case where the strep test was negative, and the doctor still prescribed antibiotics because it could be a false negative. And my kids are allowed back in daycare after 0-24 hours depending on the diagnosis, even though the medicine takes 3-5 days to work.
I was shocked to go through this the first time, after reading so much about the over-prescription of antibiotics. But doctors would rather write a prescription than explain the evidence to stressed parents and daycare providers. And daycares all copy each others’ policies, because nobody wants to admit that kids are just contagious snot-monsters and medicine can’t really help.
It’s pure theatre, at the expense of kids’ health (antibiotics do a number on the digestive system) and leads to antibiotic-resistant strains. But at least nobody ever had to stop and have a difficult conversation.
That's crazy. I have small kids and the doctors never give antibiotics. They just say it's something viral and to give Tylenol / Ibuprofen to treat discomfort. The daycare doesn't have any rule like that either they just check for fevers and they have to stay out until no fever for 24 hours. When one was really sick with croup they gave him some steroids but that's it. We have even switched doctors 3x and always been the case.
Yeah, my kids have had what feels like every illness under the sun, and I can count on one hand (maybe one finger?) the number of times we’ve been given antibiotics. They’re in public school, which may have something to do with it, but the rule has always been 24 hours sans fever with no antipyretics and you’re good to return. Sorry to hear that the parent poster has encountered such bizarre rules, that’s pretty lame.
Wow, I’m shocked (and heartened) to hear that your experience has been so different. Maybe it’s just the area I’m in or my healthcare provider. I always expect to be told “it’s a common cold, get the kid some rest and leave urgent care to the real illnesses” but I’ve literally never had that happen.
Definitely varies by country. In Czechia, they give antibiotics only after three days of fever or symptoms that strongly hint at bacterial infection. And they usually do at least a CRP test, often a cultivation.
The daycare rules here vary place by place, though. Some of them just check for fever, some don't like running noses.
I am on the west coast in the US, and my kids’ pediatric group almost never gives antibiotics. They typically tell me over the phone not to bother coming unless it has been a very high fever or multiple days of worsening symptoms.
Only antibiotics we have had were after they looked in ear and said the redness and pus indicated bacterial as well as the color and consistency of conjunctivitis discharge.
And around here, daycares do not require any doctors’ note. They just tell you not to bring your kid in if they have fever or vomiting or diarrhea within the last 24 hours.
I go to Palo Alto Medical Foundation in the Bay Area, literally down the street from Stanford. If there were any region I would expect to follow evidence-based practices I would expect it to be them.
There is damn good reason for that. Wife is a doctor, although not a pediatrician. There are some long term stats that if kid receives antibiotics before age of 1, the risk of getting diabetes later in life jumps by at least 30%.
We have tons of doctors as friends, most work in biggest hospital in Switzerland (HUG in Geneve), and all with small kids adhere to this and try to steer away from atbs as much as possible. Its not some quack unproven theory.
Thats just 1 specific situation, you can deduct that atbs do quite a mess in those little bodies and it doesnt stop with age of 1.
If you meant even adult people dont get atbs automatically, thats also is great approach especially longterm. Most infections dont need them, they do more harm than good in the body. But uneducated folks that suffer seek literally anything that can help them, some basic medical facts be damned, so doctors sometimes give up and give atbs to obnoxious patients. Then there are of course those bacterial infections where they help, but they are rather small % and usually not the most severe ones.
Meanwhile here in Vietnam (and I guess for most of the developing world) I can walk into a pharmacy and ask for any medication they have available, including antibiotics, and they'll hand it over, no prescription needed.
I've heard this is slowly changing in the big cities but I'm not holding my breath.
From a friend who was involved in health care analytics decades ago, they'd frequently find that specific norms of healthcare practice depended highly on senior medical personal (e.g., a head physician within a department), and that you'd find major differences in standards both at different-but-comparable groups and at the same group following a major personnel change (retirement, moving elsewhere).
Another friend doing roving-doctor work at a number of smaller clinics and facilities described wildly different standards amongst physicians specifically regarding antibiotic prescriptions (my friend resisted prescribing them without specific indication, other doctors offered them as a default).
As with many other aspects of the world, what we observe directly is very much through a drinking straw (if you can find one of those any more): it's a very narrow view. This doesn't mean your experience is invalid or even infrequent. It does mean that it's likely not especially generalisable.
That said, what seems to change overall behaviours most is standards and norms being applied through policy, whether institutional (think Kaiser in California) or at the governmental level (government-offered services, etc.). Thought comes to mind that much of the US is now experiencing the negative aspects of that last, as with many tools, it can cut both ways.
Must be specific your region. Not my experience around Atlanta.
Around here common illness kids can come back after 24 hours of symptom free (daycares dont ask how they became symptom free). Super contagious like pinkeye requires doctors note that it's not pink eye, or put on a treatment plan.
> bacterial infections resolve within 3-5 days with or without antibiotics.
Citation needed
I do worry about overuse of antibiotics but I know a lot of times it just doesn't "go away without", or the viral infection ends up evolving to a bacterial one
Though what the doctors should do is give the prescription but say just to take it if the situation doesn't improve. This way you save a return to the doctor if it doesn't get better.
I don’t have any citation, but if you google bacterial ear infection or strep throat you’ll see that it’s true. And my pediatrician agrees with me, even if the urgent care docs don’t mention it.
Yes, but even your link says that complications are uncommon. I’m not advocating waiting until you’re on death’s door, but isolating and waiting 2-3 days to see if you’re getting better is fine.
> The urgent care doctors always prescribe antibiotics, even though the most likely cause is viral
This is irresponsible, tackling AMR is a WHO priority and local guidance (e.g. NICE, I don't know about the states - is it ICER? the CDC?) should reflect this and steer away from "just in case" antibiotic prescriptions.
This is so skewed towards the US. Eg here in Europe people go to their GP much more often because those visits are free, and hard data says we live longer than in the the US. So the problem isn't "doctors" or "medicine", the problem is the US medical system.
Please. I've been through medical systems in several European countries, and the GP system is frustratingly bad. GPs will at best prescribe you some medication, but will otherwise act as entitled gatekeepers to the rest of the system. Unless you're bleeding on their table, they'll do their best to avoid sending you to a specialist. They'll engage in the same charlatanism that GP is talking about.
Healthcare in Europe is not free. You're taxed for it quite highly.
Calling this system "healthcare" is too generous. It only exists to keep people from complaining, and healthy enough so they can be productive enough to be taxed. There is no care.
What? I have never seen these alleged "entitled gatekeepers". I have been passed to specialists with no issue. The public sector healthcare is excellent and the same medical standard as is received in the private sector.
Let's talk about that price. So how does healthcare work out for you in the US system if you cannot pay for insurance? In a public sector system you still get healthcare just the same if your income is zero. The total tax cost for middle (or even higher) earners in European countries is often less than equivalent private insurance premiums paid in the US. In private sector systems you still ending up paying out of pocket even when you are "covered" with those deductibles. So your overall cost is even higher. Don't forget in the US you still pay taxes for healthcare for schemes like Medicare so don't forget to add that on when doing comparisons. What does the typical private insurance policy say about pre-existing conditions and congenital disorders? You're fully covered in public sector healthcare. What if you suffer from an expensive illness? You may find your insurance premiums increase. Your taxes don't increase in public sector healthcare regardless of what illness you have.
It's just americabrain. You can hardly blame them as this is the only system they know and were socialized in. I've talked to otherwise intelligent and well adjusted people who came up with the most spectacular mental gymnastics defending the US health system and coming up with the weirdest reason why public health care in the developed world isn't actually better (you have to pay taxes!!:(), it's absolutely mindboggling and I just laugh at them now. It really sucks for the families who have their lived destroyed due to unnecessary and massive medical bills.
The irony of the comment you’re responding to is that Americans also pay a lot for healthcare in taxes and we don’t even get decent healthcare in return.
> What? I have never seen these alleged "entitled gatekeepers". I have been passed to specialists with no issue. The public sector healthcare is excellent and the same medical standard as is received in the private sector.
I saw it and "suffered" it in the UK. GP visits are terrible there: You only had 15 minutes and GPs seem to always be in a hurry. I've always had IBS and had to go through several GP appointments until they refereed me to a gastroenterologist. Once I was referred, it was pure joy and incredibly good, and I din't pay A DIME.
I also experienced it in Germany. Although it was a bit better than in the UK. My GP in Germany referred me to a specialist Gastro pretty quickly.
I am talking coming from Mexico and the Mexican system. Here we are very used to two systems: A nefarious public one which is just terrible. And a private one which is quite good and at great price. Also, for private care, you can go directly to specialists.
> GP visits are terrible there: You only had 15 minutes and GPs seem to always be in a hurry.
This is how standard care in the US is, even with good insurance. I've always assumed a doctor's time is so valuable it makes sense to carve it into ever smaller pieces.
What we have in much of Europe is mostly a dream compared to clusterfuck that US healthcare is. US has by far the highest costs globally, unavoidable even if insured. People here never think 'should I go to doctor, can I afford treatment'. Thats 3rd world country stuff.
Yes we pay for it, much less than US, but its not part of our net salary so nobody actually cares, this topic is simply not discussed by commin folks, and you can easily see how much stress it causes even to wealthy US folks.
We treat people in same way regardless of their origin, wealth, status, even homeless get top notch care if they dont run away from it.
Something in your words tell me you are not a standard patient.
I can get a telephone consultation with a GP within 24 hours; if I need to see my own designated GP, I can get a face appointment within a week, usually. If consultants are appropriate, I'm referred to a consultant.
There are some specialisms where it's hard to get a referral; podiatry is an example. As far as I can tell, NHS podiatry is mainly reserved for people with diabetes. I had to hire a private podiatrist, £50 per session, 6 sessions. I gather there are long queues for mental treatment (although GPs enthusiatically diagnose depression, and hand out antidepressants like jellybeans).
I don't like taking antibiotics; I don't want to nuke my gut biome, if I can avoid it. I can't remember the last time I was prescribed antibiotics prophylactically.
There's been a wave of strikes in the NHS since Christmas; I've only used the surgery recently to renew prescriptions over the phone, and I was able to get through with a 5-minute wait. I haven't had a proper appointment for 2 years.
They are gatekeepers. That is literally their job. Doctors are a scarce resource that you're not paying for. You think all the taxes you pay in a lifetime is enough to cover even a week in a ICU?
> GPs will at best prescribe you some medication, but will otherwise act as entitled gatekeepers to the rest of the system
I feel that's more on the UK/Irish medical system
On the continent specialists will happily take you without a referral, though usually private only (which to be honest, the "GP as gatekeeper" method is stupid - thanks I know which doctor to go for a skin disease, I'm not from the sticks)
> I feel that's more on the UK/Irish medical system
I've had no issues getting a referral in the UK system, though I appreciate some people do struggle. Hell, I've had to actively turn down the offer of a referral when I felt like the problem would be better dealt with in primary care.
You are often also charged fees at the doctors office or even emergency care.
And places like Sweden have private health insurance so you domt have to stay in the “free” broken system with years of waiting before getting to a specialist.
I always cringe when nordics make fun of the US healthcare system.
Ours is just as expensive and horribly broken.
You may not get a 20k dollar bill for immediate care.
You are instead set on a 5-14 year (not a typo ) waiting list.
Sweden is a capitalist country with socialist taxes.
The real hack is having friends and family in the medical field. You can skip the chicanery of medical “intake” and diagnosis outside highly specialized conditions, get advice without extortionate bills or misaligned incentivizes, and they can help you get appointments with specialists/tell you who’s the best to see, even write you rx’s directly.
I recently had an infection that, due to being geographically isolated from my typical medical network of friends and family, resulted in $1k of bills after insurance for something that was essentially routine and which I would have been able to treat myself if I had the ability to get medicine without an rx.
The general public who don’t have the scientific/medical literacy to self-serve and lack the network to get treatment without going through the formal process are getting fleeced.
The flip side is that they sometimes genuinely want to help. As you say, be respectful.
My elderly neighbour (who I saw maybe twice in a decade) had her daughter visiting, and the daughter came by and suggested I might like to change the dressings on her mother’s ulcers because I’m “used to looking at gross stuff.”
I’m a radiographer. I’m pretty much useless in every situation unless someone has a a high field magnets and wants pictures.
Right, I am speaking more about close relationships where they’d offer help without you even having to ask, not some long-lost friend that you only ever bother when you need their medical opinion.
The medical field will soon be over-ran by software and AI specialists applying and graduating from medical school in order to build the modern individualized medicine augmentation systems of the future. Think about the specialization required to build a reliable, trusted and tested GPT-for-medicine, and then give it to all citizens for free, because, hey, it's going to be a huge boon for our country.
> A half-lifetime of experiencing and observing modern medicine, in good faith, has taught me that participating in the medical system while not in need of emergency care is risking one's health and life.
This is rather hyperbolic. And furthermore, your clearly don't have chronic but non-emergency conditions which require regular care if you care to have a reasonable life (3 going on 4 for me).
So you advocate avoiding doctors and prescriptions unless you break a leg? Good luck when you get one of the many things modern medicine does treat pretty well.
Your criticism of it may have some truth to it, possibly particularly when applied to the US, but the conclusions you draw from them are foolish.
And you'll drop them like they're nothing when you get a bacterial infection your body can't deal with, the likelihood of which will increase in the second half of your life. Or maybe you won't, and die much earlier than necessary. We just had this discussion on a societal level.
I think this is a reasonable response to the terrible atrocity that is medical care (in the US*). The way forward is likely going to be the medical form of 'self-hosted': home medical devices for self diagnosis.
There will be many that flock to this comment to make claims about home devices and how they're 'inaccurate' or other nonsense, but the truth is that it is very possible and in many situations already the case that home devices are FDA approved, and often better accuracy than what you may receive in the clinic. Obviously, this is for a subset of diagnostic tests, and certainly nothing dealing with radiation potential, but the opportunity for expansion is certainly there and I think will continue to expand and fill this enormous hole the US has.
You obviously have no clue how this stuff actually works. Most major medical insurers already have programs to distribute connected smart devices for monitoring vital signs to patients that have been diagnosed with chronic diseases such as heart failure or type-2 diabetes. But those devices are largely useless for diagnosis. You can't really get a home HbA1c blood test.
Chronically ill person here, cannot help but agree. "The doctor committed neither malpractice nor acted abusive" is the best outcome you can get out of the average healthcare professional.
It's a profession where practitioners are treated like saints, while having zero incentive to actually do their job- there's no other field in which telling every client "it's all in your head" after running some meaninglessly basic and unlikely to be wrong diagnostics until they give up and go home keeps you employed and paid.
How many people have ever heard the term iatrogenic harm? Basically no one.
"Iatrogenesis refers to harm experienced by patients resulting from medical care"
Studies put iatrogenic harm at about 30%.
It is also estimated that the 14th leading cause of death in the world is iatrogenic harm
Yup. I cannot believe how much insurance providers bend over for actual fake bullshit like chiropractors, dentists or "naturopathic doctors" who use homeopathic remedies, and related quakery, but then try to screw people over on stuff that's actually scientifically more sound.
I mean dentists who peddle homeopathic remedies.
This literally happened to me where a dental surgeon had me purchase some homeopathic thing to use before a surgery and gave me scare tactics about how much I needed to use it. I ended up forgetting to use it, and was freaked out. When they told me not to worry, I had a hunch, and sure enough when I got home, I saw "homeopathic" on it.
I ceased all service with this dental surgeon and filed complaints with my states dental board. They told me to pound sand, as I have to show that this stuff would hurt people. You could hear my eyes roll as I listened to the states dental investigator explain this crap to me.
> They told me to pound sand, as I have to show that this stuff would hurt people.
What total nonsense. What the dentist did is actually _worse_ than just stealing the same amount of money from your wallet. I guess the only reasonable approach is to try to ruin the dentist’s reputation publicly. Or I guess to just move on since that dentist is just one in a million professional charlatans in modern American society.
FWIW, I agree with you, although I experienced the medical system only as a patient / outsider. I live in a former communist country in Eastern Europe.
Hospice’s amount of involvement is largely up to you. Also hospice doesn’t only help you, but also your family. That said, it is of course your own choice. I would personally want as as little involvement as possible from people outside the family.
The real question is why the insurance companies are pushing the annual exams very hard, not just in consumer ads, but using lots of incentives for primary care physicians.
One would assume they would not want to pay for unnecessary tests for healthy people.
So either their own research shows they save money with annual checkups in spite of what the article says, or more sinisterly, they do want to spend money to be able to justify higher premiums, because in several states they are required to spend around 80% of the premiums, and this is one easily plannable way.
Does anyone know? Perhaps someone working for an insurance company?
I work at at a large health insurance company, though not involved in decision-making around annual exams or rate-setting so take that as you will.
A lot the decision-making we do is around trying to improve the health outcomes for large populations of members at scale. When dealing with millions of members, interventions that require lots of effort and time are hard to scale up. If the data shows members with annual checkups have better health outcomes on average than members without annual checkups, that is something that's relatively cheap and easy to do with potentially significant impact.
There are other benefits to annual checkups as well - catching an expensive condition early can be the difference between a $100,000 episode of care vs. a $10,000 episode of care.
To be honest internally I've noticed the tide is shifting on annual checkups. Physician time is limited and every slot is valuable. I believe we're currently exploring virtual care options as a better alternative.
> If the data shows members with annual checkups have better health outcomes on average than members without annual checkups, that is something that's relatively cheap and easy to do with potentially significant impact.
That or it's yet another example of selection bias. There have been so so many things like this where the epidemiological data shows a correlation with health, but there isn't actually a causal link. For example, annual checkups might correlate with better health because it's a more common behavior among people who can afford to do it, and wealthier people tend to be healthier.
Here's a local study that try to provide some data - although I'm a little uncertain about the control with respect to yearly checkup (would you do yearly checkup on the control, then do nothing if you found cancer?).
Maybe I’m saying the most obvious thing ever, but with that last paragraph, you really make it sound like the American healthcare regimen is decided upon by the for-profit insurance companies.
Thanks for the link! That’s quite refreshing to hear. I didn’t realize the Affordable Care Act did so much more than ensuring availability of coverage and whatnot.
The ACA got a lot of headlines for a lot of BS but some of the really great things it did were very basic, under the radar items.
For example, a lot of the research that we are reading (including possibly the article we’re responding to) is the result of funding created by the ACA.
My favorite aspect of it is the massive push to digitization which means handwritten prescriptions have pretty much been eliminated removing an entire class of death and disease causing errors (from pharmacists misreading doctors’s handwriting).
While there are some regulations, it's basically a tug of war between business interests (insurance, hospitals, pharma, device manufacturers, testing companies, revolving door government agencies) that buy politicians and scam the government* and patients. No one would plan a health system this way, but planned economies (for the interests of regular people, not private equity) are "socialism" so we get to be the victims of life-or-death extortion rackets.
Anyway, our government continues to denounce as "authoritarian and oppressive" the tiny socialist island nation of Cuba that built an incredibly impressive health system that exports doctors (such as to Italy at the start of the ongoing pandemic) when they can't even get metal for syringes b/c of U.S. sanctions.
Not OP, but I think the underlying meaning is that the focus on profit is primary. As in when it aligns with better patient outcomes it’s going to happen and that’s great.
But probably there are a ton of scenarios where profit is anti-aligned with patient outcomes and the decisions are made still to maximize profit.
I can believe that. Not because people are wicked, but collective behaviors behind the system favoring profits more than patient outcomes. The system is extremely complex and even small biases somewhere deep can possibly have a big swing in the outcomes.
> Not OP, but I think the underlying meaning is that the focus on profit is primary. As in when it aligns with better patient outcomes it’s going to happen and that’s great.
> But probably there are a ton of scenarios where profit is anti-aligned with patient outcomes and the decisions are made still to maximize profit.
It may align in their financial interests for most of these required preventive services[0] but there are some that very obviously don't like lung cancer (it would be cheaper to let smokers die quickly than to put them on immunotherapy + SBRT) and others with weak evidence, I doubt a good cost-benefit analysis has been performed for weight counseling.
Point being is that insurers are not the final say in a lot of this, the ACA did add a lot of requirements for them. But I concede there are times they don't, OP is just being overly harsh here and "improving health outcomes" isn't an insurance-specific PR line it has been used in academia and the government for a while now, even in public health systems.
But that’s how the system is supposed to work! The goal of the insurance company is to reduce costs. The govt and the healthcare system are the parts of the system that advocate for the patient.
The groups driving "improving health outcomes" are not (just or even mostly) insurance companies but rather physician societies and government agencies like the USPSTF. We can also look to other national agencies from countries with publicly funded systems (Canada, UK, France, Australia) which share the same mission statement of "improving health outcomes" and have very similar screening recommendations as the US does.
The statement is a bit of PR speak, but it's not made to sell more products. People working in healthcare generally do care about improving health outcomes.
> People working in healthcare generally do care about improving health outcomes.
If you knew the first thing about capitalism, you would know that what one "cares about" has only the most contingent relation to the end product of their labor. In other words, what the workers care about is effectively meaningless because the workers are not in charge; the profit is.
What profit in public systems and with non-profit insurers is driving increased screening?
Nihilism aside you seem to have a deep misunderstanding of evidence based medicine. While cost is a consideration in population-level screening programmes you seem to be ignoring that it is balanced with benefit and is not decided by insurers but rather the USPSTF.
> what the workers care about is effectively meaningless because the workers are not in charge
The agency in charge of screening (USPSTF) takes the work-product of physicians and other health professionals (workers) researching and building evidence on health outcomes (what they care about) which establishes the standard of care that is then forced down by the government onto insurers.
On an individual level I can also advocate as a physician by recommend screening regimens to patients who's care I am involved in and force the insurer to pay, which is what we did for breast screening before the USPSTF caught up.
Sure if you want to take a reductionist view I am using profit (specifically the fear of liability) as a tool to force the insurer but that does not mean what I care about (reducing breast cancer deaths) is effectively meaningless.
There's no need for this tone (and similarly in your previous comment). From HN guidelines:
> When disagreeing, please reply to the argument instead of calling names. "That is idiotic; 1 + 1 is 2, not 3" can be shortened to "1 + 1 is 2, not 3."
> If the data shows members with annual checkups have better health outcomes on average than members without annual checkups, that is something that's relatively cheap and easy to do with potentially significant impact.
In the case of annual checkups, I believe insurance companies are required to cover them 100% by the Affordable Care Act:
Employer subsidized plans are also mostly compliant with ACA. Based on the trends in figure 13.3, I might even say less than 10% of Americans with employer subsidized health insurance are in non ACA compliant plans.
If you bring up a complaint, it's no longer a preventative check-up, it's addressing a complaint, which has a different billing code and different reimbursement.
I feel it's a kickback to the companies that provide care.
If I bring up any health issues I'd like to discuss at my annual exam, it's billed as a doctor visit because it's no longer "preventative" care. For the visit to be free, I have to stay silent. It also gives providers an opportunity to recommend and order expensive tests or procedures that the patient might otherwise not have pursued.
> If I bring up any health issues I'd like to discuss at my annual exam, it's billed as a doctor visit because it's no longer "preventative" care. For the visit to be free, I have to stay silent. It also gives providers an opportunity to recommend and order expensive tests or procedures that the patient might otherwise not have pursued.
They tried to bill me for that in the past at practices I was a patient of. There's a fine line between preventative care and E/M. You can generally walk the "preventative care" line by presenting your concerns as an observed change to be documented rather than a problem to be solved.
If they do charge you, call the office to appeal the billing and they generally drop it as long as you can push the point that you weren't seeking a specific treatment but rather were just informing the doctor of a change in your health or conditions since the last visit.
Oh yea just call and talk to someone its easy and its not like you are going to be put through the ringer talking to 10 different people over several weeks inexplicably over several continents.
I've not found that to be an issue with smaller practices. Most of the times small practices just have one person other than the doctor who deals with billing. Sure they often outsource past that but if you can get either the doc or that person, they'll often just change the codes because even if they can technically bill you, it's probably not worth the time or effort for them.
But yeah at big practices good luck. They are a living nightmare to deal with and I feel for anyone who can't get access to a smaller (ideally solo) practice.
Wild speculation is a combination of one insurance company offering it and it becoming a relatively low cost competitive bullet point on one hand.
On the other hand, insurers probably have better actuarial data because of annual checkups and can better align their profit margins with fees. Thus reducing their own reinsurance fees.
Imagine you are an insurer and advise free annual checkups. Some of your patients don't bother. Those patients have a higher mortality. You conclude the annual checkup is good.
But you might be deceiving yourself - the kind of people to ignore health advice about getting an annual checkup might also be the kind of people to ignore the health advice on the back of a cigarette packet...
Sure, they understand the problem... But is there anything they can do about it?
I'm not aware of insurance companies being too keen on getting into medical experiments like 'people with a birthday on a Thursday don't get the free annual checkup'.
There was a case here in New Zealand where the "not for profit" insurance company "Southern Cross" was owned by a group of doctors.
You can see how something that might not be in the insurance company's best interest could be in owners best interest, particularly if they own the hospital too.
My work offers free annual check ups and it’s mostly DIY. Prick of a finger, punch in weight, height and blood pressure into web app. Eventually once the results on the blood return, you get feedback on cholesterol etc. I get $500 from it and it is psychological to an extent - it helps encourage healthier habits
That's simply not how the medical insurance business works. Since the Affordable Care Act, insurers have almost no ability to pick and choose their customers. And since profit margins are capped there is like little incentive to "save" money by reducing medical expenses.
That's not true because they can pick and choose where and what to offer based on geographic areas through the ACA plans. But even more selectively they can offer group plans to employers that incentivize maintaining a healthy workforce. Most unhealthy people don't work good jobs that provide insurance.
Under the ACA, insurance companies have a profit cap as a percentage of expenditures, so they need to drive expenses to increase total profit (but still have to be competitive price-wise so it isn't unlimited).
Around here the insurance companies created a billing code that is just for annual checkups, with discussion of ongoing care turning it into a different type of visit (that isn't necessarily free).
I got a random lab bill for like $650 (discounted from $2500) and in the follow up visit everyone agreed that was high but no could explain why it was that expensive - medicare's fee schedule has the same code costing $90. Until we stop this madness of providers basically charging whatever opaque negotiated random amount they want to insurers who then pass that down to charge payers after collecting a % the prices are just going to continue to go up and the broken medical system will stay fucked - with the consequence that the economics aren't going to make sense to seek proactive care.