Regarding arguments that the allocation of medical resources, particularly in the U.S. are wasteful and harmful in many cases—I agree in general, though the specifics are messy, and I don’t find Robin’s posts on the matter very well argued*. I’m most interested in this bit:
This is statisticians and efficiency experts and so on trying to apply standard industrial techniques to medicine and getting pushback that looks ludicrous to me. For example, human diagnosticians perform at the level or worse than simple algorithms (I’m talking linear regressions, here, not even neural networks or decision trees or so on), and this has been known in the efficiency literature for well over fifty years
Particularly since your initial claim that had me raising eyebrows was that MetaMed failed because they have great diagnostics, but medicine doesn’t want good diagnostics.
Edit: *In the RAND post he argues that lower co-pays in a well insured population resulted in no marginal benefit of health (I’m unconvinced by this but I’d rather not go there), therefore the fact that most studies show a positive effect of medicine is a sham. I’m not sure if he thinks that statins and insulin are a scam but this is a bold and unjustified conclusion. The RAND experiment is not equipped to evaluate the overall healthcare effects of medicine, and that was not its main purpose—it was for examining healthcare utilization. The specific health effects of common interventions are known by studying them directly, and getting patients to follow the treatment protocols that get those results is, as far as I know, an unsolved problem.
Particularly since your initial claim that had me raising eyebrows was that MetaMed failed because they have great diagnostics, but medicine doesn’t want good diagnostics.
Ah, that’s a slightly broader claim than the one I wanted to make. MetaMed, especially early on, optimized for diagnostics and very little else, and so ran into problems like “why is the report I paid $5,000 for so poorly typeset?”. So it’s not that medicine / patients wants bad diagnostics ceteris paribus, but that the tradeoffs they make between the various features of medical care make it clear that healing isn’t the primary goal.
The RAND experiment is not equipped to evaluate the overall healthcare effects of medicine, and that was not its main purpose—it was for examining healthcare utilization.
As I understand it, the study measured health outcomes at the beginning and end of the study, as well as utilization during the study. The group with lower copays consumed much more medicine than the group with higher copays, but was no healthier. This suggests that the marginal bit of medicine—i.e. the piece that people don’t consume, but would if it were cheaper or do consume but wouldn’t if it were more expensive—doesn’t have a net impact. (Anything that it would do to help is countered by the risks of interacting with the medical system, say.)
I think I should also make it clear that there’s a difference between medicine, the attempt to heal people, and Medicine, the part of our economy devoted to such, just like there’s a distinction between science and Science. One could make a similar claim that Science Isn’t About Discovery, for example, which would seem strange if one is only thinking about “the attempt to gain knowledge” instead of the actual academia-government-industry-journal-conference system. Most of Robin’s work is on medical spending specifically, i.e. medicine as actually practiced instead of how it could be practiced.
“People evaluated this report solely using non-medical considerations” is not the same as “medical considerations aren’t the primary goal” in the way that is normally understood. The non-medical consdierations serve as a filter.
I want to read a book with a good story (let’s call that a good book). However, I don’t want to read a good book that will cost me $5000 to read. By your definition, that means that my primary goal is not to read a good book, my primary goal is to read a cheap enough book.
That is not how most people use the phrase “primary goal”.
The non-medical consdierations serve as a filter. … That is not how most people use the phrase “primary goal”.
Which suggests to me that those are the primary goal. Now, you might say “but most people are homo hypocritus, not homo economicus, so ‘primary goal’ should mean ‘stated goal’ instead of ‘actual goal’. And if that’s your reply, go back and reread all my posts replacing “primary goal” with “actual goal,” because the wording isn’t specific.
I want to read a book with a good story (let’s call that a good book). However, I don’t want to read a good book that will cost me $5000 to read. By your definition, that means that my primary goal is not to read a good book, my primary goal is to read a cheap enough book.
Your primary goal is your life satisfaction, and good books are only one way to achieve that; if you think you can get more out of $5k worth of spending in other areas than on books, this lines up with my model.
(I will note, though, that one can view many college classes as the equivalent of “spending $5000 to read a good book.”)
The relevant comparison is more like this one: suppose you preferred a poorly reviewed book with a superior cover to a well reviewed book with an inferior cover. Then we could sensibly conclude that you care more about the cover than the reviews, even if you verbally agree that reviews are more likely to be indicative of quality than the cover.
And if that’s your reply, go back and reread all my posts replacing “primary goal” with “actual goal,” because the wording isn’t specific.
It doesn’t make any more sense with that. Pretty much nobody would say that because they wouldn’t do Y if X wasn’t true, X is their actual goal for Y. Any term that they would use is such that substituting it in makes your original statement not very insightful.
(For instance, most people wouldn’t call X a primary goal or an actual goal, but they might call X a necessary condition. But if you were to say “people found something other than healing to be a necessary condition for buying a report”, that would not really say much that isn’t already obvious.)
The relevant comparison is more like this one: suppose you preferred a poorly reviewed book with a superior cover to a well reviewed book with an inferior cover.
I prefer a poorly reviewed book that costs $10 to a well reviewed book that costs $5000. By your reasoning I “care more about the price than about the reviews”.
(I will note, though, that one can view many college classes as the equivalent of “spending $5000 to read a good book.”)
Pretty much nobody would say that because they wouldn’t do Y if X wasn’t true, X is their actual goal for Y.
I think this reveals our fundamental disagreement: I am describing people, not repeating people’s self-descriptions, and since I am claiming that people are systematically mistaken about their self-descriptions, of course there should be a disagreement between them!
That is, suppose Alice “goes to restaurants for the food” but won’t go to any restaurants that have poor decor / ambiance, but will go to restaurants that have good ambiance and poor food. If Bob suggests to Alice that they go to a hole-in-the-wall restaurant with great food, and Alice doesn’t like it or doesn’t go, then an outside observer seems correct in saying that Alice’s actual goal is the ambiance.
Now, sure, Alice could be assessing the experience along many dimensions and summing them in some way. But typically there is a dominant feature that overrides other concerns, or the tradeoffs seem to heavily favor one dimension (perhaps there need to be five units of food quality increase to outweigh one unit of ambiance quality decrease), which cashes out to the same thing when there’s a restricted range.
I prefer a poorly reviewed book that costs $10 to a well reviewed book that costs $5000. By your reasoning I “care more about the price than about the reviews”.
I think you do care more about the price than about the reviews? That is, if there were a book that cost $5k and there were a bunch of people who had read it and said that the experience of reading it was life-changingly good and totally worth $5k, and you decided not to spend the money on the book, it’s clear that you’re not in the most hardcore set of story-chasers, but instead you’re a budget-conscious story-chaser.
To bring it back to MetaMed, oftentimes the work that they did was definitely worth the cost. People pay hundreds of thousands of dollars for treatment of serious conditions, and so the idea of paying five thousand dollars to get more diagnostic work done to make sure the other money is well-spent is not obviously a strange or bad idea, whereas paying $5k for a novel is outlandish.
That’s fighting the hypothetical.
I don’t see why you think that. You could argue it’s reference class tennis, but if your point is “people don’t do weird thing X” and in fact people do weird thing X in a slightly different context, then we need to reevaluate what is generating the weirdness. If people do actually spend thousands of dollars in order to read a book (and be credentialed for having read it), then a claim that you don’t want to spend for it becomes a statement about you instead of about people in general, or a statement about what features you find most relevant.
(I don’t know your educational history, but suppose I was having this conversation with an English major who voluntarily took college classes on reading books; clearly the class experience of discussing the book, or the pressure to read the book by Monday, is what they’re after in a deeper way than they were after reading the bookt. If they just cared about reading the book, they would just read the book.)
I am describing people, not repeating people’s self-descriptions, and since I am claiming that people are systematically mistaken about their self-descriptions, of course there should be a disagreement between them!
I’m complaining about your terminology. Terminology is about which meaning your words communicate. Being wrong about one’s self-description is about whether the meaning you intend to communicate by your words is accurate. These are not the same thing and you can easily get one of them wrong independently of the other.
I think you do care more about the price than about the reviews? That is...
The sentence after the “that is” is a nonstandard definition of “caring more about the price than about the reviews”.
That’s fighting the hypothetical.
I don’t see why you think that.
It’s fighting the hypothetical because the hypothetical is that I do not want to pay $5000 for a book. Pointing out that there are situations where people want to pay $5000 for a book disputes whether the situation laid out in the hypothetical actually happens. That’s fighting the hypothetical. Even if you’re correct, whether the situation described in the hypothetical can actually happen is irrelevant to the point the hypothetical is being used to make.
but if your point is “people don’t do weird thing X”
My point is not “people don’t do weird thing X”, my point is that people do not use the term X for the type of situation described in the hypothetical. A situation does not have to actually happen in order for people to use terms to describe it.
A good place to get started there is Epistemology and the Psychology of Human Judgment, summarized on LW by badger
Thanks, I’ll try to find the relevant parts.
This suggests that the marginal bit of medicine—i.e. the piece that people don’t consume, but would if it were cheaper or do consume but wouldn’t if it were more expensive—doesn’t have a net impact
I didn’t want to get in too in depth into this discussion, because I don’t actually disagree with the weak conclusion that a lot of people receive too much healthcare and that completely free healthcare is probably a bad idea. But Robin Hanson doesn’t stop there, he concludes that the rest of medicine is a sham and the fact that other studies show otherwise is a scandal. As to why I don’t buy this, the RAND experiment does not show that health outcomes do not improve. It shows that certain measured metrics do not show a statistically significant improvement on the whole population. In fact in the original paper, the risk of dying was decreased for the poor high risk group but not the entire population. Which brings up a more general problem—such a study is obviously going to be underpowered for any particular clinical question, and it isn’t capable of detecting benefits that lie outside of those metrics.
Thanks for the detailed reply.
Regarding arguments that the allocation of medical resources, particularly in the U.S. are wasteful and harmful in many cases—I agree in general, though the specifics are messy, and I don’t find Robin’s posts on the matter very well argued*. I’m most interested in this bit:
Particularly since your initial claim that had me raising eyebrows was that MetaMed failed because they have great diagnostics, but medicine doesn’t want good diagnostics.
Edit: *In the RAND post he argues that lower co-pays in a well insured population resulted in no marginal benefit of health (I’m unconvinced by this but I’d rather not go there), therefore the fact that most studies show a positive effect of medicine is a sham. I’m not sure if he thinks that statins and insulin are a scam but this is a bold and unjustified conclusion. The RAND experiment is not equipped to evaluate the overall healthcare effects of medicine, and that was not its main purpose—it was for examining healthcare utilization. The specific health effects of common interventions are known by studying them directly, and getting patients to follow the treatment protocols that get those results is, as far as I know, an unsolved problem.
There’s also a metamed cofounder making the same case, here: https://thezvi.wordpress.com/2015/06/30/the-thing-and-the-symbolic-representation-of-the-thing/
A good place to get started there is Epistemology and the Psychology of Human Judgment, summarized on LW by badger.
Ah, that’s a slightly broader claim than the one I wanted to make. MetaMed, especially early on, optimized for diagnostics and very little else, and so ran into problems like “why is the report I paid $5,000 for so poorly typeset?”. So it’s not that medicine / patients wants bad diagnostics ceteris paribus, but that the tradeoffs they make between the various features of medical care make it clear that healing isn’t the primary goal.
As I understand it, the study measured health outcomes at the beginning and end of the study, as well as utilization during the study. The group with lower copays consumed much more medicine than the group with higher copays, but was no healthier. This suggests that the marginal bit of medicine—i.e. the piece that people don’t consume, but would if it were cheaper or do consume but wouldn’t if it were more expensive—doesn’t have a net impact. (Anything that it would do to help is countered by the risks of interacting with the medical system, say.)
I think I should also make it clear that there’s a difference between medicine, the attempt to heal people, and Medicine, the part of our economy devoted to such, just like there’s a distinction between science and Science. One could make a similar claim that Science Isn’t About Discovery, for example, which would seem strange if one is only thinking about “the attempt to gain knowledge” instead of the actual academia-government-industry-journal-conference system. Most of Robin’s work is on medical spending specifically, i.e. medicine as actually practiced instead of how it could be practiced.
“People evaluated this report solely using non-medical considerations” is not the same as “medical considerations aren’t the primary goal” in the way that is normally understood. The non-medical consdierations serve as a filter.
I want to read a book with a good story (let’s call that a good book). However, I don’t want to read a good book that will cost me $5000 to read. By your definition, that means that my primary goal is not to read a good book, my primary goal is to read a cheap enough book.
That is not how most people use the phrase “primary goal”.
Which suggests to me that those are the primary goal. Now, you might say “but most people are homo hypocritus, not homo economicus, so ‘primary goal’ should mean ‘stated goal’ instead of ‘actual goal’. And if that’s your reply, go back and reread all my posts replacing “primary goal” with “actual goal,” because the wording isn’t specific.
Your primary goal is your life satisfaction, and good books are only one way to achieve that; if you think you can get more out of $5k worth of spending in other areas than on books, this lines up with my model.
(I will note, though, that one can view many college classes as the equivalent of “spending $5000 to read a good book.”)
The relevant comparison is more like this one: suppose you preferred a poorly reviewed book with a superior cover to a well reviewed book with an inferior cover. Then we could sensibly conclude that you care more about the cover than the reviews, even if you verbally agree that reviews are more likely to be indicative of quality than the cover.
It doesn’t make any more sense with that. Pretty much nobody would say that because they wouldn’t do Y if X wasn’t true, X is their actual goal for Y. Any term that they would use is such that substituting it in makes your original statement not very insightful.
(For instance, most people wouldn’t call X a primary goal or an actual goal, but they might call X a necessary condition. But if you were to say “people found something other than healing to be a necessary condition for buying a report”, that would not really say much that isn’t already obvious.)
I prefer a poorly reviewed book that costs $10 to a well reviewed book that costs $5000. By your reasoning I “care more about the price than about the reviews”.
That’s fighting the hypothetical.
I think this reveals our fundamental disagreement: I am describing people, not repeating people’s self-descriptions, and since I am claiming that people are systematically mistaken about their self-descriptions, of course there should be a disagreement between them!
That is, suppose Alice “goes to restaurants for the food” but won’t go to any restaurants that have poor decor / ambiance, but will go to restaurants that have good ambiance and poor food. If Bob suggests to Alice that they go to a hole-in-the-wall restaurant with great food, and Alice doesn’t like it or doesn’t go, then an outside observer seems correct in saying that Alice’s actual goal is the ambiance.
Now, sure, Alice could be assessing the experience along many dimensions and summing them in some way. But typically there is a dominant feature that overrides other concerns, or the tradeoffs seem to heavily favor one dimension (perhaps there need to be five units of food quality increase to outweigh one unit of ambiance quality decrease), which cashes out to the same thing when there’s a restricted range.
I think you do care more about the price than about the reviews? That is, if there were a book that cost $5k and there were a bunch of people who had read it and said that the experience of reading it was life-changingly good and totally worth $5k, and you decided not to spend the money on the book, it’s clear that you’re not in the most hardcore set of story-chasers, but instead you’re a budget-conscious story-chaser.
To bring it back to MetaMed, oftentimes the work that they did was definitely worth the cost. People pay hundreds of thousands of dollars for treatment of serious conditions, and so the idea of paying five thousand dollars to get more diagnostic work done to make sure the other money is well-spent is not obviously a strange or bad idea, whereas paying $5k for a novel is outlandish.
I don’t see why you think that. You could argue it’s reference class tennis, but if your point is “people don’t do weird thing X” and in fact people do weird thing X in a slightly different context, then we need to reevaluate what is generating the weirdness. If people do actually spend thousands of dollars in order to read a book (and be credentialed for having read it), then a claim that you don’t want to spend for it becomes a statement about you instead of about people in general, or a statement about what features you find most relevant.
(I don’t know your educational history, but suppose I was having this conversation with an English major who voluntarily took college classes on reading books; clearly the class experience of discussing the book, or the pressure to read the book by Monday, is what they’re after in a deeper way than they were after reading the bookt. If they just cared about reading the book, they would just read the book.)
I’m complaining about your terminology. Terminology is about which meaning your words communicate. Being wrong about one’s self-description is about whether the meaning you intend to communicate by your words is accurate. These are not the same thing and you can easily get one of them wrong independently of the other.
The sentence after the “that is” is a nonstandard definition of “caring more about the price than about the reviews”.
It’s fighting the hypothetical because the hypothetical is that I do not want to pay $5000 for a book. Pointing out that there are situations where people want to pay $5000 for a book disputes whether the situation laid out in the hypothetical actually happens. That’s fighting the hypothetical. Even if you’re correct, whether the situation described in the hypothetical can actually happen is irrelevant to the point the hypothetical is being used to make.
My point is not “people don’t do weird thing X”, my point is that people do not use the term X for the type of situation described in the hypothetical. A situation does not have to actually happen in order for people to use terms to describe it.
Thanks, I’ll try to find the relevant parts.
I didn’t want to get in too in depth into this discussion, because I don’t actually disagree with the weak conclusion that a lot of people receive too much healthcare and that completely free healthcare is probably a bad idea. But Robin Hanson doesn’t stop there, he concludes that the rest of medicine is a sham and the fact that other studies show otherwise is a scandal. As to why I don’t buy this, the RAND experiment does not show that health outcomes do not improve. It shows that certain measured metrics do not show a statistically significant improvement on the whole population. In fact in the original paper, the risk of dying was decreased for the poor high risk group but not the entire population. Which brings up a more general problem—such a study is obviously going to be underpowered for any particular clinical question, and it isn’t capable of detecting benefits that lie outside of those metrics.