My first thought is that lifestyle interventions are in fact almost never free, from either a quality of life point of view or a monetary point of view.
My second thought is a question: Is it clear that patients do actually overspend on unhelpful healthcare? All of the studies I’ve read that claimed this made one or more of the following errors or limitations:
Narrowly defining “helpful” to mean just reduction in mortality or severe lasting disability;
Conflating costs imposed after the fact by the medical system with those a patient chooses to spend;
Failing to consider common causal factors in both amount of spending and medical problems;
Studying very atypical sub-populations.
It’s entirely possible that patients from general population do in fact voluntarily overspend on healthcare that on average has negligible benefit even after allowing for prior causes, and would like to see a study that made a credible attempt at testing this.
One of the examples given was a RAND RCT in which subjects had their healthcare subsidized to varying degrees. The study examined whether the more heavily subsidized groups consumed more healthcare (they did) and whether or not health outcomes differed among the different groups (they did not). Another was an Oregon RCT in which subjects were randomly assigned to receive or not receive Medicaid. The only health effects of getting subsidized healthcare here was in “feeling healthier” and mental health.
Other studies show that regional variations in healthcare consumption (i.e. surgery rates for enlarged prostate) do not correlate with different health outcomes. One shows that death rates across the 50 US states are correlated with education and income, but not amount of medical spending.
The overall conclusion seems to be that whatever people are buying at the hospital when they spend more than average, it does not appear to be health, and particularly not physical health.
The descriptions you give match a number of studies I’ve read and already evaluated. E.g. dozens of papers investigating various aspects of the Oregon randomized Medicaid trial, with substantially varying conclusions in this area.
This is just the summary given in The Elephant In the Brain, I haven’t read the original papers and I’m sure that you know more about this than me. Here’s what TEITB says about the Oregon Medicaid trial (screenshotted from my Kindle version):
If you think this misrepresents what we should take away from this study, I’m keen to hear it!
It’s mixed. As far as it goes for the original study, it’s mostly accurate but I do think that the use of the phrase “akin to a placebo effect” is misleading and the study itself did not conclude anything of the kind. There may be later re-analyses that do draw such a conclusion, though.
Most objective health outcomes of medical treatment were not measured, and many of those that were measured were diagnostic of chronic conditions that medical treatment cannot modify, but only provide treatment that reduces their impact on daily life. There are objective measures of outcomes of such treatment, but they require more effort to measure and are more specific to the medical conditions being treated. This is relevant in that a large fraction of medical expenditure is in exactly this sort of management of conditions to improve functionality and quality of life without curing or substantially modifying the underlying disease.
It should also be borne in mind that the groups in this study were largely healthy, relatively young adults. The vast majority of health service expenditure goes to people who are very sick and mostly older than 65. It seems unwise to generalize conclusions about overall effectiveness of health expenditure from samples of much healthier younger adults.
Would you characterize the Oregon Medicaid study as poorly designed, or perhaps set up to make Medicaid look bad? From your description, it sounds like they chose a population and set of health metrics that were predictably going to show no effect, even though there was probably an effect to be found.
Doesn’t necessarily mean they “neglected free lifestyle interventions”. Maybe they were already doing everything they were aware of.
If you are not an expert, when you ask people about what to do, you get lots of contradictory advice. Whatever one person recommends, another person will tell you it’s actively harmful.
“You should exercise more.” “Like this?” makes a squat. “No, definitely not like that, you will fuck up your spine and joints.” “So, how exactly?” “I don’t know actually; I am just warning you that you can hurt yourself.”
“You should only eat raw vegetables.” Starts eating raw vegetables. Another person: “If you keep doing that, the lack of proteins will destroy your muscles and organs, and that will kill you.”
The only unambiguous advice is to give up all your bodily pleasures. Later: “Hey, why are you so depressed?”
(For the record, I don’t feel epistemically helpless about this stuff now. I discussed it with some people I trust, and sorted out the advice. But it took me a few years to get there, and not everyone has this opportunity. Even now, almost everything I ever do, someone tells me it’s harmful; I just don’t listen to them anymore.)
My first thought is that lifestyle interventions are in fact almost never free, from either a quality of life point of view or a monetary point of view.
My second thought is a question: Is it clear that patients do actually overspend on unhelpful healthcare? All of the studies I’ve read that claimed this made one or more of the following errors or limitations:
Narrowly defining “helpful” to mean just reduction in mortality or severe lasting disability;
Conflating costs imposed after the fact by the medical system with those a patient chooses to spend;
Failing to consider common causal factors in both amount of spending and medical problems;
Studying very atypical sub-populations.
It’s entirely possible that patients from general population do in fact voluntarily overspend on healthcare that on average has negligible benefit even after allowing for prior causes, and would like to see a study that made a credible attempt at testing this.
One of the examples given was a RAND RCT in which subjects had their healthcare subsidized to varying degrees. The study examined whether the more heavily subsidized groups consumed more healthcare (they did) and whether or not health outcomes differed among the different groups (they did not). Another was an Oregon RCT in which subjects were randomly assigned to receive or not receive Medicaid. The only health effects of getting subsidized healthcare here was in “feeling healthier” and mental health.
Other studies show that regional variations in healthcare consumption (i.e. surgery rates for enlarged prostate) do not correlate with different health outcomes. One shows that death rates across the 50 US states are correlated with education and income, but not amount of medical spending.
The overall conclusion seems to be that whatever people are buying at the hospital when they spend more than average, it does not appear to be health, and particularly not physical health.
Do you have links?
The descriptions you give match a number of studies I’ve read and already evaluated. E.g. dozens of papers investigating various aspects of the Oregon randomized Medicaid trial, with substantially varying conclusions in this area.
This is just the summary given in The Elephant In the Brain, I haven’t read the original papers and I’m sure that you know more about this than me. Here’s what TEITB says about the Oregon Medicaid trial (screenshotted from my Kindle version):
If you think this misrepresents what we should take away from this study, I’m keen to hear it!
It’s mixed. As far as it goes for the original study, it’s mostly accurate but I do think that the use of the phrase “akin to a placebo effect” is misleading and the study itself did not conclude anything of the kind. There may be later re-analyses that do draw such a conclusion, though.
Most objective health outcomes of medical treatment were not measured, and many of those that were measured were diagnostic of chronic conditions that medical treatment cannot modify, but only provide treatment that reduces their impact on daily life. There are objective measures of outcomes of such treatment, but they require more effort to measure and are more specific to the medical conditions being treated. This is relevant in that a large fraction of medical expenditure is in exactly this sort of management of conditions to improve functionality and quality of life without curing or substantially modifying the underlying disease.
It should also be borne in mind that the groups in this study were largely healthy, relatively young adults. The vast majority of health service expenditure goes to people who are very sick and mostly older than 65. It seems unwise to generalize conclusions about overall effectiveness of health expenditure from samples of much healthier younger adults.
That’s helpful information, thanks.
Would you characterize the Oregon Medicaid study as poorly designed, or perhaps set up to make Medicaid look bad? From your description, it sounds like they chose a population and set of health metrics that were predictably going to show no effect, even though there was probably an effect to be found.
Doesn’t necessarily mean they “neglected free lifestyle interventions”. Maybe they were already doing everything they were aware of.
If you are not an expert, when you ask people about what to do, you get lots of contradictory advice. Whatever one person recommends, another person will tell you it’s actively harmful.
“You should exercise more.” “Like this?” makes a squat. “No, definitely not like that, you will fuck up your spine and joints.” “So, how exactly?” “I don’t know actually; I am just warning you that you can hurt yourself.”
“You should only eat raw vegetables.” Starts eating raw vegetables. Another person: “If you keep doing that, the lack of proteins will destroy your muscles and organs, and that will kill you.”
The only unambiguous advice is to give up all your bodily pleasures. Later: “Hey, why are you so depressed?”
(For the record, I don’t feel epistemically helpless about this stuff now. I discussed it with some people I trust, and sorted out the advice. But it took me a few years to get there, and not everyone has this opportunity. Even now, almost everything I ever do, someone tells me it’s harmful; I just don’t listen to them anymore.)