Annual checkups and the overconsumption of healthcare

Naomi Freundlich has a terrific post on annual checkups:

It sounds like heresy, but recent evidence challenges the long-held belief that the annual physical is beneficial for healthy adults. Researchers at the Nordic Cochrane Center in Copenhagen wrote last week that although a regular check-up with multiple screening tests might seem to offer the advantage of catching problems like heart disease and cancer early, their review of studies involving some 180,000 adults actually found no benefit. People who had annual check-ups were no less likely to be admitted to the hospital, become disabled or miss work than those who did not have regular physicals. Even more surprising, they were no less likely to die from heart disease, cancer or any other illness.

The study's authors offer a compelling theory for why this might be the case:

In fact, subjecting healthy adults to this yearly battery of tests may do more harm than good. The authors write, “One possible harm from health checks is the diagnosis and treatment of conditions that were not destined to cause symptoms or death. Their diagnosis will, therefore, be superfluous and carry the risk of unnecessary treatment.”

I'm increasingly starting to believe that overconsumption of healthcare is a bigger issue than previously realized.

Looking at the minimal differences in longevity between rich and poor countries only strengthens this theory.  We spend much more on healthcare than many middle-income countries, but receive very similar results in life expectancy.  The U.S. spends $7,000/person on health; Mexico spends $800.  But U.S. life expectancy is only two years longer than Mexico's (78.2 in U.S. versus 76.2 in Mexico).  And that's despite the fact that violence and traffic accidents kills 7% of Mexico's population versus only 3% in the U.S.

Links I liked

Robin Hanson on the impatience of idealism
More from Ta-Nehisi Coates on language learning
Good news
Probably good news

The 70 year theory

Is 70 years about the maximum that one party can stay in power in a given country?  Some intellectuals think it might be:

Hu Xingdou of the Beijing Institute of Technology says it has become common among intellectuals to wonder whether 70 years is about the maximum a single party can remain in power, based on the records set by the Soviet Communist Party and Mexico’s Institutional Revolutionary Party. China’s party will have done 70 years in 2019.

What are the counter-examples?  Should colonialism count?  Royal families?  What makes parties different?  Or is it not that parties are different, but rather this era of history is different?  

ACA Cost Estimates: Rising or Falling?

John Goodman has a misleading post over at his blog, claiming that the Cost for ObamaCare Soar:

When the [Affordable Care Act] passed in June 2010, the Congressional Budget Office projected the budget cost between fiscal 2012 and fiscal 2019 to be $462 billion. By June 2012, the cost for these same years had jumped to $574 billion, an increase of nearly 25 percent.

This is true, but it's very misleading.  CBO's estimates for the ACA's insurance subsidies have indeed increased, but Goodman and the American Action Forum fail to note that the CBO estimates that the overall cost of the ACA's health coverage expansions has dropped.  According to the CBO report, "the net costs of the coverage provisions of the ACA will be $84 billion less over the 2012-20122 period than they estimated in March 2012."

The entire CBO report is here.  

Flaws in the patient-doctor relationship

More excellent insight from John Wennberg's Tracking Medicine, this time on the patient-doctor relationship:

Social scientists had long recognized that the “exchange relationship” between the physician and the patient was radically different from the exchange relationship that determines the demand for other goods and services in most markets. The doctor-patient relationship is different because of the asymmetry of information. The patient, as a layman, does not know what he or she truly needs; it is the physician who knows the nature of the patient’s illness and can select the right treatment. For these reasons, many social scientists thought it was rational for patients to do something they would not dream of doing in most markets—that is, to delegate decision making to the seller of services, the physician, who by virtue of his special knowledge and skill, could act as their “rational agent” in health care purchasing decisions. 

From the patient’s point of view, the agency model was believed to be rational on the basis of several assumptions. First, it was assumed that clinical decision making is grounded in medical science; physicians have evidence-based knowledge to diagnose illness accurately and estimate the risks and benefits for the treatments they prescribe. Second, physicians make accurate judgments concerning the treatments patients want: they choose the treatment the individual patient would prefer, if only they were themselves physicians, and therefore knew the facts and better understood their own “true” wants and needs. This assumption is implicit when a patient says to his or her physician, “What would you do if you were me?” Third, the ethics of professionalism protects the trust that is the basis for the patient’s willingness to delegate decision making to the physician. Despite the fact that the physician benefits financially from higher utilization of his services, professional ethics ensure that he or she will choose what is best for the patient. Finally, egregious behavior by the few unethical physicians who induce patient demand for self-serving motives is detected and controlled through utilization review and other methods the profession adopts to discipline “outlier” behavior.

It seems that all four assumptions are flawed.

1) Medical science is evidence-based, of course, but that evidence is notoriously complex, and oftentimes deeply flawed.
2) Physician-patient communication also has a reputation for being quite poor, with overwhelmed doctors often not having the time to properly discuss options with patients.
3) Professional ethics is probably a fundamentally flawed concept.  I would argue that the concept is important in physician training and education on a micro-level, but that the healthcare system is unwise to rely on this concept on a macro-level scale.
4) And most evidence seems to indicate that our utilization review system is not working.

All that being said, I'm at a loss for solutions on how to change the nature of the patient-doctor relationship.

Theories of entitlement spending

John Goodman has a post on "grand bargains" in which he discusses entitlement reform.  I certainly agree with his analysis that raising tax has historically been easier than cutting entitlement spending, and that this should be a cause for concern.  Of more interest, however, were his positions on entitlement reform, which seemed a bit extreme for me.

Fundamental reform of Medicare and the elderly portion (which is most of the total) of Medicaid needs to proceed in much the same way. Young people need to start saving right now to pay for their health care and their nursing home needs during the years of their retirement. We also need to create more private sector options so that seniors have access to the same kind of health insurance the rest of the nation has access to (a la Paul Ryan).

The Democrats, however, will have none of this. Their idea of Social Security reform is raising the retirement age, reducing the rate of growth of benefits, raising the maximum wage subject to the payroll tax, etc. In other words, they want to tinker around the edges. And while they are perfectly willing to allow increasing the payroll tax on higher-income taxpayers immediately, all the spending reductions must only apply to future retirees, not current ones.

While cutting entitlement spending seems necessary, I prefer the idea of tinkering around the margins, since I support the basic concepts behind them.  Social Security should provide financial security for people who are too old to work or who have outlived their usefulness in the labor force.  Raising the age for Social Security is justified because people live longer and healthier lives than they did when it was originally enacted.  By raising the minimum age, we would be keeping the Social Security closer to the fundamental purpose of the law, tweaking an old law to fit our changed world.

Is Goodman's position--eliminating Medicare almost entirely--the mainstream libertarian position?  Am I misreading his argument?