Sorry to inject whatever uncertainty this produces, but how do you know that the most recent "no growth" reading is the correct one? To me your story justifies at least 1 or 2 more regular scans.

Walk into a US gastro with a hang nail and you'll walk out with a colonoscopy requisition.

They make money on the procedure, not the office hours. And they write the standards of care.

That being said, my father delayed a screening, developed colon cancer, and now no longer has a colon. Would cheaper / higher compliance tests have caught it sooner? Hard to say.

Insurance is mandated to pay for preventive colonoscopies with no patient responsibility. No coinsurance, no copay, no deductible.

https://www.cancer.org/cancer/types/colon-rectal-cancer/dete...

> The Affordable Care Act (ACA) requires both private insurers and Medicare to cover the costs of all colorectal cancer screening tests that are recommended by the United States Preventive Services Task Force (USPSTF). The law stipulates that there should be no out-of-pocket costs for patients, such as co-pays or deductibles, for these screening tests.

Smoking ironically saves in medical costs because people die before getting into real expensive age related care, and also smoking disqualifies you from a large number of medical procedures that would otherwise be given. Keeping a relatively healthy 90 year old alive for 2 more years costs significantly more than keeping an unhealthy 60 year old smoker alive 10 more years before they have a heart attack or stroke.

> Basically nobody else is recommending colonoscopies to the entire population with no cheaper tests

I'm not sure if I understand what you're saying. Kaiser Permanente sends me a take-at-home colonoscopy test every year, and some light googling suggests the cost is $20-$89. I've never done an in-person colonoscopy, but the home version must be cheaper, right?

Hypothesis: The American diet contains more carcinogens (dyes, additives, pesticides, supplements in poultry/beef/pork) and therefore USA is is more need of CRC screening.

USA generally has higher CRC rates than other developed nations:

https://pmc.ncbi.nlm.nih.gov/articles/PMC2796096/

the screenings may make sense, here

My doctor in the US did everything he could to tell me that my screening colonoscopy would be charged as diagnostic and I would have to pay over $2,000 for it, despite no history or indications of a problem. So it isn't all a bed of roses.

Most insurance covers preventive care, so that’s why it’s popular

Cigarettes have definitely gotten a trashy vibe in the US. It's kinda nuts how fast we went from smoking sections in fast food restaurants just 30 years ago to even bars banning it. In college 10 years ago, the only people I knew who regularly smoked cigarettes were from Europe, China, and India.

Cigars are still cool though, but those have always been the higher status tobacco due to the cost per stick. Also most people don't go through public spaces smoking a cigar, so it doesn't have the annoyance factor of vapes. Hookah still has a fun vibe too, probably because of the social factor.

Can you say where in the US you find it rare to see smoking in public? I live in Kansas City and have been in Vegas, Seattle, and NYC recently and there is plenty of smoking everywhere. Less than the 80s, sure, but certainly not rare.

There SHOULD be the same incintive in private health care like the US to also lower costs. but when we voted in the ACA (Obamacare) there was a well meaning clause that said insurers had to spend 85% of their premiums on care. That should also re-inforce the cost savings part, but then the largest companies started buying Pharmacies, Pharmacy Benefit Managers, Doctors offices, and even whole Hospitals.

Now they can still spend 85% of the INSURANCE premiums on care, but then those costs are going to their other divisions which can raise prices at will, and make massive profits for the whole group.

Nobody's twirling their mustaches hoping people get sick, but they don't need to be for fee-for-service incentives to bias standard practice towards responses to conditions rather than prevention. On the other hand: you can go too far the other direction (and some cardiologists would point to CAC tests as an example). Preventative care can be bad if the tests drive unnecessary procedures.

The comment said “putting 3 cups of coffee in a can we drink 4 or five of in a day” that would be 1,000–1,500 mg of caffeine. The FDA guidelines is 400mg a day and drinking 1200mg quickly can induce seizures

I don't think there's long term evidence for negative problems. However, high dosages of caffeine are dangerous and have killed people. Those dosages are easily achieved through the likes of energy drinks.

less the caffine itself and more the amount. It sounds like they are talking more about energy drinks or some highly concentrated espresso shot.

I don't think that much caffeine is good for you, especially 4-5 times a day. But with everything else we gulp down it probably isn't priority #1.

Tangential, but I suppose this is a good time to highlight how caffeine undisclosed can in fact kill some people:

https://www.bbc.com/news/articles/c5y95yylxv7o

What does individual freedom have to do with whether or not medicare will cover a preventive test?

I think you're looking at an effect instead of a cause. The main reason for the desire for a small government is not some inherent and absolute obsession with smallness, but because of the belief that larger governments are incapable of effectively utilizing their power (for reasons beyond just incompetence), are prone to inevitable abuses, and so forth. And that belief itself is not simply ideological, but based on history through most of all time.

Even with rehab versus punishment - it's the same story. The view isn't that punishment is inherently superior, but simply that rehabilitation is more of an ideal than a reality, and that typical appeals to places like Norway - a relatively homogenous and extremely wealthy microstate - don't necessarily translate well to large diverse societies, especially ones where there are substantial chunks of society that adopt cultures that glorify criminality.

> in cultural/moral expectations of how you should "pull yourself up from your bootstraps" to be great

Another word for that is freedom. With freedom comes personal agency and personal responsibility.

The primary purpose of prison is neither punishment nor rehabilitation, but rather to protect the general public. Whether incarceration is the best approach to accomplish that goal is a separate issue, but the reality is there are a lot of dangerous and antisocial people who can't be running around loose.

From Kurt Vonnegut in Slaughterhouse-Five:

  America is the wealthiest nation on Earth, but its people are mainly poor, and poor Americans are urged to hate themselves. To quote the American humorist Kin Hubbard, 'It ain’t no disgrace to be poor, but it might as well be.' It is in fact a crime for an American to be poor, even though America is a nation of poor. Every other nation has folk traditions of men who were poor but extremely wise and virtuous, and therefore more estimable than anyone with power and gold. No such tales are told by the American poor. They mock themselves and glorify their betters. The meanest eating or drinking establishment, owned by a man who is himself poor, is very likely to have a sign on its wall asking this cruel question: 'if you’re so smart, why ain’t you rich?' There will also be an American flag no larger than a child’s hand – glued to a lollipop stick and flying from the cash register.

  Americans, like human beings everywhere, believe many things that are obviously untrue. Their most destructive untruth is that it is very easy for any American to make money. They will not acknowledge how in fact hard money is to come by, and, therefore, those who have no money blame and blame and blame themselves. This inward blame has been a treasure for the rich and powerful, who have had to do less for their poor, publicly and privately, than any other ruling class since, say Napoleonic times. Many novelties have come from America. The most startling of these, a thing without precedent, is a mass of undignified poor. They do not love one another because they do not love themselves.

Everything is America is about race

If you keep in mind that the median voter in a primary is 65, then the government we have seems to do a pretty good job of reflecting the opinions of the politically engaged subset of the population.

I’d argue government investments are extremely exposed!

Consider that the majority of Americans do in-fact vote. In doing so, they literally delegate the power of the purse to the representative was most supported in their local community.

Look at the work put into ‘communication’ about those budgets also. In addition to having comptrollers to monitor the auditors or whatever.

The UK Expenses Scandal was funny, but Thatcherism is still doing too much residual harm to laugh about.

Promising x and doing y is a winner-takes-all democracy problem. Coalition governments solve this by sexing-up y as the natural outcome of the public vote. This also makes technocracy easier / more normalized.

I won't speak for other countries, but in the US, the answer to "Why do we spend so much on X" is typically because X is in large part a jobs program for special interests who are really good at lobbying, whether it is healthcare or defense or any other industry.

Representatives like high employment in their districts and employees of X like high salaries. It's an incentive-compatible equilibrium.

While I agree the US meddling in the Middle East has caused wars/terrorism, the general US military presence globally is a massive benefit for the entire world. Once the US starts pulling back more (as they seem to want to do) we'll see more and more regional chaos that grows into trade disruptions and wars. Regional tomfoolery like the South China Sea stuff will occur all over the world and will escalate into wars.

From the article:

> "As an example, consider a hypothetical 2-year wellness program that costs $400 per month per person (say, $13 per day for healthy food) and reduces the risk of heart failure by 1 percentage point, from 5% to 4%. For the first 90 days alone, heart failure treatment is much more expensive at $22 000 than the wellness program, but that doesn’t mean that the wellness program saves money. In this case, 100 people must participate in the 2-year program to reduce the incidence of heart failure by 1, from 5 people to 4 people. In other words, the number of people who must be treated with the prevention program to avoid 1 heart failure is 100 (NNT = 100)"

1. Why is the person's food cost attributed to the wellness program, instead of the person's food budget?

2. Most people are overweight or obese. I would expect $400/person/month of healthy food to lead to weight loss as part of the intervention. This skim-read study of 5000 people[1] concludes that "Modest weight losses of 5 to <10% were associated with significant improvements in CVD risk factors at 1 year". The hypothetical uses 1 percentage point, which sounds insignificant.

3. This Novo-Nordisk page[2] says: "According to a post-hoc analysis from the Look AHEAD trial, individuals with type 2 diabetes who lost ≥10% body weight had a 21% decrease in 4-point MACE incidence (defined as CV death, non-fatal acute myocardial infarction, non-fatal stroke, or hospitalisation for angina). A weight loss of 5% has significant health benefits". Again relatively small weight loss shows significant improvements.

(Comparison: someone 300lbs losing weight at 1 lb per week takes eight months to lose ten percent of their bodyweight. Healthy weight loss is often discussed at twice that rate or 2 lbs per week. In the TV show My 600lb Life Dr Nowzaradan gives morbidly obese people targets of 5-10lbs/week initially. The hypothetical wellness program is two years?).

The improvements from healthy diet which leads to weight loss ought to be more than just reduced risk of heart attack. Reducing hypertension (high blood pressure) leads to reduced risk of stroke and chronic kidney disease. Reduced body fat and healthier diet leads to reduced risk of Type 2 Diabetes and its complications (vision loss, neuropathy, slowed wound healing, worse immune function). Reduced weight leads to reduced risk of back pain, knee pain, sleep apnoeia, non-alcoholic fatty liver disease. Reduced body fat leads to reduced risk of some cancers, better diet reduces risk of other cancers. The hypothetical only considers treatment for heart attack in the savings but there should be a lot more savings.

The hypothetical only considers the treatment cost of a heart attack for 90 days but is that all the treatment they need? Are they not on regular drugs and checkups long term? And someone who survives a heart attack is at increased risk of another heart attack from all the same reasons they had the first one. American Heart Association says "about one in five people who have had a heart attack will be readmitted to the hospital for a second one within five years"[3].

And avoiding the prodcutivity loss from all the time off work from heart attack, back pain, sickness, medical appointments and treatments over years and decades. Intervention may not save money, but it may lead to increased ability for the economy to generate more money than it cost.

There's probably a point in that article, but why use such an easily criticised hypothetical to try and make a point? Not even going into $13/day vs 'beans and rice' or saving a person money on takeaway, cigarettes, alcohol, gasoline, or the costs to a person of moving to a walkable area or joining a gym, or all that kind of lifestyle intervention.

[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC3120182/

[2] https://pro.novonordisk.com/disease-area/cardiovascular-dise...

[3] https://www.heart.org/en/news/2019/04/04/proactive-steps-can...

In the limit, one would expect that to be the case: at some point the marginal cost curves will intersect. I’m quite surprised that we are already at that point. I suppose more things are at the efficiency frontier than I had imagined.

Thanks for the link. Will have to read it later.

I would read the comments on that article. The conclusion you've come to seems murky at best.

It varies. At the largest medical provider in my region they stipulate "To self-refer for a Heart Scan, you must be male between the ages of 40-65 or female between the ages of 45-70 and have a qualifying risk factor."

Wow, I would have expected something like this to be $thousand$ but a quick check with AI claims that in the U.S. the self-pay rate is anywhere from $100-$400. Still not cheap, but much more affordable than I expected.

I am not asserting that it applies in the above instance, but...

In broader medicine, one basis that can lead to the above sort of dynamic is compassionate protocol ("we are losing a little money on this deal, but you are in-need and we're here to help everyone"), as opposed to greed protocol ("we medicos are here for the big insurance money, and only charge the True Low Cost when forced").

And on balance, the nature of the people who choose the occupation of medicine tends towards the former.

A lot of doctors are willing to cut their rates if you're willing to pay cash for the full amount. It's the paperwork that inflates insurance costs. I'm sure AI will cut through that and make it less a problem though. /s

A few reasons:

- If you made a dietary change (e.g., more fiber and less saturated fat), the tests tell you whether it actually worked.

- Statins are dosed based on the LDL or ApoB reduction you need. The most powerful statins cut cholesterol by 50%, but at higher doses the risk of side effects does go up.

- Other medications like PCSK9 inhibitors and ezetimibe exist, and whether to use them depends on the other numbers. For example, PCSK9 inhibitors have a secondary benefit of lowering Lipoprotein(a), and statins and GLP-1s have a secondary benefit of lowering inflammation.

- If blood pressure, HbA1c, etc is high, then there's a slightly different set of diet advice and a very different set of medications. For example, lowering blood pressure through diet is mostly about reducing sodium and increasing potassium.

Behavioral changes can only do so much to lower ApoB. It is a meaningful marker and may trigger additional workup. It may also signal that you should at least consider a statin.

ApoA is completely out of your control and will not change with behavioral modification.

So, no, you're incorrect that these tests are superfluous and all you need to say is "diet and exercise". Besides, even if that was always the answer to these results, you should still have a baseline to see if behavioral modification is doing anything.

"Why not just skip the HbA1c tests? After all, you know they'll give you insulin. Just start taking it."

Do you think everyone with poor blood test indicators is aware of how unhealthy they are? How quickly they need to reverse course? Or do think there might be some possible validity to discussing your results with an actual doctor and understanding how acute your symptoms actually are? Do you think there are no side effects to statins and everyone should just be on one at all times, forever? Do you think there might be some value, for those patients, in discussing GLP-1s? Or nah, everyone can just like, go run 10 miles tomorrow because some 20 year old in SV said so?

I'm always deeply confused by people who think all medicine is "just repeat whatever ChatGPT said as if it's profound, like, duh - I'm smart and invincible and can't quite figure out that other people aren't me", in spite of them not knowing anything about medicine in the first place.

Because for the same behavior, risks are going to be very different on the other side. In my family, for instance, we need significant interventions to get a reasonable risk due to all the bad genetic factors. In my wife's family, not so much. So knowing how serious the risk seems much better than just handing statins to absolutely everyone.

Because everyone's heard that advice, but people don't tend to take action until they have evidence that they, personally, are at risk.

Because I’ll know how much I can slack off.

apob and lpa i believe are relatively stable even outside of diet.

Because people are lazy enough that they will pay money to be told they need to stop being lazy lmao

It’s also not just a “treat or not” decision. I have a family history and high test results so was already treating on the assumption I’m high-risk, but the scan revealed that we needed to be more aggressive. (And hopefully in a few years a scan will show we’re reversing the progression.) Personal data is always better than population data for treatment decisions.

Just vaguely remember what my cardiologist told me. This is absolute, not relative. Which, and I'm definitely not saying it's insignificant.

It is a big difference and definitely worth doing

Payers are bound by law to spend at least 80% of premiums on healthcare. So if they can drive up healthcare costs across the board, they can profit more (by taking the same 20% of a bigger pie).

Value-based care is a good idea in general in terms of better aligning provider incentives with patient best interests and controlling costs. But it doesn't necessarily equate with Medicare Advantage. Many MA health plans still operate largely on a fee-for-service basis with perhaps some minor VBC aspects.

Certainly it seems likely treating it for those instances where a heart attack would result is cheaper.

But there is no evidence presented that say for every 1,000 of these test we correctly find 1 that wouldn't have been found (and we have zero false positives) or whatever. So then 1,000 * 100 = $100,000 and saves $50,000. Even in this case there are benefits beyond the expenditures (if you save someone from the $50,000 you probably give higher quality of life...).

Basically my issue is not with the idea that more testing and preventative action would improve our current system. I believe that.

But in order to make that argument in a specific case you need more complete data. Things get complicated so I understand why people don't want to do that for a simple story. But the problem is when you leave off all sorts of costs, issues (false positives, treatment options), etc. the statements you make are not very compelling to those that know a test that tells you something bad is more likely for this person is not nearly sufficient to claim why this test is good.

Some excellent points!

>There's a lot wrong with health insurance in the US but this problem is largely on providers, not payers.

How would you fix it?

a little bit on the standard of care. also friction, and also knowledge

>Safety regulations are written in blood. They exist because people died because the industries could not and cannot be trusted to regulate themselves.

This sort of absolutist rhetoric is why people waste so much time arguing against maximal regulation and zero regulation in the abstract, neither of which is actually popular or sane.

Many regulations are good, necessary, and effective. Many of them are short sighted, over-specified, or written by lobbyists against citizens' interests (shouting that rent-seeking and safety regs are mutually exclusive doesn't make it so).

And of course the people writing things in blood are always intelligent, well informed people making strictly rational, unbiased decisions which perfectly balance the needs of all in perpetuity.

You're really missing the point. There are no regulations preventing anyone from ordering a CAC screening study if they want it. You can pay out of pocket and get it at any imaging center.

Obviously the regulations regarding ionizing radiation exposure still have to be followed as with any x-ray procedure. No one has seriously proposed deregulation on that.

The biological drive for high calorie food and fat reserves are the problem in a environment where food-scarcity is not an issue.

I modify my biological drive chemically every time I wake up and drink my daily coffee. Seems fine and we've been doing that for a long time now.

People also do it with smoking, and the only reason that is bad is because of the cancer, not the drive changes.

I guarantee the Unhealthy Snack Industry has their top scientists hard at work trying to find some kind of formula to make people on GLP-1 drugs go back to craving the soda and doritos.

If you thought that was bad you have all sorts of drugs that affect libido negatively. In evolutionary terms that’s as good as a poison pill, reproductive fitness of zero.

The pharmaceutical companies advertising GLP-1s for one.

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I have known at least two people, who while not making the claim that it doesn't work, do make the claim that it doesn't work for them.

To me this is just subconscious denial/defending of their food addiction.

I hear this all the time to the point where I don't even mention looking at a person's diet and exercise because I expect they'll be shot down

It's something I've read a few times. Most of the studies I've seen say it's effect is modest at best. At least if it was a drug there wouldn't be enough evidence for it to get FDA approval (especially with all the "side effects" such as injury)

Arguably this is a limitation on how the studies were done, as nobody is going to pay for extensive studies since you can't patent exercise.

Bodies are all different. Diet and exercise can work for one person and not another. But the type of person who wants to believe all fat people are slothful, all unemployed people are lazy, and so on, will invent in bad faith the straw man argument that we think diet and exercise do not work at all. They're not worth engaging with.

> We could remove these weird constraints by making health care a government service rather than a highly contorted pseudo-market, but that would not be the American way. It has to at least look like a market, even if it’s an ineffective, inefficient, opaque, corrupt one.

It is still a market (and a single-payer one, ultimately) in these places, but it is not a government service. It is the best solution: the government funds the appropriate cost of care, the provider group is financially responsible for meeting it, and they are incentivized directly to get it right.

The left needs to stop shrieking about Medicare-for-all and the right needs to stop pretending like it can even spell healthcare. There are good solutions.

> but also encourages just refusing to treat people.

It categorically does not. It would be foolish to do so.

Completely agree with your characterization of the current system but why does making healthcare a government service necessarily lead to better outcomes vs current state or a more sensibly constrained market?

Seems obviously right in terms of total cost to the median patient (less obvious for individuals in higher tax brackets), so I'm not disputing that. More curious about incentives to improve care delivery for better long-term outcomes.

> "fee for service"

> "per capita"

I don't quite get the difference, patients pay a fixed amount for insurance, hospitals charge "fee for service" to the insurance. Both systems coexist, it's not one or the other.

To be clear, I'm not suggesting changing the whole system, I think that's infantile sorry to be blunt, I'm proposing a more down to earth (and commercially appealing approach) of increasing the price (and thus financial incentives) of medical goods that have low cost but high health values.

My economic theory clearly isn't as strong, because how much should a CT scan and a pill be priced at relative to a heart attack response with a 1 week hospitalization and a bunch of work. Because the cost of a CT scan and a pill is low (100$), the value of it is high (50K$ lower bound), and the cost of treating a heart attack is clearly around 50K$, but the value of it is clearly lower than the preventive treatment (perhaps stochastically adjusted).

So should we be pricing by cost or pricing by value? The naïve approach is pricing by cost, so that everything is cheap, the first issue with this approach is that it disincentivizes research, which is why legal systems widely recognize patents, copyright and intellectual property.

I looked into Shkreli's case a bit deeper, and he was a stupid kid of course, but it's what comes to mind when thinking of 'raising prices' of medicine, there's not many faces to that idea.

That said, I'm not saying that prices SHOULD be hiked, just that I'm not convinced that medicine pricing should be cost based, or that it should be value based, or that some supply-and-demand principle would magically find a value in the middle. I'm just saying that it can be either way, and I just don't know which way it ought to be.

And ultimately, it's a decision that every actor in the industry can make, what they price their products and time at. And to reiterate my thesis, pricing your product as cheaply as possible might counterintuitively reduce it's impact, since there is no incentive for intermediaries (or even yourself) to work on it. So I'm not saying that prices should be maximalized either, just that the relationship between price and value contributed to society is not linear, if you price your medicine at 0, you go bankrupt, that's not helpful obviously, and evidently pricing a CT scan and a heart attack pill at 100$ is not cutting it either, hike that up.