Rethinking Healthcare... Completely

from the about-time dept

Wed, Sep 20th 2006 12:15pm — Mike Masnick

A few months back, after meeting UCLA professor David Levine at the Cato Institute conference on copyrights, I read his book, Against Intellectual Monopoly (actually a large part of it I read on the flight home from that trip). Of particular interest to me was chapter 9, on the pharmaceutical industry -- as that's often the industry held up as the perfect example of why aggressive intellectual property laws in patents makes sense. The chapter points out plenty of examples of why things aren't as great as they seem. As with any monopoly you get some pretty unwanted actions that are more harmful than helpful -- and that's especially true when it comes the tricky games pharmaceutical companies use to make sure they keep their monopoly. Some evidence of that was seen just recently in the scandal at Bristol-Myers Squibb. What I hadn't realized, was just how relevant this would all be when reading Andy Kessler's new book, The End of Medicine. I've known Andy for a while, so he and I had discussed this book over lunch back when he started writing it in 2005 -- and in our discussions I always said that it would be the insurance companies that made whatever dreams of "reinventing" healthcare more difficult. However, Andy insisted that that based on what he was learning, things would get so cheap (following the Moore's Law pattern) on many of these technologies, that insurance would be taken out of the equation. Instead, the real obstacle could very well be the pharmaceutical industry and their monopolies.

The book probably isn't what you think it is. It's not about reforming the healthcare system, and it's not just about new technologies that make healthcare better. It's really about recognizing that the way we think about healthcare may be fundamentally flawed. That is, we're very focused on curing problems, not preventing them (despite the old ounce of prevention vs. pound of cure line). A big part of this problem is that the technology just hasn't been good enough yet to see inside our bodies clearly enough to really understand what's going on. That makes it hard to actually prevent stuff when you don't know what needs preventing. However, the technology on that front is starting to change, and it's possible that it'll go down the cost/power curve of traditional computer technology (meaning: wow, watch out). But, even more interesting is the total lack of money then going into prevention and early detection using technology. Instead, all the money goes into pharmaceuticals, where the big monopoly payoff is. On top of that, these early detection techniques (which could save a ton of lives, and, as the book notes, have great unexpected benefits on the economic side) get short-changed -- especially as the FDA requires them to follow the same procedure as drug development, even though they're not drugs.

The book itself is a quick and fun read, even with the "weighty" subject matter, as per Kessler's usual writing style. Reading it, I became equally frustrated at the stupid and unnecessary barriers in the way of some of these technologies and optimistic at the potential for where all of this could go (and how quickly). Andy was kind enough to allow us to publish an excerpt of the book, discussing "the physical of the future," which you can find after the jump (if you're reading in an RSS reader or on the front page, click through). The book has been getting some great reviews, and Andy says he's received some hate mail from doctors... so you know he's doing something right.Chapter 34 - Physical of the Future
Excerpt from: The End of Medicine: How Silicon Valley (And Naked Mice) Will Reboot Your Doctor, by Andy Kessler

OK, I get it. This is the physical of the future. Sticking out your tongue and getting a finger up the wazoo is something some stooge might do, Dr. Howard, Dr. Fine and Dr. Howard back in the 1930's.

256 slice scanners, faster than your heartbeat, just might be the magic pill of diagnosis. It's as if doctors will be saying I was blind before I could see. Blind as a bat. Six blind doctors feeling around an elephant and describing a wall, spear, snake, tree, fan and a rope. Looking for clues in all the wrong places. Measuring cholesterol and blood pressure is like reading the outside temperature and humidity from inside your house and guessing if it's raining. Open the window, stick your goddamn hand outside and know for sure.

These scanners will spit out gigabytes of data, thousands of slices. We already know we can't afford radiologists to sift through all this data, not at their usual fees of $149 for 60 seconds.

But so what? Technology like R2 can help. It can flag anything suspicious. False positives will be a lot lower than the discredited scans of 2000. Higher resolution and higher speeds should mean artifacts go down, not up. Expertise embedded in silicon detector rows, 3D rendering and computer aided detection - not the Dr. Finkelsteins of the world. Again, not until we need him.

How much do these scans have to cost to become widespread? $500? $100? $20? It almost doesn't matter. The cost savings comes over time. Spread the R&D over millions and you get scale. It works. Patients as products of medicine will have to wait - thank you Blue Cross, you cheap bastards. I read there are upwards of 2 million heart procedures done each year, about half in the U.S. Scanning 300 million Americans at even $100 a throw is $30 billion, vs. $15,000 for a stent times a million procedures or $15 billion. It's cheaper for your symptoms to show up in real life - clutching chest, can't breath, life flashing in front of your eyes - then in a few gigs of a virtual scan.

* * *

Patients as consumers of medicine, well, that's a different story.

Let's see, I can buy that new Mustang or I can have a heart scan and not worry about dropping dead at work. Hmm. I have no doubt that lot's of folks will take the Mustang behind door number 2, but if we can spend billions on low carb diets and Special K cereal and Eggbeaters, let alone Viagra and Botox, parting with some discretionary cash for a life saving heart scan doesn't seem so far fetched.

No, this digital divide isn't going to be between the haves and have nots. Like PCs and cellphones, I suspect it will all get cheap enough. No, it's more the want-to-knows and the don't-want-to-knows.

If the end game of all this is more control of our healthcare, like managing your own money, some people are going to be good at it and others aren't. Maybe in some ways Darwinian - you become dependent on your own research and effort. It's going to take some combination of personality, character and intelligence just to be able to handle it - fight back the nausea when someone shows you your guts and glory.

I admit to sweating through my BVDs waiting for the results of my heart scan. I still see puppies being pulled out of a Boston Terrier whenever I'm asked to confront anything medical. It's so, like, totally grodie.

But I suspect I just had to get over it. If I want to cheat a little bit, live a little longer than predetermined by my parental gene inheritance, I needed to wake up and smell the blood. Still, this is not a small obstacle to acceptance of this new medicine. Would you like to know when you're going to die? What if these new scanning guys threw a party and no one showed up?

* * *

But plenty will. The opposite question is what if half of those million heart procedures are no longer necessary because something was detected early enough to treat in other ways? That's a lot of hospital beds and cardiologists and nurses with nothing to do. But that's exactly what is going to happen as scanning gets cheap enough, as Dr. Goldman's 256 slice machine gets utilized 24/7. He is the anti-hospital, anti-doctor doctor.

Then, do we really need doctors - at least doctors as they exist today?

The geeks are definitely at the gate and chanting in strange tongues.

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dorpus, 20 Sep 2006 @ 12:37pm

The Power of Ignorance
It's fun to watch IT types stick their heads into a field they know nothing about, and claim they can revolutionize the field.

The Public Health field has been preaching prevention since forever. However, IT types are very opposed to having the government tell people how to live. If better screening programs of the future allow insurance companies to drastically raise insurance costs for risky patients, then IT types will be whining about the "invasion of privacy" or whatever.
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slide23, 20 Sep 2006 @ 12:42pm

It's not the insurance companies...
The huge resistance to changing the healthcare industry comes from doctors and med schools.

My company (www.pkc.com) makes medical diagnostic software. The premise is that doctors cannot keep it all in their heads, but med schools and the medical profession at large teach and preach this egotistical attitude. Think of all the hype in the late 70's and early 80's about seeking a second opinion. How dare you question your doctor's judgement!

Doctors need to have ready access to a large array of knowledge and they need to think combinatorially. Humans cannot think combinatorially and they cannot hold the body of medical knowledge in their heads. The pharmaceutical firms just provide one easy out for them. Doctors don't have time to know everything, but hey! If you're patient has heartburn, just give them this purple pill! Of course, this also underscores the GOTTA HAVE IT RIGHT NOW attitude that is becoming the norm.

Do we need doctors? Most certainly. But they have to change with the times if we are to avert some real disasters.
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dorpus, 20 Sep 2006 @ 1:13pm

Re: It's not the insurance companies...
How will the technology really be used? These kinds of technologies are adopted more readily by overcrowded hospitals in California or New York, which wants to squeeze ever more patients through while doing ever less for them.

In the countryside, Bobs and Marthas enjoy brand-new spacious hospitals, built by federal money for "under-served areas". Places like California or New York with a desperate need for better health care receive no such money because they are "wealthy states", and spend decades debating over new hospitals that never get built.
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Anonymous Coward, 20 Sep 2006 @ 1:41pm

Re: Re: It's not the insurance companies...
So I need to move to the countryside when I get old?
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Reed, 20 Sep 2006 @ 1:46pm

Focus on the small stuff
Of course Medical Science is flawed when it come to prevention. It only makes sense when innovation is driven by finding cures not preventing disease which would of course destroy the foundation of how our medical system pays for itself. I would like to point out that there are many other examples in our society that shows how we only treat the symptom and not the actual problem. Treating systems as a whole with prevention first is necesary for a healthy society, but it isn't profitable according to our current model. As long as we are all stuck worrying about how we are going to make the big bucks we won't progress as a society, unless of course you think that money is the root of everything important.
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Anonymous Coward, 20 Sep 2006 @ 1:56pm

holy crap
i usually try to read every article by you guys but this is waaay too long...
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JJ, 20 Sep 2006 @ 2:15pm

Re: The Power of Ignorance
> It's fun to watch IT types stick their heads into a field they know nothing about, and claim they can revolutionize the field.

It's even more fun to watch people who clearly haven't read the book, pretend they know what it's about and then call others ignorant.

I suggest you actually read the book first, before making a bunch of false assumptions (I count at least 4 false assumptions in your one sentence above -- so it's kind of amusing to then have you call others ignorant).
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jon cable, 20 Sep 2006 @ 2:59pm

does this effect my viagra
i just want you guys to know that i need medical insurance. without it me and my boyfriend would not be able to afford the massive amounts of viagra and ridalin that we consume during our slopy wet orgies.
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Anonymous Coward, 20 Sep 2006 @ 3:12pm

Health care costs won't really go down until there is true freedom in the health care market. Let _me_ choose what qualifications I want my doctor to have. Let me treat myself if I want to. And let _me_ decide what drugs to take for myself if I want to. As long as health care is held hostage by industry regulators it will remain expensive: You can either buy _their_ product at _their_ price or die. Your choice. I don't see that changing anytime soon.
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g, 20 Sep 2006 @ 4:04pm

Re: holy crap
It may be too long for some, but I enjoyed this and I hope TechDirt does more of them.

As long as they summarize up-top so I know if I want to bother reading it all.
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dorpus, 20 Sep 2006 @ 4:43pm

Re: Re: The Power of Ignorance
I suggest you actually read the book first, before making a bunch of false assumptions (I count at least 4 false assumptions in your one sentence above -- so it's kind of amusing to then have you call others ignorant).

I flipped through the book at the store. For anyone who has had a course in epidemiology, the book is good for laughs. (For the ignorant, epidemiology is about a lot more than infectious diseases.)
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Luci, 20 Sep 2006 @ 4:44pm

Re: It's not the insurance companies...
Not all doctors and medical colleges preach this, of course, just the majority. If you want to find a good doctor/hospital, start with the area medical colleges. Find out how they do things. In my area we have a medical college that does want their students to know as much as possible. They teach them to study, though, not retain for massive periods of time. All of the residents and attendings at the hospital this college is part of carry PDAs that link up with the network within the hospital. With this network they are able to obtain lab results, research symptoms, compare drug interactions, even find out the going retail price on medications so they can work within your income. This is the level of treatment we should EXPECT. It's sad that this isn't the norm.
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dorpus, 20 Sep 2006 @ 4:48pm

Re:
Health care costs won't really go down until there is true freedom in the health care market. Let _me_ choose what qualifications I want my doctor to have. Let me treat myself if I want to. And let _me_ decide what drugs to take for myself if I want to. As long as health care is held hostage by industry regulators it will remain expensive: You can either buy _their_ product at _their_ price or die. Your choice. I don't see that changing anytime soon.

When health care isn't regulated, there are consequences like this one:

http://www.cnn.com/2006/HEALTH/09/20/internet.drugs.ap/index.html
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AMP, 20 Sep 2006 @ 4:51pm

Re:
So let me get this straight...you want your health insurance carrier to let you self medicat/heal your self? What happens when you miss-diagnose your self and put yourself into a come because you took the wrong medication, would yourr insurance carrier be on the hook for covering the prolonged hospital costs of having an actual doctor heal you?
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Jean Thibaudeau, 20 Sep 2006 @ 4:55pm

Excellent post
Very good post
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Lucy La Hurreau, 20 Sep 2006 @ 4:57pm

Doctors should stop practicing
When will doctors, lawyers, and pharmacists stop practicing their art and start doing the job? Haven't they had enough time to figure out what the herbalists have already figured out. An ounce of prevention..................
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True Believer, 20 Sep 2006 @ 5:13pm

The real issue...
So can we legalize recreational drug use yet? Screw prolonging life, let's try actually improving it!
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Anonymous Coward, 20 Sep 2006 @ 5:20pm

Re: Re:
So let me get this straight...you want your health insurance carrier to let you self medicat/heal your self?
I suppose that would be up to the insurance carrier, if any, wouldn't it? The post said nothing about requiring insurance to cover anything.
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Anonymous Coward, 20 Sep 2006 @ 5:28pm

Re: Re:
When health care isn't regulated, there are consequences like this one:
http://www.cnn.com/2006/HEALTH/09/20/internet.drugs.ap/index.html
That article is about fraud, not deregulation. Those are two very different things. For instance, if someone wants to go to a witch doctor, faith healer, or whatever, then that should be their choice. But if they choose to go to someone who claims to hold a traditional medical degree but who in fact does not, then that is fraud.

The post said nothing repealing fraud laws.
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PR, 4th yr medical student, 20 Sep 2006 @ 5:42pm

Way to completely miss the real issues
After studying to get that medical degree everyone seems to easily cast aside as useless, let me tell you why improved imaging will not make a bit of difference in prevention. It's not like 30+% of Americans don't know they're ruining their bodies by being obese. Or how most diabetics don't know losing weight or controlling their sugar will ultimately prevent them from having a heart attack or having an amputation after their peripheral neuropathy gives them a poorly healing foot ulcer and infection that's life threatening. We know these things now using just simple blood tests. The point is that people are only very rarely willing to make the lifestyle changes to prevent the disease.

You have to put down the bucket of fried chicken to prevent heart disease. And knowing that your arteries are clogging 5 years before the heart attack still isn't going to motivate them to change their lifestyle. Technology is useful only for those motivated enough to use it, and in the end most people are still willing to take a pill before they'll be willing to put down the ice cream.
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Anonymous Coward, 20 Sep 2006 @ 6:05pm

Re: The real issue...
So can we legalize recreational drug use yet?
You mean like alcohol or caffeine?
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dorpus, 20 Sep 2006 @ 7:03pm

Re: Re: Re:
That article is about fraud, not deregulation. Those are two very different things. For instance, if someone wants to go to a witch doctor, faith healer, or whatever, then that should be their choice. But if they choose to go to someone who claims to hold a traditional medical degree but who in fact does not, then that is fraud.

The post said nothing repealing fraud laws.

There is no distinction. A witch doctor, faith healer, or herb peddler is making fraudulent claims about the effectiveness of their treatment, which is not backed by scientific evidence. If health care should be "deregulated", it means doctors will also be allowed to fool their patients into taking ineffective treatments. Our problem is too little regulation, not too much. The natural health industry sells toxic herbs to consumers, which contain known carcinogens and other toxins; but in the name of "natural health", they are allowed to get away with this.
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wto605 (profile), 20 Sep 2006 @ 7:19pm

Re: The Power of Ignorance
Except that that isn't prevention?

In terms of cancer prevention means correcting genetic errors that already exist so that the deadly combinations can never be formed. The only true prevention we have in medicine is the elimination of various diseases such as small pox. We've literally killed it, and that's the only disease that is "prevented". Vaccines come close, but even then that's technically treating the disease before the actual malignant viruss attack the body. With the vaccine the body still believes it is being attacked and is "treating" against the vaccine (which, by the duck test, is the virus except that it doesn't have any genetic material to cause ailments) so that it's ready for the real virus. Screening programs are still treatment, It's just that you treat the ailment before it is a threat and/or symptoms arise.

I may be a tech type but there are 3 RN's 2 LNHA's and a Doctor in the family... don't go telling me I don't know anything about medicine.

By the way... nice projection (don't be ignorant, look it up. Hint: You're looking for the psychological term which is used in literature analysis.)

On second thoughts... http://www.heretical.com/sexsci/bpsychol.html
Scroll down... sections 2a and 2b (mostly 2a)

To Mike/Tech Dirt: Great post... I've definitely got some reading to do now!
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wto605 (profile), 20 Sep 2006 @ 7:40pm

Re: Way to completely miss the real issues
Actually... that's medicine's fault...

If we just let everyone who smoked die from lug diseases people wouldn't smoke. If we didn't have liposuction and gastric bypass surgery people wouldn't eat as much. Medicine is being an enabler to the disgusting lifestyles of Americans. Sure... they won't live as long... but with medicine that difference is down to no more than 10 years (and even that's being generous).

Besides... what do you care? they're going to be in your office/hospital/practice more than anyone else and paying you. It's their money their body... if they want to squander away their life's work and earnings to keep themselves alive because they don't want to stop eating its up to them.

I agree its terrible but judging by the trends in society and government's policies Americans are not only very insecure but we are very arrogant and expect everything to adapt to us. (can anyone say metric system?) We're going to keep on doing what we do and make everything else fix it for us... including our personal health.

In conclusion/summary: It's a capitalist market... these people are willing to pay extra for health costs to maintain their lifestyle and companies are more than willing to make money off of this market. It's better than communism... you don't have enough food to make your self obese.
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dorpus, 20 Sep 2006 @ 7:49pm

Re: Re: The Power of Ignorance
In terms of cancer prevention means correcting genetic errors that already exist so that the deadly combinations can never be formed.

The DNA in our bodies undergo thousands of mutations every second. It is not possible to prevent mutations -- if we live long enough, there is a 100% chance we will develop cancer. We can only reduce particular risk factors, such as avoiding sun exposure or certain carcinogens.

The only true prevention we have in medicine is the elimination of various diseases such as small pox. We've literally killed it, and that's the only disease that is "prevented". Vaccines come close, but even then that's technically treating the disease before the actual malignant viruss attack the body.

Your third sentence contradicts the first two sentences; gramatically, it makes no sense either.

With the vaccine the body still believes it is being attacked and is "treating" against the vaccine (which, by the duck test, is the virus except that it doesn't have any genetic material to cause ailments)

What is the "duck test"?

so that it's ready for the real virus.

The viruses in the vaccine are real. It makes more sense to talk about the wild type virus or pathogenic strain.

I may be a tech type but there are 3 RN's 2 LNHA's and a Doctor in the family... don't go telling me I don't know anything about medicine.

You speak poorly for your family, in addition to neatly fitting the stereotype of the illiterate techie.

By the way... nice projection (don't be ignorant, look it up. Hint: You're looking for the psychological term which is used in literature analysis.)

No projection is necessary. Neither the staff at Techdirt nor the articles they like to quote are written by competent health professionals.
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slide23, 20 Sep 2006 @ 7:53pm

Re: Re: It's not the insurance companies...
How will the technology really be used? These kinds of technologies are adopted more readily by overcrowded hospitals in California or New York, which wants to squeeze ever more patients through while doing ever less for them.

You are engaging in gluteal dialectic. Rural hospitals are, on average, crap. They may have level 1 trauma centers because there is nothing else nearby, but that is about the total of it. How many rural hospitals would YOU trust for an invasive procedure?

As far as "these kinds of technologies," I can tell you for a fact that none of our clients use it provide less service. Even for a crappy doctor, the nature of our tool does not allow for less service; it simply prevents the doctor from overlooking a potential diagnostic course.

But technology is a lens. It will only make a good doctor better and amplify the effects of a bad doctor.
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dorpus, 20 Sep 2006 @ 8:04pm

Re: Re: Re: It's not the insurance companies...
You are engaging in gluteal dialectic. Rural hospitals are, on average, crap. They may have level 1 trauma centers because there is nothing else nearby, but that is about the total of it. How many rural hospitals would YOU trust for an invasive procedure?

I'd trust them a lot more than the California hospitals I have been to. The reality is that lower-class blacks in rural Alabama are receiving free medical treatment at first-rate facilities, while yuppies in Silicon Valley must make appointments with doctors three months in advance to meet their basic needs. Silicon Valley doctors literally turn their backs on patients and ignore their problems -- I have experienced this multiple times. California's news media was full of reports of people dying from minor wounds because emergency rooms were too full. California's doctors and nurses have been moving out of the state in droves, because working conditions and pay are so poor there. California hospitals have taken to flying in temporary health workers from other states and putting them up in hotels for 1 week at a time. Otherwise, they hire Filipino nurses who speak no English and lie about everything.

The crap rural hospitals are usually in Western states with rapidly expanding populations of white yuppie refugees from California. The local voters don't want hospitals to treat Californians or illegal immigrants, so new hospitals never get built.
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Len, 20 Sep 2006 @ 8:06pm

It's not healtcare, it's sickness maintenance
Does this book go into the economics of so-called health care at all? I read somewhere that each case of Leukemia creates something like 15 highly-paid jobs for 3 years and stimulates the economy tremendously. Curing it might have some serious effects on the economy! (you Americans spend 15% of your GDP on healthcare)

Seems to me that there is no incentive to cure disease -- just to get more and more people defined as "sick" in one way or another and then maintain them in that state for as long as possible, so that they consume as much products and services as possible.
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dorpus, 20 Sep 2006 @ 8:19pm

Re: It's not healtcare, it's sickness maintenance
If that were true, then the health care industry should be in partnership with the tobacco industry to make more lung cancer patients. As anyone with an ounce of common sense knows, the health care industry is very anti-tobacco.

At any given time, diseases for which no cures are yet known will be the predominant health problems in the population. In the past, infectious diseases and poor nutrition were the largest killers of Americans, but those problems have largely been eradicated.
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Guru80, 20 Sep 2006 @ 8:19pm

Broad subject, small comment
I have been trying to figure out for years why the medical field in general is stuck in the stone age when there is technology out there that is down right "Star Treky".

There are much more accurate, albiet more expensive an investment by the medical community, means of preventing, testing, diagnosing and curing than what we are subjected to...especially in the typical family practice.

Sticking a stick down my throat (and up my ass) just isn't as reliable as what could, and should, be done. At least heading away from those simplistic forms of educated guess work into fail proof alternatives.
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Brandon Bailey, 20 Sep 2006 @ 8:36pm

Reply
http://robotfuturenews.blogspot.com
http://www.kurzweilai.net
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Len, 20 Sep 2006 @ 8:51pm

Re: Re: It's not healthcare, it's sickness mainten
Yes, economics creates strange bedfellows -- and when you do the analysis, the healthcare industry is not really very anti-tobacco at all -- the insurers depend on the higher premiums they collect from smokers and the doctors gain through all the service opportunities smokers present.

The most effective anti-smoking lobby has been the US state governments who have sued the tobacco companies to recover the extra costs that smoking-related illness has caused. Governments that end up footing the bill for tobacco-related illness have not been able to get direct access to tobacco taxes (which are not high enough to cover those costs anyway) so they have had to sue. Now, they have been careful not to kill these companies, because they want them on the hook for more money later, and new tobacco companies that would be formed to replace the old ones if they went bankrupt would not carry the liability of the past.

The symbiotic relationship of tobacco and healthcare companies is truly disturbing to me too.

If everyone followed the advice that has been shown to reduce illness then there would be a lot less healthcare required. Every doctor I have ever seen rather flippantly dispenses some hokey preventative advice knowing full well that I wouldn't really follow it anyway, and I am sure secretly hopes I don't.

My point is that the real gold mines for the industry are chronic, incurable diseases, with expensive treatments that are needed for as long as the patient is alive. The economics draw the R & D into a mode whereby these "sickness maintenance" products get the most funding, because they generate the most income.

This broken system is not producing cures, and measured by outcomes like longevity and lost days at work, Americans are not getting their 15% worth, compared with every other industrialised country. Not by a long shot.

http://angrybear.blogspot.com/2005/04/health-care-in-us-and-world-part-ii.html
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PR, 4th yr medical student, 20 Sep 2006 @ 9:06pm

Way to completely miss the real issues
"If we just let everyone who smoked die from lug diseases people wouldn't smoke. If we didn't have liposuction and gastric bypass surgery people wouldn't eat as much."

This completely circumvents my point. I made no claim that medicine doesn't enable poor lifestyle choices. My point is that adding new diagnostic radiologic tests will add no more benefit to prevention until behavioral interventions are implemented.

"Besides... what do you care? they're going to be in your office/hospital/practice more than anyone else and paying you. It's their money their body... if they want to squander away their life's work and earnings to keep themselves alive because they don't want to stop eating its up to them."

Riiiiiight. Because that's why I got into medicine. For the money. Laughable.

You're right it's their body, and you can't force someone to change. While obesity and lung dz's are all lifestyle based (except with problems like Alpha-1 antitrypsin deficiency), our job as physicians is to improve quality of life. Now that's a loose goal, because the definition can be defined in morbidity (symptoms) or mortality (death). And many don't follow this ethos. But we do our best. If someone comes in after quitting smoking after 30 years but with chronic obstructive pulmonary disease, yes we shake our heads internally thinking "they did this to themselves." But we also do everything in our power to help them. Letting them suffer and slowly suffocate, even though it was their choice to become like this IN A SENSE, is really just cruel.

And it's not like people don't know they could get cancer and die from smoking. Or any other number or preventable problems. The issue is that for many they just don't muster up the motivation to do anything about it until they're profoundly symptomatic. I've seen patients with severe diabetes with blood sugars in the 400's regularly (that's quite high). They don't do anything because until they've lost a few toes, they can't comprehend that they really have disease. Showing them full body scans, next gen MRI's, whatever, is not going to impact them any more than what we do now.
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PR, 4th yr medical student, 20 Sep 2006 @ 9:23pm

"My point is that the real gold mines for the industry are chronic, incurable diseases, with expensive treatments that are needed for as long as the patient is alive... Americans are not getting their 15% worth, compared with every other industrialised country. Not by a long shot."

You hit it on the head in some ways. The reason we spend so much to get so little is because we treat diseases after they're way too progressed. We'd rather spend tens of thousands on CABG surgeries than a hundred dollars on education to prevent the heart disease in the future. And that's where the difference lies between us and those other nations. They're willing to put the money into prevention, namely in EDUCATION. Just like all those anti-tobacco ads on the air, we're saturated with media that promote certain lifestyles. Whether we admit it or not, they have an influence on the decisions we make. The more effort we put into education, not new more advanced diagnostic technologies, the more results we'll get per dollar spent.

What does this mean? Educate. Get the government to stop subsidizing corn and thus putting corn syrup in everything because it's so cheap. Subsidize healthy foods (fruits and vegetables) so the poor can actually afford them. It's sadly cheaper to eat at mcdonalds than to eat your required daily fruits and veggies.

Yes the system's broken. And I'm f**kin sick of everyone blaming doctors, as if we're happy to watch our patients dying in front of us. We're not jacking up the prices of drugs, the price of technology, or causing your disease. We do what we have power to do. We don't want you to keep having that chronic illness. Really. Despite some economic logic that says it keeps us employed- believe me, there is always plenty of other work for us to do besides treating those that never quite get anywhere. I mean for god's sake we fund our own studies to see how we can get people to better follow our recommendations that have been proven to help them live longer and better.

The real truth is that watching people not take their own health seriously and slowly detiorate when so much could be prevented wears on many doctors, making them a bit numb. Think about watching a family member slowly poison themself every day. Eventually you have to emotionally remove yourself because it's just too hard to watch. I'm not even quite done with medical school and I can already see how physicians burn out. My point: This system is tough on us too, so back off with the dr. bashing. Why don't you come to medical school, or hae a real one-on-one with a dr. before you throw the blame our way.

Off my soapbox now.
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Anonymous Coward, 20 Sep 2006 @ 9:25pm

Re: Re: Re: Re:
There is no distinction.
Well, that's what intrusive bureaucrats, regulators and those with vested interests might like us to believe. But it's just not true.

A witch doctor, faith healer, or herb peddler is making fraudulent claims about the effectiveness of their treatment...
Now that's just ridiculous. How do you know what they all claim? Are you some kind of god that knows what everybody says?

Our problem is too little regulation, not too much.
I don't want to live in some kind of dystopian world where every part of our personal lives are ''regulated'' for our own good. Want more health regulation? How about requiring everybody to have their meals ''preapproved'' to ensure they are eating ''healthily''. Grocery stores and restaurants wouldn't sell you any food that you didn't have a ''prescription'' for. And your daily routine would have to be approved by an approved fitness instructor to ensure that you are getting the proper exercise. And of course there would have to be a huge enforcement mechanism of ''health police'' and informers to go along with it all. That's where ever more regulation leads. No thank you dorpus.
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michael clouser, 20 Sep 2006 @ 10:18pm

medicine
Most interesting Mike. Past this on to a few people and will buy these books as well.
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Pseudonym, 21 Sep 2006 @ 4:30am

Strangely enough...
Strange as it may seem, I don't see this at all. But then, I live in a country with nationalised health care.

Most nationalised health insurance systems collect the same amount of money from a smoker as from a non-smoker, assuming equal incomes. So the government has a legitimate interest in prevention. So, for example, my government has an interest in not being in bed with big tobacco companies, in healthy eating and in encouraging kids to be active.

Yes, the system has its disadvantages. But I'm pretty certain that the shift to prevention-based health systems will end up not coming primarily from the USA.
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mkam, 21 Sep 2006 @ 5:40am

How about requiring everybody to have their meals ''preapproved'' to ensure they are eating ''healthily''. Grocery stores and restaurants wouldn't sell you any food that you didn't have a ''prescription'' for. And your daily routine would have to be approved by an approved fitness instructor to ensure that you are getting the proper exercise. Some people pay big money for this. How about weight watchers or Jenny Craig?
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doubledoh, 21 Sep 2006 @ 6:05am

Re: Re: It's not the insurance companies...
How will the technology really be used? These kinds of technologies are adopted more readily by overcrowded hospitals in California or New York, which wants to squeeze ever more patients through while doing ever less for them.

In the countryside, Bobs and Marthas enjoy brand-new spacious hospitals, built by federal money for "under-served areas". Places like California or New York with a desperate need for better health care receive no such money because they are "wealthy states", and spend decades debating over new hospitals that never get built.

All the more reason to leave the government out of it. If the market was unregulated and free, hospitals would be built where they are demanded and the medical companies with the best ideas and technologies would come out on top...and so would its patients.
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doubledoh, 21 Sep 2006 @ 6:10am

Re: Re:
When health care isn't regulated, there are consequences like this one:

http://www.cnn.com/2006/HEALTH/09/20/internet.drugs.ap/index.html

I'm not sure if you noticed, but health care IS regulated and that story STILL HAPPENED.
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doubledoh, 21 Sep 2006 @ 6:19am

Re: Re:
So let me get this straight...you want your health insurance carrier to let you self medicat/heal your self? What happens when you miss-diagnose your self and put yourself into a come because you took the wrong medication, would yourr insurance carrier be on the hook for covering the prolonged hospital costs of having an actual doctor heal you?

First of all, no insurance company (none that expect to be profitable) would allow their policy holders to prescribe their own medicine. So, that straw man has been knocked down. Secondly, before health care regulation in this country (which was only 50 years ago), our healthcare costs were a fraction of what they are today (allowing for inflation) making most procedures affordable WITHOUT insurance. I never understand how people argue that the system will collapse without regulation. We already have historical proof that the system worked BETTER without regulation:

http://www.wnd.com/news/article.asp?ARTICLE_ID=22171
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doubledoh, 21 Sep 2006 @ 6:27am

Re: Re: Re: Re:
There is no distinction. A witch doctor, faith healer, or herb peddler is making fraudulent claims about the effectiveness of their treatment, which is not backed by scientific evidence. If health care should be "deregulated", it means doctors will also be allowed to fool their patients into taking ineffective treatments. Our problem is too little regulation, not too much. The natural health industry sells toxic herbs to consumers, which contain known carcinogens and other toxins; but in the name of "natural health", they are allowed to get away with this.

Man, you're a moron. I love your reasoning: Our system of regulation doesn't work, therefore we need more.

Are you forgetting that people have the freedom to research before buying? When you buy a used car do you just hand over your cash without looking under the hood? If you do, you are practically asking to be ripped off. The smart buyer asks for a VIN printout, looks what they can up on the internet, looks under the hood, etc. The same applies to any product or service. The government can't (or at least shouldn't) hand-hold you through every freaking buying decision in your life.

If you need a mommy to help you through life, fine. Just don't force me to pay for it. I, unlike you, am smart enough to make my own decisions.
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doubledoh, 21 Sep 2006 @ 6:32am

Re: Re: Re: Re: It's not the insurance companies..
I'd trust them a lot more than the California hospitals I have been to. The reality is that lower-class blacks in rural Alabama are receiving free medical treatment at first-rate facilities, while yuppies in Silicon Valley must make appointments with doctors three months in advance to meet their basic needs. Silicon Valley doctors literally turn their backs on patients and ignore their problems -- I have experienced this multiple times. California's news media was full of reports of people dying from minor wounds because emergency rooms were too full. California's doctors and nurses have been moving out of the state in droves, because working conditions and pay are so poor there. California hospitals have taken to flying in temporary health workers from other states and putting them up in hotels for 1 week at a time. Otherwise, they hire Filipino nurses who speak no English and lie about everything.

You just described the consequences of regulation and yet you argue for more regulation in other posts. Classic.
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Patrick Mullen, 21 Sep 2006 @ 7:45am

Interesting post, congrats to Mike for this.

I have yet to read the article, but will, and maybe change my opinion, but since pharmaceutical spending in the US is only 10-12 percent of healthcare spend, not sure how you can fix healthcare by reducing the RX spend.

Prevention is about lifestyle. Americans don't like it when you mess with their lifestyle. Want to improve Americans health, get them to not be overweight or smoke. Take a guess of what End Stage Renal disease costs Medicare today? A high percentage of healthcare dollars are spent in the last few months or years of life. Does that make sense?

The true issue is that we don't have a baseline of healthcare in the US. No one wants to talk about what every American is entitled to in terms of care. Who wants to set that bar? Who wants to tell parents sorry, but their baby just can't receive the treatment that would give them a chance at life because it is too expensive? Who wants to tell someone that their mother will die because the treatment only works 10% of the time? Who wants to tell grandma they will die because the treatment will only extend their life by 2 years?

Healthcare is a very tough issue, has many moving parts and getting everything together is no easy task. How to fix it? That is the multi-trillion dollar question. In todays political environment, I doubt if it can.
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slide23, 21 Sep 2006 @ 8:12am

Re: Re: It's not the insurance companies...
I agree that it is not all in the medical profession and I definitely over-generalized.

And always get warm fuzzies when I see a doctor, before pronouncing his or her edict, refer to a PDA or (increasingly more common but still rare) a workstation in the exam room.
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Len, 21 Sep 2006 @ 8:17am

Health Futures
I certainly don't want my comments to be seen as doctor-bashing -- I was simply trying to demonstrate some of the economic roots for the structure (and outcomes) of the system we have.

What would be really nice is if we could come up with a way to create incentives for successful treatments. No prevention systems will be 100% effective: people will still get sick (or hurt in accidents.) But we need a way to reward the industry for fixing people up, good and proper. We need to structure the system so that it is more profitable to get people OUT of the system than have them in it.

What about some kind of futures contract over your life insurance, so that your health insurance company gets a cut of your life insurance? i.e. the longer you live, the more the payout. You could have two insurance policies - one for your dependents' benefit, and one to reward the health care system for giving you a long and healthy life. The second policy's premiums would be reduced by some amount corresponding the amount spent each year for drugs or other treatments. That way, there would be an incentive to get you off drugs (i.e. cure you) and also to make you live as long as possible. It could be tweaked so that quality of life could be factored in and not just pure longevity (since a drug induced coma should not qualify as a 'healthy' existence.)

I'm not an economist, but there has to be a way to structure something like this. Some kind of "futures" contract over your life and health?
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Len, 21 Sep 2006 @ 8:38am

Re: Health Futures
Okay, I found a report "Economic Incentives for Preventive Care" by the "Agency for Healthcare Research and Quality (AHRQ)" http://www.ahrq.gov/clinic/epcsums/ecincsum.htm
From the report:
The Institute of Medicine's (IOM) recent Quality Chasm report suggests that the U.S. health care system requires major reengineering, including major realignment of incentives, if health care is to provide collaborative quality care and care management and effectively prevent and manage chronic disease. Growing recognition of this need for realignment has led to "pay for quality" initiatives for providers and a parallel search for effective economic interventions for consumer health behavior change. Similar "pay for prevention" initiatives are used to address the gap between the high cost of preventable disease and deaths and the actual practices of health providers and consumers. These initiatives use explicit, or extrinsic, incentives such as bonuses and cash or other in-kind financial incentives for providers and consumers to engage in specific preventive care or health promotion practices. The question is whether such economic incentives are a useful approach.
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ebrke, 21 Sep 2006 @ 8:52am

Re: Re: Re: Re: Re:
And when you are semi-conscious with a heart attack or a stroke or when you are suddenly told that you have an aggressive tumor that must be removed a.s.a.p., you're going to be able to make a rational, comparative assessment of 5 or 6 different medical options, right?
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Anonymous Coward, 21 Sep 2006 @ 10:13am

Here is a question. Why should anyone have to be paid to make health choices? Its their own health. Until people become responsibile for their own lifestyle choices, there will always be a problem.

Some gay factions resisted any talk about protecting themselves from HIV, they insisted on treatement once they have contracted it. Weight loss, you don't need payments from insurance companies to go to a gym to work out, you can go outside and run. People need to realize that their own choices are responsible for a lot of their health issues. No one else is going to do it for them. Maybe personal responsibility is too much to ask.
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Anonymous Coward, 21 Sep 2006 @ 12:22pm

Heartscans? Thats it? Thats going to save healthcare? Another superficial look at a small segment of healthcare. There are many issues, many competing issues. Do we go with the Hillybilly healthcare proposed by Hillary in the 90's? Do we go with the failed HMO models that was supposed to rescue us? Do we go with the private companies that turn healthcare over to consumers? Ha, its all a bad political joke.

The American people don't want a politician to tell the truth about healthcare, because they wouldn't like the answer.

Part of the answer is for people to take personal responsibility for their own health. Smoke and then get cancer, tough. Drink and drive and hurt yourself, too bad, pay for your own care. Eat too much, don't expect your insurance company to pay for your fat ass.

You think its the drug companies fault? Guess what, if Pfizer didn't sell Lipitor, people would still have bad bloodwork. If Viagria wasn't around, men would go without sex (something most posters here would be familiar with.) Perscription drugs don't cause most problems, they just let people live with them. Is it the doctors fault that people don't exercise? Is it the insurance companies fault? I don't think so.

Stop trying to blame the system, or the govt. or whatever, France has its own system, and all their people smoke. Its all about personal responsibility. My father died of lung cancer. Funny thing was, after his first operation and treatement, he went back to smoking cigars. People suck, and there is just no way to change that.
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