Is preventive care worth the cost?

by on May 24, 2017 at 2:46 am in Data Source, Economics, Medicine | Permalink

And here is yet another paper suggesting that medical care, or at least some forms of it, has relatively low marginal value.  The subtitle of this one is “Evidence from Mandatory Checkups in Japan” and the authors are Toshiaki Iizuka, Katsuhiko Nishiyama, Brian Chen, and Karen Eggleston.  Here is the abstract:

Using unique individual-level panel data, we investigate whether preventive medical care triggered by health checkups is worth the cost. We exploit the fact that biomarkers just below and above a threshold may be viewed as random. We find that people respond to health signals and increase physician visits. However, we find no evidence that additional care is cost effective. For the “borderline type” (“pre-diabetes”) threshold for diabetes, medical care utilization increases but neither physical measures nor predicted risks of mortality or serious complications improve. For efficient use of medical resources, cost effectiveness of preventive care must be carefully examined.

Here is the NBER link.

1 V May 24, 2017 at 3:27 am

The other (somewhat) related finding from claims data that health care payors often see is that specialists are significantly underpaid in terms of the value delivered to patient (or system) while primary care practitioners are significantly overpaid. A couple of the potential factors behind this (very) counter-intuitive finding are:
1) Interventions (especially curative ones like resection of a colon polyp) and definitive diagnoses (e.g., like many of those made by radiologists / pathologists / etc.) are unambiguously high-value.

Most of the work done by PCPs in contrast is not of clear-cut value (e.g. bureaucratic chart history-taking, provision of simple antibiotics (or Rxs) for conditions that a pharmacist sells medicine for in many 3rd world countries, referral to a specialist who in essence has to re-do most things anyway, etc.)

2) Specialists are paid higher than in other nations in the US but in turn have much higher productivity, negating much of the incremental labor costs.

2 P May 24, 2017 at 3:43 am

Generalists triage patients to prevent unnecessary presentation to specialists. If every patient with a headache was directed to a neurologist the overall cost would be significantly higher.

3 Hutchins May 24, 2017 at 4:00 am

That is true, but that doesnt mean they arent overpaid. The world would burn without plumbers, but they would still be overpaid if paid a million a year

4 P May 24, 2017 at 8:05 am

Fair enough, but how do you quantify the money saved by not going down the path of unnecessary investigation + the cost of investigating and managing incidentalomas?

5 Boonton May 24, 2017 at 8:54 am

In a given year 7.4 per 100,000 women will die of ovarian cancer. So imagine a network of both primary care and specialist doctors that worked something like this:

Your salary is $100,000 per year, however there are 100,000 women in this network. If there are no deaths from ovarian cancer, your salary will be $175,000. If there are 10 deaths it will be $90,000. Between the primary care and specialist doctors you now have a powerful incentive to catch ovarian cases early and get them treated effectively so as to lower the deaths as much as possible. Clearly if the primary care doctors waste the time of the specialists by sending them every case of a woman with a stomach ache ‘just to make sure’ it would be counter productive but if they worked together to figure out the best way to bring in the specialist or get the specialist to educate the primary care doctor on what to look for more effectively you could achieve a lot of value for less cost.

Needless to say some complications here are:

1. How do you construct this incentive schedule given there’s thousands of conditions?
2. How do you avoid ‘gaming the pool’? (For example, if the 100,000 women in the network are younger than average, they will naturally have fewer cases so if you advertise the coverage to younger women to get more signups you can achieve the bonus without doing anything of value).
3. People will want freedom to see any doctor they want so will they accept staying inside a network of doctors that sometimes opts not to do extra screening or tests or specialist visits? I don’t think this need be a huge problem, if people go outside the network and get additional consults they can always bring that data into the network but then the compensation model gets more complicated. If 10 women suspect something is wrong, get a specialist/diagnostic consult outside the network and then bring the diagnosis into the network the docs in network will get the bonus for an ‘early detection’ when in fact they frustrated it.

Given these challenges, though, I think a model can develop that overcomes them and boosts incentives for producing better health outcomes rather than simply covering services billed.

6 David Manheim May 24, 2017 at 5:27 pm

The model Boonton suggests sounds more than a little bit like Kaiser’s model. The incentive is to manage long-term costs, not minimize sickness – but these are fairly well aligned, at least as compared to incentives in the rest of health care. (It works fairly well.)

7 bellisaurius May 24, 2017 at 8:14 am

So, then the question could become (is becoming?) whether you need a fully qualified doctor as the gatekeeper when a nurse or PA would suffice.

Then again, how big a chunk of medical costs is primary care. I suspect it’s small percentage wise

8 Cyrus May 24, 2017 at 9:48 am

The data Kaiser has published says that PAs and NPs order more consults and imaging studies relative to family practitioners. There’s cost savings in using mid level providers where diagnosis is known and it’s a matter of treatment per protocol, but physician training in history and examination is worth something when it comes to making a diagnosis.

9 John Smith May 24, 2017 at 2:28 pm

Is the data normalized for age? I would expect PAs and NPs to be *much* younger, on average.

10 Normal May 25, 2017 at 8:20 am

…There’s cost savings in using mid level providers…

Cost savings to whom??? Consumers pay the same whether they see a PA, NP or MD – the CPT codes are the same. MD’s make almost twice the salary so the differential is going somewhere and it’s not in my pocket.

This is one example of how gamed and opaque the medical payments system is and why consumers can not shop for medical services.

11 Boonton May 24, 2017 at 1:51 pm

I suspect this is an artifact of the billing model being employed. A patient presents with something, the doctor orders a ‘scan’ to be safe. This behavior is said to cost a lot because lots of ‘scans’ end up saying nothing is wrong or produce false positives but the owner of the ‘scanner’ charges as much as possible for each scan.

But what is the true marginal cost? If the office happens to own a scanner and running the scan doesn’t require much materials then doing lots of scans doesn’t really add much to costs and could avert diseases earlier.

12 Moo cow May 24, 2017 at 2:38 pm

I just had a CT scan sinus no contrast. $553. Took 4 minutes. Checked in at a kiosk. The imaging tech got me from the waiting area. If I wanted this to count towards my deductible I had 2 choices of where to go.

The machine looked older. What was the actual cost of this 4 minute procedure? Can someone do it for $100?

13 Hazel Meade May 24, 2017 at 10:04 am

Right, but what the generalist typically do tends to be kind of rudimentary. I suspect that PCP miss a LOT of stuff because the well-visits are largely prefunctory.

14 Hoonose May 24, 2017 at 12:16 pm

Starting in the early ’80’s our general HC systems began to move from primary to specialist care. And if you look at our overall HC expenses, this is where our HC spending curve left the rest of the world.

https://static01.nyt.com/images/2009/07/09/business/econgraphic3.jpg

One major cost problem today is that too many patients remain in the domain of multiple specialists. Many would do just as well with the primary doc, along with an occasional visit/referral to the specialist. The specialists are more costly, and of course for some the specialists are mandatory. But for many there is little added benefit.

15 Mark Thorson May 24, 2017 at 1:22 pm

I completely agree. When I feared I was having a stroke, I went to the ER and was seen by three or four generalist doctors over several hours, got a CT scan, and then finally saw a neurologist the following morning. The neurologist right away determined I had a pinched nerve in my elbow. If I’d seen him first, a huge amount of expense, heavy X-ray exposure, and a very unpleasant overnight stay could have been avoided. I think a big part of the high cost of medicine is wasted, unnecessary services.

Maybe there wasn’t any neurologist available when I showed up in the evening. (This was at what is probably the largest hospital in Silicon Valley.) Maybe telemedicine can solve this problem. If there was a neurologist on duty elsewhere that could have quickly made the correct diagnosis, an enormous expense coulod have been saved. I suspect, however, there is zero incentive to do this. The hospital would have had those doctors on staff anyway, and they’d already bought the CT machine, so there’s no incentive not to use them.

16 sort_of_knowledgable May 24, 2017 at 4:08 pm

Are you sure the neurologist made the diagnosis without without looking at previous case notes and already ruled out other possibilities due to the CT scan? Even knowing that you stayed overnight and your condition didn’t change noticeably is a clue.

17 ermd May 24, 2017 at 7:32 pm

+1
hindsite is perfect
initial presentation, undifferentiated symptom equally difficult for specialist as for generalist

18 carlospln May 24, 2017 at 3:28 am

Here’s your preventative care Rx: take responsibility for your own health, eat wisely, keep the weight off and get off your ass-every day.

That’ll be fifty million dollars.

19 Hazel Meade May 24, 2017 at 10:19 am

I agree. However, it might help if the doctor could tell you at the well visit – “your blood glucose levels are such and such, if you don’t get off your ass you have a 50% likelihood of having diabetes in 5 years. ”
The problem is they just don’t do enough serious testing via well visits to provide that kind of information. (At least not from what I have seen).
GPs generally wait for people to come to them with symptoms. They don’t actually look for problems unless you are complaining about something.

20 Mark Thorson May 24, 2017 at 3:09 pm

Yes, you can’t feel blood glucose so it has to be measured. Same thing with blood pressure. You can get home test meters for both of these, though a fairly large subset of the population will not be able to use these meters correctly.

21 carlospln May 24, 2017 at 5:33 pm

“You can get home test meters for both of these, though a fairly large subset of the population will not be able to use these meters correctly”.

That’s what Elizabeth Holmes says, Mark. 😉

22 Harun May 26, 2017 at 1:41 am

Actually, you can feel high blood pressure a little. And high glucose. (You’ll feel funny.)

But its not that easy if you don’t know what it is. You have to had those for a while to realize what it is.

Blood pressure is dead simple to measure with current battery powered meters.

23 Normal May 25, 2017 at 8:26 am

Newsflash – you’re not in control of your health. You can lower the probability of some diseases by diet and exercise but many more are totally unpredictable.

24 JonFraz May 26, 2017 at 1:37 pm

You offer good advice, but it does nothing to prevent the single most significant factor in bad health: aging. Health Calvinism is in denial about one brutal reality: Unless we are “lucky” enough to die by sudden trauma before we get old, we will all suffer gradual decline and run up big bills before the end.

25 prior_test2 May 24, 2017 at 5:49 am

‘And here is yet another paper suggesting that medical care, or at least some forms of it, has relatively low marginal value.’

And here is a paper showing just how high the marginal value of medical care can be, at least compared to mortality rate – http://thelancet.com/journals/lancet/article/PIIS0140-6736%2817%2930818-8/fulltext

‘whether preventive medical care triggered by health checkups is worth the cost’

Oddly, the one area where the U.S. is a positive standout in global comparisons concerns cancer mortality. And probably the largest single factor in that (in complex ways, admittedly) is a major effort to screen for cancer. You know, ‘health check ups.’

‘However, we find no evidence that additional care is cost effective’

Which would seem to be contradicted if one where to look at cancer, and not diabetes, especially in the case of the U.S.

26 rayward May 24, 2017 at 6:25 am

The “survival” rate for cancer patients is measured from the date of detection/diagnosis, not from the date the patient likely got the disease. In the US, with “preventive” care and the preponderance of “screening” (i.e., diagnostic procedures), early detection/diagnosis is what produces the higher “survival” rate. Cancer patients don’t actually live longer, rather they live longer knowing they have the disease. Of course, the higher “survival” rate encourages people to get “screening” (i.e., diagnostics), such as for prostate cancer. Studies have shown that, on the whole, men with prostate cancer would be better off never having received the diagnosis. On the other hand, studies have shown that men with colon cancer have a much better chance of survival with early detection, which usually means by a colonoscopy, an invasive procedure most people avoid. The protocol is for people over age 50 to have regular (every five years) colonoscopies, especially if they have a history of cancer in the family. The fallacy with the protocol is that colon cancers, once developed, spread rapidly; hence, it’s simply a crap shoot whether a “regular” colonoscopy will detect the cancer in time to make a difference in “survival”.

27 M. Klaus May 24, 2017 at 6:38 am

The American trial on prostate cancer failed to show any mortality benefit, because there was a lot of screening going on in the control group…

28 The Original CC May 24, 2017 at 7:02 am

“colon cancers, once developed, spread rapidly; hence, it’s simply a crap shoot…”

I see what you did there.

29 prior_test2 May 24, 2017 at 7:24 am

‘The “survival” rate for cancer patients is measured from the date of detection/diagnosis’

That is part of the ‘(in complex ways, admittedly)’ aspect.

‘Cancer patients don’t actually live longer, rather they live longer knowing they have the disease’

There is demonstrably not true with breast cancer, to give one concrete example.

‘such as for prostate cancer’

And yes, prostate cancer, especially as it is often benign, and often occurs in men near the end of their life, is an excellent example of where screening (for those above a certain age) brings no benefit.

As I wrote, it is complex.

30 ZippyTheWonderSloth May 26, 2017 at 12:06 pm

Anecdotal only, but screening at 46 found aggressive prostate cancer (non-symptomatic) in me. Being a scientist, I did follow the initial blood test with another 3 months later and had a 40% increase in PSA. The biopsy then followed a weeks later. So I am a proponent of PSA screening for even guys in their early 40’s and charting changes over time if the PSA is 80%+ of the age adjusted statistics (2.5ng/ml for men of my age).

31 dan1111 May 24, 2017 at 7:11 am

You are correct that this is a significant problem for comparing survival rates, you overstate the case.

Early detection significantly improves the prognosis for some types of cancer.

32 JonFraz May 26, 2017 at 1:43 pm

Largely true for cancers that metastize, but not immediately after they develop.

33 Thanatos Savehn May 24, 2017 at 10:00 am

This paper is at best an exploratory data dredging exercise; throwing every country from Rwanda to USA into the bucket and comparing every definition of access, simple measles vaccination to bleeding edge cancer care, along the way. However, the 696 authors/contributors give away the game when they start talking about epidemiological transitions. When you come to a world’s worth of health correlations while clinging to the serially refuted cornerstone of modern public health activism (we’re in the third epi transition and obs epi proves it), confirmation bias guarantees the interpretations they draw from the exercise.

34 prior_test2 May 24, 2017 at 11:02 am

Actually, the main point of the paper was to attempt to quantify how various health care systems were performing within a framework measured on the one hand by mortality data, and the other by their economic data, and attempting to determine what lessons could be learned. Unsurprisingly, some countries perform well within that framework, and others don’t. What is noticeable is the improvement in life span relative to improved medical care, at a fundamental level that disputes the essential premise that Prof. Cowen attempts to defend with his cite.

35 Thanatos Savehn May 24, 2017 at 12:00 pm

Actually it’s an attempt to map the ill-/un-defined “mortality amenable to healthcare” to the equally ill-/un-defined “healthcare access” and produces an overall correlation that looks like any SES/mortality correlation. Thus the old question: “Do poor folk tend to have high mortality rates because they are poor (and thus are presumably denied the blessings of medical science), or do poor ways (i.e. defective risk/benefit decision-making) tend to produce poor folk with high mortality rates?”

In any event, I enjoyed the paper if only because the irony of listing peptic ulcer as a “mortality amenable to healthcare” and H. pylori eradication as a potentially available healthcare was deliciously lost on these public health advocates marinated in “The Third Epidemiologic Transition”.

36 prior_test2 May 24, 2017 at 12:14 pm

Yep, while attempting to use the best data possible.

‘“Do poor folk tend to have high mortality rates because they are poor (and thus are presumably denied the blessings of medical science), or do poor ways (i.e. defective risk/benefit decision-making) tend to produce poor folk with high mortality rates?”’

Oddly, the paper also attempts to see how that changes, both through policy and with economic growth.

‘if only because the irony of listing peptic ulcer as a “mortality amenable to healthcare”’

These authors seem to disagree with you, though they also point out aging matters (that’s right, a society with more people living longer will have more people dying from ulcers regardless) as the main point of the research. ‘The incidence of complicated peptic ulcer disease (PUD), including perforated and bleeding peptic ulcer, increases with advanced age [1, 2]. This increase has been attributed to the high frequency of risk factors for PUD among elderly patients, e.g., Helicobacter pylori colonization or use of non-steroidal anti-inflammatory drugs (NSAIDs).

Perforated peptic ulcer is a serious condition with an overall reported mortality of 5%–25%, rising to as high as 50% with age [4–6]. Being closely related to advanced age, increased burden of comorbidity may partially explain the higher mortality among elderly patients. Nevertheless, virtually no data exist on the influence of comorbidity on age-related increase in mortality of perforated peptic ulcer.

Despite improvements in the last decades, in monitoring and treatment, bleeding peptic ulcer carries an unchanged short-term mortality approaching 10% [7, 8]. Previous studies reported a higher short-term mortality from acute upper gastrointestinal bleeding including – but not confined to – bleeding peptic ulcer, among elderly compared with younger patients [9–11]. Again, no study has examined whether this association between age and mortality is related to increased burden of comorbidity in elderly patients.’ https://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-7-8

37 Thanatos Savehn May 24, 2017 at 1:52 pm

You missed the point. Peptic ulcer was considered a (and perhaps the) classic third (or second depending on how you count them) epidemiological transition disease until the discovery of H. pylori up-ended both the disease’s treatment and the prevailing public health paradigm (that disease mortality was mainly man-made – chemicals, stresses unique to modernity, factory food, EMFs, etc. – and thus preventable by man).

38 Hunter S. Thompson May 24, 2017 at 3:33 pm

It was dark inside and at the back of the room three girls were sitting at a table with an old woman. Across from us, at another table, sat a sailor. He sat there neither eating nor drinking. Further back, a young man in a blue suit was writing at a table. He was very smartly dressed and clean-cut looking.

As someone who’s had ulcers, I believe them to be caused more by stress, drinking, smoking, than any bacteria. In-fact, an ulcer can be a good thing, like an anti-biotic for the system that creates a defense mechanism.

Like the Fata Morgana. Yes, that was the reason — some wild and elegant hallucination in the sky.

39 Blaise May 24, 2017 at 5:57 am

“However, we find no evidence that additional care is cost effective.” This finding is true for patients around the threshold (and for a particular disease in a particular country). One explanation could be that the threshold should be adjusted as too many patients who don’t need care receive it now. It doesn’t mean that an extra health check has low marginal value.

40 Jonathan May 24, 2017 at 9:04 am

Fair enough. What it means is that the combination of health checks and too-low (or too-high… either is a logical possibility, although I’d bet on too-low as well) thresholds for treatment is of low value. But just try getting thresholds raised… the outcry is loud and instant. Everyone with a financial stake in the system — doctors, pharma, labs, profit from low thresholds. And patients demand it because they want to do something.

41 Blaise May 24, 2017 at 10:39 am

I’m not sure people really push for more interventions. Personally, I try to avoid medicines and interventions as much as I can as I’m worried by negative effects of medicines. In the country like the UK that has a very rationalized health system (for better or worst), my experience was that doctors easily take a non-interventionist approach when the threat is low. That makes their system very efficient as I think they get rid off a lot of non-necessary interventions.My gut feeling is that reducing intensity of health care is probably cost-effective in a lot of cases (and this is what this paper shows). But increasing coverage is different and an extra health check might still be very valuable if the extra person checked is on average not in good health (this is not what this paper is looking at).

42 dearieme May 24, 2017 at 6:29 am

“Is preventive care worth the cost?”

The literature is, I think pretty clear: the annual check-up beloved of USians is probably useless and certainly too expensive for any good it does. You may say that all USian medical care is too expensive, but the conclusion holds for countries with cheaper medical care too. It appears that we can now add Japan to the list of countries where it has been shown to be true.

To persuade thickos of this truth perhaps one should first explain to them the notion of Opportunity Cost.

43 Hoonose May 24, 2017 at 12:46 pm

You need to first narrow things down based on medical risk management. General checkups are simply not needed until about the age of 50+. Females get gyne and breast exams. And of course with other personal or family HC risks, checkups and/or testing can make sense. But for most patients annual physicals are not necessary or even recommended.

For the young with no obvious HC risk, you about only need a BP and cholesterol check maybe at age 20 and then every 10 years or so.

44 JonFraz May 26, 2017 at 1:45 pm

Annual checkups are not particularly expensive. In fact, compared to many other healthcare procedures they are mere chump change.

45 Lee A. Arnold May 24, 2017 at 6:52 am

Do the economists measure BEYOND the specific episodes of treatment, to the cost reduction of patient stress and stress’s related medical conditions, to the reduction of lifetime opportunity costs in various other life pursuits, to the increase in productive capability of the older worker if treated at a younger age (discounting for macro realities of course), & to the reduction of possible future social spending to take care of the needs of sick people when older?

It is likely that measuring the above things would take many years. But we might at least make an attempt at holistic thinking at the end of each paper, and note here that preventative care may be very cost effective indeed,– or at least note that, in this case, the concern for “marginal cost effectiveness of preventive care” imposes a very limited analytical purview. Perhaps also, it is the fallacy of misplaced concreteness. I realize that no one takes economics seriously anymore, but this sort of thing doesn’t doesn’t make it easier. It is also fodder for the political clowns who want to cut aid to the poor.

46 The Engineer May 24, 2017 at 8:19 am

I love this topic, because it is so indicative of the problems of modern society: unconfirmed assertions and the power of narrative.

The benefits of preventative medicine and the annual checkup are just something that people assume. It is what I call a “unconfirmed assertion”, a talking point that sounds good to most people, even ostensibly informed people. These unconfirmed assertions are so strong that we go so far as to build public policy on top of it.

Ultimately, unconfirmed assertions build narratives, and it is these narratives that as so difficult to fight. Narratives are modern day mythology. They jack into the same evolutionary pathways (talk about an unconfirmed assertion!) that mythology did for our ancestors.

47 mulp May 24, 2017 at 10:49 am

Care to make the case that “checkup nations” like the West, and “checkup classes”, like the higher educated and incomes, are not healthier than nations in Africa with no checkups, or the US poor who can never get a checkup?

Or as an engineer, care to argue that planes and vehicles should never be checked up regularly? How often to checkups of planes and vehicles find problems?

48 bruce May 24, 2017 at 12:32 pm

‘care to argue that planes and vehicles should never be checked up regularly? How often to checkups of planes and vehicles find problems?’
“Well, I’ve finished your checkup and I noticed your heart is making a funny sound. Would you like a new heart? Just step over to this table and the mechanic can slap one in. You should be out of here after lunch. I’m afraid new hearts are expensive. Can we put the whole $5000 on your credit card?”

49 Thanatos Savehn May 24, 2017 at 12:30 pm

And aphorisms like “an ounce of prevention is worth a pound of cure” drive the most powerful narratives.

Confusing correlation with causation lies at the heart of the belief that cancer caught early is more likely curable. Anyone diagnosed with cancer or with a loved one so diagnosed quickly learns about staging and from what they read immediately infer that it’s better to be stage I than stage IV; and from there it’s an easy leap to “it’s better to catch it at stage I than stage IV”. The problem of course is that very few people pause to ponder the question “why do some people go to a doctor when it’s at stage I while others don’t have sufficient symptoms until stage IV?” If they did they might conclude that there are within-category differences among the cancers and that those differences might impact treatment response. Once the hypothesis that follows was tested it began to appear that the reason for the wide variance in survival rates was driven by the fact that some types of cancer are just a bullet with your name on it and early detection only benefits Big Healthcare.

50 Hoonose May 24, 2017 at 12:59 pm

Preventive medicine and annual checkups are not the same. Annual checkups are not needed for most people. Over 50 maybe, over 65 they become more useful. But some preventatives are very useful. Colonoscopies at age 50 for most everyone, younger with a family history of colon cancer. Female gyne and mammograms. Mammos typically starting at age 40, younger with a family history of breast cancer. Men prostate checks/PSA starting age 50 until around 80. Younger with family history. For other people aside from an occasional BP and cholesterol check, there is about nothing else useful to do. Except when there is more obvious medical risk.

51 prior_test2 May 24, 2017 at 9:11 am

‘The benefits of preventative medicine and the annual checkup are just something that people assume.’

Not to mention conflate.

52 Todd K May 24, 2017 at 9:34 am

35% of Americans are obese compared to 3% of Japanese. That might affect how useful Japanese check ups are.

53 A Definite Beta Guy May 24, 2017 at 9:50 am

Probably not a big factor: this pool looks at only borderline pre-diabetic.

54 dearieme May 24, 2017 at 9:57 am

Some years ago I asked my GP how I could stop being pre-diabetic. He said “Cross the Atlantic: their threshold is higher in the US”. It’s an odd disease, eh?

55 Hoonose May 24, 2017 at 1:06 pm

Keep your weight down.

56 Harun May 26, 2017 at 1:44 am

Also helps with gout.

57 TMC May 24, 2017 at 8:58 pm

Just like all those warnings I see about how everything causes cancer in California. Stay the hell out of California!

58 prior_test2 May 24, 2017 at 11:05 am

‘this pool looks at only borderline pre-diabetic.’

Leaving aside that whole obesity diabetes link – https://www.ncbi.nlm.nih.gov/pubmed/16311223

‘The relationship between obesity and diabetes is of such interdependence that the term ‘diabesity’ has been coined. The passage from obesity to diabetes is made by a progressive defect in insulin secretion coupled with a progressive rise in insulin resistance. Both insulin resistance and defective insulin secretion appear very prematurely in obese patients, and both worsen similarly towards diabetes. Thus, the classic ‘hyperbolic relationship’ between insulin resistance and insulin secretion and the ‘glucose allostasis concept’ remain prevailing concepts in this particular field of knowledge. An increase in overall fatness, preferentially of visceral as well as ectopic fat depots, is specifically associated with insulin resistance. The accumulation of intramyocellular lipids may be due to reduced lipid oxidation capacity. The ability to lose weight is related to the capacity to oxidize fat. Thus, a relative defect in fat oxidation capacity is responsible for energy economy and hampered weight loss.’

59 Hazel Meade May 24, 2017 at 10:02 am

I don’t doubt that today’s current form of preventive care is not very effective. A typical well visit just consists of the GP checking a few basic life signs like blood pressure and heart rate and asking some basic questions.

I’m not sure that some more thorough regular testing wouldn’t be helpful though. What if every checkup included an extensive questionaire covering a wide range of subtle symptoms, along with extensive blood and urine testing? Nothing invasive, obviously – we don’t want people getting biopsies as a matter of routine. But a blood draw with a wide panel of tests to look for subtle signs of disease shouldn’t be impossible to do.

If this sounds expensive, it is probably because the medical industry doesn’t have the price incentives necessary to come up with an all-in-one test package. Like the situation with 23-and-me, where it is technically feasible to test for every known genetic risk factor at once, the medical industry is incentivized to split up testing into many individual tests for individual things and charge for each one separately, and this is supported by how the FDA regulates the industry.

60 Hazel Meade May 24, 2017 at 10:14 am

I’d also add that it is probably feasible to make this very efficient and accurate using machine learning classification algorithms. One could train a classifier on a large dataset of symptoms, diseases and blood test results, to pick out evidence of combinations of symptoms and test results that indicate a disease, so the computer does most of the work of screening complex symptoms and only flags issues that have a likelihood above some threshold to the physician for further investigation. You could have a nearly entirely automated system checking a large amount of data from each patient instead of these stupid routine prefunctory visits, in other words.

61 Amigo May 24, 2017 at 3:59 pm

It sounds like what you describe could mostly be done on a website. Let the website order labs if needed.

62 Brian P. Moore May 24, 2017 at 10:34 am

The idea that “preventative care is not cost-effective” (whether true or not) is a fundamentally different one than “is pre-diabetic/diabetes care effective (or cost-effective).” The study is answering the second question, NOT the first.

We must always be careful when looking at these kinds of studies to see *what* exact condition they are attempting to treat. If it is diabetes (or obesity), then you have to realize that modern methods for treating it are largely useless (if not actively harmful) and also expensive. Do not extrapolate to other conditions.

This study is equivalent to one saying:

“However, we find no evidence that additional care is cost effective. The patients’ imbalance in bodily humors was successfully adjusted, but neither physical measures nor predicted risks of mortality or serious complications improve. For efficient use of medical resources, cost effectiveness of preventive care must be carefully examined.”

63 Daniel Weber May 24, 2017 at 11:18 am

Given how expensive a lifetime of diabeetus is, and how it can be prevented upfront, it seems that the people who want the free lunch of “just spend money on prevention” would have a much easier time showing it’s justified for diabeetus than nearly anything else.

64 Hoonose May 24, 2017 at 1:10 pm

Diabetes, excess body weight, increased HC spending are all related. Our largest HC spending group, could be trimmed down by trimming down. Simple to say, hard to do. When we finally get either a pill or a genetic alteration to effectively combat obesity, our overall HC costs will drop significantly.

65 Todd K May 24, 2017 at 9:22 pm

Yep, and that day is much sooner than most think. By the way, have I mentioned NR?

66 mulp May 24, 2017 at 10:35 am

I will believe such studies only when they compare medical care and outcomes in Africa with care and outcomes in Japan, Europe.

Or compare US bottom 20% by income in non-Medicaid expansion States with Japan or Europe’s bottom 20% by income.

67 PCB May 24, 2017 at 11:51 am

I truly enjoy reading this form Tyler, but I have a problem with the length
of so much of the information and comments. Old school I guess, but after
15 or so words, my attention (and retention) goes to pot. Is there some
way I can load the pages with shorter sentences? Thank you.

68 mavery May 24, 2017 at 12:17 pm

The difficult truth about most things related to medicine is that answers to questions like the one posited in this post (“Is preventative care worth the cost?”) have no unambiguous or clear answer if you ask them globally but unambiguous and contradictory answers is you ask them about specific conditions/treatments and specific subpopulations. Posters above have already mentioned a few specific cases (prostate cancer in older men being a great example) where “preventative” methods are useless. At the same time, there are plenty of other examples where individuals with many risk factors will clearly benefit from early screenings.

So the real answer to the question posed is, “Sometimes, depending on who you’re talking about and what preventative procedures you’re talking about,” which for most people is equivalent to ¯\_(ツ)_/¯.

69 anon May 24, 2017 at 3:00 pm

I dislike it that quality of life is ignored in this discussion. The goal of medical treatment is not simply to keep people alive.

70 efim polenov May 25, 2017 at 1:03 am

Thanks, anon, for saying the obvious. There are few greater pleasures in life than one-on-one conversation with someone several standard deviations smarter than oneself. Seriously. Those of us who are for the foreseeable future denied such pleasures (for obvious reasons I am not going to state explicitly why I have been one of those people since, oh, 1965 or so) should still treasure the fact that we live in a world where many people who otherwise would not experience that pleasure for years and years on end are allowed, for free or for very little money, to, well, experience that pleasure one or more times every single year with “preventive medicine doctors”…my doctor, for example, graduated summa cum laude from the best university in the state where one of my favorite poets was born – (pine trees in quantities just trivially less than infinity, deep blue skies over barbecue picnics where someone brave and loving is always absent, always, sad word, isn’t it, sometimes, always?…but spectacular weeks of flowers on the trees in spring and followed half a year later by subdued modestly humble sine-wave post-autumnally pastoral not damp not dry grassy evenings – well, at least to the extent that a few trees in some back yard someone worked years to afford, with a barn somewhere a mile or two off at most, if one is lucky, can be pastoral – rhythms announcing the subdued – that word again – but intense and clear night lights of red green blue orange and even yellow little lovable lights with which Christmas is celebrated by those of us who still remember the first time we saw Christmas lights – good God that was wonderful) – humility (we are back to the ‘preventive medicine’ doctor) as measured by the fact that she even took classes like organic chemistry and linear algebra. Even I enjoy the slightly prole but unmistakably brilliant persona she chooses to project during her professional hours – I can only imagine her effect on, well, those who do not often get to talk to anyone remotely as ‘smart’ as her. Please substitute more accurate words for ‘smart’, the way you would substitute a better rhythm for what you are thinking about, sad thick difficult years later, when you remember the hours you spent listening to the breakers at the beach, in the second slow week of your honeymoon: a better rhythm than the rhythm you would articulate on a blank page with staff notation, even given a very comfortable (not cozy, no, that is not the word for how happy we were) fountain pen. (There are hundreds of thousands of miles of ocean coastline in this world: New Jersey, Long Island, California, and above all Virginia are the ones I picture and remember hearing the sad slow breakers at…almost nobody else would mention those four first, but some other four, or so, and that is in its way more interesting than any given precise articulation I could recount of recreational prime number patterns I have noted down, as much as I am fond of them…sadness does not necessarily last, no matter how wide and deep any given sad ocean in any given century might be -not that I will live to anywhere near a hundred, thank God ….de die in diem salutare eius….almost the collect for the fifth Sunday of Easter, by the way)

71 Glenn May 25, 2017 at 3:48 pm

Assumption: Out of pocket healthcare expenses are a greater burden to more Americans that they are to Japanese and nearly every other nationality. Hence, more Americans (than Japanese and nearly every other nationality) choose NOT to spend the money for preventative care, and other healthcare expenses that are not for urgent care or emergencies. Therefore, a larger share of Americans are relatively unhealthy (and underserved by an otherwise excellent healthcare system) as compared to Japanese and nearly every other nationality.
Assertion: it would be a mistake to think this Japanese study and similar ones of nearly every other nation are applicable to Americans.
Belief: A great many more Americans could/would receive outsized benefits from preventive care than Japanese and nearly every other nationality.

72 JonFraz May 26, 2017 at 1:47 pm

Because specialists are paid more than PCPs there’s a strong incentive for medical students to specialize. The supposed “overpayment” to PCPs may just be a market effect: the supply of such doctors (who are essential entry points to the system) is limited causing their salaries to increase. Remember, productivity does not determine pay scales (across large groups); supply and demand do.

73 Moishe Pipik May 26, 2017 at 4:52 pm

There’s one “preventative care” treatment that’s widely recommended by doctors, costs nothing, and results in tremendous health benefits — not being obese or overweight.

Sadly, 2/3rds of Americans can’t manage not to overstuff their pie holes. Until we can address this “elephant in the room” any other talk about preventative medicine is useless.

(Idea: no public funds for healthcare for the obese or overweight.)

74 Mike M May 26, 2017 at 5:10 pm

Did ANYONE (including Tyler) commenting actually read the full paper?

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