Medicare Will Pay $50k for Your Heart Attack. It Should Pay $100 to Prevent It
medpagetoday.com
medpagetoday.com
Coronary calcium scans quantify calcified atherosclerotic plaque but cannot reliably distinguish stable plaques from rupture-prone plaques or detect noncalcified plaques, some of which may be particularly vulnerable.
https://www.ahajournals.org/doi/pdf/10.1161/JAHA.118.008564
https://www.jacc.org/doi/10.1016/j.jcmg.2017.03.005
https://www.atherosclerosis-journal.com/article/S0021-9150(1...
In May, they told me on ultrasound that my dilated aortic root has grown by more than 2 mm in the last year and that if the progression does not stop, an operation will sooner or later be necessary.
I got a referral to magnetic resonance and had to wait for it until October. Was there last week, nervous. Today I got the result: compared to the MR from 2021, there is no progression at all. The same 44 mm as then. The ultrasound was just not as precisely done, or the doctor measured it slightly askew or what.
Ooof.
This was at IKEM in Prague, one of the best cardio units around, so I trust their judgment.
In the messy real world of medicine there are hardly any definitive screening tests or imaging studies. Everything will have some false positives and false negatives, or even if the output is physiologically accurate it may not be practically useful in improving patient outcomes. For screening tests we also have to weigh the costs versus benefits in terms of the number of procedures performed or dollars spent to save a life; if the numbers are too high then those scarce resources should be expended on other healthcare services.
For broad screening coverage by most health plans the key next step is an evaluation by the U.S. Preventive Services Task Force. This process is already underway but it takes a while for them to evaluate all the evidence and make a decision. For Medicare coverage there is a separate coverage determination process.
We're willing to spend god knows what shooting rounds that cost entire mortgages to save miltary lives and project a presence of power to deter acts of terror/war, but then are also totally fine having people way as much as 4 or 5 people, eating several days worth of sugar for breakfast, smoking tobacco, putting 3 cups of coffee in a can we drink 4 or five of in a day, do next to nothing to adress recidivism of all classes of criminal, drag our feet kicking and screaming in to a semblance of modernity in worker protections...
When the underlying economic model of CONSUMPTION = GOOD is viewed as a religion or universal law of nature, it's actually not surprising that people are irrational about this.
This may be partially due to the many all-or-nothing crusaders who would prefer to use force in their quest for full protection of the citizen. Many people overcorrect because they fear that even voluntary programs are steps in this direction. Trust is low.
We have a long and sordid history with extreme and failed prevention (prohibition, the Mann Act, war on drugs).
The policies just follow that. This comes up in all sorts of areas such as prison as punishment vs rehabilitation.
They literally wanted to kill northerners for daring to make them equal to black people.
Still do.
Not to mention how often people misinterpret a survey and add their own bias to the results.
And yes, don't underestimate how such maneuvers are very indirect means of white flight. African Americans could only (legally) own a home in much of the US for 50 years. At the very best, that is 2 generations of wealth to accrue, which puts that demographic a good century behind what potentially could have been economically.
So 58/59 years if we want an exact date. But a law passed de jure doesn't mean everyone throws their hands up and willingly complies, so the sand will still be shakey for a good decade.
Of course, YMMV per state, so it's not like the Midwest or west coast had the same level of discrimination as the deep south. But that's the line that this policy became federal.
Notwithstanding that they were examples of extra-legal discrimination (in the sense of not being direct legal prohibitions), racial covenants and red lining also didn't just effect black Americans, though nationwide they were disproportionately impacted. I only point that out because most people would say it was incongruous to claim Jews or Polish or Asians were legally prohibited from owning land in many areas.
I think it's an important distinction because there are vestiges of redlining that persist today. First time homeowner mortgage subsidies, the first major stepping stone for building wealth for most people, effectively exclude many kinds of multiunit housing, such as condos and, IIRC until recently, attached housing like duplexes. This disproportionately impacts prospective urban black homeowners, and quite deliberately. Likewise, IIUC prefabbed homes or similar are excluded, which disproportionately impacts poor rural whites and blacks alike. There are legitimate concerns behind those restrictions, such as developer and rental fraud, just as nominally there were legitimate concerns behind redlining, namely sustainability of property valuations. Though in all these cases it's obvious the reason they persist(ed) as-is is for largely discriminatory reasons, as the legitimate substance of the concerns could be addressed. At the same time, we wouldn't say they legally prohibit ownership; if you're wealthy enough they're no impediment at all, just like redlining and covenants were no impediment if you were wealthy enough (racial covenants could be overcome by just buying up all the adjacent property so there was no other property owner to enforce the covenant; the government couldn't by itself enforce such covenants, only adjoining property owner "beneficiaries").
Perhaps counterintuitively, black letter property law was one of the legal areas most resilient to both racial and sex discrimination. The 1800s saw some regression, but that didn't last long, often because courts themselves couldn't tolerate the illogic. People criticize it, but property is indeed sacrosanct to American legal and political culture, and it was very difficult to carve out exceptions that permitted blacks and women to be excluded without threatening the underlying principles of the system that secured owners' rights. That's why prejudiced treatment tended to come in the form of private, regulatory, or extra-legal discrimination, which arguably persists today in the form of restrictive zoning and related development policies which not coincidentally are impediments to free & clear property ownership, just enough to be tolerable to the well-off while disproportionately impacting the real targets.
People facing racial discrimination can and have overcome it, throughout our history.
People hold out willing non-white immigrants succeeding as proof there is no significant racial discrimination. But this ignores a large selection bias. People who voluntarily immigrate almost always have a great deal of drive and often some resources. Most of them would have been more successful then average if they had stayed in their home country.
Fixed that for you
It's a bit of a chicken and egg situation. At least when someone looks at someone who "looks like them" but is poorer, they see "potential" (there's a name for this effect, but I forget). But the end goal is getting theirs first and foremost.
At lower levels you have the “labor aristocracy” effect, which gives the more well-off workers a material stake in racism. And this division is useful to prevent organization.
> the end goal is getting theirs first and foremost
Seconded
America is the wealthiest nation on Earth, but its people are mainly poor, and poor Americans are urged to hate themselves. To quote the American humorist Kin Hubbard, 'It ain’t no disgrace to be poor, but it might as well be.' It is in fact a crime for an American to be poor, even though America is a nation of poor. Every other nation has folk traditions of men who were poor but extremely wise and virtuous, and therefore more estimable than anyone with power and gold. No such tales are told by the American poor. They mock themselves and glorify their betters. The meanest eating or drinking establishment, owned by a man who is himself poor, is very likely to have a sign on its wall asking this cruel question: 'if you’re so smart, why ain’t you rich?' There will also be an American flag no larger than a child’s hand – glued to a lollipop stick and flying from the cash register.
Americans, like human beings everywhere, believe many things that are obviously untrue. Their most destructive untruth is that it is very easy for any American to make money. They will not acknowledge how in fact hard money is to come by, and, therefore, those who have no money blame and blame and blame themselves. This inward blame has been a treasure for the rich and powerful, who have had to do less for their poor, publicly and privately, than any other ruling class since, say Napoleonic times. Many novelties have come from America. The most startling of these, a thing without precedent, is a mass of undignified poor. They do not love one another because they do not love themselves.Claiming the poor have more virtue, but only in their class status, is one way to do it.
Consider how many caste systems claim the farmer is the highest status, the wisest, the most virtuously hard working … but well still needs a good noble king to lead them.
We should do more to help the underclass and remaining desperately poor citizens to lift themselves up. But it's amazing what we've accomplished since 1969. Let's celebrate that.
If many of our welfare programs actually helped their intended recipients we would be able to help those in need get to being self sufficient instead of the fraudsters stealing all that money.
Higher income does not mean higher quality of life.
I'm an American who has spent the majority of my adult life living abroad, and much of that time has been in developing countries.
I have no illusions about poverty and am not going to pretend that the US isn't a "rich" country. But I've also noticed a very stark trend in the past decade: fewer and fewer people express interest in emigrating to the developed world.
I currently live in one of the fastest-growing countries in the world. Its per capita GDP PPP is about a fifth of the America's and...the number of people I meet who say they'd want to live in the US is tiny.
People around the world are increasingly hip to the reality: the US is still the land of opportunity. But opportunity is more and more difficult to come by. The country is expensive, has massive social problems and lacks attributes (such as safety nets provided by family) that make life in poorer countries feel better to many people.
Even your idea that the "underclass and remaining desperately poor citizens" need to "lift themselves up" is a distinctly American idea. There are tons of working poor in the US. They are trying to "lift themselves up" but can't afford a $1,500/month apartment, $30,000 starter car, $5+/gallon gas, $5,000 health insurance deductibles, etc.
Even with rehab versus punishment - it's the same story. The view isn't that punishment is inherently superior, but simply that rehabilitation is more of an ideal than a reality, and that typical appeals to places like Norway - a relatively homogenous and extremely wealthy microstate - don't necessarily translate well to large diverse societies, especially ones where there are substantial chunks of society that adopt cultures that glorify criminality.
"Microstate" is a term generally reserved for tiny geographical locations that can't even support their own defense.
But with what you had meant - it means Norway is pretty comparable to a typical US state division or, in other words, something US states could be expected to implement successfully in their state prison systems if there weren't other reasons than scale they do things differently.
Similarly, Asia is another interesting counter-example to Norway. For instance the Chinese penal system makes the US look like a trip to Disney Land. Beatings, physical+psychological torture, and more are regular aspects of their prison system which is not only punitive but borderline sadistic. And their recidivism rate? One of the lowest in the world, around 8%. And perhaps even more important than the recidivism rate is their crime rate, which is also one of the lowest in the world.
[1] - https://usasymbol.com/rankings/crime/recidivism-rates-by-sta...
I would also loosely suggest that social services should be considered part of the rehabilitation pipeline.
So for instance in both Norway and Oregon somebody isn't considered a recidivant unless they are arrested, prosecuted, and receive a minimal standard of punishment. In locations where you see much higher rates of recidivism it's because they use a more intuitive definition - if somebody's convicted of a crime, then they are a recidivant. By contrast here [1] you can see Oregon's raw data. And about 50% of people released from prison will be convicted for another crime within 5 years. In Norway 55% will face criminal charges within 4 years, and 42% will be convicted again!
So the whole point about Norway having an exceptional recidivism rate comes down, in large part, to statistical definitions! It'd be interesting to dig more into China/etc and see if there's some similar 'nuance' there. It often seems that so many things that 'everybody knows' just end up wrong upon closer inspection.
[1] - https://www.oregon.gov/cjc/CJC%20Document%20Library/2018SACG...
[2] - https://www.ssb.no/sosiale-forhold-og-kriminalitet/artikler-...
There is, of course, more than one reason people hold the views they do, but I do believe things like rugged individualism & the Protestant work ethic definitely played a major role in why the majority of Americans hold the desires and fears about government they do - particularly in the aspect of these examples. Without those influences, I think what America has tried vs what it has feared would be a very different list today (which is not to say whether it'd've been more successful or not).
It's also not just in the past. We continue to live in the era of mass domestic surveillance, Patriot Act, Snowden leaks, regular oppression for political views (see: pro-Gaza protests), two tier legal systems, and much more. All the while governments with vast resources plunge sizable chunks, verging on a majority of discretionary spending, into militarism flirting with WW3 and the viable end of humanity it would entail. And I'm not even going to get into the insanity that's going on, worldwide - including the West, with the treatment of political candidates and elections. Suffice to say that's also enough to make a lot of people quite concerned.
So again all of this makes one begin to think 'perhaps governments shouldn't have this much power or wealth' at a point that I imagine you would say is, itself, already relatively low. I think that should all be fairly reasonable, even if one might disagree at some point. But I'm not entirely sure what the comparable evidence for the alternative is.
[1] - https://www.theguardian.com/uk-news/2013/dec/13/calling-abol...
That's not arguing small government is supposed to be good or bad, it's just saying what the American mindset considers important when judging things - which is on traits which align with its mindset over its history, not on whether or not the application of policy seems evenly distributed to all.
The exact phrase 'smaller government' is triggering because it's been so politicized into being a left vs right concept, but when left leaning individuals seek to decrease the strength of ICE, decrease the rights/capacity/scope of law enforcement, limiting executive powers especially as related to war, and other such things they are themselves also directly appealing for a smaller government, in at least some ways.
I think this hypothesis (that 'anybody' would trend towards seeking smaller government) is even testable with things like Asian Americans. Many/most have roots from more social type societies, and predictably trend towards voting liberal in America as a result of such, to say nothing of historical issues. But they are leaning more and more conservative over time, to the point that at current trends they will likely be a majority conservative bloc within a few decades.
It's simply that once one sees what 'big government' amounts to in the US and the current state of the US government, it quickly leads many people to start running in the opposite direction. And once you start running from such, the opposite (self responsibility/reliability/etc) inevitably grows in proportion simply because there is no other choice.
Another word for that is freedom. With freedom comes personal agency and personal responsibility.
uh? That's literally what causes terror and wars lmao
Every accusation is a confession, as they say. How can you say this with a straight face given the current situation in Iran lol? They keep pulling the same shit and NPCs keep licking the boots, it's insane...
Consider that the majority of Americans do in-fact vote. In doing so, they literally delegate the power of the purse to the representative was most supported in their local community.
Look at the work put into ‘communication’ about those budgets also. In addition to having comptrollers to monitor the auditors or whatever.
The UK Expenses Scandal was funny, but Thatcherism is still doing too much residual harm to laugh about.
Promising x and doing y is a winner-takes-all democracy problem. Coalition governments solve this by sexing-up y as the natural outcome of the public vote. This also makes technocracy easier / more normalized.
There actually has been a really big push against this in the US. I was shocked by the amount of smoking I saw on a recent trip through Northern Europe, whereas smoking in public is pretty rare to see in the US these days.
Now we just vape our nicotine directly, or smoke weed, depending on the state.
Cigars are still cool though, but those have always been the higher status tobacco due to the cost per stick. Also most people don't go through public spaces smoking a cigar, so it doesn't have the annoyance factor of vapes. Hookah still has a fun vibe too, probably because of the social factor.
NYC vs Hamburg, Amsterdam, or Brussels are night-and-day differences on this point.
I'm not sure Vegas is representative of much of anything, but last time I was there what I smelled was weed, not tobacco.
I only bring this up because I keeping seeing people say it's "rare" in the US, but is something rare if you run into multiple times every single day?
I guess we can keep arguing about the definition of rare, but about half the smoking rate of many European countries is pretty significant, and immediately noticeable walking around cities in both places. It's also a significant reduction in the US since the 90s, when every restaurant and workplace, and decent number of homes, smelled like cigarettes.
In the 90s and earlier it was hard to be in a city and not be breathing cigarette smoke pretty much constantly. Offices had ashtrays in the elevator waiting areas for people who couldn't wait to get to their office, restaurants had half the seating reserved for smokers, there were ashtrays in the armrest of every single seat on an airplane.
Its kind of crazy how much norms have changed around smoking in public. It's not "rare" to see a smoker, its that it is much rarer than it was in the past.
Compare that to most places internationally, and the contrast is stark. The US has less than half the cigarette consumption per capita than the EU, with only the U.K., Norway, and Sweden having lower rates. China has a similar rate to the EU.
Just to drive that point home a little harder, the state with the highest number of smokers is West Virginia, sitting at 21% (the national average is 9.6%). That would be middle of the pack in Europe, similar to Italy.
Which reminds me: Also, the smoking area of every airport I’ve been to in the last 2 years has been thick with smokers.
I know it’s better than the 80s. I was there. But I don’t think it’s rare in the US at all.
The massive shift away from cigarettes is incredible. I didn't believed it possible.
If you're just looking at caffeine intake you'd be better off switching from coffee to energy drinks. You could drink about 3 per day and be close to the 400mg/day guidance.
edit: white monster has no sugar in case anyone was about to bring that up
This is less true now than it used to be. I'm somewhat sensitive to caffeine and always look on the can to see how much is in it, and 150 is on the low side of most of the options available now-. 200 to 300 seems to be a lot more common among the brands that are newer than when monster and Rockstar first came out.
Forget the numbers you’re being given - what does caffeine crop that goes into a Coke or Pepsi product look like, compared to green tea caffeine?
What does the sugar look like, as a supply chain, vs sugars ingested from fruit?
Hint: it’s disgusting.
When a flock of geese shit into the pile of beets, gnaw on the beets for a few days, and then the beets get boiled down and put into your Gatorade, sucrose ≠ sucrose.
No idea what you mean with the homeopathy quip.
And that manure is an excellent natural fertilizer?
And that outside that, worms exist? And they poop?
Oh, and that if you were to take bird shit beets and worm poop beets and mash them up and extract chemically pure sucrose from both you'd have no way of determining which came from which?
Assuming that you do know all of these things, you're saying that horse shit and worm poop is fine, but you'll be damned if a bird is involved?
I mean, I can see where you're coming from. A potatoe coming from a toilet is probably not as clean as a potatoe coming from a sterile lab, but that's not what you're saying. You're saying that the toilet has somehow altered the physical chemical compounds involved in the structure of the potatoes rather than has potentially added other chemicals to the mix that was the potatoe. The starch is the same in both. The starch = the starch. The starch and the toilet =/= the starch and the lab because the toilet =/= the lab, but those are different arguments.
and if you don’t, well, let’s just leave it here.
> You're saying that the toilet has somehow altered the physical chemical compounds involved in the structure
Nah - I’m pointing out the shit that comes along with your very simplified label should be known.
Same as the folic acid American rice is washed in - but never labeled with.
My point is: they’re not.
and in retrospect, it was weird that I ever assumed they did.
Java Monster Triple Shot Mocha comes in a can, and has 300mg of caffeine per can[1][2].
This seems to suggest that getting the equivalent of 3 cups of coffee in one can is, in fact, a thing that people can accomplish.
[0]: https://www.aboutcoffee.org/beans/decaf-coffee/ https://ific.org/resources/toolkits/caffeine/ https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-h...
[1]: https://www.monsterenergy.com/en-ca/energy-drinks/java-monst...
[2]: And they're delicious
> And easily achieved through energy drinks?
Yeah, once you start pushing 1000mg of caffeine, you are getting into areas where if you have heart problems, you could be putting yourself in danger.
> Most energy drinks
But not all. So why strongly doubt it?
There are plenty of energy drinks which are fairly popular with huge amounts of caffeine and there's little labeling requirements to let people know that. Bang energy drink is a good example of that. 300mg per can, meaning 3 cans is putting you in dangerous territories.
I don't think that much caffeine is good for you, especially 4-5 times a day. But with everything else we gulp down it probably isn't priority #1.
Tangential, but I suppose this is a good time to highlight how caffeine undisclosed can in fact kill some people:
And yes, regarding smoking, the US has had one of the most effective preventive actions in the world. Compare actual numbers of smokers in the US vs, say, Spain, France or Turkey. So it's not anywhere near as clear cut as what you are trying to make it sound.
They make money on the procedure, not the office hours. And they write the standards of care.
That being said, my father delayed a screening, developed colon cancer, and now no longer has a colon. Would cheaper / higher compliance tests have caught it sooner? Hard to say.
I'm not sure if I understand what you're saying. Kaiser Permanente sends me a take-at-home colonoscopy test every year, and some light googling suggests the cost is $20-$89. I've never done an in-person colonoscopy, but the home version must be cheaper, right?
If that tests positive then you get a colonoscopy to check more things. If you have had colon cancer then you get a full colonscopy evry two years and an MRI every year.
If this test finds something then the next step is not treatment it is you need a colonoscopy.
It is a test that cuts down on the number of colonoscopies needed and is cheap enough to find problems earlier than everyone having a colonoscopy which is just unaffordable,
The problem is that the fecal tests are totally inconclusive. Every positive test must be confirmed by a colonoscopy. And then you get into tricky waters with insurance. My Kaiser gastro doc insisted that my colonoscopy after a positive home FIT test would be billed as diagnostic and not covered at no charge as preventive screening. Which means I would pay over $2k. Despite the USPSTF publishing explicit guidance on this exact scenario still being screening. He was dead wrong, and I wasn't billed, but he and his department did everything they could to discourage me from following up with a colonoscopy.
And at one point he even turned the tables around on me and said this was all a consequence of my having opted for the FIT test instead of a colonoscopy. Which I never did, I was not given a choice. But from his statement I would assume that you can opt in to colonoscopy instead at Kaiser. Then again this could be yet another piece of misinformation on his part.
And don't start me on their pharmacy. She had root canals with some infection, and was in substantial pain. Dentist prescribes short term pain meds between procedures - she's in agony. I drive her from dentist to the Kaiser pharmacy at their UC/ER-lite/whatever facility, that I know from my previous work as a paramedic has pain management medications on site (day surgery, etc.)
"This is a pain management prescription. We do not fill those in person. You will need to submit it to our mail order." "How long will that take?" "5-7 business days, and then shipping time."
"Oh, look at you, coming from the dentist with verifiable surgical procedures done and in pain - just in case you might be drug seeking, you can hang on for a week or two and get your pain management then."
That last one is, I'd argue unethical and against most pharmacists "oaths".
USA generally has higher CRC rates than other developed nations:
https://pmc.ncbi.nlm.nih.gov/articles/PMC2796096/
the screenings may make sense, here
https://www.cancer.org/cancer/types/colon-rectal-cancer/dete...
> The Affordable Care Act (ACA) requires both private insurers and Medicare to cover the costs of all colorectal cancer screening tests that are recommended by the United States Preventive Services Task Force (USPSTF). The law stipulates that there should be no out-of-pocket costs for patients, such as co-pays or deductibles, for these screening tests.
Also have you seen the kind of medication regimes that most 90 year olds take? Many of them take as many pills in a week as a 60 year old has took over the last decade or more.
> Keeping a relatively healthy 90 year old alive for 2 more years costs significantly more than keeping an unhealthy 60 year old smoker alive 10 more years before they have a heart attack or stroke.
This is 101. If you don't like it that's fine, but not understanding it can be resolved with a simple google search.
If something disproportionately affects black people negatively, it has a significant amount of support from certain voters. The whole origin of the anti-abortion movement in the 19th century was double-pronged to displace midwives (who were often minorities) and that too many white women were getting abortions, which was labelled "race suicide" [1].
Need more? Infant mortality skews heavily by a state being red or blue and by the racial makeup [2]. Iowa is a red dot in a sea of blue because it's particularly white. Compare the US to other developed nations [3].
So this particular issue is with heart disease. And guess what? Black people are disproportionately affected and have worse outcomes [4]. Shocking.
Many people have a shallow view that racism is using slurs. It is not. Racism is systemic. And it's not as direct and nefarious as people in a smoke-filled room getting together to try and create worse heart disease outcomes for black people. It's a series of steps taken such that this problem isn't solved. It's just not prioritized.
You see the same thing with medical misogyny and medical racism. Symptoms are downplayed and ignored. This has been thoroughly tested where doctors have been given a file genders changed and there are statistically different outcomes.
[1]: https://sociology.northwestern.edu/documents/faculty-docs/fa...
[2]: https://en.wikipedia.org/wiki/List_of_U.S._states_and_territ...
[3]: https://www.americashealthrankings.org/publications/reports/...
I’m from a country where you are mailed things like a free bowel cancel screening kit every two years unsolicited from the time you turn 50 (Australia). The reason is that the kit and test cost a few cents and detecting it early saves the socialised medical system so much money this sort of thing is a no brainer. There’s a direct economic incentive for socialised medicine to integrate preventative care into day to day life.
Now they can still spend 85% of the INSURANCE premiums on care, but then those costs are going to their other divisions which can raise prices at will, and make massive profits for the whole group.
Representatives like high employment in their districts and employees of X like high salaries. It's an incentive-compatible equilibrium.
So we have to perpetually live in emergency mode to create liquidity
If we could all just live our lives there would be no reason to shift large sums of capital around for the usual hands to get their cut
Historically post office and social security ran surpluses; boring and predictable. All that was phased out to create the current shit show of a virtual economy for the youth
Sam Altman isn't concerned with efficiency except his own line go up
This sounds more like tax evasion than paperwork avoidance.
Just means I'm paying them directly instead of making them deal with my insurance.
I've had providers tell me they'd have been happy to charge me less, making less than their insurance reimbursement, but not have to mess w/ billing my insurance, but they were unable because their contract with my insurer did not allow it.
Are pennies okay? Sorry, they're not rolled. Just let me know if it's not enough.
In broader medicine, one basis that can lead to the above sort of dynamic is compassionate protocol ("we are losing a little money on this deal, but you are in-need and we're here to help everyone"), as opposed to greed protocol ("we medicos are here for the big insurance money, and only charge the True Low Cost when forced").
And on balance, the nature of the people who choose the occupation of medicine tends towards the former.
- ApoB - about 20% of people with normal cholesterol results will have abnormal ApoB, and be at risk of heart disease.
- Lp(a) - the strongest hereditary risk factor for heart disease.
- hs-CRP - inflammation roughly doubles your risk of heart disease
- HbA1c - insulin resistance is a risk factor for just about everything.
- eGFR - estimates the volume of liquid your kidneys can filter, and is an input to the latest heart disease risk models (PREVENT).
These are simple blood tests. You can get them for <$200 through my company or others:
https://empirical.health/product/comprehensive-health-panel
Imaging is great for detecting calcified plaque in your coronary arteries. But before you have calcified plaque, the above risk factors tell you about the buildup of soft plaque. And 4 out of 5 of them are modifiable through lifestyle, exercise, and medication.
- If you made a dietary change (e.g., more fiber and less saturated fat), the tests tell you whether it actually worked.
- Statins are dosed based on the LDL or ApoB reduction you need. The most powerful statins cut cholesterol by 50%, but at higher doses the risk of side effects does go up.
- Other medications like PCSK9 inhibitors and ezetimibe exist, and whether to use them depends on the other numbers. For example, PCSK9 inhibitors have a secondary benefit of lowering Lipoprotein(a), and statins and GLP-1s have a secondary benefit of lowering inflammation.
- If blood pressure, HbA1c, etc is high, then there's a slightly different set of diet advice and a very different set of medications. For example, lowering blood pressure through diet is mostly about reducing sodium and increasing potassium.
ApoB is very responsive to diet and medication--you can lower it by about 85%.
ApoA is completely out of your control and will not change with behavioral modification.
So, no, you're incorrect that these tests are superfluous and all you need to say is "diet and exercise". Besides, even if that was always the answer to these results, you should still have a baseline to see if behavioral modification is doing anything.
Do you think everyone with poor blood test indicators is aware of how unhealthy they are? How quickly they need to reverse course? Or do think there might be some possible validity to discussing your results with an actual doctor and understanding how acute your symptoms actually are? Do you think there are no side effects to statins and everyone should just be on one at all times, forever? Do you think there might be some value, for those patients, in discussing GLP-1s? Or nah, everyone can just like, go run 10 miles tomorrow because some 20 year old in SV said so?
I'm always deeply confused by people who think all medicine is "just repeat whatever ChatGPT said as if it's profound, like, duh - I'm smart and invincible and can't quite figure out that other people aren't me", in spite of them not knowing anything about medicine in the first place.
This is not about (just) the healthcare system ... it's the core problem with:
- our legal system (millions of laws and rulings and zero effort spent reconciling them into a good system that treats everyone equally)
- our economic system (we reward people who create true wealth in many different ways ... but those rewards are wildly disproportionate to how much true wealth they add)
- our tax system (again, millions of laws, and yet the people who should be paying the most pay the least because of how they fit together)
- our electrical system (although, due to its centralization, this one is actually catching up much faster than the rest)
- insert any other system here
And once we have a few dozen of them in a room together, it's the recipe for endless passionate arguments about exactly what Truth is, and what Value is, and what Goodness is, about anything and everything.
One of the biggest challenges is that rules are set by experience, but every new rule is also the start of a new story we've never read (called 'The Future'). And humanity changes pretty fast!
What does that tell you?
Whether or not people actually follow through is another story. There weren't any cigarette smokers who didn't know how bad it was for them...
Health care is actually sick care.
I obviously have a genetic condition because it runs through my mothers side of my family, but they refuse to look at my genetics. So, did. I found things. I begged a researcher to test me for a special sort of immune deficiency (ADA Deficiency) . The tests shows I have a partial immune deficiency. I showed it to my doctor and nothing.
When my condition flares up (Too mush ATP and GTP) it effects my brain and nervous sytem and I have to be institutionalized. Five times now. I keep telling them my mood problem is caused by an immune deficiency but now one cares.
Sorry, end of rant.
'Preventing a heart attack' means taking life long medication to reduce the absolute risk of heart attack by about 1%, which is worth doing, but complicates the maths a little bit. The scan doesn't magically eliminate heart attack risk
Our healthcare system has co-evolved with insurance in a sort of partial free-market, partial heavily regulated environment. Arguably we get the worse parts of both: Kafka-esque beaurocratic mazes and shareholder value optimization for private firms.
There's a paradigm shift needed in how health insurance works: optimize for total cost of care.
Can the invisible hand do this when providers are offering mainly treatments with token preventative care visits thrown in?
You're criticizing health insurance but payers are far more incentive-aligned with patients on lowering total cost of care than the providers. They carry the risk and have to pay out claims. Providers, on the other hand, have an incentive to provide lots of expensive reactive care that's bound to expensive labor.
I agree with the sentiment of your "only for emergencies" point and wish direct care was more affordable. The problem is providers charge insanely high rates for services because a) they can get payers to cover it, and b) they're covering the cost of labor that's getting increasingly expensive with no commensurate increase in productivity [0].
For prices to come down substantially in the US, we'd need a much greater supply of doctors or more automated care. The former is against the financial interests of current doctors and the latter is an uphill battle against FDA regs, state medical boards, and billing codes from CMS to make it reimbursable.
Absolutely not here to praise US health insurance companies, but they're not the ones using regional leverage to negotiate higher rates - that's the providers.
Value-based care, e.g. Medicare Advantage.
The idea is that the government gives you $X for the care of a patient, with multipliers on risk factors. The government's goal is for that to be basically exactly what care costs. The provider is incentivized to treat you for less. Which sounds perverse, but if they, for instance, deny all care, a patient will end up in the hospital and cost exponentially more than they would have through proper preventive care. It is not perfect, and it should be broader, but it is a strong optimizer for providing the right care to keep a patient healthy, without providing hundreds of unnecessary tests (and especially imaging) that are medically unnecessary.
It is absolutely a system that should be rolling out to more and more patients.
I don't like the title. I can't believe it is really $100. Even if the scan is $100 that doesn't fix things itself. There is the cost of whatever the treatment is etc. There are likely added expense from false positives (or similar idea), where it flags someone as needing more testing, new interventions when in fact they didn't...
I wish the article was more detailed on those costs (or at least not claim the cost is $100 when it is much more in reality, unless I am wrong about that and the fixes are free somehow). It feels like a biased promotion of this thing we like and/or have a financial interest in so lets make exaggerated claims that hopefully people won't notice.
But there is no evidence presented that say for every 1,000 of these test we correctly find 1 that wouldn't have been found (and we have zero false positives) or whatever. So then 1,000 * 100 = $100,000 and saves $50,000. Even in this case there are benefits beyond the expenditures (if you save someone from the $50,000 you probably give higher quality of life...).
Basically my issue is not with the idea that more testing and preventative action would improve our current system. I believe that.
But in order to make that argument in a specific case you need more complete data. Things get complicated so I understand why people don't want to do that for a simple story. But the problem is when you leave off all sorts of costs, issues (false positives, treatment options), etc. the statements you make are not very compelling to those that know a test that tells you something bad is more likely for this person is not nearly sufficient to claim why this test is good.
(aka Proactive Vs. Reactive)
((aka Present Responsibility Vs. Future Response))
"An ounce of Prevention is worth a pound of Cure" (as the old expression goes...)
Observation: Most health insurance policies today, whether they are government or private corporation, national or regional, are based on the idea of paying for medical/health problems AFTER the onset of the health problem...
Prevention, preventative health, preventative medicine, and preventative programs -- would not only do a lot to preempt future health problems, but it would also save a ton of money (a ton of taxpayer money if the health insurance is a government sponsored one), as the above article so eloquently makes clear!
Observation: Some insurance policies do include some preventative health aspects -- but as medicine is complex and there are always new discoveries, there is always another step up, another higher level in what could be delivered...
In other words, these could always be improved...
"An ounce of Prevention is worth a pound of Cure" (as the article implicitly suggests...)
Anyway, great article!
There's a lot wrong with health insurance in the US but this problem is largely on providers, not payers.
Insurance claims submitted by providers are effectively itemized using standardized Current Procedural Terminology (CPT) codes. Those codes are written by the American Medical Association (AMA), the lobbying group for physicians. Doctors make more money when services are expensive and require a doctor to be involved. As a result, reimbursable services tend to be reactive (i.e. more lucrative), rates have a tendency to go up, and CPT codes tend to favor reimbursing for physician time rather than patient outcomes.
In fact, there's a whole category of preventive health companies (e.g. Virta) that sell to insurers because the insurance companies bear the financial risk and benefit from a healthier member base. Insurers will pay for these programs on their members' behalf and try to get them to enroll so they don't have more expensive problems later. Providers make a lot less money when prevention works.
I don't think it's some grand conspiracy by evil doctors, just incentives gradually reinforcing bad patterns at scale.
>There's a lot wrong with health insurance in the US but this problem is largely on providers, not payers.
How would you fix it?
Healthcare in the US is mostly gated on physician labor. Physician labor is scarce. Scarce labor is expensive.
Physician labor shows negligible productivity growth over time. Wages have to increase to compete for labor against high productivity growth sectors (e.g. software). On top of that, institutionally managed bottlenecks on labor supply prop up high wages (e.g. limited residency slots artificially constrain the number of doctors entering the market). Training more doctors would supposedly compromise patient safety because it would mean lowering the bar for admissions and straining existing staff that need to train them. Even if you could admit and train them all, supplying enough doctors to meet market demand would cause a wage collapse breaking the ROI of med school expenses. So the labor is not going to get cheaper.
So care requires labor that's expensive and only getting more expensive. If you want to reduce the cost of care without reducing the cost of labor, you need to deliver more care per labor-hour (i.e. get more efficient). Provider orgs that employ doctors try to boost efficiency by squeezing every last ounce of time and energy out of their doctors and booking impossibly full schedules. They have a strong incentive to make this work, yet the doctors get only marginally more efficient (and way more burnt out).
To meaningfully move the cost/quality frontier, the majority of care cannot be handled by a human.
8VC laid out a vision [0] that I strongly recommend reading and mostly endorse. It's a long series of hard technical problems but I think the harder problem is actually winning over the institutional gatekeepers (FDA, state medical boards, CMS, AMA). I can't tell exactly what doctors are supposed to do in this envisioned future but the answer will have to be something that sways the gatekeepers even if it's not what's best for patients.
Hopefully future healthcare policy makers (both in the public and private sector) will read them, and get some good advice from them...
>"Training more doctors would supposedly compromise patient safety because it would mean lowering the bar for admissions and straining existing staff that need to train them. Even if you could admit and train them all, supplying enough doctors to meet market demand would cause a wage collapse breaking the ROI of med school expenses."
There seems to be a vicious circle in place between too much medical regulation requiring a corresponding amount of long and expensive education, and the high cost of medical education in general...
Which one is cause and which one is effect I do not know...
It would seem to the casual observer, that both aspects might feed into one another...
One thing I do know is that doctors from foreign countries, especially if they are third-world countries, typically have had to pay less, sometimes a whole lot less, for their medical education, compared to their U.S. counterparts...
Is that medical education as good as a U.S. medical education? Well, I don't know! Maybe it is in some cases, maybe it isn't in others...
What is known though is that foreign medical educations frequently cost less, sometimes a whole lot less -- than their U.S. counterparts...
Is hiring foreign doctors the solution or part of the solution?
I don't know that either, but I do know that there are a lot of foreign doctors (and previously foreign doctors before becoming U.S. Citizens) in the U.S., and certainly many more abroad...
Is AI the solution, or part of the solution?
It's definitely a wildcard with promise at this point; it'll be interesting to see where it goes in the future...
Anyway, you make some excellent points!
Hopefully future policy makers will read them and act on them...
And you know what? It's totally worth it to me. This year I had 4 operations+10 ER visits and my wife had 3 brain surgeries+radiation and 2 ER visits. About $2 million worth of treatments, quite good care overall. So I'm willing to continue paying for private insurance. I am fortunate I can pay for it and would like not to make you good folks pay for it.
But Medicare won't let me without penalizing me permanently more an additional 10% for every year I don't go on Medicare. Luckily Washington has phenomenal Medicare. But it would be nice if I weren't punished for trying not to be a burden to the dwindling population of taxpayers.
Same insurance company denied authorization for CAC twice; once bc I wasn't sick enough and once bc I was too sick (ie, just start taking a statin). All this happened in the last year.
I paid for it after the second denial. CAC = 175
All after the same Dr. told me my heart had "extra protection" every year since 2009.
Safety regulations are written in blood. They exist because people died because the industries could not and cannot be trusted to regulate themselves.
The most generous interpretation is that people conflate regulation with rent-seeking. These are two entirely different things.
This sort of absolutist rhetoric is why people waste so much time arguing against maximal regulation and zero regulation in the abstract, neither of which is actually popular or sane.
Many regulations are good, necessary, and effective. Many of them are short sighted, over-specified, or written by lobbyists against citizens' interests (shouting that rent-seeking and safety regs are mutually exclusive doesn't make it so).
Obviously the regulations regarding ionizing radiation exposure still have to be followed as with any x-ray procedure. No one has seriously proposed deregulation on that.
That isn't to say this might not be the best solution for many people but I still wonder.
It isn’t just playing our systems, but hacking them and giving them inputs they would never usually see for far stronger effects than would be possible.
The most tenuous of the health concious vc efforts are the nonaloholic beers though. They are eating their own industry. Bars and beer industry does not exist off people getting 2 drinks and going home. They depend on the whales who drink 10+ beers in a sitting who subsidize all the 2 drink and goers. Alcoholics make bars and the beer industry work. It is an open secret. No one is going to buy a 12 rack of Athletic NA Beer and drink the entire thing in front of the bears on tv. No one is ripping a 6 pack of athletic in the parking lot before they go into work. Bars aren’t going to be able to stay open with everyone buying just 1-2 $12 Athletic pints.
People also do it with smoking, and the only reason that is bad is because of the cancer, not the drive changes.
They'll use flawed research to claim diet and exercise don't work for obesity, then the general public uses that research and claims, "Diet doesn't work for fat people."
Soon, everyone is convinced every guy with a trivial amount of weight to lose needs to be on GLP-1s.
To me this is just subconscious denial/defending of their food addiction.
You have to actually kick your ass when you exercise. Most people don’t push that hard. Michael phelps ate what 6k calories a day or something crazy to maintain his prime form with the amount of caloric burn he was doing in training. If he continued to eat like he did in those crazy olypmpian training years, he’d be morbidly obese. If he ate like he does now in those years, he’d starve.
For the average person it's much harder to exercise out of a bad diet than just change the diet. I think it's an easier "sell" for most people to start off trying to eat less than to keep eating the same way and jump right into "kick your ass"-level exercise.
It's a real killer for "calorie blind" people to go on a 750 calorie hike, and then stop by for a "treat" on the way home. That treat being a 500 calorie blueberry muffin with 200 calories of butter on it. Then they go home and have dinner.
Learning to control your diet solves both problems.
I'd also argue there's a lot of value in learning to not be dependent on medication to control your behavior, because it's not available in most situations.
You can't take an exercise pill.
You can't take a career success pill.
You can't take a "hard, but necessary conversation with my partner" pill.
Those all require you to consistently do things you at times don't want to do, just like avoiding junk food.
Knowing that you should do something, doesn't necessarily mean can do it. There's still the question of exactly how.
E.g., diet is heavily influenced by hormones/hormonal cycles and access to quality food choices, which vary significantly between people. The glp1s available now are a big help with the hormonal part of this, but they are not within reach of a large proportion of people.
> To me this is just subconscious denial/defending of their food addiction.
If you have to make up unobservable phenomena to explain plainly visible facts, it's usually a sign to look for a different overall model.
Quitting isn't easy, but fooling yourself to avoid it is on you.
Arguably this is a limitation on how the studies were done, as nobody is going to pay for extensive studies since you can't patent exercise.
Who is "they"? Who is saying this?
I expected an article on actual prevention, but I suppose it'd unthinkable to consider not eating trash and moving oneself in any other way than by motor vehicle.
That is such incredibly bad advice. DO NOT WAIT until a CAC tells you to start a statin. You know you need to start if your LDL is high right away.
My doctor referred me to get a self pay ($100 at the time) CAC 9 years ago. It was completely clear.
However last year I had a cardiac ultrasound and it showed calcification.
In reality the CAC caused a false sense of security. My LDL had been high the whole time and not managed with any intervention despite having been tested multiple times and showing high over that time. This was a failure by my doctors IMO. (No it’s not diet or weight related before people give advice).
I didn’t need a CAC to tell me everything was fine. I needed to be on a low dose of statin that whole time.
A clear CAC doesn’t mean you are safe. And a positive CAC is already too late and is not really telling you anything useful.
What people need to do is just watch your LDL regularly starting from any age (yes even some 20 year olds need to check this). Don’t wait to middle age. And no matter your age use whatever methods you prefer to get that down as low as possible. Think of it as cumulative exposure over time that matters.
(There are new oral PCKS9 inhibitors out now which is cool, but the reality is all the misinformation about statins has been bullshit, don’t be afraid of them.)
Home insurance can benefit from this too. I just got a quote on a property i looked at with a $20k/yr premium, partly because of being in CA with a slope and age of the property.
At $20k/yr, there should be some economic way of an insurance company essentially saying "instead of $20k a year in premiums, here is a $300,000 30 year loan to do preventive measures on the property, and if you do them, your policy will drop to a more normal $3k/yr" or something along those lines.
In borderline cases it can tip the scale to prescribe statin rather than not. But telling you what has happened to your heart doesn't prevent heart attacks.
- Gym memberships
- National park passes
- Exercise equipment and sports equipment
- Subsidies for heart-healthy foods
Medicare should also:
- Fine employers if their employees are working more than 40 hours a week, pay the fines out to affected employees tax-free
It looks about 30 seconds. But it came back with a score of zero so I guess I shouldn't complain.
Recently there was an old lady in the family that had an appendicitis, an ambulance rejected her, and the next day it got worse, and at that point she was accepted, but it was a bit too late.
One hypothesis is that triaging is hard and there's a lot of demand so things only go in when it's bad enough (considering there was medical insurance, they aren't charging per patient, so there's no incentive to take on more patients). But if that were the case, then preventive measures would actually reduce the total burden on their system.
The more cynical hypothesis that I'm holidng is that that health system is maximizing for work, if there's 10 appendicitis per month, and they are all handled in time, that's maybe like 5 hours of billable hours per patient? But if the appendicitis becomes bad enough and there's a puncture, then you have infections, complications, the patients have to stay for weeks and often come back for checkups, we are looking at maybe 100 billable hours? So the financial incentive is there.
In that sense what I want to add is that the title would be completely wrong, the solution is not for the hospital to pay 100$ for prevention, but for prevention to be more accurately priced, we should be paying 50k, and maybe even 100k for prevention, because we value it more than emergency action.
In a broader economic sense, there's a lot of cases where there's a huge difference between the cost and the value, Shkreli got a lot of heat for surging up medicine prices, but I don't think it's immediately obvious that something should be valued in proportion to what it costs. Maybe if we price heart prevention at 100K, there would be more incentive for everyone involved to just get a fucking pill to those in need, imagine how many people would jump at that opportunity to make it happen, call centers, bureocrats, NOC support, legal teams, all dedicated to making sure a pill gets to the patient before a heart attack does.
There are some pockets of “per capita” payment, where the provider gets a fixed amount per person and is thus encouraged to reduce treatment costs, which indirectly should encourage preventative care, but also encourages just refusing to treat people.
We could remove these weird constraints by making health care a government service rather than a highly contorted pseudo-market, but that would not be the American way. It has to at least look like a market, even if it’s an ineffective, inefficient, opaque, corrupt one.
Seems obviously right in terms of total cost to the median patient (less obvious for individuals in higher tax brackets), so I'm not disputing that. More curious about incentives to improve care delivery for better long-term outcomes.
When goods are discretionary and there are no externalities, it’s fine to have a purely autonomous market solution. Healthcare fits neither of those criteria. There’s a reason we don’t (or at least shouldn’t) have private subscription markets for baseline levels of law enforcement, fire prevention, public transit, food and drug quality enforcement, etc. etc. That same reasoning applies to healthcare.
Capitated reimbursement is a hybrid approach that helps a bit, but you can see from Medicare Advantage how the private sector relentlessly games the system because that’s how the incentive is inherently set up by the for-profit nature of the providers.
Your criteria for when a market is (not) a good solution seem reasonable. My biggest concern is there's a fundamental problem with scaling labor-driven services that's exacerbated by entrenched interests constraining the labor supply to support wage growth. Care delivery needs to change if you want to fix both cost and quality, and I have a hard time imagining monumental changes to care delivery from a government service. Care will be expensive as long as it's constrained by scarce labor. That means either costs will balloon at the taxpayers' expense, service quality will decline to cut costs, or more likely both.
The way you fix that is either a) dramatically increasing the supply of qualified clinicians, or b) automation. Clinicians don't want more clinicians because it lowers their wages, so it will be fought at every level in the name of patient safety. But they also don't want automation to decouple care from their labor, so automation, too, will be fought at every level in the name of patient safety.
Most of this is opaque to voters who are largely under the impression that it's all health insurance executive greed, so there's not much of a political incentive to impose meaningful changes.
Where's the way out?
It is still a market (and a single-payer one, ultimately) in these places, but it is not a government service. It is the best solution: the government funds the appropriate cost of care, the provider group is financially responsible for meeting it, and they are incentivized directly to get it right.
The left needs to stop shrieking about Medicare-for-all and the right needs to stop pretending like it can even spell healthcare. There are good solutions.
> but also encourages just refusing to treat people.
It categorically does not. It would be foolish to do so.
Foolish hardly implies categorically false. It's a well-documented incentive for other risk-bearing entities (see insurance claim denials). Why are providers under capitated contracts categorically immune to refusing treatment to protect margins?
> "per capita"
I don't quite get the difference, patients pay a fixed amount for insurance, hospitals charge "fee for service" to the insurance. Both systems coexist, it's not one or the other.
To be clear, I'm not suggesting changing the whole system, I think that's infantile sorry to be blunt, I'm proposing a more down to earth (and commercially appealing approach) of increasing the price (and thus financial incentives) of medical goods that have low cost but high health values.
My economic theory clearly isn't as strong, because how much should a CT scan and a pill be priced at relative to a heart attack response with a 1 week hospitalization and a bunch of work. Because the cost of a CT scan and a pill is low (100$), the value of it is high (50K$ lower bound), and the cost of treating a heart attack is clearly around 50K$, but the value of it is clearly lower than the preventive treatment (perhaps stochastically adjusted).
So should we be pricing by cost or pricing by value? The naïve approach is pricing by cost, so that everything is cheap, the first issue with this approach is that it disincentivizes research, which is why legal systems widely recognize patents, copyright and intellectual property.
I looked into Shkreli's case a bit deeper, and he was a stupid kid of course, but it's what comes to mind when thinking of 'raising prices' of medicine, there's not many faces to that idea.
That said, I'm not saying that prices SHOULD be hiked, just that I'm not convinced that medicine pricing should be cost based, or that it should be value based, or that some supply-and-demand principle would magically find a value in the middle. I'm just saying that it can be either way, and I just don't know which way it ought to be.
And ultimately, it's a decision that every actor in the industry can make, what they price their products and time at. And to reiterate my thesis, pricing your product as cheaply as possible might counterintuitively reduce it's impact, since there is no incentive for intermediaries (or even yourself) to work on it. So I'm not saying that prices should be maximalized either, just that the relationship between price and value contributed to society is not linear, if you price your medicine at 0, you go bankrupt, that's not helpful obviously, and evidently pricing a CT scan and a heart attack pill at 100$ is not cutting it either, hike that up.
I think their reference to "per capita" here is referring to a capitated payment structure where a provider organization is given a fixed amount per patient up front instead of billing for every service they provide. The software analog would be something like a flat subscription fee vs usage-based billing. While it's not the default in the US, it theoretically encourages providers to provide cost-effective care rather than just racking up bills on unhealthy patients.
The mechanism here is who bears the financial risk. The model you're familiar with is one where the payer (commercial insurance or medicare/medicaid) is the risk-bearing entity. They want more cost-effective care so they can protect their margins while the provider is incentivized to push a high volume of expensive care so they can boost their margins. Don't have it handy but the data on this shows providers are winning this battle with healthier, growing margins vs insurance companies whose margins generally aren't great.
Great point on bigger pie increasing both shares. I didn't mean to imply it's zero sum.
Oh the irony of MLRs encouraging insurers to provide terrible service (opex recovery boosts profits) and let providers push fees ever upward (bigger pie, bigger premiums, bigger net profit on constrained margin).
The incentives align well -- people get healthcare for free and and healthcare service provider gets a nice, fat government check.
That's why we don't do preventive care -- our current sick care model is much more profitable.
Otherwise we would tax added sugar out to wazoo and use it to pay gym memberships.
https://www.healthcare.gov/preventive-care-adults/
https://www.medicare.gov/coverage/preventive-screening-servi...
* Arthur Agatston * Oren Mechanic
This truism, "an ounce of prevention is worth a pound of cure", is so true...that like so many truism, it has become a minor, persistent annoyance of thought. It can be safely filed away with the Austrian school of economics.