Scripps cardiologist Eric Topol (not commenting on this article): "That's wrong. The CAC is anything but definitive. Many patients are told they have significant coronary artery disease by calcium score and it turns out, by CT angiography or cardiac catheterization, they have normal arteries.
No less anxiety (often chronic and severe) and unnecessary procedures that are induced by false positive CACs." https://x.com/EricTopol/status/2092682606815117763
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.
What I've never understood is the weird dichotomy of preventive and reactive governance in the minds of US citizens.
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...
In some ways, US healthcare is already very aggressive for some forms of preventive medicine. Compare the colon cancer protocols across the world. Basically nobody else is recommending colonoscopies to the entire population with no cheaper tests, but that's the standard of care in the US. It's not free to receive, and it's expensive in general, but for some reason in the US it is standard, instead of starting with non-invasive tests.
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.
Walk into a US gastro with a hang nail and you'll walk out with a colonoscopy requisition.
They make money on the procedure, not the office hours. And they write the standards of care.
That being said, my father delayed a screening, developed colon cancer, and now no longer has a colon. Would cheaper / higher compliance tests have caught it sooner? Hard to say.
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.
Cigarettes have definitely gotten a trashy vibe in the US. It's kinda nuts how fast we went from smoking sections in fast food restaurants just 30 years ago to even bars banning it. In college 10 years ago, the only people I knew who regularly smoked cigarettes were from Europe, China, and India.
Cigars are still cool though, but those have always been the higher status tobacco due to the cost per stick. Also most people don't go through public spaces smoking a cigar, so it doesn't have the annoyance factor of vapes. Hookah still has a fun vibe too, probably because of the social factor.
Can you say where in the US you find it rare to see smoking in public? I live in Kansas City and have been in Vegas, Seattle, and NYC recently and there is plenty of smoking everywhere. Less than the 80s, sure, but certainly not rare.
How recently were you in Vegas? I was blown away by how little smoking there was post pandemic even compared to 2018. Like, most casinos no longer reek of cigarette smoke. I'm sure that's partly explained by better air circulation installed to reopen sooner post-COVID, and probably taking the closures as an opportunity to replace some seriously steeped carpet, but the amount of smoking was way, way down. It used to be if you saddled up to craps table, at least one, if not two people would be actively smoking. Now you can look around the entire pit and not even see one. The combination of anti-smoking measures in broader society, and the uptake of vaping has wildly reduced the amount of smokers. We're talking a 60% reduction since 2000, and that was after the trend was already heading that direction.
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.
Rare in the northeast US. In fact, I saw two students smoking on a college campus just last week and did a double take. I had not seen a single student smoking in at least a decade. Then I laughed remembering how when I was in college in the 90s, almost everybody smoked at least a little (often at parties), and seeing students smoking at the entrance to the dorm was pretty normal. I am an asthmatic so I've never smoked, and I remember my friends being stunned by this one night when we were out at a bar. Things have changed a lot around here.
I think this is a case of rare being relative to the past.
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.
Idk if it would call it rare because yeah going on a walk in a downtown area you will definitely see at least a couple people smoking. But 30 years ago it seemed like every other person you passed on the sidewalk was smoking.
Rare as in you can absolutely spot a person smoking sometimes, but there is not the perception that everyone is smoking, the air does not always smell like cigarettes on the streets and even inside businesses, and the ground is not covered in cigarette butts everywhere.
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.
In my daily life, every day, I am behind cars with people smoking, see people on their smoke breaks outside the doors of offices and retail, walk behind people on the sidewalk smoking, and see it on basically every job site I pass.
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?
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.
Because people are unable to conceptualize the idea of government-funded voluntary preventative campaigns, despite these showing success in the past.
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).
Much of the US doesn't think of it in terms of proactive vs reactive governance but instead in cultural/moral expectations of how you should "pull yourself up from your bootstraps" to be great. This view is often to the point many see removing the need to pull oneself up from their own bootstraps as removing the ability for them to better themselves (& wasting everyone else's money/freedom/whatever to do so). A soldier and an obese person are examples at polar opposites of that moral spectrum.
The policies just follow that. This comes up in all sorts of areas such as prison as punishment vs rehabilitation.
I think you're looking at an effect instead of a cause. The main reason for the desire for a small government is not some inherent and absolute obsession with smallness, but because of the belief that larger governments are incapable of effectively utilizing their power (for reasons beyond just incompetence), are prone to inevitable abuses, and so forth. And that belief itself is not simply ideological, but based on history through most of all time.
Even with rehab versus punishment - it's the same story. The view isn't that punishment is inherently superior, but simply that rehabilitation is more of an ideal than a reality, and that typical appeals to places like Norway - a relatively homogenous and extremely wealthy microstate - don't necessarily translate well to large diverse societies, especially ones where there are substantial chunks of society that adopt cultures that glorify criminality.
My views on this subject are far too detailed to want to get into here, but I am confused at your choice to call Norway a "microstate". It's certainly on the smaller side of countries, but there are over 5 million residents and 300,000km2 in size. It's just a normal country.
"Microstate" is a term generally reserved for tiny geographical locations that can't even support their own defense.
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.
To put it in context, the poor elsewhere were poor by class. No attempt to become rich was permissible by law so it was key that this supermajority of the population did not believe they were downtrodden, and unfairly opposed.
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.
America does a better job at assimilating immigrants than most of the rest of the world. It’s just a very hard problem, and the US does more of it than anyone.
I definitely wouldn't say my lineage had any call in "immigrating" into the US.
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.
Judging by the color of one's skins is one of the easiest and oldest ways to discriminate. Only behind by the contents of one's genetalia. But the latter at least has a biological need to care for one another.
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.
True, but this effect tends to diminish at the highest levels of wealth.
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
Its also about language and colloquialisms. If you grow up poor, but go to a school with many wealthy children, you will learn to speak the "language" of the wealthy, which is, in my opinion, what mostly explains the "having potential" that the ruling class will see in your as you enter adulthood.
I don't know why you got downvoted. If you don't believe this, read "Dying of Whiteness" by Jonathan Metzl. Something like 30% of this country will reject quality of life improvements for themselves if they see that it will also benefit people of other races who "don't deserve it".
The entire social structure of the south was (and mostly still is) based on wealthy whites convincing poor whites to accept the situation because blacks are even worse off.
Implementing solutions to prevent future harms is tricky and requires understanding systems we often don’t understand very well. For example with healthcare, people say that preventative medicine will reduce costs in the long run. But studies show that isn’t really true: https://jamanetwork.com/journals/jama-health-forum/fullartic.... Preventative care can improve health outcomes at higher cost, but the cost of the programs outweighs any savings from avoided costs later.
In the limit, one would expect that to be the case: at some point the marginal cost curves will intersect. I’m quite surprised that we are already at that point. I suppose more things are at the efficiency frontier than I had imagined.
It’s very strange to include caffeine in that list of unhealthy things. Everything else in that list is proven to be bad for society/health, except for caffeine. Why did you choose to highlight caffeine consumption when there is not really any evidence it causes health issues?
I don't think there's long term evidence for negative problems. However, high dosages of caffeine are dangerous and have killed people. Those dosages are easily achieved through the likes of energy drinks.
High dosage of water have also killed people. And easily achieved through energy drinks? I strongly doubt that. Most energy drinks are not any stronger than coffee
Lower dosages of caffeine kill you than the water dosages that kill you.
> 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.
The comment said “putting 3 cups of coffee in a can we drink 4 or five of in a day” that would be 1,000–1,500 mg of caffeine. The FDA guidelines is 400mg a day and drinking 1200mg quickly can induce seizures
16 oz can of white monster (stereotypical energy drink) has about 150mg of caffeine. A grande (16 oz) black coffee from Starbucks has about 310mg of caffeine. You would need to drink 2 16 oz monsters to get the same amount of caffeine as a single grande cup of coffee from Starbucks.
If you're just looking at caffeine intake you'd be better off switching from coffee to energy drinks.
edit: white monster has no sugar in case anyone was about to bring that up
It’s included in a list of things bad for “ society/health.” While overconsumption on that level would certainly be a health issue for an individual, it doesn’t even register compared to the other things he lists as a social issue, like chronic obesity and Tobacco use. It’s just weird and misleading to include it in that list, is all I was pointing out.
Big assumption that the average citizen’s opinion has any effect on what the government spends money on. It’s pretty easy to campaign on not doing X and then proceed to do X once you’ve won the election.
If you keep in mind that the median voter in a primary is 65, then the government we have seems to do a pretty good job of reflecting the opinions of the politically engaged subset of the population.
> What I've never understood is the weird dichotomy of preventive and reactive governance in the minds of US citizens.
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.
I don’t entirely agree, but it’s not inconsistent. The idea is that government is supposed to protect you from bad guys (criminals or enemy countries) but it’s not their job to protect you from yourself. If somebody wants to shoot you, the government is supposed to stop them. If you want to eat an entire cake for lunch every day, that’s your own business.
In the US there's an extreme attitude of "I'm not paying for someone else...", and any sort of preventative care, like a heart score test, would fall into that category. This attitude is grounded on the personal responsibility mindset, that every person is responsible for taking care of themselves. So, for the 800K people that had heart attacks, the attitude in the US is largely, "They should've been proactive on their own, gotten the $100 test. Their heart attack is their own fault."
It's easy to understand. US optimizes for whatever helps with more overall spending. They can print money and export inflation to others. All this new money then goes to the companies that hold power through lobbying.
While I agree the US meddling in the Middle East has caused wars/terrorism, the general US military presence globally is a massive benefit for the entire world. Once the US starts pulling back more (as they seem to want to do) we'll see more and more regional chaos that grows into trade disruptions and wars. Regional tomfoolery like the South China Sea stuff will occur all over the world and will escalate into wars.
> we'll see more and more regional chaos that grows into trade disruptions and wars
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...
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.
"Why not just skip the HbA1c tests? After all, you know they'll give you insulin. Just start taking it."
Do you think everyone with poor blood test indicators is aware of how unhealthy they are? How quickly they need to reverse course? Or do think there might be some possible validity to discussing your results with an actual doctor and understanding how acute your symptoms actually are? Do you think there are no side effects to statins and everyone should just be on one at all times, forever? Do you think there might be some value, for those patients, in discussing GLP-1s? Or nah, everyone can just like, go run 10 miles tomorrow because some 20 year old in SV said so?
I'm always deeply confused by people who think all medicine is "just repeat whatever ChatGPT said as if it's profound, like, duh - I'm smart and invincible and can't quite figure out that other people aren't me", in spite of them not knowing anything about medicine in the first place.
Because for the same behavior, risks are going to be very different on the other side. In my family, for instance, we need significant interventions to get a reasonable risk due to all the bad genetic factors. In my wife's family, not so much. So knowing how serious the risk seems much better than just handing statins to absolutely everyone.
Behavioral changes can only do so much to lower ApoB. It is a meaningful marker and may trigger additional workup. It may also signal that you should at least consider a statin.
ApoA is completely out of your control and will not change with behavioral modification.
So, no, you're incorrect that these tests are superfluous and all you need to say is "diet and exercise". Besides, even if that was always the answer to these results, you should still have a baseline to see if behavioral modification is doing anything.
'Preventing a heart attack' means taking life long medication to reduce the risk of heart attack by about 1%, which is worth doing, but complicates the maths a little bit. The scan doesn't magically make you healthy or 'much' less likely to have a heart attack
Sources? That 1% number is in my understanding wildly incorrect for statins, if that's what you're referring to. Are you comparing use of statins for people who already are low risk for heart attack over the next 10 years?
The argument made in the article seems inarguable, but I don't see how a coronary artery calcium score is going to prevent a heart attack. You gotta do statins, exercise, and eat right basically no matter what. FWIW I had a coronary artery calcium score ordered by my doctor at my last checkup. It was $120.
I assume they mean.. have the test and then act upon it with diet/exercise/medicine to prevent the heart attack
If you never had the test, maybe you don't know you are at risk and don't make any changes and then you get the heart attack
It’s also not just a “treat or not” decision. I have a family history and high test results so was already treating on the assumption I’m high-risk, but the scan revealed that we needed to be more aggressive. (And hopefully in a few years a scan will show we’re reversing the progression.) Personal data is always better than population data for treatment decisions.
This is the ultimate case for AI. Intelligence is partly scored based on predictions/planning, so if AI is really intelligent it should be able to tell what remediations are worth it and then lower your insurance cost based on following its recommendations. and back it up by backing those premiums itself.
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.
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.
It's something I've read a few times. Most of the studies I've seen say it's effect is modest at best. At least if it was a drug there wouldn't be enough evidence for it to get FDA approval (especially with all the "side effects" such as injury)
Arguably this is a limitation on how the studies were done, as nobody is going to pay for extensive studies since you can't patent exercise.
Diet and exercise tells people what to do, but not how to do it.
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.
Ok but if they acknowledge it's an addiction, that's still a medical issue requiring treatment. Maybe that means going to food addiction anonymous meetings but if GLP-1 is like methadone for food, why not do it?
If you are in a place where you truly can't control your habits then of course GLP-1s are an amazing tool. However, if you don't adjust your life-style you will relapse when you get off, so the real solution is to adjust your life style. Also, there are benefits to exercise that aren't connected to losing weight. In my experience, 100% of the people I know on GLP-1 drugs are not exercising. I'm sure I'll get 1000 responses of people who do, but in my experience they don't. So you put yourself in a position where you're not addressing the actual problem, you are on a drug for life, and you aren't being healthy in other capacities. Are there times where these drugs make sense? Yes. Of course. Spare me the lecture. Everyone I know on these drugs are middle class people who absolutely could be healthy but don't want to put in any work.
Bodies are all different. Diet and exercise can work for one person and not another. But the type of person who wants to believe all fat people are slothful, all unemployed people are lazy, and so on, will invent in bad faith the straw man argument that we think diet and exercise do not work at all. They're not worth engaging with.
I really can't believe there's anyone left who thinks deregulation solves anything. Everywhere it's tried it is a demonstrable failure. It's just an excuse for an uptick in profits at the expense of safety, the environment, etc.
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.
I have been disabled on medicare for 23 years. I have often told my doctors that if they spent the time and money to look at my biology more closely it would have saved the tax payers so much money from medicare and likability payments.
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.
I guarantee the Unhealthy Snack Industry has their top scientists hard at work trying to find some kind of formula to make people on GLP-1 drugs go back to craving the soda and doritos.
Insurance was invented to pay for emergencies. Your home insurance doesn't pay to perform routine maintenance on your roof, but neither will it pay to repair "normal" wear and tear. Your home insurance pays when a tree falls on your roof.
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?
>There's a paradigm shift needed in how health insurance works: optimize for total cost of care.
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.
> There's a paradigm shift needed in how health insurance works: optimize for total cost of care.
Value-based care, e.g. Medicare Advantage.
The idea is that the government gives you $X for the care of a patient, with multipliers on risk factors. The government's goal is for that to be basically exactly what care costs. The provider is incentivized to treat you for less. Which sounds perverse, but if they, for instance, deny all care, a patient will end up in the hospital and cost exponentially more than they would have through proper preventive care. It is not perfect, and it should be broader, but it is a strong optimizer for providing the right care to keep a patient healthy, without providing hundreds of unnecessary tests (and especially imaging) that are medically unnecessary.
It is absolutely a system that should be rolling out to more and more patients.
I'm interested in this intersection of technical problems where we already have the tech to solve it, but the bottlenecks are social/legal/financial incentive.
Recently there was an old lady in the family that had an appendicitis, an ambulance rejected her, and the next day it got worse, and at that point she was accepted, but it was a bit too late.
One hypothesis is that triaging is hard and there's a lot of demand so things only go in when it's bad enough (considering there was medical insurance, they aren't charging per patient, so there's no incentive to take on more patients). But if that were the case, then preventive measures would actually reduce the total burden on their system.
The more cynical hypothesis that I'm holidng is that that health system is maximizing for work, if there's 10 appendicitis per month, and they are all handled in time, that's maybe like 5 hours of billable hours per patient? But if the appendicitis becomes bad enough and there's a puncture, then you have infections, complications, the patients have to stay for weeks and often come back for checkups, we are looking at maybe 100 billable hours? So the financial incentive is there.
In that sense what I want to add is that the title would be completely wrong, the solution is not for the hospital to pay 100$ 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.
Nobody likes to say this out loud, but because the US healthcare system is largely based on “fee for service” billing, it is true by definition that the sicker the patients are, the more profit the providers make. So incentives for actually making people healthier have to be imposed in indirect ways.
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.
> We could remove these weird constraints by making health care a government service rather than a highly contorted pseudo-market, but that would not be the American way. It has to at least look like a market, even if it’s an ineffective, inefficient, opaque, corrupt one.
It is still a market (and a single-payer one, ultimately) in these places, but it is not a government service. It is the best solution: the government funds the appropriate cost of care, the provider group is financially responsible for meeting it, and they are incentivized directly to get it right.
The left needs to stop shrieking about Medicare-for-all and the right needs to stop pretending like it can even spell healthcare. There are good solutions.
> but also encourages just refusing to treat people.
It categorically does not. It would be foolish to do so.
Completely agree with your characterization of the current system but why does making healthcare a government service necessarily lead to better outcomes vs current state or a more sensibly constrained market?
Seems obviously right in terms of total cost to the median patient (less obvious for individuals in higher tax brackets), so I'm not disputing that. More curious about incentives to improve care delivery for better long-term outcomes.
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...
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...
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.
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.
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.
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.
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?
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/...
[4]: https://pmc.ncbi.nlm.nih.gov/articles/PMC9310198/
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.
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.
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.
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.
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
Thanks for the link. Will have to read it later.
> 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.
If you're just looking at caffeine intake you'd be better off switching from coffee to energy drinks.
edit: white monster has no sugar in case anyone was about to bring that up
I don't think that much caffeine is good for you, especially 4-5 times a day. But with everything else we gulp down it probably isn't priority #1.
Tangential, but I suppose this is a good time to highlight how caffeine undisclosed can in fact kill some people:
https://www.bbc.com/news/articles/c5y95yylxv7o
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.
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...
- 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.
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.
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.
ApoB is very responsive to diet and medication--you can lower it by about 85%.
'Preventing a heart attack' means taking life long medication to reduce the risk of heart attack by about 1%, which is worth doing, but complicates the maths a little bit. The scan doesn't magically make you healthy or 'much' less likely to have a heart attack
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.
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.
Who is "they"? Who is saying this?
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.
To me this is just subconscious denial/defending of their food addiction.
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.
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.
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.
That isn't to say this might not be the best solution for many people but I still wonder.
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.
[0] https://en.wikipedia.org/wiki/Baumol_effect#Healthcare
Value-based care, e.g. Medicare Advantage.
The idea is that the government gives you $X for the care of a patient, with multipliers on risk factors. The government's goal is for that to be basically exactly what care costs. The provider is incentivized to treat you for less. Which sounds perverse, but if they, for instance, deny all care, a patient will end up in the hospital and cost exponentially more than they would have through proper preventive care. It is not perfect, and it should be broader, but it is a strong optimizer for providing the right care to keep a patient healthy, without providing hundreds of unnecessary tests (and especially imaging) that are medically unnecessary.
It is absolutely a system that should be rolling out to more and more patients.
Recently there was an old lady in the family that had an appendicitis, an ambulance rejected her, and the next day it got worse, and at that point she was accepted, but it was a bit too late.
One hypothesis is that triaging is hard and there's a lot of demand so things only go in when it's bad enough (considering there was medical insurance, they aren't charging per patient, so there's no incentive to take on more patients). But if that were the case, then preventive measures would actually reduce the total burden on their system.
The more cynical hypothesis that I'm holidng is that that health system is maximizing for work, if there's 10 appendicitis per month, and they are all handled in time, that's maybe like 5 hours of billable hours per patient? But if the appendicitis becomes bad enough and there's a puncture, then you have infections, complications, the patients have to stay for weeks and often come back for checkups, we are looking at maybe 100 billable hours? So the financial incentive is there.
In that sense what I want to add is that the title would be completely wrong, the solution is not for the hospital to pay 100$ 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.
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.
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.