From: Damien Broderick (damien@ariel.ucs.unimelb.edu.au)
Date: Sat Jun 26 1999 - 07:45:01 MDT
Robin and others: this is the response from an Aussie medico. I suspect he
underestimates the risks to the poor in the USA, who I think might well die
or suffer drastically for lack of the treatment he assumes they'd get if
they were at grave enough hazard.
=================
>From: Robin Hanson <hanson@econ.Berkeley.EDU>
>
>A cryonet reader privately questions my claim that medicine has
>a low marginal value.
>
>The clearest evidence we have on this is the RAND Health Insurance
>Experiment [Newhouse et al, "Free for All?" '93]. [etc]
>======
I don't disagree with Hanson's basic argument. Everyone knows that the
greatest effects on health have been sanitation/hygiene/nutrition and
public safety and immunisation. The benefits of case-by-case management can
be dramatic for the individuals involved (emergency appendicectomy is one
good example), but on the population scale it pales in comparison to the 3
factors I've already mentioned.
However, there are a couple of things worth pointing out. Unfortunately I
can't do this as well as I'd like because I couldn't pull up an extract for
the RAND experiment. But judging from what's been said, I can say that
there are still a couple of important provisos to the finding. The first is
that the comparisons are between groups who ahve different levels of
insurance. However, they still live in the same society and would (I hope!)
have been randomised or case-matched so the the treatment groups were very
similar. In this context, you wouldn't expect much difference in health
outcomes because they are, for all intents and purposes, indistinguishable.
No-one is going to miss out on life-saving surgery. No-one is going to have
their heart medicine withheld. On the *key* issues, the groups would be
much the same. The paper doesn't test the "effectiveness of medicine",
because it's not comparing a group who receive medical care with a group
who don't receive medical care (an experiment that I doubt will ever be
performed). The paper doesn't actually test the "marginal effectiveness of
medicine" so much as it tests the cost-benefits of different insurance
options. And, not surprisingly, it found that most health indicators are
the comparable, but people who don't pay for their health care use more
services for very little benefit. <rant on> There is an obvious lesson here
for the architects of Australia's Medicare, but since they are mostly
brain-dead power-hungry public servants, there's very little in the way of
argument that could ever persuade them to think about the effects of what
they're doing beyond their personal feelings of cosmic significance. <rant
off>
The second issue is that other studies often look only at mortality, but
there's still an important role for treatment of morbidity in medicine.
While the RAND paper checked a number of physiological and self-assessed
wellbeing measures, it's not true that there were "no significant"
differences between the groups. At least one paper I found on Medline tried
to explain why eyesight was reportedly significantly improved in the
high-insurance group. In fact, I dug up this quote: "In a randomized trial
[the RAND trial] of the effects of medical insurance on spending and the
health status of the nonaged, we previously reported that patients with
limited cost sharing had approximately one-third less use of medical
services, similar general self-assessed health, and worse blood pressure,
functional far vision, and dental health than those with free care."
(Effects of cost sharing on physiological health, health practices, and
worry. Keeler EB; Sloss EM; Brook RH; et al. Health Serv Res, 22(3):279-306
1987 Aug.) The authors did conclude that "Overall, except for patients with
hypertension or vision problems, the effects of cost sharing on health were
minor." But this is a long way from Hanson's description. While I'd agree
with Hanson's general argument, I think he has overstated the case and (on
my limited information) tried to draw more succour from the literature than
is actually there to be had.
The other paper mentioned must be a dud reference. The Lantz paper I picked
up in that issue of JAMA doesn't actually deal with the topic Hanson uses
it for. The paper tried to answer whether altering the health-risk
behaviour of lower socioeconomic groups would lead to a significant
improvement in health outcomes. What the analysis showed was that lowest SE
group was at higher risk of mortality (hazard rate ratio of 3.2 compared to
2.34 for the highest SE group). But when the risk of modifiable behaviours,
such as smoking, was factored out, there was still a large difference
between SE groups (2.77 cf 2.14). This is indeed an interesting paper which
shows that even if we could stop risk behaviour, there would *still* be a
significant health risk in being low SE. Not really a surprise, but's it's
good to see it experimentally verified. But this doesn't seem to have much
to do with Hanson's argument. Perhaps he's thinking of another paper?
==============
Damien Broderick
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