I thought that was a really good and informative comment.

I don’t see much there that fits the description of preventive care and screening tests as commonly discussed except, perhaps, for dental checkups. Ironically, most people don’t have dental insurance and most of those who do, if not all, are subject to balance billing.

…just being whimsical with boundary conditions.

Tom

http://regionalextensioncenter.blogspot.com/2015/08/the-health-implications-of-us-gluttony.html

“Mitigation” goes mainly to “prevention” activities per his proffer, whereas “adaptation” infers post-dx treatment.

The boundaries are not so cleanly demarcated, though, are they? I am about to undergo 9 weeks of daily Calypso IMRT for prostate cancer. It’s a tx (“adaptive”?), but is “mitigative” (a “reversal”) in the sense that it will likely nuke and prevent my lesion from metastasizing, whereupon I’d need even more expensive tx (and it’s by no means clear what one can do “lifestyle-wise” to reliably avoid getting an adenocarcinoma). But, then, that will keep me alive long enough to perhaps encounter another dire clinical malady of even greater expense someday.

My old mentor Brent James, MD, M.Stat, of IHC, once noted to us that “don’t think we’re gonna QI our way out of the larger societal resource problem. Every optimal, effective treatment you provide today just insures that someone will face an older, sicker, more expensive patient down the line.”

Right on, Allan. A free market can decide–through millions of votes ( purchases)–not only what to prevent but what those costs should be. Otherwise, government and policy people are talking about fog…because each item needs a separate discussion on the agenda. One discussion: Eg. everyone as we get older acquires seborrheic keratoses. They are benign unimportant skin lesions. To prevent these would cost billions by having a dermatologist whack every new one with liquid nitrogen. It is cheaper to whack the ones that grow large and forget the small ones. Second discussion: It is easy to diagnose sickle cell disease and trait. If people who have this know they have it, they can choose to live outside of airplanes and avoid thousands of dollars in misery with thrombi and micro emboli all over the place.

Without a free market, we have to have our superiors in government discussing thousand of these individual preventive strategies, assesing risks and costs. We get it done free by the votes in a free market…as long as people are knowledgeable. Everyone can understand these simple risks if we approach them with respect and teach. The market works if we respect its participants.

Early diagnosis to date hasn’t proven that it saves money.

Prevention such as the flu vaccine might save money if targeted correctly. I am not aware of any other preventative methods that save money.

Proper infrastructure can save money and lives. Think of appropriate sewage control.

What does all markets are constrained mean when discussing healthcare? Does it mean there is no free lunch? Of course, but that doesn’t mean the free market isn’t the best way to go nor does it mean that a free market can’t take certain things into account. That is why I pointed out that the free market doesn’t prevent insurance, subsidies or other things that do not significantly alter the free marketplace.

A free market involves a willing buyer and a willing seller or at least that is how Adam Smith described a free marketplace.

“otherwise we will go for the fanciest thing that our insurance or personal finances will pay for, taking the cost as a marker for quality.”

That is because you are talking about markets and I am talking about free markets. The Soviet Union, present day Russia and Cuba all have marketplaces. The problem is they are not free marketplaces.

The consumer as a buyer and the insurer as a seller create what is known as traditional insurance. Too much coverage prices go up. Too little coverage and the consumer isn’t getting what he needs. The balance will be found in the free market place. But it is not government that decides profit margins and things of that nature rather the marketplace for if those profit margins are very high others will enter the marketplace with lower prices.

“In a fee-for-service system”

This is your problem. You are trying to decide what is best delivery system for me and others instead of letting the free marketplace make that decision. You are using the old Soviet style marketplace where government decides how things will be divided up and who should pay what to whom.

Get rid of that idea. Let capitation, FFS etc. all compete in the free marketplace. Let people be free and make their own choices. They know better what they need than you know.

> The answer is easy. Free market competition.

Not so easy. All markets are constrained in one way or another. That’s what makes them markets, if only to provide a place to sell your goods, a trusted medium of exchange, some kind of information exchange to convey the value. (“The market for sheep will be on the third Thursday of each month, in the sheep meadow south of town. All coinage may be brought to the bailiff for inspection to avoid cheating. Sellers must have all sheep present for inspection by buyers. All sellers will pay two pence to the bailiff to pay for the guards to keep out the sheep thieves.”)

In the market for preventive tests, though the need is great and clearly perceivable (“Don’t want to die of cancer!”), we as consumers rely on medical authorities to tell us what is necessary and sufficient — otherwise we will go for the fanciest thing that our insurance or personal finances will pay for, taking the cost as a marker for quality.

So what drives the competition is the question: What are we competing for? How do healthcare providers “win” in this market? In a fee-for-service system, they win by convincing the consumers to get the greatest number of the most expensive tests that the provider can get reimbursed for. Change the payment system to something that in any way pays for the outcome instead of the procedure — the maximum prevention for the least money — and the competition is upended. Then you get healthcare organizations (as Kaiser does) educating the consumer that, yes, you really need to test for colon cancer, but a mail-in stool test really is adequate for first-level screening — no need for a colonoscopy with its hefty co-pay unless we find something of concern in the stool test.

> If prevention works, it saves money.

Not necessarily, either in the aggregate, over long periods of time, or in individual cases.
Certain types of prevention will save money.

Others will cost more money, but be worth it in terms of lives saved and suffering avoided.

Some types of prevention will cost money, but could be supplanted by screening techniques that cost much less or even nothing. (examples, as I said, are the use of mammograms — especially computerized mammograms — and colonoscopies as initial mass screening for cancers.) These types are ones we would do well to focus cost-reduction efforts on. That does not happen under a fee-for-service system because we get paid to do the more expensive methods.

(Please take note that free market competition permits insurance and government subsidies.)