6 ms·

The answer to the headline is astoundingly obvious yet the article doesn't mention it once. The reason is regulation: you can't use a medical device that you've

The answer to the headline is astoundingly obvious yet the article doesn't mention it once. The reason is regulation: you can't use a medical device that you've hacked together unless it has been cleared by the relevant authorities as being safe. Sometimes it's a matter of simply getting a cheaper alternative through regulatory approval, but other times its just not worth the cost to prove a cheaper alternative is as safe as the more expensive one. Very annoying article about an interesting subject.

EamonnMR 8y ago
The agonizing part is that having incredibly expensive medical tools isn't safe either - it leads patients to avoid medical treatment because of the cost.
- jstanley 8y ago
  It's not meant to improve patient outcomes, it's meant to avoid liability.
  - aetherson 8y ago
    I wish people didn't phrase things this way. There's no single "meaning" to all of this. It's a bunch of different people with different priorities making different cost-benefit tradeoffs. I mean, what would you do if a loved one died at least in part because someone was trying to save $1,000 on their treatment? How would you feel? What if you were permanently disabled or put in months of agonizing pain, and there were more expensive options that would have had a lower chance of doing that? Or just might have had a lower chance of doing that? From the 10 miles up view, it's easy to say, "Holy shit, the US has such a high health care cost, we could get 97% of the same care at 50% of the cost," and that seems like a great idea. When you're personally looking at tragedy to save an amount of money that is not that significant for your specific medical case (the waste comes when it's applied to 50 more people who don't really benefit from it), the calculus looks very different. It may still be the right decision. But can we be compassionate about the victims of that decision? Then layer in that it is not in fact uncontroversially the case that this is what drives the costs of the US healthcare system. And layer in that there is unavoidable uncertainty about when a higher-cost procedure or device or medicine is really higher quality and when it's not, because we have well-founded limitations on how many experiments we can do on people. I don't think it serves anyone to take such a moralizing tone. Liability exists for a reason. These cost-benefit decisions are tough ones. Information is not perfect.
    - kiba 8y ago
      97% of the same care at 50% of the cost could be rolled into further R&D which improves outcome faster in the long run.
      - aetherson 8y ago
        Maybe! I mean, that's definitely one way it could go. Or maybe the extra money wouldn't get spent on medical R&D. Or maybe more money spent on medical R&D is reaching a cost/benefit asymptote where there's not much further gain. Or maybe a lot of things. And it's still cold comfort to be told that your or a loved one's inferior care today may (or may not!) be of benefit to a stranger 10 years from now. I want to be clear: I'm not arguing for the current status quo. I agree it has big downsides. I'm asking for people to acknowledge that there are hard problems here that aren't trivially fixed, and even to the extent that some problems are trivially fixed, they still produce some downsides.
    - mindslight 8y ago
      > what would you do if a loved one died at least in part because someone was trying to save $1,000 on their treatment? Accept that said loved one wasn't the type to spend $1,000 on something they didn't think was necessary, made the wrong decision, and lost. Same thing as if they were driving around in an old poor-crash-safety car and got T-boned. But embedded in your comment is an assumption that this $1,000 wasn't being paid by the patient, rather by some ambient health insurance company looking out solely for their bottom line. This double principle agent problem is a large part of the train wreck! A market cannot function without pricing information. So either we need to vastly simplify how cost sharing works and change the culture so doctors supply prices alongside treatment options, or we need to stop clinging onto the fallacy of having a functioning market. Here's an example of the principle agent problem at work. Right now I'm actually trying to price an expensive medication. The name-brand costs 50% more than the generic. Due to the way (privatized) Medicare copays work, the name brand is significantly less out of pocket for the first several months! After a whole year, the name-brand works out to be about the same. So to save money, I will be going with the name brand and driving up the general plan costs.
  - throwaway5752 8y ago
    Most of the time those are the same things.
crankylinuxuser 8y ago
Yep. And then you have to breach a very ugly topic most people don't like to discuss. When does regulation kill more people by not having the $thing versus having the $thing? And how many people would suffer complication/dying with the $thing? It's a very delicate balance, especially when you consider capitalist forces that encourage "move fast and break ~things~ people". The FDA is the chopping block for that... But also FDA overaction also kills people.
- BurningFrog 8y ago
  Right. The whole FDA system is set on the premise that inaction can cause no harm. This causes a lot of harm.
- hopler 8y ago
  For every suction pump and super glue getting held up by regulation, there is also a witch doctor or snake oil. People love to talk about the clever hacks in some poor country, but not the high cost in QALY of superstitious or scam practices. Since no one is clamoring to wholseale trade USA healthcare for India's, there are obviously done tradeoffs.
- throwaway5752 8y ago
  "Though FDA can trace its origins back to the creation of the Agricultural Division in the Patent Office in 1848, its origins as a federal consumer protection agency began with the passage of the 1906 Pure Food and Drugs Act. This law was the culmination of about 100 bills over a quarter-century that aimed to rein in long-standing, serious abuses in the consumer product marketplace." I have no personal doubt that the FDA has saved millions of lives in the US and internationally, and the balance of harm/good they have caused would would make the harm side look infinitesimally small. Also... I be interested in what cases you know that the FDA caused the deaths of people by overaction. There are people out there with axes to grind who thought they were going to get rich with some drug or device, who couldn't subsequently prove the safety and/or efficacy of their product.
  - silotis 8y ago
oarabbus_ 8y ago
"Other time its just not worth the cost to prove a cheaper alternative is as safe as the more expensive one" Sounds like a fatal flaw in the system which benefits manufacturers and insurance companies at the expense of consumers.
- warrenm 8y ago
  How do "more expensive" options benefit the insurance companies ?
  - oarabbus_ 8y ago
    Oh, they do. https://www.npr.org/sections/health-shots/2018/05/25/613685732/why-your-health-insurer-doesnt-care-about-your-big-bills https://www.npr.org/sections/health-shots/2018/05/25/6136857...
    - hopler 8y ago
      What about large companies that underwrite their own health insurance?
- shanecleveland 8y ago
  Not if you manufacture the cheaper alternative.
DontGiveTwoFlux 8y ago
You mischaracterize the article. It mentions the FDA, and perhaps more importantly other disincentives. Hospitals desire more expensive solutions because they get paid more for them. That is a second, enormous barrier. The incentives are clear here. The costs are high, between regulations, marketing, out-maneuvering rent-seeking incumbents, and cultural issues. The reward is low. No one will become a billionaire for doing this work.
bsder 8y ago
The problem is ethical: How many hours of peoples lives must I improve for every person I kill? If for example, you had a guaranteed treatment for obesity, but it killed 1 out of every 100 people it was used on, is it worth it? More than a few morbidly obese people would take those odds. I was at CES many years ago, and a doctor had developed an asthma monitor for his daughter. This monitor would alert him and the school nurse immediately, and possibly 911 immediately if the episode was bad enough. He couldn't get anybody to touch it because, at some point, it will miss an asthma event or the network will fail to deliver the event. And that child will die. And whoever sold the device will lose a multi-million dollar lawsuit. As soon as some company with really deep pockets figures out that "indemnification" would allow them to generate scores of medical devices that nobody else can take on, we're going to witness an instant monopoly.

EamonnMR 8y ago

The agonizing part is that having incredibly expensive medical tools isn't safe either - it leads patients to avoid medical treatment because of the cost.

jstanley 8y ago
It's not meant to improve patient outcomes, it's meant to avoid liability.
- aetherson 8y ago
  I wish people didn't phrase things this way. There's no single "meaning" to all of this. It's a bunch of different people with different priorities making different cost-benefit tradeoffs. I mean, what would you do if a loved one died at least in part because someone was trying to save $1,000 on their treatment? How would you feel? What if you were permanently disabled or put in months of agonizing pain, and there were more expensive options that would have had a lower chance of doing that? Or just might have had a lower chance of doing that? From the 10 miles up view, it's easy to say, "Holy shit, the US has such a high health care cost, we could get 97% of the same care at 50% of the cost," and that seems like a great idea. When you're personally looking at tragedy to save an amount of money that is not that significant for your specific medical case (the waste comes when it's applied to 50 more people who don't really benefit from it), the calculus looks very different. It may still be the right decision. But can we be compassionate about the victims of that decision? Then layer in that it is not in fact uncontroversially the case that this is what drives the costs of the US healthcare system. And layer in that there is unavoidable uncertainty about when a higher-cost procedure or device or medicine is really higher quality and when it's not, because we have well-founded limitations on how many experiments we can do on people. I don't think it serves anyone to take such a moralizing tone. Liability exists for a reason. These cost-benefit decisions are tough ones. Information is not perfect.
  - kiba 8y ago
    97% of the same care at 50% of the cost could be rolled into further R&D which improves outcome faster in the long run.
    - aetherson 8y ago
      Maybe! I mean, that's definitely one way it could go. Or maybe the extra money wouldn't get spent on medical R&D. Or maybe more money spent on medical R&D is reaching a cost/benefit asymptote where there's not much further gain. Or maybe a lot of things. And it's still cold comfort to be told that your or a loved one's inferior care today may (or may not!) be of benefit to a stranger 10 years from now. I want to be clear: I'm not arguing for the current status quo. I agree it has big downsides. I'm asking for people to acknowledge that there are hard problems here that aren't trivially fixed, and even to the extent that some problems are trivially fixed, they still produce some downsides.
  - mindslight 8y ago
    > what would you do if a loved one died at least in part because someone was trying to save $1,000 on their treatment? Accept that said loved one wasn't the type to spend $1,000 on something they didn't think was necessary, made the wrong decision, and lost. Same thing as if they were driving around in an old poor-crash-safety car and got T-boned. But embedded in your comment is an assumption that this $1,000 wasn't being paid by the patient, rather by some ambient health insurance company looking out solely for their bottom line. This double principle agent problem is a large part of the train wreck! A market cannot function without pricing information. So either we need to vastly simplify how cost sharing works and change the culture so doctors supply prices alongside treatment options, or we need to stop clinging onto the fallacy of having a functioning market. Here's an example of the principle agent problem at work. Right now I'm actually trying to price an expensive medication. The name-brand costs 50% more than the generic. Due to the way (privatized) Medicare copays work, the name brand is significantly less out of pocket for the first several months! After a whole year, the name-brand works out to be about the same. So to save money, I will be going with the name brand and driving up the general plan costs.
- throwaway5752 8y ago
  Most of the time those are the same things.

crankylinuxuser 8y ago

Yep. And then you have to breach a very ugly topic most people don't like to discuss. When does regulation kill more people by not having the $thing versus having the $thing? And how many people would suffer complication/dying with the $thing? It's a very delicate balance, especially when you consider capitalist forces that encourage "move fast and break ~things~ people". The FDA is the chopping block for that... But also FDA overaction also kills people.

BurningFrog 8y ago
Right. The whole FDA system is set on the premise that inaction can cause no harm. This causes a lot of harm.
hopler 8y ago
For every suction pump and super glue getting held up by regulation, there is also a witch doctor or snake oil. People love to talk about the clever hacks in some poor country, but not the high cost in QALY of superstitious or scam practices. Since no one is clamoring to wholseale trade USA healthcare for India's, there are obviously done tradeoffs.
throwaway5752 8y ago
"Though FDA can trace its origins back to the creation of the Agricultural Division in the Patent Office in 1848, its origins as a federal consumer protection agency began with the passage of the 1906 Pure Food and Drugs Act. This law was the culmination of about 100 bills over a quarter-century that aimed to rein in long-standing, serious abuses in the consumer product marketplace." I have no personal doubt that the FDA has saved millions of lives in the US and internationally, and the balance of harm/good they have caused would would make the harm side look infinitesimally small. Also... I be interested in what cases you know that the FDA caused the deaths of people by overaction. There are people out there with axes to grind who thought they were going to get rich with some drug or device, who couldn't subsequently prove the safety and/or efficacy of their product.
- silotis 8y ago

oarabbus_ 8y ago

"Other time its just not worth the cost to prove a cheaper alternative is as safe as the more expensive one" Sounds like a fatal flaw in the system which benefits manufacturers and insurance companies at the expense of consumers.

warrenm 8y ago
How do "more expensive" options benefit the insurance companies ?
- oarabbus_ 8y ago
  Oh, they do. https://www.npr.org/sections/health-shots/2018/05/25/613685732/why-your-health-insurer-doesnt-care-about-your-big-bills https://www.npr.org/sections/health-shots/2018/05/25/6136857...
  - hopler 8y ago
    What about large companies that underwrite their own health insurance?
shanecleveland 8y ago
Not if you manufacture the cheaper alternative.

DontGiveTwoFlux 8y ago

You mischaracterize the article. It mentions the FDA, and perhaps more importantly other disincentives. Hospitals desire more expensive solutions because they get paid more for them. That is a second, enormous barrier. The incentives are clear here. The costs are high, between regulations, marketing, out-maneuvering rent-seeking incumbents, and cultural issues. The reward is low. No one will become a billionaire for doing this work.

bsder 8y ago

The problem is ethical: How many hours of peoples lives must I improve for every person I kill? If for example, you had a guaranteed treatment for obesity, but it killed 1 out of every 100 people it was used on, is it worth it? More than a few morbidly obese people would take those odds. I was at CES many years ago, and a doctor had developed an asthma monitor for his daughter. This monitor would alert him and the school nurse immediately, and possibly 911 immediately if the episode was bad enough. He couldn't get anybody to touch it because, at some point, it will miss an asthma event or the network will fail to deliver the event. And that child will die. And whoever sold the device will lose a multi-million dollar lawsuit. As soon as some company with really deep pockets figures out that "indemnification" would allow them to generate scores of medical devices that nobody else can take on, we're going to witness an instant monopoly.