9 ms·

The issue isn't really that they're expensive - they are, they shouldn't be. Proactive access to care is good. The article kind of hints at this, but it comes

The issue isn't really that they're expensive - they are, they shouldn't be. Proactive access to care is good. The article kind of hints at this, but it comes down to Bayes theorem [1]. The general population has a relatively low incidence of disease, so even tests that are fairly reliable in a population with a high incidence of disease become super inaccurate when applied to the general population. Worse, false positives generally - especially in the US, due to high financial liability risk - end up involving expensive, invasive medical follow-up tests, and the probability of a false positive multiplied by the risk of the exploratory procedures outweighs a later diagnosis. No wonder annual physicals don't do much good. High-risk people should get periodic tests for the things they're at risk of, and people should be in a position to report issues they discover in the course of their lives. However testing otherwise-healthy people for things they probably don't have isn't likely to yield good results no matter how good the test. It's just math. [1] https://en.wikipedia.org/wiki/Bayes%27_theorem https://en.wikipedia.org/wiki/Bayes%27_theorem

orangepurple 3y ago
This isn't what happens. A huge volume of the people that come in to US hospitals are chronically ill people with no money and very commonly no regard for their own health. Quite often they are also disrespectful and combative to hospital staff. The system pays for their extended care and the healthy majority pays huge premiums to subsidize their care. The vast majority will be paying premiums vastly out of proportion to what they will use.
- deleted 3y ago
  [deleted]
- Klinky 3y ago
  This sounds like a delusionally extreme take, as if there is no in-between or nuance. You're either a victimized superhuman who never gets ill or a chronically ill scumbag with no regard for your health? Hardly realistic at all.
pbourke 3y ago
> High-risk people should get periodic tests for the things they're at risk of, and people should be in a position to report issues they discover in the course of their lives. How do you know if you’re at high risk for something? This assumes a medically literate and motivated person will seek care based on … what? Realizing that grandpa, great-grandpa and dad all didn’t live past their 60’s? High cholesterol and hypertension can be “silent killers” - how do you know to check for them?
- arcticbull 3y ago
  For what it's worth hypertension is a good example of a bad test - or a routinely poorly executed one, anyways. According to the AHA, blood pressure is supposed to be taken with feet flat on the floor, relaxed, and quiet for five whole minutes before, on an empty bladder, without caffeine and not having exercised within 30 minutes. I can count on zero hands the number of times I've had my blood pressure measured in accordance with this procedure in a doctor's office during a check-up. [1] It's a highly variable thing that can spike instantaneously and take a long period of time to return to normal without issue. Which is probably part of why 30% of people who get their blood pressure taken in a doctor's office will register a higher than normal blood pressure principally only in the doctor's office. This is called 'white-coat hypertension' and doctors and researchers are pretty split on whether or not this represents an actual problem. With that in mind, it makes this a pretty worthless test in the context of an annual physical. The optimal way to make a hypertension determination is a 24-hour continuous blood pressure monitoring cuff. You should take your blood pressure at home, on your own time, in a relaxed environment and if you see a consistently elevated reading, only then reach out to your doctor and set up an appointment to confirm with a 24h test. [1] https://www.heart.org/-/media/files/health-topics/high-blood-pressure/tylenol-hbp/aha_toolkit_poster_final_102618.pdf https://www.heart.org/-/media/files/health-topics/high-blood...
  - akiselev 3y ago
    > Which is probably part of why 30% of people who get their blood pressure taken in a doctor's office will register a higher than normal blood pressure principally only in the doctor's office. This is called 'white-coat hypertension' and doctors and researchers are pretty split on whether or not this represents an actual problem. With that in mind, it makes this a pretty worthless test in the context of an annual physical. My favorite conspiracy theory is that this is why we always have to wait so long after we're in the exam room but before the nurse comes in to take BP. My BP monitor's instructions say to sit calmly for 15 minutes for an accurate reading and I think that's what they're doing. Meanwhile, since the kids are so hyper it's not even worth trying the delay tactic so the pediatricians come in much faster.
smnrchrds 3y ago
This is better known as the base rate fallacy. https://en.wikipedia.org/wiki/Base_rate_fallacy https://en.wikipedia.org/wiki/Base_rate_fallacy
- jxf 3y ago
  This is a more specific version of the base rate fallacy, called the false-positive paradox. It's illustrated by a simple example. Suppose you have a test looking for an extremely rare genetic condition (say, 1 in 1 billion people have it). That means that the test needs to be extremely accurate (in this case, accuracy of .999999999) to avoid having so many false positives that it's worse than a coin flip about whether you have the condition or not. Therefore, in most cases you would be better off making a fake test that just says "no" every time.
  - CPLX 3y ago
    While what you’re saying is true there are other options besides giving up, like having people who test positive take another test or two to confirm.
    - jxf 3y ago
      It's true that there are other options. However, in the real world that might not help, because sometimes the erroneous circumstances which cause the test to be inaccurate will continue to persist. For example, genetic parental tests are very accurate... unless the parent being tested has chimerism, in which case you'll get the very confusing result that the child isn't your own, even under repeated testing.
lazystar 3y ago
I had a similar mindset as you describe here - but I no longer agree after experiencing long covid. My experience with long covid was made easier because of historical lab data from bloodwork tests that were taken pre-covid when I was a healthy 30 y/o white male. After suffering for months from (what I now know was) long covid, I went in for a checkup for some help. The blood test comparison of healthy me to sick me was invaluable, because the healthy tests established a baseline of my system at peak condition.
- throwing_away 3y ago
  How is that helpful? I guess for making a disability claim?
  - EdwardDiego 3y ago
    For comparing current results to historical to look for anomalous changes.
  - JumpCrisscross 3y ago
    > How is that helpful? It helps eliminate benign anomalous results in emergencies. I have a low neutrophil count. It is totally uneventful. Having that baseline means if I’m sick and have the works run, doctors need not start treating my neutropenia—that wasn’t caused by whatever is going on. More broadly, catching a vitamin D deficiency and allergy early probably saved some years of life and definitely improved my quality of life. Some doctors are test happy. Most are not. Finding the right fit is part of being a human in the midst of modern healthcare.
    - rolisz 3y ago
      Was your vitamin D deficiency and allergy related to long COVID?
      - JumpCrisscross 3y ago
        > Was your vitamin D deficiency and allergy related to long COVID Nope. Indoor lifestyle and and a proclivity for cold weather. And, like, allergies.
newZWhoDis 3y ago
Complete nonsense. If you get a bad result run the test a few more times to confirm before getting expensive exploratory surgery or something. Your attitude is actively harmful, real people suffer with uncaught diseases because we don’t routinely test “”healthy”” people.
- deleted 3y ago
  [deleted]
- rocqua 3y ago
  Running the tests again only works if the false positive rate is just due to noise. I.e. if the occurrence of a false positive is uncorrelated between re-tests. I guess most real false positives aren't due to noise, but due to the test triggering on something unrelated and rare. In that case re-testing will yield the same result.
- MobiusHorizons 3y ago
  I would urge you to do some more research. Over testing is well known to cause higher rates of unnecessary medical procedures. There are many ways it can break down. For instance, the test may false positive consistently if an individual has some other factor such as mediation, virus, or bacteria that confound the test. Tests are also only validated under certain criteria. For instance if the clinical trial only tested people who presented with certain symptoms, the efficacy of the test may be completely different on the general public.
  - newZWhoDis 3y ago
    Well then all that says is you need better standards for tests. Just because some tests might have alarmingly high false positive rates doesn’t mean all, or even most do.
EdwardDiego 3y ago
You make a good point. IIRC, the USA has a far higher rate of unnecessary MRIs "just to be sure"/to minimise liability.
- specialist 3y ago
  Overuse of MRIs are due to accounting and financing, not standards of care.
missedthecue 3y ago
I'm not sure how they can be cheaper. The bill for a checkup pays the nurse and the doctor for their time. Claims about some greedy capitalist coming in and taking massive profit margins can be discarded by pointing out that non-profit hospitals do not charge substantially different rates for identical checkup services. The way to make a checkup cost less is to pay doctors and nurses less. There are no pharmaceuticals, no surgeries, no complicated specialist medical equipment, and no expensive labwork involved in the price. Society generally doesn't agree with the notion that doctors and nurses should be paid less. Therefore, checkups are more or less priced appropriately. Paying high skilled labor for their advice simply costs a lot of money. Ask any dev contractor here on HN.
- MobiusHorizons 3y ago
  There is a lot more to it than that. At a bare minimum, you are also paying for the office rent, the administrative cost of billing through insurance, the administrative cost of the insurer, malpractice insurance, and the price of the doctor’s education. All of these factors (except maybe rent) are higher or even unique to healthcare in the US. Capitalism isn’t even to blame for most of these. A free market would have price transparency, and would incentivize direct billing over billing through insurance due to lower overhead. Just because it’s the USA doesn’t mean it’s capitalism. That said, nationalized healthcare also seems to be able to solve some these problems through collective bargaining on drug prices, and reducing the billing overhead.
- the_real_sparky 3y ago
  The Direct Primary Care model shows that the overheads for healthcare are definitely a very large contributing factor to high costs and poor patient experiences. Cutting out the insurance company and related overheads from the medical practice, lab tests, and pharmacy creates an incredible experience for the patient at a very reasonable cost. I was and continue to be baffled at the attention I receive under a DPC physician, as well as how low the associated non-subscription costs are (effectively zero with the elimination of urgent care and expensive tests). The doctors and staff at the DPC practice are all happy and stress-free. Our system is definitely broken.
danielscrubs 3y ago
This is quite the weird take. Maybe you meant to say that acceptable sensibility levels should be different depending on population sizes?
- danielscrubs 3y ago
  *sensitivity
sillymath2 3y ago
Bayes' theorem is not enough, I think you have to weight how expensive is the test, what are the consequences of false positives and true positives. For example a low price test with almost zero both false positive and negative rate whose associate treatment has low cost and risk and that can save life of patients seems to me a test that should be applied to anyone at risk.
- hgomersall 3y ago
  Bayes incorporates the false positive rate. In fact, using the posterior is exactly the point. It's just noting that the diagnostic power of many tests is not very high if the prior probability of the disease is low. All the points you make don't change that.
  - sillymath2 3y ago
    From a practical point of view, if the prior probability of the disease is low but the disease is mortal and there is a $0.1 test and $0.2 pill that cure the disease without having negative effects, I think that you should take the test and if positive take the pill. Knowing the posterior probability is not enough to decide what to do, you have to know what are the tools and trade-offs.
    - BryanBigs 3y ago
      Wouldn't you just give everyone the pill in this scenario?
      - hgsgm 3y ago
        This is how non-prescription supplements work.
amelius 3y ago
Ok, but then I'd like to see Bayes theorem being actually applied for different cases, instead of just hand-waving the issue away for all cases. Also, for some false positives there is no problem, e.g. vitamin D deficiency, where you can just take extra vitamins without much risk.
lwhi 3y ago
Surely the issue is the broken healthcare system in the US? Proactive care is good. Testing is good. However the insurance / healthcare cartel behaviour that's fuelled as a result is devastatingly expensive.
- kashunstva 3y ago
  > Testing is good. Not always. It depends on the performance characteristics of the test, i.e. the sensitivity and specificity. Tests with high sensitivity and low specificity often reveal indeterminate results that, in an effort to gain more certainty, expose the patient to significant procedural risk.
tpoacher 3y ago
Also relevant is the "Information Bias"
ClumsyPilot 3y ago
> people should be in a position to report issues they discover in the course of their lives What does this mean? Which issues? How many thousands of diseases are there? I have a friend who has low level of energy, everyone was calling him lazy his entire life. He thought thats just how life is. He cannot compare how it feel to be him with how it feel to be someone else. I convinced him to see a doctor about this at the age of 25. First doctor didnt take him seriously, didnt want to do any tests. The complains are very non-spesific. maybe you are lazy, maybe you are depressed. After weeks of fighting the medical system he discovered that he had a digestive issue, which led to low level of iron and low level of enegy. His entire life he was suffering from an easily treatable problem. Imagine he treated this at the age of 12, how many sports did he miss out on, how much academic achievement was missed, maybe his career and life trajectory would be different. A friend of mine struggled with back pain for 3 years. He coupst find the cause. It got so bad, he thought he'd become disabled. He left UK and went back to Romania to have support of his family. Suffenly in Romania he started getting better. Turned out it was vitamin D defficiency. I started taking Vitamin D agressively, 2,000 units daily, 5 times the recommended amount by the NHS. After taking it for 6 months I went private and did a first vitamin D test in my life - my level is 1/3 of normal. So how doea one know what is normal, if most people gp their entire life without ever doing a full blood test

orangepurple 3y ago

This isn't what happens. A huge volume of the people that come in to US hospitals are chronically ill people with no money and very commonly no regard for their own health. Quite often they are also disrespectful and combative to hospital staff. The system pays for their extended care and the healthy majority pays huge premiums to subsidize their care. The vast majority will be paying premiums vastly out of proportion to what they will use.

deleted 3y ago
[deleted]
Klinky 3y ago
This sounds like a delusionally extreme take, as if there is no in-between or nuance. You're either a victimized superhuman who never gets ill or a chronically ill scumbag with no regard for your health? Hardly realistic at all.

pbourke 3y ago

> High-risk people should get periodic tests for the things they're at risk of, and people should be in a position to report issues they discover in the course of their lives. How do you know if you’re at high risk for something? This assumes a medically literate and motivated person will seek care based on … what? Realizing that grandpa, great-grandpa and dad all didn’t live past their 60’s? High cholesterol and hypertension can be “silent killers” - how do you know to check for them?

arcticbull 3y ago
For what it's worth hypertension is a good example of a bad test - or a routinely poorly executed one, anyways. According to the AHA, blood pressure is supposed to be taken with feet flat on the floor, relaxed, and quiet for five whole minutes before, on an empty bladder, without caffeine and not having exercised within 30 minutes. I can count on zero hands the number of times I've had my blood pressure measured in accordance with this procedure in a doctor's office during a check-up. [1] It's a highly variable thing that can spike instantaneously and take a long period of time to return to normal without issue. Which is probably part of why 30% of people who get their blood pressure taken in a doctor's office will register a higher than normal blood pressure principally only in the doctor's office. This is called 'white-coat hypertension' and doctors and researchers are pretty split on whether or not this represents an actual problem. With that in mind, it makes this a pretty worthless test in the context of an annual physical. The optimal way to make a hypertension determination is a 24-hour continuous blood pressure monitoring cuff. You should take your blood pressure at home, on your own time, in a relaxed environment and if you see a consistently elevated reading, only then reach out to your doctor and set up an appointment to confirm with a 24h test. [1] https://www.heart.org/-/media/files/health-topics/high-blood-pressure/tylenol-hbp/aha_toolkit_poster_final_102618.pdf https://www.heart.org/-/media/files/health-topics/high-blood...
- akiselev 3y ago
  > Which is probably part of why 30% of people who get their blood pressure taken in a doctor's office will register a higher than normal blood pressure principally only in the doctor's office. This is called 'white-coat hypertension' and doctors and researchers are pretty split on whether or not this represents an actual problem. With that in mind, it makes this a pretty worthless test in the context of an annual physical. My favorite conspiracy theory is that this is why we always have to wait so long after we're in the exam room but before the nurse comes in to take BP. My BP monitor's instructions say to sit calmly for 15 minutes for an accurate reading and I think that's what they're doing. Meanwhile, since the kids are so hyper it's not even worth trying the delay tactic so the pediatricians come in much faster.

smnrchrds 3y ago

This is better known as the base rate fallacy. https://en.wikipedia.org/wiki/Base_rate_fallacy https://en.wikipedia.org/wiki/Base_rate_fallacy

jxf 3y ago
This is a more specific version of the base rate fallacy, called the false-positive paradox. It's illustrated by a simple example. Suppose you have a test looking for an extremely rare genetic condition (say, 1 in 1 billion people have it). That means that the test needs to be extremely accurate (in this case, accuracy of .999999999) to avoid having so many false positives that it's worse than a coin flip about whether you have the condition or not. Therefore, in most cases you would be better off making a fake test that just says "no" every time.
- CPLX 3y ago
  While what you’re saying is true there are other options besides giving up, like having people who test positive take another test or two to confirm.
  - jxf 3y ago
    It's true that there are other options. However, in the real world that might not help, because sometimes the erroneous circumstances which cause the test to be inaccurate will continue to persist. For example, genetic parental tests are very accurate... unless the parent being tested has chimerism, in which case you'll get the very confusing result that the child isn't your own, even under repeated testing.

lazystar 3y ago

I had a similar mindset as you describe here - but I no longer agree after experiencing long covid. My experience with long covid was made easier because of historical lab data from bloodwork tests that were taken pre-covid when I was a healthy 30 y/o white male. After suffering for months from (what I now know was) long covid, I went in for a checkup for some help. The blood test comparison of healthy me to sick me was invaluable, because the healthy tests established a baseline of my system at peak condition.

throwing_away 3y ago
How is that helpful? I guess for making a disability claim?
- EdwardDiego 3y ago
  For comparing current results to historical to look for anomalous changes.
- JumpCrisscross 3y ago
  > How is that helpful? It helps eliminate benign anomalous results in emergencies. I have a low neutrophil count. It is totally uneventful. Having that baseline means if I’m sick and have the works run, doctors need not start treating my neutropenia—that wasn’t caused by whatever is going on. More broadly, catching a vitamin D deficiency and allergy early probably saved some years of life and definitely improved my quality of life. Some doctors are test happy. Most are not. Finding the right fit is part of being a human in the midst of modern healthcare.
  - rolisz 3y ago
    Was your vitamin D deficiency and allergy related to long COVID?
    - JumpCrisscross 3y ago
      > Was your vitamin D deficiency and allergy related to long COVID Nope. Indoor lifestyle and and a proclivity for cold weather. And, like, allergies.

newZWhoDis 3y ago

Complete nonsense. If you get a bad result run the test a few more times to confirm before getting expensive exploratory surgery or something. Your attitude is actively harmful, real people suffer with uncaught diseases because we don’t routinely test “”healthy”” people.

deleted 3y ago
[deleted]
rocqua 3y ago
Running the tests again only works if the false positive rate is just due to noise. I.e. if the occurrence of a false positive is uncorrelated between re-tests. I guess most real false positives aren't due to noise, but due to the test triggering on something unrelated and rare. In that case re-testing will yield the same result.
MobiusHorizons 3y ago
I would urge you to do some more research. Over testing is well known to cause higher rates of unnecessary medical procedures. There are many ways it can break down. For instance, the test may false positive consistently if an individual has some other factor such as mediation, virus, or bacteria that confound the test. Tests are also only validated under certain criteria. For instance if the clinical trial only tested people who presented with certain symptoms, the efficacy of the test may be completely different on the general public.
- newZWhoDis 3y ago
  Well then all that says is you need better standards for tests. Just because some tests might have alarmingly high false positive rates doesn’t mean all, or even most do.

EdwardDiego 3y ago

You make a good point. IIRC, the USA has a far higher rate of unnecessary MRIs "just to be sure"/to minimise liability.

specialist 3y ago
Overuse of MRIs are due to accounting and financing, not standards of care.

missedthecue 3y ago

I'm not sure how they can be cheaper. The bill for a checkup pays the nurse and the doctor for their time. Claims about some greedy capitalist coming in and taking massive profit margins can be discarded by pointing out that non-profit hospitals do not charge substantially different rates for identical checkup services. The way to make a checkup cost less is to pay doctors and nurses less. There are no pharmaceuticals, no surgeries, no complicated specialist medical equipment, and no expensive labwork involved in the price. Society generally doesn't agree with the notion that doctors and nurses should be paid less. Therefore, checkups are more or less priced appropriately. Paying high skilled labor for their advice simply costs a lot of money. Ask any dev contractor here on HN.

MobiusHorizons 3y ago
There is a lot more to it than that. At a bare minimum, you are also paying for the office rent, the administrative cost of billing through insurance, the administrative cost of the insurer, malpractice insurance, and the price of the doctor’s education. All of these factors (except maybe rent) are higher or even unique to healthcare in the US. Capitalism isn’t even to blame for most of these. A free market would have price transparency, and would incentivize direct billing over billing through insurance due to lower overhead. Just because it’s the USA doesn’t mean it’s capitalism. That said, nationalized healthcare also seems to be able to solve some these problems through collective bargaining on drug prices, and reducing the billing overhead.
the_real_sparky 3y ago
The Direct Primary Care model shows that the overheads for healthcare are definitely a very large contributing factor to high costs and poor patient experiences. Cutting out the insurance company and related overheads from the medical practice, lab tests, and pharmacy creates an incredible experience for the patient at a very reasonable cost. I was and continue to be baffled at the attention I receive under a DPC physician, as well as how low the associated non-subscription costs are (effectively zero with the elimination of urgent care and expensive tests). The doctors and staff at the DPC practice are all happy and stress-free. Our system is definitely broken.

danielscrubs 3y ago

This is quite the weird take. Maybe you meant to say that acceptable sensibility levels should be different depending on population sizes?

danielscrubs 3y ago
*sensitivity

sillymath2 3y ago

Bayes' theorem is not enough, I think you have to weight how expensive is the test, what are the consequences of false positives and true positives. For example a low price test with almost zero both false positive and negative rate whose associate treatment has low cost and risk and that can save life of patients seems to me a test that should be applied to anyone at risk.

hgomersall 3y ago
Bayes incorporates the false positive rate. In fact, using the posterior is exactly the point. It's just noting that the diagnostic power of many tests is not very high if the prior probability of the disease is low. All the points you make don't change that.
- sillymath2 3y ago
  From a practical point of view, if the prior probability of the disease is low but the disease is mortal and there is a $0.1 test and $0.2 pill that cure the disease without having negative effects, I think that you should take the test and if positive take the pill. Knowing the posterior probability is not enough to decide what to do, you have to know what are the tools and trade-offs.
  - BryanBigs 3y ago
    Wouldn't you just give everyone the pill in this scenario?
    - hgsgm 3y ago
      This is how non-prescription supplements work.

amelius 3y ago

Ok, but then I'd like to see Bayes theorem being actually applied for different cases, instead of just hand-waving the issue away for all cases. Also, for some false positives there is no problem, e.g. vitamin D deficiency, where you can just take extra vitamins without much risk.

lwhi 3y ago

Surely the issue is the broken healthcare system in the US? Proactive care is good. Testing is good. However the insurance / healthcare cartel behaviour that's fuelled as a result is devastatingly expensive.

kashunstva 3y ago
> Testing is good. Not always. It depends on the performance characteristics of the test, i.e. the sensitivity and specificity. Tests with high sensitivity and low specificity often reveal indeterminate results that, in an effort to gain more certainty, expose the patient to significant procedural risk.

tpoacher 3y ago

Also relevant is the "Information Bias"

ClumsyPilot 3y ago

> people should be in a position to report issues they discover in the course of their lives What does this mean? Which issues? How many thousands of diseases are there? I have a friend who has low level of energy, everyone was calling him lazy his entire life. He thought thats just how life is. He cannot compare how it feel to be him with how it feel to be someone else. I convinced him to see a doctor about this at the age of 25. First doctor didnt take him seriously, didnt want to do any tests. The complains are very non-spesific. maybe you are lazy, maybe you are depressed. After weeks of fighting the medical system he discovered that he had a digestive issue, which led to low level of iron and low level of enegy. His entire life he was suffering from an easily treatable problem. Imagine he treated this at the age of 12, how many sports did he miss out on, how much academic achievement was missed, maybe his career and life trajectory would be different. A friend of mine struggled with back pain for 3 years. He coupst find the cause. It got so bad, he thought he'd become disabled. He left UK and went back to Romania to have support of his family. Suffenly in Romania he started getting better. Turned out it was vitamin D defficiency. I started taking Vitamin D agressively, 2,000 units daily, 5 times the recommended amount by the NHS. After taking it for 6 months I went private and did a first vitamin D test in my life - my level is 1/3 of normal. So how doea one know what is normal, if most people gp their entire life without ever doing a full blood test