5 ms·

This is how Dutch public healthcare motivates its general aversion to medical testing, as many a foreigner finds surprising and incongruent to the generally OK

by brnt 2y ago

This is how Dutch public healthcare motivates its general aversion to medical testing, as many a foreigner finds surprising and incongruent to the generally OK level of healthcare outcomes provided by the system. You can test and detect, but the error margins are often large (so many false positives and/or false negatives), would generate way too much workload to follow up and thereby cost time and money for better leads. Plus, as you say, knowing early doesn't always or even often mean you can actually change the outcomes. Now, this is what they say... I have tried to find the actual literature they use to motivate their protocols, and apart from occasionally, have not been able to find that evidence. I'd love to have a resource that demonstrates these sorts of things.

fidotron 2y ago
I am not sure that is unique to the Dutch, it is the line I have heard in several countries. Heavy agreement on your last part - if there is substantial evidence to back this up I would like to see it. As it stands I personally prefer the idea of constant mass testing in order that we learn as much as possible as quickly as possible, including improving the tests from the resulting feedback loop.
- brnt 2y ago
  When I see the prices of some of that testing, I know that that cannot be the reason, and indeed, establishing personal baselines by regular testing can only be helpful. The aversion to it grounded on taking some average patient, I am convinced. I really wish there was more transparency, because test aversion is exactly the same protocol you'd invent if you were trying to save money. I want to be able to see which of the two we're dealing with.
  - radicalbyte 2y ago
    Given how the Dutch system seems to be designed to maximise paper filling and busywork instead of healthcare - and of course to make the insurance companies rich - it's no surprise that they're against it. Medical experts here have very little say in how things are run. It's all bankers and bureaucrats.
    - brnt 2y ago
      Do you have any sources for that? I've worked for a hospital and I've never been able to find anything approaching a complete balance sheet. Financing it utterly opaque, but I'd love to have something solid before I accuse anyone.
      - 6510 2y ago
        I'm far from an expert on this topic, more on the contrary. The surgeons use to run the hospital. In contrast with mba's they knew things. I don't know what the difference is precisely but I hear the ziekenfonds use to have people to divide money over treatments (set prices) without their salary depending on their choices. I don't know about the scale but longer ago we would just build hospital buildings and house a workforce of nuns nearby who had their own garden. Now we some how cant afford to put down a building and with realestate prices on the rise the salaries need to follow. We might not like the factory village concept but if you have to be on call all of the time it seems fkn convenient to me. Cut the salary and give the employees a house, seems a great perk. Employee shortage is also costing a fortune. We've created ambitious labor protection laws then we created a loop hole where all you have to do is pay 190% of the salary to a job agencies (uitzendbureu) and no laws apply, anything goes. If you don't like it you can go home. This didn't need to cost 90% of the salary. Unless our labor taxes are now that complicated(?) but that doesn't work as an excuse either. Our taxes not paying for education doesn't mean we don't have to pay for it eventually (+interest) I read they are also lacking the money to streamline the processes.
  - pessimizer 2y ago
    The reason this rings wrong for people is because the reasons early testing is dangerous are entirely social. People are motivated by fear to have every test available, doctors are motivated by fear of being accused of neglect by the patient, doctors are also motivated by the profit that they make from the tests, the manufacturers and patent-holders of tests are motivated to have them done as much as possible, the labs that do tests make money on the number of tests that are done, the nonprofits that campaign based on diseases are expected to message to increase testing for those diseases and accept money from manufacturers and patent-holders, there's motivation to exaggerate the danger of what's detected by the manufacturers and patent-holders of treatments for the disease, and there's motivation by researchers who formulate the criteria for determining whether a particular feature of something detected is potentially dangerous/deserves treatment, and a motivation to give them the most expensive treatment, regardless of whether that treatment is unpleasant; in fact if the treatment is dangerous, it opens up secondary markets. There's just an enormous number of tailwinds pushing overdetection and overtreatment. The sum of that is what's important, which is that when you test earlier, you often objectively end up with more death and suffering. Which is what a state-run national healthcare systems needs to look at, they can't get lost in the trees. You pick an optimum age for testing that shifts the balance to less suffering and death (and costs), and you look for specific exceptions (genetic, lifestyle, comorbidities) and test just those people early. Could there be a way in which all testing would help instead of hurt? Yes, but it's political and psychological and not likely to ever happen. You'd have to (as a patient) trust probability in general, and additionally you'd have to trust the probabilities that they're handing you haven't been distorted by the self-interest of others. Not likely for the foreseeable future; maybe 1000 years from now. If you want to do the study, all you have to do is compare the number of deaths from a thing when people are tested early to the number of deaths when people are tested late. Or just look for other people who have done them. If early testing obviously saved lives, the people who sell testing would tout them everywhere. Instead, they're stuck trying to look for angles to argue that lessening death and suffering isn't the biggest consideration. They recently did this to push breast cancer screening earlier again, by arguing that if you specifically look at black American women, they benefit from early cancer screening. So overall, breast cancer deaths go up, but that's just your privilege talking. Woke conglomerates. Ignore that black people have a unique, neglected, discriminated against, and poverty-ridden situation in the US; in fact, it might even be racist to point that out (in backwards land.) Of course, you definitely don't have to do the studies, plenty have been done. Anybody saying that they've looked and haven't found them has not looked or has seen them and is not telling the truth. Both positive and negative, about every test. The studies that support earlier and more testing are press released and marketed, though, while the others can be suppressed or simply ignored, unless some public health system or insurance company champions them, and of course they would.
- refurb 2y ago
  The evidence is out there in published papers that do health economic analyses of various interventions. On a population based level it makes perfect sense to not do things even if it could save lives. This is exactly what NICE does in the UK. If it costs more than 30,000 GBP to give one person one more full quality year of life, then it’s not worth it.
  - vidarh 2y ago
    To the point about NICE, it's worth pointing out that this is 1) not how NICE decides. Average cost per QALY being below the preferred level is one factor. Analysis of treatments they approve suggests the "actual" threshold is closer to 45k. 2) These are averages per treatment or protocol and in most areas the NHS spends less than the threshold by simply delivering based on clinical assessment of benefits, and so the threshold is limiting treatment mainly on the fringes where you find a few very expensive treatments with marginal benefits with no cheaper alternative. In practice NICEs threshold is what any insurer would do: You know how much money there is in the system and try to maximise health output with what is available to you.
    - refurb 2y ago
      In practice NICEs threshold is what any insurer would do This is what makes Americans getting upset their insurance rejects coverage for medicines so ironic. Single payer systems do the exact same thing. The difference is in the UK is the option is just isn’t brought up in the first place because the doctor already knows it’s not paid for.
      - vidarh 2y ago
        Even then, they'll happily bring it up if you mention you're fine with private referrals or recommendations for something that isn't covered. Almost all single-payer systems are single-payer only in the sense that everyone is covered by the public system, but without preventing people from going outside it. A very few - Norway used to - strictly limits what you can go outside the system for. In the UK about 10% have private insurance on top.
leto_ii 2y ago
> would generate way too much workload to follow up and thereby cost time and money for better leads Having lived a decade in NL, my impression was that keeping costs down is the top priority. Unless you have a serious chronic condition or were in an accident, good luck getting somebody to take a look at you. (irl, after a while you learn to push, exaggerate symptoms etc. or just go back home to get tests and treatment).
- brnt 2y ago
  Yep, the loudest people get the most help. There's no good solution for that other than to become a bitchy 'client'. It's unfortunate that despite the promises, you still have to 'use it correctly' if you want those good outcomes as a patient.
mort96 2y ago
It's not just about keeping costs down, but also about increasing quality of life. If you detect a benign cancer in someone, and they then go on to receive chemotherapy, you've massively decreased that person's quality of life for a significant period with no upside.
- iknowstuff 2y ago
  A benign tumor doesn’t spread and doesn’t warrant chemotherapy I believe? And if it’s actually cancer than I don’t understand how you would not want it gone as soon as possible to avoid metastasis?
  - Fire-Dragon-DoL 2y ago
    Well, this is talking specifically about the case where the cancer is benign. Of course you want a metastatic one gone. For the benign ones, that's going to hurt the person's body quite a bit
    - jvanderbot 2y ago
      I think the jump from "protein blood test" to "Chemotherapy" is a bit of a stretch. There are almost surely additional screenings and diagnoses going on there. And I don't think anyone is going into chemo for benign tumors.
      - Fire-Dragon-DoL 2y ago
        Makes sense. Is it possible for the two types of cancer to be confused? Should also point out that tests will negatively affect your life seriously either way, especially if these benign cancers are common. Think of the time spent going to/from the doctor, the incredible stress (am I dying?), the tests itself: it is damaging the person's life. Detection is good, false positives are unacceptable though.
        jvanderbot 2y ago

by brnt 2y ago

fidotron 2y ago

I am not sure that is unique to the Dutch, it is the line I have heard in several countries. Heavy agreement on your last part - if there is substantial evidence to back this up I would like to see it. As it stands I personally prefer the idea of constant mass testing in order that we learn as much as possible as quickly as possible, including improving the tests from the resulting feedback loop.

brnt 2y ago
When I see the prices of some of that testing, I know that that cannot be the reason, and indeed, establishing personal baselines by regular testing can only be helpful. The aversion to it grounded on taking some average patient, I am convinced. I really wish there was more transparency, because test aversion is exactly the same protocol you'd invent if you were trying to save money. I want to be able to see which of the two we're dealing with.
- radicalbyte 2y ago
  Given how the Dutch system seems to be designed to maximise paper filling and busywork instead of healthcare - and of course to make the insurance companies rich - it's no surprise that they're against it. Medical experts here have very little say in how things are run. It's all bankers and bureaucrats.
  - brnt 2y ago
    Do you have any sources for that? I've worked for a hospital and I've never been able to find anything approaching a complete balance sheet. Financing it utterly opaque, but I'd love to have something solid before I accuse anyone.
    - 6510 2y ago
      I'm far from an expert on this topic, more on the contrary. The surgeons use to run the hospital. In contrast with mba's they knew things. I don't know what the difference is precisely but I hear the ziekenfonds use to have people to divide money over treatments (set prices) without their salary depending on their choices. I don't know about the scale but longer ago we would just build hospital buildings and house a workforce of nuns nearby who had their own garden. Now we some how cant afford to put down a building and with realestate prices on the rise the salaries need to follow. We might not like the factory village concept but if you have to be on call all of the time it seems fkn convenient to me. Cut the salary and give the employees a house, seems a great perk. Employee shortage is also costing a fortune. We've created ambitious labor protection laws then we created a loop hole where all you have to do is pay 190% of the salary to a job agencies (uitzendbureu) and no laws apply, anything goes. If you don't like it you can go home. This didn't need to cost 90% of the salary. Unless our labor taxes are now that complicated(?) but that doesn't work as an excuse either. Our taxes not paying for education doesn't mean we don't have to pay for it eventually (+interest) I read they are also lacking the money to streamline the processes.
- pessimizer 2y ago
  The reason this rings wrong for people is because the reasons early testing is dangerous are entirely social. People are motivated by fear to have every test available, doctors are motivated by fear of being accused of neglect by the patient, doctors are also motivated by the profit that they make from the tests, the manufacturers and patent-holders of tests are motivated to have them done as much as possible, the labs that do tests make money on the number of tests that are done, the nonprofits that campaign based on diseases are expected to message to increase testing for those diseases and accept money from manufacturers and patent-holders, there's motivation to exaggerate the danger of what's detected by the manufacturers and patent-holders of treatments for the disease, and there's motivation by researchers who formulate the criteria for determining whether a particular feature of something detected is potentially dangerous/deserves treatment, and a motivation to give them the most expensive treatment, regardless of whether that treatment is unpleasant; in fact if the treatment is dangerous, it opens up secondary markets. There's just an enormous number of tailwinds pushing overdetection and overtreatment. The sum of that is what's important, which is that when you test earlier, you often objectively end up with more death and suffering. Which is what a state-run national healthcare systems needs to look at, they can't get lost in the trees. You pick an optimum age for testing that shifts the balance to less suffering and death (and costs), and you look for specific exceptions (genetic, lifestyle, comorbidities) and test just those people early. Could there be a way in which all testing would help instead of hurt? Yes, but it's political and psychological and not likely to ever happen. You'd have to (as a patient) trust probability in general, and additionally you'd have to trust the probabilities that they're handing you haven't been distorted by the self-interest of others. Not likely for the foreseeable future; maybe 1000 years from now. If you want to do the study, all you have to do is compare the number of deaths from a thing when people are tested early to the number of deaths when people are tested late. Or just look for other people who have done them. If early testing obviously saved lives, the people who sell testing would tout them everywhere. Instead, they're stuck trying to look for angles to argue that lessening death and suffering isn't the biggest consideration. They recently did this to push breast cancer screening earlier again, by arguing that if you specifically look at black American women, they benefit from early cancer screening. So overall, breast cancer deaths go up, but that's just your privilege talking. Woke conglomerates. Ignore that black people have a unique, neglected, discriminated against, and poverty-ridden situation in the US; in fact, it might even be racist to point that out (in backwards land.) Of course, you definitely don't have to do the studies, plenty have been done. Anybody saying that they've looked and haven't found them has not looked or has seen them and is not telling the truth. Both positive and negative, about every test. The studies that support earlier and more testing are press released and marketed, though, while the others can be suppressed or simply ignored, unless some public health system or insurance company champions them, and of course they would.
refurb 2y ago
The evidence is out there in published papers that do health economic analyses of various interventions. On a population based level it makes perfect sense to not do things even if it could save lives. This is exactly what NICE does in the UK. If it costs more than 30,000 GBP to give one person one more full quality year of life, then it’s not worth it.
- vidarh 2y ago
  To the point about NICE, it's worth pointing out that this is 1) not how NICE decides. Average cost per QALY being below the preferred level is one factor. Analysis of treatments they approve suggests the "actual" threshold is closer to 45k. 2) These are averages per treatment or protocol and in most areas the NHS spends less than the threshold by simply delivering based on clinical assessment of benefits, and so the threshold is limiting treatment mainly on the fringes where you find a few very expensive treatments with marginal benefits with no cheaper alternative. In practice NICEs threshold is what any insurer would do: You know how much money there is in the system and try to maximise health output with what is available to you.
  - refurb 2y ago
    In practice NICEs threshold is what any insurer would do This is what makes Americans getting upset their insurance rejects coverage for medicines so ironic. Single payer systems do the exact same thing. The difference is in the UK is the option is just isn’t brought up in the first place because the doctor already knows it’s not paid for.
    - vidarh 2y ago
      Even then, they'll happily bring it up if you mention you're fine with private referrals or recommendations for something that isn't covered. Almost all single-payer systems are single-payer only in the sense that everyone is covered by the public system, but without preventing people from going outside it. A very few - Norway used to - strictly limits what you can go outside the system for. In the UK about 10% have private insurance on top.

leto_ii 2y ago

> would generate way too much workload to follow up and thereby cost time and money for better leads Having lived a decade in NL, my impression was that keeping costs down is the top priority. Unless you have a serious chronic condition or were in an accident, good luck getting somebody to take a look at you. (irl, after a while you learn to push, exaggerate symptoms etc. or just go back home to get tests and treatment).

brnt 2y ago
Yep, the loudest people get the most help. There's no good solution for that other than to become a bitchy 'client'. It's unfortunate that despite the promises, you still have to 'use it correctly' if you want those good outcomes as a patient.

mort96 2y ago

It's not just about keeping costs down, but also about increasing quality of life. If you detect a benign cancer in someone, and they then go on to receive chemotherapy, you've massively decreased that person's quality of life for a significant period with no upside.

iknowstuff 2y ago
A benign tumor doesn’t spread and doesn’t warrant chemotherapy I believe? And if it’s actually cancer than I don’t understand how you would not want it gone as soon as possible to avoid metastasis?
- Fire-Dragon-DoL 2y ago
  Well, this is talking specifically about the case where the cancer is benign. Of course you want a metastatic one gone. For the benign ones, that's going to hurt the person's body quite a bit
  - jvanderbot 2y ago
    I think the jump from "protein blood test" to "Chemotherapy" is a bit of a stretch. There are almost surely additional screenings and diagnoses going on there. And I don't think anyone is going into chemo for benign tumors.
    - Fire-Dragon-DoL 2y ago
      Makes sense. Is it possible for the two types of cancer to be confused? Should also point out that tests will negatively affect your life seriously either way, especially if these benign cancers are common. Think of the time spent going to/from the doctor, the incredible stress (am I dying?), the tests itself: it is damaging the person's life. Detection is good, false positives are unacceptable though.
      - jvanderbot 2y ago