3 ms·

Just because you believe things simple doesn't make it so. I noticed, for example, that you haven't actually answered my questions. How do we measure quality

Just because you believe things simple doesn't make it so. I noticed, for example, that you haven't actually answered my questions. How do we measure quality of life years in any operationally useful way? Which healthcare is optional? Is acupuncture - which requires a healthcare license in some states - included? Why or why not? How does one expropriate the health care services provided on a cruise ship, and how does it prevent fraud when there is a sole provider of power, water, etc. to said services which can charge whatever they want? Surely you need strict cost controls, but in that case you don't need to expropriate in the first place. I don't follow what you suggest by the solution to the red herring, so here's a concrete example. I was near-sighted, and paid for new prescription glasses every few years. I decided to get Lasix surgery, which I don't regret, though now I need to get (much cheaper) reading glasses every few years. Is Lasix for this case non-medical? Who is the provider which would be charged? For that matter, are prescription glasses part of health care, and if so, do people only get basic glasses (like US Army slang "Birth Control Glasses"), or are fancier glasses included, and who pays for the cost difference? Are breast implants ancillary nonmedical services? Some women find that having larger breasts improves the quality of their lives. Does that make it ancillary or not? What about for women who had a double mastectomy and are depressed about the loss of her breasts? What about gender affirming care for transwomen? What about that guy I saw on TV who got breast implants because he lost a bet? There are similar issues for cosmetic dental treatment, where fixing a chipped tooth may depend on personal vanity and external perceptions - a model's career may be negatively affected by an ugly-looking tooth. Do we factor in the difference in potential earnings when figuring out quality of life years? And on and on. These are not simple problems, and there is no simple answer.

adolph 2y ago
Your typing skills are excellent [0]. Quality of life years is an imperfect measure, but a measure that exists [1] and addresses the current provisioning regime, dubbed “profiteering” [2]. Life’s complications are certainly soluble through relatively simple algorithms. For example, what to do on a cruise ship? Start with “is the care under the jurisdiction of this healthcare regime?” If no, then it is not addressed and entirely up to the individual. If yes, then the person must make their way to the nearest government healthcare facility. I would expect a significant uptake in medical tourism in this form. Examples like “birth control glasses”: just do the math. Minor likely benefit over a likely long time period for a medium cost. Same for any other example. Will people be unhappy because they value something at more than a standard deviation from the mean? Absolutely, same as people are unhappy now. Not very interesting. 0. https://en.wikipedia.org/wiki/Gish_gallop https://en.wikipedia.org/wiki/Gish_gallop 1. https://pmc.ncbi.nlm.nih.gov/articles/PMC317370/ https://pmc.ncbi.nlm.nih.gov/articles/PMC317370/ 2. https://news.ycombinator.com/item?id=42359960 https://news.ycombinator.com/item?id=42359960
- eesmith 2y ago
  Despite what you believe, I really am trying to highlight why your advocacy will likely go nowhere. I thank you for pointing out QALYs. I had not heard of it. I have read now a few journal articles, and none of them say that QALYs stand alone. For example, https://onlinelibrary.wiley.com/doi/10.1111/j.1524-4733.2009.00515.x https://onlinelibrary.wiley.com/doi/10.1111/j.1524-4733.2009... says: > Aggregate health gains, measured by conventional QALYs, are one of many inputs to the processes of individual clinical decision-making, societal or programmatic audit, or resource allocation. The other considerations, including equity and fairness, need to be considered separately in the conventional QALY approach. Or https://www.valueinhealthjournal.com/article/S1098-3015(24)02355-6/fulltext https://www.valueinhealthjournal.com/article/S1098-3015(24)0... is more recent article, from earlier this year, titled "Quality-Adjusted Life Years, Quality-Adjusted Life-Year-Like Measures, or Neither? The Debate Continues" > The assessment of effectiveness is not and can never merely be a technical exercise. Whatever measure of effectiveness is chosen—even one that has the seeming appeal of being “objective,” such as a clinical endpoint—implies a value judgement about the importance of the various aspects of treatment outcomes. > It is also important to remember that QALYs and their use to estimate incremental cost-effectiveness ratios inform, rather than dictate, decisions. Limitations of QALYs—or, indeed, any chosen alternative to them—can in principle be handled via careful deliberative processes or addressed by the consideration of other kinds of evidence and decision rules, as is typically the case in the HTA processes of many jurisdictions. My gallop gave specific examples which require value judgements, and therefore cannot be made with "relatively simple algorithms". "Same for any other example." You don't seem to understand that no matter what system is used, it's fundamentally driven by political decisions of what is appropriate. We know that politics means some healthcare systems will prohibit gender affirmation therapy. Can the person go elsewhere, where that is allowed, and pay for said therapy, or does the other system have to accept anyone who shows up, on a first-come-first-served basis? Your proposal seems to say that there can be no healthcare outside the government system, so those who want chiropractic treatment, those who want acupuncture, etc. are forbidden by law from even using their own money. (I picked these two because while the science doesn't support their efficacy, often require licensed practitioners because doing it wrong can kill people.) There are not simple solutions, and the longer you insist it's true the more cold shoulders you'll receive.

adolph 2y ago

Your typing skills are excellent [0]. Quality of life years is an imperfect measure, but a measure that exists [1] and addresses the current provisioning regime, dubbed “profiteering” [2]. Life’s complications are certainly soluble through relatively simple algorithms. For example, what to do on a cruise ship? Start with “is the care under the jurisdiction of this healthcare regime?” If no, then it is not addressed and entirely up to the individual. If yes, then the person must make their way to the nearest government healthcare facility. I would expect a significant uptake in medical tourism in this form. Examples like “birth control glasses”: just do the math. Minor likely benefit over a likely long time period for a medium cost. Same for any other example. Will people be unhappy because they value something at more than a standard deviation from the mean? Absolutely, same as people are unhappy now. Not very interesting. 0. https://en.wikipedia.org/wiki/Gish_gallop https://en.wikipedia.org/wiki/Gish_gallop 1. https://pmc.ncbi.nlm.nih.gov/articles/PMC317370/ https://pmc.ncbi.nlm.nih.gov/articles/PMC317370/ 2. https://news.ycombinator.com/item?id=42359960 https://news.ycombinator.com/item?id=42359960

eesmith 2y ago
Despite what you believe, I really am trying to highlight why your advocacy will likely go nowhere. I thank you for pointing out QALYs. I had not heard of it. I have read now a few journal articles, and none of them say that QALYs stand alone. For example, https://onlinelibrary.wiley.com/doi/10.1111/j.1524-4733.2009.00515.x https://onlinelibrary.wiley.com/doi/10.1111/j.1524-4733.2009... says: > Aggregate health gains, measured by conventional QALYs, are one of many inputs to the processes of individual clinical decision-making, societal or programmatic audit, or resource allocation. The other considerations, including equity and fairness, need to be considered separately in the conventional QALY approach. Or https://www.valueinhealthjournal.com/article/S1098-3015(24)02355-6/fulltext https://www.valueinhealthjournal.com/article/S1098-3015(24)0... is more recent article, from earlier this year, titled "Quality-Adjusted Life Years, Quality-Adjusted Life-Year-Like Measures, or Neither? The Debate Continues" > The assessment of effectiveness is not and can never merely be a technical exercise. Whatever measure of effectiveness is chosen—even one that has the seeming appeal of being “objective,” such as a clinical endpoint—implies a value judgement about the importance of the various aspects of treatment outcomes. > It is also important to remember that QALYs and their use to estimate incremental cost-effectiveness ratios inform, rather than dictate, decisions. Limitations of QALYs—or, indeed, any chosen alternative to them—can in principle be handled via careful deliberative processes or addressed by the consideration of other kinds of evidence and decision rules, as is typically the case in the HTA processes of many jurisdictions. My gallop gave specific examples which require value judgements, and therefore cannot be made with "relatively simple algorithms". "Same for any other example." You don't seem to understand that no matter what system is used, it's fundamentally driven by political decisions of what is appropriate. We know that politics means some healthcare systems will prohibit gender affirmation therapy. Can the person go elsewhere, where that is allowed, and pay for said therapy, or does the other system have to accept anyone who shows up, on a first-come-first-served basis? Your proposal seems to say that there can be no healthcare outside the government system, so those who want chiropractic treatment, those who want acupuncture, etc. are forbidden by law from even using their own money. (I picked these two because while the science doesn't support their efficacy, often require licensed practitioners because doing it wrong can kill people.) There are not simple solutions, and the longer you insist it's true the more cold shoulders you'll receive.