Overcoming Bias

Home-Based Group Insurance

Today U.S. employees are not taxed for medical insurance obtained through their employer.  Imagine instead that medical insurance only got a tax break if it was obtained through neighborhoods, i.e., groups of contiguous neighbors banding together to deal with medical insurance plans. 

Disadvantages of this proposal include a substantial cost of change from current arrangements, higher costs of changing homes, and that neighborhood groups formed for this purpose would probably have less expertise than firms in dealing with insurance plans.  Plans would probably offer simpler contracts and wider reputations to compensate for reduced customer expertise.

Advantages of this proposal include keeping medical insurance when you lose your job, better job-employee matching because job change gets easier, better matching of plan features to more-likely-to-be-similar customer preferences, and that neighbor social pressure might be more effective than coworker pressure in encouraging healthy behavior. 

Problems with administrative overhead, adverse selection, or a lack of long term insurance wouldn't be obviously any better or worse under this proposal. 

OK, this doesn't seem a huge win, but it is an interesting alternate, to remind us that things do not have to be as they are.

Medical Ideology

anon points us to David Newman, M.D. at his NYT blog:

Studies show that the early administration of beta-blockers to heart attack victims does not save lives, and occasionally causes dangerous heart failure. While two studies support the use of beta-blockers after heart attack, there are 26 studies that found no survival benefit to administering beta-blockers early on. Moreover, in 2005, the largest, best study of the drugs showed that beta-blockers in the vulnerable, early hours of heart attacks did not save lives, but did cause a definite increase in heart failure. Remarkably, the medical community has continued to strongly recommend immediate beta-blocker treatment. Why? Because according to the theory of the straining heart, the treatment makes sense. It should work, even though it doesn’t. Ideology trumps evidence.

The practice of medicine contains countless examples of elegant medical theories that belie the best available evidence.

anon points us to David Newman, M.D. at his NYT blog:

Studies show that the early administration of beta-blockers to heart attack victims does not save lives, and occasionally causes dangerous heart failure. While two studies support the use of beta-blockers after heart attack, there are 26 studies that found no survival benefit to administering beta-blockers early on. Moreover, in 2005, the largest, best study of the drugs showed that beta-blockers in the vulnerable, early hours of heart attacks did not save lives, but did cause a definite increase in heart failure. Remarkably, the medical community has continued to strongly recommend immediate beta-blocker treatment. Why? Because according to the theory of the straining heart, the treatment makes sense. It should work, even though it doesn’t. Ideology trumps evidence.

The practice of medicine contains countless examples of elegant medical theories that belie the best available evidence.

Minchin's Mistake

At Less Wrong, Vladimir Nesov approvingly cites Tim Minchin's poem Storm, vid here, text here.  It is an entertaining, passionate, articulate rant against fuzzy-headed thinking.  It is also seriously misguided:

By definition, (I begin)
Alternative medicine, (I continue)
Is either not been proved to work,
Or been proved, not to work.
Do you know what they call
'Alternative Medicine'
That's been proved to work?
-- Medicine ...

But, here's what gives me a hard-on,
I'm a tiny, insignificant
Ignorant bit of carbon.
I have one life,
And it is short and unimportant,
But thanks to recent scientific advances...
I get to live twice as long,
As my great-great-great-great
uncleses and auntses.
Twice as long!

Sadly, most anti-mystics think their strongest case is medicine.  They don't realize that the vast majority of medical treatments have no better supporting "scientific" evidence than the alternative medicine they deride, nor that modern medicine can only claim credit for a small fraction of our lifespan gains.  Someone needs to school them; they make the rest of us anti-mystics look bad!

Added: A colleague assures me most economic historians estimate we would be  pretty much just as rich and healthy today had the only "scientists" been researchers funded directly by firms, with no government, charity, or student funding. 

New Tech Signals

New tech is usually adopted not for direct productivity gains, but to signal one is in fashion, one is technically capable, etc.  From a Post Oped Tuesday:

President Obama's proposed health-care reforms include investing $50 billion over five years to promote health information technology. Most notably, paper medical records would be replaced with linked electronic records to try to improve quality of care and lower medical costs. The recently enacted stimulus package included $20 billion for health IT. ...

Yet while this sort of reform has popular support, there is little evidence that currently available computerized systems will improve care. ... Large, randomized controlled studies -- the "gold standard" of evidence -- in this country and Britain have found that electronic records with computerized decision support did not result in a single improvement in any measure of quality of care for patients with chronic conditions including heart disease and asthma. ...

My Cryonics Hour

To encourage people to sign up for cryonics, I've offered to debate influential bloggers on the subject.  Spurred by recent successes, and failures, I'll up the ante:

I hereby offer to talk for one hour on any subject to anyone who can show me they've newly signed up for cryonics.  You can record the conversation, publish it, and can sell your time to someone else. 

Yes, I know, this may not exactly be a huge incentive to most people, but its what I have to offer. 

Added: The Blogging Heads TV folks are interested in a cryonics debate, if that tips any of you influential bloggers over the line.

Trusting Sponsored Medical Research

The comments on a recent post raised the question of how much we can trust drug studies sponsored by the very companies that manufacture the drugs in question. On that point, a recent New York Times article may be relevant:

In what may be among the longest-running and widest-ranging cases of academic fraud, one of the most prolific researchers in anesthesiology has admitted that he fabricated much of the data underlying his research, said a spokeswoman for the hospital where he works.

 The researcher, Dr. Scott S. Reuben, an anesthesiologist in Springfield, Mass., who practiced at Baystate Medical Center, never conducted the clinical trials that he wrote about in 21 journal articles dating from at least 1996, said Jane Albert, a spokeswoman for Baystate Health. . . .

The drug giant Pfizer underwrote much of Dr. Reuben’s research from 2002 to 2007. Many of his trials found that Celebrex and Lyrica, Pfizer drugs, were effective against postoperative pain. . . .

“When researchers are beholden to companies for much of their income, there is an incredible tendency to get results that are favorable to the company,” said Dr. Jerome Kassirer, a former editor of The New England Journal of Medicine and the author of a book about conflicts of interest.

Is it naive to be astonished that it took this long for someone to notice that 21 scholarly articles had been published about clinical trials that had never occurred?

Loving Cranks to Death

From the latest Journal for the Scientific Study of Religion:

[David] Hume writes that clergy (at least those of radical sects) are inherently dangerous and that if allowed to compete with one another will inspire in their adherents "the most violent abhorrence of all other sects, and continually endeavor, by some novelty, to excite the languid devotion of [their] audience." He concludes that the solution is "to bribe their indolence, by assigning stated salaries to their profession, and rendering it superfluous for them to be farther active, than merely to prevent their flock from straying in quest of new pastures". Hume, an agnostic if not an atheist, takes the position that religion is not a public good but its opposite — a public bad — and that government intervention will avert the pervasive negative externality of religious controversy, which clergy create and that threatens public safety.

My colleague Larry Iannaccone:

Looking at Figure 1, one immediately spots the exceptionally low levels of religiosity in the Scandinavian countries and, conversely, the high level of religiosity in the U.S.  As predicted by [Adam] Smith, these extremes correspond to different market structures.  A single state-run (Lutheran) church dominates the market in every Scandinavian country.  In contrast, the United States enjoys a constitutionally mandated free-for-all in which hundreds of denominations compete and none has special status.

Eliezer a year ago:

Question Medical Findings

A recurring theme here is the difficulty in knowing whether some (much?) of modern healthcare is actually beneficial or not.  A couple of recent links that add support to that theme:

1. From JAMA, a new study analyzes more than two decades of heart care guidelines (that is, the guidelines that your doctor might follow in deciding how to treat you) from the American College of Cardiology and the American Heart Association. The study found that the overwhelming majority of recommendations are not supported by good evidence:

Level of evidence provides the link between recommendations and evidence base. Although there is significant variation among individual guidelines in available evidence supporting recommendations, the median of level of evidence A recommendations [i.e., those supported by more than one randomized trial] is only 11% across current guidelines, whereas the most common grade assigned is level of evidence C, indicating little to no objective empirical evidence for the recommended action. . . . Interestingly, our findings are reflective of a specialty — cardiology — that has a large pool of research to draw on for its care recommendations. Guidelines in other medical areas in which large clinical trials are performed less frequently may have an even weaker evidence-based foundation.

2. In this post, Dr. Eades criticizes (convincingly, I think) a recent study purporting to show that statins reduce mortality.

What is Medical Quality?

The most prestigious Boston hospitals are paid 15-60% more per procedure, but are not especially healthier:

Call it the best-kept secret in Massachusetts medicine: Health insurance companies pay a handful of hospitals far more for the same work even when there is no evidence that the higher-priced care produces healthier patients. ...

Brigham, Mass. General, Children's Hospital, and a few others are, on average, paid about 15 percent to 60 percent more than their rivals by insurance companies ... The hospitals that are paid at the highest rates ... have the bargaining clout to demand higher insurance payments. Often, that clout is based on a powerful brand name and elite reputation. ... Insurers pay to keep Children's happy because they know parents won't buy insurance that doesn't include access to one of the world's most prominent pediatric hospitals. ... One influential researcher found that Beth Israel's overall mortality rate was lower in 2005 than the mortality rates at both the Brigham and Mass. General, but the hospital and its doctors still earn 15 percent to 20 percent less for the same work. ... 

Spotty Deference

The public often defers to medical experts, but not always:

Imagine you are seated at a table with two bowls in front of you. One contains peanuts, the other tablets of the illegal recreational drug MDMA (ecstasy). A stranger joins you, and you have to decide whether to give them a peanut or a pill. Which is safest? You should give them ecstasy, of course. A much larger percentage of people suffer a fatal acute reaction to peanuts than to MDMA. ... 

As New Scientist went to press, the UK government's Advisory Council on the Misuse of Drugs was widely expected to recommend downgrading it, based on evidence of its limited harmfulness (see "Ecstasy's legacy: so far, so good"). Yet the government has already rejected the advice.

No doubt this is partly a reaction to the furore over the government's de facto decriminalisation of cannabis in 2004, based on another advisory council recommendation. Despite the fact that the move actually reduced the quantity of cannabis being smoked ... the government recently reversed it in the face of implacably bad press.

For evidence of how irrational and lacking in perspective the public debate has become, consider how the advisory council's chairman, David Nutt, found himself in hot water last weekend for comparing the harm caused by ecstasy to the harm caused by horse riding.

How does the public decide when to believe medical experts and when not to?