In 2012, Brown had coauthored a paper that examined every randomized clinical trial that compared stent implantation with more conservative forms of treatment, and he found that stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all. In general, Brown says, “nobody that’s not having a heart attack needs a stent.” (Brown added that stents may improve chest pain in some patients, albeit fleetingly.) Nonetheless, hundreds of thousands of stable patients receive stents annually, and one in 50 will suffer a serious complication or die as a result of the implantation procedure.
Almost twenty years ago, Robin Hanson set out to explain some puzzling facts about health care. Most notably, “users are losers” (my phrase). That is, if you take similar populations with different levels of health care spending, outcomes tend to be the same. Note that the term “similar” precludes the explanation that the people undergoing more procedures were sicker to begin with.
Robin reasoned as follows:
1. We know that some medical procedures are effective and improve outcomes.
2. However, on average, similar populations that undergo more procedures do not have better outcomes.
3. Therefore, there must be some fairly common medical procedures that worsen outcomes (at least on average), and these tend to balance out the helpful procedures.
For many years, I have been referring to these procedures with adverse outcomes on average as Hansonian Medicine. My own book on health care policy took this issue quite seriously. I preferred to talk about procedures with high costs and low benefits, and Hansonian Medicine as strictly defined means procedures with negative benefits.
Why do we have Hansonian medicine? Epstein cites doctors who are not as well informed as they should be, the threat of lawsuits, and the opportunity to make money doing procedures.
Hanson himself had an intriguing theory, which is that you undergo unnecessary procedures because your friends and family want you to “do something” when you are not well. They show that they care by encouraging you to visit a doctor and to undergo procedures. I think that this is right, particularly in end-stage procedures, where it is often the relatives rather than the patient who demand futile care.
All this raises the question of what to do about procedures with high costs and low (or negative) benefits. The centralized solution is to come up with a way to tell doctors not to undertake these procedures. One challenge with that is there may be specific instances where a doctor knows that a procedure will work, even though in many other cases it does not. Another challenge is that friends and family were not be persuaded by a centralized agency (aka “death panel”).
The approach that I advocated was to reduce third-party payments and let the patients sort things out for themselves as best they can.