alt Hacker NewsMedicare Will Pay $50k for Your Heart Attack. It Should Pay $100 to Prevent It
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I'm too young for medicare, but when I asked my dr. to prescribe the heart scan, he kept stalling. When I followed up, he said my insurance wouldn't pay for it. Then I checked into pricing and it was $130 lol. If I have a family history, why would he assume I didn't want to pay the $130? I later found out that the his medical practice gets penalized by the insurance company for recommending "too many tests." So that plays into it.
What I've never understood is the weird dichotomy of preventive and reactive governance in the minds of US citizens.
We're willing to spend god knows what shooting rounds that cost entire mortgages to save miltary lives and project a presence of power to deter acts of terror/war, but then are also totally fine having people way as much as 4 or 5 people, eating several days worth of sugar for breakfast, smoking tobacco, putting 3 cups of coffee in a can we drink 4 or five of in a day, do next to nothing to adress recidivism of all classes of criminal, drag our feet kicking and screaming in to a semblance of modernity in worker protections...
Coronary CT calcium scans are getting more popular. But before getting one, I'd do these simpler tests first:
- ApoB - about 20% of people with normal cholesterol results will have abnormal ApoB, and be at risk of heart disease.
- Lp(a) - the strongest hereditary risk factor for heart disease.
- hs-CRP - inflammation roughly doubles your risk of heart disease
- HbA1c - insulin resistance is a risk factor for just about everything.
- eGFR - estimates the volume of liquid your kidneys can filter, and is an input to the latest heart disease risk models (PREVENT).
These are simple blood tests. You can get them for <$200 through my company or others:
https://empirical.health/product/comprehensive-health-panel
Imaging is great for detecting calcified plaque in your coronary arteries. But before you have calcified plaque, the above risk factors tell you about the buildup of soft plaque. And 4 out of 5 of them are modifiable through lifestyle, exercise, and medication.
> The CAC scan, which detects calcified plaque in the arteries, is recommended for adults with borderline or intermediate risk of coronary disease for whom the decision to start preventive therapy such as statin drugs remains uncertain.
That is such incredibly bad advice. DO NOT WAIT until a CAC tells you to start a statin. You know you need to start if your LDL is high right away.
My doctor referred me to get a self pay ($100 at the time) CAC 9 years ago. It was completely clear.
However last year I had a cardiac ultrasound and it showed calcification.
In reality the CAC caused a false sense of security. My LDL had been high the whole time and not managed with any intervention despite having been tested multiple times and showing high over that time. This was a failure by my doctors IMO. (No it’s not diet or weight related before people give advice).
I didn’t need a CAC to tell me everything was fine. I needed to be on a low dose of statin that whole time.
A clear CAC doesn’t mean you are safe. And a positive CAC is already too late and is not really telling you anything useful.
What people need to do is just watch your LDL regularly starting from any age (yes even some 20 year olds need to check this). Don’t wait to middle age. And no matter your age use whatever methods you prefer to get that down as low as possible. Think of it as cumulative exposure over time that matters.
(There are new oral PCKS9 inhibitors out now which is cool, but the reality is all the misinformation about statins has been bullshit, don’t be afraid of them.)
Its the fundamental problem of our age: everyone is building pieces of a system, and almost no one is actually looking at how those pieces fit together into a system.
This is not about (just) the healthcare system ... it's the core problem with:
- our legal system (millions of laws and rulings and zero effort spent reconciling them into a good system that treats everyone equally)
- our economic system (we reward people who create true wealth in many different ways ... but those rewards are wildly disproportionate to how much true wealth they add)
- our tax system (again, millions of laws, and yet the people who should be paying the most pay the least because of how they fit together)
- our electrical system (although, due to its centralization, this one is actually catching up much faster than the rest)
- insert any other system here
This is a little bit misleading.
'Preventing a heart attack' means taking life long medication to reduce the absolute risk of heart attack by about 1%, which is worth doing, but complicates the maths a little bit. The scan doesn't magically eliminate heart attack risk
The argument made in the article seems inarguable, but I don't see how a coronary artery calcium score is going to prevent a heart attack. You gotta do statins, exercise, and eat right basically no matter what. FWIW I had a coronary artery calcium score ordered by my doctor at my last checkup. It was $120.
Insurance was invented to pay for emergencies. Your home insurance doesn't pay to perform routine maintenance on your roof, but neither will it pay to repair "normal" wear and tear. Your home insurance pays when a tree falls on your roof.
Our healthcare system has co-evolved with insurance in a sort of partial free-market, partial heavily regulated environment. Arguably we get the worse parts of both: Kafka-esque beaurocratic mazes and shareholder value optimization for private firms.
There's a paradigm shift needed in how health insurance works: optimize for total cost of care.
Can the invisible hand do this when providers are offering mainly treatments with token preventative care visits thrown in?
I agree with the concept and idea expressed; paying for prevention is good and wise and we do far to little of it.
I don't like the title. I can't believe it is really $100. Even if the scan is $100 that doesn't fix things itself. There is the cost of whatever the treatment is etc. There are likely added expense from false positives (or similar idea), where it flags someone as needing more testing, new interventions when in fact they didn't...
I wish the article was more detailed on those costs (or at least not claim the cost is $100 when it is much more in reality, unless I am wrong about that and the fixes are free somehow). It feels like a biased promotion of this thing we like and/or have a financial interest in so lets make exaggerated claims that hopefully people won't notice.
Tangentially related: I'm about to turn 65 and would be punished if I continued to pay for my own healthcare. My Obamacare/ACA insurance here in the state of Washington costs me $70K/year with premiums, deductibles, meds, etc. That's just for me and my wife.
And you know what? It's totally worth it to me. This year I had 4 operations+10 ER visits and my wife had 3 brain surgeries+radiation and 2 ER visits. About $2 million worth of treatments, quite good care overall. So I'm willing to continue paying for private insurance. I am fortunate I can pay for it and would like not to make you good folks pay for it.
But Medicare won't let me without penalizing me permanently more an additional 10% for every year I don't go on Medicare. Luckily Washington has phenomenal Medicare. But it would be nice if I weren't punished for trying not to be a burden to the dwindling population of taxpayers.
Medicare isn't here to make you healthy, its just another conduit for private healthcare to suck as much money out of the system as possible.
Fully agree. Medicare should pay for:
- Gym memberships
- National park passes
- Exercise equipment and sports equipment
- Subsidies for heart-healthy foods
Medicare should also:
- Fine employers if their employees are working more than 40 hours a week, pay the fines out to affected employees tax-free
You should also just pay $100 yourself? I think the bigger issue is just ease. They should deregulate these so they are simple to get
We are getting very close to this with cheaper and cheaper glp-1 drugs. Soon they'll be free for any overweight American.
$100 does not "Prevent It". A $100 test detects atherosclerosis. Further treatment is required. I have no idea what the treatments are or their costs.
This is the ultimate case for AI. Intelligence is partly scored based on predictions/planning, so if AI is really intelligent it should be able to tell what remediations are worth it and then lower your insurance cost based on following its recommendations. and back it up by backing those premiums itself.
Home insurance can benefit from this too. I just got a quote on a property i looked at with a $20k/yr premium, partly because of being in CA with a slope and age of the property.
At $20k/yr, there should be some economic way of an insurance company essentially saying "instead of $20k a year in premiums, here is a $300,000 30 year loan to do preventive measures on the property, and if you do them, your policy will drop to a more normal $3k/yr" or something along those lines.
Same for diet and exercise.
They'll use flawed research to claim diet and exercise don't work for obesity, then the general public uses that research and claims, "Diet doesn't work for fat people."
Soon, everyone is convinced every guy with a trivial amount of weight to lose needs to be on GLP-1s.
And a CAC somehow magically prevents a heart attack?
In borderline cases it can tip the scale to prescribe statin rather than not. But telling you what has happened to your heart doesn't prevent heart attacks.
Medicare and medicaid are as a much a gift of revenue for the healthcare industry as it is socialized medicine.
The incentives align well -- people get healthcare for free and and healthcare service provider gets a nice, fat government check.
That's why we don't do preventive care -- our current sick care model is much more profitable.
I have been disabled on medicare for 23 years. I have often told my doctors that if they spent the time and money to look at my biology more closely it would have saved the tax payers so much money from medicare and likability payments.
Health care is actually sick care.
I obviously have a genetic condition because it runs through my mothers side of my family, but they refuse to look at my genetics. So, did. I found things. I begged a researcher to test me for a special sort of immune deficiency (ADA Deficiency) . The tests shows I have a partial immune deficiency. I showed it to my doctor and nothing.
When my condition flares up (Too mush ATP and GTP) it effects my brain and nervous sytem and I have to be institutionalized. Five times now. I keep telling them my mood problem is caused by an immune deficiency but now one cares.
Sorry, end of rant.
Medicare could be paying younger people to do the things necessary to prevent them from encountering the healthcare system later on in life. Really, if you're only going to cover part of the population based on age, you should want to cover the part of the population that 1) still produces economic output and 2) has fewer and less-expensive medical needs.
Prevention Vs. Cure...
(aka Proactive Vs. Reactive)
((aka Present Responsibility Vs. Future Response))
"An ounce of Prevention is worth a pound of Cure" (as the old expression goes...)
Observation: Most health insurance policies today, whether they are government or private corporation, national or regional, are based on the idea of paying for medical/health problems AFTER the onset of the health problem...
Prevention, preventative health, preventative medicine, and preventative programs -- would not only do a lot to preempt future health problems, but it would also save a ton of money (a ton of taxpayer money if the health insurance is a government sponsored one), as the above article so eloquently makes clear!
Observation: Some insurance policies do include some preventative health aspects -- but as medicine is complex and there are always new discoveries, there is always another step up, another higher level in what could be delivered...
In other words, these could always be improved...
"An ounce of Prevention is worth a pound of Cure" (as the article implicitly suggests...)
Anyway, great article!
Good luck getting any kind of scan from your doctor/hospital for $100.
I'm interested in this intersection of technical problems where we already have the tech to solve it, but the bottlenecks are social/legal/financial incentive.
Recently there was an old lady in the family that had an appendicitis, an ambulance rejected her, and the next day it got worse, and at that point she was accepted, but it was a bit too late.
One hypothesis is that triaging is hard and there's a lot of demand so things only go in when it's bad enough (considering there was medical insurance, they aren't charging per patient, so there's no incentive to take on more patients). But if that were the case, then preventive measures would actually reduce the total burden on their system.
The more cynical hypothesis that I'm holidng is that that health system is maximizing for work, if there's 10 appendicitis per month, and they are all handled in time, that's maybe like 5 hours of billable hours per patient? But if the appendicitis becomes bad enough and there's a puncture, then you have infections, complications, the patients have to stay for weeks and often come back for checkups, we are looking at maybe 100 billable hours? So the financial incentive is there.
In that sense what I want to add is that the title would be completely wrong, the solution is not for the hospital to pay 100$ for prevention, but for prevention to be more accurately priced, we should be paying 50k, and maybe even 100k for prevention, because we value it more than emergency action.
In a broader economic sense, there's a lot of cases where there's a huge difference between the cost and the value, Shkreli got a lot of heat for surging up medicine prices, but I don't think it's immediately obvious that something should be valued in proportion to what it costs. Maybe if we price heart prevention at 100K, there would be more incentive for everyone involved to just get a fucking pill to those in need, imagine how many people would jump at that opportunity to make it happen, call centers, bureocrats, NOC support, legal teams, all dedicated to making sure a pill gets to the patient before a heart attack does.
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Rugged Individualism. The Hero's Journey. Jesus Christ. The ethos of the one weird man and the one weird trick. None of these have anything to do with prevention. The myths of the western world are all about story arcs: conflict + resolution. And this is very much embedded in any venture, whether private-sector or public-sector. We much prefer to read the harrowing article of a poor brave man saving someone from a ridiculous dangerous situation than preventing it to begin with.
This truism, "an ounce of prevention is worth a pound of cure", is so true...that like so many truism, it has become a minor, persistent annoyance of thought. It can be safely filed away with the Austrian school of economics.
Scripps cardiologist Eric Topol (not commenting on this article): "That's wrong. The CAC is anything but definitive. Many patients are told they have significant coronary artery disease by calcium score and it turns out, by CT angiography or cardiac catheterization, they have normal arteries. No less anxiety (often chronic and severe) and unnecessary procedures that are induced by false positive CACs." https://x.com/EricTopol/status/2092682606815117763
Coronary calcium scans quantify calcified atherosclerotic plaque but cannot reliably distinguish stable plaques from rupture-prone plaques or detect noncalcified plaques, some of which may be particularly vulnerable.
https://www.ahajournals.org/doi/pdf/10.1161/JAHA.118.008564
https://www.jacc.org/doi/10.1016/j.jcmg.2017.03.005
https://www.atherosclerosis-journal.com/article/S0021-9150(1...