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Britain has universal healthcare via their National Health Service.
In this system, the doctors are paid very poorly. Junior doctors—known as "resident doctors" since September of this year—have gone on strike about this several times in recent years.
In 2016, a dispute between the government and medical unions about new junior doctor contracts came to a head and the junior doctors didn't like the terms they were offered.
So, five strikes took place across all English public hospitals between January and April of that year.
During the protests, the vast majority of junior doctors did not report for duty.
As a result, more than 100,000 outpatient appointments and more than 25,000 fewer planned admissions had to be canceled.
Senior doctors and nurses also had to be redeployed to emergency services.
Hospitals acted to mitigate the impacts of the strikes, requiring some of the junior doctors on roster for emergency services to stay out, calling freelance locum doctors into the NHS, canceling holidays and study leave for staff groups, and asking private doctors for help.
But this wasn't enough to save the NHS' volume, and the backlog of appointments the strike generated was vast.
The strike reduced emergency arrivals and admissions, as well as elective admissions considerably:
When the strikes took place, patients who still came in had different characteristics, meaning still going to the hospital on a day where there were fewer doctors available was selective.
Go ahead and read these to see how. For reference, Charlson Score is a comorbidity index:
Given elective patients were older, emergency ones were younger, etc., a strategy to identify the impacts the strike had on patients given the reduced volume of care caused isn't obvious
So, these authors leveraged the proportion of junior docs at a hospital as an exposure index
Taking this interaction out, the impact of strikes on patient characteristics is no longer significant, and that result is precise enough with small enough coefficients that we're probably fine to go ahead with using this instrument.
So let's check: What happens to patients when they're heavily exposed to a strike?
In terms of readmissions within 30 days and mortality... nothing, not even when you stratify by exposure level or control for the severity of patient condition!
The volume of care provided by the NHS is reduced by strikes, but not so much that patients are harmed.
That means there's unnecessary care happening.
This study's conclusions, by the way, are not unique. There's actually a large literature on the effects of doctor strikes.
In 2008, Cunningham et al. provided a review, in which they noted that doctor strikes with variables lengths, participation, and so on, from Jerusalem to Los Angeles had similar non-effects, or even potentially positive effects on patient mortality!
The amount of care people consume might not just be so high it's wasteful, but so high it's harmful.
Meta-analytically, the impact of doctor strikes all the way through 2021 seems to be... bupkes. It just doesn't matter when doctors go on strike.
This finding holds up in low-middle income countries, for strikes that happen for nurses and other staff too, across many sites, and even up to 250 days of striking in one study.
Care volumes are definitely affected, appointments are missed, prescription numbers decline, etc.
And yet, people carry on, and maybe even get a little better off.
Now there's obviously important care doctors need to be there to provide, but most of the time people are visiting the doc, it's just not providing them or the healthcare system any value: It's payment for nothing
There are a lot of other ways we can see that people consume too much care, aided by plenty of different designs, like RCTs comparing more and less extensive screening protocols.
But to some extent, it should be obvious that people consume too much healthcare that's way too low-value.
Consider 's explanation for a variety of stylized facts about overprovisioning of care, to explain why it's a superior good:
You can also look at simpler data to see this, like the data showing that the health share of consumption does rise very rapidly with income, and thus the reason the U.S. spends so much on healthcare is primarily because it's very rich.
Relatedly, if you take a look at health expenditures per capita versus life expectancies, you actually see evidence of nonlinearities, such that past some level of spending, the superior good status of healthcare gets ugly because it stops generating returns.
We can go on, talking about ineffective but common treatments, overprovided medicines and overly long therapies and surgeries, and more, but I think my point is clear:
People consume too much healthcare, and it doesn't benefit them to do so.
To cut costs, they could spend less.
If you want to see a country like America cut its costs, you can eliminate all the inefficiencies, and then you'll still have to deal with the fact that Americans consume too much healthcare.
How much? I think Hanson and Cutler are right, at about 30-50% and increasingly more.
Oh and this is the vital role of insurers in the healthcare system: they are the hidden rationers that keep it running.
Sources:
mercatus.org/students/resea
sciencedirect.com/science/articl
sciencedirect.com/science/articl
onlinelibrary.wiley.com/doi/10.1111/14
sciencedirect.com/science/articl
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We have really excessive health care demand in the US. A lot of it is preventable, too.
How much would widespread use of ozempic reduce health care demand?
Another known demonstration of this is that when a medical practice acquires a CT scanner or an MRI, its members begin prescribing far more scans than they do when they have no machine.
This paper alludes to it: 10.1016/j.jacr.2007.09.017
Here’s a rundown of Trump’s health policy stances and his potential top priorities in a second administration.
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Have some doubts about the "signalling" explanation of health care spending - but if spending this much sends an important signal that society cares a lot about certain patients, what does society get from those people (or others) in return for the expression of care and loyalty?
This study (and associated result that strike improves mortality) is well-known.
What is not well known is that mortality isn’t always a good measure of healthcare quality *within* a country. Endlessly debated in health economics.
Mortality is an excellent measure of health
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One example. About 90% of carpal tunnel syndrome cases can be resolved with basic massage and stretching. People are getting extremely painful surgery and often the same symptoms return because the problem is basically working posture and a sedentary lifestyle.
This take by Professor Hanson, that 50% of healthcare spending is ineffective (signaling that the spender cares?) has been in my head approx 20 years since I read it on overcomingbias.
The fusion was because of a pars interarticularis defect causing what looks like a pretty bad Grade 2 spondylolisthesis. Could have been congenital or traumatic. Looks barbaric but when the frame is cracked not much choice. I'm a family doc and it's helped many of our patients.
all of this hate would be avoided if they just stopped doing the pointless expensive stuff, instead of these scams and rugpulls when they deny claims while your mom is recovering from chemo
This is very true. Over-consumption is a huge driver of runaway costs. Add to that, that certain services (like spine surgery) are reimbursed at wildly inflated rates, so the perverse incentives multiply.
PSA:
If you or someone you know has ever had an extended hospitalization, often several different types of hospital employees, specialists, and support staff may come visit you.
All under the guise of "just checking in", asking you benign questions, or making small talk for
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Here’s a rundown of Trump’s health policy stances and his potential top priorities in a second administration.
Malingering for secondary gain is a factor. There are a lot of benefits to consuming healthcare and there costs are socialized.
There is a ton of this sort of thing. Statins for instance. SSRIs.
The problems with these analyses is similar to Marxist thought on efficiency.
Marx could see that markets were destructive and wasteful. And in armchair logic, it makes perfect sense that a single firm producing ALL the widgets with best practices and total market share might
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I would love to see the data about *who* overspends..
For example how Asians “overspend” on fire insurance relative to other groups
It’s so convenient that these “better outcomes” that no one ever seems to be experiencing also save the insurance company billions of dollars in expensive procedures 
My sister is like this. She loves seeing her doctor and getting prescriptions. I think it’s party for the attention. Her bedside table supports a small pharmacy.
For orthopedic issues I agree 100% and I know from experience with a lot of wasted time&money on surgeries and poor rehab advice from professionals. Back&neck issues are often resolved from stress management, adjusting your sleeping position and simple rehabilitation.
Here’s a rundown of Trump’s health policy stances and his potential top priorities in a second administration.
It's a human behavior, but at least in the US it's mitigated by expense.
In socialist nations there's no feedback mechanism stopping this.
Can we see some stats on how american obesity/prevalanece of type 2 diabetes impacts healthcare?
I wonder how much of this is people traveling to the US for care, rather than Americans getting it. When we were at MD Anderson (top cancer hospital) we saw many foreign people (Saudi attire was prominent) also getting in to be seen. Maybe we do more of these procedures because
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People are not ready for this conversation. But everyone wants everything on a silver platter
I’ve had two successful spinal surgeries. The second was wildly successful. (No, that’s not ironic.)
n=1
Donald Trump returns to the presidency with big ambitions to shake up health care including public health institutions, federal health programs, and high costs.
It's because they make a profit from spinal surgery so they offer it even if its likely not needed. This shouldn't be difficult to understand, profit motivations will invariably have this effect. It's why circumcision is so routine in USA but not Europe, it's an easy cash grab.
"Americans spend more than anyone else on healthcare!"
"Yes, because we want to."
Fascinating!
Robin Hansons model is consilient with ev psych theories of friendship and allies.
Highly recommend this paper on friendship and the bankers paradox if you haven’t read it: cep.ucsb.edu/wp-content/upl
Like when my shoulder dislocated every step I took and the doctor ordered an MRI but I had to get X-rays and do 10 PT sessions before I could get the MRI?
To what extent is this driven by fear of litigation and the consumer desire that a physician 'do something'?
A good pop-economics book that talks about this quite a bit is Overcharged: Why Americans Pay Too Much for Healthcare
The single largest component of the problem is that doctors/hospitals are compensated based on volume, not outcomes. It isn’t truly “Healthcare” but “sickness management”.
A lot of health care costs go to long term care, of those of an age above the life expectancy, are you sure that all holds up?
Donald Trump returns to the presidency with big ambitions to shake up health care including public health institutions, federal health programs, and high costs.
I would love it if you could convince people to not show up in the ER at 3am with the sniffles.
Good luck
I am amazed the insurers don’t have better PR. The provider PR machine is crushing insurers.
If a strike of a few days impacted mortality it would be an incredible shortcoming of the system. Even over weeks, as you pointed out, there are safety measures to guarantee that urgent care is provided.
Readmission is a completely useless outcome in this context as well.
As a physical therapist, a majority of my medicare and no fault patients don’t need to be there. Simple home exercises would be suffice. If this were forced many clinics would close
Since you mention back surgery - I injured my back falling on the ice. I need specialized PT - it is the gold standard of care. I have had insurance companies fight me in paying for it - they would rather pay for $40-60K of ineffective surgery.
Really enjoyed this post and something I’ve wrestled with as a physical therapist in the states. I believe we overmedicalize every thing. Overuse of expensive diagnostics and treatments is rampant and not slowing down despite research making this apparent.
Americans pay up to $1300 for one month’s supply while those in Great Britain pay $92.* Stop the GLP-1 price hike! Keep affordable weight-loss meds in the USA! Sign the petition today.
I think the cost in and of itself is compounded by the fact that there is a money making venture afoot. Because we pay docs for looking at lab results instead of a wage, and expectations of the public.
Investment into public health saves $10 for every $1 spent.
Yep, ever go to a prompt care facility? It’s full of people with the cold or flu, which doctors can’t do jack shit about. People are just wasting their own and everyone else’s time and money.
Let’s say there’s a patient with high blood pressure. They don’t see a doctor because of a strike or rationed medical care and therefore are not treated. The negative impact will years down the line. How does any study measure this? Very few studies measure over years.
There's also a large quantity of drugs on the approved list that either should have black box warnings for dangerous side effects, or should not be on the market at all because they show no evidence of actually improving outcomes.
I has a friend- at 39 he, while reasonably healthy (trail riding, tubing, walking/running) went on a roller coaster and felt a pinch in his neck that persisted.
Within a year- boom- surgery to *fuse two discs*.
Pure insanity.
My favorite geographic-variation anecdote: A study found massive regional variation in oxygen use that couldn't be accounted for by the patient's demographic or medical characteristics. Looked like a clear case of excess utilization or fraud until someone factored in altitude.
Donald Trump returns to the presidency with big ambitions to shake up health care including public health institutions, federal health programs, and high costs.
sqrt(.10)=0.31 This is about the size of correlation between parental SES and child IQ right?
My second favorite geographic variation story comes from a study that compared spending on patients that died of cardiac conditions and found no benefit from doctors/hospitals that engaged in higher spending...because they didn't bother to compare *survival* rates.
The Geographic Variation story championed by Skinner et al at the Dartmouth group has taken a serious beating in the past 15 years. Worth taking a look at the literature if you're interested in this topic IMO. thehealthcareblog.com/blog/2016/09/2
The hospitals and doctors also force unnecessary procedures and stays on patients with insurance that will pay
Not just "consumed", they "are prescribed" too many therapies they don't need.
It'll get worse with Semaglitude and GLP1's.
Meanwhile, the people who are literally paid to bargain on behalf of the consumers against the healthcare profiteers are being assassinated on the street
Americans are lost and searching for something out there. They need God and a worthwhile life.
Think about this. I have to get a note (called a prescription) from an individual who is a kid. I have a higher iq and many years of experience. But I have to ask for permission. I can buy a gas powered chainsaw with no note.My Hmo offers acupuncture which is fake
I guess 2.2 billion of profit per quarter can pay for a whole lot of blue-check sock puppet accounts.
If the inflated medical costs in the US are actually legitimate reflection on the true costs on these procedures, then we need to stop acting like were in a rich society that's seeing medical innovation. Innovation drives costs down(computers, cars,ect..)
The media won’t tell you, and woke liberals are clueless: Trump’s roaring comeback is driven by everyday Americans fed up with soaring bills, not obsessed about a dozen genders or the right to a transgender bathroom. #AbookThatChangesEverything #TrumpWon
– There is something so weaselly about this thread. The verbiage keeps putting the blame on "Americans" and "people," but if doctors are at fault for ordering too many tests and procedures, then why not state as much upfront and more directly?
I mean you can get adderal and ssris at will by just going to a therapist once; doctors are the same. Oh what's that, your foot hurts? gee can't really tell why without 350 grand in tests, then we'll probably have to do a surgery for 3 mil. Meanwhile you just sprained your ankle.
Fascinating breakdown once again.
Would be genuinely curious to see a similar comparison of patient outcomes during the pandemic when elective procedure rates decreased
This has been the bleak reality for almost all of human history.
Until the chemists got involved and developed proper drugs and antibiotics, going to a doctor (across millennia and civilizations) had almost no impact. If you were lucky you might learn the name of the disease the
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