YHK - yet another hacker news clone

Medicare Will Pay $50k for Your Heart Attack. It Should Pay $100 to Prevent It

68 points brandonb 1 hour ago 25 comments

brandonb 1 hour ago | parent

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.

someguydave 1 hour ago | parent

But you know the result will be recommendations for diet, exercise and statins so why not skip the tests and just do those?

brandonb 59 minutes ago | parent

A few reasons:

- If you made a dietary change (e.g., more fiber and less saturated fat), the tests tell you whether it actually worked.

- Statins are dosed based on the LDL or ApoB reduction you need. The most powerful statins cut cholesterol by 50%, but at higher doses the risk of side effects does go up.

- Other medications like PCSK9 inhibitors and ezetimibe exist, and whether to use them depends on the other numbers. For example, PCSK9 inhibitors have a secondary benefit of lowering Lipoprotein(a), and statins and GLP-1s have a secondary benefit of lowering inflammation.

- If blood pressure, HbA1c, etc is high, then there's a slightly different set of diet advice and a very different set of medications. For example, lowering blood pressure through diet is mostly about reducing sodium and increasing potassium.

goodmythical 56 minutes ago | parent

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...

swed420 51 minutes ago | parent

> What I've never understood is the weird dichotomy of preventive and reactive governance in the minds of US citizens.

When the underlying economic model of CONSUMPTION = GOOD is viewed as a religion or universal law of nature, it's actually not surprising that people are irrational about this.

iamnothere 28 minutes ago | parent

Because people are unable to conceptualize the idea of government-funded voluntary preventative campaigns, despite these showing success in the past.

This may be partially due to the many all-or-nothing crusaders who would prefer to use force in their quest for full protection of the citizen. Many people overcorrect because they fear that even voluntary programs are steps in this direction. Trust is low.

We have a long and sordid history with extreme and failed prevention (prohibition, the Mann Act, war on drugs).

zamadatix 27 minutes ago | parent

Much of the US doesn't think of it in terms of proactive vs reactive governance but instead in cultural/moral expectations of how you should "pull yourself up from your bootstraps" to be great. This view is often to the point many see removing the need to pull oneself up from their own bootstraps as removing the ability for them to better themselves (& wasting everyone else's money/freedom/whatever to do so). A soldier and an obese person are examples at polar opposites of that moral spectrum.

The policies just follow that. This comes up in all sorts of areas such as prison as punishment vs rehabilitation.

lokar 17 minutes ago | parent

Everything is America is about race

fnimick 10 minutes ago | parent

I don't know why you got downvoted. If you don't believe this, read "Dying of Whiteness" by Jonathan Metzl. Something like 30% of this country will reject quality of life improvements for themselves if they see that it will also benefit people of other races who "don't deserve it".

bitmasher9 9 minutes ago | parent

America does a better job at assimilating immigrants than most of the rest of the world. It’s just a very hard problem, and the US does more of it than anyone.

fnimick 7 minutes ago | parent

Not everyone in this country who isn't white has ancestry from an immigrant (or at least not a willing one).

ElProlactin 6 minutes ago | parent

From Kurt Vonnegut in Slaughterhouse-Five:

  America is the wealthiest nation on Earth, but its people are mainly poor, and poor Americans are urged to hate themselves. To quote the American humorist Kin Hubbard, 'It ain’t no disgrace to be poor, but it might as well be.' It is in fact a crime for an American to be poor, even though America is a nation of poor. Every other nation has folk traditions of men who were poor but extremely wise and virtuous, and therefore more estimable than anyone with power and gold. No such tales are told by the American poor. They mock themselves and glorify their betters. The meanest eating or drinking establishment, owned by a man who is himself poor, is very likely to have a sign on its wall asking this cruel question: 'if you’re so smart, why ain’t you rich?' There will also be an American flag no larger than a child’s hand – glued to a lollipop stick and flying from the cash register.

  Americans, like human beings everywhere, believe many things that are obviously untrue. Their most destructive untruth is that it is very easy for any American to make money. They will not acknowledge how in fact hard money is to come by, and, therefore, those who have no money blame and blame and blame themselves. This inward blame has been a treasure for the rich and powerful, who have had to do less for their poor, publicly and privately, than any other ruling class since, say Napoleonic times. Many novelties have come from America. The most startling of these, a thing without precedent, is a mass of undignified poor. They do not love one another because they do not love themselves.

233mhz 24 minutes ago | parent

> and project a presence of power to deter acts of terror/war

uh? That's literally what causes terror and wars lmao

MaxHoppersGhost 8 minutes ago | parent

While I agree the US meddling in the Middle East has caused wars/terrorism, the general US military presence globally is a massive benefit for the entire world. Once the US starts pulling back more (as they seem to want to do) we'll see more and more regional chaos that grows into trade disruptions and wars. Regional tomfoolery like the South China Sea stuff will occur all over the world and will escalate into wars.

ThrowawayTestr 7 minutes ago | parent

People being free to destroy their bodies with food has nothing to do with everything else you mentioned.

flerchin 42 minutes ago | parent

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.

faangguyindia 38 minutes ago | parent

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.

thinkingtoilet 26 minutes ago | parent

I've never ever heard anyone say diet and exercise don't work. Is this something a real person has said to you in real life? Not on the internet?

WarmWash 21 minutes ago | parent

I have known at least two people, who while not making the claim that it doesn't work, do make the claim that it doesn't work for them.

To me this is just subconscious denial/defending of their food addiction.

triceratops 5 minutes ago | parent

Ok but if they acknowledge it's an addiction, that's still a medical issue requiring treatment. Maybe that means going to food addiction anonymous meetings but if GLP-1 is like methadone for food, why not do it?

paxy 4 minutes ago | parent

> They'll use flawed research to claim diet and exercise don't work for obesity

Who is "they"? Who is saying this?

declan_roberts 21 minutes ago | parent

We are getting very close to this with cheaper and cheaper glp-1 drugs. Soon they'll be free for any overweight American.

mythrwy 5 minutes ago | parent

I have to wonder what the longer term consequences of modifying peoples essential biological drives chemically will turn out to be in the long run.

That isn't to say this might not be the best solution for many people but I still wonder.

TZubiri 4 minutes ago | parent

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.