Many aspects of US society today are organized under the assumption that if every individual pursues what is in his/her best financial interest, the "invisible hand of the free market" will produce the best possible outcome for everyone.
Yet here we have reputable doctors acting in their self interest, and the result is that they are ordering unnecessary surgeries for financial gain. Meanwhile, patients are essentially unable to protect themselves against this travesty.
Maybe in this case the invisible hand cannot be seen because it is not there?
This particular invisible hand has been hamstrung by malignant forces. Notably, the payer in a typical healthcare transaction is not the same as the recipient, splitting the typical buyer role into two.
Because health insurance is now commonly provided by employers because of World War II price controls, and because we have become accustomed to using health insurance to pay for all matter of health care, including routine visits, consumers are often ignorant of health care costs.
Customer A: My insurance will pay? Fine, let's do this. Cha-ching, price rises.
Customer B: My insurance will pay? Fine, let's do this. Cha-ching, price rises.
Customer C: Oh, insurance won't pay? How much? Whoa! How did the price get so high?
It's no surprise then that the invisible hand works in a way that appears flawed when one of its inputs (the buyer's sensitivity to price) is frustrated.
People of my persuasion often make the case that if automobile insurance worked the same as health insurance, and we used insurance to pay for oil changes, the price of oil changes would shoot up wildly. Reason being that you would no longer care what it costs.
Obviously the seller (the doctor in the case at hand) wants the price to be as high as possible. The invisible hand can't keep this in check—it cannot discipline the seller with lost sales—when so many buyers do not act with actual price sensitivity.
This is obviously not the case in patient-doctor relationships.
The standard Austrian response for those information assimetries are that an independent third party will arise that will offer an unbiased opinion (usual example is Underwriters Laboratory or UL).
A more government-based approach would say that more regulatory oversight is needed.
However, in practice, I haven't seen this happening, I'm not an economist but I see there are agency problems, regulatory capture problems, etc..
Stiglitz said:
"the reason that the invisible hand often seems invisible is that it is often not there. Whenever there are "externalities"—where the actions of an individual have impacts on others for which they do not pay, or for which they are not compensated—markets will not work well...
recent research has shown that these externalities are pervasive, whenever there is imperfect information or imperfect risk markets—that is always"
I broke my pinky toe when I was younger. The first doctor I went to said I needed to have surgery to place a pin in my toe and then have it taken out a month later, being relegated to walking on crutches for a whole month. I was told that if I didn't get the surgery/pin then my toe wouldn't heal properly and it could hurt for the rest of my life. I went to a second, more reputable doctor and he told me to just wear a boot for a week or two and start wearing shoes when the pain subsided. My toe is completely fine now and I have had zero problems. Since then I have definitely been wary of doctors.
I don't think many people believe that having every individual pursue what's in their best interest in a purely financial sense will result in the best possible outcome in every other sense. I always understood it as pursuing the best economic/financial result for you will result in the best economic/financial result overall, and even then, I think most reasonable individuals don't see that as an absolute law without exceptions.
My wife was in labor for a bit less than a day. Baby was fine, everything good, but apparently we were taking too long. Doctor demanded we do a c-section. When we said we wanted to wait, she walked out, slamming the door. We got scared, they made 60K for about 20 minutes of work. Guess what the c-section rate at that hospital is? 50%. Not kidding. I'm in the wrong business.
In Ontario doctors were allowed to switch to capitation, where they receive a lump sum for each patient under their care, rather than billing per service.
My personal physician loves it, he no longer wastes time filing for OHIP payments and no longer worries that maybe he is only ordering procedures to make more money rather than for a legitimate purpose.
This is a particular problem when diagnosing problems, is "your gut" or "your greed" telling you that the patient needs this $1000 test.
The two things I read in this article, minus the loaded language and assumptions:
1. "Medical offices which have equipment for certain services provide those services more often than offices that don't."
They've got the equipment in-house, so of course they're going to use it. The article doesn't take into account the possibility that patients are choosing to go to these offices _because_ they have the in-house facilities for the treatment they want. Going from "doctors who have X machine order X procedure more often" to "doctors treat patients like an ATM machine" is a huge leap.
2. "Some surgeons in Florida performed unnecessary surgeries for money."
There are bad apples in every bunch, this is why you get a second opinion before going under the knife. Yes surgeons get paid per procedure, yes it's a flawed system, but that doesn't mean they're all wheeling and dealing to get as many people to submit to surgery as possible.
It's worth noting also that whenever the article says "charged patients" what they mean is "billed patients' insurance company." Chances are the people who don't have insurance were the ones smart enough to see another doctor before paying.
This kind of fearmongering crap undermines confidence in medical professionals and medical science. The vast majority of medical professionals are extremely hard working, knowledgeable people who's primary goal is to help everyone that walks through their door. Without trust from their patients, they can't do this effectively.
As a medical professional I have witnessed this all first hand, to dismiss this as fear mongering is not very accurate. My experience was in the Cardiology field and how they use ultrasound procedures to basically increase the profitability of their practice. This was done by nearly every Cardiology practice in my community. When Medicare cut re-reimbursements of Echocardiograms guess what happened...they all just increased the frequency in which they ordered them. If you don't think a Electrophysiologist has a financial incentive to implant pace makers you're greatly mistaken.
> Going from "doctors who have X machine order X procedure more often" to "doctors treat patients like an ATM machine" is a huge leap.
I recall what a nurse once told me, that she was glad she doesn't have private insurance, because that can easily mean they put "tubes into every hole" even when there is no point in doing so (this was in the context of terminal cancer, mind you). That was in Germany, and not in some crappy backwater hospital either.
> There are bad apples in every bunch
Actually it's "a few bad apples spoil the whole bunch". So instead of blaming "fearmongering crap", maybe blame the bad apples, instead of just accepting them as given. Not that you don't have a point at all; trust is really required. But not blind trust, and not naiveté; those are just as unhelpful as unfounded distrust would be. As they say, nature abhors a vacuum.
I once read that traditional Chinese medicine practitioners work on a sort of subscription basis, where patients only pay when they are healthy, thereby creating a strong incentive for the doctor to get a sick patient back to health in a cost-effective manner.
I have no idea as to the veracity of the story or the effectiveness of such a model (and hold no truck with the pseudoscientific methods used by such practitioners), but it raises an interesting thought - would healthcare be more effectively funded through some mechanism other than private insurance or state funding? Might the debate over healthcare have been narrowed into a false dichotomy, when there may be a far better option lying unnoticed on the third hand?
This (where patients only pay when they are healthy) wouldn't work in the U.S. since a large percentage of people don't care about their health and most people are NOW oriented.
"Why should I: stop smoking, stop drinking excessively, exercise, or change my diet? If I get sick (not healthy), I don't have to pay my doctor!"
My question is, why do we keep talking about ACA like it provides care? It doesn't. It mandates insurance. If you need care, it still costs you more out of your pocket.
It seems like having the government cover all medical expenses through taxes is sort of like this. Since you pay more tax when your healthy (or I guess when you have more income).
This is why single-payer is the only way to go. There has to be some panel of disinterested experts evaluating the cost/benefit of a given treatment for a given illness, backed up by the buying power of something really huge. Yes, that's "death panels" to you Tea Party members following along at home.
Of course that wouldn't prevent any doctor and patient from doing whatever they wanted, at their own expense.
Medicare is essentially single-payer for old people, yet it's identified in the article as part of the problem. Like other government programs, it's so much better at measuring inputs (amount spent and procedures performed) than outputs, that there's an institutional bias in favor of overspending and overlooking corruption. ("Oh, no, that's not 10% more fraud and inefficiency this year, it's reaching 10% more of the needy.")
There's only one other sector of the US economy that's "single-payer": military procurement. And that's not known for its spending efficiency, either.
So it's not simply "single-payer" that magically saves money, but the specifics of the incentive system that's set up, and the other precedents from American federal governance are not positive.
Thank you for acknowledging that the main mechanism that a federal medical buyer monopsony (aka nationalization/single-payer) could use for cost-control is, essentially, "death panels" who say no to many treatments currently performed.
But can the American political system embrace that step, or will it wind up with single-payer without cost-controls? We wind up with the kinds of giant federal programs that can make it through the political system, and get implemented by the bureaucracy... not the kinds of idealized programs existing only in advocates' minds.
Finally, in single-payer systems, getting "whatever you want" done "at your own expense" is often effectively prohibited. For example, when the official system has particular limits (like price controls, limited participating providers, or waiting lists) for a covered procedure, it has often been illegal, in US Medicare or Canada's programs [1], to purchase that same procedure out-of-pocket/out-of-system for a negotiated price. Once you've nationalized, there's even a certain logic to such prohibitions: the system is straining under budget caps, and you can't risk the wealthy siphoning off capacity/copayments that could help support the common base.
Except having a single-payer system doesn't mean you'll have a panel of disinterested experts evaluating the cost/benefit of a given treatment. This isn't speculation, either. I've experienced the results of a "panel" going against the consensus of experts. It's the reason we left Quebec to come to the US, as at the time (2011) Quebec's policy for children with Autism was horrific. It hasn't changed.
I don't think single payer, per se, would do anything to help with this. The parts of the US healthcare system that are single payer, Medicaid and Medicare, suffer from this just as much as the rest of our system.
Having a government run healthcare system like Great Britain's would solve the problem, but it could do that with or without single payer. In fact, Singapore has had quite a bit of success combining a semi-government run hospital system with private payment for healthcare.
Yes, that's "death panels" to you Tea Party members following along at home.
Well, now that you've put it that way, the idea of a government-led panel -- rather than the family -- deciding that Grandma is too old to bother treating sounds so much better.
That's not even in the problem - if the doctor disagrees with the prescribed treatment plan, they have enough leeway to prescribe some other solution, that they believe to be better.
The advantage of single-payer, is that he will not have a profit motive to do so. And monopoly bargaining power on the side of the public.
I don't think single payer is the right answer especially for the USA. The US has a much stronger bent towards freedom, independence and self determination. I think some sort of hybrid, a la France, is more appropriate.
The first rule of politics is that unintended consequences abound.
That isn't to say that a single-payer is better or worse, but we should be methodical and careful when considering wholesale replacement of the incentive structures.
I take issue with the "most medical costs are accrued in the last year of life" point that gets bandied about. We don't know a priori which year is going to be your last! This makes the point into almost a tautology.
It would be incredible to do a meta-analysis and see if you could create a prediction model of mortality based on healthcare spending on individuals. It could be that as the slope of costs begins to rise you can actually figure out the mortality based on that alone and not based on disease mechanism.
>We don't know a priori which year is going to be your last!
For those times that incur large costs, I would bet that you could make a better-than-chance guess. What are the success rates of "extraordinary measures" ?
This New Yorker article examining major discrepancies in health-care costs between McAllen Texas (which is the 2nd most expensive health-care market in the country) and the town up the road was eye opening for me. The summary is that when doctors invest in medical facilities (like in-practice labs) they are financially motivated to direct patients to use those facilities.
"According to government estimates, each neurosurgeon at Halifax Health was generating more than $2 million a year in hospital profits. The hospital charged fusion patients an average of about $80,000, according to Florida records on Halifax Health analyzed by The Post, ranking the procedure as one of the more expensive."
Wow.
The image of the physician as somebody who is there to help relieve suffering is cemented as a meme, but the way the system seems to have evolved in the past few decades is towards help as a secondary duty if any.
Unfortunately, anyone who seems to want to speak out against the system is immediately rebutted with cries of "Why do you hate doctors?" and "They saved my babies!".
It is very hard to have an honest discussion and self-introspection in the current environment, especially with so much money at stake.
> "The image of the physician as somebody who is there to help relieve suffering is cemented as a meme, but the way the system seems to have evolved in the past few decades is towards help as a secondary duty if any."
To be fair, with spinal fusions in particular, when a review panel says surgery is "not medically necessary" they're recommending daily pain/numbness/loss of range of motion is better treated with narcotics/steroids/etc.
So it's hardly as simple as "doctors ignoring pain for profit". It can quite easily be "insurance company ignoring pain for profit".
You simply can't ignore the role of insurance companies. Their disincentivize to approve any treatment, necessary or not, to mitigate their own costs is also a well-studied problem.
US Healthcare System Explained in Six Succinct Points
1) A constant battle is underway between insurance companies that do not want to pay any claims, even legitimate ones, and doctors and hospitals incentivised to rip off patients, insurers, and taxpayers with unnecessary surgeries and Medicare fraud.
2) Insurance companies demand massive amounts of paperwork out of rational fear of fraud and unnecessary treatments. Doctors perform for-profit (as opposed to for-patient) procedures that guarantee more explanations and more paperwork.
3) Doctors and hospitals have direct personal contact with patients, but insurance companies don't. In cases where doctors put patients at huge risk with needless procedures and surgeries, it's easy for hospitals and doctors to point their finger at insurance companies. On the other hand, many sincere, honest doctors have difficulty getting patients the care they should have because insurers believe they are getting ripped off by unnecessary procedures, even when they aren't.
4) Doctors make needless tests out of fear of being sued for not doing them.
5) The vast majority of healthcare costs occur in final last year or so of someone's life. Politicians who want to do something sensible about this issue get accused of "rationing healthcare".
6) Doctors not only have a financial incentive to prolong life needlessly, they also worry about not prolonging life out of fear of being sued by family members unless there is a living will, and perhaps even if there is a living will.
Insurance companies typically pay out 100% of the money that comes in and they make money on the float. There is always this assumption that they are against higher prices of healthcare and that they battle the hospitals or the doctors. They don't, they just raise their premiums to match higher costs. More float equals more money for the insurance company.
I upvoted the article because it raises some important points about how people respond to incentives in the current health-care financing system in the United States, with a prediction of expected results under the Affordable Care Act as the act is implemented. The kind of comments I'd be delighted to hear from other HN participants is comments about what can be done about this.
On my part, I was just doing some Web searches for patient guides about how to select treatments and when to get second opinions. Regardless of how health care is paid for, patients sometimes need guidance about how to choose physicians, and how to choose treatments. (I know this for sure because my family lived in Taiwan for almost three years under Taiwan's single-payer national health insurance system, and we still had to decide which doctor to visit--we had choice in that matter--and whether or not to follow the doctor's treatment recommendation, which we sometimes followed and sometimes did not.) I'll keep looking for a user-friendly guide like that online, and if someone else commenting here can link to one, I'll be very grateful for that.
Interesting article, but the last premise is fairly disingenuous. He lists 6 reasons why healthcare is expensive, then claims that Obamacare doesn't fix any of them, but he's entirely wrong on at least 5 of the 6.
1. Medicare / insurance fraud --- The author obviously hasn't heard of the Health Care Fraud Prevention and Enforcement Action Team (HEAT). HEAT led to the record number of fraud charges in 2012. In addition to that, ACA standardized fraud convictions, so any provider convicted of fraud can no longer claim any federal money (Previously, a provider convicted of medicare fraud could still collect payments from medicaid et al).[2] These are only 2 provisions of the roughly 50 that directly address fraud. [2a]
2. Massive amounts of Paperwork --- This paperwork is moving to EHR / EMR systems that will file it automatically for the vast majority of patients. ACA mandates that the systems must use a standard format, so that any system built can communicate with all federal / private insurance carriers. [2]
3. Since doctors have direct contact with patients, and insurance companies don't it's easy for docs to blame insurance companies for unnecessary procedures --- I'm confused by this point, it seems a bit confused and contradictory toward his other points.
4. Doctors perform needless tests for fear of being sued --- The author has clearly never heard of ACOs. One of their primary goals is to limit the number of tests and procedures done. Insurance companies and the government will provide fairly significant bonuses when the cost of provided care comes in below average. [4a] In addition, the ACA provides research grants to study best practices and patient outcomes, having published, peer-reviewed research for common diagnoses will greatly limit the ability to sue for stuff considered CYA. [4b]
5. End of life care is insanely expensive --- This would've been addressed in the ACA, but Sarah Palin, Newt Gingrich and their dimwit followers torpedoed the 'death panels' to score some cheap political points.
6. Life is prolonged without living will --- Again, thank Sarah Palin, Newt Gingrich, and the Fox News brigade for their insane rants against 'death panels' which would have directly addressed this.
5&6 - it is nonsense to lay the blame for any aspect of the ACA/Obamacare at the feet of the Republicans (they hated on a lot more than the death panels, many things that also came to be). The Democrats own every vote in its favor, and they could have any version of the bill they desired. They are responsible for any perceived problems with the legislation.
So, the point they're making on 3 is that hospitals and docs are incentivized to bill for as much as they can (needed or not), with the expectation that some of it won't make it through the bean counters back-and-forth with the insurance company. Conversely, docs who prescribe only the necessary care can expect to still have claims denied because of the overall abuse of the system. That's what they mean.
If anyone is interested, go read the O'Reily book "Hacking Healthcare" to learn about how brainfucked the system is.
these are all laudable improvements but nibble around the margins... if Obamacare had cost insurance companies, doctors, hospitals, big pharma, or lawyers a penny it would never have passed.
It seems fun to hate on "evil" doctors, but why do we consider doctors as any different from "personal business consultants" who's business expertise is health?
I'm curious how you guys think medical professionals should actually be paid / how can pricing be done "fairly" in a system where there can never be "information symmetry"?
I can only speak for myself; I made very good experiences with doctors whenever I myself was sick, but I also worked for 11 months on a cancer ward a while ago, and some of the stuff I saw there was kind of rage inducing. Nearly all nurses were fine, most doctors were fine, but the ones that weren't, really really made up for that. I don't think doctors are all evil, nowhere near, but the reservations and skepticism I do harbour, I don't harbour because it's "fun" to have them. It's merely a way to cope with real shitty stuff that does exist.
> I'm curious how you guys think medical professionals should actually be paid / how can pricing be done "fairly" in a system where there can never be "information symmetry"?
First off, of course there can be "information symmetry". Not between patient and doctor as much as among medical professionals and health insurance providers. Medicine isn't Voodoo, things are reasoned about and tested, usually, and given the right laws and enforcement of them, everything can be documented and subject to review.
As for how to improve the situation: while I haven't thought in-depth about this, but how about a flat hourly rate for doctors etc.? That is, not being paid for the kind of treatment, but rather for being on the job. Of course, the hospital would need money depending on what kind of treatments they do, but if there was no (legal) way to pass on that "profit" to the staff itself, there would be no incentive for malpractice based on greed. As I said, I haven't thought much about this and maybe I am overlooking other problems this might cause (like offloading patients that are too expensive and/or too much work to other specialists, like a hot potato), but I wanted to put this out there anyway.
The real way to solve this problem is to get the patients motivated and involved in their own care and treatment decisions.
In a free market, driven by true choice, patients have the responsibility of learning more independently about their diagnosis, treatment options, and their physician. By doing research, a patient may be driven to get a second or third opinion when faced with a diagnosis like cancer.
By utilizing healthcare savings accounts (HSA) and high deductible low premium insurance plans, patients are driven to find the best doctor with the lowest prices.
This is how the invisible hand works, choice and competition on each side of the market. The result- A decrease in price and an increase in quality.
An ex-colleague of mine went into the pharmaceutical industry to work as a drug rep. They get $X to spend on each doctor they visit as part of their job. My colleague was quite moral, and she would only use the money for the stated purposes: improving the doctor's practise. Charts, equipment, training. Usually it's spent at discretion, and often spent on football tickets, holidays, etc.
She reported that some doctors already used it for practice-improving stuff. The middle set of doctors were a bit like "oh well, the gig is up". But the third set of doctors were outraged that she should tell them how to spend their money. They saw this drug company money as part of their personal income.
I didn't read the article thoroughly, but one point to think about is patients may be more likely to visit with a particular doctor if said doctor frequently performs the surgery they believe will help them.
I am the perfect example of this. I went to a particular doctor with the expectation that he would eventually perform the surgery I desired. He did technically evaluate if I was a good candidate, but I got the impression his patients only visit him if they want the surgery performed. He also does a lot of these surgeries, making him more experienced and more attractive as a surgeon. I would imagine this Florida doctor is similar.
The problems with US healthcare seem fairly well known. But I want to know what sorts of solutions are promising. I don't think single payer is right for the US, it's much too anti-American. I also don't think a free-market free-for-all would work...medicine is way too stacked against the customer. Obamacare, while seriously flawed, is probably still a step in the right direction. Would getting employers out of the business help? I keep hearing about insurance company inability to compete across state lines. What else?
I hate that we're not allowed to self-medicate. I understand the risks, I've done my research, I know more than my local pharmacist, yet they won't give me s&&t without a piece of paper signed by someone who supposedly knows better.
I always had a strong suspicion that the doctors prescribe too many medications (which were also brands more expensive than the generics). Not so paranoid after all.
[+] [-] cs702|12 years ago|reply
Yet here we have reputable doctors acting in their self interest, and the result is that they are ordering unnecessary surgeries for financial gain. Meanwhile, patients are essentially unable to protect themselves against this travesty.
Maybe in this case the invisible hand cannot be seen because it is not there?
[+] [-] bhauer|12 years ago|reply
Because health insurance is now commonly provided by employers because of World War II price controls, and because we have become accustomed to using health insurance to pay for all matter of health care, including routine visits, consumers are often ignorant of health care costs.
Customer A: My insurance will pay? Fine, let's do this. Cha-ching, price rises.
Customer B: My insurance will pay? Fine, let's do this. Cha-ching, price rises.
Customer C: Oh, insurance won't pay? How much? Whoa! How did the price get so high?
It's no surprise then that the invisible hand works in a way that appears flawed when one of its inputs (the buyer's sensitivity to price) is frustrated.
People of my persuasion often make the case that if automobile insurance worked the same as health insurance, and we used insurance to pay for oil changes, the price of oil changes would shoot up wildly. Reason being that you would no longer care what it costs.
Obviously the seller (the doctor in the case at hand) wants the price to be as high as possible. The invisible hand can't keep this in check—it cannot discipline the seller with lost sales—when so many buyers do not act with actual price sensitivity.
[+] [-] GFischer|12 years ago|reply
http://en.wikipedia.org/wiki/Invisible_hand
This is obviously not the case in patient-doctor relationships.
The standard Austrian response for those information assimetries are that an independent third party will arise that will offer an unbiased opinion (usual example is Underwriters Laboratory or UL).
A more government-based approach would say that more regulatory oversight is needed.
However, in practice, I haven't seen this happening, I'm not an economist but I see there are agency problems, regulatory capture problems, etc..
Stiglitz said:
"the reason that the invisible hand often seems invisible is that it is often not there. Whenever there are "externalities"—where the actions of an individual have impacts on others for which they do not pay, or for which they are not compensated—markets will not work well...
recent research has shown that these externalities are pervasive, whenever there is imperfect information or imperfect risk markets—that is always"
[+] [-] Nicholas_C|12 years ago|reply
[+] [-] k2enemy|12 years ago|reply
[+] [-] TallGuyShort|12 years ago|reply
[+] [-] maratd|12 years ago|reply
My wife was in labor for a bit less than a day. Baby was fine, everything good, but apparently we were taking too long. Doctor demanded we do a c-section. When we said we wanted to wait, she walked out, slamming the door. We got scared, they made 60K for about 20 minutes of work. Guess what the c-section rate at that hospital is? 50%. Not kidding. I'm in the wrong business.
http://www.icanofnj.com/hospitalcsectionrates.htm
[+] [-] Ensorceled|12 years ago|reply
My personal physician loves it, he no longer wastes time filing for OHIP payments and no longer worries that maybe he is only ordering procedures to make more money rather than for a legitimate purpose.
This is a particular problem when diagnosing problems, is "your gut" or "your greed" telling you that the patient needs this $1000 test.
[+] [-] xanderstrike|12 years ago|reply
1. "Medical offices which have equipment for certain services provide those services more often than offices that don't."
They've got the equipment in-house, so of course they're going to use it. The article doesn't take into account the possibility that patients are choosing to go to these offices _because_ they have the in-house facilities for the treatment they want. Going from "doctors who have X machine order X procedure more often" to "doctors treat patients like an ATM machine" is a huge leap.
2. "Some surgeons in Florida performed unnecessary surgeries for money."
There are bad apples in every bunch, this is why you get a second opinion before going under the knife. Yes surgeons get paid per procedure, yes it's a flawed system, but that doesn't mean they're all wheeling and dealing to get as many people to submit to surgery as possible.
It's worth noting also that whenever the article says "charged patients" what they mean is "billed patients' insurance company." Chances are the people who don't have insurance were the ones smart enough to see another doctor before paying.
This kind of fearmongering crap undermines confidence in medical professionals and medical science. The vast majority of medical professionals are extremely hard working, knowledgeable people who's primary goal is to help everyone that walks through their door. Without trust from their patients, they can't do this effectively.
[+] [-] paschutt|12 years ago|reply
[+] [-] PavlovsCat|12 years ago|reply
I recall what a nurse once told me, that she was glad she doesn't have private insurance, because that can easily mean they put "tubes into every hole" even when there is no point in doing so (this was in the context of terminal cancer, mind you). That was in Germany, and not in some crappy backwater hospital either.
> There are bad apples in every bunch
Actually it's "a few bad apples spoil the whole bunch". So instead of blaming "fearmongering crap", maybe blame the bad apples, instead of just accepting them as given. Not that you don't have a point at all; trust is really required. But not blind trust, and not naiveté; those are just as unhelpful as unfounded distrust would be. As they say, nature abhors a vacuum.
[+] [-] Goronmon|12 years ago|reply
Exactly, they are going to use it as much as they can, whether it's necessary or not, because they have it.
[+] [-] jdietrich|12 years ago|reply
I have no idea as to the veracity of the story or the effectiveness of such a model (and hold no truck with the pseudoscientific methods used by such practitioners), but it raises an interesting thought - would healthcare be more effectively funded through some mechanism other than private insurance or state funding? Might the debate over healthcare have been narrowed into a false dichotomy, when there may be a far better option lying unnoticed on the third hand?
[+] [-] jrs235|12 years ago|reply
"Why should I: stop smoking, stop drinking excessively, exercise, or change my diet? If I get sick (not healthy), I don't have to pay my doctor!"
My question is, why do we keep talking about ACA like it provides care? It doesn't. It mandates insurance. If you need care, it still costs you more out of your pocket.
[+] [-] erichocean|12 years ago|reply
I can't think of any objection for trying out your idea and seeing how things go.
[+] [-] gtremper|12 years ago|reply
[+] [-] thrownaway2424|12 years ago|reply
Of course that wouldn't prevent any doctor and patient from doing whatever they wanted, at their own expense.
[+] [-] gojomo|12 years ago|reply
There's only one other sector of the US economy that's "single-payer": military procurement. And that's not known for its spending efficiency, either.
So it's not simply "single-payer" that magically saves money, but the specifics of the incentive system that's set up, and the other precedents from American federal governance are not positive.
Thank you for acknowledging that the main mechanism that a federal medical buyer monopsony (aka nationalization/single-payer) could use for cost-control is, essentially, "death panels" who say no to many treatments currently performed.
But can the American political system embrace that step, or will it wind up with single-payer without cost-controls? We wind up with the kinds of giant federal programs that can make it through the political system, and get implemented by the bureaucracy... not the kinds of idealized programs existing only in advocates' minds.
Finally, in single-payer systems, getting "whatever you want" done "at your own expense" is often effectively prohibited. For example, when the official system has particular limits (like price controls, limited participating providers, or waiting lists) for a covered procedure, it has often been illegal, in US Medicare or Canada's programs [1], to purchase that same procedure out-of-pocket/out-of-system for a negotiated price. Once you've nationalized, there's even a certain logic to such prohibitions: the system is straining under budget caps, and you can't risk the wealthy siphoning off capacity/copayments that could help support the common base.
[1] http://www.cato.org/publications/policy-analysis/freedom-
[+] [-] jasonlotito|12 years ago|reply
[+] [-] Symmetry|12 years ago|reply
Having a government run healthcare system like Great Britain's would solve the problem, but it could do that with or without single payer. In fact, Singapore has had quite a bit of success combining a semi-government run hospital system with private payment for healthcare.
[+] [-] waffle_ss|12 years ago|reply
[+] [-] MrZongle2|12 years ago|reply
Well, now that you've put it that way, the idea of a government-led panel -- rather than the family -- deciding that Grandma is too old to bother treating sounds so much better.
[+] [-] vkou|12 years ago|reply
The advantage of single-payer, is that he will not have a profit motive to do so. And monopoly bargaining power on the side of the public.
[+] [-] pbreit|12 years ago|reply
[+] [-] kiba|12 years ago|reply
That isn't to say that a single-payer is better or worse, but we should be methodical and careful when considering wholesale replacement of the incentive structures.
[+] [-] nazgulnarsil|12 years ago|reply
[+] [-] kingkawn|12 years ago|reply
[+] [-] aaronblohowiak|12 years ago|reply
For those times that incur large costs, I would bet that you could make a better-than-chance guess. What are the success rates of "extraordinary measures" ?
[+] [-] Amadou|12 years ago|reply
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_...
[+] [-] angersock|12 years ago|reply
Wow.
The image of the physician as somebody who is there to help relieve suffering is cemented as a meme, but the way the system seems to have evolved in the past few decades is towards help as a secondary duty if any.
Unfortunately, anyone who seems to want to speak out against the system is immediately rebutted with cries of "Why do you hate doctors?" and "They saved my babies!".
It is very hard to have an honest discussion and self-introspection in the current environment, especially with so much money at stake.
[+] [-] roc|12 years ago|reply
To be fair, with spinal fusions in particular, when a review panel says surgery is "not medically necessary" they're recommending daily pain/numbness/loss of range of motion is better treated with narcotics/steroids/etc.
So it's hardly as simple as "doctors ignoring pain for profit". It can quite easily be "insurance company ignoring pain for profit".
You simply can't ignore the role of insurance companies. Their disincentivize to approve any treatment, necessary or not, to mitigate their own costs is also a well-studied problem.
[+] [-] 001sky|12 years ago|reply
1) A constant battle is underway between insurance companies that do not want to pay any claims, even legitimate ones, and doctors and hospitals incentivised to rip off patients, insurers, and taxpayers with unnecessary surgeries and Medicare fraud.
2) Insurance companies demand massive amounts of paperwork out of rational fear of fraud and unnecessary treatments. Doctors perform for-profit (as opposed to for-patient) procedures that guarantee more explanations and more paperwork.
3) Doctors and hospitals have direct personal contact with patients, but insurance companies don't. In cases where doctors put patients at huge risk with needless procedures and surgeries, it's easy for hospitals and doctors to point their finger at insurance companies. On the other hand, many sincere, honest doctors have difficulty getting patients the care they should have because insurers believe they are getting ripped off by unnecessary procedures, even when they aren't.
4) Doctors make needless tests out of fear of being sued for not doing them.
5) The vast majority of healthcare costs occur in final last year or so of someone's life. Politicians who want to do something sensible about this issue get accused of "rationing healthcare".
6) Doctors not only have a financial incentive to prolong life needlessly, they also worry about not prolonging life out of fear of being sued by family members unless there is a living will, and perhaps even if there is a living will.
== Buried a bit, but worth highlighting.
[+] [-] danvoell|12 years ago|reply
[+] [-] tokenadult|12 years ago|reply
On my part, I was just doing some Web searches for patient guides about how to select treatments and when to get second opinions. Regardless of how health care is paid for, patients sometimes need guidance about how to choose physicians, and how to choose treatments. (I know this for sure because my family lived in Taiwan for almost three years under Taiwan's single-payer national health insurance system, and we still had to decide which doctor to visit--we had choice in that matter--and whether or not to follow the doctor's treatment recommendation, which we sometimes followed and sometimes did not.) I'll keep looking for a user-friendly guide like that online, and if someone else commenting here can link to one, I'll be very grateful for that.
[+] [-] mikeyouse|12 years ago|reply
1. Medicare / insurance fraud --- The author obviously hasn't heard of the Health Care Fraud Prevention and Enforcement Action Team (HEAT). HEAT led to the record number of fraud charges in 2012. In addition to that, ACA standardized fraud convictions, so any provider convicted of fraud can no longer claim any federal money (Previously, a provider convicted of medicare fraud could still collect payments from medicaid et al).[2] These are only 2 provisions of the roughly 50 that directly address fraud. [2a]
2. Massive amounts of Paperwork --- This paperwork is moving to EHR / EMR systems that will file it automatically for the vast majority of patients. ACA mandates that the systems must use a standard format, so that any system built can communicate with all federal / private insurance carriers. [2]
3. Since doctors have direct contact with patients, and insurance companies don't it's easy for docs to blame insurance companies for unnecessary procedures --- I'm confused by this point, it seems a bit confused and contradictory toward his other points.
4. Doctors perform needless tests for fear of being sued --- The author has clearly never heard of ACOs. One of their primary goals is to limit the number of tests and procedures done. Insurance companies and the government will provide fairly significant bonuses when the cost of provided care comes in below average. [4a] In addition, the ACA provides research grants to study best practices and patient outcomes, having published, peer-reviewed research for common diagnoses will greatly limit the ability to sue for stuff considered CYA. [4b]
5. End of life care is insanely expensive --- This would've been addressed in the ACA, but Sarah Palin, Newt Gingrich and their dimwit followers torpedoed the 'death panels' to score some cheap political points.
6. Life is prolonged without living will --- Again, thank Sarah Palin, Newt Gingrich, and the Fox News brigade for their insane rants against 'death panels' which would have directly addressed this.
[1] - http://www.npr.org/2011/12/30/144491419/doj-posts-record-for... [2] - http://www.healthit.gov/policy-researchers-implementers/stan... [2a] - http://www.btlaw.com/files/ALERT%20-%20Healthcare_Health%20C... [4a] - http://www.washingtonpost.com/blogs/wonkblog/wp/2013/08/29/o... [4b] - http://www.nlm.nih.gov/hsrinfo/cer.html [5 & 6] - http://en.wikipedia.org/wiki/Death_panel
[+] [-] chamblin|12 years ago|reply
[+] [-] angersock|12 years ago|reply
If anyone is interested, go read the O'Reily book "Hacking Healthcare" to learn about how brainfucked the system is.
[+] [-] RockyMcNuts|12 years ago|reply
[+] [-] riahi|12 years ago|reply
I'm curious how you guys think medical professionals should actually be paid / how can pricing be done "fairly" in a system where there can never be "information symmetry"?
[+] [-] PavlovsCat|12 years ago|reply
I can only speak for myself; I made very good experiences with doctors whenever I myself was sick, but I also worked for 11 months on a cancer ward a while ago, and some of the stuff I saw there was kind of rage inducing. Nearly all nurses were fine, most doctors were fine, but the ones that weren't, really really made up for that. I don't think doctors are all evil, nowhere near, but the reservations and skepticism I do harbour, I don't harbour because it's "fun" to have them. It's merely a way to cope with real shitty stuff that does exist.
> I'm curious how you guys think medical professionals should actually be paid / how can pricing be done "fairly" in a system where there can never be "information symmetry"?
First off, of course there can be "information symmetry". Not between patient and doctor as much as among medical professionals and health insurance providers. Medicine isn't Voodoo, things are reasoned about and tested, usually, and given the right laws and enforcement of them, everything can be documented and subject to review.
As for how to improve the situation: while I haven't thought in-depth about this, but how about a flat hourly rate for doctors etc.? That is, not being paid for the kind of treatment, but rather for being on the job. Of course, the hospital would need money depending on what kind of treatments they do, but if there was no (legal) way to pass on that "profit" to the staff itself, there would be no incentive for malpractice based on greed. As I said, I haven't thought much about this and maybe I am overlooking other problems this might cause (like offloading patients that are too expensive and/or too much work to other specialists, like a hot potato), but I wanted to put this out there anyway.
[+] [-] hkiely|12 years ago|reply
[+] [-] mhb|12 years ago|reply
[+] [-] pc86|12 years ago|reply
[+] [-] pistle|12 years ago|reply
The OP read an article in NEJM once and has a numbered list of things to say, followed by an unnumbered list of things to say.
[+] [-] rryan|12 years ago|reply
[+] [-] vacri|12 years ago|reply
She reported that some doctors already used it for practice-improving stuff. The middle set of doctors were a bit like "oh well, the gig is up". But the third set of doctors were outraged that she should tell them how to spend their money. They saw this drug company money as part of their personal income.
[+] [-] EricDeb|12 years ago|reply
I am the perfect example of this. I went to a particular doctor with the expectation that he would eventually perform the surgery I desired. He did technically evaluate if I was a good candidate, but I got the impression his patients only visit him if they want the surgery performed. He also does a lot of these surgeries, making him more experienced and more attractive as a surgeon. I would imagine this Florida doctor is similar.
[+] [-] pbreit|12 years ago|reply
[+] [-] jotm|12 years ago|reply
I always had a strong suspicion that the doctors prescribe too many medications (which were also brands more expensive than the generics). Not so paranoid after all.
[+] [-] ffrryuu|12 years ago|reply