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From this website: http://seqclinic.com/chinese_medicine.html http://seqclinic.com/chinese_medicine.html Historically, a Chinese Medicine doctor was paid a

by milesf 10y ago

From this website: http://seqclinic.com/chinese_medicine.html http://seqclinic.com/chinese_medicine.html Historically, a Chinese Medicine doctor was paid a retainer to keep their patients healthy. If a patient became sick, the doctor would not be paid until the patient’s health returned. In a similar vein, a doctor that resorted to surgery was considered an inferior doctor. If he/she did their job correctly and helped their clients stay healthy, there would be no need to perform surgery. Perhaps the current incentive for drug companies is the problem. They don't care if we stay healthy (which is what we all want), they only treat illness. In fact you could argue it's in the best interest of drug companies to keep us sick! Maybe there's an alternative way to fund them, or an alternative way to deal with infections in the first place.

soohyung 10y ago
I don't think that's a very good point. In order for people to be willing to pay the ever-rising costs for the best drugs they are going to have to work, drug companies aren't going to make much money once they've lost the trust of their customers. Perhaps the funding is problematic in one way or another but I doubt it's in drug companies' best interest to keep us sick.
- deleted 10y ago
  [deleted]
- reddytowns 10y ago
  If it takes 5 to 10 years before a drug makes you sick, no one will care. It's all about next quarter
- Retric 10y ago
  The increasing cost relates to drug companies running out of useful simple molecules. If you count the number of new drugs that treat common problems aka more than 100,000 people per year in the US and are not closely related to another drug you get a very tiny number of new drugs per year. Sure we have a lot of drugs related to Morphine, but most of them are not significantly different from Morphine as to be worth high prices. When viagra goes generic at the end of the year the hurdle for the next male 'enhancement' drug ratchets up.
- akiselev 10y ago
  This isn't a hypothetical problem but a well known issue within the pharmaceutical industry. The drug companies don't purposefully make drugs that cause harm in order to sell more of their other products but the economic incentives in the United States healthcare market are extremely misaligned. The end result is, essentially, an industry that "keeps us sick" to maximize profit not because of malice, but because of a market failure. Market size and total profit over the lifetime of the patent is the primary factor that is considered at every step from random screening to clinical trials. Spinning up a clinical trial requires many tens or hundreds of man-years of work by very specialized and hard to find scientists/doctors before you even sign up your first human subject so even the biggest pharma companies have limited bandwidth. This forces them to be very selective, even when they have multiple high-potential targets, and that means choosing to run the clinical trials for drugs with the highest potential ROI and lowest regulatory approval risk. For a variety of reasons, cures are usually much more complex and difficult to develop and get approved than simple drugs that treat symptoms and since the US has a complex, opaque network of insurance companies instead of a single payer, no one is in a position to negotiate prices that maximize healthcare ROI at scale. There is little incentive for pharmaceutical companies to develop cures for diseases when they can provide a "good enough" quality of life boost for the entire lifetime of the patient and sell it for the exact same price. This means that often times cures won't even be researched past animal testing because the pharma company has a large pipeline of less risky, more profitable drugs to get through the FDA
  - refurb 10y ago
    This is wrong on a number of levels. I've worked for a couple biotech companies and typically the commercial viability of a drug isn't examined until about phase 1. And even then it's a very rough estimate. I highly doubt any company is calculating an ROI at the screening stage. Second, it's typically the science that limits the effectiveness of therapy, not the potential ROI. The reason why many drugs only treat symptoms is because that's the best science can do right now. Third, curing a disease can often have a much better ROI than just treating symptoms forever. Look at Gilead's hepatitis C cure. Before it came to market the drug revenue for that disease was maybe $2 billion. The first year that Gilead's drugs were on the market, they sold $12 billion. The cure was way more profitable.
seibelj 10y ago
Doctor: "My patient is sick and won't pay? I'll just drop him and add another."
- rscho 10y ago
  This supposes that the docs are the ones responsible for the choice of giving antibiotics or not at the population/industry level. This is already questionable. A second thing your statement supposes, is that people prescribing drugs in first-line care have the same agenda as people doing medical politics, or at least are not concerned about the well-being of their patients. Every profession has its black sheep, but I think you severely underestimate the drive docs have to see their patients do well, and the self-esteem hit we get when things go wrong.
  - seibelj 10y ago
    Whenever you assume the innate goodness of someone overrides their natural desire to earn money, you end up with a problem. With doctors, having to legislate the gifts received from pharmaceutical companies is an obvious counterpoint to the idea that the vast majority of doctors are 100% ethical and only make choices for health reasons. Clearly a lot of them were influenced by pharma money.
Devthrowaway80 10y ago
Single-payer seems like it'd incentivize preventative medicine.
- elihu 10y ago
  Well, sort of. It would depend how the government negotiates the payments given to the companies that provide medical services. If they stick with the standard fee-for-service model we mostly use now, there wouldn't be much difference.
  - mst 10y ago
    How so? Even under fee-for-service a single payer org has an incentive to provide preventative services so they don't have to pay for problems later, no?
    - elihu 10y ago
      Well, there's two issues. (Two I can think of, anyways, there may be more.) One is that without universal insurance via a single-payer system, there will be people who aren't insured and can't afford preventative services. So, single payer solves that problem. The other problem is that in a fee-for-service model, health care providers get paid a lot more for major procedures than minor ones, and they may get paid again to fix any complications that arise. So, there isn't a good incentive structure to reward fixing problems quickly and cheaply. Whether single payer fixes that problem will depend on how it's implemented. (I think there was an experiment done awhile back where Medicare stopped reimbursing hospitals for patients who were re-admitted due to infections following surgery. The result was rate of surgery complications went down.) I kind of wonder if maybe there should be a bounty program for fixing minor problems before they turn into major problems. Just this last week, I had an adenoma removed from my colon. I haven't seen the bill yet, but it was a pretty routine, minor procedure. If I hadn't had it removed, it would have probably become cancerous within the next year or two (according to the doctor that removed it), and if it were any bigger it might have required a much more invasive procedure to remove. So, fixing it now saves a whole lot of medical expenses down the road and saves me a whole lot of unpleasant experiences. It seems kind of a shame that the doctor who removed my adenoma isn't rewarded (except in the knowledge of a job well done) for that.
abalone 10y ago
> If he/she did their job correctly and helped their clients stay healthy, there would be no need to perform surgery. Sheer nonsense. This assumes that all surgeries are a result of poor preventative care which is trivially false. Why does it seem like the folks criticizing the profit motive of pharmaceutical companies see no such perverse motive in those selling holistic treatments? I don't suppose that "alternative way of dealing with infections" happens to involve spending money regularly on herbs and acupuncture...
- tabeth 10y ago
  The top cause of death in the United States is heart disease, which is also the most preventable. Assuming all causes of death have surgical intervention proportional to their occurrence in the population that would mean yeah, maybe not all, but there would be significantly less surgery if there were more prevention. However, doctors only contribute slightly to the status quo. The food industry more generally is to blame. As well as the government, for subsidizing unhealthy things.
  - ktRolster 10y ago
    doctors only contribute slightly to the status quo. The food industry more generally is to blame. Worth remembering whenever you see people comparing different healthcare systems based on longevity. Doctors are not always the primary factor in lifespans.
  - abalone 10y ago
    > there would be significantly less surgery if there were more prevention. True but that's a considerably diminished claim from the OP's, which was that all surgery is a sign of doctor failure. Also, the unscientific treatments they linked to would do nothing to prevent heart disease, and may even discourage patients from seeking care that can help them.
- Omniusaspirer 10y ago
  Thank you for saying this. You'd think the HN audience would be smart enough to actually look at evidence in regards to medicine, but there's a lot of Steve Jobs types who'd rather pay for a well placebo-ed death. I wouldn't mind if they weren't so insistent on preaching their bullshit everywhere they go and trying to pass it off as having any basis. It's kinda disheartening to dedicate years and years to studying medicine, only to realize there's more money and satisfied patients to be made in hustling bullshit to new-age fools who will preach your crap right up until they die of an easily treated disease.
smallnamespace 10y ago
To get an insurer to want to maximize your health care, you have to guarantee that the insurer saves money if they make you healthy, and loses money if they don't. If patients can switch insurers at any time, then an insurer that spends a lot of money on preventative care only sees a small fraction of the benefit; they lose it whenever the patient switches away. And if you spend 'too much' money on preventative care, you'll probably end up losing customers to cut-rate insurance providers with lower premiums. If instead we could measure health perfectly, then you could set up a system where if a person is made unhealthier by an insurer, then the old insurer has to compensate the new insurer whenever someone switches. But we don't really know how to measure health, if by 'health' we mean having a low probability that a person will become sick in the near future; we usually can only notice once a person becomes sick.
whack 10y ago
This sounds like lifetime insurance. When you're healthy, you pay premiums. When you're sick, the insurance company has to spend a lot of money treating you. In a well functioning market, the insurance company would have great incentive to engage in preventative care to keep you healthy.
deleted 10y ago
[deleted]
deleted 10y ago
[deleted]
greggman 10y ago
> In fact you could argue it's in the best interest of drug companies to keep us sick! This assumes there's only one drug company. If company A's medicine heals me an company B's medicine does not then I chose company A's and company B's goes out of business. So no, a drug company does not have an incentive to keep me sick.
- bobbybobbybob 10y ago
  And how do we know which is effective given the current flaws of the system and the various conflicts of interest....?
  - manarth 10y ago
    The current system is imperfect, but it's not outright fraudulent. In general, if a company claims "Drug X gives 10% more pain relief than aspirin", they have to support that claim with evidence, which can be reviewed (and contested, if the methodology, outcome, or other factors don't support the claim). That's not to say there aren't improvements that can be made: All Trials [1][2] is one campaign to improve the system. [1] https://en.wikipedia.org/wiki/AllTrials https://en.wikipedia.org/wiki/AllTrials [2] http://www.alltrials.net/ http://www.alltrials.net/
- deleted 10y ago
  [deleted]
arkades 10y ago
That's called a "capitated" payment plan, and we already use those on a lot of contracts with physicians. They create perverse incentives (withholding care), and tend not to work well (it implies that physicians are capable of significantly improving patient outcomes over their current level of performance, and choose not to.)

by milesf 10y ago

soohyung 10y ago

I don't think that's a very good point. In order for people to be willing to pay the ever-rising costs for the best drugs they are going to have to work, drug companies aren't going to make much money once they've lost the trust of their customers. Perhaps the funding is problematic in one way or another but I doubt it's in drug companies' best interest to keep us sick.

deleted 10y ago
[deleted]
reddytowns 10y ago
If it takes 5 to 10 years before a drug makes you sick, no one will care. It's all about next quarter
Retric 10y ago
The increasing cost relates to drug companies running out of useful simple molecules. If you count the number of new drugs that treat common problems aka more than 100,000 people per year in the US and are not closely related to another drug you get a very tiny number of new drugs per year. Sure we have a lot of drugs related to Morphine, but most of them are not significantly different from Morphine as to be worth high prices. When viagra goes generic at the end of the year the hurdle for the next male 'enhancement' drug ratchets up.
akiselev 10y ago
This isn't a hypothetical problem but a well known issue within the pharmaceutical industry. The drug companies don't purposefully make drugs that cause harm in order to sell more of their other products but the economic incentives in the United States healthcare market are extremely misaligned. The end result is, essentially, an industry that "keeps us sick" to maximize profit not because of malice, but because of a market failure. Market size and total profit over the lifetime of the patent is the primary factor that is considered at every step from random screening to clinical trials. Spinning up a clinical trial requires many tens or hundreds of man-years of work by very specialized and hard to find scientists/doctors before you even sign up your first human subject so even the biggest pharma companies have limited bandwidth. This forces them to be very selective, even when they have multiple high-potential targets, and that means choosing to run the clinical trials for drugs with the highest potential ROI and lowest regulatory approval risk. For a variety of reasons, cures are usually much more complex and difficult to develop and get approved than simple drugs that treat symptoms and since the US has a complex, opaque network of insurance companies instead of a single payer, no one is in a position to negotiate prices that maximize healthcare ROI at scale. There is little incentive for pharmaceutical companies to develop cures for diseases when they can provide a "good enough" quality of life boost for the entire lifetime of the patient and sell it for the exact same price. This means that often times cures won't even be researched past animal testing because the pharma company has a large pipeline of less risky, more profitable drugs to get through the FDA
- refurb 10y ago
  This is wrong on a number of levels. I've worked for a couple biotech companies and typically the commercial viability of a drug isn't examined until about phase 1. And even then it's a very rough estimate. I highly doubt any company is calculating an ROI at the screening stage. Second, it's typically the science that limits the effectiveness of therapy, not the potential ROI. The reason why many drugs only treat symptoms is because that's the best science can do right now. Third, curing a disease can often have a much better ROI than just treating symptoms forever. Look at Gilead's hepatitis C cure. Before it came to market the drug revenue for that disease was maybe $2 billion. The first year that Gilead's drugs were on the market, they sold $12 billion. The cure was way more profitable.

seibelj 10y ago

Doctor: "My patient is sick and won't pay? I'll just drop him and add another."

rscho 10y ago
This supposes that the docs are the ones responsible for the choice of giving antibiotics or not at the population/industry level. This is already questionable. A second thing your statement supposes, is that people prescribing drugs in first-line care have the same agenda as people doing medical politics, or at least are not concerned about the well-being of their patients. Every profession has its black sheep, but I think you severely underestimate the drive docs have to see their patients do well, and the self-esteem hit we get when things go wrong.
- seibelj 10y ago
  Whenever you assume the innate goodness of someone overrides their natural desire to earn money, you end up with a problem. With doctors, having to legislate the gifts received from pharmaceutical companies is an obvious counterpoint to the idea that the vast majority of doctors are 100% ethical and only make choices for health reasons. Clearly a lot of them were influenced by pharma money.

Devthrowaway80 10y ago

Single-payer seems like it'd incentivize preventative medicine.

elihu 10y ago
Well, sort of. It would depend how the government negotiates the payments given to the companies that provide medical services. If they stick with the standard fee-for-service model we mostly use now, there wouldn't be much difference.
- mst 10y ago
  How so? Even under fee-for-service a single payer org has an incentive to provide preventative services so they don't have to pay for problems later, no?
  - elihu 10y ago
    Well, there's two issues. (Two I can think of, anyways, there may be more.) One is that without universal insurance via a single-payer system, there will be people who aren't insured and can't afford preventative services. So, single payer solves that problem. The other problem is that in a fee-for-service model, health care providers get paid a lot more for major procedures than minor ones, and they may get paid again to fix any complications that arise. So, there isn't a good incentive structure to reward fixing problems quickly and cheaply. Whether single payer fixes that problem will depend on how it's implemented. (I think there was an experiment done awhile back where Medicare stopped reimbursing hospitals for patients who were re-admitted due to infections following surgery. The result was rate of surgery complications went down.) I kind of wonder if maybe there should be a bounty program for fixing minor problems before they turn into major problems. Just this last week, I had an adenoma removed from my colon. I haven't seen the bill yet, but it was a pretty routine, minor procedure. If I hadn't had it removed, it would have probably become cancerous within the next year or two (according to the doctor that removed it), and if it were any bigger it might have required a much more invasive procedure to remove. So, fixing it now saves a whole lot of medical expenses down the road and saves me a whole lot of unpleasant experiences. It seems kind of a shame that the doctor who removed my adenoma isn't rewarded (except in the knowledge of a job well done) for that.

abalone 10y ago

> If he/she did their job correctly and helped their clients stay healthy, there would be no need to perform surgery. Sheer nonsense. This assumes that all surgeries are a result of poor preventative care which is trivially false. Why does it seem like the folks criticizing the profit motive of pharmaceutical companies see no such perverse motive in those selling holistic treatments? I don't suppose that "alternative way of dealing with infections" happens to involve spending money regularly on herbs and acupuncture...

tabeth 10y ago
The top cause of death in the United States is heart disease, which is also the most preventable. Assuming all causes of death have surgical intervention proportional to their occurrence in the population that would mean yeah, maybe not all, but there would be significantly less surgery if there were more prevention. However, doctors only contribute slightly to the status quo. The food industry more generally is to blame. As well as the government, for subsidizing unhealthy things.
- ktRolster 10y ago
  doctors only contribute slightly to the status quo. The food industry more generally is to blame. Worth remembering whenever you see people comparing different healthcare systems based on longevity. Doctors are not always the primary factor in lifespans.
- abalone 10y ago
  > there would be significantly less surgery if there were more prevention. True but that's a considerably diminished claim from the OP's, which was that all surgery is a sign of doctor failure. Also, the unscientific treatments they linked to would do nothing to prevent heart disease, and may even discourage patients from seeking care that can help them.
Omniusaspirer 10y ago
Thank you for saying this. You'd think the HN audience would be smart enough to actually look at evidence in regards to medicine, but there's a lot of Steve Jobs types who'd rather pay for a well placebo-ed death. I wouldn't mind if they weren't so insistent on preaching their bullshit everywhere they go and trying to pass it off as having any basis. It's kinda disheartening to dedicate years and years to studying medicine, only to realize there's more money and satisfied patients to be made in hustling bullshit to new-age fools who will preach your crap right up until they die of an easily treated disease.

smallnamespace 10y ago

To get an insurer to want to maximize your health care, you have to guarantee that the insurer saves money if they make you healthy, and loses money if they don't. If patients can switch insurers at any time, then an insurer that spends a lot of money on preventative care only sees a small fraction of the benefit; they lose it whenever the patient switches away. And if you spend 'too much' money on preventative care, you'll probably end up losing customers to cut-rate insurance providers with lower premiums. If instead we could measure health perfectly, then you could set up a system where if a person is made unhealthier by an insurer, then the old insurer has to compensate the new insurer whenever someone switches. But we don't really know how to measure health, if by 'health' we mean having a low probability that a person will become sick in the near future; we usually can only notice once a person becomes sick.

whack 10y ago

This sounds like lifetime insurance. When you're healthy, you pay premiums. When you're sick, the insurance company has to spend a lot of money treating you. In a well functioning market, the insurance company would have great incentive to engage in preventative care to keep you healthy.

deleted 10y ago

[deleted]

deleted 10y ago

[deleted]

greggman 10y ago

> In fact you could argue it's in the best interest of drug companies to keep us sick! This assumes there's only one drug company. If company A's medicine heals me an company B's medicine does not then I chose company A's and company B's goes out of business. So no, a drug company does not have an incentive to keep me sick.

bobbybobbybob 10y ago
And how do we know which is effective given the current flaws of the system and the various conflicts of interest....?
- manarth 10y ago
  The current system is imperfect, but it's not outright fraudulent. In general, if a company claims "Drug X gives 10% more pain relief than aspirin", they have to support that claim with evidence, which can be reviewed (and contested, if the methodology, outcome, or other factors don't support the claim). That's not to say there aren't improvements that can be made: All Trials [1][2] is one campaign to improve the system. [1] https://en.wikipedia.org/wiki/AllTrials https://en.wikipedia.org/wiki/AllTrials [2] http://www.alltrials.net/ http://www.alltrials.net/
deleted 10y ago
[deleted]

arkades 10y ago

That's called a "capitated" payment plan, and we already use those on a lot of contracts with physicians. They create perverse incentives (withholding care), and tend not to work well (it implies that physicians are capable of significantly improving patient outcomes over their current level of performance, and choose not to.)