9 ms·

There are many, many problems with healthcare in the US. Off the top of my head, the big ones are: * Endless number of middlemen and administrators. * Every p

There are many, many problems with healthcare in the US. Off the top of my head, the big ones are: * Endless number of middlemen and administrators. * Every player in the healthcare chain benefits from higher prices. * No price transparency. * Tacit collusion is rampant. * "Cost no object" mentality to treating the dying. The last one, while insensitive, is true nonetheless, and it's alarming that over 50% of all healthcare spending takes place in the last two years of a person's life. We have basically decided that it's okay to spend literally any sum of money on a dying person in order to prolong life by an average of a few months. And the problematic word there is average, because some people do live a lot longer, and that's what we all look to. I realize this is grim and seemingly lacks humanity, but unfortunately that doesn't make it not true. Charlie Munger, who is on the board of Kaiser Permanente, said this same thing yesterday..."over-treatment of the dying" was the biggest problem they faced. It's reminiscent of our approach to college education - justified at any cost. So we push millions of kids into a schooling system that's not right for them, and the result is a lot of crappy education, worthless degrees, student loans, etc. Once we flip the switch to "there is no price you can put on _____" things get sideways FAST.

gambiting 9y ago
Well, the argument here is that for example, there are types of cancer which have extremely low survivalability rate, like 1 out 10 people who get it survive it. But we still treat them, and sure, right now 90% of them die but the data is used to create new drugs which in the future might improve the odds. If we just straight up said "it's very unlikely this person will survive so we won't spend $$$ on trying treatment" then we wouldn't get anywhere with many different medicines.
- killjoywashere 9y ago
  Those are pharma dollars. Different pot of money.
rcarrigan87 9y ago
Keeping people alive too long is definitely a really difficult problem. Having walked through many dementia floors in nursing homes, I'd prefer to have some reasonable way of opting for assisted suicide in my will. Maybe once a consortium of doctors verifies I'm at a specified stage of dementia. Assisted suicide is another tricky area but I think it is humane when administered properly.
- cloverich 9y ago
  Alternatively, we could consider a more strict "No heroic efforts" for people with dementia -- which means not spending tens to hundreds of thousands on resuscitation or surgical procedures for people with dementia if they are not in pain from their current ailment. Its obviously nuanced, but there is a hugely significant amount of savings to be made if we can get over the political obstacles.
  - rcarrigan87 9y ago
    Physical rehab has some of the highest Medicaid/care reimbursement rates and you should see how many dementia patients are getting pointless "rehab" to the maximum a facility can bill.
  - mason240 9y ago
    It's getting more common to get a DNR/DNI (Do Not Resuscitate / Do Not Intubate ) put into a "living will" that goes to into effect if you are in a situation where you will no longer be mentally cognitive.
olewhalehunter 9y ago
Keep in mind US healthcare costs are almost %20 of GDP Cutting the fat from that may mean a lot of folks lose livelihoods (and THEIR healthcare).
- bedhead 9y ago
  Besides being illogical (i.e. it's bad to eliminate waste), this exemplifies the problem with change. Any time there is a ANY constituency that is rendered worse off, no matter how justified it is, it is nearly impossible to effectuate change because the affected group screams bloody murder.
  - bluesroo 9y ago
    But, wouldn't you? More importantly, shouldn't you? If the people in your government are doing something that is not in your best interest then you SHOULD speak up against it. After all, the word "representative" is based on the word "represent". If they are not representing my interests to the government then I should make that known. If I have ailment X and a bill is being pushed that pulls funding/ assistance away from ailment X, then I should make it known that I am unhappy about it. What if it is now guaranteed that I will die from ailment X? You're saying that I shouldn't kick and yell about it? I'm about to die! However, if it is also helps people with ailment Y, Z, I, J, K, and L, then it is the government's job to recognize that maybe I am less important to the bigger picture. If enough people will be negatively impacted to the point that I will not be reelected, then maybe it doesn't truly benefit my constituency as much as I think it will. Of course all of this is in an ideal world without accounting for the power of advertisement funding and the fact that most of the voting population isn't well educated about the issues.
- alistairSH 9y ago
  Broken window fallacy. https://en.wikipedia.org/wiki/Parable_of_the_broken_window https://en.wikipedia.org/wiki/Parable_of_the_broken_window Edit: Which is not to say those impacted won't need assistance moving on to other things. But, cutting the fat should be a net benefit to society.
- 9y ago
foolrush 9y ago
Don't ignore the elephant in the room. There is a good reason the USA spends the most on medical and has less than stellar results. That is without glancing at the corporate tax evasion. Unfettered profit at all costs capitalism isn't a glowing unicorn.
rcjones 9y ago
To your first points, the system exists as it does because each party can sort of displace the onus of overspending on another party. 1. Insurers are incentivized to seek out the minimum cost to achieve maintainable health. 2. Health care providers are incentived to reap as much as possible from insurers in return for acceptable (not always exemplary) health outcomes. 3. Patients, who on average are getting older and in need of more care, are pigeonholed (sometimes good, sometimes bad) into health care decisions by their providers and insurers. 4. Device/equipment manufacturers can charge ludicrous amounts because they capture very specific pieces of markets or gain preference from health care providers. However, the risk and cost involved in creating a new/competing product and entering a market can be staggering, and so high costs become inevitable (same argument drug developers can make). As you said, 'justified at any cost' makes this whole shebang go, especially when no single party is capable of controlling the cost. We can't point to a boogeyman we all have a part in making.
- ensignavenger 9y ago
  As per 1- insurance companies justify their earnings as a percent of costs for care- so if they keep costs for care high, it actually helps them charge higher premiums. Of course, they have to ensure that costs are high for everyone. If an insurance company were to announce record profits because they were able to better control costs than their competitors, there would be immediate pressure to lower premiums and not take the additional profits. When it comes to health care, the idea that we have anything resembling a free-market and private competition to lower prices is a farce on a grand scale.
  - pandaman 9y ago
    The law actually caps their profit margin[1] so it effectively forces the insurance to pay and charge more if it wants to increase its income. Ironically, this law is called "Affordable Care Act". 1. http://abcnews.go.com/Politics/obamacare-health-insurance-rebates-check/story?id=19701785 http://abcnews.go.com/Politics/obamacare-health-insurance-re...
    - 9y ago
alistairSH 9y ago
While discussion of death is a bit morbid, some towns in the US have experimented with death planning, led by care providers and counselors at local hospitals. It has led to significant savings without resorting to "death panels". http://www.npr.org/sections/money/2014/03/05/286126451/living-wills-are-the-talk-of-the-town-in-la-crosse-wis http://www.npr.org/sections/money/2014/03/05/286126451/livin...
corey_moncure 9y ago
Here are two that I often see left out of the discussion: 1) Unfathomable amounts of money lavished on superficial appearances. From hospitals to private practices and surgery centers, everyone has to look trustworthy, exude that 'aura' of professional health care, with expensive landscaping, chic interior design with opulent materials, and of course enormous 4K television sets so that pharmaceutical manufacturers can push pills on the patients as they sit in the waiting room. Untold amounts of money are wasted on these non-essentials, which have literally nothing to do with the quality of the service provided, but which we all must pay for. 2) The epidemic of lifestyle diseases such as obesity, acquired diabetes, etc. Many of the nations where single payer is touted to work so effectively do not suffer from this issue (see Japan). The causes of this issue aside, at the end of the day, an undue burden is placed on the system generally, and as we have come to find out with ACA, young people making healthy choices rightly feel punished as their premiums climb and climb to cover the costs of treating completely avoidable conditions. We have to come together as a society and fix these problems at their root before they become the subject of medical treatments.
fencepost 9y ago
That statistic about the percentage of spending being in the last 2 years of life may be a bit misleading, just like keys are always in the last place you look. Once someone dies, most healthcare spending on them stops. Auto accident that's fatal after surgeries and a few days? In that window. The same applies to plenty of things that may have excellent recovery chances but which are not 100%. Edit: ObXKCD: https://www.xkcd.com/931/ https://www.xkcd.com/931/ (Lanes) Every one of those lanes going off to the right is the end of healthcare spending for someone, but you can't know going in which ones are going to turn off. Focusing on the "50% in the last 2 years" number is a lot like the the naive visualization at the top.
- metaphorm 9y ago
  your point is well taken, but I feel like there is still a subset of "excessive spending at end of life" that we can discuss as being more obviously problematic, from a social spending point of view. excluding trauma care for accident victims (that end up dying anyway), and excluding cases of early-in-life cancer, and excluding every other case we can think of where a spike of medical spending shortly before the person dies anyway is understandable as part of a good faith effort that had a reasonable chance of prolonging their life for many years, after all those exclusions are made we will still find many instances of cases where the end-of-life medical spending seems excessive. The canonical example I can think of would be organ transplants for very elderly people. A new kidney for a 75 year old person in advanced renal failure is unlikely to prolong their life by very much. This kind of stuff gets very emotional and very political though. This is what provoked the demagoguery about "death panels" when Obamacare was being debated in congress in 2009. We are both very uncomfortable allowing the government to make those decisions and also very uncomfortable allowing private insurers to make those decisions. We want to empower families to make those decisions and so remove cost from their consideration (via regulation, requiring insurers to pay) and then we become surprised when people who haven't made their peace with death are willing to spend any amount of money (which is a hidden cost from their point of view) to prolong end-of-life. It shouldn't be surprising. We set up a perverse incentive structure and locked it in place with regulations.
irishbro 9y ago
Freakonmics has an interesting episode where they cover the idea of offering a patient a bonus/rebate if they forego the standard end-of-life medical care. Quite a controversial suggestion but it does seem to have some though behind it http://freakonomics.com/podcast/are-you-ready-for-a-glorious-sunset-a-new-freakonomics-radio-episode/ http://freakonomics.com/podcast/are-you-ready-for-a-glorious...
zanny 9y ago
Saving peoples lives isn't a unique practice in the US. Doctors in the developed world are all bound by the Hippocratic Oath, and I'm not aware of any first world country that regularly judges the sick or old to die when doctors still have options available. They still pay a third as much in healthcare. A lot of those countries have physician assisted suicide though, which greatly improves the humanity of late term care. That is an easy and obvious piece of the solution the US should have been able to get behind a long time ago.
- DanBC 9y ago
  End of life care i not physician assisted suicide, and it's unhelpful to conflate the two. Six US states have end of life care that can include doctors prescribing fatal doses of medication. https://en.wikipedia.org/wiki/Assisted_suicide https://en.wikipedia.org/wiki/Assisted_suicide > The United States has authorized medical aid in dying in six states, which refers to a terminally ill person with 6 months or less to live taking a medication prescribed by a doctor
- makomk 9y ago
  Here in the UK, when the NHS decides whether a treatment is covered they take the cost and divide it by the estimated quality-adjusted life years it will give the patients who have it. If it costs more than £20,000-£30,000 per QALY they won't offer it. That's simply the value of a year of human life according to the NHS.

gambiting 9y ago

Well, the argument here is that for example, there are types of cancer which have extremely low survivalability rate, like 1 out 10 people who get it survive it. But we still treat them, and sure, right now 90% of them die but the data is used to create new drugs which in the future might improve the odds. If we just straight up said "it's very unlikely this person will survive so we won't spend $$$ on trying treatment" then we wouldn't get anywhere with many different medicines.

killjoywashere 9y ago
Those are pharma dollars. Different pot of money.

rcarrigan87 9y ago

Keeping people alive too long is definitely a really difficult problem. Having walked through many dementia floors in nursing homes, I'd prefer to have some reasonable way of opting for assisted suicide in my will. Maybe once a consortium of doctors verifies I'm at a specified stage of dementia. Assisted suicide is another tricky area but I think it is humane when administered properly.

cloverich 9y ago
Alternatively, we could consider a more strict "No heroic efforts" for people with dementia -- which means not spending tens to hundreds of thousands on resuscitation or surgical procedures for people with dementia if they are not in pain from their current ailment. Its obviously nuanced, but there is a hugely significant amount of savings to be made if we can get over the political obstacles.
- rcarrigan87 9y ago
  Physical rehab has some of the highest Medicaid/care reimbursement rates and you should see how many dementia patients are getting pointless "rehab" to the maximum a facility can bill.
- mason240 9y ago
  It's getting more common to get a DNR/DNI (Do Not Resuscitate / Do Not Intubate ) put into a "living will" that goes to into effect if you are in a situation where you will no longer be mentally cognitive.

olewhalehunter 9y ago

Keep in mind US healthcare costs are almost %20 of GDP Cutting the fat from that may mean a lot of folks lose livelihoods (and THEIR healthcare).

bedhead 9y ago
Besides being illogical (i.e. it's bad to eliminate waste), this exemplifies the problem with change. Any time there is a ANY constituency that is rendered worse off, no matter how justified it is, it is nearly impossible to effectuate change because the affected group screams bloody murder.
- bluesroo 9y ago
  But, wouldn't you? More importantly, shouldn't you? If the people in your government are doing something that is not in your best interest then you SHOULD speak up against it. After all, the word "representative" is based on the word "represent". If they are not representing my interests to the government then I should make that known. If I have ailment X and a bill is being pushed that pulls funding/ assistance away from ailment X, then I should make it known that I am unhappy about it. What if it is now guaranteed that I will die from ailment X? You're saying that I shouldn't kick and yell about it? I'm about to die! However, if it is also helps people with ailment Y, Z, I, J, K, and L, then it is the government's job to recognize that maybe I am less important to the bigger picture. If enough people will be negatively impacted to the point that I will not be reelected, then maybe it doesn't truly benefit my constituency as much as I think it will. Of course all of this is in an ideal world without accounting for the power of advertisement funding and the fact that most of the voting population isn't well educated about the issues.
alistairSH 9y ago
Broken window fallacy. https://en.wikipedia.org/wiki/Parable_of_the_broken_window https://en.wikipedia.org/wiki/Parable_of_the_broken_window Edit: Which is not to say those impacted won't need assistance moving on to other things. But, cutting the fat should be a net benefit to society.
9y ago

foolrush 9y ago

Don't ignore the elephant in the room. There is a good reason the USA spends the most on medical and has less than stellar results. That is without glancing at the corporate tax evasion. Unfettered profit at all costs capitalism isn't a glowing unicorn.

rcjones 9y ago

To your first points, the system exists as it does because each party can sort of displace the onus of overspending on another party. 1. Insurers are incentivized to seek out the minimum cost to achieve maintainable health. 2. Health care providers are incentived to reap as much as possible from insurers in return for acceptable (not always exemplary) health outcomes. 3. Patients, who on average are getting older and in need of more care, are pigeonholed (sometimes good, sometimes bad) into health care decisions by their providers and insurers. 4. Device/equipment manufacturers can charge ludicrous amounts because they capture very specific pieces of markets or gain preference from health care providers. However, the risk and cost involved in creating a new/competing product and entering a market can be staggering, and so high costs become inevitable (same argument drug developers can make). As you said, 'justified at any cost' makes this whole shebang go, especially when no single party is capable of controlling the cost. We can't point to a boogeyman we all have a part in making.

ensignavenger 9y ago
As per 1- insurance companies justify their earnings as a percent of costs for care- so if they keep costs for care high, it actually helps them charge higher premiums. Of course, they have to ensure that costs are high for everyone. If an insurance company were to announce record profits because they were able to better control costs than their competitors, there would be immediate pressure to lower premiums and not take the additional profits. When it comes to health care, the idea that we have anything resembling a free-market and private competition to lower prices is a farce on a grand scale.
- pandaman 9y ago
  The law actually caps their profit margin[1] so it effectively forces the insurance to pay and charge more if it wants to increase its income. Ironically, this law is called "Affordable Care Act". 1. http://abcnews.go.com/Politics/obamacare-health-insurance-rebates-check/story?id=19701785 http://abcnews.go.com/Politics/obamacare-health-insurance-re...
  - 9y ago

alistairSH 9y ago

While discussion of death is a bit morbid, some towns in the US have experimented with death planning, led by care providers and counselors at local hospitals. It has led to significant savings without resorting to "death panels". http://www.npr.org/sections/money/2014/03/05/286126451/living-wills-are-the-talk-of-the-town-in-la-crosse-wis http://www.npr.org/sections/money/2014/03/05/286126451/livin...

corey_moncure 9y ago

Here are two that I often see left out of the discussion: 1) Unfathomable amounts of money lavished on superficial appearances. From hospitals to private practices and surgery centers, everyone has to look trustworthy, exude that 'aura' of professional health care, with expensive landscaping, chic interior design with opulent materials, and of course enormous 4K television sets so that pharmaceutical manufacturers can push pills on the patients as they sit in the waiting room. Untold amounts of money are wasted on these non-essentials, which have literally nothing to do with the quality of the service provided, but which we all must pay for. 2) The epidemic of lifestyle diseases such as obesity, acquired diabetes, etc. Many of the nations where single payer is touted to work so effectively do not suffer from this issue (see Japan). The causes of this issue aside, at the end of the day, an undue burden is placed on the system generally, and as we have come to find out with ACA, young people making healthy choices rightly feel punished as their premiums climb and climb to cover the costs of treating completely avoidable conditions. We have to come together as a society and fix these problems at their root before they become the subject of medical treatments.

fencepost 9y ago

That statistic about the percentage of spending being in the last 2 years of life may be a bit misleading, just like keys are always in the last place you look. Once someone dies, most healthcare spending on them stops. Auto accident that's fatal after surgeries and a few days? In that window. The same applies to plenty of things that may have excellent recovery chances but which are not 100%. Edit: ObXKCD: https://www.xkcd.com/931/ https://www.xkcd.com/931/ (Lanes) Every one of those lanes going off to the right is the end of healthcare spending for someone, but you can't know going in which ones are going to turn off. Focusing on the "50% in the last 2 years" number is a lot like the the naive visualization at the top.

metaphorm 9y ago
your point is well taken, but I feel like there is still a subset of "excessive spending at end of life" that we can discuss as being more obviously problematic, from a social spending point of view. excluding trauma care for accident victims (that end up dying anyway), and excluding cases of early-in-life cancer, and excluding every other case we can think of where a spike of medical spending shortly before the person dies anyway is understandable as part of a good faith effort that had a reasonable chance of prolonging their life for many years, after all those exclusions are made we will still find many instances of cases where the end-of-life medical spending seems excessive. The canonical example I can think of would be organ transplants for very elderly people. A new kidney for a 75 year old person in advanced renal failure is unlikely to prolong their life by very much. This kind of stuff gets very emotional and very political though. This is what provoked the demagoguery about "death panels" when Obamacare was being debated in congress in 2009. We are both very uncomfortable allowing the government to make those decisions and also very uncomfortable allowing private insurers to make those decisions. We want to empower families to make those decisions and so remove cost from their consideration (via regulation, requiring insurers to pay) and then we become surprised when people who haven't made their peace with death are willing to spend any amount of money (which is a hidden cost from their point of view) to prolong end-of-life. It shouldn't be surprising. We set up a perverse incentive structure and locked it in place with regulations.

irishbro 9y ago

Freakonmics has an interesting episode where they cover the idea of offering a patient a bonus/rebate if they forego the standard end-of-life medical care. Quite a controversial suggestion but it does seem to have some though behind it http://freakonomics.com/podcast/are-you-ready-for-a-glorious-sunset-a-new-freakonomics-radio-episode/ http://freakonomics.com/podcast/are-you-ready-for-a-glorious...

zanny 9y ago

Saving peoples lives isn't a unique practice in the US. Doctors in the developed world are all bound by the Hippocratic Oath, and I'm not aware of any first world country that regularly judges the sick or old to die when doctors still have options available. They still pay a third as much in healthcare. A lot of those countries have physician assisted suicide though, which greatly improves the humanity of late term care. That is an easy and obvious piece of the solution the US should have been able to get behind a long time ago.

DanBC 9y ago
End of life care i not physician assisted suicide, and it's unhelpful to conflate the two. Six US states have end of life care that can include doctors prescribing fatal doses of medication. https://en.wikipedia.org/wiki/Assisted_suicide https://en.wikipedia.org/wiki/Assisted_suicide > The United States has authorized medical aid in dying in six states, which refers to a terminally ill person with 6 months or less to live taking a medication prescribed by a doctor
makomk 9y ago
Here in the UK, when the NHS decides whether a treatment is covered they take the cost and divide it by the estimated quality-adjusted life years it will give the patients who have it. If it costs more than £20,000-£30,000 per QALY they won't offer it. That's simply the value of a year of human life according to the NHS.