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> As for Huls, he is finishing up his fellowship at the hospital this summer. Wherever he ends up, he is certain he will find new cases to challenge his curiosi

• ianai 9y ago
  Is there a way to actually request a specific doctor have some time dedicated to figuring your case out at your expense? i.e. "Please do more troubleshooting for me above what insurance pays." I like your idea - but I fear the industry might have already ruled it out. -edit- Granted, I've done this in my own life by going to specialists at their own offices/outside of a hospital or medical group.
  • stevenh 9y ago
    Isn't this what concierge doctors offer?
    • arkades 9y ago
      Some. Some push the same old practice model but with reasonably cheap prices, so they can keep their old patient base and make their income off the slightly higher billings and the reduced overhead of eliminating your billing (read: calling the insurer and arguing) staff.
  • arkades 9y ago
    Unfortunately, no. Your doctor is contractually bound to the insurer’s fee structure; they can’t take an extra penny off of you. You’d have to go to someone that doesn’t take your insurance at all (or just don’t tell them you have that insurance). The side effect of all this, honestly, is that doctors stop learning how to turn off 7-minute-mode. When it comes to very serious problems, it pays to go to a practice that doesn’t accept insurance at all, because they never got into the bad habit to begin with.
    • seanmcdirmid 9y ago
      Almost makes the red envelope culture in Chinese hospitals seems appealing.
      • erric 9y ago
        https://en.wikipedia.org/wiki/Red_envelope https://en.wikipedia.org/wiki/Red_envelope I’d never heard of this before.
        • twic 9y ago
          On the situation in hospitals specifically: https://www.seattletimes.com/opinion/the-red-envelope-capitalistic-health-care-in-red-china/ https://www.seattletimes.com/opinion/the-red-envelope-capita...
        • jotm 9y ago
          Lol, that's exactly life in Eastern Europe/ex-USSR. There's socialized medicine, but if you want better service, you have to bring a gift (whisky, chocolate, money, the latter is always desirable). Not just hand cash over, that's disrespectful nowadays.
          • linkmotif 9y ago
            My grandmother was a pediatrician in Kiev in Soviet times. Her salary was about on par with anyone else, but she got tons of gifts.
  • nitrogen 9y ago
    Some possible search terms that might help (but I don't actually know the answer): concierge medicine, direct primary care, fee-for-service, out-of-network
  • sowbug 9y ago
    Yes, I've done this. I paid an out-of-network specialist for a second opinion on a cancer treatment. My HMO ended up following that specialist's recommendation. While I likely would have survived either treatment, this one was shorter and had fewer long-term side effects. I paid for the consultation out of pocket. It was less than $1,000. Not that outcome matters much to your question, but I have fewer scars, more original body parts, and better overall body function than I would have had with my HMO's original plan.
• batter 9y ago
  Why doctor? It's the most expensive part of your healthcare. But it can be trainee/researcher/AI. Which could be absolutely out of expensive healthcare system. Service which you could buy for additional cost from company which has good guess/prediction ratio based on input parameters from doctor. Service which could be in any part of the world.
  • arkades 9y ago
    What? The doctor’s visit is the cheapest part of healthcare. Procedures cost far more, and pharm far more again. Perhaps you’re outside of the US, though I can’t think of a country where this isn’t true.
    • jessaustin 9y ago
      Don't forget diagnostic scans and tests. Those are quite expensive. However GP is proposing a service that doesn't actually exist now: paying a medical expert to spend a lot of time considering a challenging case. It would have obvious benefits, so we shouldn't dismiss it out of hand just because it would be too cheap.
      • nitrogen 9y ago
        There was a now-defunct attempt at this called MetaMed: https://en.m.wikipedia.org/wiki/MetaMed https://en.m.wikipedia.org/wiki/MetaMed I'm curious if any others have succeeded.
        • feiofh398r39rty 9y ago
          It is very informative to read the founder's attempt to explain why MetaMed failed: https://thezvi.wordpress.com/2015/06/30/the-thing-and-the-symbolic-representation-of-the-thing/ https://thezvi.wordpress.com/2015/06/30/the-thing-and-the-sy...
  • inetsee 9y ago
    I have often thought that the Freestyle Chess model (a variation of Advanced Chess https://en.wikipedia.org/wiki/Advanced_Chess https://en.wikipedia.org/wiki/Advanced_Chess ) could be applied to medical diagnosis. Create a team consisting of one or more human doctors with a medical diagnostic AI. From the article it sounds to me that a lot of the research could have been done by an AI, with the human doctors making the final decision on the "best" diagnosis.
• jstanley 9y ago
  > there’s enormous value in chucking insurance out the window and just paying the doc for their time I'm sure there's enormous value in chucking economic realities out the window for everyone's job, but that doesn't make those realities go away.
  • arkades 9y ago
    You perhaps misread what I wrote. I don’t know how to reply, since I don’t know what it is you think I said. I don’t believe it “throws economic realities out the window” to say that sometimes you need an extended interaction with an expert, and that if you want more than 7 minutes of an expert’s time, you should engage with a reimbursement model that pays for more than 7 minutes. That doesn’t ignore the economic realities of healthcare at large; it’s saying sometimes you need a premium good, and those have premium prices.
    • jstanley 9y ago
      I thought you were proposing just forgetting about insurance and having the doctor's time paid for by magic.
• blakesterz 9y ago
  I know the Mayo Clinic has a totally different pay structure for docs, maybe there's other places out there like that as well. I think this is why people go there for answers to hard problems. Docs get paid a salary, they then choose how many patients they see, and that's it. I assume that's also why it can be tough to get an appointment there.
  • arkades 9y ago
    Mayo is a bit of a special case. Guwande hyped their fee structure in comparison to private practice, but it’s largely the same as every hospital: the doctor is an employee with an annual salary, the hospital is reimbursed per unit service by payors. Guwande compared them to private practices, where the doctor acts as his own employer, and thus has to maintain their own volume. The difference is that given their prestige and the number of out-of-state (read: mostly cash-paying) patients, they get much higher reimbursement than most places and can afford not to push the patient mill so hard. Normal hospitals have a patient base that is mostly insured or, if uninsured, the impoverished kind, not the globe-trotting wealthy kind. So their reimbursement is negotiated with insurers, so... they have to push the mill hard.
• curlcntr 9y ago
  There's an analogy here for software and engineering too. Getting to root cause and finding solid solutions - takes curiosity, energy... and time.
  • chrisbennet 9y ago
    You know what they call software organizations that don’t have time to do this? “Fast paced”
• majos 9y ago
  For some time my read on this situation has been that the "doctor shortage" that produces 7-minute diagnoses stems from a restricted number of residency slots, which is set (I believe?) by the federal government. I had thought the AMA was influential in lobbying to keep the number of such slots low to prop up doctors' salaries, but with some research it's unclear how true this is. Anyone know? How strong a lobbying force is the AMA, anyway?
  • arkades 9y ago
    The AMA has actually been lobbying quite strongly to expand the number of residency spots. Doctors salaries are generally pushed from the top down by Medicare and not by general supply-and-demand principles. So these shortages don’t lead to salary bumps, they lead to inferior substitutions (expansion of mid-level practice privileges), which actually puts a downward pressure on salary while also providing worse care for the public. The problem with residency slots is that they’re funded as part of the larger Medicare legislation, and no one wants to push for the bump in funding/taxes for Medicare needed to expand it. The reason visits are seven minutes long is because part of a trend that started with the HMOs in the 80s. The hypothesis on the part of insurers was that docs have a general target income - that they don’t work at maximum capacity (in general - obviously wonky things happen at the extremes.) If you reduce per-service billing, docs would maintain constant output to hit their personal target income goal. And... that’s exactly what happened. Since then, insurers have continued to hit against per-service fees, and docs and facilities have continued to shrink the time they alot to each service in order to keep afloat. In fairness, docs don’t have an awful lot of flex on this - they have to meet overhead costs which are fixed regardless of how small their reimbursement gets, and even with pitifully short visits doc real earning power has gone down quite a lot in the last 30 years. Docs work about 3x as hard as they used to, for about one third of the real income. It’s actually a bit scary: there’s not a lot of leeway left in this, and medical education is more expensive than its ever been. Docs carry the financial risk and massive increase in burnout, patients bear the risk of the reduction in time and quality of care, and everyone else is squeezing the juice out of the grapes. Something’s gonna give.
    • majos 9y ago
• Angostura 9y ago
  Well, I suppose he could end up in a country where health isn’t in the insurance straitjacket