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Unnecessary medical care is harming patients physically and financially (2015)

329 points by oftenwrong 9y ago

mhb 9y ago
[2015]
- sctb 9y ago
  Thanks! Updated.
sharemywin 9y ago
"some seven hundred and fifty BILLION dollars a year"
mtgx 9y ago
It sounds like in the "free market healthcare" system hospitals are incentivized to get the patient to spend as much as possible. That's aside from other bad incentives of such a system such as hospitals not wanting to be transparent with their prices, insurance companies not wanting to take patients with pre-existing conditions, also wanting to cover as few conditions as possible, Big Pharma being incentivized to ask for as high drug prices as possible (while lobbying for a ban on generics and imports), and so on.
- blattimwind 9y ago
  At least you're living in a free country with free healthcare and not some socialist shithole with universal healthcare.
  - Broken_Hippo 9y ago
    I'll take the socialist healthcare over the shit I got in the states, thank you. Sure, every system has its own problems and it isn't perfect. But I can get care. My yearly out-of-pocket is less than some folks pay per month for premiums, and definitely less than the average deductible. No more fears of losing a job and therefore losing medical coverage or going broke because of something out of my control. Have you even tried some of these other healthcare programs by living in such a country?
    - jessaustin 9y ago
      See irony.
      - blattimwind 9y ago
        I even threw in "free [as in choice not cost] healthcare", but I guess that's Poe's law for you.
  - Asooka 9y ago
    Literally no other country on Earth has USA-model healthcare. The choice isn't USA vs USSR healthcare (I would pick USA even with the debt issues, and I've actually lived in a socialist shithole), it's USA vs anywhere else.
- tr0ut 9y ago
  You have the wrong idea. A better example of what you're calling "free market" would be dentistry or something like Lasik surgery. You can shop around and figure out the prices because they are very much apparent since you pay out of pocket for the majority of the former and completely for the later. Would Medicaid/Medicare be "free market"? Why bother shopping around when someone else picks up the tab? Insurance companies mostly reflect the costs of the hospital. If the hospital charges you $50 for a bottle of Asprin, so be it. ICD10 and Meaningful Use were designed for billing not really for health care. Those were federal mandates not "free market" Pre-existing conditions is a lot more tricky than you think. The political ploy is to think of a poor person with a serious illness being turned away by insurance because they don't want to deal with them. When in reality it can be you're obease or someone who just did not take care of themselves period. You can imagine a group pre-existing conditions patients could bankrupt a insurance company. What if to be "fair" you were charged the same as a person with a pre-exiting condition. Say someone that smoked 2 packs a day for 30 years? ACA was just a big initiative to add more insurance companies to the mix. Now it is mandatory you pay insurance companies.
  - tdb7893 9y ago
    The underlying philosophy of mandating coverage for pre-existing conditions is the idea that everyone should be able to have basic medical care. With that idea it's really not that tricky to say pre-existing conditions should be covered.
    - tr0ut 9y ago
      I don't disagree with the philosophical purpose. Of course by simplifying the facts. You're leaving out the logistics of insurance companies that have to now take that responsibility on. Last I checked they dont work of the sake of goodness. Better option would be single-payer. I digress...
  - Cenk 9y ago
    I recently read this great article about this: http://time.com/4649914/why-the-doctor-takes-only-cash/ http://time.com/4649914/why-the-doctor-takes-only-cash/
- rvail2 9y ago
  You should look up the definition of "free market". We do not have a free market in healthcare.
  - hackeraccount 9y ago
    Exactly. It's a non-free market and whenever reforms are enacted - see ACA - they make it a bit more like itself, which is to say a bit less free. And when that doesn't work what's the fix? - more reform. More like itself. More a bit less free.
joncrane 9y ago
Sounds like another one of those "this is what happens when money (as opposed to patient wellbeing) becomes a driving factor in health care." I remember I tried to find a PCP once and I showed up for my intake appointment and the young, rushed doctor said they wouldn't enroll me as an official member unless I had two intake visits. They were gaming the insurance system.
- whb07 9y ago
  More like, “what happens when the patient does not directly feel the financial bill and the doctor tries to charge/do unnecessary things to make more money”. This is a direct result of the laws and regulations distorting the market.
  - Sumaso 9y ago
    Yeah lets get rid of laws and regulations, that will fix health care prices!!! /s
    - kent13304 9y ago
      It actually would. No need for sarcasm on that comment.
      - 0xcde4c3db 9y ago
        I'm not sure it would. Given the information asymmetries involved, how does it avoid the "market for lemons" problem?
        phil21 9y ago
        I think HN could do with some older folks on it. Heck, I remember growing up and using insurance was rare. You paid cash for your doctor visits, and typically only used insurance for major hospital stays as that's more or less all it covered. Doctor visits just 30 year ago did not cost what they do today. You could get a clean break in your arm, go into your GP, have it fully fixed and be out the door for less than a week's wages for an average blue collar worker. This was actually considered very expensive, but it prices were held down for the simple fact that people cared and there was a hard limit - can't get blood from a stone. When insurance started to become "cadillac" plans I very much noticed an insane explosion in everyday medical costs and a nosedive in quality of care. It's now a corporate factory system where everyone is miserable - the doctors and the patients. The only winners are executives and shareholders. The insanity of average cases of stuff like the flu now going to a doctor also is very new, and only is happening due to the incentives of "free visit" for the average consumer. The typical argument used against a return to "free market" health care where insurance is actually insurance again is one much like yours - if you're sick you don't care about the price. This was proven untrue just in my recent childhood, and something like 90%+ of all healthcare is not urgent or emergency related. If 90% of the market is setting prices via free market discovery the remaining 10% will be drug along or can be forced to via limited regulation. Healthcare costs in the US are almost entirely a principal agent problem. Absolutely no one has a damn clue of what anything costs at any point in the entire process. And the real issue is the consumers don't actually care since they are only harmed in an indirect sense.
marze 9y ago
This article makes it sound like medical costs in the US could be halved if everyone understood this problem, and did their own research on proposed procedures.
- jessaustin 9y ago
  So... it would be impossible to halve medical costs? People, in general, are pretty dumb. Sick people, in general, are more so.
  - announcerman 9y ago
    I don't think your mother is dumber than the general population if she has cancer though.
- luckydata 9y ago
  Go ahead, try and come back tell us how effective/easy that is. I dare you.
- tinokid 9y ago
  Nice idea, but how realistic is it? Most patients are not scientifically-literate, some are flat out incapacitated. For all the stories about heartless insurance companies denying to pay for things, perhaps they should actually be more strict. As in, refuse to pay for anything unless there is 1) rock-solid (i.e. double-blind, placebo-controlled) evidence that it helps 2) for a specific, objectively verifiable indication 3) when provided by a doctor whose track record is demonstrably non-inferior to that of other practitioners. But for all three of those things, no $. I would be interested in buying insurance like that.
  - maxerickson 9y ago
    In the US system you agree to pay any bills the insurance will not cover prior to receiving treatment. Which is an obvious opportunity for improvement. When a giant hospital and a giant insurance company get in a knife fight over whether a procedure is covered, the patient shouldn't be the loser. (Maybe some sort of system where if the provider states that something is medically necessary then they are on the hook if insurance denies the claim)
edwhitesell 9y ago
After recently getting a cancer diagnosis and going through surgery and chemotherapy, the best advice I can give is: ask lots of questions and you are your own best advocate. As with any profession, there are some great doctors who are truly looking out for your best interests and will pursue any direction you want. There are others who simply want to "follow the standard practice", even if what they know as "standard" is 35 years old. There are others who just want to get through as many procedures as possible and "see what sticks" when it comes to a diagnosis. Asking questions helps you better understand which of these you're working with, and what actions you need to take on your own. Finally, EMR sounds great, but in my experience it just doesn't work. Find a PCP who is part of a hospital system with specialists using the same computer system. This means they can all see each other's notes & test results. A lot of the time, even doctors in the same building are basically "private practice", or part of some other partnership that is not part of the hospital you are at.
- thomastjeffery 9y ago
  > Find a PCP who is part of a hospital system with specialists using the same computer system. I really can't comprehend how these people don't feel a critical need for compatible open formats, and think they are fine using incompatible proprietary ones. How is sharing information seen as a negative in this scenario?
dipppy 9y ago
Everyone has a story like this. I went in for a physical and even though they said to my face my insurance would fully cover a heart electrocardiogram (my family has a history of heart problems) I wound up with a huge bill, month long fight with insurance, and ended up just having to foot it. Maybe if medical care was driven by some other force besides capitalism this wouldn't be such an issue.
- lr4444lr 9y ago
  Just out of curiosity, because I often have this fear, did your the staff have any documentation or make assurances that he was a "participating provider" with your plan (i.e. not just saying they "will bill the insurance company")? Or did your plan not offer comprehensive coverage?
- dboreham 9y ago
  Essentially identical story in my family. And to address the sibling comment's question in my case : the hospital has a _recording_ of the insurance company rep on a phone call stating that the procedure was covered. However it appears this achieves nothing because the insurance company can use their magic powers of "pound sand suckers" and we had to pay anyway. Hospital denies any responsibility because they called insurance and were told they had coverage, and they kept a recording of said call. The fact that providers routinely record their calls to insurance companies tells you something in itself.
ycombonator 9y ago
Ivory tower elite have usually all the time to pontificate. Tell that to this girl who did not see the light of the day. https://nypost.com/2018/02/26/girl-dies-hours-after-doctor-turned-her-away-for-being-a-few-minutes-late/ https://nypost.com/2018/02/26/girl-dies-hours-after-doctor-t...
- notfromhere 9y ago
  both things being true is possible.
- conanbatt 9y ago
  What a tragedy. But lets not forget that this is what we see not what it is. It could have happened the other way: "patient died after not receiving attention even though they arrived on time. Doctor was busy providing care to previously late patients".
gjem97 9y ago
It's a question of fundamental incentives. Doctors and hospitals are paid for procedures, treatments, and appointments. Is it any surprise that there's incentive to undertake these activities? You don't even need to believe that your doctor is greedy to understand that if there's a borderline case, they might order the test or treatment "to be safe", or "because there's no downside", or because "we have the available capacity". Even if they aren't explicitly considering payment as part of the equation, it's not unreasonable to think that subconsciously the monetary incentive will tip some of these cases in the direction of overtreatment. IMO, the only way this is going to change is a movement away from the "pay for services" model that is dominant in US healthcare today.
- novalis78 9y ago
  I slightly disagree - what's missing is price transparency inviting competition. Through competition the payment and cost side of things will be added to the equation and shift incentives to cut waste and increase quality of service. That includes all aspects of the healthcare services.
  - lr4444lr 9y ago
    Also that for the majority of people, a third party pays. The receiver of care only indirectly affected by slowly rising premiums, deductibles, co-pays, caps.
    - merpnderp 9y ago
      For most people it is actually a forth party pays. There's the traditional three party insurance system, but for most people there's also the forth, their employer. So not only is the receiver of medical care removed from any price sensitivity by their insurer, they're removed from much of the insurance price sensitivity by their employer. Removing the ridiculous system of employers paying for health care and instead just paying people the money (come on, FDR's WWII salary fixing has been over for 70 years, yet its harm continues).
  - shawndimantha 9y ago
clircle 9y ago
Nothing gets HN more riled up these days than a good story about healthcare in America.
learnstats2 9y ago
The article pins part of its argument on the claim that advances in diagnostics have not changed the death rate for (e.g.) breast cancer during the past quarter century, but a superficial search immediately suggests this to be grossly false. "Death rates from female breast cancer dropped 39% from 1989 to 2015." - all other things being equal, it ought to have increased: age is a risk factor for cancers, and we have an older population. Instead, it has greatly decreased. So I dispute the veracity of several of the article's claims, but also: what is considered unnecessary changes with the benefit of hindsight. I would argue that it's expected that a majority of diagnostic tests deliver a negative result (i.e. turn out to be "unnecessary"), and this is actually a mark of a healthy healthcare system.
- Consultant32452 9y ago
  There are other likely explanations for that data. If more women are getting screened more frequently then their cancers will be detected earlier and improve survival rate. That doesn't mean the diagnostics tools themselves have improved the survival rate, only that the diagnostic tools are now used more frequently.
  - throwaway1982x 9y ago
    >If more women are getting screened more frequently then their cancers will be detected earlier and improve survival rate. Yes, but the article argues directly against this point.
  - learnstats2 9y ago
    There may be other explanations, but the article denies the truth of the data to claim this point.
- maxerickson 9y ago
  How do the survival rates speak to the impact of advances in diagnostics? For improvements in diagnostics to be particularly important to survival rates, you'd need to show things like cancer being found much more often now or that finding it sooner (than was typical in 1985) greatly improves survival rates. Really what has happened is that treatments have gotten a lot better.
hliyan 9y ago
I live in a 3rd world country (Sri Lanka). Healthcare is not as advanced as it is in the US, but it is decent for all except the most complicated cases. The vast majority of people use the free services at state hospitals. If you want slightly better care, you can go to a private hospital and still come out with most of your wealth intact. I recently had a minor surgery to remove a conjunctival granuloma from my left upper eyelid. It was a private hospital, and it cost all of $50. Compared to US standards, the facilities were spartan, but adequate and hygienic. Also, doctors and hospitals do not live in constant fear of malpractice suites. I suspect these factors have a lot to do with the costs (in addition to the obvious cost-of-living adjustment for the third world).
- deleted 9y ago
  [deleted]
- 39d3493I93 9y ago
  You bring up a couple of interesting points even if you don't realize it. There are a couple of things that impact your experience that are externalizations. For example, your "cheap" healthcare is largely due to massive amounts of subsidies and NGO work that goes into helping third wold countries provide such "cheap" medical services. In many ways, due to rather authoritarian types in control in government in the west, who think they have the right to steal from their own citizens through taxes in order to "help" others, it is actually even more expensive for Americans in particular to receive medial care because none of those costs of shipping off billions and trillions of Americans' dollars overseas to "help" others is ever included in the cost of things like healthcare. You may ask yourself how that correlates, but it's because, e.g., while American doctors and people are overseas training and "helping" others, they are neglecting their own society and people, and while billions upon billions are spent to subsidize and "help" others, those billions and billions of dollars are drained from America and Americans and their communities, which in turn is money that they cannot use to receive quality healthcare in some cases. Another point you bring up is that while you are using facilities that are spartan compared to US standards but more than adequate for providing health services, in the USA the very same people who lament the cost of healthcare want well appointed and lavish facilities that are beautifully designed and have cafes and restaurants. I have this kind of argument all the time in a country where people think that a $120 million dollar library with a $10 million dollar yearly maintenance and operation cost is an even remotely reasonable cost when you could provide the very same kind of service in a facility that isn't like a luxury hotel. It's not just that doctors don't face the same kind of fear of malpractice suits, those doctors are also not under constant pressure to perform unnecessary procedures to pay for the $1.3 billion ... yes, BILLION ... hospital and the health care sector in many countries is not the scheming and conniving and fraudulent get rich quick kind of scheme it has become in the USA. In many of the emerging countries, doctors and hospitals perform their services out of a desire to help people, in the USA there is a whole cottage industry of the medical services that has figured out how to latch onto all the various Socialist schemes Liberals devise on how to dispense with other people's money to "help", which affords them fleets of private planes and ocean side mansions.
davidscolgan 9y ago
In the book Antifragile Nassim Taleb cautions against medical care unless it's truly necessary. He argues that since so many things can go wrong in a hospital (you could get sick from someone else, mistakes could be made, etc), only go if the benefits outweigh the risks. And so if you have cancer, it's probably worth the risk. But if you have something that could just go away naturally, that's got a higher expected value of positive outcome. He is in favor of subtractive medicine - many harms are caused by adding such things as smoking, sugar, preservatives, etc, and instead of adding medicine or surgery, remove the elements that the body isn't evolved to tolerate and see if it heals itself. He gives the example of how he hurt his back weight lifting. The doctor proposed surgery. He just waited and his back healed itself, and in a way that is now more robust than if he had had surgery. As with all things, it's not a black and white kind of decision, but this mindset has worked well for me as a heuristic for health.
- DanBC 9y ago
  He's just regurgitating conventional medical wisdom that's routine in countries that aren't the US. We've been talking about the risks of over-testing, over-diagnosis, and over-treatment for many years. Mostly in the context of full body MRI scans for healthy people, or early testing for prostate cancer, but also many other things.
  - s3nnyy 9y ago
    What's the problem with full body MRI scans for healthy people? They don't cause any harm, just cost money.
    - CaptainZapp 9y ago
      Apart from the fact that it costs a lot of money. What do you want to achieve with a full body MRI scan?
      - s3nnyy 9y ago
        A friend of mine who wasn't even 30 years old had a serious brain tumour where they said "ouh, if we'd had done a MRI scan some years ago, it would have been much easier to fix." So that is why it might be a okay'ish idea to do a MRI scan of the brain every 5 years or so? Depending where you live they are actually cheap and can be paid out of pocket.
kreco 9y ago
For the physical harming, Nassim N. Taleb wrote a book called "Anti-Fragile" desribing the concept of iatrogenic illness. https://en.wiktionary.org/wiki/iatrogenic https://en.wiktionary.org/wiki/iatrogenic An alarming fact was less dying patients when an hospital workers were in a strike action (during 2 weeks).
- manjushri 9y ago
  Johns Hopkins study suggests medical errors are third-leading cause of death in U.S. https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/ https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-...
  - kreco 9y ago
    Really interesting, thx !
  - mobilefriendly 9y ago
    I was on a multi-corporate task force on medical errors in the late 1990s and the working number was about 80,000 deaths per year. I remember GM saying that statistically it worked out to something like one GM worker or retiree like every week, and that if they had that kind of mayhem on the assembly line there'd be outrage... but the inept health care system just quietly kills people.
  - ams6110 9y ago
    And yet we're all wound up about so-called assault weapons and the NRA. Not meaning to take this on a political tangent, just using that as a current-events example of things we worry about and spend political capital on, that have really very little statistical impact. Compare the much, much larger number of deaths due to medical error, automobile accidents, etc.
  - skadamou 9y ago
    I thought this excerpt from the article you posted was interesting "The researchers caution that most medical errors aren't due to inherently bad doctors, and that reporting these errors shouldn't be addressed by punishment or legal action. Rather, they say, most errors represent systemic problems, including poorly coordinated care, fragmented insurance networks, the absence or underuse of safety nets, and other protocols, in addition to unwarranted variation in physician practice patterns that lack accountability." I've seen this statistic before and had not looked into in much but it sounds like determining if docs cause more harm than good is perhaps a little more nuanced than the statistic first seems. On a related note, below I've linked to an NPR article about how women that gave birth under the care of a doctor in the 1800s were 5 times more likely to die than those seen by a midwife because doctors were not washing there hands or medical interments. https://www.npr.org/sections/health-shots/2015/01/12/375663920/the-doctor-who-championed-hand-washing-and-saved-women-s-lives https://www.npr.org/sections/health-shots/2015/01/12/3756639...
emodendroket 9y ago
> A third patient had undergone surgery for a lump that was bothering him, but whatever the surgeon removed it wasn’t the lump—the patient still had it after the operation. One wonders how the constantly trotted out panacea of making patients pay more out of pocket would help with a case like this.
s3nnyy 9y ago
Nassim Taleb explains this in "Skin in the Game" rather well. If you are sick a little bit, don't take drugs prescribed by your doctor. If you come to the doctor with a little coughing, the doctor knows you're likely fine and there is a high chance you won't need any meds BUT if you happen to die the next day, the family of the former patient will find something and might sue you because you - as a doctor - didn't prescribe the needed drugs. Some drugs are known to cause problems 10 years down the line, but this is not the doctors problem because he fixed your primary problem but doesn't really care about second-order/side-effects of the prescribed drugs.
wdn 9y ago
There issue is two folds here. 1. Medical liability. Doctors must cover their basics or will get sue. 2. There is no cost relationship between doctors and patients. Doctors and patients work with 3rd party call health insurers. Worst, a lot of people (medicaid recipients) have no skin in the game. Obama could have fixed item #2 with a universal health care that require (1) doctors to list the price of their services and (2) cover major catastrophic health expenses, such heart issue, cancer, long term care, etc. Prevention care should physical, cold should be out of pocket for the first 5 or 10 visits of the year, then it is covered. I know some may called foul because poor cannot pay. Paying $20 per visit, at 10 visit, it is $200 out of pocket. They have have skin in the game. This will cut down a lot of abuse.
- liqu0rice 9y ago
  Paying $20 per visit, at 10 visit, it is $200 out of pocket. They have have skin in the game. This will cut down a lot of abuse. Germany had something like you propose from 2004 until 2012 (1). It was not particularly successful and therefore consequently abolished. (1) https://de.wikipedia.org/wiki/Praxisgeb%C3%BChr?wprov=sfla1 https://de.wikipedia.org/wiki/Praxisgeb%C3%BChr?wprov=sfla1
- arkades 9y ago
  >Paying 20$ per visit... Such experiments have been made with Medicaid demo projects in the US. They've failed every time. People can't distinguish needed care from unneeded care; they end up foregoing needed care, deteriorate, and end up costing the system much more in the form of hospitalizations, disability, etc.
  - michaelmrose 9y ago
    Its because poor people overusing free medical care is the problem with the health care system like people buying doritos with food stamps is the problem with SNAP.
- conanbatt 9y ago
  Healthcare is expensive for multiple reasons, the fee structure being a part of it. If insurance were decoupled from the employer, the individuals would be able to pick the best insurance as opposed to a negotiated insurace by the employeer. That would move people to what is generally considered the best insurance options and that alone makes the competition a lot better. As a patient you dont know which one is better medical care, but you will make some sort of judgement per-insurance. THere are other issues, like restrictions on the importation of drugs, restrictions on the immigration of doctors, high law suit liabilities that end up costing a lot in insurance and processes that not necessarily are better healthcare, etc.
DonnyV 9y ago
Rationing medical care because the underlining system is broken makes no sense. People in the US already don't use enough medical services. "For example, Americans average 4 doctor visits a year compared to 7 in France and Canada, countries with better health outcomes than ours." http://www.pnhp.org/news/2014/january/americans-underuse-health-care http://www.pnhp.org/news/2014/january/americans-underuse-hea...
maroonblazer 9y ago
Growing up with a mom who was a non-working registered nurse, every time I or my siblings came down with symptoms like fever, nausea, vomiting, etc she almost never took us to the doctor. Instead it was rest and liquids, maybe an aspirin. I would always plead with her that we needed to seek professional medical advice. Now as an adult I realize that she knew too well the limitations of that advice when it comes to most minor maladies people suffer. And yet today I still see friends and colleagues go to the Dr or call the "teledoc" when they have these symptoms. They usually get an antibiotic (which has its own issues) or told they simply need to rest.
- bobo_legos 9y ago
  Same exact story except my mom is and still is a working R.N. There was no running to the doctor or emergency room if I got sick or banged up an knee or elbow. To this day as a grown adult I still work this way. It's a completely foreign concept to me to automatically run to the doctor like so many people around me seem to do. You're other point about knowing the limitations of doctors is completely valid. Every night at the dinner table I heard one horror story after another about the crazy shit doctors would do at her hospital. Maybe its why today I don't run to the doctor for every little thing. I got the understanding that just because someone went to medical school and got an M.D. doesn't mean they're a miracle worker. There's just as many screw ups in that industry as any other. On the upside though if something does happen where I(or someone in my family) need a doctor I can go to her(and my R.N. sister) to tell me who the good ones are and who to avoid like the plague.
deleted 9y ago
[deleted]
hestipod 9y ago
I was preparing to make a long post asking for ideas/help (been saying that for weeks but it's ready and I was waiting to Monday since weekends are slower) This sort of thing ruined my life, cost me everything, and has finally brought me to the precipice. I was convinced 15 years ago to have surgery to "prevent later disability" and it ironically left me disabled and in severe pain. I later found out abroad from several doctors that I never needed the surgery but the catastrophic damage was done, but they did improve things slightly and Ive been trying to get back to live there but cannot. A few years later in some nightmare the "repair" surgeon messed it up far worse and changed the procedure we had agreed on, but I signed the vague forms hurridly shoved in front of me as I was being prepped and legally he as allowed to. I never would have agreed to that procedure he did had I been clearly informed. They got paid...my life got ruined...and things slid downhill from there as systems and people failed me. Now I am facing seemingly insurmountable needs and costs and more surgery which terrifies me and I would never trust having in this country if at all. It's long story that has no TLDR. I am at my wits end and don't know if a comment here is the right place to share whole thing, or if I should make my own post now or Monday...I need as many eyes on it as possible if there is any hope.
- colordrops 9y ago
  Perhaps you could share the procedures so others would know to be skeptical if they are in the same situation?
  - hestipod 9y ago
    The nutshell is don't ever have foot surgery unless it's to repair a catastrophic injury/trauma and there is no choice if you want to save the foot. The risk/failure rates are so high and not honestly explained. I was left with ruined joints, damaged tendons, nerve damage, and RSD that spread up my legs and affects my whole body to a degree. I was misinformed and flat out lied to and have never met someone to this day who had such surgery that was better for it either immediately or in the long run. It ruined my life and I lost everything.
    - 9y ago
arkades 9y ago
I worked in health insurance, and had a graduate degree in health policy, before I second-careered into medicine. I helped implement some of the programs that Guwande promotes in this article; I was and am a true believer in some of these programs, and have built my medical career around implementing them properly. I say all that to provide an important caveat: Guwande's a Harvard-associated surgeon largely insulated from what any of this looks like on the ground, and basically collects anecdotes that match his views until he can tell a nice just-so story. The reality is far more complicated than he relates, and shared savings programs are far from some sort of medical panacea that addresses all the imbalanced and chaotic incentives in medicine. A few big nitpicks: (1) The ACA Shared Savings program is and was bullshit for providers. Because it was built on top of "traditional Medicare", meaning a non-HMO arrangement that did not infringe on pt's right to seek as much care as they wanted, from whomever they wanted, there was no actual assignment of responsibility. If Doctor X is to share in the profits of saving the system D dollars, you have to be able to measure the savings he generates. However, no patients are "his" - we just measure which PCP patients go to the most in a year and give the doc a benchmark based on those. This was based on an assumption that most people saw their PCP at least once/yr. Turns out that not only do people not see their PCP once/yr, but plenty are snowbirds, or have a rotating list of multiple PCPs. Medicare has not fixed the attribution issue. (2) The most effective way to create savings remains to deny care. There's a reason there was an HMO backlash. Creating that incentive reduces costs/spending, but ... (3) The vast majority of physicians do not work in pure capitated programs. They work in a mixture of shared downside, shared upside, and FFS. You can't manage patients with a mix of payors like this, because you still have to build your daily operations around the largest volume - the FFS folks. This is what I saw the most of in the rollout of the ACA: docs were "enrolled," sure, but ACO's still pay out on top of FFS, and the rest of the patients are normal FFS + shared risk, the result is daily operations built around volume, not around "spending 45 minutes to review how to take insulin." 4) Docs over-test and overprescribe for medicolegal issues that no amount of incentive-shifting can fix. Hell, my hospital antibiogram doesn't even have pseudomonas sensitivity to pip, just pip/tazo, despite the fact that pseudomonas pretty much never needs pip/tazo (the /tazo is a spectrum extender). But prescribing pip/tazo over pip is something akin to "no one ever got fired for buying IBM." Hell, we do baseline kidney function tests before giving contrast in emergency radiology, despite the fact that the biggest studies to date show that baseline kidney function doesn't have any predictive value for contrast-induced nephropathy-related outcomes 6 mos out. It's a pointless delay that actually hurts patients and costs money. But you know what? No one sues a doc for getting worse in an ED while awaiting a lab result - that " just happens". They do sue a doc for contrast-induced nephropathy, because that looks like something a doc actively caused (well, it is) - and a malpractice attorney will slam your balls to the wall for "why didn't you look at his kidney function before throwing kidney toxins at him?" The malpractice thing is honestly more insidious than that, even. It gets docs out of the mindset of thoughtfully asking "well, WHY would I order that test? How does it advance the diagnosis or management meaningfully?" to a "might as well order it to be on the safe side" mindset that infects the rest of their practice. The latter creates sloppy, over-broad testing regimens. Heck, we can't even utilize the latest research unless we can convince multiple departments worth of docs to agree on it. Because the standard for malpractice is what your peers would do, "I did X as part of our department standard, as agreed upon by all the docs in X and related specialty Y" is a very strong malpractice defense. If you can't convince all of those people to get on board and change department policy and just try to practice based on the most up to date data yourself, a malpractice attorney's question becomes: "Where did you get your PhD in statistics and clinical trial design? Oh, you don't have one? So what made you qualified to take in this study and overrule a panel of national experts on the topic that decided what the standard practice is?" We really need an iatrogenesis compensation fund built at the national level, and to get rid of malpractice suits. That will bring down bullshit spending by a fair degree right off the bat. A related issue that people overlook is that about 70% of the growth in HC costs is attributable to technological advance: new drugs, or hiked up drugs, new tech, etc. We want all these things, but refuse to take into account that they demand a premium (even when they're not actually more effective.) I could rant for ages.
whowouldathunk 9y ago
A small example is my girlfriend getting charged for a pregnancy test in the emergency room even after she told them she doesn't have a uterus.
DINKDINK 9y ago
Iatrogenics / Iatrogenesis https://en.wikipedia.org/wiki/Iatrogenesis https://en.wikipedia.org/wiki/Iatrogenesis
lostgame 9y ago
Cue 'unnecessary surgery land' in 4, 3, 2...
oftenwrong 9y ago
This article came to mind this morning when I made my second visit to the orthopaedics department at a local hospital. The department schedules all patients for pre-appointment x-rays. That is, before the patient is even seen, before the doctor can determine if an x-ray would even be useful. On my first visit, I missed my x-ray appointment. The doctor I saw that day later said that was no problem. According to him, an x-ray wasn't necessary given my symptoms. I was scheduled for an expensive, unnecessary x-ray for no reason, basically. On today's visit I simply declined the x-ray, and the doctor I saw today was fine with that because he also did not recommend that any imaging be done.
- rbanffy 9y ago
  You were scheduled for an expensive, unnecessary dose of radiation that would be billed to your insurer and that's how the provider makes a ton of money out of you. The only priority of any sane health system should be to make people's health better.
  - troycarlson 9y ago
    Bundled payments are slowly gaining traction and help align incentives a little better. https://en.wikipedia.org/wiki/Bundled_payment https://en.wikipedia.org/wiki/Bundled_payment
- astura 9y ago
  Same thing with me when I was referred to orthopedic surgeon for a lump in the soft tissue. Before even seeing me they called me in for a pre-appointment x-ray. It was never explained to be why a lump in the soft tissue would need an x-ray. I kinda went with it because it was such a surprise but I really wish I questioned it, seems like such a waste. Especially since the doctor ordered an MRI after seeing me.
  - riahi 9y ago
    Because the Radiograph is a relatively cheap screening test to rule out an underlying bony abnormality as a possible explanation for the soft tissue lump. Further, radiographs and MRI provide complementary information. Taken together, they provide much more definitive characterization than either alone.
NicoJuicy 9y ago
Medical care in the US seems... unhealthy. I'm glad to live in belgium, where i won't go broke if something happens.
blackRust 9y ago
The article's author, Atul Gawande, has written four books. So far I've only read _The Checklist Manifesto: How to Get Things Right_ and have been applying it to various aspects of work and life (travel packing checklist, Engineering team runbooks, etc). I would strongly recommend it. All his other books are on my "to read" list...
jrnichols 9y ago
"or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem" A hospital system in California should have done one of these on me, but instead didn't and I went with a herniated disc for 10 years longer than I needed to. Finally a hospital in Texas did an MRI and discovered it and I had surgery to address the issue. Previously it had been brushed off as a muscle strain or sciatica and i was constantly given pain medication that only masked the symptoms of a bigger problem. My life may be a completely different place right now had someone just done an MRI years ago. unfortunately I didn't know to ask for one. :/ "I am far more concerned about doing too little than doing too much" this is exactly why so many "unnecessary" tests and procedures happen too, unfortunately. There's also a lot of "I want you to DO something" that causes physicians to overprescribe antibiotics/etc because otherwise, they know that the patients are going to give them a lower survey score, which directly affects reimbursements. Tying reimbursements to patient satisfaction scores is an awful idea that needs to go away yesterday. http://kunr.org/post/patient-satisfaction-surveys-make-doctors-feel-pressured-prescribe-antibiotics http://kunr.org/post/patient-satisfaction-surveys-make-docto...
neuro_imager 9y ago
I would share this article but I've been living on a resident/fellow salary for way too long and need at least a few years to milk that cash cow first.

329 points by oftenwrong 9y ago

mhb 9y ago

[2015]

sctb 9y ago
Thanks! Updated.

sharemywin 9y ago

"some seven hundred and fifty BILLION dollars a year"

mtgx 9y ago

It sounds like in the "free market healthcare" system hospitals are incentivized to get the patient to spend as much as possible. That's aside from other bad incentives of such a system such as hospitals not wanting to be transparent with their prices, insurance companies not wanting to take patients with pre-existing conditions, also wanting to cover as few conditions as possible, Big Pharma being incentivized to ask for as high drug prices as possible (while lobbying for a ban on generics and imports), and so on.

blattimwind 9y ago
At least you're living in a free country with free healthcare and not some socialist shithole with universal healthcare.
- Broken_Hippo 9y ago
  I'll take the socialist healthcare over the shit I got in the states, thank you. Sure, every system has its own problems and it isn't perfect. But I can get care. My yearly out-of-pocket is less than some folks pay per month for premiums, and definitely less than the average deductible. No more fears of losing a job and therefore losing medical coverage or going broke because of something out of my control. Have you even tried some of these other healthcare programs by living in such a country?
  - jessaustin 9y ago
    See irony.
    - blattimwind 9y ago
      I even threw in "free [as in choice not cost] healthcare", but I guess that's Poe's law for you.
- Asooka 9y ago
  Literally no other country on Earth has USA-model healthcare. The choice isn't USA vs USSR healthcare (I would pick USA even with the debt issues, and I've actually lived in a socialist shithole), it's USA vs anywhere else.
tr0ut 9y ago
You have the wrong idea. A better example of what you're calling "free market" would be dentistry or something like Lasik surgery. You can shop around and figure out the prices because they are very much apparent since you pay out of pocket for the majority of the former and completely for the later. Would Medicaid/Medicare be "free market"? Why bother shopping around when someone else picks up the tab? Insurance companies mostly reflect the costs of the hospital. If the hospital charges you $50 for a bottle of Asprin, so be it. ICD10 and Meaningful Use were designed for billing not really for health care. Those were federal mandates not "free market" Pre-existing conditions is a lot more tricky than you think. The political ploy is to think of a poor person with a serious illness being turned away by insurance because they don't want to deal with them. When in reality it can be you're obease or someone who just did not take care of themselves period. You can imagine a group pre-existing conditions patients could bankrupt a insurance company. What if to be "fair" you were charged the same as a person with a pre-exiting condition. Say someone that smoked 2 packs a day for 30 years? ACA was just a big initiative to add more insurance companies to the mix. Now it is mandatory you pay insurance companies.
- tdb7893 9y ago
  The underlying philosophy of mandating coverage for pre-existing conditions is the idea that everyone should be able to have basic medical care. With that idea it's really not that tricky to say pre-existing conditions should be covered.
  - tr0ut 9y ago
    I don't disagree with the philosophical purpose. Of course by simplifying the facts. You're leaving out the logistics of insurance companies that have to now take that responsibility on. Last I checked they dont work of the sake of goodness. Better option would be single-payer. I digress...
- Cenk 9y ago
  I recently read this great article about this: http://time.com/4649914/why-the-doctor-takes-only-cash/ http://time.com/4649914/why-the-doctor-takes-only-cash/
rvail2 9y ago
You should look up the definition of "free market". We do not have a free market in healthcare.
- hackeraccount 9y ago
  Exactly. It's a non-free market and whenever reforms are enacted - see ACA - they make it a bit more like itself, which is to say a bit less free. And when that doesn't work what's the fix? - more reform. More like itself. More a bit less free.

joncrane 9y ago

Sounds like another one of those "this is what happens when money (as opposed to patient wellbeing) becomes a driving factor in health care." I remember I tried to find a PCP once and I showed up for my intake appointment and the young, rushed doctor said they wouldn't enroll me as an official member unless I had two intake visits. They were gaming the insurance system.

whb07 9y ago
More like, “what happens when the patient does not directly feel the financial bill and the doctor tries to charge/do unnecessary things to make more money”. This is a direct result of the laws and regulations distorting the market.
- Sumaso 9y ago
  Yeah lets get rid of laws and regulations, that will fix health care prices!!! /s
  - kent13304 9y ago
    It actually would. No need for sarcasm on that comment.
    - 0xcde4c3db 9y ago
      I'm not sure it would. Given the information asymmetries involved, how does it avoid the "market for lemons" problem?
      - phil21 9y ago
        I think HN could do with some older folks on it. Heck, I remember growing up and using insurance was rare. You paid cash for your doctor visits, and typically only used insurance for major hospital stays as that's more or less all it covered. Doctor visits just 30 year ago did not cost what they do today. You could get a clean break in your arm, go into your GP, have it fully fixed and be out the door for less than a week's wages for an average blue collar worker. This was actually considered very expensive, but it prices were held down for the simple fact that people cared and there was a hard limit - can't get blood from a stone. When insurance started to become "cadillac" plans I very much noticed an insane explosion in everyday medical costs and a nosedive in quality of care. It's now a corporate factory system where everyone is miserable - the doctors and the patients. The only winners are executives and shareholders. The insanity of average cases of stuff like the flu now going to a doctor also is very new, and only is happening due to the incentives of "free visit" for the average consumer. The typical argument used against a return to "free market" health care where insurance is actually insurance again is one much like yours - if you're sick you don't care about the price. This was proven untrue just in my recent childhood, and something like 90%+ of all healthcare is not urgent or emergency related. If 90% of the market is setting prices via free market discovery the remaining 10% will be drug along or can be forced to via limited regulation. Healthcare costs in the US are almost entirely a principal agent problem. Absolutely no one has a damn clue of what anything costs at any point in the entire process. And the real issue is the consumers don't actually care since they are only harmed in an indirect sense.

marze 9y ago

This article makes it sound like medical costs in the US could be halved if everyone understood this problem, and did their own research on proposed procedures.

jessaustin 9y ago
So... it would be impossible to halve medical costs? People, in general, are pretty dumb. Sick people, in general, are more so.
- announcerman 9y ago
  I don't think your mother is dumber than the general population if she has cancer though.
luckydata 9y ago
Go ahead, try and come back tell us how effective/easy that is. I dare you.
tinokid 9y ago
Nice idea, but how realistic is it? Most patients are not scientifically-literate, some are flat out incapacitated. For all the stories about heartless insurance companies denying to pay for things, perhaps they should actually be more strict. As in, refuse to pay for anything unless there is 1) rock-solid (i.e. double-blind, placebo-controlled) evidence that it helps 2) for a specific, objectively verifiable indication 3) when provided by a doctor whose track record is demonstrably non-inferior to that of other practitioners. But for all three of those things, no $. I would be interested in buying insurance like that.
- maxerickson 9y ago
  In the US system you agree to pay any bills the insurance will not cover prior to receiving treatment. Which is an obvious opportunity for improvement. When a giant hospital and a giant insurance company get in a knife fight over whether a procedure is covered, the patient shouldn't be the loser. (Maybe some sort of system where if the provider states that something is medically necessary then they are on the hook if insurance denies the claim)

edwhitesell 9y ago

After recently getting a cancer diagnosis and going through surgery and chemotherapy, the best advice I can give is: ask lots of questions and you are your own best advocate. As with any profession, there are some great doctors who are truly looking out for your best interests and will pursue any direction you want. There are others who simply want to "follow the standard practice", even if what they know as "standard" is 35 years old. There are others who just want to get through as many procedures as possible and "see what sticks" when it comes to a diagnosis. Asking questions helps you better understand which of these you're working with, and what actions you need to take on your own. Finally, EMR sounds great, but in my experience it just doesn't work. Find a PCP who is part of a hospital system with specialists using the same computer system. This means they can all see each other's notes & test results. A lot of the time, even doctors in the same building are basically "private practice", or part of some other partnership that is not part of the hospital you are at.

thomastjeffery 9y ago
> Find a PCP who is part of a hospital system with specialists using the same computer system. I really can't comprehend how these people don't feel a critical need for compatible open formats, and think they are fine using incompatible proprietary ones. How is sharing information seen as a negative in this scenario?

dipppy 9y ago

Everyone has a story like this. I went in for a physical and even though they said to my face my insurance would fully cover a heart electrocardiogram (my family has a history of heart problems) I wound up with a huge bill, month long fight with insurance, and ended up just having to foot it. Maybe if medical care was driven by some other force besides capitalism this wouldn't be such an issue.

lr4444lr 9y ago
Just out of curiosity, because I often have this fear, did your the staff have any documentation or make assurances that he was a "participating provider" with your plan (i.e. not just saying they "will bill the insurance company")? Or did your plan not offer comprehensive coverage?
dboreham 9y ago
Essentially identical story in my family. And to address the sibling comment's question in my case : the hospital has a _recording_ of the insurance company rep on a phone call stating that the procedure was covered. However it appears this achieves nothing because the insurance company can use their magic powers of "pound sand suckers" and we had to pay anyway. Hospital denies any responsibility because they called insurance and were told they had coverage, and they kept a recording of said call. The fact that providers routinely record their calls to insurance companies tells you something in itself.

ycombonator 9y ago

Ivory tower elite have usually all the time to pontificate. Tell that to this girl who did not see the light of the day. https://nypost.com/2018/02/26/girl-dies-hours-after-doctor-turned-her-away-for-being-a-few-minutes-late/ https://nypost.com/2018/02/26/girl-dies-hours-after-doctor-t...

notfromhere 9y ago
both things being true is possible.
conanbatt 9y ago
What a tragedy. But lets not forget that this is what we see not what it is. It could have happened the other way: "patient died after not receiving attention even though they arrived on time. Doctor was busy providing care to previously late patients".

gjem97 9y ago

It's a question of fundamental incentives. Doctors and hospitals are paid for procedures, treatments, and appointments. Is it any surprise that there's incentive to undertake these activities? You don't even need to believe that your doctor is greedy to understand that if there's a borderline case, they might order the test or treatment "to be safe", or "because there's no downside", or because "we have the available capacity". Even if they aren't explicitly considering payment as part of the equation, it's not unreasonable to think that subconsciously the monetary incentive will tip some of these cases in the direction of overtreatment. IMO, the only way this is going to change is a movement away from the "pay for services" model that is dominant in US healthcare today.

novalis78 9y ago
I slightly disagree - what's missing is price transparency inviting competition. Through competition the payment and cost side of things will be added to the equation and shift incentives to cut waste and increase quality of service. That includes all aspects of the healthcare services.
- lr4444lr 9y ago
  Also that for the majority of people, a third party pays. The receiver of care only indirectly affected by slowly rising premiums, deductibles, co-pays, caps.
  - merpnderp 9y ago
    For most people it is actually a forth party pays. There's the traditional three party insurance system, but for most people there's also the forth, their employer. So not only is the receiver of medical care removed from any price sensitivity by their insurer, they're removed from much of the insurance price sensitivity by their employer. Removing the ridiculous system of employers paying for health care and instead just paying people the money (come on, FDR's WWII salary fixing has been over for 70 years, yet its harm continues).
- shawndimantha 9y ago

clircle 9y ago

Nothing gets HN more riled up these days than a good story about healthcare in America.

learnstats2 9y ago

The article pins part of its argument on the claim that advances in diagnostics have not changed the death rate for (e.g.) breast cancer during the past quarter century, but a superficial search immediately suggests this to be grossly false. "Death rates from female breast cancer dropped 39% from 1989 to 2015." - all other things being equal, it ought to have increased: age is a risk factor for cancers, and we have an older population. Instead, it has greatly decreased. So I dispute the veracity of several of the article's claims, but also: what is considered unnecessary changes with the benefit of hindsight. I would argue that it's expected that a majority of diagnostic tests deliver a negative result (i.e. turn out to be "unnecessary"), and this is actually a mark of a healthy healthcare system.

Consultant32452 9y ago
There are other likely explanations for that data. If more women are getting screened more frequently then their cancers will be detected earlier and improve survival rate. That doesn't mean the diagnostics tools themselves have improved the survival rate, only that the diagnostic tools are now used more frequently.
- throwaway1982x 9y ago
  >If more women are getting screened more frequently then their cancers will be detected earlier and improve survival rate. Yes, but the article argues directly against this point.
- learnstats2 9y ago
  There may be other explanations, but the article denies the truth of the data to claim this point.
maxerickson 9y ago
How do the survival rates speak to the impact of advances in diagnostics? For improvements in diagnostics to be particularly important to survival rates, you'd need to show things like cancer being found much more often now or that finding it sooner (than was typical in 1985) greatly improves survival rates. Really what has happened is that treatments have gotten a lot better.

hliyan 9y ago

I live in a 3rd world country (Sri Lanka). Healthcare is not as advanced as it is in the US, but it is decent for all except the most complicated cases. The vast majority of people use the free services at state hospitals. If you want slightly better care, you can go to a private hospital and still come out with most of your wealth intact. I recently had a minor surgery to remove a conjunctival granuloma from my left upper eyelid. It was a private hospital, and it cost all of $50. Compared to US standards, the facilities were spartan, but adequate and hygienic. Also, doctors and hospitals do not live in constant fear of malpractice suites. I suspect these factors have a lot to do with the costs (in addition to the obvious cost-of-living adjustment for the third world).

deleted 9y ago
[deleted]
39d3493I93 9y ago
You bring up a couple of interesting points even if you don't realize it. There are a couple of things that impact your experience that are externalizations. For example, your "cheap" healthcare is largely due to massive amounts of subsidies and NGO work that goes into helping third wold countries provide such "cheap" medical services. In many ways, due to rather authoritarian types in control in government in the west, who think they have the right to steal from their own citizens through taxes in order to "help" others, it is actually even more expensive for Americans in particular to receive medial care because none of those costs of shipping off billions and trillions of Americans' dollars overseas to "help" others is ever included in the cost of things like healthcare. You may ask yourself how that correlates, but it's because, e.g., while American doctors and people are overseas training and "helping" others, they are neglecting their own society and people, and while billions upon billions are spent to subsidize and "help" others, those billions and billions of dollars are drained from America and Americans and their communities, which in turn is money that they cannot use to receive quality healthcare in some cases. Another point you bring up is that while you are using facilities that are spartan compared to US standards but more than adequate for providing health services, in the USA the very same people who lament the cost of healthcare want well appointed and lavish facilities that are beautifully designed and have cafes and restaurants. I have this kind of argument all the time in a country where people think that a $120 million dollar library with a $10 million dollar yearly maintenance and operation cost is an even remotely reasonable cost when you could provide the very same kind of service in a facility that isn't like a luxury hotel. It's not just that doctors don't face the same kind of fear of malpractice suits, those doctors are also not under constant pressure to perform unnecessary procedures to pay for the $1.3 billion ... yes, BILLION ... hospital and the health care sector in many countries is not the scheming and conniving and fraudulent get rich quick kind of scheme it has become in the USA. In many of the emerging countries, doctors and hospitals perform their services out of a desire to help people, in the USA there is a whole cottage industry of the medical services that has figured out how to latch onto all the various Socialist schemes Liberals devise on how to dispense with other people's money to "help", which affords them fleets of private planes and ocean side mansions.

davidscolgan 9y ago

In the book Antifragile Nassim Taleb cautions against medical care unless it's truly necessary. He argues that since so many things can go wrong in a hospital (you could get sick from someone else, mistakes could be made, etc), only go if the benefits outweigh the risks. And so if you have cancer, it's probably worth the risk. But if you have something that could just go away naturally, that's got a higher expected value of positive outcome. He is in favor of subtractive medicine - many harms are caused by adding such things as smoking, sugar, preservatives, etc, and instead of adding medicine or surgery, remove the elements that the body isn't evolved to tolerate and see if it heals itself. He gives the example of how he hurt his back weight lifting. The doctor proposed surgery. He just waited and his back healed itself, and in a way that is now more robust than if he had had surgery. As with all things, it's not a black and white kind of decision, but this mindset has worked well for me as a heuristic for health.

DanBC 9y ago
He's just regurgitating conventional medical wisdom that's routine in countries that aren't the US. We've been talking about the risks of over-testing, over-diagnosis, and over-treatment for many years. Mostly in the context of full body MRI scans for healthy people, or early testing for prostate cancer, but also many other things.
- s3nnyy 9y ago
  What's the problem with full body MRI scans for healthy people? They don't cause any harm, just cost money.
  - CaptainZapp 9y ago
    Apart from the fact that it costs a lot of money. What do you want to achieve with a full body MRI scan?
    - s3nnyy 9y ago
      A friend of mine who wasn't even 30 years old had a serious brain tumour where they said "ouh, if we'd had done a MRI scan some years ago, it would have been much easier to fix." So that is why it might be a okay'ish idea to do a MRI scan of the brain every 5 years or so? Depending where you live they are actually cheap and can be paid out of pocket.

kreco 9y ago

For the physical harming, Nassim N. Taleb wrote a book called "Anti-Fragile" desribing the concept of iatrogenic illness. https://en.wiktionary.org/wiki/iatrogenic https://en.wiktionary.org/wiki/iatrogenic An alarming fact was less dying patients when an hospital workers were in a strike action (during 2 weeks).

manjushri 9y ago
Johns Hopkins study suggests medical errors are third-leading cause of death in U.S. https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/ https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-...
- kreco 9y ago
  Really interesting, thx !
- mobilefriendly 9y ago
  I was on a multi-corporate task force on medical errors in the late 1990s and the working number was about 80,000 deaths per year. I remember GM saying that statistically it worked out to something like one GM worker or retiree like every week, and that if they had that kind of mayhem on the assembly line there'd be outrage... but the inept health care system just quietly kills people.
- ams6110 9y ago
  And yet we're all wound up about so-called assault weapons and the NRA. Not meaning to take this on a political tangent, just using that as a current-events example of things we worry about and spend political capital on, that have really very little statistical impact. Compare the much, much larger number of deaths due to medical error, automobile accidents, etc.
- skadamou 9y ago
  I thought this excerpt from the article you posted was interesting "The researchers caution that most medical errors aren't due to inherently bad doctors, and that reporting these errors shouldn't be addressed by punishment or legal action. Rather, they say, most errors represent systemic problems, including poorly coordinated care, fragmented insurance networks, the absence or underuse of safety nets, and other protocols, in addition to unwarranted variation in physician practice patterns that lack accountability." I've seen this statistic before and had not looked into in much but it sounds like determining if docs cause more harm than good is perhaps a little more nuanced than the statistic first seems. On a related note, below I've linked to an NPR article about how women that gave birth under the care of a doctor in the 1800s were 5 times more likely to die than those seen by a midwife because doctors were not washing there hands or medical interments. https://www.npr.org/sections/health-shots/2015/01/12/375663920/the-doctor-who-championed-hand-washing-and-saved-women-s-lives https://www.npr.org/sections/health-shots/2015/01/12/3756639...

emodendroket 9y ago

> A third patient had undergone surgery for a lump that was bothering him, but whatever the surgeon removed it wasn’t the lump—the patient still had it after the operation. One wonders how the constantly trotted out panacea of making patients pay more out of pocket would help with a case like this.

s3nnyy 9y ago

Nassim Taleb explains this in "Skin in the Game" rather well. If you are sick a little bit, don't take drugs prescribed by your doctor. If you come to the doctor with a little coughing, the doctor knows you're likely fine and there is a high chance you won't need any meds BUT if you happen to die the next day, the family of the former patient will find something and might sue you because you - as a doctor - didn't prescribe the needed drugs. Some drugs are known to cause problems 10 years down the line, but this is not the doctors problem because he fixed your primary problem but doesn't really care about second-order/side-effects of the prescribed drugs.

wdn 9y ago

There issue is two folds here. 1. Medical liability. Doctors must cover their basics or will get sue. 2. There is no cost relationship between doctors and patients. Doctors and patients work with 3rd party call health insurers. Worst, a lot of people (medicaid recipients) have no skin in the game. Obama could have fixed item #2 with a universal health care that require (1) doctors to list the price of their services and (2) cover major catastrophic health expenses, such heart issue, cancer, long term care, etc. Prevention care should physical, cold should be out of pocket for the first 5 or 10 visits of the year, then it is covered. I know some may called foul because poor cannot pay. Paying $20 per visit, at 10 visit, it is $200 out of pocket. They have have skin in the game. This will cut down a lot of abuse.

liqu0rice 9y ago
Paying $20 per visit, at 10 visit, it is $200 out of pocket. They have have skin in the game. This will cut down a lot of abuse. Germany had something like you propose from 2004 until 2012 (1). It was not particularly successful and therefore consequently abolished. (1) https://de.wikipedia.org/wiki/Praxisgeb%C3%BChr?wprov=sfla1 https://de.wikipedia.org/wiki/Praxisgeb%C3%BChr?wprov=sfla1
arkades 9y ago
>Paying 20$ per visit... Such experiments have been made with Medicaid demo projects in the US. They've failed every time. People can't distinguish needed care from unneeded care; they end up foregoing needed care, deteriorate, and end up costing the system much more in the form of hospitalizations, disability, etc.
- michaelmrose 9y ago
  Its because poor people overusing free medical care is the problem with the health care system like people buying doritos with food stamps is the problem with SNAP.
conanbatt 9y ago
Healthcare is expensive for multiple reasons, the fee structure being a part of it. If insurance were decoupled from the employer, the individuals would be able to pick the best insurance as opposed to a negotiated insurace by the employeer. That would move people to what is generally considered the best insurance options and that alone makes the competition a lot better. As a patient you dont know which one is better medical care, but you will make some sort of judgement per-insurance. THere are other issues, like restrictions on the importation of drugs, restrictions on the immigration of doctors, high law suit liabilities that end up costing a lot in insurance and processes that not necessarily are better healthcare, etc.

DonnyV 9y ago

Rationing medical care because the underlining system is broken makes no sense. People in the US already don't use enough medical services. "For example, Americans average 4 doctor visits a year compared to 7 in France and Canada, countries with better health outcomes than ours." http://www.pnhp.org/news/2014/january/americans-underuse-health-care http://www.pnhp.org/news/2014/january/americans-underuse-hea...

maroonblazer 9y ago

Growing up with a mom who was a non-working registered nurse, every time I or my siblings came down with symptoms like fever, nausea, vomiting, etc she almost never took us to the doctor. Instead it was rest and liquids, maybe an aspirin. I would always plead with her that we needed to seek professional medical advice. Now as an adult I realize that she knew too well the limitations of that advice when it comes to most minor maladies people suffer. And yet today I still see friends and colleagues go to the Dr or call the "teledoc" when they have these symptoms. They usually get an antibiotic (which has its own issues) or told they simply need to rest.

bobo_legos 9y ago
Same exact story except my mom is and still is a working R.N. There was no running to the doctor or emergency room if I got sick or banged up an knee or elbow. To this day as a grown adult I still work this way. It's a completely foreign concept to me to automatically run to the doctor like so many people around me seem to do. You're other point about knowing the limitations of doctors is completely valid. Every night at the dinner table I heard one horror story after another about the crazy shit doctors would do at her hospital. Maybe its why today I don't run to the doctor for every little thing. I got the understanding that just because someone went to medical school and got an M.D. doesn't mean they're a miracle worker. There's just as many screw ups in that industry as any other. On the upside though if something does happen where I(or someone in my family) need a doctor I can go to her(and my R.N. sister) to tell me who the good ones are and who to avoid like the plague.

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hestipod 9y ago

I was preparing to make a long post asking for ideas/help (been saying that for weeks but it's ready and I was waiting to Monday since weekends are slower) This sort of thing ruined my life, cost me everything, and has finally brought me to the precipice. I was convinced 15 years ago to have surgery to "prevent later disability" and it ironically left me disabled and in severe pain. I later found out abroad from several doctors that I never needed the surgery but the catastrophic damage was done, but they did improve things slightly and Ive been trying to get back to live there but cannot. A few years later in some nightmare the "repair" surgeon messed it up far worse and changed the procedure we had agreed on, but I signed the vague forms hurridly shoved in front of me as I was being prepped and legally he as allowed to. I never would have agreed to that procedure he did had I been clearly informed. They got paid...my life got ruined...and things slid downhill from there as systems and people failed me. Now I am facing seemingly insurmountable needs and costs and more surgery which terrifies me and I would never trust having in this country if at all. It's long story that has no TLDR. I am at my wits end and don't know if a comment here is the right place to share whole thing, or if I should make my own post now or Monday...I need as many eyes on it as possible if there is any hope.

colordrops 9y ago
Perhaps you could share the procedures so others would know to be skeptical if they are in the same situation?
- hestipod 9y ago
  The nutshell is don't ever have foot surgery unless it's to repair a catastrophic injury/trauma and there is no choice if you want to save the foot. The risk/failure rates are so high and not honestly explained. I was left with ruined joints, damaged tendons, nerve damage, and RSD that spread up my legs and affects my whole body to a degree. I was misinformed and flat out lied to and have never met someone to this day who had such surgery that was better for it either immediately or in the long run. It ruined my life and I lost everything.
  - 9y ago

arkades 9y ago

I worked in health insurance, and had a graduate degree in health policy, before I second-careered into medicine. I helped implement some of the programs that Guwande promotes in this article; I was and am a true believer in some of these programs, and have built my medical career around implementing them properly. I say all that to provide an important caveat: Guwande's a Harvard-associated surgeon largely insulated from what any of this looks like on the ground, and basically collects anecdotes that match his views until he can tell a nice just-so story. The reality is far more complicated than he relates, and shared savings programs are far from some sort of medical panacea that addresses all the imbalanced and chaotic incentives in medicine. A few big nitpicks: (1) The ACA Shared Savings program is and was bullshit for providers. Because it was built on top of "traditional Medicare", meaning a non-HMO arrangement that did not infringe on pt's right to seek as much care as they wanted, from whomever they wanted, there was no actual assignment of responsibility. If Doctor X is to share in the profits of saving the system D dollars, you have to be able to measure the savings he generates. However, no patients are "his" - we just measure which PCP patients go to the most in a year and give the doc a benchmark based on those. This was based on an assumption that most people saw their PCP at least once/yr. Turns out that not only do people not see their PCP once/yr, but plenty are snowbirds, or have a rotating list of multiple PCPs. Medicare has not fixed the attribution issue. (2) The most effective way to create savings remains to deny care. There's a reason there was an HMO backlash. Creating that incentive reduces costs/spending, but ... (3) The vast majority of physicians do not work in pure capitated programs. They work in a mixture of shared downside, shared upside, and FFS. You can't manage patients with a mix of payors like this, because you still have to build your daily operations around the largest volume - the FFS folks. This is what I saw the most of in the rollout of the ACA: docs were "enrolled," sure, but ACO's still pay out on top of FFS, and the rest of the patients are normal FFS + shared risk, the result is daily operations built around volume, not around "spending 45 minutes to review how to take insulin." 4) Docs over-test and overprescribe for medicolegal issues that no amount of incentive-shifting can fix. Hell, my hospital antibiogram doesn't even have pseudomonas sensitivity to pip, just pip/tazo, despite the fact that pseudomonas pretty much never needs pip/tazo (the /tazo is a spectrum extender). But prescribing pip/tazo over pip is something akin to "no one ever got fired for buying IBM." Hell, we do baseline kidney function tests before giving contrast in emergency radiology, despite the fact that the biggest studies to date show that baseline kidney function doesn't have any predictive value for contrast-induced nephropathy-related outcomes 6 mos out. It's a pointless delay that actually hurts patients and costs money. But you know what? No one sues a doc for getting worse in an ED while awaiting a lab result - that " just happens". They do sue a doc for contrast-induced nephropathy, because that looks like something a doc actively caused (well, it is) - and a malpractice attorney will slam your balls to the wall for "why didn't you look at his kidney function before throwing kidney toxins at him?" The malpractice thing is honestly more insidious than that, even. It gets docs out of the mindset of thoughtfully asking "well, WHY would I order that test? How does it advance the diagnosis or management meaningfully?" to a "might as well order it to be on the safe side" mindset that infects the rest of their practice. The latter creates sloppy, over-broad testing regimens. Heck, we can't even utilize the latest research unless we can convince multiple departments worth of docs to agree on it. Because the standard for malpractice is what your peers would do, "I did X as part of our department standard, as agreed upon by all the docs in X and related specialty Y" is a very strong malpractice defense. If you can't convince all of those people to get on board and change department policy and just try to practice based on the most up to date data yourself, a malpractice attorney's question becomes: "Where did you get your PhD in statistics and clinical trial design? Oh, you don't have one? So what made you qualified to take in this study and overrule a panel of national experts on the topic that decided what the standard practice is?" We really need an iatrogenesis compensation fund built at the national level, and to get rid of malpractice suits. That will bring down bullshit spending by a fair degree right off the bat. A related issue that people overlook is that about 70% of the growth in HC costs is attributable to technological advance: new drugs, or hiked up drugs, new tech, etc. We want all these things, but refuse to take into account that they demand a premium (even when they're not actually more effective.) I could rant for ages.

whowouldathunk 9y ago

A small example is my girlfriend getting charged for a pregnancy test in the emergency room even after she told them she doesn't have a uterus.

DINKDINK 9y ago

Iatrogenics / Iatrogenesis https://en.wikipedia.org/wiki/Iatrogenesis https://en.wikipedia.org/wiki/Iatrogenesis

lostgame 9y ago

Cue 'unnecessary surgery land' in 4, 3, 2...

oftenwrong 9y ago

This article came to mind this morning when I made my second visit to the orthopaedics department at a local hospital. The department schedules all patients for pre-appointment x-rays. That is, before the patient is even seen, before the doctor can determine if an x-ray would even be useful. On my first visit, I missed my x-ray appointment. The doctor I saw that day later said that was no problem. According to him, an x-ray wasn't necessary given my symptoms. I was scheduled for an expensive, unnecessary x-ray for no reason, basically. On today's visit I simply declined the x-ray, and the doctor I saw today was fine with that because he also did not recommend that any imaging be done.

rbanffy 9y ago
You were scheduled for an expensive, unnecessary dose of radiation that would be billed to your insurer and that's how the provider makes a ton of money out of you. The only priority of any sane health system should be to make people's health better.
- troycarlson 9y ago
  Bundled payments are slowly gaining traction and help align incentives a little better. https://en.wikipedia.org/wiki/Bundled_payment https://en.wikipedia.org/wiki/Bundled_payment
astura 9y ago
Same thing with me when I was referred to orthopedic surgeon for a lump in the soft tissue. Before even seeing me they called me in for a pre-appointment x-ray. It was never explained to be why a lump in the soft tissue would need an x-ray. I kinda went with it because it was such a surprise but I really wish I questioned it, seems like such a waste. Especially since the doctor ordered an MRI after seeing me.
- riahi 9y ago
  Because the Radiograph is a relatively cheap screening test to rule out an underlying bony abnormality as a possible explanation for the soft tissue lump. Further, radiographs and MRI provide complementary information. Taken together, they provide much more definitive characterization than either alone.

NicoJuicy 9y ago

Medical care in the US seems... unhealthy. I'm glad to live in belgium, where i won't go broke if something happens.

blackRust 9y ago

The article's author, Atul Gawande, has written four books. So far I've only read _The Checklist Manifesto: How to Get Things Right_ and have been applying it to various aspects of work and life (travel packing checklist, Engineering team runbooks, etc). I would strongly recommend it. All his other books are on my "to read" list...

jrnichols 9y ago

"or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem" A hospital system in California should have done one of these on me, but instead didn't and I went with a herniated disc for 10 years longer than I needed to. Finally a hospital in Texas did an MRI and discovered it and I had surgery to address the issue. Previously it had been brushed off as a muscle strain or sciatica and i was constantly given pain medication that only masked the symptoms of a bigger problem. My life may be a completely different place right now had someone just done an MRI years ago. unfortunately I didn't know to ask for one. :/ "I am far more concerned about doing too little than doing too much" this is exactly why so many "unnecessary" tests and procedures happen too, unfortunately. There's also a lot of "I want you to DO something" that causes physicians to overprescribe antibiotics/etc because otherwise, they know that the patients are going to give them a lower survey score, which directly affects reimbursements. Tying reimbursements to patient satisfaction scores is an awful idea that needs to go away yesterday. http://kunr.org/post/patient-satisfaction-surveys-make-doctors-feel-pressured-prescribe-antibiotics http://kunr.org/post/patient-satisfaction-surveys-make-docto...

neuro_imager 9y ago

I would share this article but I've been living on a resident/fellow salary for way too long and need at least a few years to milk that cash cow first.