11 ms·

Resetting the expectation that insurance is for unusual procedures, not for yearly checkups and the common cold would be a great start. It's also necessary to

Resetting the expectation that insurance is for unusual procedures, not for yearly checkups and the common cold would be a great start. It's also necessary to focus on the supply side. Just two examples: the AMA limits the number of doctors and new hospitals can't be opened without the approval of the existing hospitals in the area. There is far from a free market in health care in the US. http://reason.com/archives/2017/10/25/this-one-weird-trick-could-improve-medic http://reason.com/archives/2017/10/25/this-one-weird-trick-c...

ejstronge 8y ago
I understand your sentiment, but it is absolutely incorrect that the AMA limits the number of doctors. I presume you really mean 'residency slots' when you say doctors. In this case, the relevant administrative body is the ACGME... who sets the limits based on appropriations from Congress. The trope of doctors restricting entry to enrich themselves does not explain reported physician shortages.
- lr4444lr 8y ago
  Practicing medicine without a license is illegal in all 50 states. The AMA is a major gatekeeper of this process. It's one thing to prosecute people for falsely passing themselves off as being licensed, quite another not letting them perform procedures on consenting patients.
  - nradov 8y ago
    That was tried before and resulted in horrible levels of death and suffering. Which is exactly why we now have the AMA and laws against the unlicensed practice of medicine. No one who understands the history of medicine wants to go back.
    - fragmede 8y ago
      That's a false dichotomy, no one said anything about going back. Never mind that Josef Mengele was a licensed physicians, or that the AMA was well established before the Tuskegee syphilis experiments occurred, also with work performed by licensed physicians. Just that the bureaucracy has resulted in an industry that fails patients. Heart surgeons refuse difficult surgeries to juke the stats. Good for their mortality ratings (not that anybody could blame individuals doctors)[1], not so great for patients. Even just the notion of specialties hurts the patient - it makes perfect sense that the deep knowledge involved means that an orthopedic doctor can't (and shouldn't!) treat issues that should be seen by a podiatrist. But at the end of the day, the patient is in chronic pain, and has such a low quality of life, that to them, the risks of street heroin are acceptable. This isn't a moral failing by the patient's, nor is it a lack of intelligence, this life being too much to bear otherwise, and if you've never considered suicide as an option, be grateful. Dr. David Casarett's talk[2] takes a closer look at an alternate, but accepted medical practice, and gives some thoughts about how our medical bureaucrats have resulted in worse patient care. [1] https://www.telegraph.co.uk/science/2016/06/03/one-in-three-heart-surgeons-refuse-difficult-operations-to-avoid/ https://www.telegraph.co.uk/science/2016/06/03/one-in-three-... [2] https://www.ted.com/talks/david_casarett_a_doctor_s_case_for_medical_marijuana https://www.ted.com/talks/david_casarett_a_doctor_s_case_for...
      - ejstronge 8y ago
        I am not repeating this to be pedantic - this is simply a common misunderstanding in the public: > Never mind that Josef Mengele was a licensed physicians, or that the AMA was well established before the Tuskegee syphilis experiments The AMA has no role in licensing physicians, a task which is left to the states. > Heart surgeons refuse difficult surgeries to juke[sic] the stats. This is far more complicated than it seems. For example, consider that the sickest/most difficult patients are the most likely to die, irrespective of an intervention. At a certain point, the harm inherent to surgery outweighs any potential for benefit that the surgery might yield.
        tialaramex 8y ago
        The Heart surgeon thing is likely referring specifically to a UK press article recently featured on HN that was about surgeons in the UK reacting to a policy change that means their stats are shown to the general public. A large minority of those surveyed said that as a result they now refuse to do surgeries they think will be very bad for their stats, even if clinically the surgery might be appropriate and within their competence. A majority said they knew a surgeon who had made such choices. As a patient in that system (the NHS) I would prefer my surgeons not to make decisions based on trying to game the statistics. If I need heart surgery, I want whoever is competent and available. So if these stats block that, I'd rather we don't have the stats. Frankly it's weird anyway because surgery is a team activity, not solo. Nothing serious is done by one bloke in a surgical gown, there's a team. I had a relatively minor operation and the named surgeon will have spent most of that operation _talking_ not operating. All the sewing and some of the cutting will be the nice younger doctors I met, a woman who'd been doing this a few years and was well on her way to being an actual surgeon, and a new bloke who seemed like he'd probably graduated just a couple of years ago. The old bloke with the paperwork saying he's allowed to cut people open is mostly there to watch over them both and step in if things go to shit. The woman is doing most of the work, showing the noob what she's doing and maybe overseeing while he stitches me back up at the end. There's some Eastern European doctor lady making sure I neither die nor wake up, and two or three nurses making sure everybody has what they need, and counting things to make sure nothing is left inside me that shouldn't be there. But if I'd died (very unlikely for minor surgery) it would count against my named surgeon and not the rest of the team.
    - moorhosj 8y ago
      The AMA lobbies to limit the type of work nurse practitioners can do and they are licensed. http://articles.baltimoresun.com/1994-06-14/news/1994165047_1_nurse-practitioners-family-nurse-registered-nurses http://articles.baltimoresun.com/1994-06-14/news/1994165047_...
  - DanBC 8y ago
    People suffer real harm at the hands of unlicensed doctors. For example, this guy was prescribing powerful meds with severe side effects. http://www.chicagotribune.com/suburbs/daily-southtown/crime/ct-fake-psychiatrist-sentenced-prison-met-20170208-story.html http://www.chicagotribune.com/suburbs/daily-southtown/crime/...
    - mythrwy 8y ago
      While that's certainly true, people also suffer great harm at the hands of licensed doctors. But more to the point, almost everyone suffers harm because of the way our medical system is set up. Maybe some ailments don't need 8 year degrees to cure. Just throwing out ideas here. But anyhow, more transparency is almost always good. Particularly in the morass that is the American medical system. I keep wondering how ever let something so important get like this.
  - ejstronge 8y ago
    Medical licensing is performed at the state level. The AMA, a non-governmental organization, does not perform the function of ensuring physicians' qualifications. The AMA even explains this process: https://www.ama-assn.org/education/obtaining-medical-license https://www.ama-assn.org/education/obtaining-medical-license
    - lr4444lr 8y ago
      I'm aware. I was careful with my language about saying they are a gatekeeper, not that they set the law. But your info is appreciated.
      - ejstronge 8y ago
        I'm not aware of how the AMA acts as a gatekeeper to the medical profession - what did you have in mind?
        lr4444lr 8y ago
        In the broad sense that they are an influential industry group that has taken a number of political positions that impact laws. Chiropractors and osteopaths have in particular felt discrediting hostility from them, as I read. Now to be clear, I for one do not personally hold either of those two fields in as much esteem as much of the American public might, so I don't meant to be partisan, but to simply say that the AMA has used it's influence to maintain the standards of what should or should not be licensed medical practice. They are free to maintain their own standards, which I do much respect.
        jessaustin 8y ago
        You've made good arguments in this thread, but you lose a lot of credibility when you imply that a DO is not as good as an MD.
        maxerickson 8y ago
HarryHirsch 8y ago
Insurance is for unusual procedures In healthcare you'd not only like to even out expenses over time, you'd also like to spread expenses over a group, else people with chronic conditions are still screwed.
kurthr 8y ago
I don't think that making sure that insurance doesn't cover checkups and preventative care would have a very desirable effect. Putting people (and their young children) on high deductible plans has the very predictable effect of discouraging treatment or even 'well baby' checks. That is part of what leads to such an abysmal (third world) infant mortality in the US. You can argue that hospitals and ERs in particular are not a good place for checkups, but discouraging them is likely to be more costly (in $ and human lives) than not.
- montecarl 8y ago
  Yea, I think that those things are highly desirable FOR the insurance company, because yearly checkups reduce the chance that the insurance company has to make a big payout. So you would either see insurance rate refunds/reductions for a yearly checkup or you would see them covered.
  - dragonwriter 8y ago
    We tried that, for, well, the whole history of health insurance in the US prior to the ACA, and that's not what happened. Preventive care improves outcomes but doesn't reduce aggregate costs.
    - tcbawo 8y ago
      Is there data that backs up this assertion?
      - GFischer 8y ago
        Not sure about data, but medical costs are for the most part inelastic, and concentrated on a small number of patients with expensive conditions. What I DO know from working in insurance is that lifetime medical costs are concentrated in the last 2 years of life (I worked on credit card insurance and life insurance). That's where you could make huge costs savings (but is an ethical landmine, not to mention economic interests) https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0174 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.... https://www.nihcm.org/categories/publications/the-concentration-of-health-care-spending-data-brief?showall=1 https://www.nihcm.org/categories/publications/the-concentrat...
nradov 8y ago
The Accountable Care Act (Obamacare) specifically mandated that routine preventative care be covered by private insurance plans at no cost to the patient. That way patients won't skip preventative care to "save" money and problems can be detected early before they become serious. https://www.kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/ https://www.kff.org/health-reform/fact-sheet/preventive-serv... What you propose would work fine if humans were fully rational and not living paycheck to paycheck. Unfortunately that's not reality.
- dragonwriter 8y ago
  > The Accountable Care Act (Obamacare) The law that got the nickname “Obamacare” is not the Accountable Care Act, it is the Patient Protection and Affordable Care Act.
afarrell 8y ago
Requiring doctors to get a 4-year-degree before medical school also adds to the cost. The degree can be in anything: film crit, classics, Japanese history. those are valuable things to know, but they clearly aren't necessary to medical school or else you'd disqualify the people who couldn't give a solid explaination of how Miazaki was influenced by Heian literature. The cost of a $200,000 degree plus interest on a loan that doesn't start getting paid back until after med school shouldn't be dumped on the medical system.
- azinman2 8y ago
  The degree might be in anything, but there are many pre-reqs before you can apply, such as organic chemistry.
  - u801e 8y ago
    It would make more sense to add a year to medical education to cover the prerequisites rather than requiring a bachelors degree to apply to medical school.
- ironjunkie 8y ago
  That's also an absurdity I never understood in the US Medical school system. Why not do like other countries, and allow 18 years old to directly chose Medical School after high school?
s73v3r_ 8y ago
Except checkups and preventative care are usually far, far more effective than emergency care. So it would be to the benefit of all for insurance to cover it.
- dragonwriter 8y ago
  > Except checkups and preventative care are usually far, far more effective than emergency care. This may be true in terms of outcomes, but it turns out not to be true in terms of aggregate costs. (If you encourage smoking and discourage screenings and preventive care, you'll probably do a lot to reduce aggregate health costs, but at the expense of outcomes; the efficiencies you really want are ones that reduce cost while preserving outocomes, or improve outcomes without increasing costs. When outcomes and costs are in tension, though, desirability can be more ambiguous.)
- gbacon 8y ago
  Forcing insurers to pay for “oil changes” drives up premium costs and depletes funds that patients could otherwise use to pay for preventive care.
  - michaelmrose 8y ago
    It gets people to get more oil changes and thus avoids the insurer having to pay for more expensive matters. More importantly it leads to less people dying of preventable matters. What you seem to be implying is that its a net negative to which I say citation needed.
    - dragonwriter 8y ago
      > It gets people to get more oil changes and thus avoids the insurer having to pay for more expensive matters It also catches things that require long expensive treatment early enough for them to be treated, rather than treatment be pointless, and, even if attempted, of shorter duration (on average) than if the conditions were found earlier, which is why preventive care doesn't seem to reduce aggregate costs. The best way to reduce aggregate healthcare costs, if you have no other priorities, is to just make people less likely to seek care. No care = no costs.
chiph 8y ago
The Certificate of Need process also applies to anyone wanting to install a MRI machine. Rather than letting a doctor take the risk of buying an expensive machine for their business, the certificate process forces patients to travel to the nearest machine, possibly in the next town, instead of just walking down the hall to it. The knock-on effect of there being fewer machines built keeps the price high. The first photocopier (the Xerox 914) cost the equivalent of $220,000 in 1965, yet there are very few businesses without a copier today because the price is so reasonable (5% of the 914's cost), and they do much much more.

ejstronge 8y ago

I understand your sentiment, but it is absolutely incorrect that the AMA limits the number of doctors. I presume you really mean 'residency slots' when you say doctors. In this case, the relevant administrative body is the ACGME... who sets the limits based on appropriations from Congress. The trope of doctors restricting entry to enrich themselves does not explain reported physician shortages.

lr4444lr 8y ago
Practicing medicine without a license is illegal in all 50 states. The AMA is a major gatekeeper of this process. It's one thing to prosecute people for falsely passing themselves off as being licensed, quite another not letting them perform procedures on consenting patients.
- nradov 8y ago
  That was tried before and resulted in horrible levels of death and suffering. Which is exactly why we now have the AMA and laws against the unlicensed practice of medicine. No one who understands the history of medicine wants to go back.
  - fragmede 8y ago
    That's a false dichotomy, no one said anything about going back. Never mind that Josef Mengele was a licensed physicians, or that the AMA was well established before the Tuskegee syphilis experiments occurred, also with work performed by licensed physicians. Just that the bureaucracy has resulted in an industry that fails patients. Heart surgeons refuse difficult surgeries to juke the stats. Good for their mortality ratings (not that anybody could blame individuals doctors)[1], not so great for patients. Even just the notion of specialties hurts the patient - it makes perfect sense that the deep knowledge involved means that an orthopedic doctor can't (and shouldn't!) treat issues that should be seen by a podiatrist. But at the end of the day, the patient is in chronic pain, and has such a low quality of life, that to them, the risks of street heroin are acceptable. This isn't a moral failing by the patient's, nor is it a lack of intelligence, this life being too much to bear otherwise, and if you've never considered suicide as an option, be grateful. Dr. David Casarett's talk[2] takes a closer look at an alternate, but accepted medical practice, and gives some thoughts about how our medical bureaucrats have resulted in worse patient care. [1] https://www.telegraph.co.uk/science/2016/06/03/one-in-three-heart-surgeons-refuse-difficult-operations-to-avoid/ https://www.telegraph.co.uk/science/2016/06/03/one-in-three-... [2] https://www.ted.com/talks/david_casarett_a_doctor_s_case_for_medical_marijuana https://www.ted.com/talks/david_casarett_a_doctor_s_case_for...
    - ejstronge 8y ago
      I am not repeating this to be pedantic - this is simply a common misunderstanding in the public: > Never mind that Josef Mengele was a licensed physicians, or that the AMA was well established before the Tuskegee syphilis experiments The AMA has no role in licensing physicians, a task which is left to the states. > Heart surgeons refuse difficult surgeries to juke[sic] the stats. This is far more complicated than it seems. For example, consider that the sickest/most difficult patients are the most likely to die, irrespective of an intervention. At a certain point, the harm inherent to surgery outweighs any potential for benefit that the surgery might yield.
      - tialaramex 8y ago
        The Heart surgeon thing is likely referring specifically to a UK press article recently featured on HN that was about surgeons in the UK reacting to a policy change that means their stats are shown to the general public. A large minority of those surveyed said that as a result they now refuse to do surgeries they think will be very bad for their stats, even if clinically the surgery might be appropriate and within their competence. A majority said they knew a surgeon who had made such choices. As a patient in that system (the NHS) I would prefer my surgeons not to make decisions based on trying to game the statistics. If I need heart surgery, I want whoever is competent and available. So if these stats block that, I'd rather we don't have the stats. Frankly it's weird anyway because surgery is a team activity, not solo. Nothing serious is done by one bloke in a surgical gown, there's a team. I had a relatively minor operation and the named surgeon will have spent most of that operation _talking_ not operating. All the sewing and some of the cutting will be the nice younger doctors I met, a woman who'd been doing this a few years and was well on her way to being an actual surgeon, and a new bloke who seemed like he'd probably graduated just a couple of years ago. The old bloke with the paperwork saying he's allowed to cut people open is mostly there to watch over them both and step in if things go to shit. The woman is doing most of the work, showing the noob what she's doing and maybe overseeing while he stitches me back up at the end. There's some Eastern European doctor lady making sure I neither die nor wake up, and two or three nurses making sure everybody has what they need, and counting things to make sure nothing is left inside me that shouldn't be there. But if I'd died (very unlikely for minor surgery) it would count against my named surgeon and not the rest of the team.
  - moorhosj 8y ago
    The AMA lobbies to limit the type of work nurse practitioners can do and they are licensed. http://articles.baltimoresun.com/1994-06-14/news/1994165047_1_nurse-practitioners-family-nurse-registered-nurses http://articles.baltimoresun.com/1994-06-14/news/1994165047_...
- DanBC 8y ago
  People suffer real harm at the hands of unlicensed doctors. For example, this guy was prescribing powerful meds with severe side effects. http://www.chicagotribune.com/suburbs/daily-southtown/crime/ct-fake-psychiatrist-sentenced-prison-met-20170208-story.html http://www.chicagotribune.com/suburbs/daily-southtown/crime/...
  - mythrwy 8y ago
    While that's certainly true, people also suffer great harm at the hands of licensed doctors. But more to the point, almost everyone suffers harm because of the way our medical system is set up. Maybe some ailments don't need 8 year degrees to cure. Just throwing out ideas here. But anyhow, more transparency is almost always good. Particularly in the morass that is the American medical system. I keep wondering how ever let something so important get like this.
- ejstronge 8y ago
  Medical licensing is performed at the state level. The AMA, a non-governmental organization, does not perform the function of ensuring physicians' qualifications. The AMA even explains this process: https://www.ama-assn.org/education/obtaining-medical-license https://www.ama-assn.org/education/obtaining-medical-license
  - lr4444lr 8y ago
    I'm aware. I was careful with my language about saying they are a gatekeeper, not that they set the law. But your info is appreciated.
    - ejstronge 8y ago
      I'm not aware of how the AMA acts as a gatekeeper to the medical profession - what did you have in mind?
      - lr4444lr 8y ago
        In the broad sense that they are an influential industry group that has taken a number of political positions that impact laws. Chiropractors and osteopaths have in particular felt discrediting hostility from them, as I read. Now to be clear, I for one do not personally hold either of those two fields in as much esteem as much of the American public might, so I don't meant to be partisan, but to simply say that the AMA has used it's influence to maintain the standards of what should or should not be licensed medical practice. They are free to maintain their own standards, which I do much respect.
        jessaustin 8y ago
        You've made good arguments in this thread, but you lose a lot of credibility when you imply that a DO is not as good as an MD.
        maxerickson 8y ago

HarryHirsch 8y ago

Insurance is for unusual procedures In healthcare you'd not only like to even out expenses over time, you'd also like to spread expenses over a group, else people with chronic conditions are still screwed.

kurthr 8y ago

I don't think that making sure that insurance doesn't cover checkups and preventative care would have a very desirable effect. Putting people (and their young children) on high deductible plans has the very predictable effect of discouraging treatment or even 'well baby' checks. That is part of what leads to such an abysmal (third world) infant mortality in the US. You can argue that hospitals and ERs in particular are not a good place for checkups, but discouraging them is likely to be more costly (in $ and human lives) than not.

montecarl 8y ago
Yea, I think that those things are highly desirable FOR the insurance company, because yearly checkups reduce the chance that the insurance company has to make a big payout. So you would either see insurance rate refunds/reductions for a yearly checkup or you would see them covered.
- dragonwriter 8y ago
  We tried that, for, well, the whole history of health insurance in the US prior to the ACA, and that's not what happened. Preventive care improves outcomes but doesn't reduce aggregate costs.
  - tcbawo 8y ago
    Is there data that backs up this assertion?
    - GFischer 8y ago
      Not sure about data, but medical costs are for the most part inelastic, and concentrated on a small number of patients with expensive conditions. What I DO know from working in insurance is that lifetime medical costs are concentrated in the last 2 years of life (I worked on credit card insurance and life insurance). That's where you could make huge costs savings (but is an ethical landmine, not to mention economic interests) https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0174 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.... https://www.nihcm.org/categories/publications/the-concentration-of-health-care-spending-data-brief?showall=1 https://www.nihcm.org/categories/publications/the-concentrat...

nradov 8y ago

The Accountable Care Act (Obamacare) specifically mandated that routine preventative care be covered by private insurance plans at no cost to the patient. That way patients won't skip preventative care to "save" money and problems can be detected early before they become serious. https://www.kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/ https://www.kff.org/health-reform/fact-sheet/preventive-serv... What you propose would work fine if humans were fully rational and not living paycheck to paycheck. Unfortunately that's not reality.

dragonwriter 8y ago
> The Accountable Care Act (Obamacare) The law that got the nickname “Obamacare” is not the Accountable Care Act, it is the Patient Protection and Affordable Care Act.

afarrell 8y ago

Requiring doctors to get a 4-year-degree before medical school also adds to the cost. The degree can be in anything: film crit, classics, Japanese history. those are valuable things to know, but they clearly aren't necessary to medical school or else you'd disqualify the people who couldn't give a solid explaination of how Miazaki was influenced by Heian literature. The cost of a $200,000 degree plus interest on a loan that doesn't start getting paid back until after med school shouldn't be dumped on the medical system.

azinman2 8y ago
The degree might be in anything, but there are many pre-reqs before you can apply, such as organic chemistry.
- u801e 8y ago
  It would make more sense to add a year to medical education to cover the prerequisites rather than requiring a bachelors degree to apply to medical school.
ironjunkie 8y ago
That's also an absurdity I never understood in the US Medical school system. Why not do like other countries, and allow 18 years old to directly chose Medical School after high school?

s73v3r_ 8y ago

Except checkups and preventative care are usually far, far more effective than emergency care. So it would be to the benefit of all for insurance to cover it.

dragonwriter 8y ago
> Except checkups and preventative care are usually far, far more effective than emergency care. This may be true in terms of outcomes, but it turns out not to be true in terms of aggregate costs. (If you encourage smoking and discourage screenings and preventive care, you'll probably do a lot to reduce aggregate health costs, but at the expense of outcomes; the efficiencies you really want are ones that reduce cost while preserving outocomes, or improve outcomes without increasing costs. When outcomes and costs are in tension, though, desirability can be more ambiguous.)
gbacon 8y ago
Forcing insurers to pay for “oil changes” drives up premium costs and depletes funds that patients could otherwise use to pay for preventive care.
- michaelmrose 8y ago
  It gets people to get more oil changes and thus avoids the insurer having to pay for more expensive matters. More importantly it leads to less people dying of preventable matters. What you seem to be implying is that its a net negative to which I say citation needed.
  - dragonwriter 8y ago
    > It gets people to get more oil changes and thus avoids the insurer having to pay for more expensive matters It also catches things that require long expensive treatment early enough for them to be treated, rather than treatment be pointless, and, even if attempted, of shorter duration (on average) than if the conditions were found earlier, which is why preventive care doesn't seem to reduce aggregate costs. The best way to reduce aggregate healthcare costs, if you have no other priorities, is to just make people less likely to seek care. No care = no costs.

chiph 8y ago

The Certificate of Need process also applies to anyone wanting to install a MRI machine. Rather than letting a doctor take the risk of buying an expensive machine for their business, the certificate process forces patients to travel to the nearest machine, possibly in the next town, instead of just walking down the hall to it. The knock-on effect of there being fewer machines built keeps the price high. The first photocopier (the Xerox 914) cost the equivalent of $220,000 in 1965, yet there are very few businesses without a copier today because the price is so reasonable (5% of the 914's cost), and they do much much more.