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One thing that sometimes gets lost in the "health care is inefficient" discussion is that one person's inefficiency is another person's living. The cost control

by entee 8y ago

One thing that sometimes gets lost in the "health care is inefficient" discussion is that one person's inefficiency is another person's living. The cost controls the paper appears to advocate for literally mean someone is making less money, that someone will advocate strongly against it. I've spent the past 3.5 years in healthcare, everyone is convinced they're not the problem, that they're underpaid or overworked or whatever. I would love for some sort of centralized system to push down costs, but I fear it's not realistically every going to happen.

toomuchtodo 8y ago
> One thing that sometimes gets lost in the "health care is inefficient" discussion is that one person's inefficiency is another person's living. You are not entitled to a living as bureaucratic waste. We should of course help retrain those who lose their jobs, just as we're doing for coal workers who are going to be out of a job within the next five years. I want my healthcare dollars going to healthcare providers (doctors, nurses, nurse practitioners, CNAs, drug research R&D, medical technology innovators), not private insurance companies, not administrators or third party billers, and most assuredly, not shareholders. I want the AMA to be handicapped from preventing us from dramatically increasing the number of doctors in the US (the American Medical Association operates as a cartel/cabal, attempting to limit supply to keep wages high); they also attempt to reduce the authority given to nurse practitioners [1]. > I would love for some sort of centralized system to push down costs, but I fear it's not realistically every going to happen. The majority of Americans say the government should be responsible for ensuring health care coverage for all Americans [2]. Universal healthcare will arrive in the US eventually, the question is when. The current model is unsustainable, and will reach a tipping point. [1] https://www.modernhealthcare.com/article/20171214/NEWS/171219932 https://www.modernhealthcare.com/article/20171214/NEWS/17121... [2] http://www.pewresearch.org/fact-tank/2017/01/13/more-americans-say-government-should-ensure-health-care-coverage/ http://www.pewresearch.org/fact-tank/2017/01/13/more-america...
- ams6110 8y ago
  Only a few generations ago, healthcare was not so ruinously expensive in the USA. We've never had taxpayer-funded universal care. So what caused the explosion in costs?
  - toomuchtodo 8y ago
    TL;DR Lack of cost controls and unnecessary administrative costs. > In the U.S., they point out, drugs are more expensive. Doctors get paid more. Hospital services and diagnostic tests cost more. And a lot more money goes to planning, regulating and managing medical services at the administrative level. So, we're all getting a lower quality of care for a lot more money, due to how the healthcare "market" is configured. https://www.nytimes.com/2018/03/13/upshot/united-states-health-care-resembles-rest-of-world.html https://www.nytimes.com/2018/03/13/upshot/united-states-heal... https://www.cnbc.com/2018/03/22/the-real-reason-medical-care-costs-so-much-more-in-the-us.html https://www.cnbc.com/2018/03/22/the-real-reason-medical-care... https://www.cnn.com/2017/11/07/health/health-care-spending-study/index.html https://www.cnn.com/2017/11/07/health/health-care-spending-s... https://www.consumerreports.org/cro/magazine/2014/11/it-is-time-to-get-mad-about-the-outrageous-cost-of-health-care/index.htm https://www.consumerreports.org/cro/magazine/2014/11/it-is-t...
    - sedor0115 8y ago
      This fails to address the elephant-sized American in the room. Any analysis of increasing healthcare costs that doesn't quantify the fiscal impact of the average American's failure to care for themselves is just beating around the bush. The obesity rate alone has gone from 10% in the 60s to 40% today. These people need more care that is harder to provide, and to not expect healthcare costs to rise significantly from that is to expect healthcare workers to work for free. Our system is a little sick, sure, but the bulk of the responsibility for the current situation lies squarely at our own feet as individuals. This problem will never be solved before America puts down the fork.
  - rednerrus 8y ago
    The elastic nature of health care costs and the disconnect between the people making the purchases and the people paying the bills. If you have insurance, chances are that you are not asking your doctor how much something is going to cost. You are not likely to shop around or work to get the best deal. As a healthcare provider, where is the incentive to bring costs down.
- Analemma_ 8y ago
  You’re missing the point. The parent isn’t suggesting this situation is good, or that we shouldn’t eliminate bureaucratic waste. They’re saying that there are a ton of people highly incentivized to keep the system as it is, because it pays for their salary. Concentrated benefits, diffuse costs.
ArchTypical 8y ago
> that they're underpaid or overworked or whatever Having family in healthcare and being a lifelong patient due to a congenital defect, a job in software (including management obv) is a breeze compared to health care worker jobs across the board. They require more "schooling" (via mind-numbing training), are underpaid, have much more serious consequences from mistakes, have less oversight, work longer hours and under worse conditions. It's disheartening.
- onlyrealcuzzo 8y ago
  I'm pretty sure most people, even administrators in hospitals and insurance, are overworked. Health care in the US is the textbook definition of big business. The only people making easy, stupid money are shareholders.
- agumonkey 8y ago
  People's work shouldn't be reduced, but drugs and devices should be to an extent. Firefighters told the portable EKG costed thousands of dollars (5 or 10 don't recall). That thing had bad 2G connectivity so the graph coudn't be sent to a cardiologist. The sensor/dsp part is worth money, the rest would cost 100$ from any smartphone maker today with better performance and portability. I'm sure the price is rigged for margins. This shouldn't be a market, it should be an open duty to make these cost efficient.
  - ams6110 8y ago
    The real cost is not so much in the hardware but in the certification requirements. Medical devices need to be built to and work at a higher standard than consumer electronics, for obvious reasons.
    - agumonkey 8y ago
      Of course, but the interface and connectivity part of that EKG machine wasn't even up to 2005 cellphones standard. On that point, it's a scam.
thatfrenchguy 8y ago
And a lot of this is administrative overhead. Coming from a country outside of the US, I was also shocked by the price of medecine, every medecine magically seems to be 5-10x more expensive in the US.
- ekianjo 8y ago
  The prices help pay for the huge cost involved in developing drugs. How many drugs were developed in France in the past 10 years compared to how many were developed in the US? You know the answer.
  - Analemma_ 8y ago
    Personally, I would’ve liked to be asked whether I consented to paying 10x the price that every other country pays, in order to subsidize drug development, cause I definitely don’t recall ever agreeing to that deal.
    - ams6110 8y ago
      The problem is your other option is likely not having the drug at all.
  - jayd16 8y ago
    This is pretty specious reasoning. The US is a leader in a lot of industries that aren't healthcare.
  - monocasa 8y ago
    I know that's what's pushed, but how much of that is true? Federal grants pay for a lot of initial frubt work, and drug companies spend around twice as much on marketing as they do on R&D. And that's with all sorts of tax benefits behooving them to call as much as possible of their budget R&D.
    - ekianjo 8y ago
      Marketing is needed everywhere, pharma included. You dont spread awareness of a new drug just by filing an application to the FDA. And marketing expenses are high because potential returns are high and make or break a drug. Note that you dont have really new drugs every year so you need marketing anyway to convince prescribers why your version of the drug in the same class as your competitor is slightly better. In reality most drugs of the same class are pretty similar in efficacy and side effects, but thats a tangential topic.
village-idiot 8y ago
I’ve always worried about the political consequences to the loss of insurance jobs. I also view that job loss as a foregone conclusion due to insurance companies fighting even moderate changes tooth and nail. If even minor improvements to a nakedly broken system are going to get fought against with such ferocity, it’s not surprising that their opponents would try and move the Overton window in response.
bedhead 8y ago
Like, the living of some drug middleman who is a leach on the system and only exists because of some lobbying or other screwed up structure?
- s3r3nity 8y ago
  More like the doctor who has dropped six-figures + a crazy amount of years in education and certification to work very long hours seeing a lot of patients, many of whom think you're a quack and trust an online forum over anything you say. Oh and don't forget the high premiums for malpractice insurance, as you're working crazy hours without breaks, and if you make a mistake you're sued up the whazoo. And that's just describing a PCP - never mind a surgeon, EHS driver, hell even the nurses (though the latter are most likely unionized.)
  - erentz 8y ago
    Doctors aren’t a huge cost issue. Their pay isn’t that outrageous or out of line. It’s the pharmacy costs and administrative costs (and I think also DME costs?) that are seriously out of whack in this country.
    - s3r3nity 8y ago
      Oh I'm not claiming they're out of line - they deserve that pay. My point was that it's not all these evil salesmen / drug capitalists driving high-costs in medicine. Sometimes better quality care just costs more.
  - dc_gregory 8y ago
    These people get paid very well in Australia.
  - jashpool 8y ago
    Cost controls also have a cost. The UK NHS has chronic staffing shortages, UK doctors are going abroad for better pay; currently the favourites are Australia, Canada and the Middle East. I have heard quite a few people say they actively discourage their children from being doctors.
jorblumesea 8y ago
This is the problem with a for-profit healthcare system. Meaningful reform is almost impossible because there's jobs on the line and therefore voters to contend with. More importantly, they are also probably highly educated and well paid voters. Doctors, software engineers, sales, etc. How much white collar employment comes from healthcare inefficiencies? Probably a good percentage of the sector. These workers will need to acknowledge they are part of the problem and willingly give up these positions (or their absurd payouts from them) and vote accordingly. Or not and continue being part of the problem, which I think is your concern.
- prostoalex 8y ago
  US has a host of not-for-profit providers, they’re not drastically cheaper.
  - jorblumesea 8y ago
    Mostly due to the existing for profit system. Not for profits still have to reside within the existing construct of American healthcare and hardly provide any real advantages when they negotiate with for profit entities.
AtlasBarfed 8y ago
The cost problem in healthcare is exactly that: many pigs at the trough, and everyone points at the other pig for being the problem. Healthcare administrators! Drug companies! Device companies! Trial Lawyers! Insurance companies! Doctors (especially specialists)! They're all the problem, and yes lots of them should make less money. I know cardiologists pulling down 500k+ and that is ridiculous. I can see highly skilled surgeons making that much, but pill pushers?
- ams6110 8y ago
  > I know cardiologists pulling down 500k+ and that is ridiculous. I can see highly skilled surgeons making that much, but pill pushers? I don't know about you but I'm not willing to be a student until I'm in my mid 30s, working crazy hours, likely accumulating a significant amount of debt along the way, without some kind of a substantial payout on the other side.
  - travisoneill1 8y ago
    Which is a good reason to not make doctors spend so many years in school. The Europeans don't and their doctors are just fine.
    - jefurii 8y ago
      Also a good reason for state-funded higher education.
- naveen99 8y ago
  Cardiologists aren’t pill pushers. They are interventional radiologists of the heart. They do need lots of skill also.
specialist 8y ago
"cost controls the paper appears to advocate for literally mean someone is making less money" Reference Table S1. Cost controls would account for ~14.5% of the total savings. Hardly seems onerous. Medicare's medical loss ratio is approx 4% (?), whereas ACA caps private insurers at 15%. So clearly there's plenty of fat to be trimmed. TL;DR: Single payer is cheaper, people live longer. Transition will be painful.
rednerrus 8y ago
If we removed the profit paid to investors, isn't there additional money to be paid to people facilitating healthcare and to bring the costs down? It looks like there was $47 Billion, (~9%) in profit in healthcare companies in the US in 2018. https://www.axios.com/health-care-industry-on-track-massive-q2-profits-1533226387-dacec8f8-c9f5-406c-a49e-1103e3316c64.html https://www.axios.com/health-care-industry-on-track-massive-...
- travisoneill1 8y ago
  This accounts for less than 10% of the difference between healthcare spending between the US and other OECD states. See this report for a much more detailed analysis: https://www.mckinsey.com/~/media/McKinsey/Industries/Healthcare%20Systems%20and%20Services/Our%20Insights/Accounting%20for%20the%20cost%20of%20US%20health%20care/MGI_Accounting_for_cost_of_US_health_care_full_report.ashx https://www.mckinsey.com/~/media/McKinsey/Industries/Healthc...

by entee 8y ago

toomuchtodo 8y ago

> One thing that sometimes gets lost in the "health care is inefficient" discussion is that one person's inefficiency is another person's living. You are not entitled to a living as bureaucratic waste. We should of course help retrain those who lose their jobs, just as we're doing for coal workers who are going to be out of a job within the next five years. I want my healthcare dollars going to healthcare providers (doctors, nurses, nurse practitioners, CNAs, drug research R&D, medical technology innovators), not private insurance companies, not administrators or third party billers, and most assuredly, not shareholders. I want the AMA to be handicapped from preventing us from dramatically increasing the number of doctors in the US (the American Medical Association operates as a cartel/cabal, attempting to limit supply to keep wages high); they also attempt to reduce the authority given to nurse practitioners [1]. > I would love for some sort of centralized system to push down costs, but I fear it's not realistically every going to happen. The majority of Americans say the government should be responsible for ensuring health care coverage for all Americans [2]. Universal healthcare will arrive in the US eventually, the question is when. The current model is unsustainable, and will reach a tipping point. [1] https://www.modernhealthcare.com/article/20171214/NEWS/171219932 https://www.modernhealthcare.com/article/20171214/NEWS/17121... [2] http://www.pewresearch.org/fact-tank/2017/01/13/more-americans-say-government-should-ensure-health-care-coverage/ http://www.pewresearch.org/fact-tank/2017/01/13/more-america...

ams6110 8y ago
Only a few generations ago, healthcare was not so ruinously expensive in the USA. We've never had taxpayer-funded universal care. So what caused the explosion in costs?
- toomuchtodo 8y ago
  TL;DR Lack of cost controls and unnecessary administrative costs. > In the U.S., they point out, drugs are more expensive. Doctors get paid more. Hospital services and diagnostic tests cost more. And a lot more money goes to planning, regulating and managing medical services at the administrative level. So, we're all getting a lower quality of care for a lot more money, due to how the healthcare "market" is configured. https://www.nytimes.com/2018/03/13/upshot/united-states-health-care-resembles-rest-of-world.html https://www.nytimes.com/2018/03/13/upshot/united-states-heal... https://www.cnbc.com/2018/03/22/the-real-reason-medical-care-costs-so-much-more-in-the-us.html https://www.cnbc.com/2018/03/22/the-real-reason-medical-care... https://www.cnn.com/2017/11/07/health/health-care-spending-study/index.html https://www.cnn.com/2017/11/07/health/health-care-spending-s... https://www.consumerreports.org/cro/magazine/2014/11/it-is-time-to-get-mad-about-the-outrageous-cost-of-health-care/index.htm https://www.consumerreports.org/cro/magazine/2014/11/it-is-t...
  - sedor0115 8y ago
    This fails to address the elephant-sized American in the room. Any analysis of increasing healthcare costs that doesn't quantify the fiscal impact of the average American's failure to care for themselves is just beating around the bush. The obesity rate alone has gone from 10% in the 60s to 40% today. These people need more care that is harder to provide, and to not expect healthcare costs to rise significantly from that is to expect healthcare workers to work for free. Our system is a little sick, sure, but the bulk of the responsibility for the current situation lies squarely at our own feet as individuals. This problem will never be solved before America puts down the fork.
- rednerrus 8y ago
  The elastic nature of health care costs and the disconnect between the people making the purchases and the people paying the bills. If you have insurance, chances are that you are not asking your doctor how much something is going to cost. You are not likely to shop around or work to get the best deal. As a healthcare provider, where is the incentive to bring costs down.
Analemma_ 8y ago
You’re missing the point. The parent isn’t suggesting this situation is good, or that we shouldn’t eliminate bureaucratic waste. They’re saying that there are a ton of people highly incentivized to keep the system as it is, because it pays for their salary. Concentrated benefits, diffuse costs.

ArchTypical 8y ago

> that they're underpaid or overworked or whatever Having family in healthcare and being a lifelong patient due to a congenital defect, a job in software (including management obv) is a breeze compared to health care worker jobs across the board. They require more "schooling" (via mind-numbing training), are underpaid, have much more serious consequences from mistakes, have less oversight, work longer hours and under worse conditions. It's disheartening.

onlyrealcuzzo 8y ago
I'm pretty sure most people, even administrators in hospitals and insurance, are overworked. Health care in the US is the textbook definition of big business. The only people making easy, stupid money are shareholders.
agumonkey 8y ago
People's work shouldn't be reduced, but drugs and devices should be to an extent. Firefighters told the portable EKG costed thousands of dollars (5 or 10 don't recall). That thing had bad 2G connectivity so the graph coudn't be sent to a cardiologist. The sensor/dsp part is worth money, the rest would cost 100$ from any smartphone maker today with better performance and portability. I'm sure the price is rigged for margins. This shouldn't be a market, it should be an open duty to make these cost efficient.
- ams6110 8y ago
  The real cost is not so much in the hardware but in the certification requirements. Medical devices need to be built to and work at a higher standard than consumer electronics, for obvious reasons.
  - agumonkey 8y ago
    Of course, but the interface and connectivity part of that EKG machine wasn't even up to 2005 cellphones standard. On that point, it's a scam.

thatfrenchguy 8y ago

And a lot of this is administrative overhead. Coming from a country outside of the US, I was also shocked by the price of medecine, every medecine magically seems to be 5-10x more expensive in the US.

ekianjo 8y ago
The prices help pay for the huge cost involved in developing drugs. How many drugs were developed in France in the past 10 years compared to how many were developed in the US? You know the answer.
- Analemma_ 8y ago
  Personally, I would’ve liked to be asked whether I consented to paying 10x the price that every other country pays, in order to subsidize drug development, cause I definitely don’t recall ever agreeing to that deal.
  - ams6110 8y ago
    The problem is your other option is likely not having the drug at all.
- jayd16 8y ago
  This is pretty specious reasoning. The US is a leader in a lot of industries that aren't healthcare.
- monocasa 8y ago
  I know that's what's pushed, but how much of that is true? Federal grants pay for a lot of initial frubt work, and drug companies spend around twice as much on marketing as they do on R&D. And that's with all sorts of tax benefits behooving them to call as much as possible of their budget R&D.
  - ekianjo 8y ago
    Marketing is needed everywhere, pharma included. You dont spread awareness of a new drug just by filing an application to the FDA. And marketing expenses are high because potential returns are high and make or break a drug. Note that you dont have really new drugs every year so you need marketing anyway to convince prescribers why your version of the drug in the same class as your competitor is slightly better. In reality most drugs of the same class are pretty similar in efficacy and side effects, but thats a tangential topic.

village-idiot 8y ago

I’ve always worried about the political consequences to the loss of insurance jobs. I also view that job loss as a foregone conclusion due to insurance companies fighting even moderate changes tooth and nail. If even minor improvements to a nakedly broken system are going to get fought against with such ferocity, it’s not surprising that their opponents would try and move the Overton window in response.

bedhead 8y ago

Like, the living of some drug middleman who is a leach on the system and only exists because of some lobbying or other screwed up structure?

s3r3nity 8y ago
More like the doctor who has dropped six-figures + a crazy amount of years in education and certification to work very long hours seeing a lot of patients, many of whom think you're a quack and trust an online forum over anything you say. Oh and don't forget the high premiums for malpractice insurance, as you're working crazy hours without breaks, and if you make a mistake you're sued up the whazoo. And that's just describing a PCP - never mind a surgeon, EHS driver, hell even the nurses (though the latter are most likely unionized.)
- erentz 8y ago
  Doctors aren’t a huge cost issue. Their pay isn’t that outrageous or out of line. It’s the pharmacy costs and administrative costs (and I think also DME costs?) that are seriously out of whack in this country.
  - s3r3nity 8y ago
    Oh I'm not claiming they're out of line - they deserve that pay. My point was that it's not all these evil salesmen / drug capitalists driving high-costs in medicine. Sometimes better quality care just costs more.
- dc_gregory 8y ago
  These people get paid very well in Australia.
- jashpool 8y ago
  Cost controls also have a cost. The UK NHS has chronic staffing shortages, UK doctors are going abroad for better pay; currently the favourites are Australia, Canada and the Middle East. I have heard quite a few people say they actively discourage their children from being doctors.

jorblumesea 8y ago

This is the problem with a for-profit healthcare system. Meaningful reform is almost impossible because there's jobs on the line and therefore voters to contend with. More importantly, they are also probably highly educated and well paid voters. Doctors, software engineers, sales, etc. How much white collar employment comes from healthcare inefficiencies? Probably a good percentage of the sector. These workers will need to acknowledge they are part of the problem and willingly give up these positions (or their absurd payouts from them) and vote accordingly. Or not and continue being part of the problem, which I think is your concern.

prostoalex 8y ago
US has a host of not-for-profit providers, they’re not drastically cheaper.
- jorblumesea 8y ago
  Mostly due to the existing for profit system. Not for profits still have to reside within the existing construct of American healthcare and hardly provide any real advantages when they negotiate with for profit entities.

AtlasBarfed 8y ago

The cost problem in healthcare is exactly that: many pigs at the trough, and everyone points at the other pig for being the problem. Healthcare administrators! Drug companies! Device companies! Trial Lawyers! Insurance companies! Doctors (especially specialists)! They're all the problem, and yes lots of them should make less money. I know cardiologists pulling down 500k+ and that is ridiculous. I can see highly skilled surgeons making that much, but pill pushers?

ams6110 8y ago
> I know cardiologists pulling down 500k+ and that is ridiculous. I can see highly skilled surgeons making that much, but pill pushers? I don't know about you but I'm not willing to be a student until I'm in my mid 30s, working crazy hours, likely accumulating a significant amount of debt along the way, without some kind of a substantial payout on the other side.
- travisoneill1 8y ago
  Which is a good reason to not make doctors spend so many years in school. The Europeans don't and their doctors are just fine.
  - jefurii 8y ago
    Also a good reason for state-funded higher education.
naveen99 8y ago
Cardiologists aren’t pill pushers. They are interventional radiologists of the heart. They do need lots of skill also.

specialist 8y ago

"cost controls the paper appears to advocate for literally mean someone is making less money" Reference Table S1. Cost controls would account for ~14.5% of the total savings. Hardly seems onerous. Medicare's medical loss ratio is approx 4% (?), whereas ACA caps private insurers at 15%. So clearly there's plenty of fat to be trimmed. TL;DR: Single payer is cheaper, people live longer. Transition will be painful.

rednerrus 8y ago

If we removed the profit paid to investors, isn't there additional money to be paid to people facilitating healthcare and to bring the costs down? It looks like there was $47 Billion, (~9%) in profit in healthcare companies in the US in 2018. https://www.axios.com/health-care-industry-on-track-massive-q2-profits-1533226387-dacec8f8-c9f5-406c-a49e-1103e3316c64.html https://www.axios.com/health-care-industry-on-track-massive-...

travisoneill1 8y ago
This accounts for less than 10% of the difference between healthcare spending between the US and other OECD states. See this report for a much more detailed analysis: https://www.mckinsey.com/~/media/McKinsey/Industries/Healthcare%20Systems%20and%20Services/Our%20Insights/Accounting%20for%20the%20cost%20of%20US%20health%20care/MGI_Accounting_for_cost_of_US_health_care_full_report.ashx https://www.mckinsey.com/~/media/McKinsey/Industries/Healthc...