4 ms·

So maybe I don't know what you mean by structural problems. I assumed you meant agency problems, administrative costs, medical professional pay, liability costs

So maybe I don't know what you mean by structural problems. I assumed you meant agency problems, administrative costs, medical professional pay, liability costs, over care & end of life care. All of which are directly impacted by how we fund the system.

tptacek 8y ago
Two examples of structural problems with our health care systems: 1. We lead the world in transitioning from inpatient to outpatient care; for instance, I read a source last night that said the majority of hernia repairs in the NHS were inpatient, and the overwhelming majority of them in the US were outpatient. That's good, but an unintended consequence of it is that it's easier to route a patient to a surgical procedure if it's done outpatient, and as a consequence US patients get a lot more of these procedures, some of them (cardiac stents being a recent well-publicized example) of dubious utility. Our relative overconsumption of services doesn't lead to better outcomes, and thus represents misallocation. 2. Our health provider systems are more decentralized, delivered in smaller clinics and hospitals. Our hospitals generally, nationwide, have poor utilization. Not only do we therefore overspend on plant and salary costs (which we do, relative to Europe) but coupled with our price transparency problems we end up with the situation Atul Gawande described a year or two back, when he noted the insane difference in prices for an MRI at different imaging centers in a small region of (iirc) Texas. Our system right now isn't good and some of it (but by no means all of it) is related to how we regulate the way it's funded. But Medicare overspends on many of the same things. The structural problems will need to be corrected no matter how we design the rest of the system. Ultimately I think the problem in the US is a sort of perfect storm of badnesses. (Good sources: Kauffman's health cost explorer, the McKinsey report, the Health Care Cost Institute annual breakdowns).
- kasey_junk 8y ago
  Both of those are classic examples of the outcomes being directly related to how we fund our medical care. In the first instance it's a tension between the providers trying to maximize service, insurers trying to minimize risk and the user having little agency in the outcome. The second example is a straight up agency problem. None of that changes the argument, it is a perfect storm of badness and even if nationalized healthcare was politically feasible it wouldn't fix all of these issues. I just want to get to the point where my insurance doesn't come from my employer...
  - tptacek 8y ago
    There are a bunch of ways to rebut that argument. First, you can look at private systems that don't have these problems (ie: all the rest of the private systems). Second, you can note that Medicare, our single-payer system, interacts with the same structurally inefficient provider system. And, of course, if we switch to single-payer tomorrow, we're still going to be doing most care on an outpatient basis (because we should), and are still as a result going to be overprescribing procedures to patients.
    - dragonwriter 8y ago
      > Second, you can note that Medicare, our single-payer system, Medicare is not a single payer system, but a partial-subsidy voucher system for highly-regulated private insurance with (for the core inpatient and outpatient components) a fully-paid public option.
      - tptacek 8y ago
        Fair enough. Consider my rebuttal so revised.
        dragonwriter 8y ago
        Let me expand on that: Medicare has recognized the problems you mentioned and has, fairly recently, begun directing efforts through payment system at the first broad class (inefficient interventions) through adoption of a variety of quality-incentive payment systems. But those aren't going to be as broadly effective, even for Medicare fee-for-service patients, as they could be if delivery systems and practice is shaped by conflicting incentives from different payers (who may be involved in covering some of the same claims, because coordination of benefits is a real thing, and even when they aren't for the same claims, will often over time be for treatment of the same patient.)
  - kasey_junk 8y ago
    The VA is the best example of single payer system in the US, it does not suffer from either of these problems (though for demographic reasons it suffers from a host of others). As for the private options do any of them have the weird employer provided health care indirection?

tptacek 8y ago

Two examples of structural problems with our health care systems: 1. We lead the world in transitioning from inpatient to outpatient care; for instance, I read a source last night that said the majority of hernia repairs in the NHS were inpatient, and the overwhelming majority of them in the US were outpatient. That's good, but an unintended consequence of it is that it's easier to route a patient to a surgical procedure if it's done outpatient, and as a consequence US patients get a lot more of these procedures, some of them (cardiac stents being a recent well-publicized example) of dubious utility. Our relative overconsumption of services doesn't lead to better outcomes, and thus represents misallocation. 2. Our health provider systems are more decentralized, delivered in smaller clinics and hospitals. Our hospitals generally, nationwide, have poor utilization. Not only do we therefore overspend on plant and salary costs (which we do, relative to Europe) but coupled with our price transparency problems we end up with the situation Atul Gawande described a year or two back, when he noted the insane difference in prices for an MRI at different imaging centers in a small region of (iirc) Texas. Our system right now isn't good and some of it (but by no means all of it) is related to how we regulate the way it's funded. But Medicare overspends on many of the same things. The structural problems will need to be corrected no matter how we design the rest of the system. Ultimately I think the problem in the US is a sort of perfect storm of badnesses. (Good sources: Kauffman's health cost explorer, the McKinsey report, the Health Care Cost Institute annual breakdowns).

kasey_junk 8y ago
Both of those are classic examples of the outcomes being directly related to how we fund our medical care. In the first instance it's a tension between the providers trying to maximize service, insurers trying to minimize risk and the user having little agency in the outcome. The second example is a straight up agency problem. None of that changes the argument, it is a perfect storm of badness and even if nationalized healthcare was politically feasible it wouldn't fix all of these issues. I just want to get to the point where my insurance doesn't come from my employer...
- tptacek 8y ago
  There are a bunch of ways to rebut that argument. First, you can look at private systems that don't have these problems (ie: all the rest of the private systems). Second, you can note that Medicare, our single-payer system, interacts with the same structurally inefficient provider system. And, of course, if we switch to single-payer tomorrow, we're still going to be doing most care on an outpatient basis (because we should), and are still as a result going to be overprescribing procedures to patients.
  - dragonwriter 8y ago
    > Second, you can note that Medicare, our single-payer system, Medicare is not a single payer system, but a partial-subsidy voucher system for highly-regulated private insurance with (for the core inpatient and outpatient components) a fully-paid public option.
    - tptacek 8y ago
      Fair enough. Consider my rebuttal so revised.
      - dragonwriter 8y ago
        Let me expand on that: Medicare has recognized the problems you mentioned and has, fairly recently, begun directing efforts through payment system at the first broad class (inefficient interventions) through adoption of a variety of quality-incentive payment systems. But those aren't going to be as broadly effective, even for Medicare fee-for-service patients, as they could be if delivery systems and practice is shaped by conflicting incentives from different payers (who may be involved in covering some of the same claims, because coordination of benefits is a real thing, and even when they aren't for the same claims, will often over time be for treatment of the same patient.)
- kasey_junk 8y ago
  The VA is the best example of single payer system in the US, it does not suffer from either of these problems (though for demographic reasons it suffers from a host of others). As for the private options do any of them have the weird employer provided health care indirection?