5 ms·

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 pro

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
  I think employer-provided insurance at scale is a uniquely American problem, and agree that it is problematic, but I don't see how it produces more overconsumption and less centralization than a purely individual market would. In fact, if you maintain a system of private providers (even with a public payer), I don't see a connection between funding and these structural problems at all.
  - kasey_junk 8y ago
    Nearly 150 million people in the states get their medical funding chosen for them by an HR analyst III & their favorite consultant buddy. Then it gets paid for in a combination of literally hidden payments, pre-pay deductions & tax subsidies. The idea that there isn’t a connection between this and costs is incredible. That’s before talking about the impacts on small businesses, long term care & the like.
    - tptacek 8y ago
      Lack of price transparency is a problem. But by what I (off the top of my head) understand to be an overwhelming margin, Americans who get their health insurance from their employers like that insurance; it's also hard to see how the HR rep at your company is influencing decisions about how many hospitals to build or how many MRIs to prescribe.
      - kasey_junk 8y ago
        I'd probably report I liked my car insurance if it included a twice a year detailing and paid for my lyft rides from the bar. Especially if the real cost of it was hidden from me. That is to say, the consumer of health care being unable to accurately judge the quality and efficiency of the funding of that care is at the heart of the problems with the market based approach to health care funding. The fact that one of the major players in the funding space have an intermediary as a customer instead of the health care recipient is a further distortion of the market. Imagine if we got our car insurance the way we get our health insurance. What impact would that have on efficiency of that industry?

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
I think employer-provided insurance at scale is a uniquely American problem, and agree that it is problematic, but I don't see how it produces more overconsumption and less centralization than a purely individual market would. In fact, if you maintain a system of private providers (even with a public payer), I don't see a connection between funding and these structural problems at all.
- kasey_junk 8y ago
  Nearly 150 million people in the states get their medical funding chosen for them by an HR analyst III & their favorite consultant buddy. Then it gets paid for in a combination of literally hidden payments, pre-pay deductions & tax subsidies. The idea that there isn’t a connection between this and costs is incredible. That’s before talking about the impacts on small businesses, long term care & the like.
  - tptacek 8y ago
    Lack of price transparency is a problem. But by what I (off the top of my head) understand to be an overwhelming margin, Americans who get their health insurance from their employers like that insurance; it's also hard to see how the HR rep at your company is influencing decisions about how many hospitals to build or how many MRIs to prescribe.
    - kasey_junk 8y ago
      I'd probably report I liked my car insurance if it included a twice a year detailing and paid for my lyft rides from the bar. Especially if the real cost of it was hidden from me. That is to say, the consumer of health care being unable to accurately judge the quality and efficiency of the funding of that care is at the heart of the problems with the market based approach to health care funding. The fact that one of the major players in the funding space have an intermediary as a customer instead of the health care recipient is a further distortion of the market. Imagine if we got our car insurance the way we get our health insurance. What impact would that have on efficiency of that industry?