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Even if you can save 20% on younger people (by paying doctors/hospitals 20% less) that's still a long way away from bringing costs in line with Europe. Single

Even if you can save 20% on younger people (by paying doctors/hospitals 20% less) that's still a long way away from bringing costs in line with Europe. Single payer doesn't sound like a crazy idea to me, I'm just skeptical that it will necessarily solve the cost problem. A single payer system that is very expensive and continually increasing seems like a real possibility to me. I guess you could achieve cost savings by cutting reimbursement rates even further if you prohibit any alternatives. Hospitals can and do go bankrupt but it seems likely that physician salaries could also be cut. I'm sure this will drive many doctors that were borderline into retirement but I guess we're facing a physician shortage anyway. I think there's a number of other things we could do to contain health care costs. We could expand the role of nurses and physician assistants (possibly with the aid of computer diagnostic systems). We could increase the number of doctors produced (which will in general lower salaries). We could subsidize medical education more, so doctors graduate with less debt, in exchange for accepting a lower salary later. We could have better conversations around end-of-life care, since many patients choose treatment plans that doctors would not chose for themselves, but might not if things were explained better. We could have official guidelines to establish when certain tests are necessary using evidence-based medicine, to limit thoughtless CYA testing for liability purposes if it isn't medically warranted. So, my feelings on single payer are tied to whether it will make it more or less likely that we can explore these things. Given the current state of our political discourse I'm not encouraged.

keenmaster 7y ago
“The AMA controls state boards of licensing, limiting the number of physicians in each state and preventing competitors from treating patients. The United States has 50 percent fewer practicing physicians per capita than Sweden or Germany. Unsurprisingly, US doctors also work fewer hours while earning much higher salaries.“ https://fee.org/articles/the-medical-cartel-is-keeping-health-care-costs-high/ https://fee.org/articles/the-medical-cartel-is-keeping-healt... We absolutely need more physicians. Med school should be cheaper and shorter in duration, but the AMA has been fixing the supply of doctors like a cartel in the name of “quality.” They’re defending the economic moat for current physicians by using a false front, nothing more. Also, people started believing that end-of-life care is a problem in the U.S. partly because of misleading statistics. Let’s say your grandma is 75 and has complications due to pneumonia. The situation spirals out of control and she becomes a really costly patient. However, she has a reasonable chance of living to 85, giving you 10 more (quite valuable) years with her. No one will argue that we should give up on her. However, if she dies after all that expense, she will feed that stupid statistic about X% of Medicare spending in the last X months/years. Many people die when they have a reasonable probability of living. There are edge cases, like people that somehow enter a catatonic state or get some rare disease, but they’re overblown. Lastly, there is a subgroup of people that you just can’t “control costs” on, like Alzheimer’s patients. What kind of sick society would give up on them? End-of-life care is a red herring in the U.S. healthcare debate, as is overconsumption of diagnostic screening. It is certainly true that America has a culture of screening but 1. MRIs shouldn’t cost $1500, so its hard to fairly compare the magnitude vs. Europe where the healthcare system isn’t broken 2. Excessively high treatment costs are so much more of a problem that this is a small factor in comparison 3. There are benefits to screening which obviously net out the cost to some degree. Screening really shouldn’t feature much in the debate at all in my opinion, nor should healthcare consumption levels for that matter. For some perspective, a study estimated that $45 billion is spent on “defensive medicine” meant to avoid lawsuits out of the $2.3 trillion spent on healthcare in 2008. However, if you ask some industry insiders why healthcare costs are so high, they might quickly inform you of defensive medicine and medical liability. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048809/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048809/
- throwaway34241 7y ago
  > United States has 50 percent fewer practicing physicians per capita than Sweden or Germany. Unsurprisingly, US doctors also work fewer hours while earning much higher salaries. There's no citation, but I actually find the part about the hours to be extremely surprising if there are half as many of them doing the same work. Do Germans consume less than half as much medical care? US doctors don't work particularly short hours (even after residency), so it's very surprising if Germans work more considering they usually get much more vacation. > the AMA has been fixing the supply of doctors As far as I am aware, the supply of doctors in the US is determined by the number of Medicare-funded residency slots, which is set by Congress. > No one will argue that we should give up on her. > What kind of sick society would give up on them? No one would argue that for your specific examples, but with things like end stage cancer it can be more tricky. Part of the problem is that it is too often framed around "giving up" when it comes to aggressive interventions that are unlikely to help. But doctors who see the system from the inside would generally not choose that path for themselves, for reasons totally unrelated to cost. Too aggressive interventions usually don't make people live longer (they often die sooner!) and can really degrade any remaining quality of life. Atul Gawande wrote a book about it [1] (interestingly, he's also one of the authors of the paper you cited). Excessive testing probably isn't purely a defensive medicine thing. I don't have a citation, but apparently when the medical group ordering the tests has a financial interest in the testing center, hugely more testing is done. And of course when the guidelines are unclear it's easier to default to just ordering things, it doesn't cost the doctor anything. There's another article (again by Atul) that touches on it [2]. It's interesting, if you talk to doctors (in a non-professional setting) they'll generally tell you their profession is getting worse. That they're more and more overworked with no change in pay. And if you look at the statistics, physician pay hasn't gone anywhere while health care costs have skyrocketed. [3] [1] https://www.amazon.com/Being-Mortal-Medicine-What-Matters/dp/0805095152 https://www.amazon.com/Being-Mortal-Medicine-What-Matters/dp..., https://www.youtube.com/watch?v=mviU9OeufA0 https://www.youtube.com/watch?v=mviU9OeufA0 [2] https://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum https://www.newyorker.com/magazine/2009/06/01/the-cost-conun... [3] https://slatestarcodex.com/2017/02/09/considerations-on-cost-disease/ https://slatestarcodex.com/2017/02/09/considerations-on-cost...
- deleted 7y ago

keenmaster 7y ago

“The AMA controls state boards of licensing, limiting the number of physicians in each state and preventing competitors from treating patients. The United States has 50 percent fewer practicing physicians per capita than Sweden or Germany. Unsurprisingly, US doctors also work fewer hours while earning much higher salaries.“ https://fee.org/articles/the-medical-cartel-is-keeping-health-care-costs-high/ https://fee.org/articles/the-medical-cartel-is-keeping-healt... We absolutely need more physicians. Med school should be cheaper and shorter in duration, but the AMA has been fixing the supply of doctors like a cartel in the name of “quality.” They’re defending the economic moat for current physicians by using a false front, nothing more. Also, people started believing that end-of-life care is a problem in the U.S. partly because of misleading statistics. Let’s say your grandma is 75 and has complications due to pneumonia. The situation spirals out of control and she becomes a really costly patient. However, she has a reasonable chance of living to 85, giving you 10 more (quite valuable) years with her. No one will argue that we should give up on her. However, if she dies after all that expense, she will feed that stupid statistic about X% of Medicare spending in the last X months/years. Many people die when they have a reasonable probability of living. There are edge cases, like people that somehow enter a catatonic state or get some rare disease, but they’re overblown. Lastly, there is a subgroup of people that you just can’t “control costs” on, like Alzheimer’s patients. What kind of sick society would give up on them? End-of-life care is a red herring in the U.S. healthcare debate, as is overconsumption of diagnostic screening. It is certainly true that America has a culture of screening but 1. MRIs shouldn’t cost $1500, so its hard to fairly compare the magnitude vs. Europe where the healthcare system isn’t broken 2. Excessively high treatment costs are so much more of a problem that this is a small factor in comparison 3. There are benefits to screening which obviously net out the cost to some degree. Screening really shouldn’t feature much in the debate at all in my opinion, nor should healthcare consumption levels for that matter. For some perspective, a study estimated that $45 billion is spent on “defensive medicine” meant to avoid lawsuits out of the $2.3 trillion spent on healthcare in 2008. However, if you ask some industry insiders why healthcare costs are so high, they might quickly inform you of defensive medicine and medical liability. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048809/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048809/

throwaway34241 7y ago
> United States has 50 percent fewer practicing physicians per capita than Sweden or Germany. Unsurprisingly, US doctors also work fewer hours while earning much higher salaries. There's no citation, but I actually find the part about the hours to be extremely surprising if there are half as many of them doing the same work. Do Germans consume less than half as much medical care? US doctors don't work particularly short hours (even after residency), so it's very surprising if Germans work more considering they usually get much more vacation. > the AMA has been fixing the supply of doctors As far as I am aware, the supply of doctors in the US is determined by the number of Medicare-funded residency slots, which is set by Congress. > No one will argue that we should give up on her. > What kind of sick society would give up on them? No one would argue that for your specific examples, but with things like end stage cancer it can be more tricky. Part of the problem is that it is too often framed around "giving up" when it comes to aggressive interventions that are unlikely to help. But doctors who see the system from the inside would generally not choose that path for themselves, for reasons totally unrelated to cost. Too aggressive interventions usually don't make people live longer (they often die sooner!) and can really degrade any remaining quality of life. Atul Gawande wrote a book about it [1] (interestingly, he's also one of the authors of the paper you cited). Excessive testing probably isn't purely a defensive medicine thing. I don't have a citation, but apparently when the medical group ordering the tests has a financial interest in the testing center, hugely more testing is done. And of course when the guidelines are unclear it's easier to default to just ordering things, it doesn't cost the doctor anything. There's another article (again by Atul) that touches on it [2]. It's interesting, if you talk to doctors (in a non-professional setting) they'll generally tell you their profession is getting worse. That they're more and more overworked with no change in pay. And if you look at the statistics, physician pay hasn't gone anywhere while health care costs have skyrocketed. [3] [1] https://www.amazon.com/Being-Mortal-Medicine-What-Matters/dp/0805095152 https://www.amazon.com/Being-Mortal-Medicine-What-Matters/dp..., https://www.youtube.com/watch?v=mviU9OeufA0 https://www.youtube.com/watch?v=mviU9OeufA0 [2] https://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum https://www.newyorker.com/magazine/2009/06/01/the-cost-conun... [3] https://slatestarcodex.com/2017/02/09/considerations-on-cost-disease/ https://slatestarcodex.com/2017/02/09/considerations-on-cost...
deleted 7y ago