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Everyone with absolutely no knowledge of our healthcare system "look(s) at the medical profession as the racket it is." They then proceed to point at things as

Everyone with absolutely no knowledge of our healthcare system "look(s) at the medical profession as the racket it is." They then proceed to point at things as the root cause that every health policy expert in the country can tell you is not the root cause, and that doesn't hold up to even slight scrutiny by comparison with other, similar, countries.

asveikau 6y ago
Could that just be a way of saying that health policy experts are attached to the status quo? Do they have a consensus on how to fix commonly cited problems, and agreement that we ought to?
- arkades 6y ago
  Yes to both of the latter, but no authority to do so. Academics ain't legislators.
  - motohagiography 6y ago
    So, I've spent over a decade consulting to public sector health agencies in charge of delivering everything from electronic health records to cancer research to chronic disease management, long terms care, mental health, and privacy, among many other areas. Before you call someone ignorant and say that the bureaucracy disagrees and so what possible standing could I have, consider a little bit of charitable reasoning would add some much needed credibility to the objection.
    - arkades 6y ago
      Oh, I didn't judge you on your professional history. I judged you on the content of your comment - that is to say, on the merit of your statement rather than an appeal to authority. That you've done consulting to the healthcare sector doesn't mean much of anything to me, one way or another. Heck, the IT consultant for our CTO in my health chain can say the same, and all he does is EMR rollouts. He has about 0% understanding of healthcare policy, or how the system actually works. He understands EMR implementations. The financial analyst consulting to our COO has been in the hc sector for about a year and his knowledge of actual hc policy outstrips the EMR guy by at least an order of magnitude. As a physician and healthcare policy expert, I don't much need any credibility, outside of that provided by the contents of my posts. I'm happy to let them speak for themselves, rather than appeal to authority - the latter of which is essentially non-existent in this pseudonymous context.
      - motohagiography 6y ago
        The #1 job of policy analysts is to preserve their ability to make policy. While you have spent a respectable amount of time working in bureaucracies, a criticism of the legitimacy of those institutions' ability to improve outcomes is not something people encounter on the inside. Meaningful endogenous change isn't going to happen. As the job of physician is being reduced to that of a health care service project manager who assembles and directs specialists using technology tools, it's becoming vulnerable to the same technology changes that sidelined project managers. Skill is pareto distributed, and there is a long tail of medical services that could be done by apprenticed tradespeople, and the only thing preventing that is medical associations - and as you say, holding litigation risk.
pasquinelli 6y ago
So what's up then? Or if you can't say what's up -- fair enough, you're not an oracle -- what slight scrutiny in particular topples this particular root cause hypothesis?
- solveit 6y ago
  It doesn't cost 3k to have an MD do stitches. That money's going somewhere else (Actual experts may or may not know where).
  - arkades 6y ago
    Cost of ER, as has been said on a million posts like this throughout HN's history, are due to the fact that you're taking up one of the highest-overhead spaces in the hospital, a lot of which is malpractice-insurance-related. The criticism almost inevitably goes like this, "I went to (the absolute most expensive service center for service X) and it cost a shit-ton!" And it's almost inevitably quoting the price for an uninsured patient - because at insured, contracted rates, your OOP responsibility for ER visits is rarely >1K. Then people complain about itemization (which is why it's so rarely done)("$50 band-aids?! I could have bought my own!"), even though the itemization is nonsense. Overhead has to be allocated, and that's the itemization price - the "band-aids" item includes everything from their storage, the staff member deploying them, etc. It's not $50 band-aids. It's $50 of going to a hospital, seeing an ER doc, and having a nurse put on a band-aid for you. Don't want $50 band-aids? Go to the pharmacy and put on a band-aid for 30 cents. People pretend price transparency will make things better, but it's not obfuscation that gives rise to this - itemization is price transparency, and people who don't understand the idea of allocating overhead just get more inflamed by it. By the way, actual cost transparency has winners and losers too. The winner is generally private insurers, who can use it to negotiate reimbursement further downward. The losers are everyone else. It's pretty much never the patient, regardless of what advocates of "patient consumerism" cry. When you're a grain of sand between two massive gears, you don't ever win the game of policy arbitrage. If all you need is stitches, you can go to your PCP ($20-$60), surgeon's private office ($50-$100) or Urgent Care ($50-$200). Instead you go to the highest overhead center, occupy the attention of at least 2 nurses, a mid-level, and a doc, and... yes, pay for all of the above. In a space whose allocated overhead includes the weighted average of "stitches that shouldn't have come in" to "diabetic ketoacidosis with multiple organ failure." Part of our systemic problems is, due to how we're structured, it's borderline impossible for an ER to say (a polite version of) "You're fucking kidding me. We have an urgent care center across the street - go there." [1] We have many, many, many systemic problems. People using the ED as a primary care office and complaining about the disparity in prices is the least egregious of them. [1] In part because hospitals used to try to bounce indigent patients. So now they can't do anything that smacks of bouncing anyone. So even if you try to divert patients from the ED to an in-house Urgent-ish Care, they still have to go through the ED pathway to determine that they're stable (meaning a doc has to evaluate them), before they can be shunted over. And now you're in a hospital, so the overhead of the Urgent-ish Care is already way higher than just having gone to UC to begin with. The hospital has no incentive to establish a spot for providing the same level of care, at high overhead, for lower reimbursement.

asveikau 6y ago

Could that just be a way of saying that health policy experts are attached to the status quo? Do they have a consensus on how to fix commonly cited problems, and agreement that we ought to?

arkades 6y ago
Yes to both of the latter, but no authority to do so. Academics ain't legislators.
- motohagiography 6y ago
  So, I've spent over a decade consulting to public sector health agencies in charge of delivering everything from electronic health records to cancer research to chronic disease management, long terms care, mental health, and privacy, among many other areas. Before you call someone ignorant and say that the bureaucracy disagrees and so what possible standing could I have, consider a little bit of charitable reasoning would add some much needed credibility to the objection.
  - arkades 6y ago
    Oh, I didn't judge you on your professional history. I judged you on the content of your comment - that is to say, on the merit of your statement rather than an appeal to authority. That you've done consulting to the healthcare sector doesn't mean much of anything to me, one way or another. Heck, the IT consultant for our CTO in my health chain can say the same, and all he does is EMR rollouts. He has about 0% understanding of healthcare policy, or how the system actually works. He understands EMR implementations. The financial analyst consulting to our COO has been in the hc sector for about a year and his knowledge of actual hc policy outstrips the EMR guy by at least an order of magnitude. As a physician and healthcare policy expert, I don't much need any credibility, outside of that provided by the contents of my posts. I'm happy to let them speak for themselves, rather than appeal to authority - the latter of which is essentially non-existent in this pseudonymous context.
    - motohagiography 6y ago
      The #1 job of policy analysts is to preserve their ability to make policy. While you have spent a respectable amount of time working in bureaucracies, a criticism of the legitimacy of those institutions' ability to improve outcomes is not something people encounter on the inside. Meaningful endogenous change isn't going to happen. As the job of physician is being reduced to that of a health care service project manager who assembles and directs specialists using technology tools, it's becoming vulnerable to the same technology changes that sidelined project managers. Skill is pareto distributed, and there is a long tail of medical services that could be done by apprenticed tradespeople, and the only thing preventing that is medical associations - and as you say, holding litigation risk.

pasquinelli 6y ago

So what's up then? Or if you can't say what's up -- fair enough, you're not an oracle -- what slight scrutiny in particular topples this particular root cause hypothesis?

solveit 6y ago
It doesn't cost 3k to have an MD do stitches. That money's going somewhere else (Actual experts may or may not know where).
- arkades 6y ago
  Cost of ER, as has been said on a million posts like this throughout HN's history, are due to the fact that you're taking up one of the highest-overhead spaces in the hospital, a lot of which is malpractice-insurance-related. The criticism almost inevitably goes like this, "I went to (the absolute most expensive service center for service X) and it cost a shit-ton!" And it's almost inevitably quoting the price for an uninsured patient - because at insured, contracted rates, your OOP responsibility for ER visits is rarely >1K. Then people complain about itemization (which is why it's so rarely done)("$50 band-aids?! I could have bought my own!"), even though the itemization is nonsense. Overhead has to be allocated, and that's the itemization price - the "band-aids" item includes everything from their storage, the staff member deploying them, etc. It's not $50 band-aids. It's $50 of going to a hospital, seeing an ER doc, and having a nurse put on a band-aid for you. Don't want $50 band-aids? Go to the pharmacy and put on a band-aid for 30 cents. People pretend price transparency will make things better, but it's not obfuscation that gives rise to this - itemization is price transparency, and people who don't understand the idea of allocating overhead just get more inflamed by it. By the way, actual cost transparency has winners and losers too. The winner is generally private insurers, who can use it to negotiate reimbursement further downward. The losers are everyone else. It's pretty much never the patient, regardless of what advocates of "patient consumerism" cry. When you're a grain of sand between two massive gears, you don't ever win the game of policy arbitrage. If all you need is stitches, you can go to your PCP ($20-$60), surgeon's private office ($50-$100) or Urgent Care ($50-$200). Instead you go to the highest overhead center, occupy the attention of at least 2 nurses, a mid-level, and a doc, and... yes, pay for all of the above. In a space whose allocated overhead includes the weighted average of "stitches that shouldn't have come in" to "diabetic ketoacidosis with multiple organ failure." Part of our systemic problems is, due to how we're structured, it's borderline impossible for an ER to say (a polite version of) "You're fucking kidding me. We have an urgent care center across the street - go there." [1] We have many, many, many systemic problems. People using the ED as a primary care office and complaining about the disparity in prices is the least egregious of them. [1] In part because hospitals used to try to bounce indigent patients. So now they can't do anything that smacks of bouncing anyone. So even if you try to divert patients from the ED to an in-house Urgent-ish Care, they still have to go through the ED pathway to determine that they're stable (meaning a doc has to evaluate them), before they can be shunted over. And now you're in a hospital, so the overhead of the Urgent-ish Care is already way higher than just having gone to UC to begin with. The hospital has no incentive to establish a spot for providing the same level of care, at high overhead, for lower reimbursement.