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"Blaming the clinics doesn't work" - I trying to wrap my head around to put myself in your frame of mind to shift the blame from who is to blame to the governme

"Blaming the clinics doesn't work" - I trying to wrap my head around to put myself in your frame of mind to shift the blame from who is to blame to the government. If those clinics recommend and perform unnecessary procedures on people that can afford them (and do not benefit from govt. aid), does "blaming the clinics not work", because the actual problem is people being able to afford it? or would you go one step ahead and then say that the government is still to blame for allowing the possibility of wealth accumulation by individuals that results in unnecessary spending? or is the government still to blame because of not further regulating and auditing dental clinics? or is the government to blame because of allowing the mere existence of private dental clinics? I guess that the government did not "set things up so that the rise of clinics to exploit the rules was legal and inevitable". I am going to guess that individuals, knowing that that was not the intention of the government aid, decided they could get around it to profit. edit: typos

WalterBright 6y ago
In my experience, people who are paying the bill tend to ask more questions and be more skeptical the higher the price is.
- ggrrhh_ta 6y ago
  The government is asking those questions, that is the "work" the clinics do when they say they "would do the work" to be able to bill the government for such procedures.
- bluGill 6y ago
  The price of dental work is not very high. A few thousand dollars would cause you or me to ask questions, but the government deals with billions, so that little bit gets lost in the noise. It can make a lot of many for those in the scam without being easy to notice.
- smichel17 6y ago
  Yes, but this skepticism is problematic when it comes to healthcare. Particularly when it comes to high-deductible plans -- people are too skeptical, and will avoid seeking the care they need. Even when the cost of that early care is less than what they would otherwise be playing in premiums. edit: retracted: (sometimes leading to more expensive measures needed down the road) — see replies
  - coredog64 6y ago
    The Oregon Medicaid expansion didn’t reach this conclusion. On balance people were happier because of lower stress, and people with diabetes were better served, but there wasn’t a huge macro effect of cost reduction via early intervention. We already know the thing about diabetes, to the point that even private insurance companies will throw money at compliance because it’s cheaper than care. Outside that, vaccinations, and maybe a few more specific cases, the conventional wisdom of early intervention saves money is false. https://en.m.wikipedia.org/wiki/Oregon_Medicaid_health_experiment https://en.m.wikipedia.org/wiki/Oregon_Medicaid_health_exper...
    - smichel17 6y ago
      Thanks for the link, I edited my comment
    - ineedasername 6y ago
      patients also had a "higher self-reported mental and physical health" I think that's a heck of an important thing to mention here. Costs didn't change much, but health was improved.
  - ineedasername 6y ago
    I wouldn't be so quick to retract: According to that wikipedia link, while costs may not have changed much, mental & physical health were improved. Essentially, the cost per-unit of overall patient wellbeing was decreased because costs remained the same while patient care increased.
sreque 6y ago
I think we can safely blame both owners and employees of the clinics and the people in government who devised and implemented the program. We can blame the owners of the clinics because we have a right to expect people to to make morally correct decisions. We will never invent the perfect system of laws to incentivize everyone's good behavior. At the end of the day, society only functions when the majority of people are at least somewhat selflessly contributing to it. We can blame those who devised and implement the program because we can expect them to do more auditing as well and ensuring the program isn't gamed. People in government are responsible for spending taxpayer money wisely.
- mattcwilson 6y ago
  The trouble is that blame doesn’t address the problem either. We want the government to make wiser, less gameable policy. We want businesses to act ethically. How do we acheive those? It’s not blame. I think the answer is incentives. The government had the incentive to “help the poor” - so they did. The clinics had the incentive to “fix teeth for people in need” - so they did. Just like in software development, so much rests on properly defining the desired outcome.
  - robertlagrant 6y ago
    The problem is also that in the game of "helping people afford all their needs", governments will rarely construct solutions that involve less government. Which might well be the right answer.
    - Normal_gaussian 6y ago
      Can you exemplify this?
      - throwaway0a5e 6y ago
        Deregulation of airlines led to the modern era of cheap air travel.
topkai22 6y ago
Dentists and doctors are not all of one mind about treatment effectiveness or necessity, so the tails of the bell curve matter. There may very well be some small percentage of dentists who believe that procedure X is beneficial in almost all cases. They might be quacks, but most quacks I've met believe what they are selling (even if they are wrong.) If there also is a government program that reimburses for X in almost all cases, then you could see the emergence of clinics that "exploit" the rule even if everyone involved believes they are behaving ethically. There are feedback loops that then exacerbate the problem- for example a successful clinic might bring on additional dentists, who despite misgivings will be influenced by existing practice at the clinic and begin self justifying the procedures to conform to the senior partner. After all, they clearly know what they are doing, right? While I have no idea if that's what happened here, it is well with in the realm of possibility. The government does bear some responsibility to ensure that thier programs and rules provide sufficient oversight and feedback to keep fringey participants within the bounds of what the government considers acceptable.
- ggrrhh_ta 6y ago
  I understand your arguments, which in my view, "shift the blame", and in your view, "charge with at least some responsibility" to the government. The problem I see is that this sort of arguments, if accepted as OK/inevitable and universalized lead to a dilution of responsibility that would make no one fully accountable for any intentional wrongdoing: for example, if you pay for your car to be repaired at your regular car repair shop, but the mechanic knowingly used parts that were not certified or due to time pressure skipped standard checks, and you let someone drive your car a year later, and there is an accident that was caused as a consequence of that sloppy repair-work, do you share responsibility for your oversight? - You might argue you do; well, I would argue you don't.
  - unpolloloco 6y ago
    The moral blame rests fully on the clinic, but the responsibility to fix the system rests fully on the government (in this case). It's really no different than a production line with a quality problem. You can yell and scream about the morality of the workers all you want, but you can't expect them to improve if you don't fix the system and incentives that cause the problems.
mrfredward 6y ago
If you have a plan that relies on everyone in a nation of 300 million behaving ethically and honestly when there is a big incentive not to, you have a bad plan. The moral failing is on the clinics, sure, but if you want to fix the problem, you have to look at the government.
- ggrrhh_ta 6y ago
  I think you are implying the following when you say "you have to look at the government": "if you want to fix the problem of people/clinics/etc. abusing (dodging/fraudulently take advantage of) government programs/policies you have to ..." ----- And the "..." is not filled in. I guess I could fill it in with: "stop implementing policies/programs if you are not at the same time investing as much as it is necessary to guarantee nobody gets around the law" - that is, do not trust, add more inefficiency (clinics already need to attest the procedure is necessary) and cost.
- jmcqk6 6y ago
  Isn't the answer to this better accountability? Incentives without accountability usually lead to this type of outcome.
  - kaiju0 6y ago
    Define accountability. Now you have a cost benefit ratio. If there is personal liability who can be blamed so you get the benefit and they get the detriment.
    - jmcqk6 6y ago
      In this specific case, it would be an independent audit of the procedures to determine whether they were actually necessary or not. it's not rocket science. Poor people don't have the money required to go to the dentist and properly take care of your teeth. Since having a healthy populace is a good thing, we say "okay, we're all going to pitch in so everyone can be as healthy as possible." If people start to take advantage of that for personal gain (which we know there are always people who are going to do that), we need to have a plan in place for dealing with those assholes. The presence of assholes in society shouldn't mean we don't even try to take care of each other. It should mean that we have plans for recognizing when someone is an asshole and taking measures to change that behavior.
mrmonkeyman 6y ago
The dynamics are what they are. Morality is not a meaningful factor in the long term. You only need one drop of poison to spoil a well and all that. It is the government's job to deal with this dynamic, yes. It is up to the other actors to exploit it in whatever way they see fit. Again, morality is useful nor relevant. It's like pulling in morals in a game of chess.

WalterBright 6y ago

In my experience, people who are paying the bill tend to ask more questions and be more skeptical the higher the price is.

ggrrhh_ta 6y ago
The government is asking those questions, that is the "work" the clinics do when they say they "would do the work" to be able to bill the government for such procedures.
bluGill 6y ago
The price of dental work is not very high. A few thousand dollars would cause you or me to ask questions, but the government deals with billions, so that little bit gets lost in the noise. It can make a lot of many for those in the scam without being easy to notice.
smichel17 6y ago
Yes, but this skepticism is problematic when it comes to healthcare. Particularly when it comes to high-deductible plans -- people are too skeptical, and will avoid seeking the care they need. Even when the cost of that early care is less than what they would otherwise be playing in premiums. edit: retracted: (sometimes leading to more expensive measures needed down the road) — see replies
- coredog64 6y ago
  The Oregon Medicaid expansion didn’t reach this conclusion. On balance people were happier because of lower stress, and people with diabetes were better served, but there wasn’t a huge macro effect of cost reduction via early intervention. We already know the thing about diabetes, to the point that even private insurance companies will throw money at compliance because it’s cheaper than care. Outside that, vaccinations, and maybe a few more specific cases, the conventional wisdom of early intervention saves money is false. https://en.m.wikipedia.org/wiki/Oregon_Medicaid_health_experiment https://en.m.wikipedia.org/wiki/Oregon_Medicaid_health_exper...
  - smichel17 6y ago
    Thanks for the link, I edited my comment
  - ineedasername 6y ago
    patients also had a "higher self-reported mental and physical health" I think that's a heck of an important thing to mention here. Costs didn't change much, but health was improved.
- ineedasername 6y ago
  I wouldn't be so quick to retract: According to that wikipedia link, while costs may not have changed much, mental & physical health were improved. Essentially, the cost per-unit of overall patient wellbeing was decreased because costs remained the same while patient care increased.

sreque 6y ago

I think we can safely blame both owners and employees of the clinics and the people in government who devised and implemented the program. We can blame the owners of the clinics because we have a right to expect people to to make morally correct decisions. We will never invent the perfect system of laws to incentivize everyone's good behavior. At the end of the day, society only functions when the majority of people are at least somewhat selflessly contributing to it. We can blame those who devised and implement the program because we can expect them to do more auditing as well and ensuring the program isn't gamed. People in government are responsible for spending taxpayer money wisely.

mattcwilson 6y ago
The trouble is that blame doesn’t address the problem either. We want the government to make wiser, less gameable policy. We want businesses to act ethically. How do we acheive those? It’s not blame. I think the answer is incentives. The government had the incentive to “help the poor” - so they did. The clinics had the incentive to “fix teeth for people in need” - so they did. Just like in software development, so much rests on properly defining the desired outcome.
- robertlagrant 6y ago
  The problem is also that in the game of "helping people afford all their needs", governments will rarely construct solutions that involve less government. Which might well be the right answer.
  - Normal_gaussian 6y ago
    Can you exemplify this?
    - throwaway0a5e 6y ago
      Deregulation of airlines led to the modern era of cheap air travel.

topkai22 6y ago

Dentists and doctors are not all of one mind about treatment effectiveness or necessity, so the tails of the bell curve matter. There may very well be some small percentage of dentists who believe that procedure X is beneficial in almost all cases. They might be quacks, but most quacks I've met believe what they are selling (even if they are wrong.) If there also is a government program that reimburses for X in almost all cases, then you could see the emergence of clinics that "exploit" the rule even if everyone involved believes they are behaving ethically. There are feedback loops that then exacerbate the problem- for example a successful clinic might bring on additional dentists, who despite misgivings will be influenced by existing practice at the clinic and begin self justifying the procedures to conform to the senior partner. After all, they clearly know what they are doing, right? While I have no idea if that's what happened here, it is well with in the realm of possibility. The government does bear some responsibility to ensure that thier programs and rules provide sufficient oversight and feedback to keep fringey participants within the bounds of what the government considers acceptable.

ggrrhh_ta 6y ago
I understand your arguments, which in my view, "shift the blame", and in your view, "charge with at least some responsibility" to the government. The problem I see is that this sort of arguments, if accepted as OK/inevitable and universalized lead to a dilution of responsibility that would make no one fully accountable for any intentional wrongdoing: for example, if you pay for your car to be repaired at your regular car repair shop, but the mechanic knowingly used parts that were not certified or due to time pressure skipped standard checks, and you let someone drive your car a year later, and there is an accident that was caused as a consequence of that sloppy repair-work, do you share responsibility for your oversight? - You might argue you do; well, I would argue you don't.
- unpolloloco 6y ago
  The moral blame rests fully on the clinic, but the responsibility to fix the system rests fully on the government (in this case). It's really no different than a production line with a quality problem. You can yell and scream about the morality of the workers all you want, but you can't expect them to improve if you don't fix the system and incentives that cause the problems.

mrfredward 6y ago

If you have a plan that relies on everyone in a nation of 300 million behaving ethically and honestly when there is a big incentive not to, you have a bad plan. The moral failing is on the clinics, sure, but if you want to fix the problem, you have to look at the government.

ggrrhh_ta 6y ago
I think you are implying the following when you say "you have to look at the government": "if you want to fix the problem of people/clinics/etc. abusing (dodging/fraudulently take advantage of) government programs/policies you have to ..." ----- And the "..." is not filled in. I guess I could fill it in with: "stop implementing policies/programs if you are not at the same time investing as much as it is necessary to guarantee nobody gets around the law" - that is, do not trust, add more inefficiency (clinics already need to attest the procedure is necessary) and cost.
jmcqk6 6y ago
Isn't the answer to this better accountability? Incentives without accountability usually lead to this type of outcome.
- kaiju0 6y ago
  Define accountability. Now you have a cost benefit ratio. If there is personal liability who can be blamed so you get the benefit and they get the detriment.
  - jmcqk6 6y ago
    In this specific case, it would be an independent audit of the procedures to determine whether they were actually necessary or not. it's not rocket science. Poor people don't have the money required to go to the dentist and properly take care of your teeth. Since having a healthy populace is a good thing, we say "okay, we're all going to pitch in so everyone can be as healthy as possible." If people start to take advantage of that for personal gain (which we know there are always people who are going to do that), we need to have a plan in place for dealing with those assholes. The presence of assholes in society shouldn't mean we don't even try to take care of each other. It should mean that we have plans for recognizing when someone is an asshole and taking measures to change that behavior.

mrmonkeyman 6y ago

The dynamics are what they are. Morality is not a meaningful factor in the long term. You only need one drop of poison to spoil a well and all that. It is the government's job to deal with this dynamic, yes. It is up to the other actors to exploit it in whatever way they see fit. Again, morality is useful nor relevant. It's like pulling in morals in a game of chess.