11 ms·

The messaging in the US most commonly used to justify the lack of universal coverage and unreasonable cost of care is that we pay the most because we get the be

The messaging in the US most commonly used to justify the lack of universal coverage and unreasonable cost of care is that we pay the most because we get the best treatments and best doctors and best outcomes, so I don’t think it’s fair to blame laymen for believing that. Also, it’s not just patients that think this way. (Or, at least, if the clinicians know, they aren’t saying much to their patients.) I’ve had docs gush about amazing wonder drugs, then I go and read the actual Phase 3 trial data on the patient information sheet and it has a 15% response (not remission) rate. I’ve been told I’m being given a “gold standard” treatment—but not that the “gold standard” response rate is actually only about 33%, and in another ~33% of cases it makes things worse. I’ve had doctors refer me for surgery, tell me about how amazing the surgeon is, what a great job they’ll do, that if their own kids were sick they’d send them to this person. When I ask for hard data on the surgeon’s actual success rate for this type of surgery, well, they don’t track that—but look, just trust me, the guy’s realllyyy good. Out of dozens of specialists I’ve seen over the years, I’ve only had one ever explicitly acknowledge that, yes, I had a real problem, but modern medicine just was not advanced enough yet to identify the cause, so they’re just kind of winging it. For the rest, there are “many new options”, “great responses”, “positive outcomes”, “extremely effective”—or there’s nothing wrong with you, it’s all in your head, and the princess is in another castle.

rscho 5y ago
> When I ask for hard data on the surgeon’s actual success rate for this type of surgery, well, they don’t track that—but look, just trust me, the guy’s realllyyy good. For good reason. Tracking of clinical outcomes is the wet dream of insurance companies. It's very toxic to the healthcare system, because it pushes practitioners to focus on easy cases where a good outcome is expected and causes major inequalities in access to healthcare. I'm not saying the present situation is ideal, but for the system as a whole in its current form, tracking clinical outcomes is a very bad idea.
- csnover 5y ago
  I could see that problem occurring if the metric was “what is the success rate of everything that Surgeon X does”. I can’t see that problem occurring for “Surgeon X performing Procedure Y has N% of patients reporting relief and M% of patients reporting complications after the surgery”. What am I missing here? Edit: Follow-up question: notwithstanding the dysfunction of congress and the ability of companies to find loopholes, and assuming no universal health care to eliminate the role of insurers, surely a solution would be to prohibit the use of this information in the same way that ACA prohibits the use of pre-existing conditions to deny coverage?
  - aerostable_slug 5y ago
    Surgeons would steer away from difficult, lower-percentage-outcome procedures which is precisely what you don't want. You want risk-takers who repeatedly tackle the surgeries and (ideally) get a more positive outcome percentage than a newbie.
    - riku_iki 5y ago
      Meaning they will not take over my risky surgery, and I will still be choosing among risk takers, but with clear stats in my hands.
  - rscho 5y ago
    Surgeons will concentrate on easy procedures and will basically all have an almost identical track record of quasi perfection. So there will be nobody left to perform procedure Y, where Y has an intrinsically high rate of failure. Same thing for difficult patients. No one will touch Mr X who's got a complex problem.
  - lcuff 5y ago
    In my mind it gets worse when the procedure is identified: A difficult shoulder surgery by an orthopedic surgeon gets refused because it might be result in a mediocre outcome and lower his 'success' rate. The patient can't get the surgery because no surgeon wants to 'risk' his success rate numbers.
    - grog454 5y ago
      Seems like a good system to me. If a doctor expects a lower than average success rate for performing some specific operation, he should let some other doctor do it anyway.
      - rscho 5y ago
        Other doctors? And where will you find those? No one will ever touch you, except if you pay more. Pay more for worse outcomes, really.
- commandar 5y ago
  To some degree, there's an even more toxic element of this already in play with the amount of weight the wider US medical system puts behind patient satisfaction surveys. Many times, things that a patient wants and would make a patient happy are medically contraindicated and lead to worse outcomes, yet there's immense pressure on clinicians to maintain patient satisfaction metrics. I'm not disagreeing with you at all; more suggesting that we're currently relying on metrics that are even more perilous than actual clinical outcomes.
  - Fomite 5y ago
    This is even true when we're not talking about patient satisfaction. There's definitely conflicts for things like infection control, where what we should probably should be measuring (process measures) conflict with what patient advocacy groups care about and are pushing for (deaths).
  - henrikschroder 5y ago
    In patient satisfaction surveys, treatments like invasive surgery usually ranks very low, while treatments like massage rank very highly. One probably saved your life, the other just felt nice, and yet the second one is rated higher. It's complete insanity to even being comparing treatments that are so different.
    - lazide 5y ago
      Also getting antibiotics for something gets rated pretty high, even if it did worse than nothing.
- wins32767 5y ago
  Risk adjusted scoring is entirely viable in this age of data science, there is just no appetite for it. Doctors fight very hard against it because who actually wants to be held accountable for outcomes? Insurance companies really aren't the villains in the US healthcare system, they're going to make money no matter what because they pass cost increases on to their subscribers and are capped in how much profit they can make via regulation.
  - rscho 5y ago
    Risk adjusted scoring is currently absolutely not viable. You underestimate the messiness of the healthcare system by a huge margin. We don't even manage to record basic vital signs consistently, so believe me when I tell you that you can forget about any kind of nice statistical trick given the weakness of our data gathering processes. Plus it's not a matter of objectivity. Surgeons will subjectively assess that doing easy cases will be better. And in addition, they'll be correct. That's what really matters.
    - wins32767 5y ago
      I literally was at a startup that could do this successfully, so I'm not underestimating the messiness.
      - rscho 5y ago
        I doubt we're speaking of the same thing, here.
  - AussieWog93 5y ago
    >Risk adjusted scoring is entirely viable in this age of data science It's just not unviable, I don't think it's even possible. As soon as a metric becomes tracked, people are incentivized to game it. From my own experience as a very high-volume eBay seller, mandating a certain return rate led us to simply discourage customers from using the (convenient, well-designed) integrated returns systems. Mandating that only a tiny fraction of a percentage of items can be cancelled due to being out of stock leads to sellers sending either the wrong item or a fake tracking number (this gets us all the time on AliExpress). If data-driven software companies can't handle it for something as simple as eCommerce, I have no idea how the medical industry is supposed to get it right.
- asmithmd1 5y ago
  There are some things that are helpful that they will answer that have steered me away from a surgeon: How many of these surgeries do you do per year? An answer of 50 or above is good. What is YOUR rate of <specific complication mentioned in the consent>? Keep pushing until they tell you their rate, not the overall rate.
  - rscho 5y ago
    They almost universally don't know their own rate. I don't know my own rates of complications. But, if I want you to go away because you seem to be the kind of guy that will come back to bite me, I'll gladly tell you I have a huge rate of complication.
    - asmithmd1 5y ago
      For a colonoscopy I asked about the risk of a perforated bowel. Their first response was, “that is meaningless, if it happens to you the rate is 100%.” I said if the chances are 50:50, then I am not doing it. They said it has happened twice in their career and based on my lack of risk factors, it would not happen to me. For my daughters tonsillectomy, the doctor was very happy to share how her stats for post surgery bleeding compared to both other doctors in her group, and the national average. But I live in a Boston suburb and every doctor is a lecturer at either Harvard or Mass General. Another question to ask is will an intern take part in the surgery. At teaching hospitals the answer is almost always yes. You can ask if they operate at any other hospitals, and again the answer is almost always yes, they operate at a suburban, non-teaching hospital where they will be the only one operating. I got a little bit humbled at Boston Childrens Hospital. I was doing some Googling about the risks of a CAT scan and asked if they did low-dose ones. They informed me that they in fact invented that procedure. Sure enough, the paper I was looking at was authored by a doctor on their staff.
      - rscho 5y ago
        I have 10+ years of clinical experience in academic hospitals, and have worked in Boston at Brigham and Women's. From this experience, I can tell you 2 things: 1. Being a lecturer at Harvard does not correlate with being a skillful clinician 2. Your view of the clinical system is very skewed, and will bring you more risks than benefits.
- ropable 5y ago
  On the other hand: tracking clinical outcomes actually tells us if a treatment actually works - a net positive for the species, I'd have thought.
  - tlb 5y ago
    Doing RCTs of a treatment tells you if it works. Without random assignment (or some clever experimental design) tracking outcomes really doesn't tell you anything.
- Schroedingersat 5y ago
  > For good reason. Tracking of clinical outcomes is the wet dream of insurance companies. Sounds like a sufficient reason for single payer healthcare and single payer malpractise compensation even if all the imagined downsides were real.
- pishpash 5y ago
  You can forbid insurance from using that data by policy. It sounds like the same argument against measuring teacher performance because "toxic".
- MichaelBurge 5y ago
  Have one person do nothing but estimate the difficulty of a case(and be tracked and judged for the quality of their estimates), and the surgeon be tracked and judged on the relative performance given the difficulty. Then you could make a career out of doing well on difficult cases, or out of doing better-than-average on easy cases, and either would be viable.
- refurb 5y ago
  It's also a bad idea because the best surgeons often take on the most difficult cases you can't necessarily compare doctor to doctor without knowing the types of patients they treat.
- billfruit 5y ago
  Wouldn't that be rectifiable by also tracking the statistics of cases which a practitioner reneges or refuses. Then somebody with high success rate and high refusal rate stands out as a red flag.
dd36 5y ago
Every doctor is the best.
- deleted 5y ago
  [deleted]
refurb 5y ago
But if the alternative to a 15% response rate is “no treatment” then you are getting the gold standard. In many other countries those medicines aren’t even considered or paid for.
- headsoup 5y ago
  Only if Gold Standard means "not quite as bad as the other options," which I'm not sure is a definition that'd stick.
  - refurb 5y ago
    But that's true in general. What's another way to describe the "best doctor in the country"? "Marginally better than the next best option".
    - headsoup 5y ago
      If it has a word like 'standard' in it, you would assume there is a measure or definition for that standard, not just 'not the worst.' Best doctor in the country can quite easily still be "bronze standard." There's an expectation of quality in saying something is Gold Standard, it's not an entirely arbitrary label.
      - refurb 5y ago
        Maybe it’s a lingo thing. “Standard of care” is used all the time and just means “standard” in the sense of “best supported by data”. But the standard of care might just be “give morphine to ease pain until death”.
sirspacey 5y ago
All of this points to one thing You are being sold Thanks for sharing, love the % success rate question for surgeons.
mnw21cam 5y ago
I also think that doctors tend to dumb-down and downplay the actual truth of the effectiveness of treatments. Partly because for the majority of patients, being told that a treatment is realllyyy good can actually make it more effective, by the placebo effect. It also makes the patient happier and more confident in the abilities of the doctor. I noticed that since I got "Dr." put in front of my name on my medical records, doctors tend to firstly ask what I'm a "Dr." in, and secondly tell it to me straight.
- stichers 5y ago
  I've noticed that too. I went to the ER with a dog bite and the triage nurse was keen to know if I was a medical doctor before she looked at it.

rscho 5y ago

> When I ask for hard data on the surgeon’s actual success rate for this type of surgery, well, they don’t track that—but look, just trust me, the guy’s realllyyy good. For good reason. Tracking of clinical outcomes is the wet dream of insurance companies. It's very toxic to the healthcare system, because it pushes practitioners to focus on easy cases where a good outcome is expected and causes major inequalities in access to healthcare. I'm not saying the present situation is ideal, but for the system as a whole in its current form, tracking clinical outcomes is a very bad idea.

csnover 5y ago
I could see that problem occurring if the metric was “what is the success rate of everything that Surgeon X does”. I can’t see that problem occurring for “Surgeon X performing Procedure Y has N% of patients reporting relief and M% of patients reporting complications after the surgery”. What am I missing here? Edit: Follow-up question: notwithstanding the dysfunction of congress and the ability of companies to find loopholes, and assuming no universal health care to eliminate the role of insurers, surely a solution would be to prohibit the use of this information in the same way that ACA prohibits the use of pre-existing conditions to deny coverage?
- aerostable_slug 5y ago
  Surgeons would steer away from difficult, lower-percentage-outcome procedures which is precisely what you don't want. You want risk-takers who repeatedly tackle the surgeries and (ideally) get a more positive outcome percentage than a newbie.
  - riku_iki 5y ago
    Meaning they will not take over my risky surgery, and I will still be choosing among risk takers, but with clear stats in my hands.
- rscho 5y ago
  Surgeons will concentrate on easy procedures and will basically all have an almost identical track record of quasi perfection. So there will be nobody left to perform procedure Y, where Y has an intrinsically high rate of failure. Same thing for difficult patients. No one will touch Mr X who's got a complex problem.
- lcuff 5y ago
  In my mind it gets worse when the procedure is identified: A difficult shoulder surgery by an orthopedic surgeon gets refused because it might be result in a mediocre outcome and lower his 'success' rate. The patient can't get the surgery because no surgeon wants to 'risk' his success rate numbers.
  - grog454 5y ago
    Seems like a good system to me. If a doctor expects a lower than average success rate for performing some specific operation, he should let some other doctor do it anyway.
    - rscho 5y ago
      Other doctors? And where will you find those? No one will ever touch you, except if you pay more. Pay more for worse outcomes, really.
commandar 5y ago
To some degree, there's an even more toxic element of this already in play with the amount of weight the wider US medical system puts behind patient satisfaction surveys. Many times, things that a patient wants and would make a patient happy are medically contraindicated and lead to worse outcomes, yet there's immense pressure on clinicians to maintain patient satisfaction metrics. I'm not disagreeing with you at all; more suggesting that we're currently relying on metrics that are even more perilous than actual clinical outcomes.
- Fomite 5y ago
  This is even true when we're not talking about patient satisfaction. There's definitely conflicts for things like infection control, where what we should probably should be measuring (process measures) conflict with what patient advocacy groups care about and are pushing for (deaths).
- henrikschroder 5y ago
  In patient satisfaction surveys, treatments like invasive surgery usually ranks very low, while treatments like massage rank very highly. One probably saved your life, the other just felt nice, and yet the second one is rated higher. It's complete insanity to even being comparing treatments that are so different.
  - lazide 5y ago
    Also getting antibiotics for something gets rated pretty high, even if it did worse than nothing.
wins32767 5y ago
Risk adjusted scoring is entirely viable in this age of data science, there is just no appetite for it. Doctors fight very hard against it because who actually wants to be held accountable for outcomes? Insurance companies really aren't the villains in the US healthcare system, they're going to make money no matter what because they pass cost increases on to their subscribers and are capped in how much profit they can make via regulation.
- rscho 5y ago
  Risk adjusted scoring is currently absolutely not viable. You underestimate the messiness of the healthcare system by a huge margin. We don't even manage to record basic vital signs consistently, so believe me when I tell you that you can forget about any kind of nice statistical trick given the weakness of our data gathering processes. Plus it's not a matter of objectivity. Surgeons will subjectively assess that doing easy cases will be better. And in addition, they'll be correct. That's what really matters.
  - wins32767 5y ago
    I literally was at a startup that could do this successfully, so I'm not underestimating the messiness.
    - rscho 5y ago
      I doubt we're speaking of the same thing, here.
- AussieWog93 5y ago
  >Risk adjusted scoring is entirely viable in this age of data science It's just not unviable, I don't think it's even possible. As soon as a metric becomes tracked, people are incentivized to game it. From my own experience as a very high-volume eBay seller, mandating a certain return rate led us to simply discourage customers from using the (convenient, well-designed) integrated returns systems. Mandating that only a tiny fraction of a percentage of items can be cancelled due to being out of stock leads to sellers sending either the wrong item or a fake tracking number (this gets us all the time on AliExpress). If data-driven software companies can't handle it for something as simple as eCommerce, I have no idea how the medical industry is supposed to get it right.
asmithmd1 5y ago
There are some things that are helpful that they will answer that have steered me away from a surgeon: How many of these surgeries do you do per year? An answer of 50 or above is good. What is YOUR rate of <specific complication mentioned in the consent>? Keep pushing until they tell you their rate, not the overall rate.
- rscho 5y ago
  They almost universally don't know their own rate. I don't know my own rates of complications. But, if I want you to go away because you seem to be the kind of guy that will come back to bite me, I'll gladly tell you I have a huge rate of complication.
  - asmithmd1 5y ago
    For a colonoscopy I asked about the risk of a perforated bowel. Their first response was, “that is meaningless, if it happens to you the rate is 100%.” I said if the chances are 50:50, then I am not doing it. They said it has happened twice in their career and based on my lack of risk factors, it would not happen to me. For my daughters tonsillectomy, the doctor was very happy to share how her stats for post surgery bleeding compared to both other doctors in her group, and the national average. But I live in a Boston suburb and every doctor is a lecturer at either Harvard or Mass General. Another question to ask is will an intern take part in the surgery. At teaching hospitals the answer is almost always yes. You can ask if they operate at any other hospitals, and again the answer is almost always yes, they operate at a suburban, non-teaching hospital where they will be the only one operating. I got a little bit humbled at Boston Childrens Hospital. I was doing some Googling about the risks of a CAT scan and asked if they did low-dose ones. They informed me that they in fact invented that procedure. Sure enough, the paper I was looking at was authored by a doctor on their staff.
    - rscho 5y ago
      I have 10+ years of clinical experience in academic hospitals, and have worked in Boston at Brigham and Women's. From this experience, I can tell you 2 things: 1. Being a lecturer at Harvard does not correlate with being a skillful clinician 2. Your view of the clinical system is very skewed, and will bring you more risks than benefits.
ropable 5y ago
On the other hand: tracking clinical outcomes actually tells us if a treatment actually works - a net positive for the species, I'd have thought.
- tlb 5y ago
  Doing RCTs of a treatment tells you if it works. Without random assignment (or some clever experimental design) tracking outcomes really doesn't tell you anything.
Schroedingersat 5y ago
> For good reason. Tracking of clinical outcomes is the wet dream of insurance companies. Sounds like a sufficient reason for single payer healthcare and single payer malpractise compensation even if all the imagined downsides were real.
pishpash 5y ago
You can forbid insurance from using that data by policy. It sounds like the same argument against measuring teacher performance because "toxic".
MichaelBurge 5y ago
Have one person do nothing but estimate the difficulty of a case(and be tracked and judged for the quality of their estimates), and the surgeon be tracked and judged on the relative performance given the difficulty. Then you could make a career out of doing well on difficult cases, or out of doing better-than-average on easy cases, and either would be viable.
refurb 5y ago
It's also a bad idea because the best surgeons often take on the most difficult cases you can't necessarily compare doctor to doctor without knowing the types of patients they treat.
billfruit 5y ago
Wouldn't that be rectifiable by also tracking the statistics of cases which a practitioner reneges or refuses. Then somebody with high success rate and high refusal rate stands out as a red flag.

dd36 5y ago

Every doctor is the best.

deleted 5y ago
[deleted]

refurb 5y ago

But if the alternative to a 15% response rate is “no treatment” then you are getting the gold standard. In many other countries those medicines aren’t even considered or paid for.

headsoup 5y ago
Only if Gold Standard means "not quite as bad as the other options," which I'm not sure is a definition that'd stick.
- refurb 5y ago
  But that's true in general. What's another way to describe the "best doctor in the country"? "Marginally better than the next best option".
  - headsoup 5y ago
    If it has a word like 'standard' in it, you would assume there is a measure or definition for that standard, not just 'not the worst.' Best doctor in the country can quite easily still be "bronze standard." There's an expectation of quality in saying something is Gold Standard, it's not an entirely arbitrary label.
    - refurb 5y ago
      Maybe it’s a lingo thing. “Standard of care” is used all the time and just means “standard” in the sense of “best supported by data”. But the standard of care might just be “give morphine to ease pain until death”.

sirspacey 5y ago

All of this points to one thing You are being sold Thanks for sharing, love the % success rate question for surgeons.

mnw21cam 5y ago

I also think that doctors tend to dumb-down and downplay the actual truth of the effectiveness of treatments. Partly because for the majority of patients, being told that a treatment is realllyyy good can actually make it more effective, by the placebo effect. It also makes the patient happier and more confident in the abilities of the doctor. I noticed that since I got "Dr." put in front of my name on my medical records, doctors tend to firstly ask what I'm a "Dr." in, and secondly tell it to me straight.

stichers 5y ago
I've noticed that too. I went to the ER with a dog bite and the triage nurse was keen to know if I was a medical doctor before she looked at it.