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Insurance companies. Everything is controlled by insurance companies. You can’t do anything unless it’s exactly how insurance wants and only for what insurance

Insurance companies. Everything is controlled by insurance companies. You can’t do anything unless it’s exactly how insurance wants and only for what insurance will pay. It limits everything, including how every profession can be compensated simply because you can’t easily hire somebody for more than what insurance will pay for their services. You can, but the funds have to come from somewhere.

belval 5y ago
I doubt that it's as simple as that. Nurses are also leaving in Canada and we don't have insurance breathing down their neck.
- reedjosh 5y ago
  But they have zero autonomy there too I assume?
  - belval 5y ago
    Sample size of 1, but my gf blames forced overtime. Being legally obliged to stay for an 8 hours shift after finishing one has a way to drive you to depression.
    - px43 5y ago
      I would pay more to go to a hospital where I know people are actually well rested. My last few hospital stays have been saturated with clearly agitated staff (doctors, nurses, reception) who were putting in minimal effort, and clearly didn't want to be there, and I can't blame them given the conditions that they're being forced to work under. This is in the US, and I can't figure out why the Department of Labor hasn't cracked down on the medical industry yet. It's really horrific, especially because these are the people we're supposed to be relying on to keep us healthy and safe. How hard is it to enforce 8 hour days 5 days a week? Every other industry has figured it out.
      - belval 5y ago
        To be fair, most industries don't have evening and night shifts and a supply mismatch, most nurses want to work the day shift, it's harder to find candidates for evening and night.
    - rootusrootus 5y ago
      At least at my local hospital, it's not just overtime -- regular shifts are 12 hours even when everything is normal. That's nuts.
      - belval 5y ago
        That's a little bit different and not as detrimental though. It's actually an incentive for nurses because they get to work fewer days. Instead of doing 10 8 hours shift every two weeks they'll do 6 12 hours and basically get 8 days off every 2 weeks, which is pretty interesting from a free time perspective. My gf did both and while she was tired after 12 hours, overall I think she preferred it.
- icelancer 5y ago
  Insurance / government repayment is mostly the same thing. A layer of bureaucracy.
- alexashka 5y ago
  Are they? Leaving to do what, exactly? For every story of 'X leaves to do Y', there are a thousand people claiming they'll leave, that never do.
  - belval 5y ago
    Some just leave to stay-at-home, some go back to school and a lot will take early retirement.
  - klyrs 5y ago
    Instead, you're left with the diminished quality of care from people who desperately want to leave but they're only there because they can't afford to.
- tubalcain 5y ago
  Canada's solution will be to mass-import nurses from the third world who will do twice as much work for half as much money. Mark my words. It's already happened with low-wage fast food jobs. Health care is next. Nurses and doctors will be replaced by poorly-trained third-world counterparts.
  - belval 5y ago
    > Canada's solution will be to mass-import nurses from the third world Yes that's basically what Quebec (and probably other provinces) is doing. > Do twice as much work for half as much money I might get tomatoes thrown at me for this, but anecdotally "third-world" nurses are usually not as good due to having experience on different equipment, drugs and often languages. It's better than having no one to cover the shift, but it can be seriously dangerous due to lack of training on specific protocols. They get paid the exact same amount of money and are in the same union, so they absolutely don't do "twice as much work for half as much money".
    - tubalcain 5y ago
      I agree with your assessment regarding foreign trained nurses. I think it also applies to doctors as well. Regarding the pay structure for nurses, over time the unions will be filled with mostly third-world ones, so I predict their bargaining position will be weakened and they will accept worse conditions.
onlyrealcuzzo 5y ago
Have US hospitals ever had transparent pricing? This seems like the root of the problem, and insurance seems like what "fixes" that but causes tons of downstream unwanted side-effects.
- teeray 5y ago
  It’s always astonishing how I can get a fully itemized vet bill right after a visit and pay for it. Meanwhile going to the hospital is like “well gee, let’s submit to insurance, see what they’ll pay, we’ll readjust prices and then come back to you in a few months.”
  - lostcolony 5y ago
    More than that, I can get an estimate upfront, that in 100% of cases matches the bill unless they find something additional they need to do, which they'll inform me of and create a new total estimate for. Of note, my vet insurance doesn't negotiate on my behalf; they just pay X% afterwards. The price the provider quotes for a given service is the price everyone gets (probably; some of the smaller vets might modify it if someone is low income and in need).
  - MiddleEndian 5y ago
    Months after my last real procedure in a hospital, even after the insurance was settled, I could not get them to tell me how much money I owed them. Even when I went in person and told them "I want to pay you all of the money right now" they just shrugged their shoulders and told me they didn't know how much I owed them. They just sent me a bunch of small bills in the mail one at a time and had a text field online where I could blindly pay them without indicating whether or not I had completed my payments.
    - brightball 5y ago
      Yep. Seems ripe for fraud too.
      - 5y ago
pc86 5y ago
Insurance is the only industry where they agree to pay for something (in this case, "medical care"), but then after service has been rendered can decide to pay less, or not pay at all, or stop paying that provider altogether, etc. This combined with hospitals being run by non-physicians*, and people thinking being able to Google and read WebMD qualifies them to argue with their doctor about treatment plans**, healthcare in the US is going to absolute shit***. * I strongly believe that only physicians should be running hospitals. Certainly not administrators whose only education is an MHA and only experience is working for for-profit health companies. Medical decisions need to be made outside of cost considerations. The only factors should be medical science, quality of life, and patient wishes (in that order). ** In stark contrast to asking questions and trying to understand. But I have family members who are the "look everything up and then try to tell my doctor how they're going to treat me" ilk and it's crazy. *** I don't think the above points are unique to US healthcare other than cost considerations, but that's all I have experience with.*
- deleted 5y ago
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- wolf550e 5y ago
  re: "Medical decisions need to be made outside of cost considerations." In the end, labor hours of professionals are finite. Even if you don't need to pay doctors, you only have so many, they can only work so many hours, you will need to prioritize who to help in what way, which procedures to do. Same with all the other personnel, the consumable stuff, the devices/scanners/equipment, etc. So someone is going to have to prioritize. It can be just "how much quality of life can we save using the resources we have", regardless of the patient's ability to pay/insurance/citizenship, but some prioritization will need to happen. The policy of the death panels can be changed, but their existence is inevitable.
  - deleted 5y ago
    [deleted]
  - slantedview 5y ago
    > labor hours of professionals are finite. This is why it makes no sense to have doctors and nurses waste time battling insurance companies over treatments, and hospitals over staffing. Their time is indeed too valuable.
mfer 5y ago
In the book The innovator's prescription: a disruptive solution for health care by Clayton Christenson, there are some good analysis of where the complexity and problems come from in the current US medical system. A lot of it has to do with size and the complexity that goes along with it. So, as hospitals get bigger, do more, and increase in size and complexity these issues become worse. The economics math even mirrors factories... a factory that can build 100 things compared to one that just produces one thing. The book was enlightening, even though many of the time frames called out in the book were wrong. Disrupting medicine is a lot harder than something like technology.
- mikkergp 5y ago
  I think this alludes to it, but it's one thing mentioned in one of Atul Gawande's book is that in India they have hospitals that focus on one thing: https://www.businessinsider.com/inside-indias-no-frills-hospitals-where-heart-surgery-costs-just-800-2013-4 https://www.businessinsider.com/inside-indias-no-frills-hosp... So like a 2000 bed hospital just for heart surgeries. Like you're saying, the more a heart surgeon specializes, the better they are at it and the cheaper they can do it. Better Outcomes for less money.
  - 2143 5y ago
    Yes there are hospitals in India that cater to a specific aliment. For instance, eye hospitals, cancer centres, hospitals that cater to pregnancy, childbirth and neonatology etc. > Like you're saying, the more a heart surgeon specializes, the better they are at it and the cheaper they can do it. Better Outcomes for less money. Not necessarily. 1. A heart surgeon is going to be doing heart surgery at more or less the same frequency regardless of whether the hospital they're at handles only heart patients or not. Wouldn't they? 2. I doubt if anybody here considers them cheap. Yes it's probably cheaper than in the US, but still it's rather expensive. But then again, since life is priceless, ...
    - mikkergp 5y ago
      At a 2000 bed facility though, you could specialize in specific types of heart surgeries. At a general hospital you're probably more likely to take on a wider variety of heart procedures. It's not just experience, but experience in specific procedures that can dictate outcomes: https://www.reuters.com/article/us-healthcare-quality-surgery/study-suggests-surgeons-do-get-better-with-experience-idUSKBN0MT1P920150402 https://www.reuters.com/article/us-healthcare-quality-surger... Maybe cheap is the wrong term, but less expensive? I mean $800 may be expensive but certainly it's better than more?
brimble 5y ago
Consolidation's a big part of it. The last decade has seen nearly all the small practices and offices in my city gobbled up by a couple of huge companies. With that comes the MBAs and the bureaucracy.
- Workaccount2 5y ago
  The healthcare in my area is like watching feudal lords rapidly claiming their territory. With central fortresses (hospitals) and outposts (smaller treatment centers).
cwbrandsma 5y ago
The hospitals themselves are also to blame. There are a couple court cases where the hospital threw the nurse under the bus to cover up for their own issues (short staffing, bad safety procedures, covering up for a doctor, etc), and nurses are justifiably pissed off right now. There was a time when hospitals could have helped the nurses with the stress and workload, but the admins bungled it at every possible turn, and now it seems they missed their window.
polskibus 5y ago
It’s like that in many countries, also in EU. Average age of a nurse is rising, richer countries rescue themselves by importing workforce, because they can’t find workers for the rates they have budgeted at home. It’s is like that in other professions too if it’s only the tech that gets compensated well. There is a shortage of skilled labour.
- soco 5y ago
  Errata: there's a shortage of skilled labour for these working conditions. Said budgeting is not set in stone, and as long nurses and whatever else professions can vote with their feet (by leaving the profession) no amount of politics-led finger-pointing can replace a real-world change in the healthcare policies.
caycep 5y ago
Granted, there's a niche for cash pay docs. Example being psychiatry - it's extremely hard to find a psychiatrist who takes insurance, even Medicare. The good ones are all cash pay...
slantedview 5y ago
Insurance companies are awful and should not exist, sucking up a lot of doctor time, but when it comes to nursing, hospitals are particularly awful, cutting staffing levels to the bone in order to maximize profit. People die as a result, and nurses are burnt out.
ajross 5y ago
> Everything is controlled by insurance companies. You can’t do anything unless it’s exactly how insurance wants and only for what insurance will pay. Framed that way, this sounds terrible. But... the truth is actual health care outcomes for insured patients in the USA are extremely good. This holds in comparison to other nations, when corrected for GDP and patient income, etc... "Insurance companies" are, at least in the narrow sense, doing what we pay them to do really well. They may or may not be making things easier for nurses, which is a different metric. But nurses aren't their customers, we are. And we're getting a fairly good[1] product. [1] Albeit extremely expensive relative to other nations.
legitster 5y ago
I've worked with both, and by far hospitals are much, much worse actors. Hospitals are legally enforced local monopolies (look up Certificates of Need). Meanwhile, you might have a dozen choices of insurance companies, but they all suck because they have to take what the hospital billing departments give them and take the blame or risk being dumped by the hospital.
lettergram 5y ago
No one wants to hear the truth. There’s near-infinite demand for healthcare and a constrained (mostly artificially) supply. Insurance, people and government can’t solve the problem of the supply and demand by throwing money on it. You either expand supply or remove demand. Given removing demand is... not desirable. The only alternative to fix the issue is remove regulation and expand supply. That’s it. Insurance makes the issue worse by increasing demand and in a way limiting supply through requirements and procedures. Government limits supply through regulation AND expands demand by paying for procedures. An approach is to deregulate, such as removing government licensing, remove Medicare, etc. Imo Prices would drop >95% within a 2-5 years (to India or Mexico levels). I worked in medical billing for a few years and the issues are beyond obvious.
- lefstathiou 5y ago
  I think there needs to be some new approach to how medical services are being paid for. My 70yo father fell off a ladder and drove himself to the hospital in Calhoun Georgia (2 hours north of Atlanta, a small town) with a bruised eye and a broken wrist. He got in late afternoon, left the next day, and the bill to insurance (which of course they won't pay) was $69,000... more than per capita income in the US. The system is ridiculous. In my opinion, healthcare has reached the state where the people who receive the benefit are too far removed from the people who pay for it and given there is no "victim" of price gauging, the prices will just keep going up up and way. I defer to those wiser than me for the solution. I don't like complaining without being constructive so here is my ignorant pass at it. This will require a few key steps: 1) Yes, we need more supply (by deregulating the profession) 2) I personally think a more effective solution would be to gradually eliminate insurance except for catastrophic risk (like emergency medical care from a car accident). #2 will shift responsibility to the individual and the system will be capped at what they can charge based on the average person's ability to pay for it (which is how it works in many parts of the world).
  - lettergram 5y ago
    > left the next day, and the bill to insurance (which of course they won't pay) was $69,000 I agree with you and the quote above is because of insurance. Medicare will pay 10% of that total and your father would be charged 2-5%. If he has private insurance you’ll see something different, maybe 15% and your father would be charged 3-6%. If he’s going out of network could be 100%. Hospitals / practices charge insane bills because people pay just a small fraction typically. It really impacts those without insurance or private insurance the worst. It is insane. This is why I have suggested deregulation, particularly around licensing. It drives down the cost. Insurance may cover doctor X, but if nurse Y can do it for 5% the price... well use the nurse. All doctors would have to reduce prices and insurance would have to raise the coverage amount to compete. It’s what is done elsewhere in the world.
UncleOxidant 5y ago
This. I had a great doc until a few years back. Best doc I've ever had by a long ways. He'd spend a good amount of time with you, actually listen to your concerns and even bring up recent papers he'd seen on topics related to my health issues. A few years ago he decided to mostly get out of doctoring because he was tired of dealing with insurance companies. For a while he went to a retainer model ($2K/year up front, $250/visit) and cut the number of patients he was seeing down significantly. I can't say as I blame him.
- brightball 5y ago
  MDVIP does that model in the US too.
andrei_says_ 5y ago
Prioritizing profit corrupts the commitment to providing care. Healthcare can be either care or industry. Applying corporate values to a healthcare system leads to maximum wealth extraction from both providers and patients. In this context innovation focuses not on the care part but on the extraction. The care is secondary. How can anyone who cares be a proponent or coexist with a healthcare industry?
micromacrofoot 5y ago
I've heard the same thing from mental health counselors and therapists. In wealthier areas many will just stop accepting insurance entirely and make people pay out of pocket to avoid all the insurance paperwork and requirements (some insurers require specific diagnosis to continue paying for services). If an insurer decides to not pay you? good luck. Now you need to throw hours of unpaid labor at them to get money you're owed. Unsurprisingly, this means many normal people can't afford a therapist and they're getting harder to find.
bitsnbytes 5y ago
Insurance companies is a symptom of the REAL issue. Unfortunately the American public hasn't figured out what the real issue is yet. They reason why they haven't is mostly because the Democrat party , Republican party, entertainment industry , the Main Stream Media, tech industry, and the the Commission on Presidential Debates (CPD) has them occupied with the symptoms of the REAL issue in order to keep them chasing their tails. The REAL ISSUE why healthcare isn't getting fixed is because of Conflict of interest.The American public hasn't figured out that going to congress who is riddled with conflict of interest and who designed the existing system that we have in place and is benefiting from it, might not be the best idea to fix healthcare. In fact the best thing to fix healthcare (and the other 99 problems)is to STFU about it and focus ONLY On reducing conflict of interest in congress. Until we reduce conflict of interest in congress nothing will be fixed. The Democrat party ,republican party, CPD and MSM want you focused on everything but reducing conflict of interest in congress. In order to fix healthcare and any of the other issues we must FIRST try to minimize conflict of interest by implementing the following as a start: 1. Term limits 2. Closing or reducing revolving doors between private and public sector. 3. No private campaigning contributions. Use tech to overcome the need of money. 4. Reform lobbying by doing away with the money aspect of it and utilizing technology to get your voice heard. 5. Pay congress members more and better benefits, but in return demand complete transparency from financial information to limitations in investments , NCA , and make pay and benefits tied to the general overall approval of congress by the American tax payers. 6.etc Both party and the MSM solution to fix healthcare is the equivalent of going to the MOB and asking them to fix crime in your neighborhood which the MOB is benefiting from and is promoting. It just makes no sense to talk solutions with people riddled with conflict of interest. You want to fix healthcare stop talking about healthcare and get the individual republicans and individual democrats to put their political ideology on hold and join forces to demand that their party ONLY focuses on reducing conflict of interest in congress.
DaltonCoffee 5y ago
This inefficiency and it's resulting poor working conditions aren't unique to countries with health insurance and private healthcare tho, see Canada.
syedkarim 5y ago
Why doesn’t the American Medical Association start its own insurance company?
at_a_remove 5y ago
Previously, that wasn't entirely true. In the very early nineties, insurance companies lured doctors in with promises of referral if they would just accept certain terms. Originally, this was to the benefit of the doctor -- more referrals. But only originally: once lock-in occurred, the insurance companies began to set their own terms. They couldn't have accomplished this without some greed on the part of many doctors early on.
bakuninsbart 5y ago
It is definetely a (big) part of the reason, but if it was the only one, things wouldn't be in a similarly terrible situation in other countries. Take the UK as an example which has a single-payer system, and morale is overall really low, too, and nursing isn't an enticing career. (On a side-note, the BBC show "This is going to hurt" is quite good and on topic) Apart from administrators and insurers, I think a large problem is that the job has become substantially more difficult and technology intense, while support and pay hasn't kept pace. At the same time, liability is more serious these days, which I don't think is a bad thing, but certainly sucks for the workers who have to constantly justify themselves and can get crucified for mistakes.
- seabrookmx 5y ago
  +1 very similar story in Canada. It blows my mind that super long shifts are the norm for a job that's generally more exerting/stressful than your average 9-5. But it's a viscious cycle now because of the shortages of qualified staff. Here in BC we have a full on crisis where family doctors are retiring at an alarming rate and not being replaced.
rootusrootus 5y ago
> You can’t do anything unless it’s exactly how insurance wants and only for what insurance will pay. This is the part that makes the whole experience so sadly ridiculous. Nobody could ever tell patients what something might cost and let them make choices, it was (and is) "Sign here to acknowledge you'll ultimately be responsible for all charges, no matter what they turn out to be." But the insurance company doesn't operate like that, they say "Want to be part of our network? Guess what, you have to ask us for permission or we just won't pay you." We need to rip off the bandaid, as it were, and reboot the damn system. Pick one of any number of good examples from other modern industrialized nations that have functioning healthcare, and copy it. Yes, everything will be a zoo for a while. We'll survive, and maybe even come out the other side with a better system. And maybe some bankrupt insurance companies, let me find my handkerchief.
darkerside 5y ago
I don't hear it talked about enough, but I think the biggest problem with insurance is that their profits are pinned to how much they spend on medical costs. https://www.verywellhealth.com/health-insurance-companies-unreasonable-profits-1738941#:~:text=And%20so%20are%20profits.,costs%2C%20including%20profits%20and%20salaries https://www.verywellhealth.com/health-insurance-companies-un.... In theory, this sounds like a great way to make sure insurance companies aren't just taking unreasonable profits, and that they are spending money on medical care, not administration, keeping the business lean. In _practice_, what it means is that profits are constrained by medical costs, so the insurance companies are literally incentivized to pay _more_ for medical services. Originally, insurance companies were supposed to be an intelligent negotiator on behalf of their customers. After all, their experts should know much more than a layperson every will. But with the poisoned incentive to raise costs, customers are basically held hostage by a bag faith negotiator. Not bad faith as in malicious, but in terms of having an enormous conflict of interest.
Melatonic 5y ago
Offer to pay in cash and it is amazing how much better the customer service and general demeanour is from a medical office - it always blows me away. They must REALLY hate dealing all of the insurance BS. I had not done an eye appointment in years and years because my vision is generally very good - I went in expecting to offer cash, negotiate, and generally play a bit of hardball. I was amazed when the front desk person IMMEDIATELY perked up, looked super happy, and started offering massive discounts before I even threw numbers out. The eye doctors as well were very enthusiastic.

belval 5y ago

I doubt that it's as simple as that. Nurses are also leaving in Canada and we don't have insurance breathing down their neck.

reedjosh 5y ago
But they have zero autonomy there too I assume?
- belval 5y ago
  Sample size of 1, but my gf blames forced overtime. Being legally obliged to stay for an 8 hours shift after finishing one has a way to drive you to depression.
  - px43 5y ago
    I would pay more to go to a hospital where I know people are actually well rested. My last few hospital stays have been saturated with clearly agitated staff (doctors, nurses, reception) who were putting in minimal effort, and clearly didn't want to be there, and I can't blame them given the conditions that they're being forced to work under. This is in the US, and I can't figure out why the Department of Labor hasn't cracked down on the medical industry yet. It's really horrific, especially because these are the people we're supposed to be relying on to keep us healthy and safe. How hard is it to enforce 8 hour days 5 days a week? Every other industry has figured it out.
    - belval 5y ago
      To be fair, most industries don't have evening and night shifts and a supply mismatch, most nurses want to work the day shift, it's harder to find candidates for evening and night.
  - rootusrootus 5y ago
    At least at my local hospital, it's not just overtime -- regular shifts are 12 hours even when everything is normal. That's nuts.
    - belval 5y ago
      That's a little bit different and not as detrimental though. It's actually an incentive for nurses because they get to work fewer days. Instead of doing 10 8 hours shift every two weeks they'll do 6 12 hours and basically get 8 days off every 2 weeks, which is pretty interesting from a free time perspective. My gf did both and while she was tired after 12 hours, overall I think she preferred it.
icelancer 5y ago
Insurance / government repayment is mostly the same thing. A layer of bureaucracy.
alexashka 5y ago
Are they? Leaving to do what, exactly? For every story of 'X leaves to do Y', there are a thousand people claiming they'll leave, that never do.
- belval 5y ago
  Some just leave to stay-at-home, some go back to school and a lot will take early retirement.
- klyrs 5y ago
  Instead, you're left with the diminished quality of care from people who desperately want to leave but they're only there because they can't afford to.
tubalcain 5y ago
Canada's solution will be to mass-import nurses from the third world who will do twice as much work for half as much money. Mark my words. It's already happened with low-wage fast food jobs. Health care is next. Nurses and doctors will be replaced by poorly-trained third-world counterparts.
- belval 5y ago
  > Canada's solution will be to mass-import nurses from the third world Yes that's basically what Quebec (and probably other provinces) is doing. > Do twice as much work for half as much money I might get tomatoes thrown at me for this, but anecdotally "third-world" nurses are usually not as good due to having experience on different equipment, drugs and often languages. It's better than having no one to cover the shift, but it can be seriously dangerous due to lack of training on specific protocols. They get paid the exact same amount of money and are in the same union, so they absolutely don't do "twice as much work for half as much money".
  - tubalcain 5y ago
    I agree with your assessment regarding foreign trained nurses. I think it also applies to doctors as well. Regarding the pay structure for nurses, over time the unions will be filled with mostly third-world ones, so I predict their bargaining position will be weakened and they will accept worse conditions.

onlyrealcuzzo 5y ago

Have US hospitals ever had transparent pricing? This seems like the root of the problem, and insurance seems like what "fixes" that but causes tons of downstream unwanted side-effects.

teeray 5y ago
It’s always astonishing how I can get a fully itemized vet bill right after a visit and pay for it. Meanwhile going to the hospital is like “well gee, let’s submit to insurance, see what they’ll pay, we’ll readjust prices and then come back to you in a few months.”
- lostcolony 5y ago
  More than that, I can get an estimate upfront, that in 100% of cases matches the bill unless they find something additional they need to do, which they'll inform me of and create a new total estimate for. Of note, my vet insurance doesn't negotiate on my behalf; they just pay X% afterwards. The price the provider quotes for a given service is the price everyone gets (probably; some of the smaller vets might modify it if someone is low income and in need).
- MiddleEndian 5y ago
  Months after my last real procedure in a hospital, even after the insurance was settled, I could not get them to tell me how much money I owed them. Even when I went in person and told them "I want to pay you all of the money right now" they just shrugged their shoulders and told me they didn't know how much I owed them. They just sent me a bunch of small bills in the mail one at a time and had a text field online where I could blindly pay them without indicating whether or not I had completed my payments.
  - brightball 5y ago
    Yep. Seems ripe for fraud too.
    - 5y ago

pc86 5y ago

Insurance is the only industry where they agree to pay for something (in this case, "medical care"), but then after service has been rendered can decide to pay less, or not pay at all, or stop paying that provider altogether, etc. This combined with hospitals being run by non-physicians*, and people thinking being able to Google and read WebMD qualifies them to argue with their doctor about treatment plans**, healthcare in the US is going to absolute shit***. * I strongly believe that only physicians should be running hospitals. Certainly not administrators whose only education is an MHA and only experience is working for for-profit health companies. Medical decisions need to be made outside of cost considerations. The only factors should be medical science, quality of life, and patient wishes (in that order). ** In stark contrast to asking questions and trying to understand. But I have family members who are the "look everything up and then try to tell my doctor how they're going to treat me" ilk and it's crazy. *** I don't think the above points are unique to US healthcare other than cost considerations, but that's all I have experience with.*

deleted 5y ago
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wolf550e 5y ago
re: "Medical decisions need to be made outside of cost considerations." In the end, labor hours of professionals are finite. Even if you don't need to pay doctors, you only have so many, they can only work so many hours, you will need to prioritize who to help in what way, which procedures to do. Same with all the other personnel, the consumable stuff, the devices/scanners/equipment, etc. So someone is going to have to prioritize. It can be just "how much quality of life can we save using the resources we have", regardless of the patient's ability to pay/insurance/citizenship, but some prioritization will need to happen. The policy of the death panels can be changed, but their existence is inevitable.
- deleted 5y ago
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- slantedview 5y ago
  > labor hours of professionals are finite. This is why it makes no sense to have doctors and nurses waste time battling insurance companies over treatments, and hospitals over staffing. Their time is indeed too valuable.

mfer 5y ago

In the book The innovator's prescription: a disruptive solution for health care by Clayton Christenson, there are some good analysis of where the complexity and problems come from in the current US medical system. A lot of it has to do with size and the complexity that goes along with it. So, as hospitals get bigger, do more, and increase in size and complexity these issues become worse. The economics math even mirrors factories... a factory that can build 100 things compared to one that just produces one thing. The book was enlightening, even though many of the time frames called out in the book were wrong. Disrupting medicine is a lot harder than something like technology.

mikkergp 5y ago
I think this alludes to it, but it's one thing mentioned in one of Atul Gawande's book is that in India they have hospitals that focus on one thing: https://www.businessinsider.com/inside-indias-no-frills-hospitals-where-heart-surgery-costs-just-800-2013-4 https://www.businessinsider.com/inside-indias-no-frills-hosp... So like a 2000 bed hospital just for heart surgeries. Like you're saying, the more a heart surgeon specializes, the better they are at it and the cheaper they can do it. Better Outcomes for less money.
- 2143 5y ago
  Yes there are hospitals in India that cater to a specific aliment. For instance, eye hospitals, cancer centres, hospitals that cater to pregnancy, childbirth and neonatology etc. > Like you're saying, the more a heart surgeon specializes, the better they are at it and the cheaper they can do it. Better Outcomes for less money. Not necessarily. 1. A heart surgeon is going to be doing heart surgery at more or less the same frequency regardless of whether the hospital they're at handles only heart patients or not. Wouldn't they? 2. I doubt if anybody here considers them cheap. Yes it's probably cheaper than in the US, but still it's rather expensive. But then again, since life is priceless, ...
  - mikkergp 5y ago
    At a 2000 bed facility though, you could specialize in specific types of heart surgeries. At a general hospital you're probably more likely to take on a wider variety of heart procedures. It's not just experience, but experience in specific procedures that can dictate outcomes: https://www.reuters.com/article/us-healthcare-quality-surgery/study-suggests-surgeons-do-get-better-with-experience-idUSKBN0MT1P920150402 https://www.reuters.com/article/us-healthcare-quality-surger... Maybe cheap is the wrong term, but less expensive? I mean $800 may be expensive but certainly it's better than more?

brimble 5y ago

Consolidation's a big part of it. The last decade has seen nearly all the small practices and offices in my city gobbled up by a couple of huge companies. With that comes the MBAs and the bureaucracy.

Workaccount2 5y ago
The healthcare in my area is like watching feudal lords rapidly claiming their territory. With central fortresses (hospitals) and outposts (smaller treatment centers).

cwbrandsma 5y ago

The hospitals themselves are also to blame. There are a couple court cases where the hospital threw the nurse under the bus to cover up for their own issues (short staffing, bad safety procedures, covering up for a doctor, etc), and nurses are justifiably pissed off right now. There was a time when hospitals could have helped the nurses with the stress and workload, but the admins bungled it at every possible turn, and now it seems they missed their window.

polskibus 5y ago

It’s like that in many countries, also in EU. Average age of a nurse is rising, richer countries rescue themselves by importing workforce, because they can’t find workers for the rates they have budgeted at home. It’s is like that in other professions too if it’s only the tech that gets compensated well. There is a shortage of skilled labour.

soco 5y ago
Errata: there's a shortage of skilled labour for these working conditions. Said budgeting is not set in stone, and as long nurses and whatever else professions can vote with their feet (by leaving the profession) no amount of politics-led finger-pointing can replace a real-world change in the healthcare policies.

caycep 5y ago

Granted, there's a niche for cash pay docs. Example being psychiatry - it's extremely hard to find a psychiatrist who takes insurance, even Medicare. The good ones are all cash pay...

slantedview 5y ago

Insurance companies are awful and should not exist, sucking up a lot of doctor time, but when it comes to nursing, hospitals are particularly awful, cutting staffing levels to the bone in order to maximize profit. People die as a result, and nurses are burnt out.

ajross 5y ago

> Everything is controlled by insurance companies. You can’t do anything unless it’s exactly how insurance wants and only for what insurance will pay. Framed that way, this sounds terrible. But... the truth is actual health care outcomes for insured patients in the USA are extremely good. This holds in comparison to other nations, when corrected for GDP and patient income, etc... "Insurance companies" are, at least in the narrow sense, doing what we pay them to do really well. They may or may not be making things easier for nurses, which is a different metric. But nurses aren't their customers, we are. And we're getting a fairly good[1] product. [1] Albeit extremely expensive relative to other nations.

legitster 5y ago

I've worked with both, and by far hospitals are much, much worse actors. Hospitals are legally enforced local monopolies (look up Certificates of Need). Meanwhile, you might have a dozen choices of insurance companies, but they all suck because they have to take what the hospital billing departments give them and take the blame or risk being dumped by the hospital.

lettergram 5y ago

No one wants to hear the truth. There’s near-infinite demand for healthcare and a constrained (mostly artificially) supply. Insurance, people and government can’t solve the problem of the supply and demand by throwing money on it. You either expand supply or remove demand. Given removing demand is... not desirable. The only alternative to fix the issue is remove regulation and expand supply. That’s it. Insurance makes the issue worse by increasing demand and in a way limiting supply through requirements and procedures. Government limits supply through regulation AND expands demand by paying for procedures. An approach is to deregulate, such as removing government licensing, remove Medicare, etc. Imo Prices would drop >95% within a 2-5 years (to India or Mexico levels). I worked in medical billing for a few years and the issues are beyond obvious.

lefstathiou 5y ago
I think there needs to be some new approach to how medical services are being paid for. My 70yo father fell off a ladder and drove himself to the hospital in Calhoun Georgia (2 hours north of Atlanta, a small town) with a bruised eye and a broken wrist. He got in late afternoon, left the next day, and the bill to insurance (which of course they won't pay) was $69,000... more than per capita income in the US. The system is ridiculous. In my opinion, healthcare has reached the state where the people who receive the benefit are too far removed from the people who pay for it and given there is no "victim" of price gauging, the prices will just keep going up up and way. I defer to those wiser than me for the solution. I don't like complaining without being constructive so here is my ignorant pass at it. This will require a few key steps: 1) Yes, we need more supply (by deregulating the profession) 2) I personally think a more effective solution would be to gradually eliminate insurance except for catastrophic risk (like emergency medical care from a car accident). #2 will shift responsibility to the individual and the system will be capped at what they can charge based on the average person's ability to pay for it (which is how it works in many parts of the world).
- lettergram 5y ago
  > left the next day, and the bill to insurance (which of course they won't pay) was $69,000 I agree with you and the quote above is because of insurance. Medicare will pay 10% of that total and your father would be charged 2-5%. If he has private insurance you’ll see something different, maybe 15% and your father would be charged 3-6%. If he’s going out of network could be 100%. Hospitals / practices charge insane bills because people pay just a small fraction typically. It really impacts those without insurance or private insurance the worst. It is insane. This is why I have suggested deregulation, particularly around licensing. It drives down the cost. Insurance may cover doctor X, but if nurse Y can do it for 5% the price... well use the nurse. All doctors would have to reduce prices and insurance would have to raise the coverage amount to compete. It’s what is done elsewhere in the world.

UncleOxidant 5y ago

This. I had a great doc until a few years back. Best doc I've ever had by a long ways. He'd spend a good amount of time with you, actually listen to your concerns and even bring up recent papers he'd seen on topics related to my health issues. A few years ago he decided to mostly get out of doctoring because he was tired of dealing with insurance companies. For a while he went to a retainer model ($2K/year up front, $250/visit) and cut the number of patients he was seeing down significantly. I can't say as I blame him.

brightball 5y ago
MDVIP does that model in the US too.

andrei_says_ 5y ago

Prioritizing profit corrupts the commitment to providing care. Healthcare can be either care or industry. Applying corporate values to a healthcare system leads to maximum wealth extraction from both providers and patients. In this context innovation focuses not on the care part but on the extraction. The care is secondary. How can anyone who cares be a proponent or coexist with a healthcare industry?

micromacrofoot 5y ago

I've heard the same thing from mental health counselors and therapists. In wealthier areas many will just stop accepting insurance entirely and make people pay out of pocket to avoid all the insurance paperwork and requirements (some insurers require specific diagnosis to continue paying for services). If an insurer decides to not pay you? good luck. Now you need to throw hours of unpaid labor at them to get money you're owed. Unsurprisingly, this means many normal people can't afford a therapist and they're getting harder to find.

bitsnbytes 5y ago

Insurance companies is a symptom of the REAL issue. Unfortunately the American public hasn't figured out what the real issue is yet. They reason why they haven't is mostly because the Democrat party , Republican party, entertainment industry , the Main Stream Media, tech industry, and the the Commission on Presidential Debates (CPD) has them occupied with the symptoms of the REAL issue in order to keep them chasing their tails. The REAL ISSUE why healthcare isn't getting fixed is because of Conflict of interest.The American public hasn't figured out that going to congress who is riddled with conflict of interest and who designed the existing system that we have in place and is benefiting from it, might not be the best idea to fix healthcare. In fact the best thing to fix healthcare (and the other 99 problems)is to STFU about it and focus ONLY On reducing conflict of interest in congress. Until we reduce conflict of interest in congress nothing will be fixed. The Democrat party ,republican party, CPD and MSM want you focused on everything but reducing conflict of interest in congress. In order to fix healthcare and any of the other issues we must FIRST try to minimize conflict of interest by implementing the following as a start: 1. Term limits 2. Closing or reducing revolving doors between private and public sector. 3. No private campaigning contributions. Use tech to overcome the need of money. 4. Reform lobbying by doing away with the money aspect of it and utilizing technology to get your voice heard. 5. Pay congress members more and better benefits, but in return demand complete transparency from financial information to limitations in investments , NCA , and make pay and benefits tied to the general overall approval of congress by the American tax payers. 6.etc Both party and the MSM solution to fix healthcare is the equivalent of going to the MOB and asking them to fix crime in your neighborhood which the MOB is benefiting from and is promoting. It just makes no sense to talk solutions with people riddled with conflict of interest. You want to fix healthcare stop talking about healthcare and get the individual republicans and individual democrats to put their political ideology on hold and join forces to demand that their party ONLY focuses on reducing conflict of interest in congress.

DaltonCoffee 5y ago

This inefficiency and it's resulting poor working conditions aren't unique to countries with health insurance and private healthcare tho, see Canada.

syedkarim 5y ago

Why doesn’t the American Medical Association start its own insurance company?

at_a_remove 5y ago

Previously, that wasn't entirely true. In the very early nineties, insurance companies lured doctors in with promises of referral if they would just accept certain terms. Originally, this was to the benefit of the doctor -- more referrals. But only originally: once lock-in occurred, the insurance companies began to set their own terms. They couldn't have accomplished this without some greed on the part of many doctors early on.

bakuninsbart 5y ago

It is definetely a (big) part of the reason, but if it was the only one, things wouldn't be in a similarly terrible situation in other countries. Take the UK as an example which has a single-payer system, and morale is overall really low, too, and nursing isn't an enticing career. (On a side-note, the BBC show "This is going to hurt" is quite good and on topic) Apart from administrators and insurers, I think a large problem is that the job has become substantially more difficult and technology intense, while support and pay hasn't kept pace. At the same time, liability is more serious these days, which I don't think is a bad thing, but certainly sucks for the workers who have to constantly justify themselves and can get crucified for mistakes.

seabrookmx 5y ago
+1 very similar story in Canada. It blows my mind that super long shifts are the norm for a job that's generally more exerting/stressful than your average 9-5. But it's a viscious cycle now because of the shortages of qualified staff. Here in BC we have a full on crisis where family doctors are retiring at an alarming rate and not being replaced.

rootusrootus 5y ago

> You can’t do anything unless it’s exactly how insurance wants and only for what insurance will pay. This is the part that makes the whole experience so sadly ridiculous. Nobody could ever tell patients what something might cost and let them make choices, it was (and is) "Sign here to acknowledge you'll ultimately be responsible for all charges, no matter what they turn out to be." But the insurance company doesn't operate like that, they say "Want to be part of our network? Guess what, you have to ask us for permission or we just won't pay you." We need to rip off the bandaid, as it were, and reboot the damn system. Pick one of any number of good examples from other modern industrialized nations that have functioning healthcare, and copy it. Yes, everything will be a zoo for a while. We'll survive, and maybe even come out the other side with a better system. And maybe some bankrupt insurance companies, let me find my handkerchief.

darkerside 5y ago

I don't hear it talked about enough, but I think the biggest problem with insurance is that their profits are pinned to how much they spend on medical costs. https://www.verywellhealth.com/health-insurance-companies-unreasonable-profits-1738941#:~:text=And%20so%20are%20profits.,costs%2C%20including%20profits%20and%20salaries https://www.verywellhealth.com/health-insurance-companies-un.... In theory, this sounds like a great way to make sure insurance companies aren't just taking unreasonable profits, and that they are spending money on medical care, not administration, keeping the business lean. In _practice_, what it means is that profits are constrained by medical costs, so the insurance companies are literally incentivized to pay _more_ for medical services. Originally, insurance companies were supposed to be an intelligent negotiator on behalf of their customers. After all, their experts should know much more than a layperson every will. But with the poisoned incentive to raise costs, customers are basically held hostage by a bag faith negotiator. Not bad faith as in malicious, but in terms of having an enormous conflict of interest.

Melatonic 5y ago

Offer to pay in cash and it is amazing how much better the customer service and general demeanour is from a medical office - it always blows me away. They must REALLY hate dealing all of the insurance BS. I had not done an eye appointment in years and years because my vision is generally very good - I went in expecting to offer cash, negotiate, and generally play a bit of hardball. I was amazed when the front desk person IMMEDIATELY perked up, looked super happy, and started offering massive discounts before I even threw numbers out. The eye doctors as well were very enthusiastic.