9 ms·

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

by 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
[deleted]
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.
  - wing-_-nuts 5y ago
    This is exactly why we should simply just expand medicare to be an option for everyone. If it's good enough for everyone over 65, it's good enough for everyone under it too. I'm ok with paying a reasonable premium to have access to the largest insurance network in the nation.
    - elhudy 5y ago
      Simply? It is not so simple. Medicare reimbursement rates are way below commercial rates and hospitals wouldn't survive just from medicare reimbursement alone. Let's stop trying to come up with "simple" solutions to the healthcare catastrophe in the US because the reality is more complex.
      - wing-_-nuts 5y ago
        So raise the reimbursement rates to the point where hospitals can survive, or cut the fat. See? Simple. Every time someone makes an argument like this, it's always to say that somehow, medical treatment in the USA is special compared to other countries. We couldn't possibly have universal healthcare work here. Please.
        bumby 5y ago
        Possibly misattributed, but usually given to HL Mencken: "For every problem, there is a solution that is simple, neat, and wrong." Don't kid yourself into thinking a complex system that makes up 20% of GDP is going to have a simple solution. Just a couple examples you'd have to contend with: 1) Insurance companies get a say too, according to the Constitution. That means they get to lobby in their own interests. That political problem itself is a boondoggle. 2) The US funds a disproportionate amount of medical R&D. Some of that fat is going to be cut from research. You need to have a plan on how that will effect long term quality of care and innovation. 3) Physician licensures are limited by the AMA. If you expand coverage, you will need to expand supply because any time something becomes "free", people will consume more of it. That's not a necessarily bad thing in healthcare, but needs to be addressed. The AMA also gets to defend their political interests. There's lots and lots of other issues. I'm not claiming the US healthcare system is great. But pretending it has a simple fix is naïve.
mminer237 5y ago
> I strongly believe that only physicians should be running hospitals. This is how it is for other professional industries. As an attorney, you can lose your license for sharing any profits with someone who isn't a lawyer. I believe states typically require accounting and engineering firms to either be wholly or two-thirds owned by such professionals as well.
- brianwawok 5y ago
  > I believe states typically require accounting and engineering firms to either be wholly or two-thirds owned by such professionals as well. What states are these, Canadian states? In the US, many many many SaaS shops are wholly owned by businessmen / bean counters. It's like, weird, to be an engineer who runs a software company.
  - nawgz 5y ago
    > engineering firm > SaaS shop Now, I get we like to refer to ourselves as Software Engineers, but surely you understand he means actual certified engineering firms, not groups of code monkeys, right? Software is virtually never engineering, you'd have to get to a situation like flight control software before you're doing anything legit
    - brianwawok 5y ago
      I am a software engineer and do not consider myself a code monkey. Do not speak for all of us.
      - nawgz 5y ago
        If you have never stepped into a domain where you have to formally verify your software, I think you should probably not take too much offense to such a comment. While I admit it may be slightly negatively connoted, I primarily used it to illustrate that the kind of engineering going into making a bridge differs greatly from making your UI widget pixel-perfect or your SQL query from being too polynomial
giraffe_lady 5y ago
The "only physicians should run hospitals" doesn't make that much sense to me. Reminds of the technocratic argument you used to see a lot on the internet that instead of politicians we should have scientists and engineers in legislature. The issue is if you have someone with a scientific background doing politics, what you have at the end is still a politician. Same thing here. An MD doing hospital administration is an administrator. Which is not to devalue specialist expertise in these roles. I definitely think you want people with these backgrounds in those roles as well. Just not necessarily exclusively. A career administrator has different skills than a physician, you want people with both, and other, roles working to run a hospital. The real problem as I see it is probably the incentives, constraints, and pressures they work under, or towards. A physician forced to run a for-profit hospital maximizing returns is going to make a lot of the same decisions as someone with a business background in the same situation. The thing is to change the situation, not put different people into that role and expect them to do it dramatically better.
- caycep 5y ago
  The problem with this is that the MBA programs that churn out hospital administrators tend not to be very good...focus on mergers, cost cutting, not so much on optimizing care. The pendulum has swung too much onto the MBA for MBA's sake hospital administrators and less so on actual medicine.
- slantedview 5y ago
  > A physician forced to run a for-profit hospital maximizing returns is going to make a lot of the same decisions as someone with a business background in the same situation. Indeed! Whereas a doctor might say yes, give that patient with cancer the treatment they need, the MBA is going to say no, it costs to much, let them die. If the goal is to maximize profit, the MBA is doing a better job. If the goal is to maximize the health of your patients, the doctor is. We must realize that these two goals are fundamentally in conflict with one another. The question isn't whether a doctor or an MBA should be running a for profit hospital, it's whether we should even have for profit hospitals. If we care about people more than profits, then clearly we should not.
slantedview 5y ago
> I strongly believe that only physicians should be running hospitals. More than that - hands on healthcare should not be a for profit industry. The need to make profit is fundamentally opposed to providing the best care. As the push for profit increases, more people get sick and die. This goes for long term care as well, which is facing a similar staffing crisis for similar reasons.
- legitster 5y ago
  Your local hospital is likely a non-profit. Your health insurance company might even be a non-profit. But they don't do any better. Corporate profit motive doesn't seem to be at play here.
  - candiddevmike 5y ago
    It's executive/board/administrative compensation that's more of a problem than profits for most hospitals/insurance companies.
Djvacto 5y ago
As a quick counter-point to *, there is another sub-problem with healthcare/doctors in the US, where often patients with chronic illnesses or not-easily-testable conditions have to fight hard for doctors to take them seriously. The why of this varies a lot from what I've seen, but includes: - an attitude of "most patients are just trying to wring medications out of you" - an ego-hit of "if I didn't make the diagnosis, I don't want to help" (this applies to both patients coming in with a suspicion of what they have, or getting a diagnosis from another doctor) - burn-out/overworking, where doctors have a hard time managing all the different cases coming at them without dropping the ball here and there It's not a simple, single-cause problem at all, but just want to provide an alternative point of view about patients who look things up or come in asking about a specific condition or diagnosis. When I got my ADHD diagnosis after a quarter-century, I went in specifically asking about ADHD because I had seen some flags that made me think I might have ADHD. Contrast that with the people doctors screen out who are trying to get a stimulant prescription despite not needing it, and you have a situation where it's hard for doctors to tell who does or doesn't need meds, and where patients with actual conditions have to fight hard for those to be diagnosed. Even in cases like POTS, which has no medication involved in treatment, just lifestyle changes, and yet people close to me who have POTS all had an uphill battle getting it recognized by anyone, especially doctors who could diagnose (disclaimer: sample size = 3).
- argc 5y ago
  > When I got my ADHD diagnosis after a quarter-century, I went in specifically asking about ADHD because I had seen some flags that made me think I might have ADHD. Contrast that with the people doctors screen out who are trying to get a stimulant prescription despite not needing it, and you have a situation where it's hard for doctors to tell who does or doesn't need meds, and where patients with actual conditions have to fight hard for those to be diagnosed. I told my doctor I had already been diagnosed with ADHD because I had a strong suspicion I had it and wanted to see for myself if the medication helped (it helped massively). I think medicine should be accessible for patients who need it but I don't know how to avoid large amounts of patients then taking medications for the wrong thing, which would probably happen if it was a free-for-all. It kinda comes down to the question of having the personal freedom to hurt yourself doing something stupid, which is a balance (a little of that freedom is good, too much probably bad). All-in-all I lean toward the current system of using on experts to make the final decision. Still, I would be really pissed if a doctor prevented me from getting stimulants for something I believe I need, so I am not 100% satisfied with the current system either.
travisjungroth 5y ago
> * 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 still think it’s better than the other extreme of just showing up and trusting the professionals. That should work in theory, but my experience for myself and those around me is it’s incredibly ineffective. If what you’re dealing with requires the least bit of thought, odds are you’re getting brushed off to the extent you allow. The real model of US healthcare is essentially apprentice/master, with the patient as apprentice. Apprentice does a lot of the work, not all, some needs to be approved by the master and the apprentice better know how to learn from the master, when to push back, and how to make it seem like it was their idea all along. You can imagine how this falls apart for mental health.
- AlphaOne1 5y ago
  I also think the complete implosion of family medicine has made this worse. In the past, you would keep the same family medicine doctor for decades and trust them. They in turn would know what your values and priorities are. Moreover, they would be able to guide you through difficult healthcare decisions that inevitably come up (cancer diagnosis, mental health etc.). We have lost the human connection aspect of medicine and those few physicians that are able to hang on to it are burning out due to the massive amounts of paperwork they need to accomplish. From the hospital perspective, (which many physicians now work for) good paperwork=good patient care. Paperwork is measurable. Relationships (other than in the abstract) are not.
scythe 5y ago
>Medical decisions need to be made outside of cost considerations. It's really jarring to read an otherwise reasonable comment that drops a whopper like this. Nothing exists outside of cost considerations. The NSA has cost considerations. The Space Shuttle had cost considerations (obviously, not great ones!). The design of nuclear submarines involves cost considerations, however unsettling that may seem. You're telling me that my broken hand needs to be judged outside of cost considerations? Give me a break. The problem is that there is a lack of "trustworthy" parties to evaluate cost expectations in medicine. The patient often doesn't understand their condition or its treatments, the doctor has a clear perverse incentive to inflate costs, and the insurance company may actually be better off if the patient dies. At least that's the conventional picture. Leftist pundits often complain that the American economy is based on "greed", but a more precise criticism is that there has recently been a trend away from expecting benevolence and for-its-own-sake honesty from anyone under any circumstances, or equivalently an increasing cynicism about human motivations. It remains to be seen whether a medical system can function when nobody expects to trust anyone.
- inglor_cz 5y ago
  "The Space Shuttle had cost considerations (obviously, not great ones!)." It absolutely did, and great ones too. The program was too costly and never lived up to the original expectations of fast and easy access to orbit. Falcon 9 + Dragon is the first American human-rated launcher and ship that can be labeled as somewhat cost effective.
adolph 5y ago
> Medical decisions need to be made outside of cost considerations. A common attitude which may cause: Health care is extremely costly in the United States. Although the rate of growth in spending has attenuated in recent years, per capita spending on health care is estimated to be 50 to 200 percent greater in the United States than in other economically developed countries. Despite leading the world in costs, however, the United States ranks twenty-sixth in the world for life expectancy and ranks poorly on other indicators of quality. https://journalofethics.ama-assn.org/article/complex-relationship-between-cost-and-quality-us-health-care/2014-02 https://journalofethics.ama-assn.org/article/complex-relatio...
- inglor_cz 5y ago
  Looking at the levels of obesity in the U.S., I consider the 26th place a true miracle of American medicine. If it can prevent people who devastate their bodies with junk food for decades from dying at 50 ... On the other hand, imagine the world where Coca-Cola makes billions on healthy drinks, people are slim and fit until they die, and half of the money spent on treatment of chronic diseases of excess can be used for something else.
  - rootusrootus 5y ago
    > Looking at the levels of obesity in the U.S., This is not unique to the US. Can't really say "but we only have 25% obesity here" and call that any kind of win. Maybe the US leads in this regards (though it varies by region, some areas have European-level obesity rates), but obesity is a worldwide problem.
legitster 5y ago
> after service has been rendered can decide to pay less, or not pay at all, or stop paying that provider altogether, etc This actually isn't necessarily true when you learn how billing codes work. Most insurance companies pay out at a fixed rate per billing code based on your plan. That doesn't change. What does change is that hospitals can retroactively apply new additional billing codes. This happened to us once for an ER visit where we got 3 additional surprise bills over 6 months because the hospital retroactively applied new billing codes to our visit.
JackFr 5y ago
> * 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. The skills need to run a hospital are quite different than those required to be a doctor. I'm not saying hospitals aren't unique - I believe they are and their adminstration is highly specialized. Doctors should inform the administration at every level but it would be a waste of their training and a bad idea for doctors to run everything. > 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). Would you be as quick to say "Doctors should work without pay." ?
- cmorgan31 5y ago
  Why would not paying doctors be the natural consequence? It’s a fairly significant jump to go from don’t let cost be a primary decision driver to let’s force doctors to work without pay.
  - bumby 5y ago
    Because in reality, there are always tradeoffs and constraints. In the US, a disproportionate amount of healthcare costs come at the very, very end of life. It's possible to meet the sole criteria of science, quality, and patient wishes with exploding costs. I think the OP's point was that money has to come from somewhere.
    - zeruch 5y ago
      "a disproportionate amount of healthcare costs come at the very, very end of life." One might ask why that is; while some is surely due to natural decline in later years, one could likely also posit that the cost-fears leading up through that period (decades), and the general inability to get people to do preventative care throughout adulthood contribute to that significantly.
      - bumby 5y ago
ryanbrunner 5y ago
> * 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 think this is exacerbated by doctors a lot of the time. I'm in Canada so it's obviously a very different system, but visits to a GP often have strict time limits and "one issue only" rules. When you can only talk about one symptom, and you only have 5 minutes to explain it, it's natural to try and do homework first to see what you're going to use your limited time on.
dr_ 5y ago
Let me add two more payment scenarios: 1) Pay in the form of a credit card number, where the provider ends up paying CC processing fees to process the payment. 2) Ask for the money back, months later.
umvi 5y ago
> * I strongly believe that only physicians should be running hospitals. Strong disagree. This same attitude pervades the military ("only pilots should run the air force") and really all it does is that lower representation of the interests of the other non-pilot 90% of your organization and put a pilot bias on every decision being made.
- advael 5y ago
  Those are extremely different situations and you’ve not really justified why they’re being compared. A “doctor bias” in every decision being made would ideally prioritize health outcomes over decisions made for profit or convenience. It’s possible that doctors will make poor decisions too, but on balance our expectation based on their training is that decisions made because of healthcare outcomes would be more likely in this scenario than the current state of affairs, which prioritizes economic considerations as administrators in every context currently tend to
  - bumby 5y ago
    I think the point is that "doctor bias" will not take a balanced approach to the other systemic factors. I'd argue it's the same with the pilots. If you asked pilots, they'd likely say the same thing: their priorities are going to align with the mission better than anyone else's. Anecdotally, this has been true in my experience on complex engineering projects. When the project manager is a mechanical engineer, guess which systems get the most time, money, and priority? Mechanical. And when it's an electrical engineer, the electrical system gets the priority. When it's a software engineer, the software etc. They all recognize the other systems, but availability bias skews their worldview and priorities to the neglect of others.
hinkley 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 That's not always the case. The reason I stopped writing mobile applications long ago was because the mobile carriers were doing exactly this, and not even providing enough paperwork for you to argue with them about it. People like to lambast the Apple App Store for being greedy, but the fact of the matter is that people netted 3x as much off Apple that they did from the carriers. They are asking too much money now but their rates were absolutely defensible at the time. It's not a coincidence that we had a gold rush that started almost exactly when the App Store became a viable target. One might ask what would happen if we joined the rest of the 1st World in providing medical care and marginalized private health insurance. Would it be a similar watershed moment?
- towaway15463 5y ago
  The only gold rush in medicine where I’m from involves moving to the US to get away from a nationalized health care system.
  - ejb999 5y ago
    curious - where is that?
bumby 5y ago
>I strongly believe that only physicians should be running hospitals. Can you elaborate on your rationale? I ask because I've worked in hospitals run by a cadre of physicians and it was not run well. Anecdotal, obviously, so I'm curious on your thoughts on what they provide. My worry is that it can lead to an unbalanced technocracy. It's like saying a politician needs to come from [industry x] to govern [industry x]. Technical competence is a necessary, but insufficient criteria when managing a multifaceted problem. The risk is that the front-line physician priorities would always become the organization's top priority. In reality, a hospital administrator has to manage competing priorities across many different domains.
ipaddr 5y ago
* In this day and age not being your own doctor/advocate will produce unwanted unnecessary results. If you look up possible treatments /side effects and your personal history you will be in a better position to engage and weight options. If you blindly accept everything you will end up on the most profitable treatment plan plan insurance allowed.
samstave 5y ago
>I strongly believe that only physicians should be running hospitals. (Disclaimer: I have been on the design team for several hospitals, including El Camino and San Francisco General, in the bay area - and I have a family of doctors and nurses in my family - my brother was head of the Veteran Administration for the state of Alaska, and is currently CMO for a large health provider (he is a doctor) --- That said, the "running" of a hospital isa hell of a lot more than medicine (when we are specifically talking to the running of -- but this comment was made in relation to costs/efficiencies as far as outcomes, patient treatment, insurance etc...) Hospitals are really complex ecosystems and should be thought of more like an aircraft carrier than an other form of business. The costs within the realm of a hospital are ridiculous - as are the methods and manner in which hospitals raise money. Insurance is cancer to be sure, but there are so many other factors that go into the operational costs of a hospital - and I don't just mean ngoing care and operations - systems and technology and medicine evolve. People are people and regardless have the same hierachy of needs in any environment. You have every single actor as an enemy of the hospital bottom line: New tech, $$ Older nursing pop $$ Current nursing/doctor market salaries $$ Maintenance for existing systems $$ Insurance billing code lock-in $$ Competing hospitals for doctors and nursing staff $$ California $$ Corruption $$ Utilities and related redundant infra to ensure life systems The ridiculous cost to upgrade The list goes on and on... (The cheapest hospital project I worked on was hundreds of millions of dollars) etc... Hospitals are really expensive to run, and it requires a hell of a lot more skills than simply being a "doctor" to run one.
93po 5y ago
> people thinking being able to Google and read WebMD qualifies them to argue with their doctor about treatment plans In my experience, I have had: 1. Doctors that know nothing about a really basic ailment and not have any meaningful guidance or treatment to suggest 2. Doctors that Google something literally in front of me, things that I have already Googled myself, and draw the wrong conclusion because they're looking at results at a glance - when I had searched myself earlier and dug deeper though, it was clear to me the result he was looking at was just plain wrong 3. Doctors that provide very little to no guidance about a wide selection of medications available to treat a problem, leaving me to essentially guess which option of a dozen or more I should go with 4. Doctors that force me to advocate for myself and my condition before they agree to help treat it - so much so that I had to visit 4 different doctors to find one that would, wasting nearly a thousand dollars of office visits with nothing to show for it. It's no wonder people do their own research and dare to advocate for themselves. Most doctors are fucking worthless.
- hallway_monitor 5y ago
  I cannot agree enough. I think anyone who has dealt with a puzzling condition quickly learns how limited the "expertise" of these supposed authorities is. Sure, insurance companies are terrible, but so are most doctors. Great, quit, you probably sucked anyway.
  - aqfamnzc 5y ago
    It also probably doesn't help that doctors are jacks-of-all-trades medically - there are simply too much complexity to thoroughly understand the nuances of every obscure condition and interaction. However, I think acknowledging when one doesn't know something is a skill many could benefit from improving...
- ClumsyPilot 5y ago
  Indeed, there have been mutiple instances where, if I had not put my foot down,i would be left untreated and undiagnosed. Doctors are not like other proffeshions, they cannot put things right if the opportunity for treatment is missed
scarface74 5y ago
Opposite anecdote: For done reason about 10 years ago my asthma that had just been a minor nuisance and didn’t stop me from running, teaching fitness classes part time, etc. for a decade, sent me to the hospital and kept me coughing for nearly a year. The doctors and specialists gave me every treatment under the son to no avail. Then I did my own research and read I should try OTC psuedophredrine. It worked like a charm. Now every time I catch a cold (and when I got Covid), I pop psuedophredrine for a few days and I am good. Yes, psuedophredrine is suggested to treat Covid if you have virus induced asthma. Second anecdote: I have relatively mild cerebral palsy. As I’ve gotten older, my affected foot tightens up especially in the winter. My neurologist said it was physical and not neurological. I went on vacation and was drinking more alcohol than I usual do. I noticed I was walking without pain. I did my research when I got home and found a prescription muscle relaxant with the fewest side effects and ask my doctor about it. He prescribed it to me. He didn’t bother telling me that I should get blood work done to check for liver problems. I had to bring it up to him. I can now walk without pain and run when properly conditioned.
dan_quixote 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 This is precisely why I think we will never be able to effectively treat healthcare as a "free market" with tools like HSAs, posted price sheet, etc. The end user can never know the true cost of their procedure until it's long over (sometimes years later) and often don't get to choose at all.

by pc86 5y ago

deleted 5y ago

[deleted]

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.
- wing-_-nuts 5y ago
  This is exactly why we should simply just expand medicare to be an option for everyone. If it's good enough for everyone over 65, it's good enough for everyone under it too. I'm ok with paying a reasonable premium to have access to the largest insurance network in the nation.
  - elhudy 5y ago
    Simply? It is not so simple. Medicare reimbursement rates are way below commercial rates and hospitals wouldn't survive just from medicare reimbursement alone. Let's stop trying to come up with "simple" solutions to the healthcare catastrophe in the US because the reality is more complex.
    - wing-_-nuts 5y ago
      So raise the reimbursement rates to the point where hospitals can survive, or cut the fat. See? Simple. Every time someone makes an argument like this, it's always to say that somehow, medical treatment in the USA is special compared to other countries. We couldn't possibly have universal healthcare work here. Please.
      - bumby 5y ago
        Possibly misattributed, but usually given to HL Mencken: "For every problem, there is a solution that is simple, neat, and wrong." Don't kid yourself into thinking a complex system that makes up 20% of GDP is going to have a simple solution. Just a couple examples you'd have to contend with: 1) Insurance companies get a say too, according to the Constitution. That means they get to lobby in their own interests. That political problem itself is a boondoggle. 2) The US funds a disproportionate amount of medical R&D. Some of that fat is going to be cut from research. You need to have a plan on how that will effect long term quality of care and innovation. 3) Physician licensures are limited by the AMA. If you expand coverage, you will need to expand supply because any time something becomes "free", people will consume more of it. That's not a necessarily bad thing in healthcare, but needs to be addressed. The AMA also gets to defend their political interests. There's lots and lots of other issues. I'm not claiming the US healthcare system is great. But pretending it has a simple fix is naïve.

mminer237 5y ago

> I strongly believe that only physicians should be running hospitals. This is how it is for other professional industries. As an attorney, you can lose your license for sharing any profits with someone who isn't a lawyer. I believe states typically require accounting and engineering firms to either be wholly or two-thirds owned by such professionals as well.

brianwawok 5y ago
> I believe states typically require accounting and engineering firms to either be wholly or two-thirds owned by such professionals as well. What states are these, Canadian states? In the US, many many many SaaS shops are wholly owned by businessmen / bean counters. It's like, weird, to be an engineer who runs a software company.
- nawgz 5y ago
  > engineering firm > SaaS shop Now, I get we like to refer to ourselves as Software Engineers, but surely you understand he means actual certified engineering firms, not groups of code monkeys, right? Software is virtually never engineering, you'd have to get to a situation like flight control software before you're doing anything legit
  - brianwawok 5y ago
    I am a software engineer and do not consider myself a code monkey. Do not speak for all of us.
    - nawgz 5y ago
      If you have never stepped into a domain where you have to formally verify your software, I think you should probably not take too much offense to such a comment. While I admit it may be slightly negatively connoted, I primarily used it to illustrate that the kind of engineering going into making a bridge differs greatly from making your UI widget pixel-perfect or your SQL query from being too polynomial

giraffe_lady 5y ago

The "only physicians should run hospitals" doesn't make that much sense to me. Reminds of the technocratic argument you used to see a lot on the internet that instead of politicians we should have scientists and engineers in legislature. The issue is if you have someone with a scientific background doing politics, what you have at the end is still a politician. Same thing here. An MD doing hospital administration is an administrator. Which is not to devalue specialist expertise in these roles. I definitely think you want people with these backgrounds in those roles as well. Just not necessarily exclusively. A career administrator has different skills than a physician, you want people with both, and other, roles working to run a hospital. The real problem as I see it is probably the incentives, constraints, and pressures they work under, or towards. A physician forced to run a for-profit hospital maximizing returns is going to make a lot of the same decisions as someone with a business background in the same situation. The thing is to change the situation, not put different people into that role and expect them to do it dramatically better.

caycep 5y ago
The problem with this is that the MBA programs that churn out hospital administrators tend not to be very good...focus on mergers, cost cutting, not so much on optimizing care. The pendulum has swung too much onto the MBA for MBA's sake hospital administrators and less so on actual medicine.
slantedview 5y ago
> A physician forced to run a for-profit hospital maximizing returns is going to make a lot of the same decisions as someone with a business background in the same situation. Indeed! Whereas a doctor might say yes, give that patient with cancer the treatment they need, the MBA is going to say no, it costs to much, let them die. If the goal is to maximize profit, the MBA is doing a better job. If the goal is to maximize the health of your patients, the doctor is. We must realize that these two goals are fundamentally in conflict with one another. The question isn't whether a doctor or an MBA should be running a for profit hospital, it's whether we should even have for profit hospitals. If we care about people more than profits, then clearly we should not.

slantedview 5y ago

> I strongly believe that only physicians should be running hospitals. More than that - hands on healthcare should not be a for profit industry. The need to make profit is fundamentally opposed to providing the best care. As the push for profit increases, more people get sick and die. This goes for long term care as well, which is facing a similar staffing crisis for similar reasons.

legitster 5y ago
Your local hospital is likely a non-profit. Your health insurance company might even be a non-profit. But they don't do any better. Corporate profit motive doesn't seem to be at play here.
- candiddevmike 5y ago
  It's executive/board/administrative compensation that's more of a problem than profits for most hospitals/insurance companies.

Djvacto 5y ago

As a quick counter-point to *, there is another sub-problem with healthcare/doctors in the US, where often patients with chronic illnesses or not-easily-testable conditions have to fight hard for doctors to take them seriously. The why of this varies a lot from what I've seen, but includes: - an attitude of "most patients are just trying to wring medications out of you" - an ego-hit of "if I didn't make the diagnosis, I don't want to help" (this applies to both patients coming in with a suspicion of what they have, or getting a diagnosis from another doctor) - burn-out/overworking, where doctors have a hard time managing all the different cases coming at them without dropping the ball here and there It's not a simple, single-cause problem at all, but just want to provide an alternative point of view about patients who look things up or come in asking about a specific condition or diagnosis. When I got my ADHD diagnosis after a quarter-century, I went in specifically asking about ADHD because I had seen some flags that made me think I might have ADHD. Contrast that with the people doctors screen out who are trying to get a stimulant prescription despite not needing it, and you have a situation where it's hard for doctors to tell who does or doesn't need meds, and where patients with actual conditions have to fight hard for those to be diagnosed. Even in cases like POTS, which has no medication involved in treatment, just lifestyle changes, and yet people close to me who have POTS all had an uphill battle getting it recognized by anyone, especially doctors who could diagnose (disclaimer: sample size = 3).

argc 5y ago
> When I got my ADHD diagnosis after a quarter-century, I went in specifically asking about ADHD because I had seen some flags that made me think I might have ADHD. Contrast that with the people doctors screen out who are trying to get a stimulant prescription despite not needing it, and you have a situation where it's hard for doctors to tell who does or doesn't need meds, and where patients with actual conditions have to fight hard for those to be diagnosed. I told my doctor I had already been diagnosed with ADHD because I had a strong suspicion I had it and wanted to see for myself if the medication helped (it helped massively). I think medicine should be accessible for patients who need it but I don't know how to avoid large amounts of patients then taking medications for the wrong thing, which would probably happen if it was a free-for-all. It kinda comes down to the question of having the personal freedom to hurt yourself doing something stupid, which is a balance (a little of that freedom is good, too much probably bad). All-in-all I lean toward the current system of using on experts to make the final decision. Still, I would be really pissed if a doctor prevented me from getting stimulants for something I believe I need, so I am not 100% satisfied with the current system either.

travisjungroth 5y ago

> * 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 still think it’s better than the other extreme of just showing up and trusting the professionals. That should work in theory, but my experience for myself and those around me is it’s incredibly ineffective. If what you’re dealing with requires the least bit of thought, odds are you’re getting brushed off to the extent you allow. The real model of US healthcare is essentially apprentice/master, with the patient as apprentice. Apprentice does a lot of the work, not all, some needs to be approved by the master and the apprentice better know how to learn from the master, when to push back, and how to make it seem like it was their idea all along. You can imagine how this falls apart for mental health.

AlphaOne1 5y ago
I also think the complete implosion of family medicine has made this worse. In the past, you would keep the same family medicine doctor for decades and trust them. They in turn would know what your values and priorities are. Moreover, they would be able to guide you through difficult healthcare decisions that inevitably come up (cancer diagnosis, mental health etc.). We have lost the human connection aspect of medicine and those few physicians that are able to hang on to it are burning out due to the massive amounts of paperwork they need to accomplish. From the hospital perspective, (which many physicians now work for) good paperwork=good patient care. Paperwork is measurable. Relationships (other than in the abstract) are not.

scythe 5y ago

>Medical decisions need to be made outside of cost considerations. It's really jarring to read an otherwise reasonable comment that drops a whopper like this. Nothing exists outside of cost considerations. The NSA has cost considerations. The Space Shuttle had cost considerations (obviously, not great ones!). The design of nuclear submarines involves cost considerations, however unsettling that may seem. You're telling me that my broken hand needs to be judged outside of cost considerations? Give me a break. The problem is that there is a lack of "trustworthy" parties to evaluate cost expectations in medicine. The patient often doesn't understand their condition or its treatments, the doctor has a clear perverse incentive to inflate costs, and the insurance company may actually be better off if the patient dies. At least that's the conventional picture. Leftist pundits often complain that the American economy is based on "greed", but a more precise criticism is that there has recently been a trend away from expecting benevolence and for-its-own-sake honesty from anyone under any circumstances, or equivalently an increasing cynicism about human motivations. It remains to be seen whether a medical system can function when nobody expects to trust anyone.

inglor_cz 5y ago
"The Space Shuttle had cost considerations (obviously, not great ones!)." It absolutely did, and great ones too. The program was too costly and never lived up to the original expectations of fast and easy access to orbit. Falcon 9 + Dragon is the first American human-rated launcher and ship that can be labeled as somewhat cost effective.

adolph 5y ago

> Medical decisions need to be made outside of cost considerations. A common attitude which may cause: Health care is extremely costly in the United States. Although the rate of growth in spending has attenuated in recent years, per capita spending on health care is estimated to be 50 to 200 percent greater in the United States than in other economically developed countries. Despite leading the world in costs, however, the United States ranks twenty-sixth in the world for life expectancy and ranks poorly on other indicators of quality. https://journalofethics.ama-assn.org/article/complex-relationship-between-cost-and-quality-us-health-care/2014-02 https://journalofethics.ama-assn.org/article/complex-relatio...

inglor_cz 5y ago
Looking at the levels of obesity in the U.S., I consider the 26th place a true miracle of American medicine. If it can prevent people who devastate their bodies with junk food for decades from dying at 50 ... On the other hand, imagine the world where Coca-Cola makes billions on healthy drinks, people are slim and fit until they die, and half of the money spent on treatment of chronic diseases of excess can be used for something else.
- rootusrootus 5y ago
  > Looking at the levels of obesity in the U.S., This is not unique to the US. Can't really say "but we only have 25% obesity here" and call that any kind of win. Maybe the US leads in this regards (though it varies by region, some areas have European-level obesity rates), but obesity is a worldwide problem.

legitster 5y ago

> after service has been rendered can decide to pay less, or not pay at all, or stop paying that provider altogether, etc This actually isn't necessarily true when you learn how billing codes work. Most insurance companies pay out at a fixed rate per billing code based on your plan. That doesn't change. What does change is that hospitals can retroactively apply new additional billing codes. This happened to us once for an ER visit where we got 3 additional surprise bills over 6 months because the hospital retroactively applied new billing codes to our visit.

JackFr 5y ago

> * 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. The skills need to run a hospital are quite different than those required to be a doctor. I'm not saying hospitals aren't unique - I believe they are and their adminstration is highly specialized. Doctors should inform the administration at every level but it would be a waste of their training and a bad idea for doctors to run everything. > 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). Would you be as quick to say "Doctors should work without pay." ?

cmorgan31 5y ago
Why would not paying doctors be the natural consequence? It’s a fairly significant jump to go from don’t let cost be a primary decision driver to let’s force doctors to work without pay.
- bumby 5y ago
  Because in reality, there are always tradeoffs and constraints. In the US, a disproportionate amount of healthcare costs come at the very, very end of life. It's possible to meet the sole criteria of science, quality, and patient wishes with exploding costs. I think the OP's point was that money has to come from somewhere.
  - zeruch 5y ago
    "a disproportionate amount of healthcare costs come at the very, very end of life." One might ask why that is; while some is surely due to natural decline in later years, one could likely also posit that the cost-fears leading up through that period (decades), and the general inability to get people to do preventative care throughout adulthood contribute to that significantly.
    - bumby 5y ago

ryanbrunner 5y ago

> * 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 think this is exacerbated by doctors a lot of the time. I'm in Canada so it's obviously a very different system, but visits to a GP often have strict time limits and "one issue only" rules. When you can only talk about one symptom, and you only have 5 minutes to explain it, it's natural to try and do homework first to see what you're going to use your limited time on.

dr_ 5y ago

Let me add two more payment scenarios: 1) Pay in the form of a credit card number, where the provider ends up paying CC processing fees to process the payment. 2) Ask for the money back, months later.

umvi 5y ago

> * I strongly believe that only physicians should be running hospitals. Strong disagree. This same attitude pervades the military ("only pilots should run the air force") and really all it does is that lower representation of the interests of the other non-pilot 90% of your organization and put a pilot bias on every decision being made.

advael 5y ago
Those are extremely different situations and you’ve not really justified why they’re being compared. A “doctor bias” in every decision being made would ideally prioritize health outcomes over decisions made for profit or convenience. It’s possible that doctors will make poor decisions too, but on balance our expectation based on their training is that decisions made because of healthcare outcomes would be more likely in this scenario than the current state of affairs, which prioritizes economic considerations as administrators in every context currently tend to
- bumby 5y ago
  I think the point is that "doctor bias" will not take a balanced approach to the other systemic factors. I'd argue it's the same with the pilots. If you asked pilots, they'd likely say the same thing: their priorities are going to align with the mission better than anyone else's. Anecdotally, this has been true in my experience on complex engineering projects. When the project manager is a mechanical engineer, guess which systems get the most time, money, and priority? Mechanical. And when it's an electrical engineer, the electrical system gets the priority. When it's a software engineer, the software etc. They all recognize the other systems, but availability bias skews their worldview and priorities to the neglect of others.

hinkley 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 That's not always the case. The reason I stopped writing mobile applications long ago was because the mobile carriers were doing exactly this, and not even providing enough paperwork for you to argue with them about it. People like to lambast the Apple App Store for being greedy, but the fact of the matter is that people netted 3x as much off Apple that they did from the carriers. They are asking too much money now but their rates were absolutely defensible at the time. It's not a coincidence that we had a gold rush that started almost exactly when the App Store became a viable target. One might ask what would happen if we joined the rest of the 1st World in providing medical care and marginalized private health insurance. Would it be a similar watershed moment?

towaway15463 5y ago
The only gold rush in medicine where I’m from involves moving to the US to get away from a nationalized health care system.
- ejb999 5y ago
  curious - where is that?

bumby 5y ago

>I strongly believe that only physicians should be running hospitals. Can you elaborate on your rationale? I ask because I've worked in hospitals run by a cadre of physicians and it was not run well. Anecdotal, obviously, so I'm curious on your thoughts on what they provide. My worry is that it can lead to an unbalanced technocracy. It's like saying a politician needs to come from [industry x] to govern [industry x]. Technical competence is a necessary, but insufficient criteria when managing a multifaceted problem. The risk is that the front-line physician priorities would always become the organization's top priority. In reality, a hospital administrator has to manage competing priorities across many different domains.

ipaddr 5y ago

* In this day and age not being your own doctor/advocate will produce unwanted unnecessary results. If you look up possible treatments /side effects and your personal history you will be in a better position to engage and weight options. If you blindly accept everything you will end up on the most profitable treatment plan plan insurance allowed.

samstave 5y ago

>I strongly believe that only physicians should be running hospitals. (Disclaimer: I have been on the design team for several hospitals, including El Camino and San Francisco General, in the bay area - and I have a family of doctors and nurses in my family - my brother was head of the Veteran Administration for the state of Alaska, and is currently CMO for a large health provider (he is a doctor) --- That said, the "running" of a hospital isa hell of a lot more than medicine (when we are specifically talking to the running of -- but this comment was made in relation to costs/efficiencies as far as outcomes, patient treatment, insurance etc...) Hospitals are really complex ecosystems and should be thought of more like an aircraft carrier than an other form of business. The costs within the realm of a hospital are ridiculous - as are the methods and manner in which hospitals raise money. Insurance is cancer to be sure, but there are so many other factors that go into the operational costs of a hospital - and I don't just mean ngoing care and operations - systems and technology and medicine evolve. People are people and regardless have the same hierachy of needs in any environment. You have every single actor as an enemy of the hospital bottom line: New tech, $$ Older nursing pop $$ Current nursing/doctor market salaries $$ Maintenance for existing systems $$ Insurance billing code lock-in $$ Competing hospitals for doctors and nursing staff $$ California $$ Corruption $$ Utilities and related redundant infra to ensure life systems The ridiculous cost to upgrade The list goes on and on... (The cheapest hospital project I worked on was hundreds of millions of dollars) etc... Hospitals are really expensive to run, and it requires a hell of a lot more skills than simply being a "doctor" to run one.

93po 5y ago

> people thinking being able to Google and read WebMD qualifies them to argue with their doctor about treatment plans In my experience, I have had: 1. Doctors that know nothing about a really basic ailment and not have any meaningful guidance or treatment to suggest 2. Doctors that Google something literally in front of me, things that I have already Googled myself, and draw the wrong conclusion because they're looking at results at a glance - when I had searched myself earlier and dug deeper though, it was clear to me the result he was looking at was just plain wrong 3. Doctors that provide very little to no guidance about a wide selection of medications available to treat a problem, leaving me to essentially guess which option of a dozen or more I should go with 4. Doctors that force me to advocate for myself and my condition before they agree to help treat it - so much so that I had to visit 4 different doctors to find one that would, wasting nearly a thousand dollars of office visits with nothing to show for it. It's no wonder people do their own research and dare to advocate for themselves. Most doctors are fucking worthless.

hallway_monitor 5y ago
I cannot agree enough. I think anyone who has dealt with a puzzling condition quickly learns how limited the "expertise" of these supposed authorities is. Sure, insurance companies are terrible, but so are most doctors. Great, quit, you probably sucked anyway.
- aqfamnzc 5y ago
  It also probably doesn't help that doctors are jacks-of-all-trades medically - there are simply too much complexity to thoroughly understand the nuances of every obscure condition and interaction. However, I think acknowledging when one doesn't know something is a skill many could benefit from improving...
ClumsyPilot 5y ago
Indeed, there have been mutiple instances where, if I had not put my foot down,i would be left untreated and undiagnosed. Doctors are not like other proffeshions, they cannot put things right if the opportunity for treatment is missed

scarface74 5y ago

Opposite anecdote: For done reason about 10 years ago my asthma that had just been a minor nuisance and didn’t stop me from running, teaching fitness classes part time, etc. for a decade, sent me to the hospital and kept me coughing for nearly a year. The doctors and specialists gave me every treatment under the son to no avail. Then I did my own research and read I should try OTC psuedophredrine. It worked like a charm. Now every time I catch a cold (and when I got Covid), I pop psuedophredrine for a few days and I am good. Yes, psuedophredrine is suggested to treat Covid if you have virus induced asthma. Second anecdote: I have relatively mild cerebral palsy. As I’ve gotten older, my affected foot tightens up especially in the winter. My neurologist said it was physical and not neurological. I went on vacation and was drinking more alcohol than I usual do. I noticed I was walking without pain. I did my research when I got home and found a prescription muscle relaxant with the fewest side effects and ask my doctor about it. He prescribed it to me. He didn’t bother telling me that I should get blood work done to check for liver problems. I had to bring it up to him. I can now walk without pain and run when properly conditioned.

dan_quixote 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 This is precisely why I think we will never be able to effectively treat healthcare as a "free market" with tools like HSAs, posted price sheet, etc. The end user can never know the true cost of their procedure until it's long over (sometimes years later) and often don't get to choose at all.