3 ms·
The fundamental problem with US health care is that the incentives are exactly backwards. With “fee for service” the prevailing system, of course we get the max
by wrs 3y ago
The fundamental problem with US health care is that the incentives are exactly backwards. With “fee for service” the prevailing system, of course we get the maximum number of “services”, with providers being driven to provide the most specialized and rare “services”. All while the primary care doctors, who are the ones avoiding the need for services, also known as keeping people healthy, and thus are the most valuable from the point of view of actual societal good, are being driven away.
The system literally generates more revenue the sicker people are. So it’s no wonder it optimizes itself away from keeping people from getting sick. It worked for a while, perhaps because most doctors have morals, but now it seems the shareholders are in charge rather than the doctors.
There is an alternative (“value-based care”) that is slowly catching on, as the governments and companies paying for all these unnecessary services are starting to wonder if there’s a better way. Essentially, you pay a fixed amount per person, so the system is incented to keep people healthier, not sicker. But lord, there are so many entrenched interests fighting against improvement. And even that system can of course be gamed at the expense of society.
- philwelch 3y ago> There is an alternative (“value-based care”) that is slowly catching on, as the governments and companies paying for all these unnecessary services are starting to wonder if there’s a better way. Essentially, you pay a fixed amount per person, so the system is incented to keep people healthier, not sicker. This sounds like rationing. Sorry buddy, they only pay a fixed amount per person so we can’t actually afford that expensive surgery or MRI or whatever else you need, go home and walk it off.
- viraptor 3y agoThe costs per person are pooled in those cases, similar to insurance, so it's expected that some people will "use what others paid in". That's ok. And sure, you can call it rationing, but whatever model of funding you're thinking of, at some point you'll get to make a decision like "do we spend 5M to save those 6 people or that 1 person?" - it's not a few layers detached.
- wrs 3y agoThe setup is more complicated than I described (I was trying to make the core difference clear). You have metrics to ensure that you’re actually keeping people healthy. The amount you get paid per capita is set by negotiation and informed by past spending. I think if you compare the “expensive” MRI in the US to other countries, you’ll find it’s “expensive” because it’s connected to an infinite money spigot and there’s no upper limit on how much it can cost, not because it’s a better MRI.
- cryptonector 3y agoMetrics get gamed.
- wrs 3y agoAs I said. But it’s at least a better starting point to make the top-level goal about outcomes, not money.
- cryptonector 3y ago80/20 insurance didn't get gamed. Maybe that's why we can have it anymore.
- HDThoreaun 3y agoProviding bad service under value based care comes with heavy penalties. If the patient actually needed the surgery their health outcomes would be bad when they don't get it and the healthcare provider would lose a lot of money.
- philwelch 3y agoHow does this happen under value based care? What’s to stop providers from just gaming the metrics and gaslighting people into thinking there’s nothing that can be done for their complicated and expensive medical problems?
- HDThoreaun 3y agoThere are a variety of metrics that are tracked and difficult to game. The easiest to explain is rate of rehospitalization. If patients return to the hospital within x months of being treated at a higher rate than other hospitals you face heavy penalties. Then there's survey results and the like, it's not that hard to come up with reasonably objective metrics that are out of providers hands and therefore difficult to game. In the end it's still a competition, if a patient is unhappy with the care they can switch providers.
- philwelch 3y ago> In the end it's still a competition, if a patient is unhappy with the care they can switch providers. So providers have an incentive to encourage adverse selection and keep the “difficult patients” away from their practices.
- HDThoreaun 3y agoProviders are paid more to deal with “difficult” patients. Of course it’s a risk but for the right price everyone will be taken care of.
- cryptonector 3y agoThe model that used to work, and still would if we hadn't made it practically illegal, is the 80%/20% high-deductible insurance model. That model gives the consumer the incentives to keep consumption levels reasonable, but if they must consume lots (accidents, serious illness) then the insurance company kicks in. Young people today have never experienced such a system, but for decades it was the system. We started moving away from it in the 90s, and completed that move away from it in 2011. Coincidentally (or maybe not so-coincidentally) we've had faster-than-inflation healthcare cost increases since then.