13 ms·

If this were a pill, you’d do anything to get it

243 points by vellum 13y ago

josephlord 13y ago
In the UK the NHS has district nurses one whose roles is exactly this sort of work and it can make big difference especially where the GP is underperforming. These patients can be unwilling to change GP to a better one (which you can do in the NHS).
danso 13y ago
This reminds me of the health care cost paradox that Atul Gawande wrote about in 2011. In Camden, NJ, one percent of the patients accounted for as much as a third of the city's medical costs. A doctor proposed in a small study that giving these lost causes better care actually reduced costs overall. But good luck convincing politicians to devote more money to cocaine addicts and extremely obese patients. http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande?currentPage=all http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...
- tomjen3 13y ago
  Why more money? It seems that even more money could be saved by excluding drug adicts and those who are so fat that their fatness interfere with their treatment.
  - danso 13y ago
    Did you read the article? These people still are treated in emergency care...doctors and emergency medical staff will not ignore someone who needs ER care. Inevitably, most of these patients can't pay, which means the public pays. But putting extra money into the care of these patients prevents costly ER episodes...a little more money upfront apparently saves money in the long run. But of course, we mostly obsess about what we have to pay upfront
    - anonymous 13y ago
      This reminds me of two quotes: > Those who don't make time for exercise today will have to make time for illness tomorrow. and > An apple a day keeps the doctor away. It's all the same concept - preventative care now keeps you healthy for tomorrow and out of the ER.
    - tomjen3 13y ago
      From the article ER wasn't the expensive part, it was the months in ICU. No reason you couldn't identify him there -- granted it would only cut down, not eliminate the costs but it would give a decent motivation to become more healthy.
      - DanBC 13y ago
        No, it would not. People who inject heroin know that injecting heroin is harmful. People who are bariatric patients know that being 500 lbs is considerably risky for their health. Telling these people that they will have yet another bad thing happen if they continue their existing behaviour has little effect to change their behaviour. There's already a long list of bad things. That's why people who've had their leg chopped off continue to inject heroin in the other leg.
        tomjen3 13y ago
        Hmm, maybe just send them directly to an addiction treatment program would work?
  - deleted 13y ago
    [deleted]
  - tonymontona 13y ago
    Yep, the other factor the article mentions is the patients "died, reducing their costs permanently". We could just round up the obese and drug addicts and save a whole bunch of money by killing them. /s
    - mikeash 13y ago
      You could have the healthiest country in the world by a huge margin if you just summarily executed anyone who got a serious illness!
  - DanBC 13y ago
    Getting a drug addict to medical treatment (and addiction harm reduction measures such as clean needles and prescribed heroin) means that they are avoiding crime to get the money to pay for drugs; they're avoiding spreading various diseases such as HIV, hepatitis, etc (which can all be expensive to treat) and they're at less risk of losing limbs or needing very serious surgery. It also helps to keep them out of prison. Even if you hate people who are addicted to drugs and you think they deserve a miserable horrible life you should be persuaded by the fact that modest spending early on prevents large spending -funded by your taxes- later on.
    - tomjen3 13y ago
      How much more money is saved if they stop? Look I don't care if they do drugs, but I will argue against wasting more money on them, unless that money is spent on the real problem: getting them out of their drug addiction.
  - brown9-2 13y ago
    Most of us don't want to live in a society where making bad choices in life (or having bad luck) excludes you from live-saving care.
    - Evbn 13y ago
      And since HN tends to lean anti-social: for the objectivists: most of us would don't want to get denied care because we look like a junkie during an emergency.
      - randallsquared 13y ago
        I think you meant anti-socialist. While HN might or might not lean anti-social, I'm not sure it would have a clear effect on political arguments.
    - tomjen3 13y ago
      I wouldn't want to exclude them, I just don't want to spend (even more) money supporting their bad habits. It is a two-way street: they want more money? They have to take that in the form of drug treatment. The libertarian in me don't want to waste money on them at all but I am not blind to the fact that their life wouldn't have been as miserable as it is if we didn't have a stupid war on drugs.
  - mikeash 13y ago
    How do you propose, in the middle of a medical emergency, to identify the people who have been excluded with enough speed to deny them expensive care but not harm the chances of saving someone who has not been excluded?
    - joshgel 13y ago
      I agree with the general point, but real medical emergencies aren't Grey's Anatomy or ER with people screaming for this or that medication and running down the halls. You have 4.5 hours to treat someone for a stroke and 6 hours for an MI. Not that you don't have to go quickly, but you also don't have to rush unnecessarily.
      - mikeash 13y ago
        There clearly are some medical emergencies that need responses that fast, otherwise I wouldn't see so many ambulances flying by with lights and sirens. Now, maybe there aren't enough of those in the problem category to make a difference in costs. However, even 4-6 hours seems like a pretty short amount of time given that you're going to be trying to identify someone as on a blacklist when they most likely will be trying not to be identified, and measures like requiring ID before treatment will exclude a lot of people not on the blacklist.
      - Cass 13y ago
        You have 4.5 hours to treat someone for a stroke if they teleport to the hospital the second they notice the first symptom. In real life, you often have an hour or four where the patients wait for their weird symptoms to go away again because they don't want to overreact and bother some busy doctor who should be taking care of Serious Emergencies, and then another half hour to get them to the ER, and then you're lucky if they're still in the treatment window at all by the time a doctor sees them. There's not a lot of running down halls in screaming in real ERs, but there's also no time to, for example, send someone to go home and get the ID the patient forgot in their panic and hurry, to prove they're not blacklisted "no medical treatment" somewhere.
      - moioci 13y ago
- Evbn 13y ago
  Don't give up hope. Cities are making progress in HRF and preventive care.
  - stunt_preamble 13y ago
    What does HRF stand for?
- SoftwareMaven 13y ago
  It's not just medical care. Housing follows the same trend[1]. These kinds of studies make me wonder if, politically, we care about cost savings at all. 1. http://www.upenn.edu/pennnews/news/housing-homeless-mentally-ill-pays-itself-according-university-pennsylvania http://www.upenn.edu/pennnews/news/housing-homeless-mentally...
  - mikeash 13y ago
    I think we care about cost savings politically, but we don't care about evidence. If someone holds the political belief that cutting public services for the poor saves public money, it's unlikely that any number of studies will change their mind. Politicians seem to have decent motives, but the system is almost inherently allergic to facts.
  - ahoyhere 13y ago
    I've been watching these issues for a long time and here's the conclusion I've come to: Americans care far more about people getting "what they deserve," than caring about costs in the long run. Many of the Americans who have the least will still argue against people like them getting "free" things like healthcare -- "I DON'T HAVE HEALTHCARE, LOOK AT ME, I'M FINE". Because they believe those other people don't deserve it. On some level, they believe they don't deserve it either. (In America, land of opportunity, you get what you deserve! So if you don't have it already, you don't deserve it, post ergo propter hoc.) This also explains why allegedly fiscally conservative Republicans don't support a guaranteed minimum income, because "those people" haven't "earned" it -- no matter that the uncountable costs to society, and the totally countable costs to the government/taxation system, is much greater when people go poor and raise their children in poverty and in slums. Americans, by and large, are so afraid that one person will get something they don't "deserve" that they'd rather punish them, and everyone else, many times over. The opposite of "Better 10 guilty men go free, than one innocent suffer." IMO this also explains our ridiculously punitive sentences, instead of simple rehabilitation which is proven to reduce recidivism. "Why would you give them THERAPY? and GYMS? and let them have PUPPIES? THEY'RE SUPPOSED TO BE IN JAIL!" And why so much (much more than you'd think) of the general spirit seems to be against young women who are raped. And on and on. People obviously must be getting what they deserve, or nothing makes sense about their beliefs about themselves, their country, what they've achieved (or not) in their lives, etc. (I say "Americans" because I've lived for years in another country and traveled all over, and this is far from a universal feeling.) Puritannical background at work? Perhaps. Certainly not Quaker.
adpirz 13y ago
Atul Gawande wrote about a similar initiative in Camden, NJ, two years ago: http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...
loceng 13y ago
Well, now we're fighting mental illness at an alarming rate due to many factors - that we could manage better. I'd like to see the graph of rate of mental illness from the past, to now - and yes, I realize there's a strong argument for that we're better at diagnosing people now, however it just doesn't add up IMHO.
venomsnake 13y ago
It is about job description. Just put into law that all government money should ensure the best outcomes for the patients and then a lot of things become possible. Give simple and powerful mandate to all health related businesses.
- brown9-2 13y ago
  A part of the issue is that it's hard to define "best outcome", you'd have to make sure to not accidentally incentivize drastic short-term procedures like open heart surgery, where the immediate affect is positive (patient hasn't died) but a longer term view would have questioned the care that led the patient to that state in the first place.
CurtMonash 13y ago
My grandfather, a physician, made house calls 7 days a week. It was just assumed in those days. When he couldn't drive during WW2 (German refugee = enemy alien) he couldn't be in private practice. Replacing doctors with nurses in that story is a perfectly sensible modern adaptation. But the house calls are a really good idea. Not coincidentally, they're a central aspect of the exploding trend toward assisted living.
- jnbiche 13y ago
  Please forgive me for going off-topic and for asking a personal question (and please don't answer if it's too personal), but how did the government inform your grandfather that his movement was restricted during WWII? Did he receive some sort of notice from the FBI? I'm sorry that our government chose to restrict the civil liberties of a very important member of his community during WWII on the basis of his ethnicity. A cautionary tale for today's America.
  - adestefan 13y ago
    Note that the OP's grandfather was not a US citizen, but a refugee from a declared enemy during a time of war. There's a huge difference between the two. That fact that he was even allowed to practice medicine is amazing.
    - Evbn 13y ago
      The atomic bomb was built in large part by refugees from a declared enemy during time of war.
      - gngeal 13y ago
        But those weren't doing house calls and were under guard. :)
      - adestefan 13y ago
        Most of the US based scientists were either US citizens (some natural born; others naturalized) or came to the US in the 20s or early 30s. Even then very, very few of these men were German citizens. Fuchs, who was one of the few German refugees, was part of a contingent from the UK. The only reason why Fuchs was even allowed to be a part of the project was because of political pressure outside the project. This is all documented in exrutiating detail in Rhodes' series on the making if both the atomic and hydrogen bombs.
MichaelGG 13y ago
Why do people like to use average life expectancy? "Average life expectancy was 45 years old at the turn of the century." That provides very little information about the distribution of lifetimes and provides a biased view when compared to the 85-year-olds mentioned in the next sentence. Infant/child mortality skews the average a lot. You could have everyone living to 90, if they survive to 5, and still have an average of 45. War and other disasters can also change the average in ways that have little meaning for the medical programs in question.
- rocky1138 13y ago
  It also bugs me when people say "at the turn of the century," since we just recently had one of those but the person is talking about the one previous. /nitpick
  - Evbn 13y ago
    Fin de Ceicle
- NuZZ 13y ago
  It's like it's a warm story that we propagate to make us feel great. As if we stand as demi-gods in comparison to the relative cavemen of 200 years ago. The most major accomplishment in respect to longevity appears to be... not letting our young perish. Which is obviously all well and good until this kind of argument is used to validify medicine perhaps beyond its merit. Forgive the generalizations.
- monkeypizza 13y ago
  This mistake seems to be getting more and more common. I use the example of sea turtles - the average lifespan across a clutch of eggs is maybe 1 year - because one out of 100 survives. But the one that survives usually lives for 100+ years. The fact that the life expectancy at hatching is only one year tells you nothing about the distribution.
tokenadult 13y ago
I repeatedly post this chart that shows life expectancy stratified by age to HN: http://www.scientificamerican.com/article.cfm?id=longevity-why-we-die-global-life-expectancy http://www.scientificamerican.com/article.cfm?id=longevity-w... I learned about this article from another participant's submission to Hacker News. I happen to be part of a "journal club" with a researcher who studies, among other things, demography of aging, and from him I've learned some startling facts about increases in life expectancy around the world. Girls born since 2000 in the developed world are more likely than not to reach the age of 100, with boys likely to enjoy lifespans almost as long. The article "The Biodemography of Human Ageing" by James Vaupel, http://www.demographic-challenge.com/files/downloads/2eb51e2860ef54d218ce5ce19abe6a59/dc_biodemography_of_human_ageing_nature_2010_vaupel.pdf http://www.demographic-challenge.com/files/downloads/2eb51e2... originally published in the journal Nature in 2010, is a good current reference on the subject. Vaupel is one of the leading scholars on the demography of aging and how to adjust for time trends in life expectancy. His striking finding is "Humans are living longer than ever before. In fact, newborn children in high-income countries can expect to live to more than 100 years. Starting in the mid-1800s, human longevity has increased dramatically and life expectancy is increasing by an average of six hours a day." http://www.prb.org/Journalists/Webcasts/2010/humanlongevity.aspx http://www.prb.org/Journalists/Webcasts/2010/humanlongevity.... A comparison of period life expectancy tables and cohort life expectancy tables for men and women in Britain http://www.ons.gov.uk/ons/rel/lifetables/period-and-cohort-life-expectancy-tables/2010-based/p-and-c-le.html http://www.ons.gov.uk/ons/rel/lifetables/period-and-cohort-l... helps make the picture more clear. ("Period life expectancy" is what is usually reported for a whole country. But cohort life expectancy provides a better estimate of future lifespans of young people today, http://www.time.com/time/specials/packages/article/0,28804,1963392_1963367,00.html http://www.time.com/time/specials/packages/article/0,28804,1... and is still steadily on the rise around the world.) Life expectancy at age 40, at age 60, and at even higher ages is still rising throughout the developed countries of the world.
- jessriedel 13y ago
  From the Vaupel article: > If progress in reducing mortality continues at the same pace as it has over the past two centuries, which is a matter of debate, then in countries with high life expediencies most children born since the year 2000 will celebrate their 100th birthday — in the twenty-second century. Um, color me very skeptical. My guess is there is a lot more disagreement with the startling hypothetical "if progress in reducing mortality continues at the same pace as it has over the past two centuries" then the single reference after "debate" would have you believe. (italics mine)
rocky1138 13y ago
My Taiwanese friends frequently remind me of the historic Chinese practice of a doctor visiting the family regularly to keep health well. The doctor would receive weekly pay only while the family was well; once someone got sick, they stopped getting paid until the doctor helped them recover. This preventative practice reminds me a lot of what my Taiwanese friends speak about. It seems the age-old cliche "An ounce of prevention is worth a pound of cure" applies here.
- venomsnake 13y ago
  Except in the cases of some types of cancer (breast/prostate/liver) where whether you will live or die dices are rolled during the genesis of the cancer and can be influenced little by the treatment. But more than pays about melanoma. It is all about the illness.
- mikeash 13y ago
  That sounds like it could go very badly if you have a mercenary doctor and you come down with an incurable but manageable condition.
  - roguecoder 13y ago
    By the time you've spent years caring for a family, you probably care about their health for more than just the cash. Not to mention the reputation effects of abandoning sick patients...
tomohawk 13y ago
Three points were interesting to me: 1) The chart with the blip for the 1918 flu. If we reduce costs by closing facilities, how we cope with the next blip? 2) This is an area ripe for disruption, but regulatory capture seems to prevent this. 3) We should all be spending more time with our elders and noticing these sorts of issues, if for no other reason than it will improve their health.
- DennisP 13y ago
  1) It's not like those facilities are sitting around empty right now. If we close them only by the amount that we reduce the need for them, we'll have about the same reserve capacity.
ajtaylor 13y ago
The money quote for me was this: “If we scaled what Ken is doing,” Brenner says, “you would probably shut down a third of the hospitals in the country. It’s a disruptive innovation. It just guts the current business model.” Wouldn't it be better if people never had to go into the hospital in the first place? Aside from the supplemental costs - "surgical complications increase the margin the hospital makes on the patient by 330 percent for the privately insured and 190 percent for Medicare patients." - consider the quality of life issues. If Medicare is concerned with scaling this program up from a couple thousand people, instead of completely cutting a program which has proven its ability to cut costs AND improve quality of life, why not try it with five or ten thousand people first? If that works, then try it with 20 thousand people, then 50 thousand. If it doesn't scale at that point, then cut it. Another possible solution is to find a way to eliminate the for-profit hospitals. But Medicare's solution - "It’s pushing providers to band together into accountable care organizations, or ACO, that get a flat fee for all care related to a patient." - sounds destined to fail from the outset to this layman.
- DanBC 13y ago
  Yes. For illnesses like diabetes it's best if you can prevent people getting it, but if they have it it's best if you can help them to avoid getting the complications. "Diabetic foot" sounds funny, until you realise that it kills people and is a reason for leg amputation. (Prognosis after such amputation wasn't great last time I looked, in about 2004.) Sending a real person in a car to visit someone at their home sounds intensive, and sounds expensive. Compare it to a tele-medicine device that takes measurements and sends those to a centre somewhere, with people calling over the phone. It's a shame that the evidence base appears to be being ignored. EDIT (after adestefan and ajtaylor commented) -- it feels expensive, but the evidence base is clear that it's not expensive because it works, where as the thing that feels cheap is wasted money because evidence shows it doesn't work. And it's a shame that people in charge appear to be ignoring evidence, and going by 'gut feeling', because it means effective interventions are not happening. I hope that mentioning the research that a decision is based on becomes more widespread. Even organisations that claim to be evidence based can make odd decisions.
  - 13y ago
wisty 13y ago
> Medicare is referring to the newly created Center for Medicare and Medicaid Innovation, which gives the program power to create and expand projects without congressional authorization. This authority could also be used to create projects based on HQP’s lessons. It’s not. Instead, Medicare has created a raft of projects and experiments meant to move the system from fee-for-service toward pay-for-quality — with the hope that if they can get the payment incentives right, then the market will have reason to support programs like HQP. Yep. As long as the government bureaucrats develop perfect payment incentives, the market will do its job. It's the same story in education. And programming - if you can find the perfect metric for code production (SLOC? function points? story points?) you don't need to do anything else. But with an imperfect metric, Cambell's Law (http://en.wikipedia.org/wiki/Campbell%27s_law http://en.wikipedia.org/wiki/Campbell%27s_law) kicks in. Want to reduce waiting times? Kick out patients so they die at home. Increase successful surgeries? Tell the doctors to fix a lot of ingrown toenails. Increased lifespan? Make decisions which increase life expectancy, at the expense of quality of life. Or just try to get rid of patients who have poor prospects. The greatest strength of markets is also their greatest weakness - they are much smarter and more agile than government departments. They can become a malicious literal genie, which optimises whatever the incentives are.
- carbocation 13y ago
  Personally, I like the adage of the Cobra effect to describe similar situations: https://en.wikipedia.org/wiki/Cobra_effect https://en.wikipedia.org/wiki/Cobra_effect
- notatoad 13y ago
  Well there needs to be some sort of artificial incentive if you're going to keep medicine profit-based. The best way to generate profit without those incentives is to keep as many people as sick as possible, because sick people are more profitable than healthy people.
glenra 13y ago
One big problem with medicine in this country is that bad hospitals can't just go out of business and be replaced by better ones. If you want to open a new hospital today, there are hearings in which all the crappy existing other hospitals have to say it's okay before you can get a "Certificate Of Need". So if you had an idea for a new hospital structure that would dramatically improve patient health and cut costs, you wouldn't be allowed to just build it and try it - the existing providers all get a veto. So we have hospitals that hide all the prices and make MORE money if they screw up and introduce complications, and it's ILLEGAL to drive those idiots out of business with a more customer-responsive system. It's like if you couldn't open a new coffee shop without permission from Starbucks or a new restaurant without permission from McDonald's. In anything even vaguely resembling a free market, reforms like this wouldn't need to be pushed by a monolithic central bureaucracy - they'd just spread on their own, with old providers rushing to adopt the modern changes for fear of becoming obsolete. http://en.wikipedia.org/wiki/Certificate_of_need http://en.wikipedia.org/wiki/Certificate_of_need
- tosseraccount 13y ago
  Looks like the hospitals are using the same techniques as the taxis to keep out the competition.
- pekk 13y ago
  The free market offers no incentive to give health services to people who cannot pay for it, or don't know that these services will reduce hospitalization by 33% and costs by 22%. Basic health care is not McDonald's because your mother does not die prematurely (and miserably, and expensively) for the lack of McDonald's. The core issue is not about some private business being 'customer-responsive' in the vein of Starbucks. You can, today, start private clinics which are more "customer-responsive" (leave a mint on your pillow, etc.) but how are you going to recoup the costs and in particular, how does that benefit the populace in aggregate?
  - HarryHirsch 13y ago
    > The free market offers no incentive to give health services to people who cannot pay for it, or don't know that these services will reduce hospitalization by 33% and costs by 22% Amen to that. The major killers at the turn of the last century were tuberculosis and waterborne diseases, and the free market did nothing to improve living conditions or supply clean water to the urban population then. I am in Portugal right now, where Dr Sousa Martins, a physician who spearheaded the fight against tuberculosis, is considered a saint. Public health is always political issue. It is as true 100 years ago as it is now.
dkarl 13y ago
According to a new study in the Journal of the American Medical Association, surgical complications increase the margin the hospital makes on the patient by 330 percent for the privately insured and 190 percent for Medicare patients. This is scary when you consider how good people are at the subconscious mental gymnastics that allow them to justify pursuing their own interests at the expense of others. Either human beings are perfect angels -- inhumanly good, too good for much of human history to have actually happened -- or many people have been tortured and killed for those margins.
- Cass 13y ago
  How many doctors actually stand to gain by mistreating patients, though? I don't know about the USA, but in my country, most medical care is provided by salaried doctors who are paid the same regardless of the hospital's profit margin. Now, obviously we do want the hospital to be profitable enough that they don't start firing us, but there's certainly no immediate benefit along the lines of "Well, I don't this guy to get an infection, but I'd make an extra $ 1000 if he did," which I agree would certainly provide skewed incentives. The only thing that happens when my patients get complications is I get to pull more unpaid overtime.
  - dkarl 13y ago
    Complication rates are affected by hospital procedures and policies, staffing levels, training, and presumably the pressures that are or aren't put on doctors. All of those are under the control of the administrators who look out for the bottom line. Whether complications make money or cost money surely affects administrators' eagerness to revamp and/or enforce handwashing policies, update training for nurses, keep staffing levels high enough that inexperienced nurses are properly supervised, and put pressure on doctors with high complication rates. To make it more concrete, there was an article on HN a few years ago suggesting that post-surgical complication rates could be reduced by creating surgery checklists where very basic surgical steps would be checked off as the surgery proceeded: patient identity verified, everything properly sanitized, materials accounted for afterwards, things like that. You would expect a hospital administrator to make a cost-benefit analysis taking into account the cost of researching this idea, creating a trial program, and monitoring compliance and effectiveness. The cost-benefit analysis looks like this: If the program is ineffective, we lose money. If it's effective, we lose even more money. If it's really, really effective, it could screw up the bottom line so much that I lose my bonus or even my job.
bconway 13y ago
Average life expectancy was 45 years old at the turn of the century. You didn’t have 85-year-olds with chronic diseases. Yes you did. That's like saying there weren't old people a hundred years ago. The reason the average was 45 years is because of the astounding rate of infant mortality (much improved now).
- jmhain 13y ago
  Thank you, I was hoping somebody would have already made this point. Funny thing is, both statements are true; you really didn't have 85-year-olds with chronic diseases. There were 85-year-olds, they just didn't have chronic diseases. The idea that we have them now is due to improved treatment of other diseases ignores tons of epidemiological evidence that says otherwise.
commanda 13y ago
It seems to me that health insurers are already aligned with the goal of keeping patients from receiving care for acute conditions, so perhaps some of them, being private companies, unencumbered by special interests or government bureaucracy, will adopt systems like the one outlined in this article. Maybe that's a cynical outlook, but since it has been demonstrated that hospitals, being for-profit, are tragically misaligned with maintaining patients' wellness.
SoftwareMaven 13y ago
“The largest group in the top one percent of income in America are physicians.” It is going to be very challenging to introduce changes that negatively impact a profession with the social respect and the deep pockets physicians have. It could probably succeed in a countries like Canada, Sweden or Germany, but overcoming entrenched interests in the US and not getting labelled "socialized medicine"[1] in the process is unlikely. 1. Of course it's no more socialized medicine than Medicare, but it's a good way to discredit your opponents.
- carbocation 13y ago
  As of 2008, nearly 59% of US physicians supported national health insurance [1]. Doctors are not the culprit. 1 = http://annals.org/article.aspx?articleid=740467 http://annals.org/article.aspx?articleid=740467
  - refurb 13y ago
    What do that "national health insurance" look like for physicians? Does it include pay cuts? I'm pretty sure in those 59% of physician's eyes it doesn't.
    - carbocation 13y ago
      The answer to that question depends on whether you think physicians lack insight. I think that most physicians are smart enough to look at the national insurance that already exists (Medicaid & Medicare) and to recognize that their reimbursements would be cut. I think they can balance that against the complexities of the current system and some might be willing to trade somewhat lower pay for the ability to focus on providing care. 20% of health care costs come from physician pay, of which about half goes to the cost of running a practice. Most reformers know that cutting physician pay, while part of almost any plan, is not going to be the most important way to save money.
    - roguecoder 13y ago
      If pay cuts were accompanied by less annoying insurance infrastructure, I'm sure some doctors would take the pay cuts.
savrajsingh 13y ago
"if this were a pill"
kens 13y ago
This looks like a good approach to health care, and I don't want to be snarky guy, but... Health Quality Partners is about to lose their funding and they get an 8-page glowing article on washingtonpost.com about how great their program is and why it should be continued. It looks like some PR agency is really earning their money. See, of course, Paul Graham's article on PR agencies: http://www.paulgraham.com/submarine.html http://www.paulgraham.com/submarine.html Going back to the subject of the article, I wonder how much this visit program actually costs, and whether it could be direct-marketed to wealthy people with elderly parents. "For $10,000(e.g.) a year, we can reduce your parents' hospitalizations by 33% and help them live independently." Sort of like concierge medicine.
- davycro 13y ago
  > Going back to the subject of the article, I wonder how much this visit program actually costs, and whether it could be direct-marketed to wealthy people with elderly parents. "For $10,000(e.g.) a year, we can reduce your parents' hospitalizations by 33% and help them live independently." Sort of like concierge medicine. Better yet, maybe health insurance companies could offer lower rates to chronic patients who enroll in a visit-program. They are the organizations with the most financial incentive to implement these programs.
  - tomjen3 13y ago
    They absolutely would (and I still don't see why they don't the cost/benefit ratio of paying for that should make sense) but in this case they are talking about the people who have no insurance or whoes bills are paid by the federal tax payers. And while there are a fair amount of positive things to say about the federal government, prudent financial planning isn't exactly one of them.
- ajross 13y ago
  Just for clarity, it's an Ezra Klein blog entry, not an article. Obviously Klein is no less susceptible to PR, but this isn't being presented as an unbiased news article. He's an opinion journalist.
roguecoder 13y ago
This reminds me an awful lot of the role of village witch in Terry Pratchette's books. I think we've lost that caretaker role in society because we always assumed it was their children's responsibility. It seems like if capitalism can get something for free, it is assumed to be worthless.
claudiusd 13y ago
The challenge with health care in the US is that nobody has incentives for reducing health care expenditures. Hospitals get paid when you get sick. Insurance companies see higher margin from reducing administrative costs. Patients are largely uninformed and there are few services out there to help them make lifestyle changes... not to mention that they expect somebody else to pay for it. Employers actually bear most of the non-medicare/medicaid financial risk, but they aren't health experts and have been burned in the past by tele-medicine programs that don't work. Preventive care programs like the one at HQP are proving that preventive care is effective, but sending a nurse to your home regularly is expensive and I'd question the ROI from doing so, absent some focus on a particular disease. With a solid ROI and some good hard evidence, HQP shouldn't have to rely on CMS to keep them afloat... with some work they would be able to sell their program to payers. HQP also isn't addressing the systemic issues I mentioned above, so what's especially frustrating about the article is that they bash on ACOs, which is one of the first attempts by CMS to actually align incentives and mend those issues. And frankly, those changes aren't going to be good for hospitals... I'm sure a lot will go out of business as people get healthier and don't need them. This piece of the article in particular makes me question HQP's motives.
CurtMonash 13y ago
As for going into hospitals making you worse -- I agree from experience. One of my parents went into the hospital for a back procedure, and came back with her mind significantly diminished. She died 8 months later. The other, in and out of the hospital, eventually died the same week, and one of his complications was MRSA. Both were at Riverside Methodist Hospital in Columbus, OH, which I gather is a perfectly solid institution.
teeja 13y ago
Wow. If we can't maintain ways for the cream to rise to the top in the US, we'll continue to become increasingly mediocre.
rthomas6 13y ago
If this is as cost-effective as it claims, what's to stop private insurance companies from pushing and covering it? It should theoretically cut their own costs in the long run, right?
- GFischer 13y ago
  I wish some insurance companies could figure out that. In reality, if they are something like the one I work for, politicking and manager infighting will prevent it - everyone wants the OTHER divisions to lose power, but not their own. My own manager created his own personal software factory (for a freaking country branch), in spite of my belief that it's extremely inefficient for the company as a whole. The shareholders don't care as long as the company makes money.
bjhoops1 13y ago
The tendency among physicians to be dismissive towards remedies that are procedural in nature reminds me of the tendency of programmers to show disinterest in non-technical solutions to problems. But as Jeff Atwood reminds us, "The Best Code is No Code At All," and I imagine that physicians could use a similar reminder: "The Best Treatment is No Treatment at All."

243 points by vellum 13y ago

In the UK the NHS has district nurses one whose roles is exactly this sort of work and it can make big difference especially where the GP is underperforming. These patients can be unwilling to change GP to a better one (which you can do in the NHS).

danso 13y ago

This reminds me of the health care cost paradox that Atul Gawande wrote about in 2011. In Camden, NJ, one percent of the patients accounted for as much as a third of the city's medical costs. A doctor proposed in a small study that giving these lost causes better care actually reduced costs overall. But good luck convincing politicians to devote more money to cocaine addicts and extremely obese patients. http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande?currentPage=all http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...

tomjen3 13y ago
Why more money? It seems that even more money could be saved by excluding drug adicts and those who are so fat that their fatness interfere with their treatment.
- danso 13y ago
  Did you read the article? These people still are treated in emergency care...doctors and emergency medical staff will not ignore someone who needs ER care. Inevitably, most of these patients can't pay, which means the public pays. But putting extra money into the care of these patients prevents costly ER episodes...a little more money upfront apparently saves money in the long run. But of course, we mostly obsess about what we have to pay upfront
  - anonymous 13y ago
    This reminds me of two quotes: > Those who don't make time for exercise today will have to make time for illness tomorrow. and > An apple a day keeps the doctor away. It's all the same concept - preventative care now keeps you healthy for tomorrow and out of the ER.
  - tomjen3 13y ago
    From the article ER wasn't the expensive part, it was the months in ICU. No reason you couldn't identify him there -- granted it would only cut down, not eliminate the costs but it would give a decent motivation to become more healthy.
    - DanBC 13y ago
      No, it would not. People who inject heroin know that injecting heroin is harmful. People who are bariatric patients know that being 500 lbs is considerably risky for their health. Telling these people that they will have yet another bad thing happen if they continue their existing behaviour has little effect to change their behaviour. There's already a long list of bad things. That's why people who've had their leg chopped off continue to inject heroin in the other leg.
      - tomjen3 13y ago
        Hmm, maybe just send them directly to an addiction treatment program would work?
- deleted 13y ago
  [deleted]
- tonymontona 13y ago
  Yep, the other factor the article mentions is the patients "died, reducing their costs permanently". We could just round up the obese and drug addicts and save a whole bunch of money by killing them. /s
  - mikeash 13y ago
    You could have the healthiest country in the world by a huge margin if you just summarily executed anyone who got a serious illness!
- DanBC 13y ago
  Getting a drug addict to medical treatment (and addiction harm reduction measures such as clean needles and prescribed heroin) means that they are avoiding crime to get the money to pay for drugs; they're avoiding spreading various diseases such as HIV, hepatitis, etc (which can all be expensive to treat) and they're at less risk of losing limbs or needing very serious surgery. It also helps to keep them out of prison. Even if you hate people who are addicted to drugs and you think they deserve a miserable horrible life you should be persuaded by the fact that modest spending early on prevents large spending -funded by your taxes- later on.
  - tomjen3 13y ago
    How much more money is saved if they stop? Look I don't care if they do drugs, but I will argue against wasting more money on them, unless that money is spent on the real problem: getting them out of their drug addiction.
- brown9-2 13y ago
  Most of us don't want to live in a society where making bad choices in life (or having bad luck) excludes you from live-saving care.
  - Evbn 13y ago
    And since HN tends to lean anti-social: for the objectivists: most of us would don't want to get denied care because we look like a junkie during an emergency.
    - randallsquared 13y ago
      I think you meant anti-socialist. While HN might or might not lean anti-social, I'm not sure it would have a clear effect on political arguments.
  - tomjen3 13y ago
    I wouldn't want to exclude them, I just don't want to spend (even more) money supporting their bad habits. It is a two-way street: they want more money? They have to take that in the form of drug treatment. The libertarian in me don't want to waste money on them at all but I am not blind to the fact that their life wouldn't have been as miserable as it is if we didn't have a stupid war on drugs.
- mikeash 13y ago
  How do you propose, in the middle of a medical emergency, to identify the people who have been excluded with enough speed to deny them expensive care but not harm the chances of saving someone who has not been excluded?
  - joshgel 13y ago
    I agree with the general point, but real medical emergencies aren't Grey's Anatomy or ER with people screaming for this or that medication and running down the halls. You have 4.5 hours to treat someone for a stroke and 6 hours for an MI. Not that you don't have to go quickly, but you also don't have to rush unnecessarily.
    - mikeash 13y ago
      There clearly are some medical emergencies that need responses that fast, otherwise I wouldn't see so many ambulances flying by with lights and sirens. Now, maybe there aren't enough of those in the problem category to make a difference in costs. However, even 4-6 hours seems like a pretty short amount of time given that you're going to be trying to identify someone as on a blacklist when they most likely will be trying not to be identified, and measures like requiring ID before treatment will exclude a lot of people not on the blacklist.
    - Cass 13y ago
      You have 4.5 hours to treat someone for a stroke if they teleport to the hospital the second they notice the first symptom. In real life, you often have an hour or four where the patients wait for their weird symptoms to go away again because they don't want to overreact and bother some busy doctor who should be taking care of Serious Emergencies, and then another half hour to get them to the ER, and then you're lucky if they're still in the treatment window at all by the time a doctor sees them. There's not a lot of running down halls in screaming in real ERs, but there's also no time to, for example, send someone to go home and get the ID the patient forgot in their panic and hurry, to prove they're not blacklisted "no medical treatment" somewhere.
    - moioci 13y ago
Evbn 13y ago
Don't give up hope. Cities are making progress in HRF and preventive care.
- stunt_preamble 13y ago
  What does HRF stand for?
SoftwareMaven 13y ago
It's not just medical care. Housing follows the same trend[1]. These kinds of studies make me wonder if, politically, we care about cost savings at all. 1. http://www.upenn.edu/pennnews/news/housing-homeless-mentally-ill-pays-itself-according-university-pennsylvania http://www.upenn.edu/pennnews/news/housing-homeless-mentally...
- mikeash 13y ago
  I think we care about cost savings politically, but we don't care about evidence. If someone holds the political belief that cutting public services for the poor saves public money, it's unlikely that any number of studies will change their mind. Politicians seem to have decent motives, but the system is almost inherently allergic to facts.
- ahoyhere 13y ago
  I've been watching these issues for a long time and here's the conclusion I've come to: Americans care far more about people getting "what they deserve," than caring about costs in the long run. Many of the Americans who have the least will still argue against people like them getting "free" things like healthcare -- "I DON'T HAVE HEALTHCARE, LOOK AT ME, I'M FINE". Because they believe those other people don't deserve it. On some level, they believe they don't deserve it either. (In America, land of opportunity, you get what you deserve! So if you don't have it already, you don't deserve it, post ergo propter hoc.) This also explains why allegedly fiscally conservative Republicans don't support a guaranteed minimum income, because "those people" haven't "earned" it -- no matter that the uncountable costs to society, and the totally countable costs to the government/taxation system, is much greater when people go poor and raise their children in poverty and in slums. Americans, by and large, are so afraid that one person will get something they don't "deserve" that they'd rather punish them, and everyone else, many times over. The opposite of "Better 10 guilty men go free, than one innocent suffer." IMO this also explains our ridiculously punitive sentences, instead of simple rehabilitation which is proven to reduce recidivism. "Why would you give them THERAPY? and GYMS? and let them have PUPPIES? THEY'RE SUPPOSED TO BE IN JAIL!" And why so much (much more than you'd think) of the general spirit seems to be against young women who are raped. And on and on. People obviously must be getting what they deserve, or nothing makes sense about their beliefs about themselves, their country, what they've achieved (or not) in their lives, etc. (I say "Americans" because I've lived for years in another country and traveled all over, and this is far from a universal feeling.) Puritannical background at work? Perhaps. Certainly not Quaker.

adpirz 13y ago

Atul Gawande wrote about a similar initiative in Camden, NJ, two years ago: http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...

loceng 13y ago

Well, now we're fighting mental illness at an alarming rate due to many factors - that we could manage better. I'd like to see the graph of rate of mental illness from the past, to now - and yes, I realize there's a strong argument for that we're better at diagnosing people now, however it just doesn't add up IMHO.

venomsnake 13y ago

It is about job description. Just put into law that all government money should ensure the best outcomes for the patients and then a lot of things become possible. Give simple and powerful mandate to all health related businesses.

brown9-2 13y ago
A part of the issue is that it's hard to define "best outcome", you'd have to make sure to not accidentally incentivize drastic short-term procedures like open heart surgery, where the immediate affect is positive (patient hasn't died) but a longer term view would have questioned the care that led the patient to that state in the first place.

CurtMonash 13y ago

My grandfather, a physician, made house calls 7 days a week. It was just assumed in those days. When he couldn't drive during WW2 (German refugee = enemy alien) he couldn't be in private practice. Replacing doctors with nurses in that story is a perfectly sensible modern adaptation. But the house calls are a really good idea. Not coincidentally, they're a central aspect of the exploding trend toward assisted living.

jnbiche 13y ago
Please forgive me for going off-topic and for asking a personal question (and please don't answer if it's too personal), but how did the government inform your grandfather that his movement was restricted during WWII? Did he receive some sort of notice from the FBI? I'm sorry that our government chose to restrict the civil liberties of a very important member of his community during WWII on the basis of his ethnicity. A cautionary tale for today's America.
- adestefan 13y ago
  Note that the OP's grandfather was not a US citizen, but a refugee from a declared enemy during a time of war. There's a huge difference between the two. That fact that he was even allowed to practice medicine is amazing.
  - Evbn 13y ago
    The atomic bomb was built in large part by refugees from a declared enemy during time of war.
    - gngeal 13y ago
      But those weren't doing house calls and were under guard. :)
    - adestefan 13y ago
      Most of the US based scientists were either US citizens (some natural born; others naturalized) or came to the US in the 20s or early 30s. Even then very, very few of these men were German citizens. Fuchs, who was one of the few German refugees, was part of a contingent from the UK. The only reason why Fuchs was even allowed to be a part of the project was because of political pressure outside the project. This is all documented in exrutiating detail in Rhodes' series on the making if both the atomic and hydrogen bombs.

MichaelGG 13y ago

Why do people like to use average life expectancy? "Average life expectancy was 45 years old at the turn of the century." That provides very little information about the distribution of lifetimes and provides a biased view when compared to the 85-year-olds mentioned in the next sentence. Infant/child mortality skews the average a lot. You could have everyone living to 90, if they survive to 5, and still have an average of 45. War and other disasters can also change the average in ways that have little meaning for the medical programs in question.

rocky1138 13y ago
It also bugs me when people say "at the turn of the century," since we just recently had one of those but the person is talking about the one previous. /nitpick
- Evbn 13y ago
  Fin de Ceicle
NuZZ 13y ago
It's like it's a warm story that we propagate to make us feel great. As if we stand as demi-gods in comparison to the relative cavemen of 200 years ago. The most major accomplishment in respect to longevity appears to be... not letting our young perish. Which is obviously all well and good until this kind of argument is used to validify medicine perhaps beyond its merit. Forgive the generalizations.
monkeypizza 13y ago
This mistake seems to be getting more and more common. I use the example of sea turtles - the average lifespan across a clutch of eggs is maybe 1 year - because one out of 100 survives. But the one that survives usually lives for 100+ years. The fact that the life expectancy at hatching is only one year tells you nothing about the distribution.

tokenadult 13y ago

I repeatedly post this chart that shows life expectancy stratified by age to HN: http://www.scientificamerican.com/article.cfm?id=longevity-why-we-die-global-life-expectancy http://www.scientificamerican.com/article.cfm?id=longevity-w... I learned about this article from another participant's submission to Hacker News. I happen to be part of a "journal club" with a researcher who studies, among other things, demography of aging, and from him I've learned some startling facts about increases in life expectancy around the world. Girls born since 2000 in the developed world are more likely than not to reach the age of 100, with boys likely to enjoy lifespans almost as long. The article "The Biodemography of Human Ageing" by James Vaupel, http://www.demographic-challenge.com/files/downloads/2eb51e2860ef54d218ce5ce19abe6a59/dc_biodemography_of_human_ageing_nature_2010_vaupel.pdf http://www.demographic-challenge.com/files/downloads/2eb51e2... originally published in the journal Nature in 2010, is a good current reference on the subject. Vaupel is one of the leading scholars on the demography of aging and how to adjust for time trends in life expectancy. His striking finding is "Humans are living longer than ever before. In fact, newborn children in high-income countries can expect to live to more than 100 years. Starting in the mid-1800s, human longevity has increased dramatically and life expectancy is increasing by an average of six hours a day." http://www.prb.org/Journalists/Webcasts/2010/humanlongevity.aspx http://www.prb.org/Journalists/Webcasts/2010/humanlongevity.... A comparison of period life expectancy tables and cohort life expectancy tables for men and women in Britain http://www.ons.gov.uk/ons/rel/lifetables/period-and-cohort-life-expectancy-tables/2010-based/p-and-c-le.html http://www.ons.gov.uk/ons/rel/lifetables/period-and-cohort-l... helps make the picture more clear. ("Period life expectancy" is what is usually reported for a whole country. But cohort life expectancy provides a better estimate of future lifespans of young people today, http://www.time.com/time/specials/packages/article/0,28804,1963392_1963367,00.html http://www.time.com/time/specials/packages/article/0,28804,1... and is still steadily on the rise around the world.) Life expectancy at age 40, at age 60, and at even higher ages is still rising throughout the developed countries of the world.

jessriedel 13y ago
From the Vaupel article: > If progress in reducing mortality continues at the same pace as it has over the past two centuries, which is a matter of debate, then in countries with high life expediencies most children born since the year 2000 will celebrate their 100th birthday — in the twenty-second century. Um, color me very skeptical. My guess is there is a lot more disagreement with the startling hypothetical "if progress in reducing mortality continues at the same pace as it has over the past two centuries" then the single reference after "debate" would have you believe. (italics mine)

rocky1138 13y ago

My Taiwanese friends frequently remind me of the historic Chinese practice of a doctor visiting the family regularly to keep health well. The doctor would receive weekly pay only while the family was well; once someone got sick, they stopped getting paid until the doctor helped them recover. This preventative practice reminds me a lot of what my Taiwanese friends speak about. It seems the age-old cliche "An ounce of prevention is worth a pound of cure" applies here.

venomsnake 13y ago
Except in the cases of some types of cancer (breast/prostate/liver) where whether you will live or die dices are rolled during the genesis of the cancer and can be influenced little by the treatment. But more than pays about melanoma. It is all about the illness.
mikeash 13y ago
That sounds like it could go very badly if you have a mercenary doctor and you come down with an incurable but manageable condition.
- roguecoder 13y ago
  By the time you've spent years caring for a family, you probably care about their health for more than just the cash. Not to mention the reputation effects of abandoning sick patients...

tomohawk 13y ago

Three points were interesting to me: 1) The chart with the blip for the 1918 flu. If we reduce costs by closing facilities, how we cope with the next blip? 2) This is an area ripe for disruption, but regulatory capture seems to prevent this. 3) We should all be spending more time with our elders and noticing these sorts of issues, if for no other reason than it will improve their health.

DennisP 13y ago
1) It's not like those facilities are sitting around empty right now. If we close them only by the amount that we reduce the need for them, we'll have about the same reserve capacity.

ajtaylor 13y ago

The money quote for me was this: “If we scaled what Ken is doing,” Brenner says, “you would probably shut down a third of the hospitals in the country. It’s a disruptive innovation. It just guts the current business model.” Wouldn't it be better if people never had to go into the hospital in the first place? Aside from the supplemental costs - "surgical complications increase the margin the hospital makes on the patient by 330 percent for the privately insured and 190 percent for Medicare patients." - consider the quality of life issues. If Medicare is concerned with scaling this program up from a couple thousand people, instead of completely cutting a program which has proven its ability to cut costs AND improve quality of life, why not try it with five or ten thousand people first? If that works, then try it with 20 thousand people, then 50 thousand. If it doesn't scale at that point, then cut it. Another possible solution is to find a way to eliminate the for-profit hospitals. But Medicare's solution - "It’s pushing providers to band together into accountable care organizations, or ACO, that get a flat fee for all care related to a patient." - sounds destined to fail from the outset to this layman.

DanBC 13y ago
Yes. For illnesses like diabetes it's best if you can prevent people getting it, but if they have it it's best if you can help them to avoid getting the complications. "Diabetic foot" sounds funny, until you realise that it kills people and is a reason for leg amputation. (Prognosis after such amputation wasn't great last time I looked, in about 2004.) Sending a real person in a car to visit someone at their home sounds intensive, and sounds expensive. Compare it to a tele-medicine device that takes measurements and sends those to a centre somewhere, with people calling over the phone. It's a shame that the evidence base appears to be being ignored. EDIT (after adestefan and ajtaylor commented) -- it feels expensive, but the evidence base is clear that it's not expensive because it works, where as the thing that feels cheap is wasted money because evidence shows it doesn't work. And it's a shame that people in charge appear to be ignoring evidence, and going by 'gut feeling', because it means effective interventions are not happening. I hope that mentioning the research that a decision is based on becomes more widespread. Even organisations that claim to be evidence based can make odd decisions.
- 13y ago

wisty 13y ago

> Medicare is referring to the newly created Center for Medicare and Medicaid Innovation, which gives the program power to create and expand projects without congressional authorization. This authority could also be used to create projects based on HQP’s lessons. It’s not. Instead, Medicare has created a raft of projects and experiments meant to move the system from fee-for-service toward pay-for-quality — with the hope that if they can get the payment incentives right, then the market will have reason to support programs like HQP. Yep. As long as the government bureaucrats develop perfect payment incentives, the market will do its job. It's the same story in education. And programming - if you can find the perfect metric for code production (SLOC? function points? story points?) you don't need to do anything else. But with an imperfect metric, Cambell's Law (http://en.wikipedia.org/wiki/Campbell%27s_law http://en.wikipedia.org/wiki/Campbell%27s_law) kicks in. Want to reduce waiting times? Kick out patients so they die at home. Increase successful surgeries? Tell the doctors to fix a lot of ingrown toenails. Increased lifespan? Make decisions which increase life expectancy, at the expense of quality of life. Or just try to get rid of patients who have poor prospects. The greatest strength of markets is also their greatest weakness - they are much smarter and more agile than government departments. They can become a malicious literal genie, which optimises whatever the incentives are.

carbocation 13y ago
Personally, I like the adage of the Cobra effect to describe similar situations: https://en.wikipedia.org/wiki/Cobra_effect https://en.wikipedia.org/wiki/Cobra_effect
notatoad 13y ago
Well there needs to be some sort of artificial incentive if you're going to keep medicine profit-based. The best way to generate profit without those incentives is to keep as many people as sick as possible, because sick people are more profitable than healthy people.

glenra 13y ago

One big problem with medicine in this country is that bad hospitals can't just go out of business and be replaced by better ones. If you want to open a new hospital today, there are hearings in which all the crappy existing other hospitals have to say it's okay before you can get a "Certificate Of Need". So if you had an idea for a new hospital structure that would dramatically improve patient health and cut costs, you wouldn't be allowed to just build it and try it - the existing providers all get a veto. So we have hospitals that hide all the prices and make MORE money if they screw up and introduce complications, and it's ILLEGAL to drive those idiots out of business with a more customer-responsive system. It's like if you couldn't open a new coffee shop without permission from Starbucks or a new restaurant without permission from McDonald's. In anything even vaguely resembling a free market, reforms like this wouldn't need to be pushed by a monolithic central bureaucracy - they'd just spread on their own, with old providers rushing to adopt the modern changes for fear of becoming obsolete. http://en.wikipedia.org/wiki/Certificate_of_need http://en.wikipedia.org/wiki/Certificate_of_need

tosseraccount 13y ago
Looks like the hospitals are using the same techniques as the taxis to keep out the competition.
pekk 13y ago
The free market offers no incentive to give health services to people who cannot pay for it, or don't know that these services will reduce hospitalization by 33% and costs by 22%. Basic health care is not McDonald's because your mother does not die prematurely (and miserably, and expensively) for the lack of McDonald's. The core issue is not about some private business being 'customer-responsive' in the vein of Starbucks. You can, today, start private clinics which are more "customer-responsive" (leave a mint on your pillow, etc.) but how are you going to recoup the costs and in particular, how does that benefit the populace in aggregate?
- HarryHirsch 13y ago
  > The free market offers no incentive to give health services to people who cannot pay for it, or don't know that these services will reduce hospitalization by 33% and costs by 22% Amen to that. The major killers at the turn of the last century were tuberculosis and waterborne diseases, and the free market did nothing to improve living conditions or supply clean water to the urban population then. I am in Portugal right now, where Dr Sousa Martins, a physician who spearheaded the fight against tuberculosis, is considered a saint. Public health is always political issue. It is as true 100 years ago as it is now.

dkarl 13y ago

According to a new study in the Journal of the American Medical Association, surgical complications increase the margin the hospital makes on the patient by 330 percent for the privately insured and 190 percent for Medicare patients. This is scary when you consider how good people are at the subconscious mental gymnastics that allow them to justify pursuing their own interests at the expense of others. Either human beings are perfect angels -- inhumanly good, too good for much of human history to have actually happened -- or many people have been tortured and killed for those margins.

Cass 13y ago
How many doctors actually stand to gain by mistreating patients, though? I don't know about the USA, but in my country, most medical care is provided by salaried doctors who are paid the same regardless of the hospital's profit margin. Now, obviously we do want the hospital to be profitable enough that they don't start firing us, but there's certainly no immediate benefit along the lines of "Well, I don't this guy to get an infection, but I'd make an extra $ 1000 if he did," which I agree would certainly provide skewed incentives. The only thing that happens when my patients get complications is I get to pull more unpaid overtime.
- dkarl 13y ago
  Complication rates are affected by hospital procedures and policies, staffing levels, training, and presumably the pressures that are or aren't put on doctors. All of those are under the control of the administrators who look out for the bottom line. Whether complications make money or cost money surely affects administrators' eagerness to revamp and/or enforce handwashing policies, update training for nurses, keep staffing levels high enough that inexperienced nurses are properly supervised, and put pressure on doctors with high complication rates. To make it more concrete, there was an article on HN a few years ago suggesting that post-surgical complication rates could be reduced by creating surgery checklists where very basic surgical steps would be checked off as the surgery proceeded: patient identity verified, everything properly sanitized, materials accounted for afterwards, things like that. You would expect a hospital administrator to make a cost-benefit analysis taking into account the cost of researching this idea, creating a trial program, and monitoring compliance and effectiveness. The cost-benefit analysis looks like this: If the program is ineffective, we lose money. If it's effective, we lose even more money. If it's really, really effective, it could screw up the bottom line so much that I lose my bonus or even my job.

bconway 13y ago

Average life expectancy was 45 years old at the turn of the century. You didn’t have 85-year-olds with chronic diseases. Yes you did. That's like saying there weren't old people a hundred years ago. The reason the average was 45 years is because of the astounding rate of infant mortality (much improved now).

jmhain 13y ago
Thank you, I was hoping somebody would have already made this point. Funny thing is, both statements are true; you really didn't have 85-year-olds with chronic diseases. There were 85-year-olds, they just didn't have chronic diseases. The idea that we have them now is due to improved treatment of other diseases ignores tons of epidemiological evidence that says otherwise.

commanda 13y ago

It seems to me that health insurers are already aligned with the goal of keeping patients from receiving care for acute conditions, so perhaps some of them, being private companies, unencumbered by special interests or government bureaucracy, will adopt systems like the one outlined in this article. Maybe that's a cynical outlook, but since it has been demonstrated that hospitals, being for-profit, are tragically misaligned with maintaining patients' wellness.

SoftwareMaven 13y ago

“The largest group in the top one percent of income in America are physicians.” It is going to be very challenging to introduce changes that negatively impact a profession with the social respect and the deep pockets physicians have. It could probably succeed in a countries like Canada, Sweden or Germany, but overcoming entrenched interests in the US and not getting labelled "socialized medicine"[1] in the process is unlikely. 1. Of course it's no more socialized medicine than Medicare, but it's a good way to discredit your opponents.

carbocation 13y ago
As of 2008, nearly 59% of US physicians supported national health insurance [1]. Doctors are not the culprit. 1 = http://annals.org/article.aspx?articleid=740467 http://annals.org/article.aspx?articleid=740467
- refurb 13y ago
  What do that "national health insurance" look like for physicians? Does it include pay cuts? I'm pretty sure in those 59% of physician's eyes it doesn't.
  - carbocation 13y ago
    The answer to that question depends on whether you think physicians lack insight. I think that most physicians are smart enough to look at the national insurance that already exists (Medicaid & Medicare) and to recognize that their reimbursements would be cut. I think they can balance that against the complexities of the current system and some might be willing to trade somewhat lower pay for the ability to focus on providing care. 20% of health care costs come from physician pay, of which about half goes to the cost of running a practice. Most reformers know that cutting physician pay, while part of almost any plan, is not going to be the most important way to save money.
  - roguecoder 13y ago
    If pay cuts were accompanied by less annoying insurance infrastructure, I'm sure some doctors would take the pay cuts.

savrajsingh 13y ago

"if this were a pill"

kens 13y ago

This looks like a good approach to health care, and I don't want to be snarky guy, but... Health Quality Partners is about to lose their funding and they get an 8-page glowing article on washingtonpost.com about how great their program is and why it should be continued. It looks like some PR agency is really earning their money. See, of course, Paul Graham's article on PR agencies: http://www.paulgraham.com/submarine.html http://www.paulgraham.com/submarine.html Going back to the subject of the article, I wonder how much this visit program actually costs, and whether it could be direct-marketed to wealthy people with elderly parents. "For $10,000(e.g.) a year, we can reduce your parents' hospitalizations by 33% and help them live independently." Sort of like concierge medicine.

davycro 13y ago
> Going back to the subject of the article, I wonder how much this visit program actually costs, and whether it could be direct-marketed to wealthy people with elderly parents. "For $10,000(e.g.) a year, we can reduce your parents' hospitalizations by 33% and help them live independently." Sort of like concierge medicine. Better yet, maybe health insurance companies could offer lower rates to chronic patients who enroll in a visit-program. They are the organizations with the most financial incentive to implement these programs.
- tomjen3 13y ago
  They absolutely would (and I still don't see why they don't the cost/benefit ratio of paying for that should make sense) but in this case they are talking about the people who have no insurance or whoes bills are paid by the federal tax payers. And while there are a fair amount of positive things to say about the federal government, prudent financial planning isn't exactly one of them.
ajross 13y ago
Just for clarity, it's an Ezra Klein blog entry, not an article. Obviously Klein is no less susceptible to PR, but this isn't being presented as an unbiased news article. He's an opinion journalist.

roguecoder 13y ago

This reminds me an awful lot of the role of village witch in Terry Pratchette's books. I think we've lost that caretaker role in society because we always assumed it was their children's responsibility. It seems like if capitalism can get something for free, it is assumed to be worthless.

claudiusd 13y ago

The challenge with health care in the US is that nobody has incentives for reducing health care expenditures. Hospitals get paid when you get sick. Insurance companies see higher margin from reducing administrative costs. Patients are largely uninformed and there are few services out there to help them make lifestyle changes... not to mention that they expect somebody else to pay for it. Employers actually bear most of the non-medicare/medicaid financial risk, but they aren't health experts and have been burned in the past by tele-medicine programs that don't work. Preventive care programs like the one at HQP are proving that preventive care is effective, but sending a nurse to your home regularly is expensive and I'd question the ROI from doing so, absent some focus on a particular disease. With a solid ROI and some good hard evidence, HQP shouldn't have to rely on CMS to keep them afloat... with some work they would be able to sell their program to payers. HQP also isn't addressing the systemic issues I mentioned above, so what's especially frustrating about the article is that they bash on ACOs, which is one of the first attempts by CMS to actually align incentives and mend those issues. And frankly, those changes aren't going to be good for hospitals... I'm sure a lot will go out of business as people get healthier and don't need them. This piece of the article in particular makes me question HQP's motives.

CurtMonash 13y ago

As for going into hospitals making you worse -- I agree from experience. One of my parents went into the hospital for a back procedure, and came back with her mind significantly diminished. She died 8 months later. The other, in and out of the hospital, eventually died the same week, and one of his complications was MRSA. Both were at Riverside Methodist Hospital in Columbus, OH, which I gather is a perfectly solid institution.

teeja 13y ago

Wow. If we can't maintain ways for the cream to rise to the top in the US, we'll continue to become increasingly mediocre.

rthomas6 13y ago

If this is as cost-effective as it claims, what's to stop private insurance companies from pushing and covering it? It should theoretically cut their own costs in the long run, right?

GFischer 13y ago
I wish some insurance companies could figure out that. In reality, if they are something like the one I work for, politicking and manager infighting will prevent it - everyone wants the OTHER divisions to lose power, but not their own. My own manager created his own personal software factory (for a freaking country branch), in spite of my belief that it's extremely inefficient for the company as a whole. The shareholders don't care as long as the company makes money.

bjhoops1 13y ago

The tendency among physicians to be dismissive towards remedies that are procedural in nature reminds me of the tendency of programmers to show disinterest in non-technical solutions to problems. But as Jeff Atwood reminds us, "The Best Code is No Code At All," and I imagine that physicians could use a similar reminder: "The Best Treatment is No Treatment at All."