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Profit affects doctors' treatment decisions

• thrownaway2424 13y ago
  This is why single-payer is the only way to go. There has to be some panel of disinterested experts evaluating the cost/benefit of a given treatment for a given illness, backed up by the buying power of something really huge. Yes, that's "death panels" to you Tea Party members following along at home. Of course that wouldn't prevent any doctor and patient from doing whatever they wanted, at their own expense.
  • vkou 13y ago
    That's not even in the problem - if the doctor disagrees with the prescribed treatment plan, they have enough leeway to prescribe some other solution, that they believe to be better. The advantage of single-payer, is that he will not have a profit motive to do so. And monopoly bargaining power on the side of the public.
    • mhb 13y ago
      The advantage of single-payer, is that he will not have a profit motive to do so According to the article (Physicians in general aren’t allowed to refer their patients for treatment in facilities that they also own), that's also generally true in the existing system except for some exceptions. In particular the one cited in the article.
  • kiba 13y ago
    The first rule of politics is that unintended consequences abound. That isn't to say that a single-payer is better or worse, but we should be methodical and careful when considering wholesale replacement of the incentive structures.
    • gopher1 13y ago
      Well, the great thing about single-payer is you have the rest of the industrialized world to learn from. The pitfalls are not entirely unknown.
  • waffle_ss 13y ago
    Hopefully these won't be the same disinterested experts that granted the contracts to build healthcare.gov.
  • jasonlotito 13y ago
    Except having a single-payer system doesn't mean you'll have a panel of disinterested experts evaluating the cost/benefit of a given treatment. This isn't speculation, either. I've experienced the results of a "panel" going against the consensus of experts. It's the reason we left Quebec to come to the US, as at the time (2011) Quebec's policy for children with Autism was horrific. It hasn't changed.
    • patmcc 13y ago
      What was their policy? And why did you leave to the US as opposed to another province?
      • jasonlotito 13y ago
        Basically, they didn't believe that early intervention was a priority. You can search for Autism problems in Quebec, specifically Montreal, and read lots of stories regarding that. As for moving to the US, two reasons. 1) Wait times in other provinces were much longer than we wanted to wait. Even going the private route in Quebec would have mean a year and a half (that was on top of the year we had already been waiting). In the PA, we got more help for my son's Autism in the first 2 weeks than we had the entire time up in Quebec. 2) I'm American, and because of that, my sons are also American. Note, I don't pretend that this means the US health care system as a whole is better, or that Canadian health care is worse. However, my experience with a child with Autism in Quebec is not unusual, and my recommendation to parents with Autistic children in Quebec is to leave.
        • patmcc 13y ago
          Thanks for your reply, that's very informative. I'm Canadian (BC) and like to keep an eye on the health care system as my parents are aging and I'm looking to have kids soon. Glad to hear you found treatment for your son, and best wishes for the future.
  • Symmetry 13y ago
    I don't think single payer, per se, would do anything to help with this. The parts of the US healthcare system that are single payer, Medicaid and Medicare, suffer from this just as much as the rest of our system. Having a government run healthcare system like Great Britain's would solve the problem, but it could do that with or without single payer. In fact, Singapore has had quite a bit of success combining a semi-government run hospital system with private payment for healthcare.
  • MrZongle2 13y ago
    Yes, that's "death panels" to you Tea Party members following along at home. Well, now that you've put it that way, the idea of a government-led panel -- rather than the family -- deciding that Grandma is too old to bother treating sounds so much better.
    • steven777400 13y ago
      Very disingenuous. It's a matter of a government-led panel allocating government funds. If the family wants to keep treating Grandma indefinitely, that is absolutely their right ... if they do it on their own dollar. The "death panel" bit is just the question of how long the government would have continued to pay benefits.
      • nsxwolf 13y ago
        We're not always talking about vegetables on life support here. There's a lot more to care of the elderly. My 93 year old grandfather recently got a hip replacement and he's doing great. Would he have received that hip under the ACA? Recall that a woman asked Obama a similar question and he said maybe she should just take a pill.
        • steven777400 13y ago
          Who paid for that hip? If he did, or you did, or any other private party did; then it would work exactly the same! The question here (death panels) is only about what the government would have paid for. Since the government has finite money, it must decide what it will and will not pay for. There is not enough money to pay for everything. Decisions must be made.
          • nsxwolf 13y ago
            We could have a situation where it's possible that you were paying for a plan that would pay for your hip, but the government decides to dissolve that plan and force you to buy a new plan that's not allowed to pay for your hip.
  • gojomo 13y ago
    Medicare is essentially single-payer for old people, yet it's identified in the article as part of the problem. Like other government programs, it's so much better at measuring inputs (amount spent and procedures performed) than outputs, that there's an institutional bias in favor of overspending and overlooking corruption. ("Oh, no, that's not 10% more fraud and inefficiency this year, it's reaching 10% more of the needy.") There's only one other sector of the US economy that's "single-payer": military procurement. And that's not known for its spending efficiency, either. So it's not simply "single-payer" that magically saves money, but the specifics of the incentive system that's set up, and the other precedents from American federal governance are not positive. Thank you for acknowledging that the main mechanism that a federal medical buyer monopsony (aka nationalization/single-payer) could use for cost-control is, essentially, "death panels" who say no to many treatments currently performed. But can the American political system embrace that step, or will it wind up with single-payer without cost-controls? We wind up with the kinds of giant federal programs that can make it through the political system, and get implemented by the bureaucracy... not the kinds of idealized programs existing only in advocates' minds. Finally, in single-payer systems, getting "whatever you want" done "at your own expense" is often effectively prohibited. For example, when the official system has particular limits (like price controls, limited participating providers, or waiting lists) for a covered procedure, it has often been illegal, in US Medicare or Canada's programs [1], to purchase that same procedure out-of-pocket/out-of-system for a negotiated price. Once you've nationalized, there's even a certain logic to such prohibitions: the system is straining under budget caps, and you can't risk the wealthy siphoning off capacity/copayments that could help support the common base. [1] http://www.cato.org/publications/policy-analysis/freedom- http://www.cato.org/publications/policy-analysis/freedom-
    • drzaiusapelord 13y ago
      A cato link isn't convincing. Its an extremely biased source. Cato can't stand that the single payer works in the rest of the world.
      • gojomo 13y ago
        Your glib bias-accusation is unimpressive and unresponsive: Cato cites verifiable details about the particular point I was making, that single-payer systems often do "prevent any doctor and patient from doing whatever they wanted, at their own expense". Similar to the claim that under ACA, no one would lose a plan they liked [1], the claim that single-payer will still allow full freedom to work outside the system is a pre-implementation falsehood used to build support. Hell, it's even in the name: "single-payer". You have to crack down on competing payers, or your price leverage slips away, and voters stuck in the single-payer system get angry that they're facing the political cost-benefit rationing that others aren't. None of the other-country "single-payer"-ish systems cover even 1/4th the population size of the US. If single-payer can work so well for cost-control in the US political reality, why doesn't it work for Medicare, and the Defense Department? [1] http://networkedblogs.com/Qy7JI http://networkedblogs.com/Qy7JI
  • pbreit 13y ago
    I don't think single payer is the right answer especially for the USA. The US has a much stronger bent towards freedom, independence and self determination. I think some sort of hybrid, a la France, is more appropriate.
    • patmcc 13y ago
      Not being able to quit your corporate job because you desperately need the health insurance is a really interesting kind of freedom, independence and self determination.
      • bdcravens 13y ago
        Calculated risk assessment isn't the same thing as lack of freedom. I have cystic fibrosis, so I've been making those decisions for a long time. (100% freelancer here)
      • pbreit 13y ago
        Not sure how that's relevant to single-payer or not. Obamacare is not single-payer and addresses that issue.
• tokenadult 13y ago
  I upvoted the article because it raises some important points about how people respond to incentives in the current health-care financing system in the United States, with a prediction of expected results under the Affordable Care Act as the act is implemented. The kind of comments I'd be delighted to hear from other HN participants is comments about what can be done about this. On my part, I was just doing some Web searches for patient guides about how to select treatments and when to get second opinions. Regardless of how health care is paid for, patients sometimes need guidance about how to choose physicians, and how to choose treatments. (I know this for sure because my family lived in Taiwan for almost three years under Taiwan's single-payer national health insurance system, and we still had to decide which doctor to visit--we had choice in that matter--and whether or not to follow the doctor's treatment recommendation, which we sometimes followed and sometimes did not.) I'll keep looking for a user-friendly guide like that online, and if someone else commenting here can link to one, I'll be very grateful for that.
• Ensorceled 13y ago
  In Ontario doctors were allowed to switch to capitation, where they receive a lump sum for each patient under their care, rather than billing per service. My personal physician loves it, he no longer wastes time filing for OHIP payments and no longer worries that maybe he is only ordering procedures to make more money rather than for a legitimate purpose. This is a particular problem when diagnosing problems, is "your gut" or "your greed" telling you that the patient needs this $1000 test.
  • angersock 13y ago
    Given how long the billing process is over in the US, that makes a whole lot of sense actually.
  • CaveTech 13y ago
    Couldn't it then be argued that the doctor is incentivized to give short simple treatments so he can work with more patients?
    • gcb0 13y ago
      Ineffective treatment is visible. The discussion is about cheap effective treatment vs expensive effective treatment.
    • stonemetal 13y ago
      What would be wrong with that scenario? Shorter, simpler treatments sound like a win for both patient and doc. They wouldn't necessarily be cheaper than long, complicated treatments but on the whole they probably would be.
      • CaveTech 13y ago
        Because it doesn't imply that the treatment is successful. If I have a condition or disease it could be misdiagnosed as something much simpler and go unnoticed by me for years. Maybe it's not debilitating but that doesn't mean it can't be cured or managed better. When/how do these errors get caught? I'm sure many never are.
• nazgulnarsil 13y ago
  I take issue with the "most medical costs are accrued in the last year of life" point that gets bandied about. We don't know a priori which year is going to be your last! This makes the point into almost a tautology.
  • kingkawn 13y ago
    It would be incredible to do a meta-analysis and see if you could create a prediction model of mortality based on healthcare spending on individuals. It could be that as the slope of costs begins to rise you can actually figure out the mortality based on that alone and not based on disease mechanism.
    • eruditely 13y ago
      This is just talk. I doubt it is that easy.
      • kingkawn 13y ago
        right, its an idea. an idea that can then be followed up on and proven wrong or proven right. That is how you discover things. Without talk you've just got raw accident as the driving force for innovation. It gets some stuff done, but its not everything.
  • aaronblohowiak 13y ago
    >We don't know a priori which year is going to be your last! For those times that incur large costs, I would bet that you could make a better-than-chance guess. What are the success rates of "extraordinary measures" ?
• mhb 13y ago
  Why is NEJM in this title (Profit massively affects doctor surgery choice (NEJM))?
  • rryan 13y ago
    To indicate the original place the study was published?
    • mhb 13y ago
      Maybe that shouldn't be in the title here of a blog post that references a newspaper article that references the NEJM study (http://www.nejm.org/doi/full/10.1056/NEJMsa1201141 http://www.nejm.org/doi/full/10.1056/NEJMsa1201141). Forgive the pedantry. I'm sure the title will be changed soon anyway.
    • rcfox 13y ago
      I had no idea what NEJM meant. It was noise to me. Also, link to the original study, rather than some random person's commentary.
  • pc86 13y ago
    Because globaleconomicanalysis.blogspot.com is not known as an authority in medicine, while the New England Journal of Medicine is.
  • pistle 13y ago
    Clicks n stuff - and it's working. The OP read an article in NEJM once and has a numbered list of things to say, followed by an unnumbered list of things to say.
• zaidf 13y ago
  Does defensive medicine have no role in doctors opting for aggressive treatment to the conservative alternative?
• notdrunkatall 13y ago
  It would have been nice if Obamacare fixed some of the above problems. Unfortunately, Obamacare did not fix any of them. Fraud, ridiculous amounts of paperwork, and incentives to do the wrong thing were everywhere you looked before Obamacare. The same problems exist now. Worse yet, Obamacare added to the mess by over-charging millennials and their kids, and undercharging smokers and others with unhealthy lifestyles. Except for those below certain wage thresholds, insurance costs are likely to increase. Yep.
  • sshThis 13y ago
    Nope. This article's main point indicates that government should further expand into the healthcare business. Obamacare sets the vital, initial steps into the industry. Conservatives love to jump on this line because it bashes Obamacare. IN REALITY, it means it didn't go far enough.
    • erichocean 13y ago
      Obamacare sets the vital, initial steps into the industry. False. The US federal government initially entered the private healthcare market in 1966, with the passage of Medicare. The transformation from private to public healthcare has been going on for nearly 50 years now.
• cs702 13y ago
  Many aspects of US society today are organized under the assumption that if every individual pursues what is in his/her best financial interest, the "invisible hand of the free market" will produce the best possible outcome for everyone. Yet here we have reputable doctors acting in their self interest, and the result is that they are ordering unnecessary surgeries for financial gain. Meanwhile, patients are essentially unable to protect themselves against this travesty. Maybe in this case the invisible hand cannot be seen because it is not there?
  • TallGuyShort 13y ago
    I don't think many people believe that having every individual pursue what's in their best interest in a purely financial sense will result in the best possible outcome in every other sense. I always understood it as pursuing the best economic/financial result for you will result in the best economic/financial result overall, and even then, I think most reasonable individuals don't see that as an absolute law without exceptions.
    • gxs 13y ago
      This is exactly right. Why do people corner themselves into mutually exclusive, absolute truths, with absolutely no room for compromise? It just doesn't make any sense. When I was in 4th grade I wrote a country report on the US. When I got to the economics portion of the encyclopedia, I still remember the opening line.. "The United States is a mixed economy operating predominantly under capitalistic principles.." Why settle for one when you pick the best from both worlds? Unbelievable how much this affects people's lives..you can ONLY like Go or C++..you can ONLY like Apple OR non apple products..you either watch Art House Cinema or you watch Hollywood blockbusters, absolutely not allowed to watch both..you're either 100% capitalist or 100% socialist. The idea of the "truth lies somewhere in the middle" is at least as old as the Greeks (that quote was attributed to Aristotle when I first read it), and yet every single day, the same people regurgitate the same tired arguments to the point that I'm starting to sound like a broken record myself in response.
      • jjoonathan 13y ago
• mikeyouse 13y ago
  Interesting article, but the last premise is fairly disingenuous. He lists 6 reasons why healthcare is expensive, then claims that Obamacare doesn't fix any of them, but he's entirely wrong on at least 5 of the 6. 1. Medicare / insurance fraud --- The author obviously hasn't heard of the Health Care Fraud Prevention and Enforcement Action Team (HEAT). HEAT led to the record number of fraud charges in 2012. In addition to that, ACA standardized fraud convictions, so any provider convicted of fraud can no longer claim any federal money (Previously, a provider convicted of medicare fraud could still collect payments from medicaid et al).[2] These are only 2 provisions of the roughly 50 that directly address fraud. [2a] 2. Massive amounts of Paperwork --- This paperwork is moving to EHR / EMR systems that will file it automatically for the vast majority of patients. ACA mandates that the systems must use a standard format, so that any system built can communicate with all federal / private insurance carriers. [2] 3. Since doctors have direct contact with patients, and insurance companies don't it's easy for docs to blame insurance companies for unnecessary procedures --- I'm confused by this point, it seems a bit confused and contradictory toward his other points. 4. Doctors perform needless tests for fear of being sued --- The author has clearly never heard of ACOs. One of their primary goals is to limit the number of tests and procedures done. Insurance companies and the government will provide fairly significant bonuses when the cost of provided care comes in below average. [4a] In addition, the ACA provides research grants to study best practices and patient outcomes, having published, peer-reviewed research for common diagnoses will greatly limit the ability to sue for stuff considered CYA. [4b] 5. End of life care is insanely expensive --- This would've been addressed in the ACA, but Sarah Palin, Newt Gingrich and their dimwit followers torpedoed the 'death panels' to score some cheap political points. 6. Life is prolonged without living will --- Again, thank Sarah Palin, Newt Gingrich, and the Fox News brigade for their insane rants against 'death panels' which would have directly addressed this. [1] - http://www.npr.org/2011/12/30/144491419/doj-posts-record-for-health-care-fraud-cases http://www.npr.org/2011/12/30/144491419/doj-posts-record-for... [2] - http://www.healthit.gov/policy-researchers-implementers/standards-certification-rules http://www.healthit.gov/policy-researchers-implementers/stan... [2a] - http://www.btlaw.com/files/ALERT%20-%20Healthcare_Health%20Care%20Reform%20Fraud%20Abuse.pdf http://www.btlaw.com/files/ALERT%20-%20Healthcare_Health%20C... [4a] - http://www.washingtonpost.com/blogs/wonkblog/wp/2013/08/29/obamacares-cost-control-programs-may-be-contagious/ http://www.washingtonpost.com/blogs/wonkblog/wp/2013/08/29/o... [4b] - http://www.nlm.nih.gov/hsrinfo/cer.html http://www.nlm.nih.gov/hsrinfo/cer.html [5 & 6] - http://en.wikipedia.org/wiki/Death_panel http://en.wikipedia.org/wiki/Death_panel
• angersock 13y ago
  "According to government estimates, each neurosurgeon at Halifax Health was generating more than $2 million a year in hospital profits. The hospital charged fusion patients an average of about $80,000, according to Florida records on Halifax Health analyzed by The Post, ranking the procedure as one of the more expensive." Wow. The image of the physician as somebody who is there to help relieve suffering is cemented as a meme, but the way the system seems to have evolved in the past few decades is towards help as a secondary duty if any. Unfortunately, anyone who seems to want to speak out against the system is immediately rebutted with cries of "Why do you hate doctors?" and "They saved my babies!". It is very hard to have an honest discussion and self-introspection in the current environment, especially with so much money at stake.
  • roc 13y ago
    > "The image of the physician as somebody who is there to help relieve suffering is cemented as a meme, but the way the system seems to have evolved in the past few decades is towards help as a secondary duty if any." To be fair, with spinal fusions in particular, when a review panel says surgery is "not medically necessary" they're recommending daily pain/numbness/loss of range of motion is better treated with narcotics/steroids/etc. So it's hardly as simple as "doctors ignoring pain for profit". It can quite easily be "insurance company ignoring pain for profit". You simply can't ignore the role of insurance companies. Their disincentivize to approve any treatment, necessary or not, to mitigate their own costs is also a well-studied problem.
    • angersock 13y ago
      Quite so. Reminds me of the song "Stuck in the middle with you": Clowns to the left of me, jokers to the right.
• maratd 13y ago
  Is this really surprising? Who doesn't know this? My wife was in labor for a bit less than a day. Baby was fine, everything good, but apparently we were taking too long. Doctor demanded we do a c-section. When we said we wanted to wait, she walked out, slamming the door. We got scared, they made 60K for about 20 minutes of work. Guess what the c-section rate at that hospital is? 50%. Not kidding. I'm in the wrong business. http://www.icanofnj.com/hospitalcsectionrates.htm http://www.icanofnj.com/hospitalcsectionrates.htm
  • pyre 13y ago
    I've heard that doctors get a bonus per baby they deliver, so some will recommend C-sections when it looks like the baby won't be born before the end of their shift. Maybe the doctor slammed the door because she was really looking forward to going shopping with her bonus (like an angry retail customer that once told me I was "taking money out of his pocket" because I wouldn't give him an expired sale price on a stack of blank CD-Rs).
  • esw 13y ago
    We actually shopped around until we found a hospital in our area with low c-section rates. On a related note, the anesthesiologist was paid close to $10k for administering the epidural.
    • fudge 13y ago
      Here in Norway, we were refused a c-section as my wife being fed up after 26 hours wasn't a valid reason for having one. It also cost $0 total, with a baby delivered and 5 days in the 'new-parents-hotel' at the hospital, which included monitoring, help and instruction, and vaccines.
      • esw 13y ago
        That's great. I should also clarify that because we have health insurance, our out-of-pocket expense was less than $200.
    • ars 13y ago
• xanderstrike 13y ago
  The two things I read in this article, minus the loaded language and assumptions: 1. "Medical offices which have equipment for certain services provide those services more often than offices that don't." They've got the equipment in-house, so of course they're going to use it. The article doesn't take into account the possibility that patients are choosing to go to these offices _because_ they have the in-house facilities for the treatment they want. Going from "doctors who have X machine order X procedure more often" to "doctors treat patients like an ATM machine" is a huge leap. 2. "Some surgeons in Florida performed unnecessary surgeries for money." There are bad apples in every bunch, this is why you get a second opinion before going under the knife. Yes surgeons get paid per procedure, yes it's a flawed system, but that doesn't mean they're all wheeling and dealing to get as many people to submit to surgery as possible. It's worth noting also that whenever the article says "charged patients" what they mean is "billed patients' insurance company." Chances are the people who don't have insurance were the ones smart enough to see another doctor before paying. This kind of fearmongering crap undermines confidence in medical professionals and medical science. The vast majority of medical professionals are extremely hard working, knowledgeable people who's primary goal is to help everyone that walks through their door. Without trust from their patients, they can't do this effectively.
  • paschutt 13y ago
    As a medical professional I have witnessed this all first hand, to dismiss this as fear mongering is not very accurate. My experience was in the Cardiology field and how they use ultrasound procedures to basically increase the profitability of their practice. This was done by nearly every Cardiology practice in my community. When Medicare cut re-reimbursements of Echocardiograms guess what happened...they all just increased the frequency in which they ordered them. If you don't think a Electrophysiologist has a financial incentive to implant pace makers you're greatly mistaken.
  • Goronmon 13y ago
    They've got the equipment in-house, so of course they're going to use it. Exactly, they are going to use it as much as they can, whether it's necessary or not, because they have it.
  • 13y ago
• 001sky 13y ago
  US Healthcare System Explained in Six Succinct Points 1) A constant battle is underway between insurance companies that do not want to pay any claims, even legitimate ones, and doctors and hospitals incentivised to rip off patients, insurers, and taxpayers with unnecessary surgeries and Medicare fraud. 2) Insurance companies demand massive amounts of paperwork out of rational fear of fraud and unnecessary treatments. Doctors perform for-profit (as opposed to for-patient) procedures that guarantee more explanations and more paperwork. 3) Doctors and hospitals have direct personal contact with patients, but insurance companies don't. In cases where doctors put patients at huge risk with needless procedures and surgeries, it's easy for hospitals and doctors to point their finger at insurance companies. On the other hand, many sincere, honest doctors have difficulty getting patients the care they should have because insurers believe they are getting ripped off by unnecessary procedures, even when they aren't. 4) Doctors make needless tests out of fear of being sued for not doing them. 5) The vast majority of healthcare costs occur in final last year or so of someone's life. Politicians who want to do something sensible about this issue get accused of "rationing healthcare". 6) Doctors not only have a financial incentive to prolong life needlessly, they also worry about not prolonging life out of fear of being sued by family members unless there is a living will, and perhaps even if there is a living will. == Buried a bit, but worth highlighting.
  • danvoell 13y ago
    Insurance companies typically pay out 100% of the money that comes in and they make money on the float. There is always this assumption that they are against higher prices of healthcare and that they battle the hospitals or the doctors. They don't, they just raise their premiums to match higher costs. More float equals more money for the insurance company.
• ffrryuu 13y ago
  Doctors love to give you drugs that the salesman already gave to the doctor, it's sad. Here have a free sample!
• nilsbunger 13y ago
  In general most people will operate in their financial self-interest over the long term. Taking it back to startup-land, this is why sales team compensation structure is discussed at such length at the board level. You generally get exactly what you compensate for, and it's easy to create unintended consequences.
• pbreit 13y ago
  The problems with US healthcare seem fairly well known. But I want to know what sorts of solutions are promising. I don't think single payer is right for the US, it's much too anti-American. I also don't think a free-market free-for-all would work...medicine is way too stacked against the customer. Obamacare, while seriously flawed, is probably still a step in the right direction. Would getting employers out of the business help? I keep hearing about insurance company inability to compete across state lines. What else?
  • dllthomas 13y ago
    I think the cap on the MLR is probably the single best thing in Obamacare. It seems to shift incentives in a meaningful way. This just addresses incentives for the insurance companies, though, not doctors...
• crazy1van 13y ago
  Of course this is true. How could this be at all surprising?
• VladRussian2 13y ago
  only in software engineering tools and runtimes are choosen based on what is best for the project/customer.
• jdietrich 13y ago
  I once read that traditional Chinese medicine practitioners work on a sort of subscription basis, where patients only pay when they are healthy, thereby creating a strong incentive for the doctor to get a sick patient back to health in a cost-effective manner. I have no idea as to the veracity of the story or the effectiveness of such a model (and hold no truck with the pseudoscientific methods used by such practitioners), but it raises an interesting thought - would healthcare be more effectively funded through some mechanism other than private insurance or state funding? Might the debate over healthcare have been narrowed into a false dichotomy, when there may be a far better option lying unnoticed on the third hand?
  • erichocean 13y ago
    What you're describing is an SLA, which the HN community should be very familiar with. So it's not actually a weird way to sell a service at all. I can't think of any objection for trying out your idea and seeing how things go.
  • jrs235 13y ago
    This (where patients only pay when they are healthy) wouldn't work in the U.S. since a large percentage of people don't care about their health and most people are NOW oriented. "Why should I: stop smoking, stop drinking excessively, exercise, or change my diet? If I get sick (not healthy), I don't have to pay my doctor!" My question is, why do we keep talking about ACA like it provides care? It doesn't. It mandates insurance. If you need care, it still costs you more out of your pocket.
  • gtremper 13y ago
    It seems like having the government cover all medical expenses through taxes is sort of like this. Since you pay more tax when your healthy (or I guess when you have more income).
• EricDeb 13y ago
  I didn't read the article thoroughly, but one point to think about is patients may be more likely to visit with a particular doctor if said doctor frequently performs the surgery they believe will help them. I am the perfect example of this. I went to a particular doctor with the expectation that he would eventually perform the surgery I desired. He did technically evaluate if I was a good candidate, but I got the impression his patients only visit him if they want the surgery performed. He also does a lot of these surgeries, making him more experienced and more attractive as a surgeon. I would imagine this Florida doctor is similar.
• yequalsx 13y ago
  I have recently come to the conclusion that ultimately problems like this stem from high income inequality. Humans have a tendency to compare themselves to people who are better off than them. Fifty years ago doctors were very well off in general and were esteemed. But now this is not the case and the desired prestige can now only be accomplished through financial gain. Back when income inequality was not so great other motivations came into play besides profit. There is a perniciousness in American society where too many people have bought into the "I've got mine, forget you" attitude. Where money is the main source of prestige of a person. The problem highlighted by the article is a societal one. Profit is not a great motivator of innovation and ought not be as high a goal as it currently is in the U.S. What fascinates me the most is that the segment of society that appears to be doggedly in favor of a profit first public policy appear to be people who follow a book that says that love of money is the root of all evil.
• riahi 13y ago
  It seems fun to hate on "evil" doctors, but why do we consider doctors as any different from "personal business consultants" who's business expertise is health? I'm curious how you guys think medical professionals should actually be paid / how can pricing be done "fairly" in a system where there can never be "information symmetry"?
  • PavlovsCat 13y ago
    > It seems fun to hate on "evil" doctors I can only speak for myself; I made very good experiences with doctors whenever I myself was sick, but I also worked for 11 months on a cancer ward a while ago, and some of the stuff I saw there was kind of rage inducing. Nearly all nurses were fine, most doctors were fine, but the ones that weren't, really really made up for that. I don't think doctors are all evil, nowhere near, but the reservations and skepticism I do harbour, I don't harbour because it's "fun" to have them. It's merely a way to cope with real shitty stuff that does exist. > I'm curious how you guys think medical professionals should actually be paid / how can pricing be done "fairly" in a system where there can never be "information symmetry"? First off, of course there can be "information symmetry". Not between patient and doctor as much as among medical professionals and health insurance providers. Medicine isn't Voodoo, things are reasoned about and tested, usually, and given the right laws and enforcement of them, everything can be documented and subject to review. As for how to improve the situation: while I haven't thought in-depth about this, but how about a flat hourly rate for doctors etc.? That is, not being paid for the kind of treatment, but rather for being on the job. Of course, the hospital would need money depending on what kind of treatments they do, but if there was no (legal) way to pass on that "profit" to the staff itself, there would be no incentive for malpractice based on greed. As I said, I haven't thought much about this and maybe I am overlooking other problems this might cause (like offloading patients that are too expensive and/or too much work to other specialists, like a hot potato), but I wanted to put this out there anyway.
• Amadou 13y ago
  This New Yorker article examining major discrepancies in health-care costs between McAllen Texas (which is the 2nd most expensive health-care market in the country) and the town up the road was eye opening for me. The summary is that when doctors invest in medical facilities (like in-practice labs) they are financially motivated to direct patients to use those facilities. http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_...
• jotm 13y ago
  I hate that we're not allowed to self-medicate. I understand the risks, I've done my research, I know more than my local pharmacist, yet they won't give me s&&t without a piece of paper signed by someone who supposedly knows better. I always had a strong suspicion that the doctors prescribe too many medications (which were also brands more expensive than the generics). Not so paranoid after all.
• cobolorum 13y ago
  bhauer: a few flaws in your analysis. Insurance companies do not like prices being high either. They have to raise premiums and this discourages people from purchasing insurance. Insurance companies have a vested interest in making sure that you do not get ill. They have to pay if you get ill. This is the reason that people who smoke pay higher insurance premiums. Outside of other comments: of course profit changes doctors' decisions! Why wouldn't it? The medical industry is a business. It is, however, the most regulated industry in the USA. Tech is the least regulated. In the tech industry progress and innovation abounds. It does not in the medical industry. I see a correlation there.
• hkiely 13y ago
  The real way to solve this problem is to get the patients motivated and involved in their own care and treatment decisions. In a free market, driven by true choice, patients have the responsibility of learning more independently about their diagnosis, treatment options, and their physician. By doing research, a patient may be driven to get a second or third opinion when faced with a diagnosis like cancer. By utilizing healthcare savings accounts (HSA) and high deductible low premium insurance plans, patients are driven to find the best doctor with the lowest prices. This is how the invisible hand works, choice and competition on each side of the market. The result- A decrease in price and an increase in quality.
• vacri 13y ago
  An ex-colleague of mine went into the pharmaceutical industry to work as a drug rep. They get $X to spend on each doctor they visit as part of their job. My colleague was quite moral, and she would only use the money for the stated purposes: improving the doctor's practise. Charts, equipment, training. Usually it's spent at discretion, and often spent on football tickets, holidays, etc. She reported that some doctors already used it for practice-improving stuff. The middle set of doctors were a bit like "oh well, the gig is up". But the third set of doctors were outraged that she should tell them how to spend their money. They saw this drug company money as part of their personal income.