YC Research: Universal Healthcare • Hacker News Board

Re: YC Research: Universal Healthcare

#281

Post by refurb » Wed, Feb 08, 2017, 4:04 AM UTC

finnh wrote: post #233

refurb wrote: post #207

Earlier quoted context omitted.

Why is a third party negotiating for Medicare Look back at the last paragraph in my response above. Medicare is required to cover a number of classes of drugs. they can't say "no, we're not paying for it." As a result, Medicare has no negotiating power. Unless you can walk away from the table, why would drug companies budge? And if Medicare did have the power to say "no", how would that work politically? I'm guessing…

> Medicare is required to cover a number of classes of drugs. they can't say "no, we're not paying for it." > As a result, Medicare has no negotiating power. Unless you can walk away from the table, why would drug companies budge? Those statements are only true for drugs with no alternatives - which doesn't apply to all (most?) drugs. And, even for those, couldn't the government say "we're not going to pay $(RANSOMPR…

we will not buy any other drugs from you

Private payers are free to do that, but don't. The reason why they don't is because they have customers and telling someone "no you can't have this drug" makes people really upset.

I'm not sure Medicare would have much more success in that area. I could imagine politicians phones ringing off the hook with call from retirees stating "why won't you pay for my drug"?

Re: YC Research: Universal Healthcare

#282

Post by davidgay » Wed, Feb 08, 2017, 4:05 AM UTC

rayiner wrote: post #234

warcher wrote: post #33

Earlier quoted context omitted.

In the united states we can't successfully implement negotiation on drug prices for MediCare . They literally can't negotiate with their suppliers. By law. Anybody thinking software is going to solve that is way in a bubble. http://healthaffairs.org/blog/2016/09/19/the-politics-of-med...

You're trivializing what is actually a very complicated economic issue. Medicare negotiating drug prices raises a serious buyer-side market power concern: https://en.wikipedia.org/wiki/Monopsony . You can't have a "real market" where something like Medicare exists. So you design the rules to try to mitigate various exercises of market power. That's really hard to do. Of course, you can say "who cares if Medicare driv…

> All around the country you can see regulated rates that are too low and drive out investment. A great example is water utilities. Almost everywhere, water rates are far lower than they should be, and as a result water infrastructure is crumbling, customers are drinking water through lead pipes that haven't been replaced in a century, etc.

It's too simplistic to blame this on government regulation. The rest of the world also regulates utilities, and far from all of it has the crumbling water infrastructure problem.

Re: YC Research: Universal Healthcare

#283

Post by dragonwriter » Wed, Feb 08, 2017, 4:05 AM UTC

intrasight wrote: post #270

dragonwriter wrote: post #127

Earlier quoted context omitted.

> Reduce spending by 40% would reduce US GDP by almost 10%. No, it wouldn't, because most of that would go straight back to labor and result primarily in increased consumer spending, and secondarily in increased consumer investment (which leads to increased business spending.) It's not like the money not being spent on healthcare inefficiencies is going to just vanish out of the system.

I'm not sure. At what point does automation lead to a big drop in GDP?

Never; except perhaps when the fact that it results in greater concentration of wealth isn't mitigated and leads to destructive, violent revolution, which cuts GDP.

But that's not really analogous to eliminating health care inefficiencies.

Re: YC Research: Universal Healthcare

#284

Post by refurb » Wed, Feb 08, 2017, 4:05 AM UTC

spangry wrote: post #257

Arnt wrote: post #134

Earlier quoted context omitted.

Switzerland, England, Canada, the Netherlands... which negotiator in any of those countries is not smaller than Medicare?

England has a single-payer (the NHS) and a population of 53m people. So I guess the answer is England?

Nope. Medicare has 55.3M beneficiaries.[1]

[1]http://www.ncpssm.org/Medicare/MedicareFastFacts

Re: YC Research: Universal Healthcare

#285

Post by dragonwriter » Wed, Feb 08, 2017, 4:14 AM UTC

refurb wrote: post #284

spangry wrote: post #257

Earlier quoted context omitted.

England has a single-payer (the NHS) and a population of 53m people. So I guess the answer is England?

Nope. Medicare has 55.3M beneficiaries.[1] [1] http://www.ncpssm.org/Medicare/MedicareFastFacts

57 million, but that oncludes 17.6 million that are in third-party at-risk plans where Medicare is just paying a portion of the premiums (Medicare Advantage), not traditional "single payer" Medicare, so don't count in Medicare's negotiating power. So there's just under 40 million in traditional Medicare.

http://kff.org/medicare/fact-sheet/medicare-advantage/

Re: YC Research: Universal Healthcare

#286

Post by lkbm » Wed, Feb 08, 2017, 4:14 AM UTC

Eliezer wrote: post #141

It boots nothing to subsidize that which is in restricted supply. So long as there are only 350 othodontists allowed to graduate per year, there's a corresponding limit on how many patients are allowed to have straight teeth regardless of who pays for what or what software is used. Improve the software, and the price of orthodontia must still equalize demand to the limited supply. Offer free dollar bills, and a line…

The article claims that 40% of the cost is operational inefficiencies, fraud, and ineffective care citing [0]. If all orthodontists are fully occupied and there's no demand being cut, then yes, removing those inefficiencies will just boost orthodontic pay.

But it sounds like at least some of those inefficiencies involve: 1. People getting unnecessary orthodontic treatments (eliminating those cuts demand [not just quantity demanded]) 2. People getting ineffective treatments and needing a second treatment (same as 1) 3. Orthodontists being allocated in a way that lowers their overall productivity--empty time in their schedules, doing stuff they're less skilled at, etc.

If my orthodontist spends less time on administrivia or repeat procedures, he can fix more people's teeth without us training a second orthodontist.

Similarly, if there are apartments sitting empty for a month because it's hard to match people with apartments, better software can fit more people into San Francisco. (Going deeper, my bedroom is empty 12+ hours a day. I could totally sublet it to someone who works the night shift. I just need an efficient system to find such a person who's as interested in saving money as much as I am. Or as much as I was a few years ago. Now, I might not opt for this plan.)

[0] http://www.who.int/whr/2010/10_summary_en.pdf?ua=1

Re: YC Research: Universal Healthcare

#287

Post by chimeracoder » Wed, Feb 08, 2017, 4:18 AM UTC

surfmike wrote: post #253

Sanddancer wrote: post #244

Earlier quoted context omitted.

Or we could start funding medical research through our system of universities and the like. We have immense public and non-profit institutions that can take over. Maybe we'll even be able to see more benefit in treatment of rare and neglected diseases that way. It also means that a large number of people could actually afford medication, doctors, etc. I have friends who can't afford going to the doctor, can't afford…

Indeed, there are not enough incentives for pharma companies to target third world or not-so-common disease, but instead to push things like Viagra. That's one of the things Gates Foundation is helping address but ideally we do it at the government level. Research through grants to universities and labs already fuels a lot of great R&D in the US and I feel like we need to have even more of it for medicine.

> Indeed, there are not enough incentives for pharma companies to target third world or not-so-common disease, but instead to push things like Viagra.

Viagra was originally developed as a medication for cardiovascular disorders and hypertension, which are major problems in both the "third world" and in developed nations. It was only later on that they discovered its use for erectile dysfunction.

As for marketing Viagra - why is that a bad thing? Given that they've already done the bulk of the R&D for it, making money off the blockbuster drugs is exactly how pharmaceutical companies can afford to pour research into drugs that are a lot less likely to succeed, or which target poorer populations.

Or, if you don't want to look at Pfizer, look at Gilead. While it's easy to criticize them for charging so much money for Sovaldi (or charging so much for Tenofovir a decade ago) charging the patients who can afford it for the early years is exactly how they recover their costs and justify things like clinical trials for PrEP (which, it's easy to forget today, were a massive risk at the time), or direct market subsidizes of PrEP for people who can't afford it otherwise. I wouldn't be surprised if they did something similar for Sovaldi in the next decade as well.

Re: YC Research: Universal Healthcare

#288

Post by chimeracoder » Wed, Feb 08, 2017, 4:33 AM UTC

SilasX wrote: post #232

waffle_ss wrote: post #218

Earlier quoted context omitted.

Residency slots are the limiting factor, not medical school slots. There's no point increasing medical school slots if you're going to create a bunch of people shut out on Match Day with $200K+ in debt. It should be noted that licensing requirements of doctors mean that medical school graduates are also competing against foreign Blaming the AMA is a dated view. I believe that used to be the case, but certainly isn't…

If there really is excess demand for a kind of labor, then the labor can borrow enough to pay for it; it wouldn't make sense to blame an insufficient subsidy as a bottleneck.

> If there really is excess demand for a kind of labor, then the labor can borrow enough to pay for it;

You're right, but the reason that doesn't happen is that the price (ie, expected future earnings) is effectively fixed[0], and the current trajectory of that is already on the threshold of discouraging people from entering the field. As it is, a person who enters medical school at the age of 22 can reasonably expect to pay off their final student loan payment in their 40s[1]. That's a pretty hefty gamble to take at that age - you're assuming (against all evidence![2]) that medicine will continue to pay roughly the same in the future as it does today, and based on that assumption, you have to be willing to take a gamble that won't even break even until you're past normal childbearing age. That's a really tough sell, and I say this not hypothetically, but from experience.

It's similar to the "engineering shortage" in Silicon Valley - we know for a literal fact that the largest companies colluded to suppress wages, but simultaneously complain that they can't find enough workers that price. Except, we don't have to take out large amounts of debt before we can start working, whereas would-be doctors do.

[0] Not exactly fixed, but far from an actually competitive market that would allow proper consumption smoothing like you describe

[1] There are a lot of factors that determine this, like which specialty you choose, and where you practice, but that's a pretty reasonable rule-of-thumb estimate for someone who's still only thinking of applying to medical school in the first place.

[2] Physician earnings have been dropping steadily over the last few decades

Re: YC Research: Universal Healthcare

#289

Post by chimeracoder » Wed, Feb 08, 2017, 4:37 AM UTC

tcbawo wrote: post #273

djrogers wrote: post #260

Earlier quoted context omitted.

> Most people seem to like Medicare. Except for the doctors that can't afford to treat Medicare patients due to the criminally low/skewed reimbursement rates for some services. There's a reason so many private practices don't take Medicare patients...

On another thread, it was explained to me that Medicare reimbursement for a vaccine doesn't even cover the cost of the vaccine itself. I'm sure there is a Byzantine reimbursement model, but something tells me that if the entire country switched over to Medicare overnight, vaccines would quickly get much more affordable.

> something tells me that if the entire country switched over to Medicare overnight, vaccines would quickly get much more affordable.

Quite the opposite - if the entire country switched to Medicare overnight, Medicare would have to dramatically increase its reimbursement rates, or else hospitals would literally go out of business, and doctors would close up shop. The only reason most can afford to stay in business currently at all is that they can make up the money the lose on Medicare by treating patients on private insurance.

This would result in extreme tax increases - not the proportional amount that you'd expect to cover the remainder of the population, but enough to make up for the difference that's currently being subsidized by private insurance premiums.

Re: YC Research: Universal Healthcare

#290

Post by henrikschroder » Wed, Feb 08, 2017, 4:44 AM UTC

MR4D wrote: post #42

maxerickson wrote: post #26

Earlier quoted context omitted.

I bet making structural changes so that cost of care is more visible to patients would help a lot in the US. Of course this means disincentivizing health care as a benefit rather than incentivizing it, so it will never happen. It is kind of happening with things like HSAs, but not really. We should also work on removing arbitrary barriers to entering the supply side of the market. Not just for individuals that want t…

This, times 1,000 !! Imagine you go in for an oil change. You ask how much it costs, and find out it's $20. Great. You get the oil change. One month later you get a bill for "environmental disposal" for $35. The next month you get another bill for "Safety specialist" for $15. This is how healthcare works in the US. If retail worked like this, we'd be in a worldwide depression in about 6 months. Lunacy.

Oh wow, I encountered this exact problem today for the first time. It's absolutely insane!

I went for a routine doctor's visit a month ago, and paid the $30 copay or whatever it was before the visit. Today I got a bill for $208 where my insurance covers $193, which comes out as them wanting exactly $15 extra from me.

I have Kaiser insurance, I went to a Kaiser facility, saw a Kaiser doctor. It is completely incomprehensible to me how they couldn't know that my visit was actually going to be $45 beforehand, such that I could have paid that instead of the $30 I did. The $208 is obviously just a bullshit number some system pulled out of its ass, and the insurance coverage is just bullshit - 15. I don't get it, it's pure madness!