The Dark Side of Doctoring • Hacker News Board

Re: The Dark Side of Doctoring

#111

Post by mikeyouse » Tue, May 16, 2017, 1:36 AM UTC

leekyle wrote: post #99

mikeyouse wrote: post #62

Earlier quoted context omitted.

You should do a lot more reading about healthcare if you think there isn't pay for performance. The payers in the system all have massive incentives to reduce healthcare utilization. Docs and hospitals have been dealing with 'P4P' for decades and the ACA ramped it up significantly for the CMS.

What is a good example of pay for performance in healthcare?

The latest example from CMS is the Readmission Reduction program;

https://www.medicare.gov/hospitalcompare/readmission-reducti...

In general, Medicare pays a certain amount of money for a patient with a specific diagnosis. So if 70-year old woman X is admitted with condition Y, the hospital will receive $Z for treating her -- no matter what it costs. Hospitals don't love that since having patients in beds is expensive, so they would often times discharge patients before it was medically appropriate. They would take $Z and then when the patient came back in a few days, they could bill for follow-up services.

With the ACA we started tracking hospital readmissions to see how big of a problem that really was, and if hospitals underperformed their peers (aka they saw a lot of readmissions indicating that patients were discharged too early), they would either not pay for the followup visits or just lower the overall reimbursement for future patients.

Another good example was the Hospital-Acquired Condition reduction program. There is an enormous amount of cost associated with hosptial-acquired infections and the US was particularly bad in terms of modern systems. If patients in your hospital are consistently catching bugs, Medicare will dramatically reduce your reimbursement rate.

http://www.beckershospitalreview.com/quality/769-hospitals-s...

Since the 1990s though, Docs have been working with P4P -- whether it's increased reimbursement from insurance companies for prescribing an appropriate ratio of generics vs. brand name medicines, to the lump-sum payment per patient, to bonuses for hospitals adhering to best-practices (what % of patients with chest pain get an aspirin with 30 minutes or what % are cath'ed within 90 minutes of presenting).

Re: The Dark Side of Doctoring

#112

Post by maxerickson » Tue, May 16, 2017, 1:46 AM UTC

slackingoff2017 wrote: post #108

pixelmonkey wrote: post #18

My wife is a medical resident and the issues described by this doctor are absolutely pervasive in residency. The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents. As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commoditi…

It's well known within the medical field that being a doctor is really really tough. It takes a lot of smarts and grueling years in residency before you officially become a doctor. However it also pays incredibly well. Even moreso for specialities and surgeons, who can make over 200k a year even in low cost of living areas. Despite the difficulties of being a doctor it's harder to get into medical school than ever. T…

It pays well because supply is constrained and demand is inelastic.

It isn't clear how much the grueling training actually factors in to limiting the supply.

Re: The Dark Side of Doctoring

#113

Post by josh33 » Tue, May 16, 2017, 1:46 AM UTC

pixelmonkey wrote: post #18

My wife is a medical resident and the issues described by this doctor are absolutely pervasive in residency. The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents. As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commoditi…

I'm a former healthcare administrator and just want to point out that many many administrators work much more than the 9-5.

I'm also working at a healthcare tech startup aimed at reduced the administrative burden to doctors, administrators and insurers of managing their patients at home, which is where the worst outcomes often happen.

Each segment we work with feels this burden, it is not isolated to the physicians.

Re: The Dark Side of Doctoring

#114

Post by hbosch » Tue, May 16, 2017, 1:48 AM UTC

kendallpark wrote: post #81

This is a problem in medical school as well. I can't tell you how many anonymous posts have been popping up on r/medicalschool lately about being depressed, isolated, lonely, and/or suicidal. Missouri just passed the first bill of its kind to try and combat mental health issues in med school. http://krcgtv.com/news/local/medical-student-suicide-prompts... > The bill, also known as the Show-Me Compassionate Medical Ed…

I have a friend who is graduating from med school this week and starting residency. The stories of med school drama, gossip, backstabbing and cheating are insane - on par with anything on television drama. Moving into residency, they also feel alone, exhausted and anxious... I don't know how many people manage.

I think knowing a doctor, or someone becoming a doctor, has changed my perception of doctors entirely.

Re: The Dark Side of Doctoring

#115

Post by nathancahill » Tue, May 16, 2017, 1:48 AM UTC

nkurz wrote: post #63

karpodiem wrote: post #49

Earlier quoted context omitted.

Western medicine has turned into a ponzi scheme. The verifiable proof of this is to have an elderly family member in a nursing home who goes through the usual monthly trips to the hospital from 'falling'. While Medicare covers almost all of it, it became so nauseating to read the outrageous EOB totals that I tried to put a end to it - I requested that unless the on call nurse (after hours) or physician (during busine…

We have two family members in an assisted car facility for almost eight years now, and between the two of them, they've tapped Medicare for just under $700K. Together, the sum of both their incomes throughout their entire working lives never totaled that amount. Oh, but it gets worse. It's bad enough that the government is being bilked for hundreds of thousands of dollars on behalf of those without the ability to pay…

More book recommendations on HN should be a link to a good review like this, instead of just an Amazon link.

Re: The Dark Side of Doctoring

#116

Post by Mz » Tue, May 16, 2017, 1:51 AM UTC

josh33 wrote: post #113

pixelmonkey wrote: post #18

My wife is a medical resident and the issues described by this doctor are absolutely pervasive in residency. The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents. As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commoditi…

I'm a former healthcare administrator and just want to point out that many many administrators work much more than the 9-5. I'm also working at a healthcare tech startup aimed at reduced the administrative burden to doctors, administrators and insurers of managing their patients at home, which is where the worst outcomes often happen. Each segment we work with feels this burden, it is not isolated to the physicians.

You might be interested in joining: https://groups.google.com/forum/#!forum/health-techies

Re: The Dark Side of Doctoring

#117

Post by leekyle » Tue, May 16, 2017, 1:55 AM UTC

mikeyouse wrote: post #111

leekyle wrote: post #99

Earlier quoted context omitted.

What is a good example of pay for performance in healthcare?

The latest example from CMS is the Readmission Reduction program; https://www.medicare.gov/hospitalcompare/readmission-reducti... In general, Medicare pays a certain amount of money for a patient with a specific diagnosis. So if 70-year old woman X is admitted with condition Y, the hospital will receive $Z for treating her -- no matter what it costs. Hospitals don't love that since having patients in beds is expensiv…

Medicare is obviously a big part of healthcare, but is this same pay for performance happening with private insurance? How has the consolidation of hospitals impacted this? Has it become harder to negotiate these deals with massive hosptital networks?

Re: The Dark Side of Doctoring

#118

Post by kingbirdy » Tue, May 16, 2017, 2:06 AM UTC

slackingoff2017 wrote: post #108

pixelmonkey wrote: post #18

My wife is a medical resident and the issues described by this doctor are absolutely pervasive in residency. The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents. As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commoditi…

It's well known within the medical field that being a doctor is really really tough. It takes a lot of smarts and grueling years in residency before you officially become a doctor. However it also pays incredibly well. Even moreso for specialities and surgeons, who can make over 200k a year even in low cost of living areas. Despite the difficulties of being a doctor it's harder to get into medical school than ever. T…

So it's okay that doctor's commit suicide because at least they're paid well?

Re: The Dark Side of Doctoring

#119

Post by Kali909 » Tue, May 16, 2017, 2:07 AM UTC

robbiep wrote: post #64

Gatsky wrote: post #58

Earlier quoted context omitted.

I wish I could applaud this. But what sort of professional organisation waits until its members are actually dying before putting well-being in the radar? The RACS, RACP etc are sclerotic organisations run by old white men in bow ties (I've met several of them) with no real incentive to improve conditions for trainees. The only way I have seen actual change happen is when junior staff band together and effectively go…

Couldn't agree with you more re RACS, I attended their 'gala ball' at the end of their ACS last year and was sickened by the pomp and bullshit. The (female) RCS president, visiting from England, also appeared weirded out by the pomp (and that the RACS had not had a female president). Having said that within both organisations there are people who strongly and fiercely advocate for innovation and change, but you are r…

I don't know too much about the RACS etc (father was a radiologist but can't recall him complaining about their equivalent in Aus too much, though it's likely the same).

If you have to be a member of this, and that's government mandated, then them profiting from that arrangement is a blatant monopoly isn't it?

Re: The Dark Side of Doctoring

#120

Post by paulcole » Tue, May 16, 2017, 2:15 AM UTC

themantalope wrote: post #98

joshuaheard wrote: post #95

I am a lawyer, and if this was a lawyer's story, this would be my advice for the firm. First, they need to hire more lawyers. This guy is way too busy and will make a mistake. Second, he needs a receptionist, secretary, and paralegal to support him. It is wasteful to pay him a doctor's salary to answer phones. Third, they need to streamline their record keeping so he doesn't spend so much time filling out paperwork.

>It is wasteful to pay him a doctor's salary to answer phones. This is something I don't understand. I'm a medical student, and the amount of time I've seen wasted watching older physicians type notes is staggering. Just have them dictate the notes and hire a secretary. Perhaps for legal/liability reasons doctors need to write their own notes but it's just such a waste of time, and we pay a lot for it.

>we pay a lot for it.

Do we really though? I'm assuming a doctor is a salaried position so the more busy work they get the more hours they work? Doesn't this mean their time becomes less valuable?