Unnecessary medical care is harming patients physically and financially (2015) • Hacker News Board

Re: Unnecessary medical care is harming patients physically and financially (2015)

#31

Post by lr4444lr » Fri, Mar 02, 2018, 2:33 PM UTC

novalis78 wrote: post #30

gjem97 wrote: post #26

It's a question of fundamental incentives. Doctors and hospitals are paid for procedures, treatments, and appointments. Is it any surprise that there's incentive to undertake these activities? You don't even need to believe that your doctor is greedy to understand that if there's a borderline case, they might order the test or treatment "to be safe", or "because there's no downside", or because "we have the available…

I slightly disagree - what's missing is price transparency inviting competition. Through competition the payment and cost side of things will be added to the equation and shift incentives to cut waste and increase quality of service. That includes all aspects of the healthcare services.

Also that for the majority of people, a third party pays. The receiver of care only indirectly affected by slowly rising premiums, deductibles, co-pays, caps.

Re: Unnecessary medical care is harming patients physically and financially (2015)

#32

Post by shimon » Fri, Mar 02, 2018, 2:33 PM UTC

gjem97 wrote: post #26

It's a question of fundamental incentives. Doctors and hospitals are paid for procedures, treatments, and appointments. Is it any surprise that there's incentive to undertake these activities? You don't even need to believe that your doctor is greedy to understand that if there's a borderline case, they might order the test or treatment "to be safe", or "because there's no downside", or because "we have the available…

Patients also often want more stuff to be done. Humans evaluate treatment decisions as "let's keep trying vs. give up" not "I'd take on a 5% risk of complications for a 20% better chance of living another 3 months".

The complexity of these tradeoffs means that unusual choices are really hard to make well. This is most obvious in the expensive treatments that are sometimes applied before a patient's death -- expensive both in cost to deliver and harm to the patient's remaining days.

Re: Unnecessary medical care is harming patients physically and financially (2015)

#33

Post by phil21 » Fri, Mar 02, 2018, 2:34 PM UTC

0xcde4c3db wrote: post #23

kent13304 wrote: post #18

Earlier quoted context omitted.

It actually would. No need for sarcasm on that comment.

I'm not sure it would. Given the information asymmetries involved, how does it avoid the "market for lemons" problem?

I think HN could do with some older folks on it. Heck, I remember growing up and using insurance was rare. You paid cash for your doctor visits, and typically only used insurance for major hospital stays as that's more or less all it covered.

Doctor visits just 30 year ago did not cost what they do today. You could get a clean break in your arm, go into your GP, have it fully fixed and be out the door for less than a week's wages for an average blue collar worker. This was actually considered very expensive, but it prices were held down for the simple fact that people cared and there was a hard limit - can't get blood from a stone.

When insurance started to become "cadillac" plans I very much noticed an insane explosion in everyday medical costs and a nosedive in quality of care. It's now a corporate factory system where everyone is miserable - the doctors and the patients. The only winners are executives and shareholders. The insanity of average cases of stuff like the flu now going to a doctor also is very new, and only is happening due to the incentives of "free visit" for the average consumer.

The typical argument used against a return to "free market" health care where insurance is actually insurance again is one much like yours - if you're sick you don't care about the price. This was proven untrue just in my recent childhood, and something like 90%+ of all healthcare is not urgent or emergency related. If 90% of the market is setting prices via free market discovery the remaining 10% will be drug along or can be forced to via limited regulation.

Healthcare costs in the US are almost entirely a principal agent problem. Absolutely no one has a damn clue of what anything costs at any point in the entire process. And the real issue is the consumers don't actually care since they are only harmed in an indirect sense.

Re: Unnecessary medical care is harming patients physically and financially (2015)

#34

Post by saint_fiasco » Fri, Mar 02, 2018, 2:34 PM UTC

0xcde4c3db wrote: post #23

kent13304 wrote: post #18

Earlier quoted context omitted.

It actually would. No need for sarcasm on that comment.

I'm not sure it would. Given the information asymmetries involved, how does it avoid the "market for lemons" problem?

Add a regulation that says every hospital must publish anonimized aggregated patient outcomes. Remove as many other regulations as it would take for them to be willing to compromise and accept this one.

Re: Unnecessary medical care is harming patients physically and financially (2015)

#35

Post by shawndimantha » Fri, Mar 02, 2018, 2:35 PM UTC

novalis78 wrote: post #30

gjem97 wrote: post #26

It's a question of fundamental incentives. Doctors and hospitals are paid for procedures, treatments, and appointments. Is it any surprise that there's incentive to undertake these activities? You don't even need to believe that your doctor is greedy to understand that if there's a borderline case, they might order the test or treatment "to be safe", or "because there's no downside", or because "we have the available…

I slightly disagree - what's missing is price transparency inviting competition. Through competition the payment and cost side of things will be added to the equation and shift incentives to cut waste and increase quality of service. That includes all aspects of the healthcare services.

It is probably both. The primary reason for healthcare cost growth is price not utilization (refer to work from IHME, others), but there also have to be appropriate incentives in place such as exist in ACOs to ensure quality care is delivered cost effectively. Agree that value based care by itself may not be the answer, just look at the way drug companies claim to price medications based on value such as Gilead’s Sovaldi curing Hepatitis C.

Re: Unnecessary medical care is harming patients physically and financially (2015)

#36

Post by lr4444lr » Fri, Mar 02, 2018, 2:36 PM UTC

dipppy wrote: post #21

Everyone has a story like this. I went in for a physical and even though they said to my face my insurance would fully cover a heart electrocardiogram (my family has a history of heart problems) I wound up with a huge bill, month long fight with insurance, and ended up just having to foot it. Maybe if medical care was driven by some other force besides capitalism this wouldn't be such an issue.

Just out of curiosity, because I often have this fear, did your the staff have any documentation or make assurances that he was a "participating provider" with your plan (i.e. not just saying they "will bill the insurance company")? Or did your plan not offer comprehensive coverage?

Re: Unnecessary medical care is harming patients physically and financially (2015)

#37

Post by hliyan » Fri, Mar 02, 2018, 2:36 PM UTC

I live in a 3rd world country (Sri Lanka). Healthcare is not as advanced as it is in the US, but it is decent for all except the most complicated cases. The vast majority of people use the free services at state hospitals. If you want slightly better care, you can go to a private hospital and still come out with most of your wealth intact.

I recently had a minor surgery to remove a conjunctival granuloma from my left upper eyelid. It was a private hospital, and it cost all of $50. Compared to US standards, the facilities were spartan, but adequate and hygienic. Also, doctors and hospitals do not live in constant fear of malpractice suites. I suspect these factors have a lot to do with the costs (in addition to the obvious cost-of-living adjustment for the third world).

Re: Unnecessary medical care is harming patients physically and financially (2015)

#38

Post by dharmapure » Fri, Mar 02, 2018, 2:36 PM UTC

In the book Antifragile Nassim Taleb cautions against medical care unless it's truly necessary. He argues that since so many things can go wrong in a hospital (you could get sick from someone else, mistakes could be made, etc), only go if the benefits outweigh the risks.

And so if you have cancer, it's probably worth the risk. But if you have something that could just go away naturally, that's got a higher expected value of positive outcome.

He is in favor of subtractive medicine - many harms are caused by adding such things as smoking, sugar, preservatives, etc, and instead of adding medicine or surgery, remove the elements that the body isn't evolved to tolerate and see if it heals itself.

He gives the example of how he hurt his back weight lifting. The doctor proposed surgery. He just waited and his back healed itself, and in a way that is now more robust than if he had had surgery.

As with all things, it's not a black and white kind of decision, but this mindset has worked well for me as a heuristic for health.

Re: Unnecessary medical care is harming patients physically and financially (2015)

#39

Post by merpnderp » Fri, Mar 02, 2018, 2:37 PM UTC

lr4444lr wrote: post #31

novalis78 wrote: post #30

Earlier quoted context omitted.

I slightly disagree - what's missing is price transparency inviting competition. Through competition the payment and cost side of things will be added to the equation and shift incentives to cut waste and increase quality of service. That includes all aspects of the healthcare services.

Also that for the majority of people, a third party pays. The receiver of care only indirectly affected by slowly rising premiums, deductibles, co-pays, caps.

For most people it is actually a forth party pays. There's the traditional three party insurance system, but for most people there's also the forth, their employer. So not only is the receiver of medical care removed from any price sensitivity by their insurer, they're removed from much of the insurance price sensitivity by their employer.

Removing the ridiculous system of employers paying for health care and instead just paying people the money (come on, FDR's WWII salary fixing has been over for 70 years, yet its harm continues).

Re: Unnecessary medical care is harming patients physically and financially (2015)

#40

Post by Consultant32452 » Fri, Mar 02, 2018, 2:39 PM UTC

learnstats2 wrote: post #29

The article pins part of its argument on the claim that advances in diagnostics have not changed the death rate for (e.g.) breast cancer during the past quarter century, but a superficial search immediately suggests this to be grossly false. "Death rates from female breast cancer dropped 39% from 1989 to 2015." - all other things being equal, it ought to have increased: age is a risk factor for cancers, and we have a…

There are other likely explanations for that data. If more women are getting screened more frequently then their cancers will be detected earlier and improve survival rate. That doesn't mean the diagnostics tools themselves have improved the survival rate, only that the diagnostic tools are now used more frequently.