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The Greedy Doctor Problem

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91–100 of 182 posts

Re: The Greedy Doctor Problem

#91

The article proposes prepayment options. Why not go to the "other, other obvious" solution, which is results-based payments? In healthcare, that's value-based care. In other industries w/ agent-principle problems, it's called "taking on risk". You're incentivizing results and outcomes, rather than whatever specific actions lead up to those results. It means that the focus is no longer on the activity provided by the…

One potential difficultly here is that good metrics are hard, and outcomes for a lot of medicine are hard to evaluate. Obviously not true everywhere.

So a potential path will be that the incentives start to line up with measurable impact on symptoms short term (easy outcome to evaluate) instead of meaningful shift in root causes (difficult and/or slow to measure)

Re: The Greedy Doctor Problem

#92

Earlier quoted context omitted.

> To cure health care, give your care-givers a clear incentive to keep you well. Make sure that when you lose, they lose, and just as much. Buy lots of life and disability insurance from your care-givers, and have a third party, unable to act against your life or health, pay you to be the beneficiary.

So, basically bundling insurance with the healthcare provider, like kaiser?

The quantitative difference is big enough to be qualitative. You have to buy a lot of life insurance, more than people normally get, to make it work. The disinterested third party beneficiary makes this affordable:

> There are, however, two big problems with this approach. The first is that even though my life may be worth $10 million to me, most of the (huge) insurance premium to pay for this insurance would be wasted from my point of view -- there probably is not one person to whom I would want to give this much money when I die. The other problem is moral hazard -- heavy insurance may reduce my incentive to keep myself healthy, and may even create incentives for my relatives to try and hurt me. It might be a problem if I could only give my doctor a 50 percent interest in my life by taking away 50 percent of my own interest, or by giving a minus 50 percent interest to my relatives.

Re: The Greedy Doctor Problem

#93

The article proposes prepayment options. Why not go to the "other, other obvious" solution, which is results-based payments? In healthcare, that's value-based care. In other industries w/ agent-principle problems, it's called "taking on risk". You're incentivizing results and outcomes, rather than whatever specific actions lead up to those results. It means that the focus is no longer on the activity provided by the…

I think that the author is assuming that you, the patient, have no way to assess whether the diagnosis was correct. I think that eliminates what I also thought of as a strategy, which is how this works in real life - some combination of being able to tell, as the patient, when treatment is working, combined with (the threat of) second opinions, and of course all the “human” stuff that the author sets aside about doct…

The thing is, in many cases you don't need to know if the diagnosis is correct, so long as the results are directionally correct. If the outcome is an improvement in health, that meets your threshold for value delivered, hence payment rendered. I think there are many cases when you don't need to be smarter than the other person to benefit from their expertise. You can take it a step further and make the distinction between absolute value versus perceived/relative value -- if we have a patient with cancer, absolute value might mean destroying all cancer cells (which is an absolute metric but extremely hard to model). But perceived value might be "feeling better". It's important to make this distinction particularly in healthcare because absolute benefits and relative benefits are extremely important. Hospice/end-of-life care is a good example of this (as is the cancer example above). Most people would prefer relative or perceived comfort as opposed to absolute results that only end up prolonging a painful process.

Outside of healthcare, for another example example, you don't need to understand engineering and tension dynamics in order to appreciate that the second floor of your home support you and your roof doesn't cave in on itself. I don't have examples on hand, but in medicine we've had cases where people do some logical variation of "the right thing for the wrong reasons." I.e., rituals that correlate with healthy outcomes because there is some not-yet-understood principle at play (i.e, you don't need to understand germ theory to benefit from cleanliness rituals).

I think this is one of those logical conundrums which falls into the trap of "in theory, in practice". The artificial constraints around the problem space result in artificial logical conundrums.

Re: The Greedy Doctor Problem

#94
post #52

Someone uses “greedy doctor” as an example to talk about an easy to understand version of the Control Problem, and the comments make it into a discussion of healthcare systems. I’m starting to think most readers on HN don’t really read the articles and go straight into the comment section..

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Re: The Greedy Doctor Problem

#95

Competition cures greed. Instead of going to one doctor, go to three. Go with the doctor that has the best value (price/service). If the doctor gets greedy, shop around. Tell the doctor you found a lower price, and if he is not competitive, you will fire him, and find a new doctor.

How many people are in a position to find out which doctor has the best value?

Is there even a theoretical possibility that this could be done other than after the fact?

Re: The Greedy Doctor Problem

#96

The article proposes prepayment options. Why not go to the "other, other obvious" solution, which is results-based payments? In healthcare, that's value-based care. In other industries w/ agent-principle problems, it's called "taking on risk". You're incentivizing results and outcomes, rather than whatever specific actions lead up to those results. It means that the focus is no longer on the activity provided by the…

> Why not go to the "other, other obvious" solution, which is results-based payments?

There is a story about doctors in ancient China who are paid by their clients only so long as the client is healthy. When they fall sick, the doctor is not paid again until the patient is healthy again. Then the goal is not a cure for a disease but the prevention of disease.

I don't know if any such thing ever really happened but it seems like it might be worth exploring even if only to illuminate the various possibilities.

Re: The Greedy Doctor Problem

#97

The article proposes prepayment options. Why not go to the "other, other obvious" solution, which is results-based payments? In healthcare, that's value-based care. In other industries w/ agent-principle problems, it's called "taking on risk". You're incentivizing results and outcomes, rather than whatever specific actions lead up to those results. It means that the focus is no longer on the activity provided by the…

> Why not go to the "other, other obvious" solution, which is results-based payments? There is a story about doctors in ancient China who are paid by their clients only so long as the client is healthy. When they fall sick, the doctor is not paid again until the patient is healthy again. Then the goal is not a cure for a disease but the prevention of disease. I don't know if any such thing ever really happened but it…

It's an interesting idea but the pessimist in me just sees this as incentivizing under-diagnosing, running fewer tests, etc.

Re: The Greedy Doctor Problem

#98

The article proposes prepayment options. Why not go to the "other, other obvious" solution, which is results-based payments? In healthcare, that's value-based care. In other industries w/ agent-principle problems, it's called "taking on risk". You're incentivizing results and outcomes, rather than whatever specific actions lead up to those results. It means that the focus is no longer on the activity provided by the…

Then doctors filter what patients they take to guarantee these good outcomes. This is already done by some surgeons. Surgery is already a subset of medicine heavily judged on outcomes.

Re: The Greedy Doctor Problem

#99

Earlier quoted context omitted.

> Why not go to the "other, other obvious" solution, which is results-based payments? There is a story about doctors in ancient China who are paid by their clients only so long as the client is healthy. When they fall sick, the doctor is not paid again until the patient is healthy again. Then the goal is not a cure for a disease but the prevention of disease. I don't know if any such thing ever really happened but it…

It's an interesting idea but the pessimist in me just sees this as incentivizing under-diagnosing, running fewer tests, etc.

Running fewer tests is not necessarily bad, especially if your baseline is a system where the system is paid per-test.

Re: The Greedy Doctor Problem

#100

Earlier quoted context omitted.

> Why not go to the "other, other obvious" solution, which is results-based payments? There is a story about doctors in ancient China who are paid by their clients only so long as the client is healthy. When they fall sick, the doctor is not paid again until the patient is healthy again. Then the goal is not a cure for a disease but the prevention of disease. I don't know if any such thing ever really happened but it…

It's an interesting idea but the pessimist in me just sees this as incentivizing under-diagnosing, running fewer tests, etc.

Also they have no interest in treating elderly (or anyone all that ill) if it requires any effort at all, as future healthy payments will not cover the expense.

It is easy to see an optimal strategy of never treating anything.

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