Diagnosis: Insufficient Outrage • Hacker News Board

Re: Diagnosis: Insufficient Outrage

#51

Post by crs » Sun, Jul 07, 2013, 7:25 AM UTC

BadCookie wrote: post #2

What if every clinic had to make a price list of procedures publicly available, and could not legally charge people different amounts for the same procedure (regardless of insurance status and so on)? That would solve at least some of the problems. But I think it's obvious that almost no one actually wants to fix the broken system, because too many people are making too much money from it. (Doesn't that apply to almo…

I actually had a discussion with my doctor on this very subject. He was complaining that he could not actually advertise prices as it is apparently considered price fixing if doctors do that (or so he says). He also told me he would be stupid not to bill the highest possible price he could for things because he doesn't know exactly what the insurance companies will accept and he could be leaving money on the table otherwise. So don't try to distinguish between specialists and GP's, they all do it.

Re: Diagnosis: Insufficient Outrage

#52

Post by arethuza » Sun, Jul 07, 2013, 7:29 AM UTC

haldujai wrote: post #18

gregsq wrote: post #10

Earlier quoted context omitted.

Actually Indonesia, a country clawing its way out of third world status, is in the process of introducing universal health care, [1] so it's not only commonwealth countries. Hopefully, this 'socialised' system can be implemented in such a way as to flourish within the rapidly growing economy to come. In the UK, after we've charged you nothing in the NHS, we'll give you the bus fare home. 1. http://www.marketplace.org…

Yes but try getting an appointment with a doctor in a reasonable time under NHS. It's been a while since I've left the UK but I remember getting appointments with a primary care physician using private insurance I would get one the next day, with NHS the next month.

It does seem to have got worse in the last few years - not that I go to a GP often (maybe once every 3 or 4 years) but I was used to getting an appointment within 1 or 2 days and the last time the only appointement was about a week away.

However, it is worth noting that recent published statistics (for 2011/2012) show that:

"85 per cent could see or speak to a doctor or nurse within two working days compared to 90 per cent in 2009/10."

Note that this is for NHS Scotland - there actually isn't a single NHS for the entire UK.

http://www.scotland.gov.uk/Publications/2012/05/8250/3

One of the problems with the NHS is that it seems to suffer from having regular waves of (probably very expensive) management re-organisation inflicted on it in efforts to make it "more efficient" - often with non-medical managers being incentivized on performance, so they end up gaming the metrics.

Still, I think the NHS and the concept of "free at the point of delivery" championed by Nye Bevan "In Place of Fear" are still fantastically important to society the UK - though nobody claims it is perfect. Clearly the absolute best level of individual care are to be found elsewhere (probably in the US). However, when I see quotes elsewhere in this thread such as:

"I broke my knee this spring but didn't go to a hospital on my families request because the last time I broke a bone I reset it myself and the hospital still charged $8k."

Those pretty much fill me with horror/fear that anyone has to put up with that - which is precisely the reason the NHS was created.

Re: Diagnosis: Insufficient Outrage

#53

Post by zaroth » Sun, Jul 07, 2013, 7:37 AM UTC

pyre wrote: post #42

bmmayer1 wrote: post #32

Yes, if prices are skyrocketing it must be a "Crime" caused by all the dirty capitalists enriching themselves. There could be no possible explanation for it. Unless, of course, you want to consider: 1) The stifling HIPAA regime that makes it almost impossible for small, potentially competitive practices to stay open without insane amounts of overhead, explaining their sellouts to larger at-scale healthcare corporatio…

| The necessity to offset insanely low negotiated | and subsidized Medicare/Medicaid rates My understanding is that insurance companies often get rates lower than Medicare. It goes something like this: 1) Government mandates the rates for procedure X to make sure that the government is getting the 'best' deal. 2) Hospitals charge insurance companies using these rates (they aren't allowed to be lower, or it wouldn't b…

As it was explained to me by the CFO of a major hospital, you are incorrect.

Hospitals would be out of of business if their average revenue per procedure was equal to the Medicare rates per procedure. But that's not to say that hospitals are "losing money" on every Medicare patient, it's much more complicated.

Running a hospital is like running an airline, there are extraordinary fixed costs just to open the doors, regardless if any patients (aka customers) show up. When you have high fixed and low variable cost, if you are operating below capacity then the marginal cost to serve 'just one more patient' is low, and so providing the service at Medicare rates results in net income, all else equal.

Of course the money for the fixed costs eventually has to come from somewhere. Right now, that comes largely from private donations, and rate shifting (higher rates for the privately insured and uninsured).

Simply put it comes down to buying power. No one buys more than Medicare, so it's not surprising that they get the best rates.

Re: Diagnosis: Insufficient Outrage

#54

Post by haldujai » Sun, Jul 07, 2013, 7:39 AM UTC

arethuza wrote: post #52

haldujai wrote: post #18

Earlier quoted context omitted.

Yes but try getting an appointment with a doctor in a reasonable time under NHS. It's been a while since I've left the UK but I remember getting appointments with a primary care physician using private insurance I would get one the next day, with NHS the next month.

It does seem to have got worse in the last few years - not that I go to a GP often (maybe once every 3 or 4 years) but I was used to getting an appointment within 1 or 2 days and the last time the only appointement was about a week away. However, it is worth noting that recent published statistics (for 2011/2012) show that: "85 per cent could see or speak to a doctor or nurse within two working days compared to 90 pe…

I actually like the dual system offered in the UK. I was in London back before 97, it appears things have gotten much better (http://www.mirror.co.uk/news/uk-news/exclusive-nhs-hospital-...).

Although specialist visits are still lagging behind the US (23 weeks for knee replacements).

Yes, the non medical managers (i.e. those annoying MPH people who make drastic irrational changes to justify their positions), we have the same problem in Canada.

Re: Diagnosis: Insufficient Outrage

#55

Post by jamesaguilar » Sun, Jul 07, 2013, 7:40 AM UTC

zanny wrote: post #33

jamesaguilar wrote: post #23

Earlier quoted context omitted.

Doctors and medical facilities would need to make a lot less money. That is the source of most of the cost difference. The vehicle of payment is maybe a secondary cause. It might be good to change it, but if it's not directly responsible for the majority of the difference in what doctors are getting paid, it's not going to fix the problem.

My Uncle is a doctor, went the full 9 years at Tulane and everything. He had to close his own practice because Medicare paid dirt, insurers would delay payments for years, and malpractice insurance was thousands a month. He was running around a 2,000 a month deficit when he had to fire his secretary and close down. He now works in a general hospital as a surgeon, and is actually happier not having to try to haggle ge…

The overhead of insurance companies are minimal. Less than five percent of the overall spend (edit: this is wrong, it is more like 8%, see [1]).

As much as you prefer to think of your uncle as the good guy and faceless insurance companies as the bad guy, a big part of the problem is he makes between 150% and 200% what his European and Canadian counterparts make. http://economix.blogs.nytimes.com/2009/07/15/how-much-do-doc.... Ahmdahls law makes it nearly inevitable that we'll pay doctors less if we want to reduce our overall costs.

1 http://tbd-consulting.typepad.com/healthcare_talent/2010/09/...

Re: Diagnosis: Insufficient Outrage

#56

Post by polemic » Sun, Jul 07, 2013, 7:44 AM UTC

loginalready wrote: post #40

Qantourisc wrote: post #22

Seriously, just copy the EU on healthcare. You might need to pay extra taxes, and take an extra insurance against hospitals fees. But it's all very affordable. If it wasn't for A) getting the same answer for most of my ills: inflammations :p B) The doctor being very busy. C) Basic respect to not stress our medical system. One would go for the tiniest medical complain.

The EU is not a country. The EU has no single healthcare system. Every country has it's own system, which range from anything between 100% government provided to mostly privatized. No system is the same. And it's not just the EU, it's the entire Western civilization outside the US. This is extremely important, because the healthcare debate in the US is falsely framed as a choice for or against "socialized medicine",…

This.

Germany has compulsory health care insurance, Britain has the NHS, New Zealand has a largely free public health care system (with ACC for accident care and private health insurance for those that can afford a slightly higher level of care).

These are all "socialized" schemes of one variety or another, but they all work. You'd get funny looks framing a discussion about health care in those sorts of terms in most of those countries - and the stories shared here sound perverse to anyone in a western democracy outside of the US.

Re: Diagnosis: Insufficient Outrage

#57

Post by grey-area » Sun, Jul 07, 2013, 7:48 AM UTC

haldujai wrote: post #18

gregsq wrote: post #10

Earlier quoted context omitted.

Actually Indonesia, a country clawing its way out of third world status, is in the process of introducing universal health care, [1] so it's not only commonwealth countries. Hopefully, this 'socialised' system can be implemented in such a way as to flourish within the rapidly growing economy to come. In the UK, after we've charged you nothing in the NHS, we'll give you the bus fare home. 1. http://www.marketplace.org…

Yes but try getting an appointment with a doctor in a reasonable time under NHS. It's been a while since I've left the UK but I remember getting appointments with a primary care physician using private insurance I would get one the next day, with NHS the next month.

Yes but try getting an appointment with a doctor in a reasonable time under NHS.

You can usually get an appointment with your GP within days, sometimes the next day (depends on your local GP). In an emergency you can call them and get an appointment straight away. It's never been a problem when I needed to see a UK doctor.

The GP can decide with you if you need to see a specialist and refer you (the vast majority of people don't).

Re: Diagnosis: Insufficient Outrage

#58

Post by vacri » Sun, Jul 07, 2013, 7:48 AM UTC

haldujai wrote: post #37

lostlogin wrote: post #27

Earlier quoted context omitted.

Yes - it pays to have a big defib (not one of the 'press button now' mall variety), an experienced and qualified staff member or 5 with high level CPR training, and some good cardiac event type drugs, and a load of proper monitoring gear (heart rate, BP, etc). While these things aren't especially cheap, they would pay off fairly quickly at a decent clinic, and I was involved in the purchase of most this stuff for sub…

$2000 isn't that ridiculous depending on the circumstances, but $75 is impossibly low with America's system. In Canada they bill ~$200 +/- 100 depending on the details. A comparable figure in the states (again factoring insurance non-payment issues and convenience factors, i.e. how soon you can get it, having facilities close by) would be reasonable at $800-$1500.

$2000 is utterly ridiculous for a stress test. I used to work as a neurology tech, mostly dealing with epilepsy. Our tests themselves could invoke seizures, and we frequently saw seizures anyway, which can be life threatening if not handled. We were a private department in a hospital - as techs, we knew enough first aid to keep the person alive and call for the crash cart.

$2000 might sound reasonable if every single patient required emergency attention, but in truth, far from it. Medical tests aren't meant to bring you to the brink of death, and are generally designed to keep you safe. It's not even worth pretending that $2k 'might' be worth it; it's just not. As for covering for insurance non-payment, isn't that chicken-and-egg? When a test costs ten times what it should? That would suggest that for each test that someone pays for, there are nine patients effectively getting it for free.

Re: Diagnosis: Insufficient Outrage

#59

Post by arethuza » Sun, Jul 07, 2013, 7:56 AM UTC

haldujai wrote: post #54

arethuza wrote: post #52

Earlier quoted context omitted.

It does seem to have got worse in the last few years - not that I go to a GP often (maybe once every 3 or 4 years) but I was used to getting an appointment within 1 or 2 days and the last time the only appointement was about a week away. However, it is worth noting that recent published statistics (for 2011/2012) show that: "85 per cent could see or speak to a doctor or nurse within two working days compared to 90 pe…

I actually like the dual system offered in the UK. I was in London back before 97, it appears things have gotten much better ( http://www.mirror.co.uk/news/uk-news/exclusive-nhs-hospital-... ). Although specialist visits are still lagging behind the US (23 weeks for knee replacements). Yes, the non medical managers (i.e. those annoying MPH people who make drastic irrational changes to justify their positions), we hav…

Of course, one thing about the NHS in the UK, as with state provided education, you can opt out of using it but you can't opt out of paying for it!

Re: Diagnosis: Insufficient Outrage

#60

Post by haldujai » Sun, Jul 07, 2013, 7:58 AM UTC

vacri wrote: post #58

haldujai wrote: post #37

Earlier quoted context omitted.

$2000 isn't that ridiculous depending on the circumstances, but $75 is impossibly low with America's system. In Canada they bill ~$200 +/- 100 depending on the details. A comparable figure in the states (again factoring insurance non-payment issues and convenience factors, i.e. how soon you can get it, having facilities close by) would be reasonable at $800-$1500.

$2000 is utterly ridiculous for a stress test. I used to work as a neurology tech, mostly dealing with epilepsy. Our tests themselves could invoke seizures, and we frequently saw seizures anyway, which can be life threatening if not handled. We were a private department in a hospital - as techs, we knew enough first aid to keep the person alive and call for the crash cart. $2000 might sound reasonable if every single…

You're assuming the cost is $200. In Canada it can be up to 6 months (from my own experience) to get a stress test booking. In the states you can do it the next week. That gets a significant premium. Compare it to buying something on eBay from Hong Kong and waiting 5-8 weeks vs paying 4x and getting it right this second from Best Buy. At the end of the day you're going to get what you need either way but it's how long you're willing to wait.

$2000 is only for uninsured patients, and as has been demonstrated numerous times results in you getting shafted when it comes to pricing. A better problem to attack is reducing the amount of stress tests given, as they're often completely unnecessary. Ontario has recently decided to stop paying doctors who give unnecessary stress tests, resulting in ~5000 fewer tests given every year.