Post-apocalyptic life in American health care • Hacker News Board

Re: Post-apocalyptic life in American health care

#111

Post by maxander » Tue, Jan 02, 2018, 9:15 PM UTC

trowawee wrote: post #69

nradov wrote: post #63

Earlier quoted context omitted.

Standardize what? With a complex medical condition like that every patient is different so it's tough to apply evidence-based medicine practices. The technology for sharing patient records is gradually being standardized. But that won't help if the doctors don't actually take time for a detailed review of the patient's records.

Personally, from my observations as a software engineer married to a doctor and friendly with lots of doctors, and as an occasional participant in the American healthcare system, the general inadequacy of electronic medical systems is one of the most maddening aspects of our system. Epic is a monstrosity and none of the other systems are much better. The tech is outdated, the interfaces are awful, they're incredibly…

> whoever the members of our profession are who are building those systems are doing a crap job.

They're doing an excellent job, probably producing a level of functionality comparable to Amazon web developers or Oracle database writers. They're doing an excellent job at navigating the unholy mess of archaic regulations, mismatching institutional requirements, and hostile corporate interests, without getting sued or convicted. User experience, or even user usability, is a secondary concern, since being difficult to use (even if this leads to multiple deaths per day) is in no way illegal.

Medical informatics is definitely a field where smart and motivated people can make a huge difference to the world, and perhaps even get filthy rich while doing it. But it will take much more than a hotshot UX designer to work out.

Re: Post-apocalyptic life in American health care

#112

Post by conanbatt » Tue, Jan 02, 2018, 9:17 PM UTC

dragonwriter wrote: post #102

conanbatt wrote: post #68

Earlier quoted context omitted.

I would argue that food escapes its measure of utility because otherwise, we would all be eating only the cheapest and healthiest option all the time, but our constant hunger also makes us purchase things against our long term interest. If so, you would expect the market to be really inefficient, but at least in terms of satisfying demand, its very hard to make money producing food. Its true healthcare has less frequ…

> I would argue that food escapes its measure of utility because otherwise, we would all be eating only the cheapest and healthiest option all the time Economic utility is subjective; while it includes health effects, to be sure, it also includes things like the taste and other enjoyment factors. It absolutely is not the case that, were food a perfect example of rational choice, we would only be buying options that c…

> Economic utility is subjective; while it includes health effects, to be sure, it also includes things like the taste and other enjoyment factors. It absolutely is not the case that, were food a perfect example of rational choice, we would only be buying options that cost-effectively optimized healthiness.

Sure, I agree completely, but at least nominally the argument that healthcare is unique because its a necessity and it has irrational behaving actors is not qualitatively different than the food market.

> “Healthcare” is a broad class of different products and services, many of which are far less frequently purchased than autos (if you buy open heart surgery more often than you buy a car, you are way out in a tail of frequency-of-purchase distribution of at least one of those items.)

Thats as practical a segregation as saying that the people that buy the same model of a car the same year and with the same gas price tends to be 1 at most, hence almost no car purchases are ever repeated!

> OTOH, cars are also a market in which purchasers take a number of steps to counteract the low frequency. No one is test driving a variety of different surgerical interventions before choosing one.

Not really qualitative differences, just quantitative. Many car purchases are done without test drives (argentina doesnt do test drives often for example).

But again, even if you find some truly unique property of healthcare, which in this debate i don't recognize yet, i dont know how it will show that it should be private but public.

Re: Post-apocalyptic life in American health care

#113

Post by maxander » Tue, Jan 02, 2018, 9:24 PM UTC

If someone has a reasonably high-level position in a major medical services organization, and wants to help us advance as a species, here's something to push for; get your company to throw out all its fax machines.

Every office in the world can use non-fax communication technologies; they just have policies that prevent them. If they encounter a sufficiently large healthcare entity that simply shrugs at them and says "we don't do faxes," those policies won't matter, for precisely the reasons stated in the article. People will do what needs to be done to get things to happen, policy or no (if they care; if they don't, it won't get done, regardless of the number of fax machines involved.)

One organization making a stand could start the process of getting us past that particular perverse element of the medical system.

Re: Post-apocalyptic life in American health care

#114

Post by AnIdiotOnTheNet » Tue, Jan 02, 2018, 9:27 PM UTC

maxxxxx wrote: post #87

u801e wrote: post #60

Earlier quoted context omitted.

Shouldn't the results of the previous tests be part of the medical record? If so, then the other doctor should have been able to view the results.

I don't know. It should but something wasn't clear. The point is that for some reason they didn't make a quick call to clarify and seemed genuinely confused about this suggestion. Instead they ran the tests again.

I have a hypotheses. My experience with doctors (that is, general practitioners) is that they think very highly of themselves but usually aren't actually that good at their job. Consequently, they believe they know everything and other doctors know nothing.

It's possible I've just had a lot of bad doctors though.

Re: Post-apocalyptic life in American health care

#115

Post by 1_2__4 » Tue, Jan 02, 2018, 9:32 PM UTC

conanbatt wrote: post #85

shrike wrote: post #25

About 8 years ago I broke my leg and eventually developed a methicillin-resistant infection where screws had been inserted. Fighting this type of infection in the bone is difficult. I spent 11 months in a hospital bed plus some time in a SNF. A total of 7 surgeries in the first 18 months and another 2 after that, the most recent 3 years ago. I can second the experience of the author. All in I had contact with over 40…

> It's broken and I am sure it's killing people. I also don't see a technology fix. Anything that requires more than two or three providers is an edge case, this space is 90% edge cases. Vertical integration is the biggest hope. With vertical integration, there is no billing.

There’s also no choice or incentive to improve.

Re: Post-apocalyptic life in American health care

#116

Post by riverstones » Tue, Jan 02, 2018, 9:33 PM UTC

trowawee wrote: post #69

nradov wrote: post #63

Earlier quoted context omitted.

Standardize what? With a complex medical condition like that every patient is different so it's tough to apply evidence-based medicine practices. The technology for sharing patient records is gradually being standardized. But that won't help if the doctors don't actually take time for a detailed review of the patient's records.

Personally, from my observations as a software engineer married to a doctor and friendly with lots of doctors, and as an occasional participant in the American healthcare system, the general inadequacy of electronic medical systems is one of the most maddening aspects of our system. Epic is a monstrosity and none of the other systems are much better. The tech is outdated, the interfaces are awful, they're incredibly…

Our situation is almost identical. I refuse to even go to the doctor unless I have something I suspect is going to be life threatening. My wife thinks I'm nuts, but she understands. I grew up in Europe under the "socialist model" and I miss it dearly.

If I need to go because I have an infection, I go to the indigent clinic, and pay the $25 for anything they need to do. I then go around the corner to the indigent pharmacy and get my $4 RX.

Yes, we have insurance. But it's still so freaking expensive to use it I never go. Insurance premiums, co-pays, RX costs. Why even go unless you HAVE to go. My wife takes the children to see the doctor when they need it. I refuse to go. I've not had a physical since the early 90s and I don't plan on going. I refuse to enrich the system. Now that the mandate has been undone, I may drop myself and cover my family alone. I can always go to the indigent clinic. Anything more serious and I just cannot afford to pay. I do not want to leave my family in medical bankruptcy or massive debt. It really sucks that in America, one has to first consider whether one can afford to visit the doctor in the first place. And I cannot convince my wife to consider living in Europe or Australia, both places we could easily move to and adapt with our relative skill sets.

Re: Post-apocalyptic life in American health care

#117

Post by faitswulff » Tue, Jan 02, 2018, 9:34 PM UTC

jfoutz wrote: post #105

EvanAnderson wrote: post #101

Earlier quoted context omitted.

More and more I am becoming convinced "killing people" is an intended "feature" rather than a bug. I'm sure it's not an explicit goal of any but a tiny fraction of participants in the "system", but, cynically, I am becoming convinced it is somebody's goal.

I don't think it's on purpose. It's decomposing a monolith down to microservices, without any verification. Since each player is only responsible for their little corner of the world, no one actually has any sort of responsibility to ensure the overall system still works.

https://en.wikipedia.org/wiki/The_purpose_of_a_system_is_wha...

Re: Post-apocalyptic life in American health care

#118

Post by dragonwriter » Tue, Jan 02, 2018, 9:36 PM UTC

conanbatt wrote: post #112

dragonwriter wrote: post #102

Earlier quoted context omitted.

> I would argue that food escapes its measure of utility because otherwise, we would all be eating only the cheapest and healthiest option all the time Economic utility is subjective; while it includes health effects, to be sure, it also includes things like the taste and other enjoyment factors. It absolutely is not the case that, were food a perfect example of rational choice, we would only be buying options that c…

> Economic utility is subjective; while it includes health effects, to be sure, it also includes things like the taste and other enjoyment factors. It absolutely is not the case that, were food a perfect example of rational choice, we would only be buying options that cost-effectively optimized healthiness. Sure, I agree completely, but at least nominally the argument that healthcare is unique because its a necessity…

> Sure, I agree completely, but at least nominally the argument that healthcare is unique because its a necessity and it has irrational behaving actors is not qualitatively different than the food market.

“Necessity” wasn't part of the argument, and the argument wasn't really of a qualitative difference so much as them being different degrees of the same issues (food is considerably regulated—even by the same agency involved in much healthcare regulation in the US—for many of the same reasons, though the degree of deviation from ideal market conditions is lesser than for healthcare.)

Re: Post-apocalyptic life in American health care

#119

Post by hectorr1 » Tue, Jan 02, 2018, 9:37 PM UTC

The need to hire a 'consultant' is extremely depressing. That is what doctors (primary care managers in particular) are supposed to do.

But their pay is terrible compared to specialists, especially when you consider medical school debt and that they don't start earning until years later than most. They have diminishing power in the hospital organizations unless they go into management. There are exceptions, but most medical students with options don't choose Primary Care.

For specialists, the model is just as broken. If you do procedures, you are incentivized to do procedures. Sometimes this is the best option for the patient, sometimes it's not, but you are going to get paid one way and not the other. And there is a good chance that unless you are at a top-tier academic hospital, there will not be anyone around to second guess you unless you realllllly screw up.

There is also tremendous pressure to produce, which is why doctors triple book fifteen minute appointments, and you end up in freezing the waiting room with no LTE for two hours. A good doctor would love to spend more time with you directly, and a lot more time managing your care, but that's not what the system incentivizes. And tying compensation to quality ratings is hugely problematic when the job is to often tell people they are fat alcoholics who need to quit doing opiates.

My wife is a doc, and it breaks my heart when she says she wouldn't recommend it for our kids.

Re: Post-apocalyptic life in American health care

#120

Post by AnIdiotOnTheNet » Tue, Jan 02, 2018, 9:41 PM UTC

ams6110 wrote: post #52

jbob2000 wrote: post #12

I know this is going to be controversial, but at this point: > My mother’s mild dementia began accelerating rapidly a year ago. I’ve been picking up pieces of her life as she drops them. That has grown from a part-time job to a full-time job. In the past month, as she’s developed unrelated serious medical issues, it’s become a way-more-than-full-time job. I would have kept my mother out of the healthcare system and l…

I don't think it's controversial at all. Nobody gets out of life alive. If I make it to 65 or so, I feel I've had my share. It's all downhill after that point anyway, why would I want to prolong the misery?

An easy statement to make when you're nowhere near 65. I've spent a lot of time in my life thinking about death, and as a result I've come to certain philosophical conclusions regarding it. But I know that philosophy is something that exists comfortably in mind of someone without a gun to their head.