A Pioneer in 'Flat-Fee Primary Care' Had to Close Its Clinics • Hacker News Board

Re: A Pioneer in 'Flat-Fee Primary Care' Had to Close Its Clinics

#61

Post by tertius » Wed, Jun 21, 2017, 12:45 PM UTC

douche wrote: post #30

oldandtired wrote: post #9

A former travelling companion (on a long distance train trip) moved from Head of R&D for an advertising agency into working in the medical technology industry. After six months or so, he returned to his former job of head of R&D at the advertising agency. When quizzed by the staff at the advertising agency as to why he came back to such a corrupt industry. His comment was that advertising were little children in term…

There's also a lot of stupid shit that you need to have a prescription for that you ought to just be able to go out and buy. Case in point, my dad has a CPAP machine for sleep apnea, and it stopped working a few months ago. You'd think something that is conceptually similar to a vacuum cleaner operating in reverse with a mask on the end would be something that you could just go find on Amazon and have shipped to you…

Self-diagnosis may be the reason for something like that?

I agree that it's silly in general though.

Re: A Pioneer in 'Flat-Fee Primary Care' Had to Close Its Clinics

#62

Post by maxerickson » Wed, Jun 21, 2017, 12:47 PM UTC

NoGravitas wrote: post #47

fennecfoxen wrote: post #28

Earlier quoted context omitted.

1. What percentage of your health issues are "emergency, heart attack RIGHT NOW"-class issues? What percentage of health care spending overall are these issues? 2. Have you or someone you know in the United States ever "shopped around" or otherwise prepared in advance for an emergency through the provision of, say, catastrophic health care insurance, which promises to pay for emergency room visits? (Employer coverage…

Even for non-emergency care, it's not feasible to shop around in the US healthcare market. Doctors don't know prices. Typically, front-office staff won't know prices until they've talked to your insurance company. It's probably not possible to get prices from your insurance company except in the context of a very specific claim, which can only come from the doctor's office or hospital's office staff. A small differen…

I believe their point was in the abstract. In a system where it is feasible to shop around, people will tend to do so and it will put downward pressure on prices.

Maybe the thing to do is to start treating insurance-hospital networks that do not disclose pricing as collusion. It certainly makes no sense to me that our system has individual patients having adversarial dealings with 2 huge institutions every time they need care.

Re: A Pioneer in 'Flat-Fee Primary Care' Had to Close Its Clinics

#63

Post by mattkrause » Wed, Jun 21, 2017, 1:04 PM UTC

tertius wrote: post #60

crusso wrote: post #45

Earlier quoted context omitted.

If outrageous healthcare costs were only kicking in for life-or-death emergencies then you might have a point. Healthcare costs across the board - except in unregulated, uninsured spheres like plastic surgery, lasik, etc. - are extraordinarily high.

The point he's making is that it's only unfeasible to negotiate when you need treatment this minute. Therefore a free market system is feasible for everything else. Not that it's what we currently have as you point out.

Even there though....

Do you think (or the average person) knows enough to shop around? This stuff is complicated! I'm not sure I could make a rational decision between treatments that have different prices, but also different likelihoods of success, side effect profiles, and all that. This is even more complicated when you're paying for a diagnosis too, rather than just a treatment.

Lasik and plastic surgery are interesting because they're essentially commodities and the patient can easily evaluate the results themselves.

Re: A Pioneer in 'Flat-Fee Primary Care' Had to Close Its Clinics

#64

Post by maxerickson » Wed, Jun 21, 2017, 1:05 PM UTC

distances wrote: post #33

dr_ wrote: post #27

The affordable care act has enrolled millions on to some kind of health insurance plan. Even if you are stuck with a high deductible plan, oftentimes that annual check up (preventive care) is fully covered without requiring a deductible payment. And, of course, if you are on Medicaid - you have Medicaid. If you are relatively young and/or healthy, that's all you would really need. As a result, their patient populatio…

Being from Europe, the concept of annual check ups sounds very wasteful. Is this what everyone does in the US? As far as I see it, schools should teach enough to keep you in a good baseline health and doctors are available if something comes up. What is done in a normal annual check up?

Lots of people don't do it.

I guess a minority by population. I needed to make an appointment a couple years ago and the woman on the other end of the phone didn't really believe me that I didn't know where my medical records would be (in the past 10 years I'd had some stitches and a tetanus shot).

Re: A Pioneer in 'Flat-Fee Primary Care' Had to Close Its Clinics

#65

Post by crusso » Wed, Jun 21, 2017, 1:06 PM UTC

tertius wrote: post #52

crusso wrote: post #38

Earlier quoted context omitted.

factor of 10 over what they would sell the same product for to non-health care areas That's a key statement. So these same people charge less for the same product in other fields. Why? The reason has to do with the construction of the healthcare industry. Lots of regulations. Lots of middlemen. Laws designed to destroy innovation. Very little transparency for costs and outcomes.

Why? Because the market will bear it. Simple.

The "market" bears it because the regulatory structure of the market allows for no alternatives.

Re: A Pioneer in 'Flat-Fee Primary Care' Had to Close Its Clinics

#66

Post by Shivetya » Wed, Jun 21, 2017, 1:09 PM UTC

alkonaut wrote: post #24

> "some health care analysts are questioning whether the approach to medical care is valid and viable." Perhaps just stop trying to figure this out from scratch, look at any of N countries where healthcare is just a solved background issue? Yes there are issues with people overusing services that don't have an associated cost for usage, and many similar issues. But every damn country in the world has been adjusting t…

sure, but the politicians and such here don't want to solve the problem, or should I say follow the example of other countries. They will regularly cite other countries of how we are failing then comes the litany of "buts" when confronted with issues seen in those countries. The "but litany" is how their solution will fix all raised issues or provide coverage not seen elsewhere for less and better.

which in the end results in nothing getting done as the problems cannot be agreed to. so its mostly hyperbole to claim it is a solved problem. even in nations with free healthcare problems exist, it just depends on what you want to ignore as a problem

Re: A Pioneer in 'Flat-Fee Primary Care' Had to Close Its Clinics

#67

Post by baldfat » Wed, Jun 21, 2017, 1:13 PM UTC

zxcmx wrote: post #43

brightball wrote: post #37

Earlier quoted context omitted.

Well, doctors have to go to school for a very long time, especially to specialize. Then they go through residency programs. In all their general education before practicing on their own tends to be about 10 years more than the average American. Which is 10 years less income and 10 years more of expenses/loans. Most specialties cause doctors to be on call. Working in hospitals creates difficult hours. And with all tha…

I find it really interesting that we don't have, for example, a cheaper way of doing front-line health care than teaching people to diagnose every possible ailment. Similarly that that the mechanics of surgery aren't considered a manual skill practicable in a largely assembly line fashion. Apparently, everyone gets artisanal health care, regardless of the level of complication (or not) of their condition. Nothing wro…

Robots have been in the operating room for several years now. People are just not aware they certainly aren't there to reduce cost as much as reduce risk from human error.

http://fortune.com/2016/07/11/robots-medical-surgeons/

Re: A Pioneer in 'Flat-Fee Primary Care' Had to Close Its Clinics

#68

Post by brightball » Wed, Jun 21, 2017, 1:13 PM UTC

zxcmx wrote: post #43

brightball wrote: post #37

Earlier quoted context omitted.

Well, doctors have to go to school for a very long time, especially to specialize. Then they go through residency programs. In all their general education before practicing on their own tends to be about 10 years more than the average American. Which is 10 years less income and 10 years more of expenses/loans. Most specialties cause doctors to be on call. Working in hospitals creates difficult hours. And with all tha…

I find it really interesting that we don't have, for example, a cheaper way of doing front-line health care than teaching people to diagnose every possible ailment. Similarly that that the mechanics of surgery aren't considered a manual skill practicable in a largely assembly line fashion. Apparently, everyone gets artisanal health care, regardless of the level of complication (or not) of their condition. Nothing wro…

It's a valid concern and this is where the free market aspects really come into play.

If a school opened up with the goal of training people to diagnose and treat cold and flu symptoms, so that the graduates could diagnose those symptoms and their severity, then recommend a course of care or call in a prescription...here are the potential barriers.

1. Insurance companies wouldn't pay for it at all because those graduates would lack any type of professional credentials.

2. Those graduates wouldn't actually be allowed to call in prescriptions, also due to lack of credentials.

3. Getting credentials approval would require a lot of money to push things through the process, if at all. Then the school would have to be setup in an effort to recoup those costs. The school would be setup with the goal of making money most likely and everything else in the process would have to happen before the school even became feasible.

Assuming all of those things happen, then insurance companies would largely decide whether or not to even pay for those services and people who had companies that wouldn't...would not likely go to those providers. If they did pay for them and the pay was too low to justify the time commitment of dealing with the insurance companies, additional costs would be involved in terms of staff to deal with billing and followup. (Insurance companies often deny on first request, requiring rebilling).

When it comes to cash flow, insurance changes at the beginning of every year can cause payments to be delayed for up to 3 months which becomes a huge problem for office leases and payroll. Between all that if the compensation isn't high enough, it disincentives people to go into the field at all.

The alternative is pure private pay and allowing individuals to decide, this care is good enough for me. Which would require signing something indemnifying the practitioner from legal recourse since they wouldn't be able to get malpractice insurance. If that care costs more than the co-pay at their regular doctor...they will have no reason to choose it. And even with private pay, those same practitioners still wouldn't be able to call in prescriptions.

That is the industry that has been created by removing health care from the free market.

Re: A Pioneer in 'Flat-Fee Primary Care' Had to Close Its Clinics

#69

Post by crusso » Wed, Jun 21, 2017, 1:15 PM UTC

fao_ wrote: post #48

crusso wrote: post #38

Earlier quoted context omitted.

factor of 10 over what they would sell the same product for to non-health care areas That's a key statement. So these same people charge less for the same product in other fields. Why? The reason has to do with the construction of the healthcare industry. Lots of regulations. Lots of middlemen. Laws designed to destroy innovation. Very little transparency for costs and outcomes.

> The reason has to do with the construction of the healthcare industry. Lots of regulations. Lots of middlemen. Laws designed to destroy innovation. Very little transparency for costs and outcomes. Or the reason has to do with the fact that the people that need these treatments are willing to pay any price for it because their life literally depends on it. I don't see why regulations, and laws "designed to destroy i…

their life literally depends on it.

That would only explain emergency procedure costs.

Everyday healthcare costs that are not life-or-death are also extremely high.

Almost all of the regulations in the medical industry are for ensuring people are safe

Are tax laws that benefit employers and lock employees into healthcare plans there to keep people safe? How about laws that prevent companies from selling insurance across state lines? Allowing companies to confiscate unused FSA money at the end of every year?

And even then, there are many regulations and laws that I'm sure are ostensibly to keep people safe in the short term - but they have the negative effect of stifling innovation that could bring down costs and make people safer in the long run. Look at the disastrously-slow pace of the FDA drug approval process that has continued for decades.

Re: A Pioneer in 'Flat-Fee Primary Care' Had to Close Its Clinics

#70

Post by vxNsr » Wed, Jun 21, 2017, 1:16 PM UTC

timthelion wrote: post #25

Meanwhile in the Czech Republic, for caa 50$ a month (for a person making minimum wage, it's double that for median wage workers) there is no copay on anything and the insurance covers everything including sex change surgery (but not facelifts and dental)...

I always chuckle when I see people compare what amount to 3rd world countries with the US system, my mother was trained and worked in Moscow's largest hospital. The shenanigans that went on there, the level of training and expected knowledge of staff, the baseline expected standard of care all don't even hold a candle to what she had to reach to be considered competent in the US.

On top of that I don't know if this applies to CR as much as other European countries, but homogeneous populations really are easier to care for and create actuarial tables around than the stew of the US; when people bring Sweden with its <50 million pop of white people with very similar ancestry to prove their method might work, they ignore how medicine and the whole industry actually is practiced (and needs to be practiced). Let's wait 20-30 years now that they've taken in 1.5 million refugees from a very different background who are projected to grow 3x faster than the current population before we start trying to emulate unproven theories.