http://reason.com/archives/2017/10/25/this-one-weird-trick-c...
You can argue that hospitals and ERs in particular are not a good place for checkups, but discouraging them is likely to be more costly (in $ and human lives) than not.
It makes so much sense: If your father had to decide between a beer and you getting that wound checked, kids would die.
(For clarification, I'm all in for universal free healthcare, but comparisons need to be fair, and comparing the US to the nordics, is not fair)
What I DO know from working in insurance is that lifetime medical costs are concentrated in the last 2 years of life (I worked on credit card insurance and life insurance).
That's where you could make huge costs savings (but is an ethical landmine, not to mention economic interests)
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017....
https://www.nihcm.org/categories/publications/the-concentrat...
I presume you really mean 'residency slots' when you say doctors. In this case, the relevant administrative body is the ACGME... who sets the limits based on appropriations from Congress.
The trope of doctors restricting entry to enrich themselves does not explain reported physician shortages.
http://articles.baltimoresun.com/1994-06-14/news/1994165047_...
Never mind that Josef Mengele was a licensed physicians, or that the AMA was well established before the Tuskegee syphilis experiments occurred, also with work performed by licensed physicians.
Just that the bureaucracy has resulted in an industry that fails patients. Heart surgeons refuse difficult surgeries to juke the stats. Good for their mortality ratings (not that anybody could blame individuals doctors)[1], not so great for patients.
Even just the notion of specialties hurts the patient - it makes perfect sense that the deep knowledge involved means that an orthopedic doctor can't (and shouldn't!) treat issues that should be seen by a podiatrist. But at the end of the day, the patient is in chronic pain, and has such a low quality of life, that to them, the risks of street heroin are acceptable. This isn't a moral failing by the patient's, nor is it a lack of intelligence, this life being too much to bear otherwise, and if you've never considered suicide as an option, be grateful.
Dr. David Casarett's talk[2] takes a closer look at an alternate, but accepted medical practice, and gives some thoughts about how our medical bureaucrats have resulted in worse patient care.
[1] https://www.telegraph.co.uk/science/2016/06/03/one-in-three-... [2] https://www.ted.com/talks/david_casarett_a_doctor_s_case_for...
> Never mind that Josef Mengele was a licensed physicians, or that the AMA was well established before the Tuskegee syphilis experiments
The AMA has no role in licensing physicians, a task which is left to the states.
> Heart surgeons refuse difficult surgeries to juke[sic] the stats.
This is far more complicated than it seems. For example, consider that the sickest/most difficult patients are the most likely to die, irrespective of an intervention. At a certain point, the harm inherent to surgery outweighs any potential for benefit that the surgery might yield.
As a patient in that system (the NHS) I would prefer my surgeons not to make decisions based on trying to game the statistics. If I need heart surgery, I want whoever is competent and available. So if these stats block that, I'd rather we don't have the stats.
Frankly it's weird anyway because surgery is a team activity, not solo. Nothing serious is done by one bloke in a surgical gown, there's a team. I had a relatively minor operation and the named surgeon will have spent most of that operation _talking_ not operating. All the sewing and some of the cutting will be the nice younger doctors I met, a woman who'd been doing this a few years and was well on her way to being an actual surgeon, and a new bloke who seemed like he'd probably graduated just a couple of years ago. The old bloke with the paperwork saying he's allowed to cut people open is mostly there to watch over them both and step in if things go to shit. The woman is doing most of the work, showing the noob what she's doing and maybe overseeing while he stitches me back up at the end. There's some Eastern European doctor lady making sure I neither die nor wake up, and two or three nurses making sure everybody has what they need, and counting things to make sure nothing is left inside me that shouldn't be there. But if I'd died (very unlikely for minor surgery) it would count against my named surgeon and not the rest of the team.
The AMA even explains this process: https://www.ama-assn.org/education/obtaining-medical-license
For example, this guy was prescribing powerful meds with severe side effects.
http://www.chicagotribune.com/suburbs/daily-southtown/crime/...
But more to the point, almost everyone suffers harm because of the way our medical system is set up.
Maybe some ailments don't need 8 year degrees to cure. Just throwing out ideas here.
But anyhow, more transparency is almost always good. Particularly in the morass that is the American medical system. I keep wondering how ever let something so important get like this.
The knock-on effect of there being fewer machines built keeps the price high. The first photocopier (the Xerox 914) cost the equivalent of $220,000 in 1965, yet there are very few businesses without a copier today because the price is so reasonable (5% of the 914's cost), and they do much much more.
In healthcare you'd not only like to even out expenses over time, you'd also like to spread expenses over a group, else people with chronic conditions are still screwed.
https://www.kff.org/health-reform/fact-sheet/preventive-serv...
What you propose would work fine if humans were fully rational and not living paycheck to paycheck. Unfortunately that's not reality.
The law that got the nickname “Obamacare” is not the Accountable Care Act, it is the Patient Protection and Affordable Care Act.
That is, for any one particular patient who's found to have a disease down the road - say, cancer - it would have been cheaper for him if that problem had been found very early, so for his individual case the checkups and tests would have been a big savings.
But when you account for all the people that do not turn out to have the problem at all, and the cost of checkups and tests, and then especially the costs of the followups due to false positives that are a risk in every test, the overall cost of test and prevention is actually worse.
Firstly putting a bullet in the head of anyone with non trivial cancer would probably be a financial savings for the insurer but the real equation is the human/societal benefit of treatment vs costs to best make use of a finite resource.
A simple cost of treatment analysis even misses out on the income that a person would have earned had they not died and the money that could have been paid in taxes and used to fund more treatment.
Drilling down into just the cost of treatment your statement isn't even wrong its a category error like saying that adding 2 integers always yields a number greater than 42.
For any given test and set of circumstances under which it is administered there can be a cost benefit analysis.
Example if you spend a thousand dollars on each false positive result and save 10k for each and have a 1% false positive rate and test a million people with a 1 in a million true positive rate. You will find one true positive saving 10k unfortunately you will also find 10k false positives and waste 10 million dollars.
In actuality you wouldn't do this you would test people whose symptoms or circumstances suggest they are likely to have it.
It seems fantastic to suggest that preventative medicine is always financially negative when people who actually study health care say otherwise.
Mr. Gruber [yes, it's THAT Jonathan Gruber] found that when retirees in California began visiting their doctor less often and filling fewer prescriptions, overall medical spending fell. People did get sick more often, but treating their illnesses was still less costly than widespread basic care — in the form of doctors visits and drugs. ... As Dr. Mark R. Chassin, a former New York state health commissioner, says, preventive care “reduces costs, yes, for the individual who didn’t get sick.” [1]
You go on to state that the additional productivity of the person we saved also nets us additional savings. But the same article contradicts this notion as well:
The actual savings are also not as large as might at first seem. Even if you don’t develop diabetes, your lifetime medical costs won’t drop to zero. You might live longer and better and yet still ultimately run up almost as big a lifetime medical bill, because you’ll eventually have other problems. That would be an undeniably better outcome, but it wouldn’t produce a financial windfall for society.
You go on to suggest that medical professionals would not be wasting money on doing too many tests: "For any given test and set of circumstances under which it is administered there can be a cost benefit analysis."
That seems logical, but it's not how the real world works. People get emotional about the potential risks, and demand the tests even when there's not a clear indication. You might remember the hubbub a couple of years ago when it was suggested, based on historical evidence, that regular mammograms should be delayed a few years later than was currently the practice. But women's health advocacy groups raised such a hue and cry that the actual medical guidelines were not changed to follow the evidence.
[1] https://www.nytimes.com/2007/08/08/business/08leonhardt.html
This may be true in terms of outcomes, but it turns out not to be true in terms of aggregate costs.
(If you encourage smoking and discourage screenings and preventive care, you'll probably do a lot to reduce aggregate health costs, but at the expense of outcomes; the efficiencies you really want are ones that reduce cost while preserving outocomes, or improve outcomes without increasing costs. When outcomes and costs are in tension, though, desirability can be more ambiguous.)
More importantly it leads to less people dying of preventable matters. What you seem to be implying is that its a net negative to which I say citation needed.
Doing that could also drive up the price of oil changes such that they're no longer affordable without the use of insurance. If you could get an oil change for $50, then most people could afford it by paying for it outright. If that oil change now costs $500, then most people would have to go through insurance, and get the "discounted" price of $100 (which either has to be paid if the deductible has not been met, or you end up paying 10 to 30% of it).
It also catches things that require long expensive treatment early enough for them to be treated, rather than treatment be pointless, and, even if attempted, of shorter duration (on average) than if the conditions were found earlier, which is why preventive care doesn't seem to reduce aggregate costs.
The best way to reduce aggregate healthcare costs, if you have no other priorities, is to just make people less likely to seek care. No care = no costs.
Goods and services are allocated by price or by time. Take out the price component and assume that people will go to doctor more often, obtaining an appointment will take longer. How do time and hassle required to see a doctor disincentivize well visits?
You'd have even more people avoiding easily treatable conditions due to cost.
Frankly, no one wants to talk about chronic ailments. ADHD (the so-called fake disease) for example.
Nevermind that they are a real part of why premiums are likely as high as they are.
Nevermind that it is essentially a life-long tax for the patient.
Nevermind that the law deprives those who suffer from a case for which narcotic therapies work and CBT doesn't into profit slaves to drug manufacturer's and their 'attending' prescription writer.
They have a solution to the problem (that generally works out better for the supply chain than the patient)! How dare you suggest it isn't the best approach! What are you, some communist? /s
But alas, if we don't say it no one will listen.
So...
As the parent said...
"If it worked like normal insurance, people with chronic illnesses would still go bankrupt."
I'm pretty conservative and I'd love to see a solution to the healthcare marketplace that doesn't amount to nationalization, but at this point, the market is so distorted and fundamentally unworkable that even a nationalized healthcare industry would be preferable.
There is no definition that fits better than "FUBAR" [0]. The only solution is going to be tear down the industry that we have and build something more sustainable in its place, whether that new thing is a nationalized health system or just very serious regulations to ensure healthy and functioning competition and free-market ideals (Obamacare does the opposite of this, literally making it illegal to not pay a health insurer; good policy would make non-catastrophic medical coverage illegal). Whatever the answer is, there's going to be a lot of people who are unhappy about it, but we have to fix this.
That other conservatives are just slamming their heads into the sand and saying "free market" when it's impossible to know how much a given medical procedure will actually cost until 3-6 months after the fact is just utterly and fundamentally embarrassing for everyone. Pricing is the most fundamental element in a functioning market. You can't pretend to be making rational choices if you can't even find out the cost. The whole thing shows how very little anyone is paying attention to anything other than virtue signaling.
The government is a big bad powerful thing, but it exists for a reason, and reducing every argument down to "just let those nice men in the Hamptons handle it, they wouldn't be rich if they weren't real smart" gets really tiresome.
There's plenty of people that could afford higher deductibles than that (and would prefer the accompanying lower premiums), but not really the majority of people.
Cutting the basic benefits out of them wouldn't even really save that much money (because insurance negotiates reasonable prices for basic office visits...).
We need to stop looking at the individual level and "What can we eek out of people who don't qualify for Medicaid?", and look to the macro-scale effects. Insurance is the wrong model for routine services (indeed, insurance usually functions as a discount program rather than true insurance) and people shouldn't be able to sell it for that purpose due to the debilitating effects it has on the marketplace.
Docs and pharamacies should be up front about their real prices. Today, even people who are "posting prices" can't be up front about it because posted prices function as high anchors for insurance negotiations. This is why you can often get a massive "cash discount" if you call about a bill that you're going to self-pay. That's what they'd really like to charge you, but if they don't start out charging the sticker price they quoted the insurer, they're in big trouble.
For a market to work, there must be a real pricing dynamic where the consumer can be reasonably well informed about the actual total cost and vote with their feet. Hyperinflated 300% prices, necessitated by insurer demands for large discounts, don't count, they're still not real numbers. Markets simply cannot work without meaningful and accessible pricing information.
The medical system will remain a disaster until we can break this dynamic around pricing, and the only way to do that is to fundamentally change the way that medical insurance works, either by nationalizing insurance and/or medicine so that the government writes all the checks and price becomes only indirectly relevant to the public anyway, or by imposing law that mandates price transparency and seriously limits what "medical insurance" and "discount programs" can do, so that we don't immediately descend back into this.
IMO this is a textbook case of a market screaming for good regulation. Ideally we would identify the malicious actors (primarily insurers), develop rules and systems that minimize their ability to operate, and allow the free flow of commerce to handle everything else. "Nationalize it" is a clear power grab, but lacking any willingness to do anything else about such a breathtakingly large economic and humanitarian issue, even that would be better than "let's just keep crossing our fingers".
It's so sad that the level of conservative dialogue is not "let's find a good minimalist intervention that will get this market working again" but rather "Did someone say 'MURICA wasn't the best at something?!"
https://www.amazon.com/dp/034580273X/ref=cm_sw_r_tw_dp_U_x_-...
The big issue, as you mention, is health insurance companies themselves. They aren't actual insurance companies—they are payers, like others in this thread have called out. Real insurance exists when unlikely but disastrous events occur, like a house fire or a car accident.
Payers act more like surrogates—they bargain and make purchasing decisions on behalf of users like us. This is the fundamental problem in healthcare because surrogates cannot make financial decisions as well as a free market can.
Goldhill’s proposal for changing the industry is to eliminate the role of surrogates and replace it with a version of a health savings account that everybody would be required to contribute into and carry indefinitely, and require everybody to have a very high deductible catastrophic insurance plan. For example, all healthcare payments under $30k would be paid for directly by the patient and come out of the savings account. When something truly big and expensive occurs in a patient’s health (e.g., a cancer diagnosis) is when catastrophic health insurance would kick in and cover it.
This would allow for patients to make active decisions about which type of care to choose, and would force providers to become more competitive to earn the business of actual customers.
In America we are happy to burn a dollar as long as a rich person somewhere can make an extra penny.
As a nation we have no notion of public ethics and haven't for decades. We believe in every man for himself and rather than resignation we feel pride. Venerating not caring about our fellow man as if it was self reliance.
We believe in the dysfunction of the public sphere as an article of faith, implacable as gravity, instead of it being the result of our collective failure to build a system that works.
We feel pride in ourselves when we ought to feel shame for all of us.
But this doesn't answer the question: what is the revamping that would be done to solve the problem? I get that "We believe in the dysfunction of the public sphere as an article of faith" is true and the answer to my next question "okay cool, so why haven't we implemented that", but I'd first like to know what "that" is.
(not that you're on the hook for the time to educate me on a complex public policy issue)
The goal has to be making medicine work like everything else we buy, including the daily non-negotiables like food, water, clothing, and energy resources. There's no reason medicine shouldn't or can't work that way in the general case.
But as long as we make it about moving numbers around so that Group X is slightly less inconvenienced by this farce, we're playing their game. We need to be talking about how to break their stranglehold, and I don't think just "move it into the government so we can get installed as bureaucrats, who are even harder to get rid than executives!" is necessarily a great macro-scale response (though I continue to believe it's better than doing nothing).
I don't suggest taking anything from anyone who is actually involved in the thing here. The only people I want to take out of the equation are the pencil-pushers leeching gargantuan quantities of otherwise-useful time and money away from the public.
That so many people find it so difficult to conceive of routine medical care without an insurance carrier of some type is a testament to the work we have ahead of us.
We do this just fine with other usually-non-emergent necessities of life like food, clothing, and housing. We didn't need to nationalize land ownership or food distribution to create vibrant economies for these, despite the fact that people can't really just "choose not to buy them".
Things are that way in part because there is a controlled regulatory regime in there, not trying to nationalize everything but also acknowledging the duty to protect the market from bad actors. Food, clothing, and housing aren't perfect analogs because medicine is a professional service, but this suffices to show that necessities aren't necessarily exempt from market forces just by virtue of their non-optionality.
Medicine needs a middle ground between "nationalize it" and "ignore it", but in this case, if those are the only two options, "ignore it" is clearly the worse one.
My wife and kids had 0 medical emergencies last year and we still paid over $10k in doctor and dentist bills just from deductibles, copays, and coinsurance. That's after having nearly $1k per month deducted from my paychecks for insurance premiums, not to mention the part that my employer contributed on top of that. It makes me sick to add those figures up, so I'll just leave that as an exercise. You can bet that if there were any actual optionality here, we'd spend a few days trying to sort out the most efficient way to handle this stuff.
Let's also not forget that insurance imposes a significant amount of rationing too. Our policy only covered up to 40 "habilitative care" visits per year, despite the fact that every therapist and doctor we saw recommended about 3x that. These are relatively mild speech and occupational therapy visits -- 40 visits is combined, every speech and pt/ot visit counts against it. "You need insurance because you'll have to buy medical care or you'll die" doesn't always play out that way.
If we don't go the single payer route, it seems one of the #1 things we could do is to help move "insurance" back to being actual insurance (i.e., we'll keep you from being bankrupted by your medical bills) rather than a system that highly subsidizes your regular medical care but then may not actually be there for you when the bills really pile up... If consumers had to actually shop for procedures (as opposed to knowing the out-of-pocket is $250 and who knows what happens beyond that), I think you'd start to see people screaming for transparency, and medical providers would have to get their acts together.
Only one of many problems, I know.