Private prisons come close. They incentivize having more people in prison.
So, when you see people lobbying against legalizing weed, some of that is genuine concern, but it also aligns very closely to people who realize what a drop in prison inmates could mean for there business...
It's insane.
(their, BTW)
Cf. the California prison-guards' union: https://www.latimes.com/politics/la-pol-ca-road-map-prison-g...
https://www.snopes.com/fact-check/drug-law-lobbying-by-corre...
The corrections corporation of America only spends a million a year on lobbying- this would be small change even if it was solely spent on anti-marijuana lobbying. But It's more likely that the majority of their lobbying budget would be spent on issues directly related to regulation and spending for private prisons
Several judges took bribes from private prisons to incarcerate juveniles for minor offenses. While the judges have substantial jail sentences, the developers got off light at <2 years in jail and some fines. For wrongly keeping minors imprisoned, and leading to the suicide of at least one of the wrongfully jailed.
I couldn't find anything about this on the link you provided. Any other sources?
this [1] doesn't differentiate between violent and non-violent
https://www.marijuanalawyerblog.com/how-many-federal-prisone...
from the second link: "This is a total of 11,533 people incarcerated as a result of their involvement with cannabis products."
Considering that the percentage of prisoners in private prisons is below 10%, we can see that there are less than 1100 people in private prisons for marijuana related crimes.
There is no way that you can generate returns on lobbying for one of the most hot issues in US off of the profit of 1100 prisoners
My issue happened to be with sesamoid/metatarsal fracture, flat rootedness, and poor gait. No doctor cared about my gait which turned out to be the root cause of my other symptoms. They all wanted to do surgery/orthotics and basically thought that would fix it alone vs combined with PT.
Those companies where you count some kind of points as you eat and pay membership to turn up for a weekly weigh-in and pep talk rely on the good habits being poorly embedded so that you get fat again without the meetings.
I disagree with the conflict of interest RE doctors.
At least with doctors, people will always get ill. If people no longer turn up for lifestyle-related ailments, they will still come in with a rash or pain or whatever. They will also have fewer complications or confounding factors for diagnosis.
In a profit-driven healthcare system, I would imagine that lots of healthy patients is more profitable for a GP than a few sick ones. The sick ones incur more costs, and end up getting referred away to specialists for much of their care anyway.
For me, losing a bunch of weight was as simple as cutting out big sugar bombs and alcohol. After about a month, anything that could be classified as a "dessert" became cloyingly sweet and gave me indigestion. I pretty much eat whatever I want otherwise.
I don't know how much weight you lost, but I can't imagine it was all that much if all you had to do was cut out sugar and booze, unless that was the majority of your caloric intake.
Encouraging this shift is largely how eating disorders are treated; though in my case it came as a result of dealing with a lot of trauma that I had buried. But ultimately it's about holistic emotional and physical health, and reframing your relationship to food in that context.
Even if it is only 10% of the caloric intake, it works. Obviously not for losing 100kg, but a 200kcal deficit per day (one less dessert or one bottle of beer) adds up to 10kg weight loss within a year.
Having consulted for the healthcare sector a little bit, I am terrified of ever going into the system if I develop anything slightly unusual.
This is a sector that really needs to be overhauled with evidence based practice and heavy, heavy use of automation and ML to minimise the human element.
I don't think that's correct. Many states require a certain amount of continuing medical education to maintain a medical or nursing license. It's often not a TON of training and you have some flexibility in what topics you choose to study, but it's something.
Doctors get one thing wrong and then people want to self-diagnose with the internet. It's like a programmer originally thinking a bug is in one function when it's really in another. And then the customer reads a Java for dummies book and thinks they can find the answer.
It's hard to compare doctors with other fields because a fuckup in most fields will cost money, but a fuckup in medicine will cost permanent damage and lives. If doctors can't live up to a higher standard (and they can't) then we need to minimise the human element in diagnosis and treatment as quickly and aggressively as possible.
Anecdotal but I've personally been saved from a potentially permanently-crippling medical procedure only because my med student friend visited me in the ward and questioned the procedure as it didn't make sense given my condition. If he wasn't around, I would be spending the rest of my life with a mild disability. That's not acceptable, but it happens all the time.
This is a fantastic example! I often think about the distribution of talent/competence in fields and that is a very interesting anomaly.
Does anybody know why this is the case? I understand that it's a (fairly) repetitive task, and technology certainly assists, but I think I recently read that there are .2 "incidents" per million commercial flights.
How has an entire industry created a standard that seems to be well above any other?
Nothing like this exists in the medical industry. In fact surgeons and doctors are notoriously anti-process, anti-statistics, and basically don't want anyone scrutinising how they work. I'm not sure how they've been able to get away with it for so long.
Sounds an awful lot like the situation every GP is in... no one human can know everything about the body, so there are GPs that legitimately can't diagnose you.
On the other hand, the person with a particular bug to troubleshoot in themselves has all the time in the world to become their own specialist and do the knowledge synthesis that the generalists don't have the scope for.
I've read way more about my relatively common condition than anyone but the specialist I'm seeing, and I've come up with some things that he was not aware of in the process. Once down a certain condition's rabbit hole, the patient/specialist dialog really should be a give and take.
The reason it's unquestionably better than humans is because it's not possible for humans to be aware of every recorded case of every recorded disease and the various ways it presents itself. But as long as data capture capability exists, an ML model can be updated to incorporate all that knowledge on a regular basis.
The second element of this is that the vast majority of doctors just follow a primitive flowchart to diagnose conditions. It's not like Dr House where they're experts on human anatomy and drug interactions etc. GPs are better compared to phone customer service reps running through a script. ML is better than that.
I can not believe I had an issue for decades and no medical professional suggested an elimination diet.
Maybe in the short term. In the long term, people will get older and will get more ailments due to age and still go to the doctor. When I visit a GP in the Netherlands, I mostly see children and old people in the waiting room.
The problem is health care companies. To them patients are just faceless entities with wallets. The executive making decisions screwing them over never have to see their pain.
There is a parallel to Nazi Germany here one could use. The reason concentration camps were made was because it was mentally taxing to just gun down innocent people day after day for normal soldiers. Concentration camps in contrast got organized so that the victims had to pick up the dead ones and car them off. All the ugliness was out of view for the evil people running the show.
It was easy for Nazi bureaucrats to kill people with the stroke of a pen. Just names on a list. Never had to see somebody choking or bleeding to death.
Hence you get a big problem when power is moved away from doctors to companies. In this example e.g. the doctor while immoral may not have been quite as immoral had it not been for a company actively pushing him to provide patients.
Private enterprise should not be allowed to provide financial incentives to doctors. Who the doctor sends their patients to, should be entirely decided by medical necessity and not influenced by a potential for profit.
One side of the coin. Pharmacy benefit management companies should be scrutinised for their choice of drugs included in an insurance policy and how they price them, etc.
https://en.wikipedia.org/wiki/Pharmacy_benefit_management#Co...
Not just because it’s unethical. The mechanism doesn’t work: your future income will benefit a lot more from being regarded as a competent doctor, than it ever would from the minuscule damage you could do to public health with being purposefully bad.
I’ve also rarely seen doctors that cared about patient acquisition in the way normal businesses do. Since health care is somewhat expensive, governments tend to try running the system with a slightly low number of people.
> Not just because it’s unethical. The mechanism doesn’t work: your future income will benefit a lot more from being regarded as a competent doctor, than it ever would from the minuscule damage you could do to public health with being purposefully bad.
Almost none - certainly not when it comes to preventive care. The original article shows misaligned incentives with a tiny, short feedback loop, and even then these instances are (thankfully) not common on a large scale.
The idea that a GP would encourage their patients to have unhealthy diets and never exercise, just so that in twenty years some other doctor - a cardiologist, endocrinologist, etc. - could have a greater supply of patients in need of care is absurd. The GP's expected lifetime earnings are not going to go up if their patients decide not to engage in preventive care, and the GP's expected lifetime earnings definitely will go down if they actually discourage preventive care, because they'll develop a reputation as a shoddy doctor.
My luck ran out last time I tried to find one. I wonder why there isn't any repercussions for lot of self claimed doctors...though government tried to deny the WHO report that said approx 65% doctors are not qualified in India and the rest are dubious to good. Doubled down and passed a bill for recognising ayurveds, homoeopaths, etc as actual doctors.
There's this crowdsourced list:
https://docs.google.com/spreadsheets/d/1pzckT6ns2H1IlmwYwJa8...
Sad reality.
Not in countries with a national health system, where the government is incentivized to keep people healthy in order to reduce cost.
Because the NHS doesn't optimise for cost, it optimises for cost per QALY (quality adjusted life years). Given the high impact to quality of life for blindness your claim is dubious.
NICE make the decisions over cost effectiveness of treatments, and publish their findings. If you can tell me the name of the drug we can find the actual report.
Some Trusts were attempting to make this the first line treatment as an off-license prescription as it was cheaper and the pharmaceutical companies were trying to sue the Trusts for "not providing NICE approved medications and therefore disadvantaging patients" while simultaneously not seeking to license Avastin for wet AMD.
This was a few years ago so I may have misremembered some details.
I'm getting really repetitive but transparency transparency transparency.
Let's make public the cases where the suppliers collude to withhold drugs for actual effective usages "because we have this other more expensive option that's the only one we sent in for approval" whine bitch stfu and do what's best for the patients you money grubbing bastards.
Lots of hits in google.
https://www.independent.co.uk/news/health/glaucoma-nhs-delay...
https://www.thetimes.co.uk/article/elderly-go-blind-as-nhs-i...
https://www.telegraph.co.uk/news/2018/06/06/hundreds-going-b...
https://www.dailymail.co.uk/health/article-122995/You-blind-...
https://www.lbc.co.uk/news/long-nhs-delays-mean-patients-are...
https://www.thesun.co.uk/news/10702618/nhs-delays-left-patie...
https://www.dailymail.co.uk/health/article-7864729/22-glauco...
The cost decision involved was of course not to have the follow up appointments sooner..
In 2012 they issued a report about the usage of Visudyne/photodynamic terapy which the Royal National Institute of Blind People objected to.
Avastin / Lucentis does not support the point being made. Lucentis, a very expensive medication, was both licenced for AMD and was approved by NICE for that use.
Avastin is identical, but was not licenced for AMD and so NICE was not able to recommend its use for AMD.
Doctors were using Avastin off label, and they wanted the government to force Avastin to be licenced for AMD which would have allowed it to be recommended by NICE.
The makers of Avastin and Lucentis fought this in the courts for years, and took action against NHS Trusts using Avastin off-label. The NHS won that legal case.
https://www.bbc.co.uk/news/health-30138097
https://www.hsj.co.uk/finance-and-efficiency/breaking-nhs-wi...
There is a problem of people going blind while waiting for treatment, but this is related to cataracts and glaucoma, not AMD, and it has nothing to do with NICE (who are the organisation that decides about cost effectiveness) and everything to do with a government that has chosen to de-fund the NHS.
This is what I was referring to.
The cost decision involved was of course not to have the follow up appointments sooner.
I don't really believe that doctors are keeping people sick on purpose to keep demand for their profession high, but if that were going on, I don't think socialized healthcare would necessarily erase that incentive. There are plenty of government and private sector workers who try to preserve their own jobs to the detriment of the whole.
Of course, it’s far from perfect just like any regulatory agency ever.
I know Canada used to be fee-for-service. The more the doctor does, the more they get paid.
They certainly had an incentive to “do more”.
On short: much better to be a healthcare provider in US; much better to be a patient in EU.
The ability of national health systems to say “no” is one of the big levers to controlling cost, in the US, that control is quite fragmented.
Except that in such countries healthcare costs completely explode over time as well.
0: https://www.businessinsider.com/cost-of-healthcare-countries...
Yes, the US has the highest cost. But the ratio between the US and others has stayed roughly the same over the last 50 years (maybe longer--that's as far back as my data source goes). The US pays twice as much as France now because we paid twice as much as France in 1990, and both systems have had costs explode by about the same factor since then.
Here's a table of costs per capita in US dollars for the UK, France, and the US:
Year UK FR US
1980 385 659 1036
1990 782 1458 2700
2000 1561 2686 4557
2010 2871 4048 7939
2018 4070 4965 10586
Year UK FR US
1990 2.0 2.2 2.6
2000 4.1 4.1 4.4
2010 7.5 6.1 7.7
2018 10.6 7.5 10.2
Source:
1. Go to https://data.oecd.org/healthres/health-spending.htm
2. Uncheck "latest data available". This enables the year range selector control.
3. Use the year range selector to expand the range to 1970-2018.
4. The chart will then show the total costs in US dollars/capita by year of health care in 50 countries. You can use the "Highlighted Countries" drop down to narrow that to select a "background" of OECD, EU, Euro Area, G7, or G20 if you want. You can then add individual countries using the list on the left of that dialog.
5. You can change what is shown from total to government/compulsory, voluntary, or out-of-pocket and you can change the measure from per capita to % of GDP.
About 50% of all R&D worldwide happens in the US. The US's global share has shrunk a bit, but only because China and India have grown rapidly, not because Europe has ramped up (it hasn't).
Some new drugs are developed in European countries, or by European pharmaceutical companies - that's true. But European pharmaceutical companies all make a disproportionate amount of their revenue off of sales in the US market. So Europeans quite literally benefit the most from the fact that Americans pay more for the same drugs.
Yes, I agree that it's a foolish choice for the US to subsidize foreign countries' healthcare in this manner. Regardless of this decision that we both agree is foolish, it means that it's misleading to compare cost-effectiveness between the US and other countries directly.
Can you elaborate? Genuinely interested in the details.
It's hard to see how this can be true, since government operations are infamous for excessive cost.
The US system is very far from a free market.
If a lot of people in the US can’t afford treatment, then why does the US lead the world in several cancer outcomes? If people were just dying for lack of treatment, that would make outcomes far worse.
0: https://www.theguardian.com/us-news/2020/jan/07/americans-he...
The US even had a popular TV show about someone who got cancer and started making and selling meth to be able to afford treatment. Fantasy, sure, but nobody outside the US would even consider that a remotely plausible premise.
Sounds like you've never had a friend or family member die because the NHS found a reason to refuse treatment for their non-terminal cancer. At that point, if you don't want to die, your options are actually more expensive than in the US.
Yes, this happens - a lot more than people on HN like to admit. It's one of the reasons that the UK has one of the worst success rates for cancer treatment out of all of Europe.
Sounds like this is more a problem with NHS-specific bureaucracy or NHS funding rather than universal healthcare in general, though.
For a system designed to heal people, the priority should be to heal people, and to make the cost of doing so as low as possible. In this system, when somehow someone is unable to access healthcare they need, it's a failure of this particular implementation of the system, and something that needs to be fixed. The goal of the system is to take care of everybody.
The US system isn’t designed at all. Many if not most hospitals and insurers are non-profits, while others are operated by varying levels of government. The resulting patchwork is regulated on multiple levels of government with a variety of differing policy outcomes, but “profit” is not generally one of them.
There are, indeed, for-profit producers of drugs and medical equipment, but this is also true in the UK (GlaxoSmithKline is a British drug company).
> For a system designed to heal people, the priority should be to heal people, and to make the cost of doing so as low as possible. In this system, when somehow someone is unable to access healthcare they need, it's a failure of this particular implementation of the system, and something that needs to be fixed.
Minimizing cost and maximizing access are, in fact, competing goals. If a certain medical treatment is inherently costly to provide, you have to make a specific choice between cost and access. If you are unwilling to budget for competitive pay for health care professionals, you directly affect the availability of care by risking shortages of these professionals. Likewise if you don’t build enough hospitals. This fundamental constraint applies to all health care systems.
I would argue that having the government individually operate each hospital and directly employ each doctor and nurse imposes a heavy administrative burden that is fundamentally impossible to optimize for cost-efficacy. “Failures of implementation” are inevitable and systemic in this model; you may have paved a road with good intentions but that doesn’t mean it leads where you want to go. This is why the NHS is relatively unique even among universal systems and was not broadly replicated even in other European or Commonwealth countries, most of which seem to have better health outcomes.
I’m not saying the US system is perfect, or even better for that matter, but countries like Switzerland and a Singapore have systems that are arguably more privatized than the US while providing better outcomes as well. Even most countries with universal health insurance have some private sector involvement. The problems with the US health care system are far more complicated than the oversimplified conspiracy theories people keep spouting (theories that aren’t far off from those of anti-vaxxers or known frauds like Kevin Trudeau).
That isn't what happens in the English NHS. https://www.kingsfund.org.uk/audio-video/how-does-nhs-in-eng...
Current inefficiencies in the NHS are caused by lack of investment in buildings and in staff. The NHS has less management than similarly-sized commercial companies, and none of that management is The Government.
> CCGs buy services from organisations of different shapes and sizes – from NHS trusts that run hospitals and community services, to GPs and others that provide NHS care, including organisations run by charities and the private sector.
Right, so “the government” funds a few public agencies which themselves pass on money to the CCG’s, which also seem to be quasi-autonomous public agencies. The actual care providers are sometimes in the private sector. I’m not sure what distinguishes NHS England or the CCG’s from “the government” other than semantics, but sure.
This is still more administrative overhead than other “universal” systems and does not seem to address the tradeoffs between cost and availability of care. Per Wikipedia:
> A survey of CCGs by the Health Service Journal in April 2015 found that more than a third were planning to save money by restricting access to services, particularly on "procedures of limited effectiveness", podiatry, IVF, and limiting access to procedures based on aspects of a patient's health, for example whether they smoke or are obese, which can affect outcomes.[30] A similar survey by the GP magazine Pulse, in July 2015, found that many CCGs were planning to restrict access to routine care in various ways.[31]
They're not run by a government minister; they're not staffed by civil servants; they're not a government department.
> This is still more administrative overhead than other “universal” systems
It really isn't though. Of course some management exists, it's a budget of over £100bn. But compared to other healthcare systems the NHS is relatively efficient. "The NHS is over-managed" is a persistent myth. See for example chapter 2 of this study: https://www.nuffieldtrust.org.uk/files/2018-06/the-nhs-at-70... (This study does contain a lot of stuff that the NHS is poor at).
>> They found that the NHS spends relatively little on overseeing and planning care, relative to other comparable systems. In 2014, the UK, Portugal and Ireland all devoted 1.5% or less of their government or compulsory health care expenditure to administration. This compares with an average of 3.1%, with 4.1% in France, and 7.9% in the United States.
> "procedures of limited effectiveness"
They're not going to fund things that don't work. Why is that a bad thing?
But, again, I've said that there are problems caused by the choice to de-fund the NHS and that if we had comparable funding as other nations we'd start seeing better outcomes.
It is extremly expensive to run the "insurance industry", much more than inefficiency in goverment run healthcare.
Do you think your insurance agent work without getting paid?
Well, sort of. Some treatments are free. Some other treatments are not covered at all by the NHS, which counterintuitively makes those conditions more expensive to treat in the UK than they would be in the US.
> longer life expectancy
Life expectancy is a horrible way to compare healthcare systems, because there are far too many confounding variables to draw any meaningful conclusions. In reality, factors such as genetics, economic history, and demographics will overpower any effects that healthcare delivery could possibly provide.
> and better health outcomes
Not quite. The UK scores better on some healthcare outcomes, but it scores dramatically worse on others. For cancer treatment, in fact, it's one of the worst in Europe, and far behind the US. (This has been demonstrated by a series of studies that have been replicated multiple times over the past 20 years, the most recent being published only one year ago).
It's only hard to see when you believe what business lobbyists tell you. It's actually easy to see when you look at the numbers.
The real lesson here is: don't believe everything people tell you. Look at the evidence first.
Now there are plenty of government projects that are woefully inefficient, but health insurance seems to be one that governments are actually good at. Maybe not great, but better than an unregulated market.
The US health system is very highly regulated. For what an unregulated market looks like, see the software business. Consumer costs for software have been largely driven to zero.
The software market is a very different market from the health care market. An unregulated software market may not quite be a free market due to monopolies and vendor lock-in, but for consumers, it's quite possible to say no to any software purchase. That's not the case with health care, where often your options are to pay or die. That means that in a profit-driven health care market, prices can be raised indiscriminately, especially in the case of the US where health care prices are often kept hidden, because the people who can afford to, will pay anyway. There's better margins in providing health care to the rich than in providing it to the poor. It's profitable to let the poor go without healthcare.
This makes the healthcare market a very poor market to let be government primarily by a profit motive. Of course health care companies in other systems still make a profit, but they are very limited in how far they can rip off their customers compared to the US.
Sure, private businesses want to charge as much as possible. But they only succeed when they've managed to get the government to limit or eliminate their competition (as goes on in health care).
At the same time most average employees will struggle to buy a house.
And the social security will reimburse well only medical costs (visit to family doctors or medical acts done in hospitals). For other costs, hospital care, glasses, dental or hearing costs, it reimburses very little.
So for me France's SS is actually a kind of mandatory way to channel money towards doctors.
Thus, that money doesn't just go to health care. It also goes to other social security programs and government projects.
I'd rather be alive and renting than dead with an estate that has ownership of a building.
I've been through this, and I've seen a close friend go through this, and doctors have been far more harmful than helpful in my n=2 experience. They're quick to diagnose the most common possibility, and dismissive of any other possibility. But here's the thing: that all makes sense! Given the demands on doctors time and the ROI for quality of life for patients, doctors are, and should be incentivized to spend as little time as possible per patient and to diagnose them with what is most likely, given the evidence and previous knowledge.
I think medicine is one of the last great frontiers for the people to relaim through the internet. We don't take anyone's word for it when it comes to any other field, only medicine. I think we should all come to accept that we are our own doctors, first and foremost. We need to research how to take care of ourselves. Doctors are dramatically undertrained on preventive medicine (particularly diet), and I've had them tell me things that are flat out wrong, including outdated science: "losing that much weight is bad for you" when I dropped from being obese over a 6 month period, "that diet is very unhealthy" when I tried Paleo, "fat's will give you heart disease" when I tested with keto and wanted blood work done, "there really is no need to supplement" when my blood work showed severe deficiencies in vitamin D and Magnesium (both extremely important), etc etc.
Preventive medicine and health optimization does not come from doctors, we need to stop expecting it.
After 2 years of weekly injections, during which my health declined precipitously, and a couple of surgeries that took ~4x longer than expected for recovery, I abandoned this approach. I have since gotten my condition almost entirely under control through diet and other lifestyle changes.
If a doctor had told me the simple rules I now follow, perhaps surgery and $4k/mo biologics could have been avoided, but the incentives are aggressively aligned against this option.
That coupled with genetic diversity, ignorance of their customers and relative ignorance of the practitioners itself (we still don't know more than we know) could truly be a recipe for disaster.
My celiac was misdiagnosed for pharyngitis for long, and since I've stopped taking any doctor very seriously. I read A LOT, visit a bunch of doctors (preferably leading to specialists) and ask a lot of questions before deciding what course of action I want to take.
Luckily, in India, doctors don't charge as much (~$20-40) per session.