Before you call someone ignorant and say that the bureaucracy disagrees and so what possible standing could I have, consider a little bit of charitable reasoning would add some much needed credibility to the objection.
That you've done consulting to the healthcare sector doesn't mean much of anything to me, one way or another. Heck, the IT consultant for our CTO in my health chain can say the same, and all he does is EMR rollouts. He has about 0% understanding of healthcare policy, or how the system actually works. He understands EMR implementations. The financial analyst consulting to our COO has been in the hc sector for about a year and his knowledge of actual hc policy outstrips the EMR guy by at least an order of magnitude.
As a physician and healthcare policy expert, I don't much need any credibility, outside of that provided by the contents of my posts. I'm happy to let them speak for themselves, rather than appeal to authority - the latter of which is essentially non-existent in this pseudonymous context.
As the job of physician is being reduced to that of a health care service project manager who assembles and directs specialists using technology tools, it's becoming vulnerable to the same technology changes that sidelined project managers.
Skill is pareto distributed, and there is a long tail of medical services that could be done by apprenticed tradespeople, and the only thing preventing that is medical associations - and as you say, holding litigation risk.
The concept of 'efficiency of scale' does not translate to service industries. The only efficiency that happens is efficiency of funneling more money to higher salaries of higher executives. Hospitals are driven by profit and their incentives do not align with the precepts that led to their formation.
By the way, actual cost transparency has winners and losers too. The winner is generally private insurers, who can use it to negotiate reimbursement further downward. The losers are everyone else. It's pretty much never the patient, regardless of what advocates of "patient consumerism" cry. When you're a grain of sand between two massive gears, you don't ever win the game of policy arbitrage.
If all you need is stitches, you can go to your PCP ($20-$60), surgeon's private office ($50-$100) or Urgent Care ($50-$200). Instead you go to the highest overhead center, occupy the attention of at least 2 nurses, a mid-level, and a doc, and... yes, pay for all of the above. In a space whose allocated overhead includes the weighted average of "stitches that shouldn't have come in" to "diabetic ketoacidosis with multiple organ failure."
Part of our systemic problems is, due to how we're structured, it's borderline impossible for an ER to say (a polite version of) "You're fucking kidding me. We have an urgent care center across the street - go there." [1]
We have many, many, many systemic problems. People using the ED as a primary care office and complaining about the disparity in prices is the least egregious of them.
[1] In part because hospitals used to try to bounce indigent patients. So now they can't do anything that smacks of bouncing anyone. So even if you try to divert patients from the ED to an in-house Urgent-ish Care, they still have to go through the ED pathway to determine that they're stable (meaning a doc has to evaluate them), before they can be shunted over. And now you're in a hospital, so the overhead of the Urgent-ish Care is already way higher than just having gone to UC to begin with. The hospital has no incentive to establish a spot for providing the same level of care, at high overhead, for lower reimbursement.
1. We are fractured. There is no "healthcare system." That's a singular noun. We have a marketplace: that means things like three top-tier specialty centers in walking distance of each other in some areas, and nothing at all in others. About 90% of our problems derive from this. As do a number of our strengths (if you're in Boston, you should never have to wait more than two weeks for a colonoscopy. Ever.)
1a. The healthcare "system" is not equivalent to hospitals. Hospitals are a single strain of profit-seeking enterprise (non-profit hospitals are the same shit.) People keep confusing the two, resulting in advocacy for policies that just concentrate power harder into the hands of a few, massive, corporations.
2. We are bipolar. A huge, huge proportion of our healthcare dollars flows from medicare. A large portion of our people are uninsured or underinsured. The result is that healthcare operations are built (generally) around Medicare's billing practices and needs - that's what you optimize on to stay afloat. This means when someone uninsured comes in, though, they're thrown into an operational flow for which they're barely an after-thought. Prices set as a negotiation point with private insurers are brought to bear against uninsured people - and they get nailed with ridiculous, unpredictable prices that have nothing to do with... almost anything. These people either need to be brought under the umbrella of contracted rates (Medicare For All), or I don't know what. You're not going to convince an organization with operating margins <2% to launch a massive operational restructuring to accommodate people that generate <<1% of its profits. And don't think there isn't legislative collusion in this - in places like CA, hospitals are obligated to go to collections for all patients. They used to say, fuck it, that guy was poor as fuck, write it off as uncollectible and deduct it as charity care. The state didn't want to lose the tax dollars the hospital didn't bother collecting, so now hospitals are required to send those indigent patients to collections, or else the hospital has to eat the entirety of the cost - not even a tax deduction to soften the hit. That adds up to a lot of dollars.
3. Unfunded Mandates. Every policy change pushed through our healthcare system is perceived as targeting "those wealthy doctors" (doctor != hospital != healthcare system). Most docs I know drive a Nissan Altima or a Camry - they're middle-class cogs buried under debt. But the stereotype makes a good excuse for pushing policy changes and then not allocating money to accomplishing them. Which means every policy change fractures the system further apart socioeconomically - you have wealthy-client practices that can afford to stop taking insurance, opt-out of Medicare, and thus avoid all these unfunded mandates... and then you have everyone else. Which puts basically everyone but hospitals out of business, because only hospitals have the capital and the scale to be able to meet the new requirements. You think FB likes privacy regs because it builds a moat? Hospitals don't just get moats, they basically get to buy up every small practice in the area at cost. Your local PCP is small and nimble enough to say "oh, you're uninsured? Fuck it, $40." It's the hospital that says, "Oh, we'll send you a bill later," and then ho boy, get ready. This also includes getting docs who are super-bought into the status quo: "We profited off charging you hundreds of thousands in tuition. We sold the idea that you'd be set afterwards, and could just be a good doctor. Turns out that while paying off your loans, you're just middle-middle-class, after having been impoverished into your 30s. And now, for the good of society, we'd like to cut your income by another 20%, while asking you to continue working like a madman. No, we will not offer you one penny of federal loan forgiveness, even though it is the federal government that is gutting your income. In fact, we won't even let you declare bankruptcy - that's cause for revoking your license." Yeah, docs are going to buck really hard against most changes in hc reimbursement. Even so, look at organizations like Doctors For America - a shit ton of docs still agitate for reform, for the good of their nation, if not the good of their own pocket. A related point is the "shortage" of docs: training positions in hospitals are funded by the federal government. Funding which barely crawls. "We have a doctor shortage!" "Will you open new training positions?" "No." "Then..." "No worries, we'll have nurses take some night classes, skip the entirety of actual residency training, and then we can call them doctors, too! We'll just confuse people by telling them they're going to see 'providers', and that way we can avoid paying doctors for doctoring."
There's a lot of other headline bullet points, but most issues in American healthcare boil down to an interaction of the above three.
edit: I should add, big picture, that healthcare isn't magically divorced from the rest of our social ills. As wealth inequality grows, bear in mind two things: (1) wealth correlates to health, and disease burden to correlates to poverty, (2) people can still vote themselves healthcare allocation (i.e., medicaid). The result is that increasingly more disease is concentrated among the increasingly impoverished, which means they're legislatively allocating themselves healthcare ... without the resources to pay for it. Whether or not you like or dislike any of the above, a lot of our issues with hc reimbursement are linked - directly or indirectly - to questions of wealth inequality. Adjusted for inflation, most docs have seen their real income stagnating, hard, for decades - and that's specifically as a result of trying to cheapen them, because they're increasingly paid for with redistributed tax dollars rather than anyone actually buying healthcare.
Yet, these are highly paid jobs because It’s not about being able to do it, it’s about understanding what they are doing. This way, they don’t just know how to do it but why to do it and what are the implications of doings it and how to debug it when the outcome is not the expected one.
Any junior can probably do %99 of what their seniors can do, yet when you look for a highly paid senior you don’t take a cheap junior as an option.
US health system might be a racket but not the health profession. No where else visiting a hospital is a financial decision(yet the med staff is still well paid), you only worry about the medical issue and it’s impact on your life and the lives of your loved ones, except maybe when you need some very novel treatment for your rare condition.
I have to add that this way of thinking, in general, is a very blue collar mental model on how world works. Nurses claim that they can do what doctors do, mechanics claim that they can do what engineers do all the time.
If someone wants to hire someone who can kinda program a little, because they charge less, and are likely able to accomplish the task the person has in mind, then they should be free to do that.
(Of course, if the task is one where failure causes a big problem, then one should get someone more qualified.)
The vast majority of developers cannot kill you if they screw up. In the cases where that isn't true, e.g. software for medical equipment, I'd expect to find some significantly higher hurdles to get past before you can release that software.
We don't generally require developers to have certain qualifications, but their output can be measured in other standardised ways nonetheless.
What are these standardised ways to measure developer output? I've never seen any, beyond "burndown charts" and "LOC", which I don't believe pass the sniff test.
Low affordance causes spilled blood, blood causes regulations.
It is if you are developing software in some high risk settings!
This gets so rarely uttered if ever I'm having a hard time believing it hasn't been down voted by hyper-credentialists on HN.
I fully believe the number of doctors allowed to start practicing medicine is heavily controlled using arbitrary rationales and spurious education / training thresholds.
There's no need for so much garbage bureaucracy in medical pedagogy especially when so many doctors are paid insanely lofty salaries.
The whole enterprise of medicine and the way its practiced in the U.S. ( including HIPAA ), needs some heavy de-bloating.
[1]https://www.npr.org/sections/money/2019/03/12/702500408/are-...
"Of course" says everyone because it seems like an easy answer.
"Then you're sprained ancle will need a team of 20 super MDs, an MRI, CAT scan, sterile isolation ward and a helicopter to get you there. That will be 100 million dollars please!" says the greedy fuck maximising profit, and he's giving you what you said you wanted...
This is basically the US system in a nutshell. Other nations have an approach with more focus on affordability, but the US system (from hospitals, to doctors themselves, to insurers, to drug makers, to the courts) is entirely focused on maximum quality. That's what makes it unaffordable. That's also why you don't have teired treatment like you say: an MD is 0.5% better than a trained nurse at setting a bone. They cost 100 times more. But you decide purely based on the 0.5%
I mean I get it, wounds can turn (really) bad, but other people than MDs (like nurses, or pharmacists were even discussed for this in France) should be able to do them, and give a follow up appointment to some MD / nurse a few days later to check if recovery is going well. Only time tells how the healing goes anyways.
It's another problem or set of problems that occurs in the USA.
In light of this, Abraham Flexner was commissioned by the Carnegie Foundation to produce a report on the state of medical education and to make recommendations.
The Flexner Report was published in book form in 1910 and set forth a programme of reform for medical education and the broader healthcare system in America. The structure envisioned by Flexner largely remains with us to this day.
The crux of the problem is that in response to a very chaotic system, order was imposed in the form of strict licensing and educational requirements which made sense given the problems of the time but have contributed to new problems in our time. Outdated regulations, standard practices and conventions have artificially restricted supply of qualified medical personnel in America and it's time we address these structural issues.
Targeted reform of the system is the best solution for American healthcare.
The issue seems more complex than something simple like number of physicians. A high ratio is unnecessary for cheaper, quality healthcare (e.g. Canada, Japan), and whatever dynamics control the ratio in the U.S. (schooling, licensing) probably also exist in other countries with similar legal systems, but with different outcomes.
Data: https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?location...
EDIT: Looking at the ratio of GP to specialists for Canada (~1:1) and California (~1:2), it's more likely that the problem (such as it relates to numbers of physicians) is that we have too many specialists in the U.S. See https://www.cma.ca/sites/default/files/pdf/Physician%20Data/... and https://www.chcf.org/wp-content/uploads/2018/06/CAPhysicianS... And that probably has to do with 1) how we consume healthcare in this country and 2) the career expectations of medical students. And arguably this is a typical pattern of American culture more generally and in all our industries. Everybody wants to push the envelope and everybody expects the products and services they consume to be bleeding edge, both as a cultural expectation and in pursuit of higher profits--as consumers we tend to assume more costly services are more advanced.
I mean do doctors really need to spend 4 years getting a bachelor's degree in "pre-med"? If you know you're going to be a doctor why not just start off with biology, anatomy, physiology, chemistry in year one and go on to cutting up bodies in year 2? It seems utterly ridiculous to spend 4 years majoring in humanities, or calculus[1] only to seek entrance to med school.
The UK doesn't feel the need to do this.[2]
1. https://prepexpert.com/pre-med-class-recommendations/
2. https://en.wikipedia.org/wiki/Medical_school_in_the_United_K...
Granted, you could theoretically shorten the program by removing all the humanities courses; but shouldn't doctors-to-be take ethics courses?
You're right, I hold my hands up. I don't have any medical training.
> Where I went to Uni, you didn't take biochem until you were a senior. The reason for this is because before you take biochem you need General Chemistry 1 & 2, Organic Chemistry 1 & 2, and some smattering of Biology. You have to take these courses sequentially, they build on each other.
You obviously know what you're talking about and I won't debate you on how this works. But again, does a prospective doctor need to spend 4 years on this? How does every country other than the US and Canada manage to train their doctors without making them get a Bachelor's along the way in something non-medical? Why can't doctors study 5 or 6 years and graduate with a medical degree, ready to become a general practitioner? That's how they do it in the UK. Are you saying their docs didn't pass biochem or don't know what a nucleophile is?
> shouldn't doctors-to-be take ethics courses?
Pretty sure med students have time to take ethics courses if they do a 5/6 year medical degree.
Do doc's need to spend 4 years doing an undergrad before med school? Maybe. There are a lot of things that you need to learn before you can learn what you need to be a doctor. Do you need to know physics? Eh, only kind of.
I'm not terribly familiar with the system in the UK, but at least where I went to school, most of the folks who were planning on going to med school studied either Chem, Biochem or straight Biology. In fact, it was something of an issue because the Chemistry courses tended to be weed out courses, i.e. you had to pass Organic chem 1 & 2 with a (3.0+)/4.0, or you didn't have a ghost of a chance of getting in to med school. I, personally, didn't know anyone who was planning on going to med school who was studying anything outside the STEM umbrella.
>Pretty sure med students have time to take ethics courses if they do a 5/6 year medical degree. Reasonably. I was really only picking on this point because of, what I had thought was, a dismissal to the usage of the humanities as a doc.
Things you need to learn, not an inclusive list, before med school: Chemistry, drug interactions, A&P, Ethics, Statistics, Maths, and Biology.
That's (6, 2, 1, 2, 3, 4) 18 courses minimum. Remembering that they have to be done sequentially rather than concurrently and you're looking at, bare minimum, 2 years rather than 2 semesters.
This is as it should be. To bring it back to your CS example, if you are making a web app and you fail to secure your attack surface, the worst that happens is that folks get their info stolen. If you fail to do your drug interaction math correctly, people die.
Finance capitalists keep the vicious cycle going. Doctors' unions scratch and claw for high comp because without it their new entrants are screwed.
The free market in shampoo is okay, sort of. For a lot of other stuff "free market" + fiat looks like a mess.
Why haven't dental costs fallen through the floor if it's a free market?
Of course since the latter are elective, customers have the luxury of shopping around and taking their time.
I've had to deal with the true cost of dental work and I can guarantee you anyone that's needed to deal with significant dental issues has had the same experience. So why hasn't the free market dropped down prices? Why are we still paying more for basic dental work compared to other countries?
Just as with politics, it's mostly well-intentioned, "good people in a bad system"; nonetheless, each individual is perversely-incentivized to normalize the moral hazard.
It costs <$300 of an MD's time to set a bone, even if you get MD service. GP doctors aren't very expensive. The costs are elsewhere.
You do, however, need to be an MD to recognize some of the other 20% as not being part of the 80%.
Let me suggest you fire-up a spreadsheet and start to calculate the cost structures surrounding healthcare in the US. I don't think you have enough information yet to fully understand the subject enough to answer the question you posed.
I'll suggest you model something like a team conducting surgery at a mid size hospital.
You have to model the cost structure each person in that room is subjected to. Three simple items are the cost of their education, malpractice insurance and taxes.
The next step is to estimate the number of people who support that team within that hospital. From administration to nurses and janitors.
Add to that external services such as labs.
Now calculate the equipment costs. You could dig deeper and understand the regulatory costs, taxation and liability equipment manufacturers are subjected to. Interesting point to note: The Trump administration had to guarantee protection from liability before anyone was willing to make even something as simple as an N95 mask for use in hospitals.
Now calculate the cost structure for the hospital. Again, regulatory, liability/malpractice, taxation, etc. If the ambulance service is independent, add them to the exercise.
If you run through the above exercise you will actually be surprised that it only costs $3,000 for an MD to perform a procedure.
Notice insurance isn't anywhere in these calculation. Health insurance is an easy to point to evil, yet it is perhaps the most insignificant portion of the cost matrix that drives the cost of healthcare in the US. In fact, health insurance is NOT a driver, it's a symptom. You cannot fix our medical system by manipulating insurance. If the costs are high, care will be expensive. If the costs are lower, care will become more affordable. And this will drive insurance costs down as a result. Insurance isn't the cause, it's the effect. Remember that next time you hear a politician claim that they can improve things by screwing with insurance. They are lying to you. Don't allow that to happen. Be informed.
If the equipment is the same, the admin overhead is the same and the education is the same, then that leaves only one real difference between us and other countries. And that's our Byzantine insurance system.
But the most striking difference is that everything is for profit. Health care.
Exact same costs? Surely you are joking.
Costs, regulatory overhead, education and taxes are different everywhere.
My wife pays tens of thousands of dollars per year in malpractice insurance...and she isn't even at the top of the scale in terms of these costs. The cost of education? An MD can graduate with anywhere from $300K and more in debt.
And lawsuits? Show me a place on earth where attorneys will go after anyone, medical industry or not, as quickly, easily and violently as they do in the US?
Show me a place on earth where the government guarantees student loans to the extent that university costs are bloated to the point of creating financial slavery for graduates.
Show me a place on earth where doctors have to order a pile of unnecessary tests in order to protect themselves from being sued.
Show me a place on earth where developing the simplest medical device costs tens of millions of dollars in regulatory fees alone (if you are lucky).
Show me a place on earth where bringing a drug to market comes with potentially billions of dollars in regulatory costs.
Show me a place on earth where a manufacturer of N95 masks and gowns is not allowed to supply them to hospitals during an emergency due to regulatory burdens, the fear of lawsuits and has to demand immunity from the president of the country before they are able to do so.
I tried to develop a relatively simple hearing device to help people who suffer from SSD (Single Side Deafness). We have someone in the family with this condition. I designed and built a device for her. She loved it. I then looked into going to market with it. The costs would run into the tens of millions of dollars (or more). There was no way to take that leap. And that doesn't include protecting from or fighting the inevitable lawsuits.
No, nothing is "the exact same". And that's my point. Unless you pull-up a spreadsheet and analyze the cost structure you will never understand why healthcare costs what it does in the US. It has nothing to do with insurance, or profit, or greed or any of the nonsense ideas being floated around --particularly by politicians who just want to manipulate the audience for votes.
This is a simple equation: If you want to lower consumer costs you have to lower the cost structure driving the process and resources necessary to deliver the goods and services they receive.
I would urge you not to form opinions as you have until and unless you have taken the time to truly understand the details of the matter, which is to say: Analyze the cost structure tree down to a good level of granularity and then see what you would change in order to reduce consumer costs. Insurance will not be on that list.
edit: that said though, your opening question is kind of odd - doesn't pretty much everyone view the medical field as a racket?
Insurance companies are awful, but seriously, we can train field medics to do stitches and set bones, why should it cost $3000 to have an MD do it? Listening the hand wringing about it is infuriating when you realize that the reason you have to wait for simple procedures that barbers used to do is because there is a med school bottleneck.