1) Insurance companies - extract profit from the usual insurance model applied to healthcare.
2) Drug/Device companies - extract maximum profit from patent monopolies, FDA regulatory capture, and marketing.
3) Malpractice lawyers - use regressive law precedent to maximize individual payout and lawyer billing to the detriment of everyone else
4) AMA/Providers - restrict supply, and maximize billing for services
Really, none of these pigs have the interests of overall public health in mind:
- Insurance companies are incentivized to maximize the cost of insurance and deny coverage as much as possible, like any insurance company vertical. Obviously this results in denial of care. However, an insurance company is motivated to reduce provider costs and possibly to incentivize preventative care. Insurance companies are also vertically integrating into owning provider facilities to solidify local monopolies (so people HAVE to use their insurance if they live in an area) and to be able to impose cost cuts to actual providers.
- Drug/Device companies are incentivized to maximize the profits from 20 years of provided patent monopolies, often exploiting desperate people looking for relief from maladies, but the cost is usually beyond the ability of individuals to afford. Lawyers are incentivized to bill/get percentages of settlements and maximize awards of "damages" regardless of the overall impact to health services costs and the implicit denial of care that involves. However, these orgs, while generally not doing the core science of new treatment modalities (universities do that), they do help usher treatments through safety review.
- Trial lawyers are incentivized to maximize their patient damages and billing, which obviously is transferred to higher costs for all. Lawyers are one of the few hammers to get insurance companies to properly pay out, keep hospitals from devolving into managerial corruption, and keep Drug/Device companies from fudging the numbers.
- And the AMA/Providers are incentivized to maximize the billing for their services, overbill for often superfluous services, resist any intermediate level profession (Nurse Practitioners, etc) from devaluing their law-enforced professional monopoly, and incentivized to not address general health of patients but rather bill with expensive specialist care rather than help patients maintain wellness that averts serious illness. In my experience no provider ever cared about how much their services cost the patient, until it became apparent the patient could no longer pay. Then their economic awareness of the cost of care become VERY APPARENT. The AMA is criminally complicit in restricting supply of doctors, which it very well knows raises the cost of medical services and of course denies care to people on the aggregate.
Each of the four pigs simply points to other pigs as someone to blame and lobbies with maximum force to prevent any threat to their gravy train.
To address US healthcare costs will generally require all four pigs: a public insurance option (at a minimum). Reduce patent length or invalidate patents, and with cases like unpatented production that has been monopolized (epipen, insulin) enforce antitrust. Fix prices if necessary. Obviously trial lawyers awards should be capped. Finally, nurse practitioners and AI expert systems used to decrease costs, and supply of doctors increased vastly. Overall, government needs to address the total lack of preventative care.
I can tell you that more than 75% of my medical school class was not in it for the money, for what it’s worth.
That's what the "restricted supply" bit is about.
Even the worst, most harmful doctors I've come across are making more than everyone else I know.
The specialists, the two I know probably make 700k and up, are superficially in it to "help people" but it is apparent they love the money. Radiology, Cardiology, and AssDocs.
US specialists make far too much money, especially considering that GPs barely make 100k sometimes, but for two extra years you get 6-7x the salary? Come on.
I worked at a drug/device company. It started out in a garage and was originally a "morally run company". But it had long devolved into an MBA enshittified acquisition-deal company.
I worked at a major insurance company. They can't for public reasons show TOO much of a profit, which is PERFECT for the MBAs running that company, because they hoover up all the excess in a bloated executive structure and embarrassingly huge bonuses.
Never worked for a law firm. I generally assume them to be the smallest pig, the runt, which is useful for the other pigs to bully and blame for everything.
But gp is where you do preventative care to avoid the specialists.
Your second point is right, so what are you gonna do? Make a medical system where preventative care and quality of care are valued? Then you'll get called a "communist" who wants "death camps" and get your birthplace questioned. So here we are.
In the 70s and 80s, I'm told general practitioners made more money then specialists, something I agree with. But even now, lots of people want to do general practice. The smartest person in my med school class went into pediatrics because she loved it. Money is not the biggest motivator for speciality choice, but it is one. Isn't this the case in literally every other field? Maybe SWEs who are full stack get paid more or something?
Nonsense if you read the SEC filings and compare health insurance executive compensation to other business' executives that lead similar number of employees and revenue.
Try to make sense for why people getting paid in equity would want to lower their own compensation by hiding profit. Across the entire industry, at least 7 publicly listed businesses (UNH/Elevance/CVS/Cigna/Humana/Centene/Molina). That would be a very impressive collusion scheme, if they can pull that off maybe they deserve it.
Insurance company profurs are in the 5-15% range. Drug/device can be in the 50-100% range depending on what patent monopoly they are riding.
But the health insurance companies operate regional monopolies or duopolies, which they achieve with vertical integration with hospital networks.
Health insurance knows they are riding a delicate balancing act. The entire first world besides the us has social health care. They all have better outcomes and vastly reduced costs. They are pure corruption.
So they can't show the drug device profit margins. They have to look like the hood guys who push down costs from the evil drug companies and those know it all doctors/ama.
Most importantly, though, is you would need to show what incentive an executive of a publicly listed business would have to show less profit rather than more profit (net income). Investors pay higher prices for shares of more highly profitable businesses, and executives get paid in shares.
So claiming that a publicly listed business chooses to somehow hide less net income (ignoring the claim of fraud), first you would have to provide the incentive for why executives would want to earn less.
UHC and other health insurers are swimming in money. Yet the reported profits are very low ... why?
Obamacare was ground zero for public healthcare. If it wasn't for utter slimeball Joe Lieberman doing the dirty work blocking medicare for all for the insurance companies, they would have been tossed out completely.
Again, the US is the ONLY first world economy that doesn't have social health insurance. The economics of our health care system are not sustainable, and large changes will eventually come. The health care cartel cannot show the profit margins of drug/device companies. Insurance companies are the ones that deny coverage, so they are front and center with people hating the current healthcare system.
So the healthcare companies DON'T show profit, instead they expand revenue as much as possible, and the executives funnel money to a bloated management structure. You don't need high profits to drive stock growth, you just need to get ... bigger, and that's what they do. You can do other things to boost stock price without showing profits ... use ... wait for it ... excess revenue to do stock buybacks. You can "reinvest" into expanding the vertical integration of your monopoly. You can buyout more hospital networks, effectively expanding the number of people that HAVE to use your insurance.
Let me give another example. Why are MBAs flocking to nonprofit universities? There's no stock options. There's no cashing out in mergers and acquisitions. Why?
Money floods into the universities as the endowments explode, every year the tuition increases well above inflation. Yes there is a facilities race, but why do MBAs love it? Well, it is a cushy job, universities are nice places to work. But, since there's no shareholders, no owner to show profits to, they can skim off the vast revenue increase from exploding endowments and tuition increases and... pay themselves more money.
This is false. Stock buybacks can only happen from net income, which is why health insurers don’t do them…since they have very little net income (aka profit).
> executives funnel money to a bloated management structure
You will have to provide proof that at least 7 publicly listed companies’ executives are colluding in such a manner AND their shareholders are willingly going along with employees enriching themselves at the shareholders’ expense. Lots of bold claims with no evidence, and some outright wrong ones.
>If it wasn't for utter slimeball Joe Lieberman doing the dirty work blocking medicare for all for the insurance companies, they would have been tossed out completely.
Also, there are 100 senators, and so legislation passing/not passing can never be blamed on just one. Leiberman took the public relations hit, but there were 40 other nay votes to blame also.
Are you aware of the lack of standards in NP education and training? The American public has no idea how raw of a deal they are getting. This is shrinkflation in healthcare, whereas you might have expected to see a doctor before, now you have to see a PA/NP, where the barrier to entry is extremely low and the training standards are loosely enforced, if at all.
In a perfect world, healthcare services would be well-matched to the level of care needed. Standards would be laid out and followed, and effectively priced care delivered.
And then, please don't laugh, if lower cost healthcare was delivered, then premiums would go down. No, no, don't laugh. Okay, you're right, there's no incentive for a local monopoly health insurer that owns the hospitals to pass the money to the consumer. YOU DON'T HAVE A REAL CHOICE. So if you are in buttshit Indiana, you basically get to use Anthem. And they have no incentive to deliver cost savings to the insured.
So of the four pigs, they are all opposed to each other to some degree:
Doctors: hate insurers (who want to lower their salaries/fees/billing) and trial lawyers (who cost them in malpractice insurance).
Drug/Device: hate insurers (who want then to pay less than bloated retail price) and trial lawyers (who sue them in massive class action lawsuits)
Insurers: hate everyone (because they own the money that comes into the system, they attempt to let it go to anyone else, be it drug company, doctor, lawyer, or claim)
Lawyers: hate insurers
BUT, the one shadow incentive they all have is to increase spending on healthcare. So even though the pigs oppose each other on details, they all want people and the government to pay more money for healthcare.
https://www.ama-assn.org/press-center/press-releases/ama-fun...
https://www.openhealthpolicy.com/p/medical-residency-slots-c...
But don't know how much is talk versus walk. It is not clear to me why only the US Federal Congress can fund residencies. Surely, with how much doctors can earn, a private underwriter would be willing to finance a residency.
https://www.washingtonian.com/2020/04/13/were-short-on-healt...
Anyone can fund residencies. If a wealthy donor has enough money to spare, a teaching hospital would probably be willing to create an endowed residency slot in their name. And there is already some private funding, although it is a tiny fraction of Medicare funding. Commercial payers (medical insurers) also indirectly subsidize residencies by reimbursing teaching hospitals at higher rates than other facilities for the same procedures. None of the other major healthcare industry players have a direct incentive to fund residencies.
https://www.chcf.org/wp-content/uploads/2018/08/GuideGraduat...
One of the problems is that regulations require MD oversight but not necesssrily performing all operations. That’s a good thing but forces them into a role where they hover for a few minutes then get rushed to the next supervision activity.
So there are lots of dials to play with in addition to supply.
That's an understatement. It is blatant and deliberate.
We (the AMA?) regulate where a doctor gets their education in order to become a doctor. This gives schools a lot of power. It also gives hospitals a lot of power when those doctors work insane shifts during their rotations.
https://www.ama-assn.org/education/gme-funding/save-graduate...
It was obviously meant to be provocative and tongue in cheek. But all medical boards are exclusively run by doctors, so you have to assign blame to the profession for doctor NIMBYism.
Imo, it's another case of : "you can't get someone to understand something, if their wealth depends on them not understanding it."
You can see a lot more patients when you have less busywork. You can also be more caring and thoughtful when you’re focused on the patient and not the chart. A lot of patients give misleading answers (I don’t eat much! How are you 50lbs+ since last visit?)
More doctors will help. But management runs the hospitals so poorly they can’t run more resident spots!
1. https://www.advisory.com/daily-briefing/2013/08/27/the-secre...
I honestly hate this sort of stuff though. When I pay my toll on the highway, I expect it to pay for maintaining the road I used, not for unrelated things. Anyhow, may be a similar kind of thing going on here, or you know... just flat out profiteering.
This is a great example. You expect to pay for the "maintenance of the road", but what about the ongoing opportunity cost of the road and all the externalities of the road? What about all the roads that do not have tolls on them? The toll road does not exist in a vacuum, and life is not so simple so as to be able to sequester all costs into separate line items.
In fact, one of the main uses for tolls is not for the maintenance of the toll, it is for managing congestion of the road, since the road has a carrying capacity. After a certain number of vehicles, the road becomes less and less useful, so a variable rate toll can ensure a limited number of vehicles operate on the road at peak congestion.
It is simply not feasible to tie revenue to expenses 1 to 1, and specific taxes (like tolls) legislated to do that for government expenses hamstrings leaders because it removes flexibility needed to move resources around (which obviously could be used for bad, but also good, as you demonstrated your business's example).
What? I've never heard this requirement and I cannot think of why it would be the case (I'm a PCP). The rest of your comment is pretty much the issue as PCP though. I have at least 30 minutes a day of "out of visit" requests (reviewing documents from outside hospital/consults, labs, imaging, other results, extra nurse patient triages) in addition to anywhere from 30 minutes to 2 hours of completing my notes each night.
The payment methods for primary care do not work.
It's also ridiculous that I have to promise to pay any bills that my insurance won't cover. If some care can't be justified as medically necessary, there should be a specific contract for that when it comes up, not a blanket rider prior to accessing treatment.
Forcing the two sophisticated entities to have a workable agreement where they can't dump costs off on the individual patient would at least improve perceptions of care.
https://www.cms.gov/newsroom/fact-sheets/no-surprises-unders...
And after each appointment they need to document everything in the chart. If you aren't charting in the room, you will be there for hours after your last patient catching up. But if you do chart in the room, your patients get mad at you because you are on the computer the whole visit.
Then you have to prechart at the end of the day on all of your patients tomorrow and get ready to do it all again.
10 appointments a day, 30 mins each.
You have to write /everything/ down the patient tells you. You often have to go over the 30mins because some patients need it. You need to follow up to order extra tests, you need to occasionally google something.
You skip lunch often. You need to find time to reply to messages from previous patients. Nurses will mess up something or a patient will show up late. Want to see patients past 5? The nurses have left and you can't legally 'bill' or code the appointment without the nurses.
day is over and you review tomorrow's patients. You read through their histories. Now you check the messages. There's between 5-45 a day. You see a lot of patients.
Then you're told that your department isn't bringing in enough money. They want you to see 11 patients a day. The reason? They didn't bill people correctly. For the past year.
A lot of doctors quit.