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In the US, if people take the mystique out of health care and treated it more like food service, then it'd be a lot easier to understand why the industry is so hit-and-miss with a wide range of issues. In other terms, the demand is so strong in the industry that I have no doubt the competency is something to genuinely be concerned about as a patient. I've seen it first hand - Docs and Nurses are humans, and humans get tired, or forgetful, or distracted and those aren't personal faults. However, when they screw up, instead of being apologetic, getting defensive is a very typical response.
What this article points out is something a little deeper, in that knowing the language and culture will allow an individual to social engineer through challenges. I've done it with the medical community, also in Wall St. finance, but it's most useful in my day-to-day life when going out to eat in a restaurant. There are cues and phrases to drop which can alert a competent server as to the experience level - and possible expectations - I will have of the meal. Being deeply involved in such things can have that affect on people, at least it really has for me. Criticism from another industry participant tends to sting more, because it cuts to the point.
> There are cues and phrases to drop which can alert a competent server as to the experience level - and possible expectations - I will have of the meal.
I typically do the opposite. I underplay my experience level, and gloss over their mistakes. It's more important to me to make sure that they can relax and be comfortable, than to manipulate out of them the best possible meal. Intentional "raise expectations" dialogue seems rude, and I'm generally uncomfortable around people who try that.
But maybe I'm also just covering up for my own imposter-syndrome in case I inadvertently set the overall expectations too high. Interesting to think about.
There are cues and phrases to drop which can alert a competent server as to the experience level - and possible expectations - I will have of the meal.
Maybe I've just been bing-watching too much Silicon Valley lately, but I pictured Erlich Bachman saying that right before the waitstaff rolls their eyes on the way to the kitchen before they spit on the food. A competent server might very well be tuned in to manipulation as well as being able to sling a mean plate of food.
Can you describe the types of language and culture? Or have resources to look into this further, I find it interesting.
Read up on Shibboleth [1]. Using language or phrasing, it's a way to suss out members of a certain group. One can argue that the internet memes are a type of shibboleth for internet groups. One example is The Narwhal Bacons at Midnight [2]. I'm sure YC alumni have some type of shibboleth to identify themselves in situations.
Shibboleth entered mainstream culture (and when I learned it) via a West Wing episode called "Shibboleth" [3]. The clip is worth a watch.
[1] https://en.wikipedia.org/wiki/Shibboleth
[2] http://knowyourmeme.com/memes/the-narwhal-bacons-at-midnight
> Shibboleth entered mainstream culture (and when I learned it) via a West Wing episode called "Shibboleth"
The concept of a shibboleth entered mainstream culture many centuries ago; it is a story from the Bible.
To an extent I can describe it the concept would be "jargon" on a broad level.
https://en.wikipedia.org/wiki/Jargon
Thus, certain groups engage in trying to build up minor tests or cues to test a person's depth or familiarity with a professional subject. So if I'm talking to a person at a bar, and I find out they work at a major bank, say, Comerica, I can probe enough, politely, to probably understand what they do. This level of professional knowledge is not easily faked - it's like a web of synaptic references tagged to various terms and concepts (mostly "made up" for an industry).
The doctor privilege angle is overblown. That's a shortcut, but you just need to be squeaky to get similar results. I think that instead of trying to create the fantasy that medicine is some sort of open market, we need to do something else.
My wife went through a series of medical procedures that are time sensitive, expensive and require a bunch of expensive speciality medication.
The pharmacy is impossible -- mail order only and dedicated to being obnoxious. Their aim is very obvious -- push prescription fulfillment into the next month, quarter or year. I'm sure bonuses are tied to this, because their stupid behavior wastes money... On three seperate occasions drugs were couriered to my wife (as in, a dude carrying a box got on a plane and took a cab to my home from the airport)
It's dumb behavior that results from applying market incentives to one stakeholder. For want of a $1000 drug, a $15000 procedure could be rendered a waste.
Some party should be given a "project manager" type role, and be responsible for overall patient outcome.
This is (thankfully) the direction medical care is going in the US - a shift from "fee for service" to "value based care".
It's wrapped up as part of the Affordable Care Act, and basically hospital reimbursements are being moved from "Did you do the treatment? Here's $XX", to being based on metrics like re-admittance, customer complaints, etc. A focus on the population statistics, as opposed to just providing treatment.
So large hospitals today are already starting to have these "project managers", though they call it "population health" - and it is gradually becoming more directly tied to the hospital's bottom line.
It seems like every time I have to deal with a pharmacy, I am continually blown away. It's a uniquely terrible experience, more akin to the DMV than a retail store.
Out of interest (I'm not from the US) - how can a pharmacy be bad - every time I go to one it's a case of handing across a prescription, waiting a few minutes and then getting the drugs/whatever.
Insurance craziness. CVS is becoming a classic horizontally integrated monopoly for drug distribution (benefit management, wholesale distribution and retail) so it's getting much worse in recent years.
For normal drugs they have "step up" process for new drugs so they won't pay for a 90 day script without you first getting two 30 day scripts. They make more money via co-payments on 30 days so shockingly, they fuck this up all of the time to make more money.
In my case, I am on a blood pressure med that went generic. So the script changed to the generic... Which triggered the 30 day "step up" for the same drug. I lost alot of weight and had the generic script changed to a different dosage... Again, back to the 30 day "step up". My insurance penalizes you for short term scripts for maintenance medication, so I get to pay $50 each for two 30-day scripts vs. $25 for a 90 day.
My wife was different, "speciality" drugs, which include stuff like type-1 diabetes and fertility meds require that you use the insurance company's pharmacy and jump through more hoops. My co-worker has a daughter with type-1 diabetes. He's a "type A" PM and actually has developed a project plan with about 100 documented steps to ensure that her medications are delivered on time. He did that after he daughter had to be admitted to the hospital when they ran out of drugs -- which cost the other insurance coverage $25k or more, so it's not saving money.
It's all about delaying expenses over some reporting period and maximizing revenue. Nickel and diming co-pays is how they make a profit with a huge employer like mine with lots of bargaining power. Delaying issuance of speciality drugs is also a profit center, as they are paid a commission/incentive for "controlling" costs in a given quarter/year.
They won't have a medication in stock, they can only partially fill it (requiring you to forfeit the rest), you have to bring in a physical prescription (it cannot be called or faxed in), they say the wait time is 1 hour and it ends up being days, they have to call the doctor, pickup requires a pharmacist consult but no pharmacist is presently available, their computers (and thus insurance billing) are down therefore only cash is accepted. I could go on.
"These workarounds are necessary because the health care system doesn’t follow any rational rules of economics, where the customer should be king."
The health care system how it's currently organised in the US _does_ follow rational rules of economics. It is very good at extracting value from the medical process. It's horribly bad at solving health issues, let alone efficiently.
> The health care system how it's currently organised in the US _does_ follow rational rules of economics.
Really‽ If prices of service were disclosed in some sane way the market could reward the efficient providers. Instead it's shrouded in mystery and the providers hide behind the complexity of the agreements among the many insurance agencies. They're certainly able to figure it out once it's time to generate a bill.
If there were healthcare providers that worked like my auto mechanic or plumber, it would be so much easier to work with. "sign here, not to exceed $150 for diagnosis, etc..." and then you discuss with the physician later, "Ok treatment option 1) these pills, $50 for your insurance, 2) amputation, $3000 for your insurance and BTW you satisfy your annual deductible, ..." It's not that they couldn't do that, it's just that there's little incentive for them to do it and none of the competition does it. And much of the time the diagnosis would reveal "Sir it's probably just a virus which means that we could spend tons more time and money diagnosing this and then just rule out tons of other things and end up with no treatment options anyways. If your symptoms don't go away in three weeks then come back."
You misunderstand the grandparent post. He is saying that you don't get to change rules of economics. But you (in this case the government) does get to setup the rules of the marketplace. And it is this combination of basic economics and rules of the marketplace (in this case government hiding cross subsidies for Medicare) that results in the mess we are in. But the basic rules of supply, demand and self-interest are the same here as they are in the auto mechanic business and as they were in Soviet Union.
Indeed. The free market is only efficient if property rights exist and are enforced, transaction costs are low, and there are low barriers to entry. In the US we had the property rights done fairly well, the transaction costs were manageable (outside of emergencies where every second counts)... it was the barriers to entry that were a major pain, and no reform in recent memory has done anything but make those worse.
Unless and until it becomes easier to start new businesses, hospitals, practices and careers in the medical-care profession, no one should expect the market to be functional.
You left out the biggest difference between what we have and a free market: third party payment.
If the party paying is not the party demanding, it does not resemble a free market.
The real issue here is not perks for physicians but the corrupt, inefficient, self-serving system that insurance companies and hospital bureaucrats have devised for the American public.
> The real issue here is not perks for physicians but the corrupt, inefficient, self-serving system that insurance companies and hospital bureaucrats have devised for the American public.
I agree with what you're saying, but if anyone's responsible for it, it's actually Congress, not the insurance companies and hospital bureaucrats. Private insurers and hospitals actually hate the status quo even more than you do, trust me.
I've written about this in more detail on HN previously[0][1][2], and I'm on my phone, so forgive me if I just link to those instead of typing it out again.
[0] https://news.ycombinator.com/item?id=8122377
> I agree with what you're saying, but if anyone's responsible for it, it's actually Congress
And by Congress, it really means YOU, the (American citizen) reader, who keeps voting for the same crooks.
Right, I'll just choose the non-crook option next time! A foolproof plan.
Do you know of a study that shows real cost breakdown of medical care by payer type, including these cross subsidies to Medicare? Somebody must have put this together.
I highly recommend Zeke Emanuel's "Reinventing American Healthcare" which covers the current status of the US healthcare system and the many reasons about why it turned out the way that it did. It's fairly comprehensive for a primer but is very accessible.
If I remember correctly, the book covers the question you're asking directly. I don't have the book handy otherwise I would summarize it for you.
Ever wonder why the cost of healthcare is so ridiculously expensive in this country? The American Medical Association (the AMA is the most powerful union in history) has pushed through laws to protect its members from competition, making it extraordinarily difficult to provide low cost healthcare. Basically, all entrepreneurs who don’t join the union are shut off the health care industry. This is why you pay so much money in insurance & for simple doctors visits. Do you think if a fresh entrepreneur opened a hospital you would pay $8,000 per day for a room? I very much doubt it.
If physicians were the primary driver behind high healthcare costs, I would expect physician income to be a larger fraction of healthcare expenditure. Currently, physician pay represents about ~10% of US healthcare spending. This is dwarfed by administrative costs, which represent 25% of US healthcare spending.
If the AMA/AAMC are to blame, then it seems likely to be implicitly: by keeping entrepreneurs out of the hospital administration game so they can't reduce inefficiency. But you don't have to be a physician to be a hospital administrator, so this doesn't make sense to me.
Reducing physician salaries to 0 only reduces healthcare costs by <10%, and entrepreneurs can become hospital administrators without becoming physicians. So, I think that the ire directed at the AMA is misplaced, but I'd be interested to hear more (and I'm an obviously interested party, though I'm not an AMA member). The regulatory bodies are most likely what you have concerns about.
Medical professionals are the highest paid profession in America - http://www.businessinsider.com/top-paying-jobs-in-america-20.... 16 of the 30 jobs and all of the top 5 on this list are in the medical profession.
The high pay in these professions is simple economics: supply is tightly constricted through the number of residencies allowed. Those in the profession have a strong interest in continuing to restrict the number of people in their field and so they have trade organizations that do this.
The line of defense they use is that consumers are too stupid to select a good healthcare provider without their intervention. I believe consumers would be very good at selecting the best provider, and would love to see all of the regulations dropped to open free competition into the marketplace.
Do you have a source for those percentages? I'm genuinely curious.
...Calm down the conspiracy theories.
The AMA only represents at BEST 15% of American physicians [1]. If you want ANYONE to blame, it's Medicare/Medicaid, Insurers, and Hospitals. CMS and Insurance regulations mean you cannot charge different prices to different people.
Eg. I can't charge a poor person less and still bill the full Medicare allowable for other patients. I either charge the low rate for all or none. Insurers have similar language in their individual contracts. They even go so far as barring us from discussing our reimbursement rates / charge list to allow patients to comparison shop.
The only real innovations in "price transparency" come when you reject Medicare patients. Surgery Center of Oklahoma [2] is a frequently cited example of a successful model of price transparency; however, they MUST explicitly opt out of Medicare billing else they are in violation of the law.
I have considered opening a Radiology practice with an imaging center that offers flat rate charges for people to price shop, but a LOT of patients who require imaging are Medicare patients and I'm pretty sure they aren't going to fork over $1-2000 for their every 3 month head-to-toe restaging scans, especially when it's a PETCT. Perhaps if I marketed to young people and focused on MSK MRI I could pull it off, but the market of people who are looking to comparison shop for imaging prices is smaller than all the people who rant about healthcare think it is.
1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3153537/ 2. http://surgerycenterok.com
Can you help me understand, if charging differing rates to the insurers is verboten, why a "cash only" patient can often (and easily) receive a substantial discount off their medical bills just by asking for it? I'm not being adversarial, I honestly don't understand it, and would like to.
It seems to me that the "cash" rate is what the "market will bear", which makes the hospital administration complicit in defrauding taxpayers and the general insured by overcharging for procedures and consumables when an insurer is the one receiving the bill. I suspect there's more to it, though, and I've never been able to figure out what it is.
> The American Medical Association (the AMA is the most powerful union in history) has pushed through laws to protect its members from competition, making it extraordinarily difficult to provide low cost healthcare
This is a common misconception. I've posted about this many times before, but in short, it's the AAMC, not the AMA, that used to medical school spots. They are no longer the bottleneck anymore, however; the issue is that we don't have enough residency slots, and the funding for those comes through Medicare[0].
That said, this isn't really a driver of costs anyway, because providers themselves are responsible for only 10-15% of spending.
> Basically, all entrepreneurs who don’t join the union are shut off the health care industry. This is why you pay so much money in insurance & for simple doctors visits. Do you think if a fresh entrepreneur opened a hospital you would pay $8,000 per day for a room?
No, the reason that you pay so much is because of the convoluted way that Medicare reimbursements work (even if you're not on Medicare). In short, Medicare doesn't cover its own costs, so private insurers and uninsured patients are overcharged in order to cover the difference[1]
> They are no longer the bottleneck anymore, however; the issue is that we don't have enough residency slots, and the funding for those comes through Medicare[0].
Can you elaborate? I don't understand what dynamic is being alleged with this often-cited reference to limited residency funding. If there really are (quasi) monopoly profits to be made, why would government funding limit that? That is, if it's really lucrative to become a doctor, but you have to do a residency, but no one will pay for it, then potential doctors should be happy to eat the costs, knowing that they can lay it back from later high salaries.
Let me put the argument in another context to say why it doesn't make sense: "demand for passenger air travel is through the roof, with revenues at hundred of times the cost of a flight. But we can't increase the number of flights because the government won't purchase more airplanes to give to the airlines."
In that case, it would be a poor argument: buy the new airplanes with the passenger revenue; you don't need a government subsidy there.
Oh, so there is free movement of foreign medical staff to the US, so that medical professionals have to compete on the same basis as a working class manufacturing employees?
It's comforting to see a doctor venting his frustration over Insurance companies. I've gotten to the point where I've kinda just given up. I'm sick of the entire mess.
I've gotten to the point where I just wish patients had more of a say over what medications they could have refilled.
Say, for instance, a person has been taking Blood Presssure medication for over five years; they should be able to renew their original script? Or, a person has been on anti-anxiety/depression medication for over five years; let that person authorize their own refills? Require blood tests--that's fine.
The patient couldn't increase the dose, but wouldn't have to deal with doctors over refills. The patients who abuse the privilege would have to go back to our lovely system of being held hostage.
I guess refill are on my mind because I'm going into detox over the lack of a medication I've been on twenty years. The pharmacy is waiting for her approval. I think my doctor is on an extended vacation?
Of course this will never take place because Americans are all drug seeking zombies according to our government, and I don't think AMA lobbyists would ever even consider such a crazy notion.
As to this, "Nepotism occurs in many fields; friends and family of New York City police officers often carry Patrolmen’s Benevolent Association cards, which may confer special treatment in a traffic stop."
Yea, this is very common. In San Francisco, my father best friend (now a retired cop) gave him a special business card. A "Get out of jail free" card. My father used it a few times. It saved him from a DUI. My father was a very conservative man. He hated what that card stood for, but always carried it around.
If someone is on some medication, it is probably a good idea to have them regularly check in with a doctor to make sure their condition isn't getting worse (or better!). Forcing them to see a doctor when their medication runs out seems like a reliable way to get them to go to such checkups.
I realize that sounds pretty reasonable and all, but I can assure you that no such checkup is being performed the vast majority of times a patient comes in to renew a script. It's just an excuse to get the patient in so that they can cover their ass and increase billables.
Here in Germany, we have something called "Gebührenordnung für (Tier)Ärzte" (fee catalogue for (veterinary) doctors).
Everything you can think of has a standardized pricing set, with the option to go up to 3.5x the standard rate for difficult procedures.
Kind of prevents that bullshit mentioned in the article; also, national health insurance covers nearly everything that's medically neccessary and deductibles are highly limited.
In BC (and I assume other Canadian provinces) the dental association publishes an annual fee guide. They recommend that dentists charge the suggested fees, but they do not require it. Many insurance companies use the suggested fees as limits on how much they will pay for certain procedures. But patients who are paying cash don't know how much the "suggested" rate is for the services they received -- unless they borrow a copy from their local library, since the dental association explicitly refuses to put the guide online. (Their argument is that the fee schedule is too complicated for patients to understand.)
So despite having nominally standardized pricing, in practice there's nothing keeping pricing standardized beyond what insurance companies are willing to pay for their clients.
Ontario has it posted prominently. The top Google result is the official PDF. It's only 76 pages.
BC's page has an FAQ saying public library and that its over 1400 pages.
There's also professional courtesy between doctors and police. They'll very often let you off for minor traffic violations even if you're not on the way to an emergency (source: relative who's a doctor).
It was described to me as "if they get shot and you end up being their surgeon they want your goodwill", although it's not limited to surgeons so I suspect that's not quite the whole story.
We used to just call that kind of thing "courtesy" and people in the community who were known for being good were given it, while jerks and scumbags had it denied.
I imagine it played a large part in community good will until our communities got too big for us.
Doubtful the police officer is thinking that far ahead. There's no need for an explanation. When your profession is both prestigious[1] and seen as being for the greater good, you tend to get treated well by the police. Especially if it's on your driver's license (military id works too).
Try telling someone you're a doctor at a bar to see this in action.
1 - http://media.theharrispoll.com/documents/Prestigious+Occupat...
> In most realms, those with the least ability to pay should receive the biggest discounts. In health care, it is often the uninsured and indigent who receive bills with the full “chargemaster” fee — the wildly inflated prices that nobody really pays — while large insurance companies get the biggest breaks.
This bothers me more than almost any other piece of our system. It's corrupt from the start, with prices being presented that do not have any relation to the price that the parties in the transaction actually expect to pay/receive. So even if we had "price transparency" for medical procedures, it wouldn't really reflect reality.
A few examples of the system at work:
* I have a HSA so I don't put small medical expenses through my insurance. I went to a doctor for a strep throat check and was told that my 30m appointment would be $350 if put through my insurance (and I hadn't hit my deductible yet) or $150 if I paid in cash at the office. So I paid cash with my HSA. Why should there by these two wildly divergent prices? Even if I had no deductible and took the $350 option that just means my insurance company is paying $200 over what the doctor actually wants for the service, which means some other person in the insurance pool will receive $200 less in services down the road.
* One time I got food poisoning in college and because it happened in a classroom and I was unable to really walk/balance the school said I could only leave in an ambulance. So an ambulance was called to drive me the 0.25mi to the university hospital. I waited a few hours in the ER, then a doctor saw me for 15 minutes and no medicine or care was actually administered since I was fine by then. I get a bill in the mail for $1000 a few weeks later, that's $700 for the drive and $300 for the doctor's time. My dad (a dentist) advised me to not pay the bill and let it go to collection. Then a few weeks later the bill collector called me and since I had my income listed as $0 (college student) they said I could pay the bill in installments or just make it all go away for a $300 lump sum (which I took). So just by waiting around suddenly the cost of treatment went down by 70%.
Medicine should not be a negotation. There should be one price for everyone and you shouldn't have to know anyone or pull strange tricks to get the real price. If we don't even know what something costs, how can we begin to drive the cost down?
I do not believe for a single second that your insurance company "pays" their full share as demonstrated when they tell you you have to pay 20% of the cost. I have no evidence but I am strongly convinced that there is some sort of account reconciliation between an insurance company and an in network provider where they settle accounts in a ... more palatable manner.
There is just no way Humana would pay over $7k for two hours of waiting for triage in the emergency room and eventually a rabies vaccine shot.
You've hit the problem right in the head here.
> Medicine should not be a negotation. There should be one price for everyone and you shouldn't have to know anyone or pull strange tricks to get the real price. If we don't even know what something costs, how can we begin to drive the cost down?
From what I've read: Part of the problem is hospitals themselves don't know the exact cost.
I think another part should be the introduction of death panels. There should be a point being which we will "put down" a suffering patient. We do this with dogs and cats all the time. If someone is suffering and very unlikely to make a good recovery, we should put them out of their misery. Or at least we shouldn't pour so much effort into keeping them alive.
Just letting you know, the monospace formatting appears as a single line and is unreadable on mobile.
Fixed, thanks!
Real issue is the public's willingness to provide care for itself.
To glaring examples of this are obesity and fatally rates related to medical error; 250000 deaths a year are related to medical error.
On the last point, you'd think this is an institutional issue, but if you account for how little attention the public gives the issue compared to other issues, it's clear the real issue is the public.
My wife is a member of the R.N. club, but sadly it appears that there are no perks associated.