This was not the article I expected. My experience is that vets are like doctors yesterday for a different reason.
I tore my ACL this year. Last year, my dog tore his.
One thing I learned when talking to (UK) doctors about my ACL is that there has been a lot of recent evidence-based medicine about surgical interventions. As a result, surgeons are less gung-ho: it turns out, quite often, surgery just doesn't do much good compared to physio.
By contrast, when I looked at the literature for animal cruciate ligament treatment, it's... oh gosh. I went into depth on this. In 2003 there was an article pointing out that there was almost no scientific evidence for most of the existing treatments. Ten years later, there was a review article which essentially said "oh, now the evidence is much better, we can rest easy". It categorized the research into four categories, the best one being credible randomized controlled trials. So I looked at the top category. The only RCT I found had about 40 animals, with substantial dropout (very likely non-random). There's a lot of natural improvement, and tiny effects from treatment, with significant results for some (out of many!) measured dependent variables.
After reading the top category, I didn't bother with the rest. What a disaster!
Cruciate ligament treatment for dogs is a $1bn industry. But there's just no decent science being done. It's all tests of 8 dogs without a control group, done by some guy pushing his new methodology. Honestly, it's shameful.
By contrast, one of the strengths of the NHS is maybe that it can knock heads together , get large-scale RCTs going, and learn something.
there's actually a lot of evidence that cruciate surgery improves return to function, but you're right- a lot of vets unfortunately recommend surgery for the wrong reasons (unwittingly or not).
Surgery only really makes a difference in moderate to severe tears or those with meniscal injury. There's 4+ different ways to fix a cruciate. Half of them are useless (and evidence shows no difference c.f. conservative treatment) and if a surgeon recommend them I would see it as a red flag.
Interestingly a lot of pet owners could not go to surgery because of the recent COVID lockdowns, and it was found that a lot of those animals healed well with just some rest anyway.
The linked article looks like a way to skirt the use of Human Growth Hormone by athletes. Is it doping if it's to cure an ACL injury? Such a grey area...!
medecine is highly emotional, if you give people the choice of doing nothing vs doing something/anything people will, out of shame, do that thing. There has to be a strong cultural, evidence based, or other, justification to do nothing. Probably not the case most of the time, and it's going to stay that way, because as you mentioned, there's a boatload of money to be made out of it and careers depend on it.
Doing something, anything is very much the american school of thought. In Europe, people are often very happy if they can just do nothing. Incidentally, that's also the real reason why US healthcare is so much more expensive.
> if you give people the choice of doing nothing vs doing something/anything people will, out of shame, do that thing.
That’s an awfully broad generalization. Anecdotally I prefer to avoid intervention though I don’t mind going to the doctor in case that would be the wrong choice.
I am the child of a doctor so I wonder if that influenced my attitude.
The veterinary industry for pets in the US is about 100 billion dollars a year. I think assuming 1% of that is cruciate ligament treatment/surgery is probably a bit too high but it is a pretty common problem for dogs and surgery is a pretty expensive intervention so I am not sure. Its at least 100s of millions though.
I have talked about it on here before, but I genuinely despise the modern experience of going to the doctor. They spend the entire time asking questions from a screen, most of which I answered last time, while staring at the computer. It feels more like an interrogation.
I have also literally had my doctor google my symptoms right then and there, and the “I could have done that” feeling just doesn’t build confidence. Clearly it’s through the filter of his knowledge but still feels wrong.
Going to the doctor in the 90s felt way more personal, way more like they actually cared about you and your health. Sit down and just talk about what was going on face to face.
Like sure, maybe the modern way has better results overall? But it sure feels impersonal and I never leave with any feeling of confidence. I would have to imagine there’s a middle ground with similar if not better results.
I was working for an EHR (electronic health records) software company a few years ago, and we had a presentation by a doctor. He was around 60-70 years old, and he was talking about his experience with our EHR.
He said "before EHR, I would look at the patient while they talked and my hand wrote on a piece of paper. Now, I'm listening to them while typing into a computer. I used to have at least one patient cry a day, now I can't remember when someone last cried."
Doctors know it's feels crap, it feels crap for them too, but they do it because it saves them a bunch of hours and mistakes every single day. We need a better EHR experience, though.
> I have also literally had my doctor google my symptoms right then and there, and the “I could have done that” feeling just doesn’t build confidence. Clearly it’s through the filter of his knowledge but still feels wrong.
That's an interesting point, because I often google people's computer error messages in front of them, quickly determine the solution, and fix their problem.
I have the same experience as you watching a doctor do that, but from the inside this feels like a straightforward and easy way to get the information I need. I never quite thought about how it must look to someone on the outside.
In my experience, for most general practitioners, it's not!
There are specialists for a reason though. But I've found that YOU need to be able to do the work to get the referral and make the diagnoses.
Interestingly though, I had a family practice MD early on in my medical process that had a hunch, long before I suspected I had what he thought I did. (i.e. before I was able to steer the conversation to heavily emphasize certain symptoms after I'd pretty much figured out what I had and needed some diagnostics to confirm.) He just knew... Alas, the test came back negative, and he got roped into other endeavors before retiring. He was brilliant though, he had a PhD in epidemiology as well as an MD. (He even saw one of the very last smallpox cases in the wild.) Much later on, and several doctors later, we finally got that diagnosis right. For one doctor, I had to walk him through the results of the test before he finally put it together.... pretty unbelieveable, and there's no hope for the average patient in that scenario.
One thing that a lot of people without familiarity in medicine as an industry, the residency match process, etc. don't realize, is that family medicine/GP is the least competitive field. If you don't match into any residency process, you go into a scramble mode to try to get picked up unless you want to wait a year and try again. Those scrambled slots are almost all in family medicine, and largely in toxic training programs or very undesirable areas. There's a decent chance your GP finished toward the bottom of their med school class and/or did poorly on their step exams and/or didn't even want to be a GP anyway.
None of this is to say that they're not smart, or good people, or hard working, any of that. But it's important to know the person sitting across from you very likely didn't dream of sitting in that seat the way a surgeon or ICU doc or neurologist very likely did. It changes the dynamic quite a bit. For general medical issues they likely know more than you. If you have a disease or condition requiring specialty treatment, you likely know more about it than they do within the first year or two of specialist visits.
> you go into a scramble mode to try to get picked up unless you want to wait a year and try again. Those scrambled slots are almost all in family medicine,
There's some errors/gross oversimplification in this post. Most scrambled spots are one year prelims, not family medicine. Of the minority categorical scrambled slots more are actually internal medicine, next is FM (but again this is the minority), then neuro, psych, etc.
Also minor point, if you fail to SOAP ("scramble" is kind of outdated), you can find job openings outside of the match system entirely, so waiting a year is not inevitable.
> and largely in toxic training programs or very undesirable areas.
Actually, most of these programs know this and they target FMGs - they tend to fill most of their spots through the regular match. Meanwhile numerous top academic programs SOAP/scramble their prelim spots.
> very likely didn't dream of sitting in that seat the way a surgeon or ICU doc or neurologist very likely did.
IM, Peds, EM, rads, anesthesia, neurology (not competitive at all), PM&R, psych, even gen surg are all relatively non-competitive. You may be surprised about surgery, but all those surgical subspecialty hopefuls that fail to match - many of them end up in gen surg via a "scramble" to a prelim, some may make it on round 2, but many will not and they will go on to an open categorical gen surg program - ie amongst the relatively "competitive" there is the not competitive that doesn't end up where they want to be.
Meanwhile whether your doctor was bottom of the class/poor academic pedigree has more to do with region. The IM and FMs at the top academic major regional centers will often be AOA/top of class/top programs.
IM/FM is just a hell of a lot more variable - it's also very large.
> If you have a disease or condition requiring specialty treatment.....
I dunno if this really has to do with academic pedigree/the process you're calling out as much as scope of practice. Even amazing GPs, unless they have a particular personal interest in something cannot faux subspecialize in everything.
> They spend the entire time asking questions from a screen, most of which I answered last time, while staring at the computer. It feels more like an interrogation.
I go to a family doctor in his 70s for this very reason. He isn't in a rush. He (or his nurse) actually looks at the old form responses instead of asking me the same old questions. He cares about me beyond the list of symptoms, and asked about the job I started a year ago at the last visit.
I feel like the move to larger clinics (at least in the US) over old school one physician offices has standardized the process and made it more bureaucratic. But there could be a more human approach if someone actually cared to invest in it. I don't see it happening when larger practices and health systems are optimizing for cost and throughput.
"I feel like the move to larger clinics (at least in the US) over old school one physician offices has standardized the process and made it more bureaucratic."
The cause and effect might be backwards here. Many physicians retired or consolidated as regulations increased, and ghe cost of complying with the regulations increased. For example, we saw a lot of this when digitization of files became mandatory.
It is ultimately the influence of Federal Healthcare programs that have pushed small doctors out of business. The cost of regulation is ENOURMOUS. And the following effect is that because the federal government is the largest spender in the sector, private insurance companies tend to follow suit, making the whole thing worse.
I don't have a solution for solving medical billing, but it's a huge racket and it's driving up costs.
Yes, you could have googled the symptoms, but do you have the background & experience to evaluate the results?
Anyone can google "how to program", but you wouldn't put those results into production, and yet professional SW engineers do that all the time because they have the background and experience to evaluate the results.
Which country if you dont mind me asking? I know of many similar stories about doctors typing stuff into google and prescribing paracetamol from the UK, Spain or Germany - but it's hard to imagine such a situation in central europe.
There’s an opportunity here in the less regulated pet health space: flip the pipeline around and treat it like a staging environment for human healthcare, rather than a place to expand treatments later to extend ROI.
One example: glucose monitors for pets lag a generation or two behind glucose monitors for humans. Releasing a human glucose monitor requires lots of testing and certification. Starting in the pet space and then expanding into humans would allow you to iterate faster than your human health care first competitors.
There are definitely companies and investors thinking/working in this space. They think if you can demonstrate an ability solve X in “staging” it has a chance to transfer to “prod”. It works better for some things (generally, simpler/smaller and deterministic things) than others.
Practically speaking, the human health space is heavily regulated, and the costs associated with compliance are high. Intuitively, to me, there are not many health-specific innovations that one can discover in pet care that will lead to reduced costs in human care. Because most costs are not technologically-induced, rather they’re regulatory or bureaucratic.
You can iterate towards a better mouse trap in pet-land, but the time and financial costs of getting that mouse trap FDA-approved do not magically go away, and unfortunately human care is not a very free market, so being a 10x better mousetrap is not enough to break through.
The human healthcare market is also stupidly bigger than the pet care space, like 100x depending on what you include in each category. So if you’re after the big bucks, which most investors / investees are, it’s still generally worth it to target humans first.
That being said, some are seeing pets as an angle because human stuff is proving so hard and slow-going, they’re willing to experiment with any potential shortcuts.
Human healthcare has 3rd parties subsidizing the bills. This makes consumers price immune. Plus most surgeons can't tell you accurately how much the total bill with be because insurers pay different rates for same procedure.
One thing I've been wondering about recently is SENS for pets. Lab rats can already be given extreme longevity, but I suspect there are plenty of dog owners who would pay a lot for double or treble life expectancy for their pets, especially as the lab rat with that treatment (reportedly) spent their years close to the peak of fitness.
Most of experimental medical research fits your model and is usually called “basic” or “preclinical research”.
This is well regulated by federal laws and guidelines (and hassled relentlessly ironically by non-Vegan PETA members).
Much of the progress in medicine is driven by this basic and preclinical work—-from brewer’s yeast to mice, rats, and monkeys.
If anyone suggests that experimental research using animals has not delivered over the last 100 years please do not just roll your eyes. Tell them that they are flat-out wrong. Almost every disease or human condition has useful animal models—yes even dyslexia and schizophrenia. One exception—-gun-ownership mania.
I know it's not what you meant, but I seem to remember a short clip of some idiots giving a monkey (or was it a chimp?) what looked to my unskilled eyes like an AK-47.
there's not many specialised glucose monitor for animals. it's not feasible for manufacturers to release products just for one species or test for every breed of dogs.
we use continuous blood glucose monitors (made for humans) which can take wireless readings through a skin implant. they do well in animals (once you shave the fur). there are papers that confirm human glucometer readings correlate with an animal's blood glucose- so many clinics use human glucometers.
I think you are illustrating my point rather than refuting it. A new company could introduce a pet CGM with less barrier to entry than a human first company for the reasons you list.
His analysis is based on the comparison between his grand father era and his mother area ; but this predicate is if not wrong, at least still unproved.
He took a sample of 2 persons, with different characteristics and made deductions based on that. Nothing can't be deduced from his sample in fact.
For example, we compare at the same time a 'psychiatrist' from period X, to a 'dermatologist' from period Y.
Psychiatrists in general will not have the same mentality as dermatologists!
Medecines in the psychiatrist area will meddle with the brain and will try to affect the mood of a patient. Effects are hard to measure and side effects often unclear.
At the opposite, it is quite easy to see the effects and side effects of medecines in dermatology.
You can tell someone: go have a walk in the forest and your depression might pass, but your scabies problem will not resolve itself alone like that...
Tangentially related: I think the price of veterinary care is likely the best (albeit still an imperfect) estimator of how much human healthcare actually costs. There are virtually no price distortions caused by insurance markets, single payer systems, or strict regulations. It’s the closest thing to a fully free market in healthcare there is.
Uh...it still has the "you need this or you see a loved one suffer" thing going for it which leads to an ability to seek maximum profit. Large multinationals are monopolizing by buying out small vet practices, also allowing them to set prices. And those monopolies not only offer their own insurance, but there are also numerous others offering pet insurance.
So it might be the "closest thing to a fully free market in healthcare there is (in the US)", in that it's slightly better than the human healthcare market...but that's it. It's still nowhere close.
And there are plenty of other markets, all of them cheaper, and many with better outcomes...though I guess few countries with "freer" markets (since pretty much every other western country either has a single payer system, or has mandatory private insurance or similar, such as Switzerland), so I guess if your point is that having a "free market" approach to healthcare leads to worse outcomes in every instance?
Veterinary medicine technically deals with property, not really loved ones. Numbered dairy cow or muddy sow needing a c-section is an asset, not a loved family member. Pets are loved but they are property with negligible economic value, unlike a human life.
Where I live those are two different kinds of vets, with two distinct clienteles. While it's possible to find mixed practices (cattle + pets) in smaller towns, it's typically not the case in larger cities. There's no point in having your practice located downtown if you go to your clients anyway.
> Pets are loved but they are property with negligible economic value, unlike a human life.
You're missing the point, which is not about "economic value" (whatever you mean by that -- the amount someone would be willing to pay to save their own life? Their income?). The point is that no one who loves their pets dearly wants them to suffer, which puts the buyer in a worse bargaining position. I would (and have) paid many thousands to save a pet's life.
Fine, for the terminally pedantic - I refer to the fact that the prospective buyer can not easily say "nah" and walk away; healthcare for a loved one can't be viewed as a purely economic transaction. It's easy to say "I don't need that expensive a car", even possible to say "I can make it work without a car", it's incredibly hard to not get Spot his life saving surgery because of money.
It ceases to be a purely economic function because people can't just walk away, and that has market effects that mean the typical pressures of a free market (such as 'supply and demand') become muddied. Sufficient supply is irrelevant if Spot is suffering -right now-, all the providers form a monopoly, and their prices are massively inflated.
The point of my pedantic comment was to note that the goal of seeking maximum profit is universal, what is not is being able to extract maximum profit, which is made possible by supply and demand, which you alluded to with "you need this or you see a loved one suffer".
>It ceases to be a purely economic function because people can't just walk away, and that has market effects that mean the typical pressures of a free market (such as 'supply and demand') become muddied.
Supply and demand has not become muddied. The ability to extract maximum profit is from the fact that there is very little supply and extremely high demand.
>Sufficient supply is irrelevant if Spot is suffering -right now-, all the providers form a monopoly, and their prices are massively inflated.
Sufficient supply and demand implies lots of agents supplying demand and lots of agents willing to buy, resulting in a situation where either party can walk away from the other to enable price discovery. If all the providers form a monopoly, they no longer act as individual agents, and hence there is no longer sufficient supply.
The dynamics of supply and demand and price discovery do not quite care about the suffering during the process, which is where the concept of insurance comes in. It could be provided by well regulated private markets with sufficiently well behaved actors, or by society at large via taxes, but the concept is the same. You prepare for unaffordable, unexpected expenses by "paying" in advance so that at the time of needing the product/services, you are not having to negotiate because the negotiations have already happened.
Not even close! Supply of veterinarians has been artifically constrained by insufficient expansion of veterinary schools, which has caused truly nasty market effects. Pet pharma is relatively highly regulated with American consumers paying high prices that are detached from market costs. Compare prices of medications in livestock vials or drenches vs the pet form.
I think dentistry would be more or a free market. You don't have much of the pharma issue, staffing is okay in some regions, there is decent price transparency, and insurance is not as terribly byzantine as it is for medical.
Prices still seem ridiculous to me, though. At my last dental visit they wanted to charge me $87 for someone to spend 15 seconds with a q-tip applying fluoride to my teeth. And this wasn't a case of "charge as much as the insurance will pay", as this would have been something not covered by my insurance.
Maybe that's less than what a similar (non-dental) medical procedure would cost, but that's still excessive.
Insurance isn’t universal yet, but I do think it’s already causing price distortions in the veterinary market. I have used pet insurance for about a decade, and I have (anecdotally) seen both insurance become much more common and prices increase significantly. I think those phenomena are likely linked. My dog had several obscure, severe medical issues throughout his life, and while I loved him dearly and would have treated the issues regardless of cost, the insurance made it much easier to say “yes” to more complex or repeated treatments without doing any financial analysis.
tl;dr is that private equity firms are _so_ aggressive in buying up local veterinary practices (especially 24-hour veterinary ERs), and making already-fat margins even fatter, that the FTC is trying to stop it.
Interesting article. I agree with other commenters that change in medical science over time probably necessitates changes in the industry, but I don't think this precludes making the work of medical professionals less onerous and expensive. Prior authorizations in particular seem like a uniquely wasteful and American phenomenon, whereby time (and thus money) is burned just so doctors and insurance can try to get on the same page. That cost, we can be sure, is then passed along to patients, on both the service and insurance ends. But more interesting to me, the broad picture in this article is of a world in which insurers have steadily clawed away more and more diagnostic and prescriptive responsibilities away from doctors, because the economic logic of a world with private health insurance allows them to do so, to the detriment of doctors' lives (as the article describes) but more saliently (for an American non-doctor like me) to that of all Americans trying to receive healthcare via insurance. I think it's pretty hard to dispute this phenomenon is real and harmful. The question, which this article doesn't really address, is what to do about it?
> The malpractice insurance of a family doctor is $13,000 a year, while an obstetrician’s insurance can cost $71,000 a year.
This is flat out wrong. No one is paying $71,000 a year in medical malpractice. An average OB/GYN is at $5k / year in insurance costs [1].
A really good source for medical malpractice claims data is the National Practitioner Data Bank which posts data on all paid medical malpractice claims since 1991 [2].
A summary of the data for the U.S. as well as for each individual state is here [3]. All of this is to say, the number of paid malpractice claims has been dropping since 2001, and the total amount paid on these claims has also dropped by 23% since 2003.
What is the real issue here? Defensive Medicine.
Doctors are terrified of being sued so they order batteries of unnecessary tests on patients and make unnecessary referrals in order to avoid lawsuits. These unnecessary tests drive up healthcare costs, not the direct cost of medical malpractice.
This is a problem with the healthcare system and how patients can initiate lawsuits. I don't think it is entirely fair to blame the physician in this instance for covering their bases. Any doctor who has been sued for medical malpractice will tell you that it was a humiliating and degrading experience even if they won their case.
Your own link [1] says "Ob/Gyn about $30,000- $35,000". The OP said "an Ob's ins CAN COST 71k a year" [emphasis mine] so doesn't sound 'flat out wrong' to me.
Next - could you explain why you are bringing in malpractice CLAIMS data in a conversation about PREMIUMS?
> Your own link [1] says "Ob/Gyn about $30,000- $35,000". The OP said "an Ob's ins CAN COST 71k a year" [emphasis mine] so doesn't sound 'flat out wrong' to me.
And that's in California, while a chart lower down shows doctors in New York pay 7 times as much on average, and $35k on average across all specialities.
First, the vast majority of OB/Gyns practicing are employed by hospitals. The hospital covers the malpractice costs for the Ob/Gyns / any other physician's employed [1].
OB/Gyns are making $336k total comp on average in 2022 (including salary, bonus, and profit-sharing contributions) [2].
I am confused as to what your problem is? What exactly are you trying to articulate here? OB/Gyns are well compensated, and their insurance premiums are covered by the hospital. They are making above $300k/yr. :)
You claimed that the annual malpractice insurance cost for OB/GYNs comes to around $5k when the true value (according to your link) appears to be several times higher. This is orthogonal to whether OB/GYNs make enough money to cover premiums or whether the hospital covers those premiums.
But the vast majority, as I stated above, are hospital employed and so it is covered by the hospital. It isn't considered as part of the TC (total comp) that is reported by Medscape [1]. If it was, then the TC for Ob/Gyns would skyrocket to nearly $400k per year.
The average annual salary for a plastic surgeon was $576k in 2022. And $60,000 is not $71,000. Still yet to see perhaps more than maybe 0.001% of clinicians practicing pay that out of pocket fully.
Medscape is widely regarded as the reputable source for physician salaries.
They do not consider hospital-issued / covered malpractice insurance as part of the TC listed on their yearly averages, hence why I don't think it should be made as big of a deal as it is being here.
I should say, these numbers affect private practices almost exclusively; and private practices are dying out/being bought out in droves.
TFA's point was that indeed - no individual is paying it. The cost of insurance strongly encourages working for hospitals who will cover that cost, rather than striking out and running the kind of small, one man band practice that the author is nostalgic for.
Took my dog who tore his ACL to the vet in Kiel, WI. They wanted to put him on life ending pain medication which would get him a few more months tops.
Took him to another vet in a local smaller community with staff that actually cared, they were able to properly wire the tendon and give that dog 5 years relatively pain-free life.
Many vets are absolute hacks and need to be roasted for it.
Dad had his interests (hip dysplasia and veterinary orthopaedics) but was comfortable with pretty much everything including dentistry, most surgery and internal medicine. Newer DVMs do specialize somewhat in the sense that they tend to adopt more limited scopes of practice. There are even some that don't do spays and neuters which would have horrified my late father; those and vaccinations were the business bread and butter. Veterinary HMOs and PPOs are still a small part of the market and Dad never took them or completed claim forms for clients, but they're growing.
When I was in general practice I had a fair number of fee-for-service and cash pay patients (most were Medicaid/dual Medi-Medi and some HMO-PPO, but not the overwhelming majority), and I had the list of the (then) $4 drugs at the local supermarket pharmacies and we used that like a formulary to keep their out-of-pocket costs down. I'd say about a third of my patients were pediatric, the rest adults, and a smattering of prenatal. However, by modern standards even though we're trained to do it in family medicine I don't think many family practice physicians do full-scope because of the liability, particularly for prenatal care. I'm not in general care anymore, though I still see patients intermittently.
Veterinarians may have been more like yesterday's primary care a decade ago, but I'd argue that's increasingly no longer true.
As far as I can tell, specialization is increasingly popular. Within the past few years I've dealt personally with vets who specialized entirely in ophthalmology, oncology, and obstetrics. At the same practice as my oncologist there are specialists in cardiology and internal medicine as well.
I've also had to seek out specialists in rabbit care, which are surprisingly hard to find (though no vet I'm aware of treats solely rabbits -- usually they're exotic vets often with a "real" specialty in birds).
My experience with vets is extremely different. Either I’ll go to one that’ll charge significantly more for testing/operations or the one that charges less will make up the difference by aggressively pushing unnecessary testing and treatment (and charging insane materials rates for something as simple as saline).
I wouldn’t look towards veterinary medicine as the model, at least not from what I’ve seen (granted a lot of this exists for human treatments too).
> [2] The biggest contributors to these are the twin demons of prior authorization and electronic medical records. Prior authorization is when health insurance companies require doctors to ask for permission to perform specific services for specific patients. This is incredibly time consuming (14.4 hours per week as of 2020) and also demoralizing for the physicians, as the ultimate decision on how to treat a patient is often not made by the highly-trained physician or the patient in need, but instead by a 25 year old making 40k/year reading off a script over the phone.
This is a dramatic oversimplification.
The person reading the script may issue a denial, and then there is a process of appeal, which may include other steps.
Physicians interacting with insurance companies practice what is known as a "peer to peer", where a physician discusses the case with an insurance-employed physician, often trained in the same specialty as the physician. Sometimes the notes provided by a surgeon were inadequate, sometimes they need clarification, sometimes the incorrect codes were used, and payment is retroactively denied.
There are a few things too many rejections can cause:
1 - Insurance switches
2 - Regulator problems
3 - Competing model with insurance
4 - Lawsuit, as some legal firms specifically target insurance companies for this activity
Every time I read about how insurance works in the US medical system it's pretty plain to see that it's distorting both costs and patient care (neither for the better). How are people in the US still putting up with this garbage? How is any of this more efficient than single-payer or some other form of socialized medicine? It's absurd.
There are similar mechanisms in taxpayer funded healthcare countries also. The government does not simply pay doctors for any and all services they provide. At some point, there will be a person or group of persons deciding if certain services are warranted and/or to monitor for fraud.
In taxpayer funded countries they mostly aren't getting paid by the procedure, and in the cases that they are it's not enough to incentive very much fraud. Socialized medicine healthcare salaries are actual salaries and far lower than earnings in the US.
You make it sound like it's okay for the insurance company, a middleman, to decide someone's healthcare.
But insurance companies aren't collaborators. They rarely add to the process of making you healthier, they only take away options through denials. Seems silly that an insurance company allows a doctor into their network, then repeatedly questions that doctor's decisions (until you remember that insurance companies just want to make money).
> You make it sound like it's okay for the insurance company, a middleman, to decide someone's healthcare.
The insurance company is not deciding someone’s healthcare, they are deciding if they are going to pay for specific healthcare. Providers and patients are free to engage in any healthcare they want.
> Seems silly that an insurance company allows a doctor into their network, then repeatedly questions that doctor's decisions
Why? Does a car insurance company pay a mechanic in their network to replace an engine for a fender bender?
> (until you remember that insurance companies just want to make money).
This is meaningless. Everyone “just” wants to make money.
incredibly apologetic for an industry that’s wholly unnecessary, that without we could just have the “peer to peer” communication and patient interest in mind. that would be terrible though, as some folks would have to pay more than they would’ve if they were able to live their whole life without needing medical care.
I am not apologetic, this is just a matter-of-fact response on how it works, and what happens.
Keep in mind that healthcare fraud is a giant business [1] [2]
I'm not trying to push any particular thing, though I do believe that the Kaiser Permanente type of business model (health maintenance organization) will eventually kill off much insurance.
As a a vet I think this author's limited experience is a bit out of date.
In the veterinary industry, medical management is always influenced by costs. Just yesterday I had to deal with a blocked cat. Gold standard treatment costs thousands of dollars and the owner only had $200. You not only have to take into account the hospital costs, but how the owner can manage their pet at home for ongoing care too. Costs are one of the main stressors in the industry (there's plenty of Ted Talks on the high suicide rate), and commonly owners shift their responsibility by blaming vets as "money grabbers" or who are only "in it for the money".
Thankfully insurance is quite common now (depending on the area) and with less financial restraint on costs we are able to do more advanced treatments. We have specialists referral daily and even recently had a brain surgery on a dog. This would have been very rare in the past and the limited opportunity to perform complex treatments like this hinders how much data we can collect and learn from this.
You do have old-school vets or those in rural clinics who would be happy to do every treatment under the sun. But being a 'jack-of-all-trades' is unrealistic when each sub-field is rapidly expanding in knowledge, and most younger vets (especially in big cities) are more than happy to refer to specialists (and avoid risk of complaints), unless of course the owner cannot afford to do so.
There are now chains of for-profit full service pet hospitals, expanding into a business that not long ago was served by a few not-for-profit centers. For instance, locally, if I needed a service my local vet couldn't provide, I went to Angell Memorial in Boston. I adopted all of my cats there. Now there's a couple of Blue Pearl hospitals here too.
This isn't entirely a bad thing. But one presumes that increasing use of pet insurance and the commericialization of the vet business will mean rising costs. And my local vet has had some staff turnover of late.
Probably a naive question, but why is EMR still so atrocious? I know there's a lot of garbage software out there, esp when it's single-purpose. But I usually assume that's a combination of low returns to better UI and little money to optimize (eg software improvements that make waiters marginally more efficient).
By contrast, supply of doctor-minutes is a chronic bottleneck in a system that spends trillions. I know healthcare (esp in the US) is full of wonky incentives, but surely improving doctor productivity is connected to hospital outcomes in some straightforward way?
Being in the veterinary care with my small pet (which I learned have very short all-good to all-dead journey) I noticed that vet clinic is a very depressing place.
Sure, animals are cute, but a lot of them are dying or seriously ill and even being in the waiting room where loving owners rush-in scared or wait restlessly worried about their pets’ lives is a dark experience.
Seeing how vets are handling animals I’d say it takes a very specific mindset and resolution to do the job. I can imagine that even the hardest of such resolutions can crack under the weight of owners breaking down over their pets misery.
I believe that everyone should have access to periodic mental health evaluation, support and professional supervision. For people working in such hard to digest professions it is a necessity.
> Being in the veterinary care with my small pet (which I learned have very short all-good to all-dead journey) I noticed that vet clinic is a very depressing place.
I wouldn't call them small (necessarily), but this is my experience with rabbits. Over the decade we've taken care of them we've gone at least five or six times from "everything's okay" to "Georgie's lethargic and won't eat" -- which can mean death -- in the span of a few hours. So I'm driving over an hour each way in the middle of the night to take my rabbit to the nearest 24h emergency vet that treats them, not knowing if this is just gas or a blockage that will need surgery, mentally preparing myself for thousands of dollars in costs and the possible death of my pet. I imagine it's no fun for the vets who have to deal with me and others like me all night long, though I try my best to seem upbeat and empathetic externally.
The problem with both these 'sectors', in my view, is that it is almost impossible for the doctor/vet to actually act in the patient's interests.
The doctors have to worry about lawsuits, giving the correct (pharmaceutical) treatment. The vets are better, but really I've been unimpressed with the care - lots of unnecessary cutting for the sake of insurance, sterilisation, etc.
The background reason is that the incentives are 180° in the wrong direction. Practioners aren't paid for keeping you healthy, out of hospital, managing health by better diet selection, etc. Their 'best' scenario is the opposite to that - they want a long protracted illness with lots of treatment. Diabetes for example is a blessing, not a curse. Long illnesses pay the bills.
Not only this, but doctors are fully boxed in with dysfunctional protocols/treatments (wrt the patient's best interests) as insurance companies' 'best practice', etc inculcate a set of behaviours that suit pharmaceutical corps that pay their bills.
So the incentives and model are all wrong. But they are also hardened in law, insurance etc. So apparently we must proceed on this flawed model.
But for the individual, for me at least, I do not plan to visit a doctor. Except in narrow circumstances (burns, force trauma) even if the practioners are considering my care (in the old-fashioned sense of the word), I don't think I can trust them to actually do the right thing, so fully deputised are they to big pharma. I have far more faith in my ability to resolve a problem myself or in alternative health practioners. The same applies to vets, to a lesser extent.
I've worked in car sales for over a decade. I've always hated the service departments for their totally militant focus on extracting as much money as possible from customers, with any concept of value or honest recommendations be damned.
The last few times I've stepped into several vet offices, I get the exact same sense of money extraction and even see many of the same methods/training/tools/tactics.
In the USA since 1960, healthcare has gone from 5% of GDP to nearly 20% of GDP, something I would consider a crisis. If you think of the enormous amount of money that’s being spent, and then ask if we’re really living better or longer lives, I would disagree.
Some might argue that the average lifespan has gone up a 8-10 years, but take out infant mortality, account for improvements in vehicular safety, the fact that most people no longer smoke cigarettes, and improvements in workplace, food and drug safety, and what are you actually left with?
I would say most dollars in healthcare are selfishly spent squeezing a year or two of extra time in the twilight of most peoples’ lives, while destroying our society in the process.
> Some might argue that the average lifespan has gone up a 8-10 years
I don't think anyone would argue that's what we're getting for the quadrupling in cost, because nobody else spends half as much as we do and they all live longer than we do. Cubans, Panamanians, Albanians, and the Lebanese have longer life expectancies.
In the UK healthcare costs about half as much (and you the consumer don't pay any of that out-of-pocket), and the average life expectancy is about three years longer here.
When doing these kind of comparisons, I feel we should separate out deaths from "excess" (drugs / alcohol / cigarettes) - or at least control for differing levels of use in the various countries. I suspect differing incidence of young people dying of drug overdoses makes a big difference to average lifespan, but it seems to me that's more reflective of a society's regulatory and legal environment than a reflection of healthcare
In 1960 if you had a heart attack and collapsed in a mall things weren't going to go well. Today you'll get CPR from a bystander, an AED shock from an EMT, stenting in an interventional radiology lab, and statins to reduce cardiac risk. All of this adds cost but can add a few decades of life.
Not if you're having a heart attack. That's a mechanical problem - your heart is gunked up with fatty crud and cannot pump blood. The symptoms are chest pain, sudden weakness, and shortness of breath. *Usually* you don't just drop to the floor clutching your chest.
You're thinking of a cardiac arrest, which is an electrical problem - your heart is not getting the right pulses to generate the right muscle contractions to pump. An AED will absolutely help here and you should not wait to start using it. Just grab the AED that's right there and open the lid, switch it on, and wait for it to start telling you what to do.
It's very unlikely it could ever shock a patient who wasn't actually having a cardiac arrest because they detect the heart's electrical signals and look for a "shockable rhythm". If the rhythm looks normal, or looks like one that won't be improved by a quick zap, it won't do it. Even so, never stick the pads on someone who isn't actually in cardiac arrest because if it gets it wrong it probably *would* drop them into cardiac arrest.
Pretty much every public space has a defib now. Often they're in a box with a locked door which you can get the code for from the emergency services operator. You're going to need to ring for an ambulance anyway so this doesn't waste time.
The main thing though is just start CPR and get someone to call an ambulance. You might just save someone's life with that, maybe even today.
"Even so, never stick the pads on someone who isn't actually in cardiac arrest because if it gets it wrong it probably would drop them into cardiac arrest."
MD here, I strongly disagree - the AED is designed for use by minimally trained people. And the chances of a shock being wrongly administered is many times lower than the chance of saving a life if they are in a shockable rhythm.
I think it's really hard to definitively diagnose cardiac arrest in the first few seconds to minutes, even for some medical personnel - even if you have no cardiac output, a person often still has some residual apparent breathing ("agonal breathing") which often leads people to delay CPR, and delay applying the AED/monitor+defibrillator.
Perhaps we can agree there is no point placing it on patients who can talk to you? :) But if as an untrained person you applied it to every person who lost consciousness in front of you, you would do a lot more good than harm, with almost zero absolute risk of harm.
> Perhaps we can agree there is no point placing it on patients who can talk to you?
Yes, that's kind of what I was getting at.
Or to put it another way "don't fuck about with the AED because it's not a toy and its safety systems are not infallible". If you stick it on someone unresponsive - and you've got enough reason to suspect they're in a shockable state - it probably won't make them any worse.
Like my old trauma instructor used to say, "You can't make dead any deader!"
Heart attack (myocardial infarction) leads to cardiac arrest all the time. That's how people die from heart attacks.
If someone has a myocardial infarction and then goes into cardiac arrest with a shockable rhythm, shocking is absolutely the appropriate thing to do. (But it is only a temporizing measure - if the person does not get treatment for the underlying myocardial infarction, they will simply go into cardiac arrest again.)
>All of this adds cost but can add a few decades of life.
The cruel irony, though, is that you now have several decades in which to potentially come down with cancer, Alzheimer's, or other illnesses associated with old age that are even more costly to treat.
If you collapsed in a mall in the 1960 your chance of having died on the spot from a preventable cause were much higher (like smoking, or a non-diagnosed heart problem)
Today, that chance is also smaller. Defibrillators help but not in all cases.
> I would say most dollars in healthcare are selfishly spent squeezing a year or two of extra time in the twilight of most peoples’ lives, while destroying our society in the process.
The vast majority of spend is on chronic disease patients in the 50–85 age range.
I think this is a bit of a fallacy (the decision to let people die). Do we know that all this money and processes (as described in the article) has led to better outcomes? Has the impact of the current methodology been objectively evaluated after excluding all other variables?
And months that often aren't a great quality of life and are questionably in the patients' interest.
It made a huge impression on me as a kid when my greataunt, a physician, decided that she didn't want to be treated for her leukemia diagnosis. She died within a month (I assume it was late-stage).
(IIRC, better end-of-life counseling is what the Obamacare "death panels" kerfuffle was in reference to)
It is an American problem, we must do something. Which leads to antibiotics being over prescribed because parents don’t want to leave the doctors office without something to do afterwards. Life is worth living well, but it’s also worth accepting the end, something to which many people are openly hostile.
Which leads to antibiotics being over prescribed because parents don’t want to leave the doctors office without something to do afterwards.
You're not wrong, but sometimes this is purely preemptive and might still be a sound decision. For example, influenza almost never directly kills anyone--the monster flu in 1918 is an exception--whereas secondary bacterial infections (leading to pneumonia) can and do. Antibiotics are often prescribed as an extra precaution; given the atrocious financial resources of most Americans, most doctors know that they only get one shot with most patients, because they can't afford the copays or get the time off work, and that if they under-prescribe and are read to have missed something, they'll face malpractice suits from the desperate. So, they err on the side of immediate caution, since antibiotic resistance is one of those diffuse long-term problems.
Life is worth living well, but it’s also worth accepting the end, something to which many people are openly hostile.
Part of the problem is that capitalism creates a collapse of trust from which there is no recovery. Is the hospital denying or rationing care based on sound medical reasoning (i.e., that the requested procedures won't work, and will divert resources away from people who need them) or because they don't think the patient will be able to pay? Is the doctor performing a surgery because it will improve the patient's quality of life, or because he needs to generate fees? I'm sure most doctors are ethical and try to make the best decisions for the patients--I imagine, at least 90 percent of them do--but, as soon as the profit motive gets involved, distrust becomes endemic and personally mandatory.
Medicine is, to put it bluntly and factually, too important to trust to the profit motive and capitalism.
Are you sure it was "capitalism" that led to the "collapse of trust"? Did Soviet citizens trust the local healthcare system when the quality of care you received depended on your party rank?
From a Wikipedia article on the Soviet healthcare system[1]
"Many medical treatments and diagnoses were unsophisticated and substandard (with doctors often making diagnoses by interviewing patients without conducting any medical tests), the standard of care provided by healthcare providers was poor, and there was a high risk of infection from surgery. The Soviet healthcare system was plagued by shortages of medical equipment, drugs, and diagnostic chemicals, and lacked many medications and medical technologies available in the Western world. Its facilities had low technical standards, and medical personnel underwent mediocre training. Soviet hospitals also offered poor hotel amenities such as food and linen. Special hospitals and clinics existed for the nomenklatura which offered a higher standard of care, but one still often below Western standards"
I think the problem more generally is that of adverse incentives, whether in "capitalist" or "socialist" systems. I worked in the UK National Health Service which is "free at the point of use" which often results in rationing via waiting list. In my experience, many patients believe that their GP is inappropriately limiting their treatment to save money, particularly with respect to limiting testing, which is unsurprising because "gatekeeping" is often an explicit responsibility for general practitioners in the NHS [2][3]
Everything you're saying about the Soviet health system is true of capitalism's health system now. The difference is that, in the US, we go into debt for our mediocre care.
The main reason for the discrepancy in care quality during the midcentury is... drumroll please... that the Soviet Union was poor, due to initial conditions. It encompassed countries that had long been impoverished. The US had a middle class to build on; the USSR did not. It built a middle class where none had ever existed. Not to mention, the US was in the historically rare situation of winning a war (since, in economic and humanitarian terms, wars are negative-sum and most often only have losers). The USSR, on the other hand, consisted of nations that had taken a beating in World War II.
If you compare Kyrgyzstan to Alabama, the Soviet Union looks bad, but that's not really a fair comparison. Capitalism, as a sea empire, could dominate people from afar and keep them in nominally separate nations while exacting tribute; the Soviet system, as a land empire, could not. It had to integrate them. That's a harder problem. If you make a fairer comparison--say, if you compare Kyrgyzstan to Honduras or Haiti, the picture lines up a lot better. I imagine the quality of healthcare in the poorest countries under capitalism's thumb is even worse than it was in the poorest SSRs as of 1989.
This isn't to say the USSR was great. It was an authoritarian regime, and it launched some really ugly wars (such as the one in Afghanistan). It remained poor (relative to the West) throughout its lifespan because, ultimately, there is no magical economic system that guarantees 12% annual GDP growth--doesn't exist, never has. Socialism solves one set of problems--and a big set of very ugly problems--that capitalism lets fester, but does it automatically bring about utopia? No, not even close. On the other hand, socialism iterates toward a better standard of living for the common people; capitalism, unless heavily checked (as it was in the Cold War) iterates toward a worsening standard of living. So, on that dimension alone, capitalism loses. Everything said above about shortages and nosocomial infections and substandard care applies to capitalism's medical system today.
Medicare is what pays for that btw. Dialysis is covered, as is any life saving treatment (like heart attack).
What ends up happening is hospitals then charge others to cover their costs (hence high rates). Granted hospitals do take a bigger cut imo than they deserve, as do pharma, doctors, etc.
Let’s not forget the number of doctors is intentionally restricted. They also seem to have a political bias imo (how much volunteer work and what kind you’ve done).
Then you have regulations around drugs (FDA), hospitals / practice insurance, etc
Combined, the entire industry is over regulated and captured effectively by cartels (what is Johnson and Johnson but a legal cartel). You can’t even sue for vaccine (any vaccine) injury. Think about that for a moment and explain it.
Fixing the medical industry can only be done by deregulating it. I don’t think it would even be that hard; but people would lose their minds. I’ve spent a lot of time in one of the largest medical billing companies in the US. My family worked in this space for decades. The issue is really just fear.
Regulatory / legislative changes:
1. Remove any protections pharma has against lawsuits
2. Remove bloated credentialing for doctors, instead have an apprenticeship program (at least for military and gov doctors)
3. phase out Medicare, no one under 60 will ever receive it again.
4. Completely defund the FDA
5. Remove much of the requirements around drugs. Enable easy purchasing of medication. Could just be consultation with pharmacist. Or maybe nurse. Or no one.
Do that and overnight the cost of medicine would drop massively. The medical costs in the US would be less than Mexico.
A much simpler first step that I think would be really helpful is:
1) Prevent any group discounts or employer discounts for health insurance
2) Possibly, to go even farther, ban health insurance as employee compensation
Benefits:
1) People see the actual cost of their health insurance
2) People can choose insurance on a competitive market instead of picking between 3 packages their employer subsidizes, so insurance companies actually have to be competitive
3) People aren't forced to pick a difference insurance company every time their employer renegotiates with a different provider, which can also change their healthcare network
4) Lower barrier to leave or change jobs since you can keep paying the same known amount for health insurance and receive the same service
5) Lower barrier to self-employment since you are no longer at a disadvantage for health care costs
> 2) People can choose insurance on a competitive market instead of picking between 3 packages their employer subsidizes, so insurance companies actually have to be competitive
You're only solving half the problem. The other half of the problem is that you'll still have no idea as to what you'll be getting for the money you pay your insurer.
I don't really care about whether the copay for a doctor's visit is $10 or $20, what I care about is whether or not I'll get a surprise bill for $15,000 for a medical procedure. And I can't predict which insurer it's more likely to happen with.
When you're buying a pig in a poke, knowing how much you'll pay for it isn't of much use.
Sure, but you also can’t guarantee that without insurance either.
Are you going to ask the ambulance to take you to a different hospital when the first one gives you their rate schedule for heart attack interventions?
I haven't used it and don't know how good it actually is, but I have browsed for insurance on the Healthcare Marketplace (aka Obamacare) and they set out some pretty strict levels of coverage, services, deductibles, etc. in a standardized way.
But most people don't participate in that market because it would be silly to when your employer gives you a group buy rate plus an extra employer-paid subsidy to incentivize you to be part of the group buy.
For 2) it is much simpler to say something like "employer pays half of the monthly rate up to $X", while you freely pick which insurance. That is how it works in Germany by the way.
Concerning the competition I would caution that from my experience some American insurances lack standards. For example insane copay, cancer not covered or other crazy exceptions. So to have actual competition you should also require by law that all essentials have to be covered with a limited copay and not discriminate. The insurances can still compete on non-essentials (e.g. fitness, cheaper checkups). Otherwise you run into the issue that poor people are forced to buy scam insurance.
You’re still just adding more regulation. More complexity and spaghetti laws aren’t going to solve things. Pre 1970s healthcare costs were in-line with the rest of the world. Revert the push to corporatize and socialize and we’d have cheaper care.
The fact employers pay for healthcare isn’t an issue. Who cares? It’s just part of compensation. I can take my money and do the same thing. No one will btw, they’d just buy cheaper insurance and have a higher out of pocket expense.
End-of-the-day Medicare and regulatory capture is the issue. I can’t go to my local store and get antibiotics, even if I have a test showing strep. Instead, I have to go to a doctors office. A doctor who is intentionally being made scarce (ie driving up demand). Then I get my antibiotics, but they request a follow up.
No amount of insurance wizardry will fix that scenario. You have to deregulate to fix it.
i do think, Insurance companies will insist you follow their rules to cut their costs. Making healthcare worse for you. Even if you were to deregulate, insurance will still be able to apply pressure. IMO ban insurance outright for medical related items. You have a right to medical privacy and the idea insurance is required is BS.
It will cost more than the package negotiated by your employer since you are out of the group-rate.
Which means it isn’t actually a free market choice with competition.
Applying free market choice to the healthcare itself sounds great but it’s difficult to make such choices when unconscious in the back of an ambulance, or after a drug company or doctor causes you permanent injury or death.
Step 1 should be “every health plan is a high deductible health plan.”
Step 2 should be “Absolute price transparency.”
We need to make patients cost-sensitive. It’s utterly ridiculous that there’s a pill to treat low testosterone that’s $1,000 a month when a weekly injection costs $20 a month. Sure, taking a pill is easier and less painful. 99.9% of people would still choose the needle if they actually had to pay for it - and that would mean the manufacturer of the pills would have to lower the cost.
The same thing goes for many other medications and treatments. Why bother trying to price out that MRI if you’re hitting your deductible either way? Not like they’d tell you the cost up front anyways.
Switching everyone to a high-deductible would be disastrous for people with expensive chronic conditions like diabetes. It would force people to forgo treatment or select suboptimal treatment even in the absence of chronic conditions, leading to complications that require further treatment down the line. Not a fan of this idea.
Er, "best case" you end up creating a better version of the thing. We are on HN where you always see "Rewrite from scratch in rust, go,..." or "Version 3.0 drops backward compatibility and greatly improves ....".
After multiple decades large agencies probably need big reforms. If you can implement these within the agency, great. If not, splitting off some of the work to a new agency with these changes is a practical option.
You cannot simply reenact the same policies in a different organization and not get the same problems. Politically, you have to start over on many established political policies. While there would be an opportunity to split the org chart, then introduce new shortcuts and workarounds to the previous implementation, you just restart the same divisive issues with new contexts.
This approach makes no sense to start on. You want an overhaul of FDA policies, then advocate for that unless you have some plan other than throw everything away and let someone else deal with the practicalities.
Things used to get overhauled more regularly. The last however was probably 20 years ago with the creation of the Department of Homeland Security. Since then, crickets.
Phase out medicare? How will poor people afford any kind of care? No matter how efficiently you do things, it's still going to be somewhat expensive to provide modern standards of care. And the poorest people get a lot of injuries, germs, and pollutants.
It's not fear, it's money. All of those unnecessary things are huge profit centers for certain people. Health care is middle-manned to death, and not just insurance. There are loads of other middle men at every step.
I mean fear of deregulation. The truth is that we push politicians to do what we want.
As it stands, people are afraid to completely deregulate healthcare.
Funny enough, even though imo it is the only way. I do think money would stop it from becoming a movement. When’s the last time you saw a leader stand up and say “let’s dissolve XXX three letter agency!”? You don’t see it. Wonder why?
Last one I recall was Trump. Media did a number on him, so much so we can’t even discuss him without worrying about being attacked. Isn’t that something?
It varies. But often it is less regulated or more efficient. There will be 10 suppliers of a generic medication rather than 2 or 3. 8 years for college and med school won't literally include 2 to 3 years of vacation. And so on.
Overhead itself might not be the problem. But it is process it leads to. One way I could see is to mandate one single list price. No discounts. If hospital wants to do charity they can setup fund that pays the bill or part of it back to itself.
I think it's not that everyone is chasing their extra 1.5 years at the end. People always did that as much as they could.
A massive portion of healthcare spending (50%) goes to a tiny percentage of the population (<2%). We've grown that population and increased our spending on them in various ways. Back in the day, many issues would not have arisen because the way people lived prevented them, or they would have not been acknowledged as matters for healthcare at all.
- Many kinds of drug addiction basically didn't exist, due to lower availability and a very different social environment.
- Diseases of affluence like obesity and its endless related problems.
- People would deal with their mental health issues on their own, or with their family.
- Many things back then didn't have treatments, which now do have treatments - often expensive ones.
Life was both harsher on individuals and less corrupted by illnesses that come from technology, affluence, and worldly connections. People's every mental and physical issue wasn't held up as a thing for sociotechnological treatment, and they were left on their own, but this also made people have more inner strength and not fall into a pit of helpless victim mentality.
We've gained a tremendous wealth surplus since then, and it seems to be a law of societies that industrial surplus mostly gets consumed by concurrent bio-social deterioration. We coddle and support people who would have been told to deal with their own issues, or just laughed out of the doctor's office back then. For better or worse.
Society is also lower in trust and less homogenous. Because of concerns about discrimination, decisions that would have been made cheaply and informally on the spot now have to be formalized and done through rubrics which give suboptimal answers because they lack human judgment and also consume more resources. Society is way more litigious and doctors have to spend a lot more time and effort covering their asses from lawsuits and accusations of all kinds.
It's a complex issue with a lot of causes.
I suspect Scott Alexander has some good writings on this.
Imo all western countries are within the margin of error. The real truth is that the US subsidizes the medical fields of Europe.
The US provides protection; which means the EU doesn’t have to pay for military and they dedicated funds to healthcare. Further, all the drug revenue for R&D recovery comes from the US market.
With the countries of Europe gearing up for war. I’m curious if they’ll keep paying for the medical treatments of everyone.
That makes no sense. The point is that those countries spend way less money for better outcomes and your "rebutal" is that they have more money to spend? And pharmaceutical companies just charge less in these countries because of the kindness on their hearts? Eventhough they supposedly could charge much more than the US because Europeans have money left over?
They charge less because those countries would simply go “no, we’re not going to offer that drug for that price” if the manufacturers ask for too much.
If insurers did that here people would be upset, and with their revenue tied to how much they pay out they don’t have much of a reason to.
All that leads to them making up the difference in the US market.
If by "back in the day" you mean the half-century following WWII, the USA had it uncommonly good: dirt-cheap post-secondary education, increasing upward mobility for everyone, low cost of living relative to income, and pensions. That's 3 of the 5 Social Determinants of Health, arguably better on average throughout the 1950s-1990s than post-2008.
To the extent there is a wealth surplus now, it hasn't reached most people. Some of our current situation (including what you call diseases of affluence) feels linked to increasingly insecure prospects of housing, income, and retirement for the people who our increasingly labor-automated economy is leaving behind.
Overregulation has done more to shift the focus of healthcare from actually providing healthcare to instead feeding the bureaucracy.
I switched to a health savings account and regularly negotiate paying for things with cash instead of going through insurance and the cost difference is mind blowing - routinely 1/3 to 1/5 the amount if you force your doctors to go through insurance.
I saw the same doctor between the ages of 11 and 27. He owned his own practice in California.
The experience at the modern healthcare network is just not the same.
I understand the need for hospitals to go the corporatized route, but I think corporatization of family practice has significantly degraded the experience for patient and doctor
In addition to the regulations, there is also corporatism in sometimes unexpected places.
During COVID in France, there was an idea for vets to provide shots of the virus, especially in places where we do not have a lot of doctors.
This sounded reasonable to me, but apparently not to everyone as they were allowed to provide the shots only in vaccine centers. That were lacking exactly in the paces where they had their office.
Speaking from a US perspective: I'll just add onto the point about EHR/EMRs being generally pretty bad. It's like medical IT is about 20 years behind in terms of tech, so I'm not surprised to see that it's contributing to an overall inefficiency in the medical space. On one hand, you have Epic's EMR, which is easily the best in the industry, and reasonably feature-rich and appears appreciated by doctors in my experience. On the other hand, you have almost everyone else, down to utter dogshit like eClinicalWorks (apologies if any employees frequent this forum unless you work in UI/UX, in which case kindly consider a career change), which essentially exists to allow less well-funded operations to meet regulatory requirements (despite the fact that they're literally being sued for failing to meet this bare minimum [^1]).
I'll just quickly add on that if you want to write software to connect your EMR/EHR you're in for a bit of a pain to say the least. There's essentially a whole middleman industry for various data solutions like APIs or on-prem SQL databases[^2] that somehow managed to get vendor status with one or several EMR companies or managed to find the obscure way of actually accessing the hospitals' own data. I'll note here too that 1. sometimes the data is stored on site, so you should be able to read it off your own server, but I imagine a decent number of places treat it as SaaS which makes the task more difficult and 2. that I think EHRs should follow the FHIR spec but whether you can openly communicate with the software along this is another problem. I haven't tried to work with Epic, so maybe they're kinder.
I know this isn't really the point of the article, but the tech infrastructure around medicine really is shockingly poor. There's a lot of problems with inconvenience (handwriting really is often _that_ much faster than typing stuff into software especially when the software is so un-ergonomic), double-entry (since a lot of operations weren't designed with technology in mind), and lack of inter-operability. Combine this with outdated software infrastructures (I've seen Drs still use windows 7 on hospital laptops since that's the only thing their sw runs on, I've also seen a weird OS that looks like a 98 clone with less features and far slower on modern hardware), annoying problems like shitty WiFi in hospitals, really high stakes since it's patient data, and regulatory pressure - you end up with a system with little new competition, which means no innovations except in extorting hospitals.
Apologies for a long rant, but there really is a need for talented developers to work on these sorts of problems, because the current situation is like being forced to either have mountains of paper charts (I visited a small clinic that does exactly 1 operation and they had an entire basement filled with shelves of charts) or use some terrible software and likely have your data locked into it.
[^2]: Admittedly it's not always clear _what_ they're selling. One rather dubiously named "datasheet" lists "designed to be flexible to support definition changes in an AGILE fashion rather than via a prolonged software development and release cycle" as a feature despite the product being just a MS SQL server with data cloned from the EHR
b) I personally dislike blame-culture but I think that's already more debatable (you could reframe it as assigning responsibility, aggressively)
c) I want the higher chance of successful therapy, as I am sure most of us do. So if you claim we are off path and "folklore and word-of-mouth" gets us back AND you can prove that, fine. Otherwise spare me the nostalgia and anecdotal data. I wanna live.
I don't just want to live, I want to understand why many things still seem to operate so irrationally in terms of cost. vs. value received.
I actually appreciated the unique perspective, and the experience, and don't care that it is not statistically validated, since the point is to stimulate thinking.
It suggests a few aspects to look into - an overly litigious society, crappy systems, an insulation of patients and doctors from the costs of treatments by insurance intermediatories etc...
Private Equity is acquiring and combining small practice veterinarians and pet insurance is becoming more common. Soon vet care may feel much more like human care.
That’s exactly what I was thinking and I thought it was where the post was going to go. The writer’s grandfather and mother would have seen how it happened in human medicine, I bet very direct comparisons could be drawn to the current state of veterinary medicine by the author.
The fact that private equity firms aren't being bombed for the shit they're pulling now--i.e., the way they're moving into the housing market--is an embarrassment to us as a people.
When they were playing abstract numbers games, it was easy and well enough to ignore them; now that they're getting involved in things that affect human life, it's time to take action.
That said, I don't think pet insurance itself is a bad thing... no one should have to give up on their pet because of bullshit money concerns... but I think insurance should be universal... and we should solve human health insurance first.
As much as I love my pets and am willing to spend beaucoup bucks on their health care, I'm not sure I ever see free universal veterinary care being a thing. Too many people human problems will always be there for people to be comfortable using taxes to fund Fido's chemo.
> Many of the conditions that vets see don’t have specific drugs associated with them (or even high quality studies), so vets often have to get creative.
> If I want to market to doctors, I’m best served by having high-profile researchers in that specific indication and high profile studies. Ideally, I’d also get a change to the treatment protocols, too. If I want to market to vets, I’m best served by having well-known speakers (who don’t necessarily specialize in that indication) and well-run (not high-profile) studies.
> There's something sad about what American physicians have become.
Yes, we have an expectation today that medical procedures be backed by scientific evidence of efficacy. It's not like the "good ol' days" where doctors had carte blanche to do whatever they want. If you want to market a product without scientific evidence that it works, go ahead, just don't do it when people's lives are on the line.
The problem with that perspective is that it essentially dooms every "life on the line" with a condition which can not be established with "scientific evidence"
For a simple example, the multitude of young lives lost to cancer because "scientific evidence" does not support screening before age 50. That perspective seeks to minimize and mischaracterize early warning symptoms because of public health probabilities.
Are you implying that more active screening would cause more good than harm, and that the scientific evidence that shows otherwise is mistaken? What makes you think the evidence is wrong?
Or do you simply not support using scientific evidence and/or harm reduction to guide medical policy? What do you propose should be used instead in that case?
There is no problem with screening literally all the time, provided that the goal of screening isn't to immediately trigger a response from a single sample, but rather just to gather time-series sample points which can later be fed into predictive models to trigger alerting. (Where those "predictive models" can just be, y'know, your GP's eyes at your yearly checkup, as they flip through a series of your CT scans as a little flip-book.)
> There is no problem with screening literally all the time,
I have no opinion on the matter but this is disputed for some screening methods, which supposedly can increase the the risk with statistical significance. I don't believe that they ever nailed down the cause though, but I'm not a medical professional so I am not really well read on the topic.
Yes, but that's not a problem with screening as a concept, that's a problem with those screening methods. We accept "destructive testing" in medical screening (e.g. biopsies; x-ray fluroscopy with both radiation and carcinogenic chemical tracers; etc.) because we haven't structured medical screening in such a way as to incentivize investment into "non-destructive testing."
The medical establishment doesn't care about the potential for harm from repeated use of methods on patients†, precisely because we think of them as things that only need to be done rarely. There's been no need to optimize for "low cumulative impact" in screening methods, because there's currently no incentive to do screening often enough for it to matter.
Let me put it this way: the state of the art in MRI technology (reducing required size + cost per machine to enable more frequent + "trivial" use) is being pushed forward economically almost entirely by demand from Operations Research in the aerospace industry, rather than by demand from hospitals wanting to have more MRI-machine capacity per patient. That's ridiculous.
† The freshest example of this on my own mind isn't diagnostic per se. Have you ever noticed that dentists don't tell you to close your eyes — nor give you UV-blocking wraparound goggles — despite shining a UV light directly at your face for 30 seconds at a time to harden UV bonding resin they've used? They know it'll hurt their eyes if they stare at it all day — which is why the UV lights they use have circles of UV-blocking backscatter guards, to allow them to look at your face without reflected UV light hitting their eyes. But there's no concern for what they're doing to you, because you're only getting a few cumulative minutes of concentrated dental UV per year, vs. their cumulative hours of exposure.
A cost-benefit analysis can have different answers when applied to an individual vs. a population. That something is rare isn’t much comfort when you’re the one in a million rarity.
I think the point is that not all cases are cut and dry. There are many for which evidence is inconclusive; and for those having a blanket regulation is worse than letting the patient and the doctor select a choice that the patient prefers.
Then they chose a poor example to illustrate their point, since anyone is free to book a cancer screening even if they are younger than the recommended age, if they so prefer.
You can try and book anything you like, but the doctor/technologist is under no obligation to actually run the screening test for you, and if they do there is not requirement that your insurance pay for it. So you can have a full body MRI reference done, but it will cost many k$ out of pocket, if you can get someone to do it for you.
Your video seems good and I don't know if he is an authority but his description he makes clear that he is not an authority.. but it's about asymptomatic screening, while my point was about continuous symptom minimization and mischaracterization.
There are also some obvious mistakes in his overessentialization of the statistics, which imply that early detection never results in a nonfatal prognosis.
This analysis assumes there is no harm from false positives in screening tests. This is obviously false even if the only side effects are cost and stress induced by say a false cancer diagnosis.
> "scientific evidence" does not support screening before age 50
There is a difference between science has no idea and science suggests it would be harmful (in aggregate). My understanding is that cancer screening is more the latter not the former.
> Yes, we have an expectation today that medical procedures be backed by scientific evidence of efficacy.
Statistical evidence of efficacy, you mean. Doctors today are much less "scientific", insofar as they're less willing to work with a patient to try to experimentally derive an intervention that will work uniquely well for that patient. Instead, modern doctors try to fit the patient into a coarse-grained statistical mold, and then apply the flowcharts of rote treatments that are "proven" to work for people who were labelled as fitting that mold according to some arm of a trial. They persist in this, even when it can be seen that the individual patient isn't responding.
A doctor who's actually practicing medicine as science would, for example, run a patient up the current DSMV flowchart for treatment of depression, rather than down it — first determining, as the most important step, whether the most hard-line treatment will do anything at all for the patient; before then finding the weakest treatment that will still have a useful effect.
Also, a doctor practicing medicine as science would be doing a lot less "try this because it has no side-effects, regardless of whether you're likely to be a responder to it", and a lot more measurement to "cleave the problem-space at the joints."
(Yes, ER doctors can't afford time to measure. Most doctors are not ER doctors.)
I'm glad somebody is making the distinction between scientific experimentalism and executing a protocol based on scientific research.
I've worked in medicine as an experimental phycisist (radiology, imaging), and I found so-called evidence based medicine anything but. Evidence based is used to cement existing methods over new ones into protocols that are very, very slow to evolve.
A doctor who follows those course grained recommendations derived from statistical evidence will provide the best outcomes to the most patients in aggregate.
A doctor who tries to uniquely discover the best outcome for each individual as they come through, may provide the best outcome for any given individual. But overall the deviation from the statistically recommended procedure will lead to worse outcomes in aggregate. It has to, because if it lead to better outcomes, the doctors 'personalized' process should become the statistically validated process with time.
When initially presented with the trolley problem, most people side with the saving the group over the individual. It's funny how quickly their minds change when they realise that in a healthcare context, they are never the group, they are always the individual.
Measurement in medicine is also in many cases not particularly quantitative. E.g., fatigue, pain, cognitive dysfunction etc. So taking more measurements doesn't necessarily give you any useful information.
In fact, near as I can tell. In the US, there is so much fear from doctors of misdiagnosing and starting patients on the wrong treatment plan, that they order too many measurements. Overall reducing the quality of care. The time needed to take measurements, as well as the risks of measurements are not negligible factors in healthcare outcomes.
> But overall the deviation from the statistically recommended procedure will lead to worse outcomes in aggregate. It has to, because if it lead to better outcomes, the doctors 'personalized' process should become the statistically validated process with time.
Yes, but not for the reasons you're implying.
Following the impersonal process leads to better outcomes in aggregate because it's less labor-intensive; and so doctors end up seeing more patients; and so more patients end up being seen.
But "number of doctors per patient" is only a bottleneck because we make it one, with medieval-guild-like limited-acceptance-per-year medical-bar licensing.
(And the medical bar does what it does, IIRC, because doctors really like being paid as much as they are; and having a more efficient market for doctors would mean doctors would be paid less. Even if it'd also mean that e.g. hospital doctors could work 8-hour shifts rather than 24-hour shifts.)
There's also the fact that flowchart-based diagnosis is liability-minimizing from a medical-malpractice-insurance perspective. With the flowchart, a hospital being sued can always use the defense that the doctor took the lowest-risk, best-practice next step they possibly could at each juncture. (Mind you, it's the best practice because it's the lowest-liability-risk — not for any other reason.)
> Measurement in medicine is also in many cases not particularly quantitative. E.g., fatigue, pain, cognitive dysfunction etc. So taking more measurements doesn't necessarily give you any useful information.
You only need quantitative instruments if your goal is to aggregate data to achieve statistical significance. An individual patient can be evaluated perfectly well ("clinical significance") with qualitative instruments. There are tons of objective-yet-qualitative instruments — e.g. observation of signs (rather than symptoms) of a syndrome, where there's no clear weightings to give to any given sign, but where one can always track each sign "dimension" of the syndrome separately, and then observe whether a given intervention improves outcomes along the "dimensions" you're tracking.
Following the impersonal process leads to better outcomes in aggregate because it's less labor-intensive; and so doctors end up seeing more patients; and so more patients end up being seen.
If the personalized process performs better on medical outcomes. Then over time doctors should be pushed to include more personalized steps in their treatment plans. I actually think that in many cases, personalized steps are already included in treatment plans that contain many branching paths.
It's also quantitatively true that in some cases (I believe most cases, but I don't have a good data set in front of me), a well validated flowchart leads to much better diagnoses and healthcare outcomes.
A good example: When a standardized checklist for the diagnosis of a heart attack was first introduced, doctors were upset about it, claiming that it took away professional judgement from clinical assessments.
Over time though, the checklist proved itself to be much more effective at diagnosing heart attacks than the vast majority of doctors. And most people who were having a heart attack were diagnosed correctly.
Of course some people will still be misdiagnosed (and unfortunately the misdiagnosed ones often fall into minority groups). But the statistically validated processes are not aiming for perfect. They're aiming for better than a human can do, most of the time.
And research will improve the flowcharts over time.
It also means that we can begin to think about delegating routine assessments where outcomes are very well understood to nurses, leaving doctors free to think about more complicated cases.
My understanding is the price variability in dentistry is much less then for various other medical procedures. I have been told it because much of dental work is non inssured but I am just relying what I have heard.
That's not responsive. Nobody is asking what does happen, they're asking why it should happen on this specific issue. I can make you pray in school and call it public health.
> My grandfather, trained in an era before strong FDA regulation of medications, was mostly distrustful of medications.
Technically that Supreme Court ruling on the EPA is going to likely impact the FDA. At least, it’s a sign of where the Supreme Court is at on the issue. All the FDA has congressional authority over is labeling between states. That is to say; the FDA labels a drug as safe and you can advertise for said drug. That’s it.
There is nothing stopping you from ordering and taking almost any drug. At least in a legal sense. Provided it’s not regulated by congress (such as opium and derivatives). It’s why doctors can prescribe “off label” and what not. It’s very common.
There's no way this Supreme Court is going to alter the CSA.
Edit: Thank you Peyton for the additional context. I didn't realize that. I was reacting to "There is nothing stopping you from ordering and taking almost any drug." and I'd be shocked if the Supreme Court altered the interpretation of the CSA in such a way to allow arbitrary people to order controlled substances without a doctors prescription. Even if their state law allowed it.
"On June 27, 2022, the United States Supreme Court ruled that doctors who act in subjective good faith in prescribing controlled substances to their patients cannot be convicted under the Controlled Substance Act (“CSA”). The Court’s decision will have broad implications for physicians and patients alike. Practitioners who sincerely and honestly believe – even if mistakenly – that their prescriptions are within the usual course of professional practice will be shielded from criminal liability.
...
The Court’s decision will protect patient access to prescriptions written in good faith. However, for the government, the Court’s decision means prosecutors face an uphill battle in charging, much less convicting, physicians under the CSA. Indeed, the Court’s decision may have a chilling effect on the recent surge in DOJ prosecutions of medical practitioners and pain clinics. "
This is a ridiculous take. Veterinary medicine is not some capitalist utopia. Most vets are miserable and, unlike doctors, most of them don't even make any money for their suffering.
First of all, a substantial portion of the job is putting animals down, and I'm not talking about 20-year-old dogs with so many health issues that it's a mercy. A portion of the animals are in this case, of course; but a lot of the time, these are animals who'd be fine with proper treatment, and the issue is of owners who either don't care (yuppie shits who can afford the treatment, but who bought the pet for the kids, who are now in college, and see the pet as "just an animal") or who can't afford treatment at all. The idea that veterinary medicine is some capitalist utopia just because the prices are more reasonable (for now) is absurd... because the fact is that we live in what free-market capitalism has reduced (due to runaway wage collapse) to a third-world country, and so most people can't even afford basic services for beloved pets, even at the relatively low service prices of a few hundred dollars instead of a few thousand, because so many Americans don't even have that.
Veterinarians have an astronomically high suicide rate. They are right in the firing line of this shitfucked economic system that should have been overthrown forty years ago when it stopped functioning for the people who do the actual work.
This was not the article I expected. My experience is that vets are like doctors yesterday for a different reason.
I tore my ACL this year. Last year, my dog tore his.
One thing I learned when talking to (UK) doctors about my ACL is that there has been a lot of recent evidence-based medicine about surgical interventions. As a result, surgeons are less gung-ho: it turns out, quite often, surgery just doesn't do much good compared to physio.
By contrast, when I looked at the literature for animal cruciate ligament treatment, it's... oh gosh. I went into depth on this. In 2003 there was an article pointing out that there was almost no scientific evidence for most of the existing treatments. Ten years later, there was a review article which essentially said "oh, now the evidence is much better, we can rest easy". It categorized the research into four categories, the best one being credible randomized controlled trials. So I looked at the top category. The only RCT I found had about 40 animals, with substantial dropout (very likely non-random). There's a lot of natural improvement, and tiny effects from treatment, with significant results for some (out of many!) measured dependent variables.
After reading the top category, I didn't bother with the rest. What a disaster!
Cruciate ligament treatment for dogs is a $1bn industry. But there's just no decent science being done. It's all tests of 8 dogs without a control group, done by some guy pushing his new methodology. Honestly, it's shameful.
By contrast, one of the strengths of the NHS is maybe that it can knock heads together , get large-scale RCTs going, and learn something.
there's actually a lot of evidence that cruciate surgery improves return to function, but you're right- a lot of vets unfortunately recommend surgery for the wrong reasons (unwittingly or not).
Surgery only really makes a difference in moderate to severe tears or those with meniscal injury. There's 4+ different ways to fix a cruciate. Half of them are useless (and evidence shows no difference c.f. conservative treatment) and if a surgeon recommend them I would see it as a red flag.
Interestingly a lot of pet owners could not go to surgery because of the recent COVID lockdowns, and it was found that a lot of those animals healed well with just some rest anyway.
Sorry, that you tore your ACL. This is not cool.
And you are right, modern medicine, especially if you can afford it, provides so much more today: https://www.sciencedaily.com/releases/2020/05/200527181322.h...
The linked article looks like a way to skirt the use of Human Growth Hormone by athletes. Is it doping if it's to cure an ACL injury? Such a grey area...!
medecine is highly emotional, if you give people the choice of doing nothing vs doing something/anything people will, out of shame, do that thing. There has to be a strong cultural, evidence based, or other, justification to do nothing. Probably not the case most of the time, and it's going to stay that way, because as you mentioned, there's a boatload of money to be made out of it and careers depend on it.
Doing something, anything is very much the american school of thought. In Europe, people are often very happy if they can just do nothing. Incidentally, that's also the real reason why US healthcare is so much more expensive.
> if you give people the choice of doing nothing vs doing something/anything people will, out of shame, do that thing.
That’s an awfully broad generalization. Anecdotally I prefer to avoid intervention though I don’t mind going to the doctor in case that would be the wrong choice.
I am the child of a doctor so I wonder if that influenced my attitude.
There is a huge lack of investment into animal research, and what is invested usually goes to profitable animal research like livestock.
> Cruciate ligament treatment for dogs is a $1bn industry
Is that true? $1bn in what sense?
TIL dogs have cruciate ligaments.
The veterinary industry for pets in the US is about 100 billion dollars a year. I think assuming 1% of that is cruciate ligament treatment/surgery is probably a bit too high but it is a pretty common problem for dogs and surgery is a pretty expensive intervention so I am not sure. Its at least 100s of millions though.
I have talked about it on here before, but I genuinely despise the modern experience of going to the doctor. They spend the entire time asking questions from a screen, most of which I answered last time, while staring at the computer. It feels more like an interrogation.
I have also literally had my doctor google my symptoms right then and there, and the “I could have done that” feeling just doesn’t build confidence. Clearly it’s through the filter of his knowledge but still feels wrong.
Going to the doctor in the 90s felt way more personal, way more like they actually cared about you and your health. Sit down and just talk about what was going on face to face.
Like sure, maybe the modern way has better results overall? But it sure feels impersonal and I never leave with any feeling of confidence. I would have to imagine there’s a middle ground with similar if not better results.
I was working for an EHR (electronic health records) software company a few years ago, and we had a presentation by a doctor. He was around 60-70 years old, and he was talking about his experience with our EHR.
He said "before EHR, I would look at the patient while they talked and my hand wrote on a piece of paper. Now, I'm listening to them while typing into a computer. I used to have at least one patient cry a day, now I can't remember when someone last cried."
Doctors know it's feels crap, it feels crap for them too, but they do it because it saves them a bunch of hours and mistakes every single day. We need a better EHR experience, though.
Dude needs a tablet, right?
> I have also literally had my doctor google my symptoms right then and there, and the “I could have done that” feeling just doesn’t build confidence. Clearly it’s through the filter of his knowledge but still feels wrong.
That's an interesting point, because I often google people's computer error messages in front of them, quickly determine the solution, and fix their problem.
I have the same experience as you watching a doctor do that, but from the inside this feels like a straightforward and easy way to get the information I need. I never quite thought about how it must look to someone on the outside.
I’m not convinced a doctor’s knowledge is stronger than my ability to read papers and evaluate statistical evidence for niche cases though.
In my experience, for most general practitioners, it's not!
There are specialists for a reason though. But I've found that YOU need to be able to do the work to get the referral and make the diagnoses.
Interestingly though, I had a family practice MD early on in my medical process that had a hunch, long before I suspected I had what he thought I did. (i.e. before I was able to steer the conversation to heavily emphasize certain symptoms after I'd pretty much figured out what I had and needed some diagnostics to confirm.) He just knew... Alas, the test came back negative, and he got roped into other endeavors before retiring. He was brilliant though, he had a PhD in epidemiology as well as an MD. (He even saw one of the very last smallpox cases in the wild.) Much later on, and several doctors later, we finally got that diagnosis right. For one doctor, I had to walk him through the results of the test before he finally put it together.... pretty unbelieveable, and there's no hope for the average patient in that scenario.
One thing that a lot of people without familiarity in medicine as an industry, the residency match process, etc. don't realize, is that family medicine/GP is the least competitive field. If you don't match into any residency process, you go into a scramble mode to try to get picked up unless you want to wait a year and try again. Those scrambled slots are almost all in family medicine, and largely in toxic training programs or very undesirable areas. There's a decent chance your GP finished toward the bottom of their med school class and/or did poorly on their step exams and/or didn't even want to be a GP anyway.
None of this is to say that they're not smart, or good people, or hard working, any of that. But it's important to know the person sitting across from you very likely didn't dream of sitting in that seat the way a surgeon or ICU doc or neurologist very likely did. It changes the dynamic quite a bit. For general medical issues they likely know more than you. If you have a disease or condition requiring specialty treatment, you likely know more about it than they do within the first year or two of specialist visits.
> you go into a scramble mode to try to get picked up unless you want to wait a year and try again. Those scrambled slots are almost all in family medicine,
There's some errors/gross oversimplification in this post. Most scrambled spots are one year prelims, not family medicine. Of the minority categorical scrambled slots more are actually internal medicine, next is FM (but again this is the minority), then neuro, psych, etc.
Also minor point, if you fail to SOAP ("scramble" is kind of outdated), you can find job openings outside of the match system entirely, so waiting a year is not inevitable.
> and largely in toxic training programs or very undesirable areas.
Actually, most of these programs know this and they target FMGs - they tend to fill most of their spots through the regular match. Meanwhile numerous top academic programs SOAP/scramble their prelim spots.
> very likely didn't dream of sitting in that seat the way a surgeon or ICU doc or neurologist very likely did.
IM, Peds, EM, rads, anesthesia, neurology (not competitive at all), PM&R, psych, even gen surg are all relatively non-competitive. You may be surprised about surgery, but all those surgical subspecialty hopefuls that fail to match - many of them end up in gen surg via a "scramble" to a prelim, some may make it on round 2, but many will not and they will go on to an open categorical gen surg program - ie amongst the relatively "competitive" there is the not competitive that doesn't end up where they want to be.
Meanwhile whether your doctor was bottom of the class/poor academic pedigree has more to do with region. The IM and FMs at the top academic major regional centers will often be AOA/top of class/top programs.
IM/FM is just a hell of a lot more variable - it's also very large.
> If you have a disease or condition requiring specialty treatment.....
I dunno if this really has to do with academic pedigree/the process you're calling out as much as scope of practice. Even amazing GPs, unless they have a particular personal interest in something cannot faux subspecialize in everything.
> They spend the entire time asking questions from a screen, most of which I answered last time, while staring at the computer. It feels more like an interrogation.
It's like dealing with a shitty support script.
Yes! Honestly that’s a much better description of the feeling than my own!
I go to a family doctor in his 70s for this very reason. He isn't in a rush. He (or his nurse) actually looks at the old form responses instead of asking me the same old questions. He cares about me beyond the list of symptoms, and asked about the job I started a year ago at the last visit.
I feel like the move to larger clinics (at least in the US) over old school one physician offices has standardized the process and made it more bureaucratic. But there could be a more human approach if someone actually cared to invest in it. I don't see it happening when larger practices and health systems are optimizing for cost and throughput.
Edit: grammar
"I feel like the move to larger clinics (at least in the US) over old school one physician offices has standardized the process and made it more bureaucratic."
The cause and effect might be backwards here. Many physicians retired or consolidated as regulations increased, and ghe cost of complying with the regulations increased. For example, we saw a lot of this when digitization of files became mandatory.
It is ultimately the influence of Federal Healthcare programs that have pushed small doctors out of business. The cost of regulation is ENOURMOUS. And the following effect is that because the federal government is the largest spender in the sector, private insurance companies tend to follow suit, making the whole thing worse.
I don't have a solution for solving medical billing, but it's a huge racket and it's driving up costs.
So in the end we basically get the worst of both worlds. Sigh.
> But there could be a more human approach if someone actually cared to invest in it.
Most people cannot afford a more human approach.
Yes, you could have googled the symptoms, but do you have the background & experience to evaluate the results?
Anyone can google "how to program", but you wouldn't put those results into production, and yet professional SW engineers do that all the time because they have the background and experience to evaluate the results.
Which country if you dont mind me asking? I know of many similar stories about doctors typing stuff into google and prescribing paracetamol from the UK, Spain or Germany - but it's hard to imagine such a situation in central europe.
United States.
It seems much of medicine today is about following the established protocols so you don't get sued. Reading checklists off the screen fits this well.
I honestly can't wait for AI doctors.
There’s an opportunity here in the less regulated pet health space: flip the pipeline around and treat it like a staging environment for human healthcare, rather than a place to expand treatments later to extend ROI.
One example: glucose monitors for pets lag a generation or two behind glucose monitors for humans. Releasing a human glucose monitor requires lots of testing and certification. Starting in the pet space and then expanding into humans would allow you to iterate faster than your human health care first competitors.
There are definitely companies and investors thinking/working in this space. They think if you can demonstrate an ability solve X in “staging” it has a chance to transfer to “prod”. It works better for some things (generally, simpler/smaller and deterministic things) than others.
Practically speaking, the human health space is heavily regulated, and the costs associated with compliance are high. Intuitively, to me, there are not many health-specific innovations that one can discover in pet care that will lead to reduced costs in human care. Because most costs are not technologically-induced, rather they’re regulatory or bureaucratic.
You can iterate towards a better mouse trap in pet-land, but the time and financial costs of getting that mouse trap FDA-approved do not magically go away, and unfortunately human care is not a very free market, so being a 10x better mousetrap is not enough to break through.
The human healthcare market is also stupidly bigger than the pet care space, like 100x depending on what you include in each category. So if you’re after the big bucks, which most investors / investees are, it’s still generally worth it to target humans first.
That being said, some are seeing pets as an angle because human stuff is proving so hard and slow-going, they’re willing to experiment with any potential shortcuts.
Worked in human health and pet health.
Human healthcare has 3rd parties subsidizing the bills. This makes consumers price immune. Plus most surgeons can't tell you accurately how much the total bill with be because insurers pay different rates for same procedure.
Vets are mostly out of pocket payments.
One thing I've been wondering about recently is SENS for pets. Lab rats can already be given extreme longevity, but I suspect there are plenty of dog owners who would pay a lot for double or treble life expectancy for their pets, especially as the lab rat with that treatment (reportedly) spent their years close to the peak of fitness.
There’s at least one company I knows of whose long term target is human life extension, and they’re bootstrapping with pets [1].
Personally I’m bearish on the whole notion of life extension writ large so I don’t know much about them, but it does exist!
[1]: https://www.lifespan.io/news/new-harvard-startup-wants-to-re...
Most of experimental medical research fits your model and is usually called “basic” or “preclinical research”.
This is well regulated by federal laws and guidelines (and hassled relentlessly ironically by non-Vegan PETA members).
Much of the progress in medicine is driven by this basic and preclinical work—-from brewer’s yeast to mice, rats, and monkeys.
If anyone suggests that experimental research using animals has not delivered over the last 100 years please do not just roll your eyes. Tell them that they are flat-out wrong. Almost every disease or human condition has useful animal models—yes even dyslexia and schizophrenia. One exception—-gun-ownership mania.
I read it as "if you want to build health products start building products for animals because it's not regulated and you get to iterate/develop fast"
> One exception—-gun-ownership mania.
I know it's not what you meant, but I seem to remember a short clip of some idiots giving a monkey (or was it a chimp?) what looked to my unskilled eyes like an AK-47.
That clip was a viral marketing campaign video created for Rise of the Planet of the Apes.
https://www.adweek.com/creativity/movie-teaser-reminds-you-n...
I think that might have been it, yes. Nicely done, even now it doesn't feel CGI.
As a former caretaker of a diabetic pet, I wish that had an measurable impact on the quality of care in the pet space, but it doesn’t.
This comment really puts the whole "on the Internet, nobody knows you're a dog" saying in perspective.
there's not many specialised glucose monitor for animals. it's not feasible for manufacturers to release products just for one species or test for every breed of dogs.
we use continuous blood glucose monitors (made for humans) which can take wireless readings through a skin implant. they do well in animals (once you shave the fur). there are papers that confirm human glucometer readings correlate with an animal's blood glucose- so many clinics use human glucometers.
I think you are illustrating my point rather than refuting it. A new company could introduce a pet CGM with less barrier to entry than a human first company for the reasons you list.
His analysis is based on the comparison between his grand father era and his mother area ; but this predicate is if not wrong, at least still unproved.
He took a sample of 2 persons, with different characteristics and made deductions based on that. Nothing can't be deduced from his sample in fact.
For example, we compare at the same time a 'psychiatrist' from period X, to a 'dermatologist' from period Y.
Psychiatrists in general will not have the same mentality as dermatologists!
Medecines in the psychiatrist area will meddle with the brain and will try to affect the mood of a patient. Effects are hard to measure and side effects often unclear.
At the opposite, it is quite easy to see the effects and side effects of medecines in dermatology.
You can tell someone: go have a walk in the forest and your depression might pass, but your scabies problem will not resolve itself alone like that...
Thank you, there needs to be way more statistical skepticism for situations like this.
Tangentially related: I think the price of veterinary care is likely the best (albeit still an imperfect) estimator of how much human healthcare actually costs. There are virtually no price distortions caused by insurance markets, single payer systems, or strict regulations. It’s the closest thing to a fully free market in healthcare there is.
Uh...it still has the "you need this or you see a loved one suffer" thing going for it which leads to an ability to seek maximum profit. Large multinationals are monopolizing by buying out small vet practices, also allowing them to set prices. And those monopolies not only offer their own insurance, but there are also numerous others offering pet insurance.
So it might be the "closest thing to a fully free market in healthcare there is (in the US)", in that it's slightly better than the human healthcare market...but that's it. It's still nowhere close.
And there are plenty of other markets, all of them cheaper, and many with better outcomes...though I guess few countries with "freer" markets (since pretty much every other western country either has a single payer system, or has mandatory private insurance or similar, such as Switzerland), so I guess if your point is that having a "free market" approach to healthcare leads to worse outcomes in every instance?
Veterinary medicine technically deals with property, not really loved ones. Numbered dairy cow or muddy sow needing a c-section is an asset, not a loved family member. Pets are loved but they are property with negligible economic value, unlike a human life.
Where I live those are two different kinds of vets, with two distinct clienteles. While it's possible to find mixed practices (cattle + pets) in smaller towns, it's typically not the case in larger cities. There's no point in having your practice located downtown if you go to your clients anyway.
So I think op point still stands.
> Pets are loved but they are property with negligible economic value, unlike a human life.
You're missing the point, which is not about "economic value" (whatever you mean by that -- the amount someone would be willing to pay to save their own life? Their income?). The point is that no one who loves their pets dearly wants them to suffer, which puts the buyer in a worse bargaining position. I would (and have) paid many thousands to save a pet's life.
> which leads to an ability to seek maximum profit
Being human with human desires leads to an ability to seek maximum profit, in 99.99% of people.
Fine, for the terminally pedantic - I refer to the fact that the prospective buyer can not easily say "nah" and walk away; healthcare for a loved one can't be viewed as a purely economic transaction. It's easy to say "I don't need that expensive a car", even possible to say "I can make it work without a car", it's incredibly hard to not get Spot his life saving surgery because of money.
It ceases to be a purely economic function because people can't just walk away, and that has market effects that mean the typical pressures of a free market (such as 'supply and demand') become muddied. Sufficient supply is irrelevant if Spot is suffering -right now-, all the providers form a monopoly, and their prices are massively inflated.
The point of my pedantic comment was to note that the goal of seeking maximum profit is universal, what is not is being able to extract maximum profit, which is made possible by supply and demand, which you alluded to with "you need this or you see a loved one suffer".
>It ceases to be a purely economic function because people can't just walk away, and that has market effects that mean the typical pressures of a free market (such as 'supply and demand') become muddied.
Supply and demand has not become muddied. The ability to extract maximum profit is from the fact that there is very little supply and extremely high demand.
>Sufficient supply is irrelevant if Spot is suffering -right now-, all the providers form a monopoly, and their prices are massively inflated.
Sufficient supply and demand implies lots of agents supplying demand and lots of agents willing to buy, resulting in a situation where either party can walk away from the other to enable price discovery. If all the providers form a monopoly, they no longer act as individual agents, and hence there is no longer sufficient supply.
The dynamics of supply and demand and price discovery do not quite care about the suffering during the process, which is where the concept of insurance comes in. It could be provided by well regulated private markets with sufficiently well behaved actors, or by society at large via taxes, but the concept is the same. You prepare for unaffordable, unexpected expenses by "paying" in advance so that at the time of needing the product/services, you are not having to negotiate because the negotiations have already happened.
Not even close! Supply of veterinarians has been artifically constrained by insufficient expansion of veterinary schools, which has caused truly nasty market effects. Pet pharma is relatively highly regulated with American consumers paying high prices that are detached from market costs. Compare prices of medications in livestock vials or drenches vs the pet form.
I think dentistry would be more or a free market. You don't have much of the pharma issue, staffing is okay in some regions, there is decent price transparency, and insurance is not as terribly byzantine as it is for medical.
Prices still seem ridiculous to me, though. At my last dental visit they wanted to charge me $87 for someone to spend 15 seconds with a q-tip applying fluoride to my teeth. And this wasn't a case of "charge as much as the insurance will pay", as this would have been something not covered by my insurance.
Maybe that's less than what a similar (non-dental) medical procedure would cost, but that's still excessive.
Try a grody dental clinic in a low rent, low income area and you might find less of the extractive pricing.
Insurance isn’t universal yet, but I do think it’s already causing price distortions in the veterinary market. I have used pet insurance for about a decade, and I have (anecdotally) seen both insurance become much more common and prices increase significantly. I think those phenomena are likely linked. My dog had several obscure, severe medical issues throughout his life, and while I loved him dearly and would have treated the issues regardless of cost, the insurance made it much easier to say “yes” to more complex or repeated treatments without doing any financial analysis.
That's probably true. They also like to sell expensive but useless treatments. What's missing is clear information about efficacy of treatments.
That's not the impression I got from this recent HN post: https://news.ycombinator.com/item?id=31728350
tl;dr is that private equity firms are _so_ aggressive in buying up local veterinary practices (especially 24-hour veterinary ERs), and making already-fat margins even fatter, that the FTC is trying to stop it.
Is there even a way to know if a local practice gets bought out by a large corp? Seems like the FTC could help with that
Interesting article. I agree with other commenters that change in medical science over time probably necessitates changes in the industry, but I don't think this precludes making the work of medical professionals less onerous and expensive. Prior authorizations in particular seem like a uniquely wasteful and American phenomenon, whereby time (and thus money) is burned just so doctors and insurance can try to get on the same page. That cost, we can be sure, is then passed along to patients, on both the service and insurance ends. But more interesting to me, the broad picture in this article is of a world in which insurers have steadily clawed away more and more diagnostic and prescriptive responsibilities away from doctors, because the economic logic of a world with private health insurance allows them to do so, to the detriment of doctors' lives (as the article describes) but more saliently (for an American non-doctor like me) to that of all Americans trying to receive healthcare via insurance. I think it's pretty hard to dispute this phenomenon is real and harmful. The question, which this article doesn't really address, is what to do about it?
> The malpractice insurance of a family doctor is $13,000 a year, while an obstetrician’s insurance can cost $71,000 a year.
This is flat out wrong. No one is paying $71,000 a year in medical malpractice. An average OB/GYN is at $5k / year in insurance costs [1].
A really good source for medical malpractice claims data is the National Practitioner Data Bank which posts data on all paid medical malpractice claims since 1991 [2].
A summary of the data for the U.S. as well as for each individual state is here [3]. All of this is to say, the number of paid malpractice claims has been dropping since 2001, and the total amount paid on these claims has also dropped by 23% since 2003.
What is the real issue here? Defensive Medicine.
Doctors are terrified of being sued so they order batteries of unnecessary tests on patients and make unnecessary referrals in order to avoid lawsuits. These unnecessary tests drive up healthcare costs, not the direct cost of medical malpractice.
This is a problem with the healthcare system and how patients can initiate lawsuits. I don't think it is entirely fair to blame the physician in this instance for covering their bases. Any doctor who has been sued for medical malpractice will tell you that it was a humiliating and degrading experience even if they won their case.
[1] https://truecostofhealthcare.org/malpractice/
[2] https://www.npdb.hrsa.gov/analysistool/
[3] https://truecostofhealthcare.org/malpractice_statistics/
Your own link [1] says "Ob/Gyn about $30,000- $35,000". The OP said "an Ob's ins CAN COST 71k a year" [emphasis mine] so doesn't sound 'flat out wrong' to me.
Next - could you explain why you are bringing in malpractice CLAIMS data in a conversation about PREMIUMS?
> Your own link [1] says "Ob/Gyn about $30,000- $35,000". The OP said "an Ob's ins CAN COST 71k a year" [emphasis mine] so doesn't sound 'flat out wrong' to me.
And that's in California, while a chart lower down shows doctors in New York pay 7 times as much on average, and $35k on average across all specialities.
First, the vast majority of OB/Gyns practicing are employed by hospitals. The hospital covers the malpractice costs for the Ob/Gyns / any other physician's employed [1].
OB/Gyns are making $336k total comp on average in 2022 (including salary, bonus, and profit-sharing contributions) [2].
[1] https://www.medscape.com/slideshow/2019-malprac-prem-rep-601...
[2] https://www.medscape.com/slideshow/2022-compensation-overvie...
I am confused as to what your problem is? What exactly are you trying to articulate here? OB/Gyns are well compensated, and their insurance premiums are covered by the hospital. They are making above $300k/yr. :)
> What exactly are you trying to articulate here
You claimed that the annual malpractice insurance cost for OB/GYNs comes to around $5k when the true value (according to your link) appears to be several times higher. This is orthogonal to whether OB/GYNs make enough money to cover premiums or whether the hospital covers those premiums.
> could you explain why you are bringing in malpractice CLAIMS data in a conversation about PREMIUMS?
Because this guy has no idea what he’s talking about lmao. $35,000 is more like it for OB/GYNs
The average for OB/Gyn is $43,000
But the vast majority, as I stated above, are hospital employed and so it is covered by the hospital. It isn't considered as part of the TC (total comp) that is reported by Medscape [1]. If it was, then the TC for Ob/Gyns would skyrocket to nearly $400k per year.
[1] https://www.medscape.com/slideshow/2022-compensation-overvie...
35k sounds like a median or mode in a distribution. 2x sounds very feasible to me for deltas between geographic regions.
> This is flat out wrong. No one is paying $71,000 a year in medical malpractice
The plastic surgeon to whom I am married said her numbers was 60k a year previously, and still going up.
The average annual salary for a plastic surgeon was $576k in 2022. And $60,000 is not $71,000. Still yet to see perhaps more than maybe 0.001% of clinicians practicing pay that out of pocket fully.
I must not be understanding what your point is because I think the data show that some doctors pay much more than $71k/yr[1]
[1] specifically the table on the last page of https://www.ama-assn.org/sites/ama-assn.org/files/corp/media...
Medscape is widely regarded as the reputable source for physician salaries.
They do not consider hospital-issued / covered malpractice insurance as part of the TC listed on their yearly averages, hence why I don't think it should be made as big of a deal as it is being here.
I should say, these numbers affect private practices almost exclusively; and private practices are dying out/being bought out in droves.
TFA's point was that indeed - no individual is paying it. The cost of insurance strongly encourages working for hospitals who will cover that cost, rather than striking out and running the kind of small, one man band practice that the author is nostalgic for.
Took my dog who tore his ACL to the vet in Kiel, WI. They wanted to put him on life ending pain medication which would get him a few more months tops.
Took him to another vet in a local smaller community with staff that actually cared, they were able to properly wire the tendon and give that dog 5 years relatively pain-free life.
Many vets are absolute hacks and need to be roasted for it.
As an MD who is the son of a DVM:
Dad had his interests (hip dysplasia and veterinary orthopaedics) but was comfortable with pretty much everything including dentistry, most surgery and internal medicine. Newer DVMs do specialize somewhat in the sense that they tend to adopt more limited scopes of practice. There are even some that don't do spays and neuters which would have horrified my late father; those and vaccinations were the business bread and butter. Veterinary HMOs and PPOs are still a small part of the market and Dad never took them or completed claim forms for clients, but they're growing.
When I was in general practice I had a fair number of fee-for-service and cash pay patients (most were Medicaid/dual Medi-Medi and some HMO-PPO, but not the overwhelming majority), and I had the list of the (then) $4 drugs at the local supermarket pharmacies and we used that like a formulary to keep their out-of-pocket costs down. I'd say about a third of my patients were pediatric, the rest adults, and a smattering of prenatal. However, by modern standards even though we're trained to do it in family medicine I don't think many family practice physicians do full-scope because of the liability, particularly for prenatal care. I'm not in general care anymore, though I still see patients intermittently.
Veterinarians may have been more like yesterday's primary care a decade ago, but I'd argue that's increasingly no longer true.
As far as I can tell, specialization is increasingly popular. Within the past few years I've dealt personally with vets who specialized entirely in ophthalmology, oncology, and obstetrics. At the same practice as my oncologist there are specialists in cardiology and internal medicine as well.
I've also had to seek out specialists in rabbit care, which are surprisingly hard to find (though no vet I'm aware of treats solely rabbits -- usually they're exotic vets often with a "real" specialty in birds).
My experience with vets is extremely different. Either I’ll go to one that’ll charge significantly more for testing/operations or the one that charges less will make up the difference by aggressively pushing unnecessary testing and treatment (and charging insane materials rates for something as simple as saline).
I wouldn’t look towards veterinary medicine as the model, at least not from what I’ve seen (granted a lot of this exists for human treatments too).
> [2] The biggest contributors to these are the twin demons of prior authorization and electronic medical records. Prior authorization is when health insurance companies require doctors to ask for permission to perform specific services for specific patients. This is incredibly time consuming (14.4 hours per week as of 2020) and also demoralizing for the physicians, as the ultimate decision on how to treat a patient is often not made by the highly-trained physician or the patient in need, but instead by a 25 year old making 40k/year reading off a script over the phone.
This is a dramatic oversimplification.
The person reading the script may issue a denial, and then there is a process of appeal, which may include other steps.
Physicians interacting with insurance companies practice what is known as a "peer to peer", where a physician discusses the case with an insurance-employed physician, often trained in the same specialty as the physician. Sometimes the notes provided by a surgeon were inadequate, sometimes they need clarification, sometimes the incorrect codes were used, and payment is retroactively denied.
There are a few things too many rejections can cause:
1 - Insurance switches
2 - Regulator problems
3 - Competing model with insurance
4 - Lawsuit, as some legal firms specifically target insurance companies for this activity
Every time I read about how insurance works in the US medical system it's pretty plain to see that it's distorting both costs and patient care (neither for the better). How are people in the US still putting up with this garbage? How is any of this more efficient than single-payer or some other form of socialized medicine? It's absurd.
There are similar mechanisms in taxpayer funded healthcare countries also. The government does not simply pay doctors for any and all services they provide. At some point, there will be a person or group of persons deciding if certain services are warranted and/or to monitor for fraud.
In taxpayer funded countries they mostly aren't getting paid by the procedure, and in the cases that they are it's not enough to incentive very much fraud. Socialized medicine healthcare salaries are actual salaries and far lower than earnings in the US.
You make it sound like it's okay for the insurance company, a middleman, to decide someone's healthcare.
But insurance companies aren't collaborators. They rarely add to the process of making you healthier, they only take away options through denials. Seems silly that an insurance company allows a doctor into their network, then repeatedly questions that doctor's decisions (until you remember that insurance companies just want to make money).
> You make it sound like it's okay for the insurance company, a middleman, to decide someone's healthcare.
The insurance company is not deciding someone’s healthcare, they are deciding if they are going to pay for specific healthcare. Providers and patients are free to engage in any healthcare they want.
> Seems silly that an insurance company allows a doctor into their network, then repeatedly questions that doctor's decisions
Why? Does a car insurance company pay a mechanic in their network to replace an engine for a fender bender?
> (until you remember that insurance companies just want to make money).
This is meaningless. Everyone “just” wants to make money.
> Everyone “just” wants to make money
Not really, a lot of people just want to do what they love and in medicine that's fairly common.
Don't shoot the messenger
incredibly apologetic for an industry that’s wholly unnecessary, that without we could just have the “peer to peer” communication and patient interest in mind. that would be terrible though, as some folks would have to pay more than they would’ve if they were able to live their whole life without needing medical care.
I am not apologetic, this is just a matter-of-fact response on how it works, and what happens.
Keep in mind that healthcare fraud is a giant business [1] [2]
I'm not trying to push any particular thing, though I do believe that the Kaiser Permanente type of business model (health maintenance organization) will eventually kill off much insurance.
[1] https://www.justice.gov/usao-wdmi/health-care-fraud
[2] https://www.govinfosecurity.com/doj-healthcare-at-center-big...
As a a vet I think this author's limited experience is a bit out of date.
In the veterinary industry, medical management is always influenced by costs. Just yesterday I had to deal with a blocked cat. Gold standard treatment costs thousands of dollars and the owner only had $200. You not only have to take into account the hospital costs, but how the owner can manage their pet at home for ongoing care too. Costs are one of the main stressors in the industry (there's plenty of Ted Talks on the high suicide rate), and commonly owners shift their responsibility by blaming vets as "money grabbers" or who are only "in it for the money".
Thankfully insurance is quite common now (depending on the area) and with less financial restraint on costs we are able to do more advanced treatments. We have specialists referral daily and even recently had a brain surgery on a dog. This would have been very rare in the past and the limited opportunity to perform complex treatments like this hinders how much data we can collect and learn from this.
You do have old-school vets or those in rural clinics who would be happy to do every treatment under the sun. But being a 'jack-of-all-trades' is unrealistic when each sub-field is rapidly expanding in knowledge, and most younger vets (especially in big cities) are more than happy to refer to specialists (and avoid risk of complaints), unless of course the owner cannot afford to do so.
There are now chains of for-profit full service pet hospitals, expanding into a business that not long ago was served by a few not-for-profit centers. For instance, locally, if I needed a service my local vet couldn't provide, I went to Angell Memorial in Boston. I adopted all of my cats there. Now there's a couple of Blue Pearl hospitals here too.
This isn't entirely a bad thing. But one presumes that increasing use of pet insurance and the commericialization of the vet business will mean rising costs. And my local vet has had some staff turnover of late.
Probably a naive question, but why is EMR still so atrocious? I know there's a lot of garbage software out there, esp when it's single-purpose. But I usually assume that's a combination of low returns to better UI and little money to optimize (eg software improvements that make waiters marginally more efficient).
By contrast, supply of doctor-minutes is a chronic bottleneck in a system that spends trillions. I know healthcare (esp in the US) is full of wonky incentives, but surely improving doctor productivity is connected to hospital outcomes in some straightforward way?
One difference is that doctors don’t have the high suicide rate veterinarians do: https://blogs.cdc.gov/niosh-science-blog/2019/09/04/veterina...
I’m not surprised by that.
Being in the veterinary care with my small pet (which I learned have very short all-good to all-dead journey) I noticed that vet clinic is a very depressing place.
Sure, animals are cute, but a lot of them are dying or seriously ill and even being in the waiting room where loving owners rush-in scared or wait restlessly worried about their pets’ lives is a dark experience.
Seeing how vets are handling animals I’d say it takes a very specific mindset and resolution to do the job. I can imagine that even the hardest of such resolutions can crack under the weight of owners breaking down over their pets misery.
I believe that everyone should have access to periodic mental health evaluation, support and professional supervision. For people working in such hard to digest professions it is a necessity.
> Being in the veterinary care with my small pet (which I learned have very short all-good to all-dead journey) I noticed that vet clinic is a very depressing place.
I wouldn't call them small (necessarily), but this is my experience with rabbits. Over the decade we've taken care of them we've gone at least five or six times from "everything's okay" to "Georgie's lethargic and won't eat" -- which can mean death -- in the span of a few hours. So I'm driving over an hour each way in the middle of the night to take my rabbit to the nearest 24h emergency vet that treats them, not knowing if this is just gas or a blockage that will need surgery, mentally preparing myself for thousands of dollars in costs and the possible death of my pet. I imagine it's no fun for the vets who have to deal with me and others like me all night long, though I try my best to seem upbeat and empathetic externally.
https://en.wikipedia.org/wiki/Compassion_fatigue
Related TED talk: https://www.youtube.com/watch?v=objP3E625Xo
The problem with both these 'sectors', in my view, is that it is almost impossible for the doctor/vet to actually act in the patient's interests.
The doctors have to worry about lawsuits, giving the correct (pharmaceutical) treatment. The vets are better, but really I've been unimpressed with the care - lots of unnecessary cutting for the sake of insurance, sterilisation, etc.
The background reason is that the incentives are 180° in the wrong direction. Practioners aren't paid for keeping you healthy, out of hospital, managing health by better diet selection, etc. Their 'best' scenario is the opposite to that - they want a long protracted illness with lots of treatment. Diabetes for example is a blessing, not a curse. Long illnesses pay the bills.
Not only this, but doctors are fully boxed in with dysfunctional protocols/treatments (wrt the patient's best interests) as insurance companies' 'best practice', etc inculcate a set of behaviours that suit pharmaceutical corps that pay their bills.
So the incentives and model are all wrong. But they are also hardened in law, insurance etc. So apparently we must proceed on this flawed model.
But for the individual, for me at least, I do not plan to visit a doctor. Except in narrow circumstances (burns, force trauma) even if the practioners are considering my care (in the old-fashioned sense of the word), I don't think I can trust them to actually do the right thing, so fully deputised are they to big pharma. I have far more faith in my ability to resolve a problem myself or in alternative health practioners. The same applies to vets, to a lesser extent.
I've worked in car sales for over a decade. I've always hated the service departments for their totally militant focus on extracting as much money as possible from customers, with any concept of value or honest recommendations be damned.
The last few times I've stepped into several vet offices, I get the exact same sense of money extraction and even see many of the same methods/training/tools/tactics.
In the USA since 1960, healthcare has gone from 5% of GDP to nearly 20% of GDP, something I would consider a crisis. If you think of the enormous amount of money that’s being spent, and then ask if we’re really living better or longer lives, I would disagree.
Some might argue that the average lifespan has gone up a 8-10 years, but take out infant mortality, account for improvements in vehicular safety, the fact that most people no longer smoke cigarettes, and improvements in workplace, food and drug safety, and what are you actually left with?
I would say most dollars in healthcare are selfishly spent squeezing a year or two of extra time in the twilight of most peoples’ lives, while destroying our society in the process.
> Some might argue that the average lifespan has gone up a 8-10 years
I don't think anyone would argue that's what we're getting for the quadrupling in cost, because nobody else spends half as much as we do and they all live longer than we do. Cubans, Panamanians, Albanians, and the Lebanese have longer life expectancies.
Many of these countries are such that I'd not be very-very certain about their statistics reports.
Cuba's health statistics are backed by the WHO. They were the first, for instance, to prevent mother-infant AIDS transmission.
In the UK healthcare costs about half as much (and you the consumer don't pay any of that out-of-pocket), and the average life expectancy is about three years longer here.
When doing these kind of comparisons, I feel we should separate out deaths from "excess" (drugs / alcohol / cigarettes) - or at least control for differing levels of use in the various countries. I suspect differing incidence of young people dying of drug overdoses makes a big difference to average lifespan, but it seems to me that's more reflective of a society's regulatory and legal environment than a reflection of healthcare
In 1960 if you had a heart attack and collapsed in a mall things weren't going to go well. Today you'll get CPR from a bystander, an AED shock from an EMT, stenting in an interventional radiology lab, and statins to reduce cardiac risk. All of this adds cost but can add a few decades of life.
> an AED shock from an EMT,
Not if you're having a heart attack. That's a mechanical problem - your heart is gunked up with fatty crud and cannot pump blood. The symptoms are chest pain, sudden weakness, and shortness of breath. *Usually* you don't just drop to the floor clutching your chest.
You're thinking of a cardiac arrest, which is an electrical problem - your heart is not getting the right pulses to generate the right muscle contractions to pump. An AED will absolutely help here and you should not wait to start using it. Just grab the AED that's right there and open the lid, switch it on, and wait for it to start telling you what to do.
It's very unlikely it could ever shock a patient who wasn't actually having a cardiac arrest because they detect the heart's electrical signals and look for a "shockable rhythm". If the rhythm looks normal, or looks like one that won't be improved by a quick zap, it won't do it. Even so, never stick the pads on someone who isn't actually in cardiac arrest because if it gets it wrong it probably *would* drop them into cardiac arrest.
Pretty much every public space has a defib now. Often they're in a box with a locked door which you can get the code for from the emergency services operator. You're going to need to ring for an ambulance anyway so this doesn't waste time.
The main thing though is just start CPR and get someone to call an ambulance. You might just save someone's life with that, maybe even today.
"Even so, never stick the pads on someone who isn't actually in cardiac arrest because if it gets it wrong it probably would drop them into cardiac arrest."
MD here, I strongly disagree - the AED is designed for use by minimally trained people. And the chances of a shock being wrongly administered is many times lower than the chance of saving a life if they are in a shockable rhythm.
I think it's really hard to definitively diagnose cardiac arrest in the first few seconds to minutes, even for some medical personnel - even if you have no cardiac output, a person often still has some residual apparent breathing ("agonal breathing") which often leads people to delay CPR, and delay applying the AED/monitor+defibrillator.
Perhaps we can agree there is no point placing it on patients who can talk to you? :) But if as an untrained person you applied it to every person who lost consciousness in front of you, you would do a lot more good than harm, with almost zero absolute risk of harm.
> Perhaps we can agree there is no point placing it on patients who can talk to you?
Yes, that's kind of what I was getting at.
Or to put it another way "don't fuck about with the AED because it's not a toy and its safety systems are not infallible". If you stick it on someone unresponsive - and you've got enough reason to suspect they're in a shockable state - it probably won't make them any worse.
Like my old trauma instructor used to say, "You can't make dead any deader!"
Heart attack (myocardial infarction) leads to cardiac arrest all the time. That's how people die from heart attacks.
If someone has a myocardial infarction and then goes into cardiac arrest with a shockable rhythm, shocking is absolutely the appropriate thing to do. (But it is only a temporizing measure - if the person does not get treatment for the underlying myocardial infarction, they will simply go into cardiac arrest again.)
>All of this adds cost but can add a few decades of life.
The cruel irony, though, is that you now have several decades in which to potentially come down with cancer, Alzheimer's, or other illnesses associated with old age that are even more costly to treat.
There are several layers to this story
If you collapsed in a mall in the 1960 your chance of having died on the spot from a preventable cause were much higher (like smoking, or a non-diagnosed heart problem)
Today, that chance is also smaller. Defibrillators help but not in all cases.
> I would say most dollars in healthcare are selfishly spent squeezing a year or two of extra time in the twilight of most peoples’ lives, while destroying our society in the process.
The vast majority of spend is on chronic disease patients in the 50–85 age range.
The insurance middle man takes a huge slice too without offering much in return.
But I do agree with you. What’s the solution though? How do you decide when to let people die?
I think this is a bit of a fallacy (the decision to let people die). Do we know that all this money and processes (as described in the article) has led to better outcomes? Has the impact of the current methodology been objectively evaluated after excluding all other variables?
Brutal take. Squeezing hundreds of thousands of dollars out of patients/insurance for maybe a few extra months is immoral imo
And months that often aren't a great quality of life and are questionably in the patients' interest.
It made a huge impression on me as a kid when my greataunt, a physician, decided that she didn't want to be treated for her leukemia diagnosis. She died within a month (I assume it was late-stage).
(IIRC, better end-of-life counseling is what the Obamacare "death panels" kerfuffle was in reference to)
It is an American problem, we must do something. Which leads to antibiotics being over prescribed because parents don’t want to leave the doctors office without something to do afterwards. Life is worth living well, but it’s also worth accepting the end, something to which many people are openly hostile.
Which leads to antibiotics being over prescribed because parents don’t want to leave the doctors office without something to do afterwards.
You're not wrong, but sometimes this is purely preemptive and might still be a sound decision. For example, influenza almost never directly kills anyone--the monster flu in 1918 is an exception--whereas secondary bacterial infections (leading to pneumonia) can and do. Antibiotics are often prescribed as an extra precaution; given the atrocious financial resources of most Americans, most doctors know that they only get one shot with most patients, because they can't afford the copays or get the time off work, and that if they under-prescribe and are read to have missed something, they'll face malpractice suits from the desperate. So, they err on the side of immediate caution, since antibiotic resistance is one of those diffuse long-term problems.
Life is worth living well, but it’s also worth accepting the end, something to which many people are openly hostile.
Part of the problem is that capitalism creates a collapse of trust from which there is no recovery. Is the hospital denying or rationing care based on sound medical reasoning (i.e., that the requested procedures won't work, and will divert resources away from people who need them) or because they don't think the patient will be able to pay? Is the doctor performing a surgery because it will improve the patient's quality of life, or because he needs to generate fees? I'm sure most doctors are ethical and try to make the best decisions for the patients--I imagine, at least 90 percent of them do--but, as soon as the profit motive gets involved, distrust becomes endemic and personally mandatory.
Medicine is, to put it bluntly and factually, too important to trust to the profit motive and capitalism.
Are you sure it was "capitalism" that led to the "collapse of trust"? Did Soviet citizens trust the local healthcare system when the quality of care you received depended on your party rank?
From a Wikipedia article on the Soviet healthcare system[1]
"Many medical treatments and diagnoses were unsophisticated and substandard (with doctors often making diagnoses by interviewing patients without conducting any medical tests), the standard of care provided by healthcare providers was poor, and there was a high risk of infection from surgery. The Soviet healthcare system was plagued by shortages of medical equipment, drugs, and diagnostic chemicals, and lacked many medications and medical technologies available in the Western world. Its facilities had low technical standards, and medical personnel underwent mediocre training. Soviet hospitals also offered poor hotel amenities such as food and linen. Special hospitals and clinics existed for the nomenklatura which offered a higher standard of care, but one still often below Western standards"
I think the problem more generally is that of adverse incentives, whether in "capitalist" or "socialist" systems. I worked in the UK National Health Service which is "free at the point of use" which often results in rationing via waiting list. In my experience, many patients believe that their GP is inappropriately limiting their treatment to save money, particularly with respect to limiting testing, which is unsurprising because "gatekeeping" is often an explicit responsibility for general practitioners in the NHS [2][3]
[1] https://en.m.wikipedia.org/wiki/Healthcare_in_Russia#Early_S...
[2] https://www.theguardian.com/society/2001/sep/15/NHS
[3] https://bjgp.org/content/69/681/e224
Everything you're saying about the Soviet health system is true of capitalism's health system now. The difference is that, in the US, we go into debt for our mediocre care.
The main reason for the discrepancy in care quality during the midcentury is... drumroll please... that the Soviet Union was poor, due to initial conditions. It encompassed countries that had long been impoverished. The US had a middle class to build on; the USSR did not. It built a middle class where none had ever existed. Not to mention, the US was in the historically rare situation of winning a war (since, in economic and humanitarian terms, wars are negative-sum and most often only have losers). The USSR, on the other hand, consisted of nations that had taken a beating in World War II.
If you compare Kyrgyzstan to Alabama, the Soviet Union looks bad, but that's not really a fair comparison. Capitalism, as a sea empire, could dominate people from afar and keep them in nominally separate nations while exacting tribute; the Soviet system, as a land empire, could not. It had to integrate them. That's a harder problem. If you make a fairer comparison--say, if you compare Kyrgyzstan to Honduras or Haiti, the picture lines up a lot better. I imagine the quality of healthcare in the poorest countries under capitalism's thumb is even worse than it was in the poorest SSRs as of 1989.
This isn't to say the USSR was great. It was an authoritarian regime, and it launched some really ugly wars (such as the one in Afghanistan). It remained poor (relative to the West) throughout its lifespan because, ultimately, there is no magical economic system that guarantees 12% annual GDP growth--doesn't exist, never has. Socialism solves one set of problems--and a big set of very ugly problems--that capitalism lets fester, but does it automatically bring about utopia? No, not even close. On the other hand, socialism iterates toward a better standard of living for the common people; capitalism, unless heavily checked (as it was in the Cold War) iterates toward a worsening standard of living. So, on that dimension alone, capitalism loses. Everything said above about shortages and nosocomial infections and substandard care applies to capitalism's medical system today.
Just happened to read a report on this exact topic last week: https://ourworldindata.org/us-life-expectancy-low
A lot as gotten considerably worse since the 60s. Pointing out why gets you flagged though.
Medicare is what pays for that btw. Dialysis is covered, as is any life saving treatment (like heart attack).
What ends up happening is hospitals then charge others to cover their costs (hence high rates). Granted hospitals do take a bigger cut imo than they deserve, as do pharma, doctors, etc.
Let’s not forget the number of doctors is intentionally restricted. They also seem to have a political bias imo (how much volunteer work and what kind you’ve done).
Then you have regulations around drugs (FDA), hospitals / practice insurance, etc
Combined, the entire industry is over regulated and captured effectively by cartels (what is Johnson and Johnson but a legal cartel). You can’t even sue for vaccine (any vaccine) injury. Think about that for a moment and explain it.
Fixing the medical industry can only be done by deregulating it. I don’t think it would even be that hard; but people would lose their minds. I’ve spent a lot of time in one of the largest medical billing companies in the US. My family worked in this space for decades. The issue is really just fear.
Regulatory / legislative changes:
1. Remove any protections pharma has against lawsuits
2. Remove bloated credentialing for doctors, instead have an apprenticeship program (at least for military and gov doctors)
3. phase out Medicare, no one under 60 will ever receive it again.
4. Completely defund the FDA
5. Remove much of the requirements around drugs. Enable easy purchasing of medication. Could just be consultation with pharmacist. Or maybe nurse. Or no one.
Do that and overnight the cost of medicine would drop massively. The medical costs in the US would be less than Mexico.
A much simpler first step that I think would be really helpful is:
1) Prevent any group discounts or employer discounts for health insurance
2) Possibly, to go even farther, ban health insurance as employee compensation
Benefits:
1) People see the actual cost of their health insurance
2) People can choose insurance on a competitive market instead of picking between 3 packages their employer subsidizes, so insurance companies actually have to be competitive
3) People aren't forced to pick a difference insurance company every time their employer renegotiates with a different provider, which can also change their healthcare network
4) Lower barrier to leave or change jobs since you can keep paying the same known amount for health insurance and receive the same service
5) Lower barrier to self-employment since you are no longer at a disadvantage for health care costs
> 2) People can choose insurance on a competitive market instead of picking between 3 packages their employer subsidizes, so insurance companies actually have to be competitive
You're only solving half the problem. The other half of the problem is that you'll still have no idea as to what you'll be getting for the money you pay your insurer.
I don't really care about whether the copay for a doctor's visit is $10 or $20, what I care about is whether or not I'll get a surprise bill for $15,000 for a medical procedure. And I can't predict which insurer it's more likely to happen with.
When you're buying a pig in a poke, knowing how much you'll pay for it isn't of much use.
Sure, but you also can’t guarantee that without insurance either.
Are you going to ask the ambulance to take you to a different hospital when the first one gives you their rate schedule for heart attack interventions?
That's the other, other half of the problem.
I haven't used it and don't know how good it actually is, but I have browsed for insurance on the Healthcare Marketplace (aka Obamacare) and they set out some pretty strict levels of coverage, services, deductibles, etc. in a standardized way.
But most people don't participate in that market because it would be silly to when your employer gives you a group buy rate plus an extra employer-paid subsidy to incentivize you to be part of the group buy.
For 2) it is much simpler to say something like "employer pays half of the monthly rate up to $X", while you freely pick which insurance. That is how it works in Germany by the way.
Concerning the competition I would caution that from my experience some American insurances lack standards. For example insane copay, cancer not covered or other crazy exceptions. So to have actual competition you should also require by law that all essentials have to be covered with a limited copay and not discriminate. The insurances can still compete on non-essentials (e.g. fitness, cheaper checkups). Otherwise you run into the issue that poor people are forced to buy scam insurance.
Agreed. We actually have some of those standards for insurance packages in the “Obamacare” market.
But many people don’t participate in that market because they get a much better deal with their employer’s negotiated and subsidized option.
You’re still just adding more regulation. More complexity and spaghetti laws aren’t going to solve things. Pre 1970s healthcare costs were in-line with the rest of the world. Revert the push to corporatize and socialize and we’d have cheaper care.
The fact employers pay for healthcare isn’t an issue. Who cares? It’s just part of compensation. I can take my money and do the same thing. No one will btw, they’d just buy cheaper insurance and have a higher out of pocket expense.
End-of-the-day Medicare and regulatory capture is the issue. I can’t go to my local store and get antibiotics, even if I have a test showing strep. Instead, I have to go to a doctors office. A doctor who is intentionally being made scarce (ie driving up demand). Then I get my antibiotics, but they request a follow up.
No amount of insurance wizardry will fix that scenario. You have to deregulate to fix it.
i do think, Insurance companies will insist you follow their rules to cut their costs. Making healthcare worse for you. Even if you were to deregulate, insurance will still be able to apply pressure. IMO ban insurance outright for medical related items. You have a right to medical privacy and the idea insurance is required is BS.
> I can take my money and do the same thing.
It will cost more than the package negotiated by your employer since you are out of the group-rate.
Which means it isn’t actually a free market choice with competition.
Applying free market choice to the healthcare itself sounds great but it’s difficult to make such choices when unconscious in the back of an ambulance, or after a drug company or doctor causes you permanent injury or death.
Step 1 should be “every health plan is a high deductible health plan.”
Step 2 should be “Absolute price transparency.”
We need to make patients cost-sensitive. It’s utterly ridiculous that there’s a pill to treat low testosterone that’s $1,000 a month when a weekly injection costs $20 a month. Sure, taking a pill is easier and less painful. 99.9% of people would still choose the needle if they actually had to pay for it - and that would mean the manufacturer of the pills would have to lower the cost.
The same thing goes for many other medications and treatments. Why bother trying to price out that MRI if you’re hitting your deductible either way? Not like they’d tell you the cost up front anyways.
Switching everyone to a high-deductible would be disastrous for people with expensive chronic conditions like diabetes. It would force people to forgo treatment or select suboptimal treatment even in the absence of chronic conditions, leading to complications that require further treatment down the line. Not a fan of this idea.
Ideally for the truly low income there would be subsidies, but it’d have to be limited enough for them to still have skin in the game.
The end point is that what are now expensive, chronic conditions would become much less expensive. There would be some pain in the interim.
Frankly I’d be all for tying our drug prices to the prices in other countries. If I were king for a day I’d do both that and what I detailed above.
> Completely defund the FDA
Deconstructing a necessary regulatory agency isn't the solution.
Best case, you end up creating a worse version of the same thing.
Er, "best case" you end up creating a better version of the thing. We are on HN where you always see "Rewrite from scratch in rust, go,..." or "Version 3.0 drops backward compatibility and greatly improves ....".
After multiple decades large agencies probably need big reforms. If you can implement these within the agency, great. If not, splitting off some of the work to a new agency with these changes is a practical option.
You cannot simply reenact the same policies in a different organization and not get the same problems. Politically, you have to start over on many established political policies. While there would be an opportunity to split the org chart, then introduce new shortcuts and workarounds to the previous implementation, you just restart the same divisive issues with new contexts.
This approach makes no sense to start on. You want an overhaul of FDA policies, then advocate for that unless you have some plan other than throw everything away and let someone else deal with the practicalities.
FDA 2.0 the complete rewrite is a good idea.
Things used to get overhauled more regularly. The last however was probably 20 years ago with the creation of the Department of Homeland Security. Since then, crickets.
Phase out medicare? How will poor people afford any kind of care? No matter how efficiently you do things, it's still going to be somewhat expensive to provide modern standards of care. And the poorest people get a lot of injuries, germs, and pollutants.
It's not fear, it's money. All of those unnecessary things are huge profit centers for certain people. Health care is middle-manned to death, and not just insurance. There are loads of other middle men at every step.
I mean fear of deregulation. The truth is that we push politicians to do what we want.
As it stands, people are afraid to completely deregulate healthcare.
Funny enough, even though imo it is the only way. I do think money would stop it from becoming a movement. When’s the last time you saw a leader stand up and say “let’s dissolve XXX three letter agency!”? You don’t see it. Wonder why?
Last one I recall was Trump. Media did a number on him, so much so we can’t even discuss him without worrying about being attacked. Isn’t that something?
Why this obsession with deregulation, it seems to be inconsistent with empirical evidence?
Basically every first world country other than the US has better and cheaper healthcare, but they don't have any less regulation.
> As it stands, people are afraid to completely deregulate healthcare.
The countries that America is compared to and found wanting aren't running completely deregulated healthcare. What makes them different?
It varies. But often it is less regulated or more efficient. There will be 10 suppliers of a generic medication rather than 2 or 3. 8 years for college and med school won't literally include 2 to 3 years of vacation. And so on.
Negotiate to pay for medical services with cash - the price difference is astonishing.
The overhead of the insurance companies is insane!
Overhead itself might not be the problem. But it is process it leads to. One way I could see is to mandate one single list price. No discounts. If hospital wants to do charity they can setup fund that pays the bill or part of it back to itself.
I think it's not that everyone is chasing their extra 1.5 years at the end. People always did that as much as they could.
A massive portion of healthcare spending (50%) goes to a tiny percentage of the population (<2%). We've grown that population and increased our spending on them in various ways. Back in the day, many issues would not have arisen because the way people lived prevented them, or they would have not been acknowledged as matters for healthcare at all.
- Many kinds of drug addiction basically didn't exist, due to lower availability and a very different social environment. - Diseases of affluence like obesity and its endless related problems. - People would deal with their mental health issues on their own, or with their family. - Many things back then didn't have treatments, which now do have treatments - often expensive ones.
Life was both harsher on individuals and less corrupted by illnesses that come from technology, affluence, and worldly connections. People's every mental and physical issue wasn't held up as a thing for sociotechnological treatment, and they were left on their own, but this also made people have more inner strength and not fall into a pit of helpless victim mentality.
We've gained a tremendous wealth surplus since then, and it seems to be a law of societies that industrial surplus mostly gets consumed by concurrent bio-social deterioration. We coddle and support people who would have been told to deal with their own issues, or just laughed out of the doctor's office back then. For better or worse.
Society is also lower in trust and less homogenous. Because of concerns about discrimination, decisions that would have been made cheaply and informally on the spot now have to be formalized and done through rubrics which give suboptimal answers because they lack human judgment and also consume more resources. Society is way more litigious and doctors have to spend a lot more time and effort covering their asses from lawsuits and accusations of all kinds.
It's a complex issue with a lot of causes.
I suspect Scott Alexander has some good writings on this.
This is all nonsense. Other affluent countries spend much much less, live much much longer, and don't practice eugenics.
If you look at the US state by state you would see similar outcomes.
“Much much longer”
Imo all western countries are within the margin of error. The real truth is that the US subsidizes the medical fields of Europe.
The US provides protection; which means the EU doesn’t have to pay for military and they dedicated funds to healthcare. Further, all the drug revenue for R&D recovery comes from the US market.
With the countries of Europe gearing up for war. I’m curious if they’ll keep paying for the medical treatments of everyone.
That makes no sense. The point is that those countries spend way less money for better outcomes and your "rebutal" is that they have more money to spend? And pharmaceutical companies just charge less in these countries because of the kindness on their hearts? Eventhough they supposedly could charge much more than the US because Europeans have money left over?
They charge less because those countries would simply go “no, we’re not going to offer that drug for that price” if the manufacturers ask for too much.
If insurers did that here people would be upset, and with their revenue tied to how much they pay out they don’t have much of a reason to.
All that leads to them making up the difference in the US market.
If by "back in the day" you mean the half-century following WWII, the USA had it uncommonly good: dirt-cheap post-secondary education, increasing upward mobility for everyone, low cost of living relative to income, and pensions. That's 3 of the 5 Social Determinants of Health, arguably better on average throughout the 1950s-1990s than post-2008.
To the extent there is a wealth surplus now, it hasn't reached most people. Some of our current situation (including what you call diseases of affluence) feels linked to increasingly insecure prospects of housing, income, and retirement for the people who our increasingly labor-automated economy is leaving behind.
Overregulation has done more to shift the focus of healthcare from actually providing healthcare to instead feeding the bureaucracy.
I switched to a health savings account and regularly negotiate paying for things with cash instead of going through insurance and the cost difference is mind blowing - routinely 1/3 to 1/5 the amount if you force your doctors to go through insurance.
I saw the same doctor between the ages of 11 and 27. He owned his own practice in California.
The experience at the modern healthcare network is just not the same.
I understand the need for hospitals to go the corporatized route, but I think corporatization of family practice has significantly degraded the experience for patient and doctor
Let us not forget that Barber's also doubled as surgeons.
https://barbersurgeonsguild.com/magazine/history-barber-surg...
In addition to the regulations, there is also corporatism in sometimes unexpected places.
During COVID in France, there was an idea for vets to provide shots of the virus, especially in places where we do not have a lot of doctors.
This sounded reasonable to me, but apparently not to everyone as they were allowed to provide the shots only in vaccine centers. That were lacking exactly in the paces where they had their office.
Speaking from a US perspective: I'll just add onto the point about EHR/EMRs being generally pretty bad. It's like medical IT is about 20 years behind in terms of tech, so I'm not surprised to see that it's contributing to an overall inefficiency in the medical space. On one hand, you have Epic's EMR, which is easily the best in the industry, and reasonably feature-rich and appears appreciated by doctors in my experience. On the other hand, you have almost everyone else, down to utter dogshit like eClinicalWorks (apologies if any employees frequent this forum unless you work in UI/UX, in which case kindly consider a career change), which essentially exists to allow less well-funded operations to meet regulatory requirements (despite the fact that they're literally being sued for failing to meet this bare minimum [^1]).
I'll just quickly add on that if you want to write software to connect your EMR/EHR you're in for a bit of a pain to say the least. There's essentially a whole middleman industry for various data solutions like APIs or on-prem SQL databases[^2] that somehow managed to get vendor status with one or several EMR companies or managed to find the obscure way of actually accessing the hospitals' own data. I'll note here too that 1. sometimes the data is stored on site, so you should be able to read it off your own server, but I imagine a decent number of places treat it as SaaS which makes the task more difficult and 2. that I think EHRs should follow the FHIR spec but whether you can openly communicate with the software along this is another problem. I haven't tried to work with Epic, so maybe they're kinder.
I know this isn't really the point of the article, but the tech infrastructure around medicine really is shockingly poor. There's a lot of problems with inconvenience (handwriting really is often _that_ much faster than typing stuff into software especially when the software is so un-ergonomic), double-entry (since a lot of operations weren't designed with technology in mind), and lack of inter-operability. Combine this with outdated software infrastructures (I've seen Drs still use windows 7 on hospital laptops since that's the only thing their sw runs on, I've also seen a weird OS that looks like a 98 clone with less features and far slower on modern hardware), annoying problems like shitty WiFi in hospitals, really high stakes since it's patient data, and regulatory pressure - you end up with a system with little new competition, which means no innovations except in extorting hospitals.
Apologies for a long rant, but there really is a need for talented developers to work on these sorts of problems, because the current situation is like being forced to either have mountains of paper charts (I visited a small clinic that does exactly 1 operation and they had an entire basement filled with shelves of charts) or use some terrible software and likely have your data locked into it.
[^1]: https://www.fiercehealthcare.com/ehr/eclinicalworks-ehr-clas... and https://www.healthcareitnews.com/news/eclinicalworks-sued-ne...
[^2]: Admittedly it's not always clear _what_ they're selling. One rather dubiously named "datasheet" lists "designed to be flexible to support definition changes in an AGILE fashion rather than via a prolonged software development and release cycle" as a feature despite the product being just a MS SQL server with data cloned from the EHR
I think it's country based. In DK Vets are way better than doctors. You could just see a different level of preparation and equipment.
Heh but look where the trends with vets and dentists are. This won't last for long!
Where are they trending?Curious if you can expand
There was a thing a few weeks back of PE buying up vets to consolidate them and jack up prices.
a) People should be happy.
b) I personally dislike blame-culture but I think that's already more debatable (you could reframe it as assigning responsibility, aggressively)
c) I want the higher chance of successful therapy, as I am sure most of us do. So if you claim we are off path and "folklore and word-of-mouth" gets us back AND you can prove that, fine. Otherwise spare me the nostalgia and anecdotal data. I wanna live.
I don't just want to live, I want to understand why many things still seem to operate so irrationally in terms of cost. vs. value received.
I actually appreciated the unique perspective, and the experience, and don't care that it is not statistically validated, since the point is to stimulate thinking.
It suggests a few aspects to look into - an overly litigious society, crappy systems, an insulation of patients and doctors from the costs of treatments by insurance intermediatories etc...
Private Equity is acquiring and combining small practice veterinarians and pet insurance is becoming more common. Soon vet care may feel much more like human care.
https://www.axios.com/2022/03/04/pet-care-lures-private-equi...
Some of it seems to be unwinding: http://www.ftc.gov/news-events/news/press-releases/2022/06/f...
That’s exactly what I was thinking and I thought it was where the post was going to go. The writer’s grandfather and mother would have seen how it happened in human medicine, I bet very direct comparisons could be drawn to the current state of veterinary medicine by the author.
The fact that private equity firms aren't being bombed for the shit they're pulling now--i.e., the way they're moving into the housing market--is an embarrassment to us as a people.
When they were playing abstract numbers games, it was easy and well enough to ignore them; now that they're getting involved in things that affect human life, it's time to take action.
That said, I don't think pet insurance itself is a bad thing... no one should have to give up on their pet because of bullshit money concerns... but I think insurance should be universal... and we should solve human health insurance first.
As much as I love my pets and am willing to spend beaucoup bucks on their health care, I'm not sure I ever see free universal veterinary care being a thing. Too many people human problems will always be there for people to be comfortable using taxes to fund Fido's chemo.
> Many of the conditions that vets see don’t have specific drugs associated with them (or even high quality studies), so vets often have to get creative.
> If I want to market to doctors, I’m best served by having high-profile researchers in that specific indication and high profile studies. Ideally, I’d also get a change to the treatment protocols, too. If I want to market to vets, I’m best served by having well-known speakers (who don’t necessarily specialize in that indication) and well-run (not high-profile) studies.
> There's something sad about what American physicians have become.
Yes, we have an expectation today that medical procedures be backed by scientific evidence of efficacy. It's not like the "good ol' days" where doctors had carte blanche to do whatever they want. If you want to market a product without scientific evidence that it works, go ahead, just don't do it when people's lives are on the line.
The problem with that perspective is that it essentially dooms every "life on the line" with a condition which can not be established with "scientific evidence"
For a simple example, the multitude of young lives lost to cancer because "scientific evidence" does not support screening before age 50. That perspective seeks to minimize and mischaracterize early warning symptoms because of public health probabilities.
Are you implying that more active screening would cause more good than harm, and that the scientific evidence that shows otherwise is mistaken? What makes you think the evidence is wrong?
Screening is a very complicated topic and being overly aggressive with screening can really hurt patients. https://www.youtube.com/watch?v=yNzQ_sLGIuA
Or do you simply not support using scientific evidence and/or harm reduction to guide medical policy? What do you propose should be used instead in that case?
There is no problem with screening literally all the time, provided that the goal of screening isn't to immediately trigger a response from a single sample, but rather just to gather time-series sample points which can later be fed into predictive models to trigger alerting. (Where those "predictive models" can just be, y'know, your GP's eyes at your yearly checkup, as they flip through a series of your CT scans as a little flip-book.)
> There is no problem with screening literally all the time,
I have no opinion on the matter but this is disputed for some screening methods, which supposedly can increase the the risk with statistical significance. I don't believe that they ever nailed down the cause though, but I'm not a medical professional so I am not really well read on the topic.
Yes, but that's not a problem with screening as a concept, that's a problem with those screening methods. We accept "destructive testing" in medical screening (e.g. biopsies; x-ray fluroscopy with both radiation and carcinogenic chemical tracers; etc.) because we haven't structured medical screening in such a way as to incentivize investment into "non-destructive testing."
The medical establishment doesn't care about the potential for harm from repeated use of methods on patients†, precisely because we think of them as things that only need to be done rarely. There's been no need to optimize for "low cumulative impact" in screening methods, because there's currently no incentive to do screening often enough for it to matter.
Let me put it this way: the state of the art in MRI technology (reducing required size + cost per machine to enable more frequent + "trivial" use) is being pushed forward economically almost entirely by demand from Operations Research in the aerospace industry, rather than by demand from hospitals wanting to have more MRI-machine capacity per patient. That's ridiculous.
† The freshest example of this on my own mind isn't diagnostic per se. Have you ever noticed that dentists don't tell you to close your eyes — nor give you UV-blocking wraparound goggles — despite shining a UV light directly at your face for 30 seconds at a time to harden UV bonding resin they've used? They know it'll hurt their eyes if they stare at it all day — which is why the UV lights they use have circles of UV-blocking backscatter guards, to allow them to look at your face without reflected UV light hitting their eyes. But there's no concern for what they're doing to you, because you're only getting a few cumulative minutes of concentrated dental UV per year, vs. their cumulative hours of exposure.
So multiple doses of CT scan-level radiation are not a risk of harm. Got it.
Planning screening strategies is a very specialized job. There are good reasons to that.
A cost-benefit analysis can have different answers when applied to an individual vs. a population. That something is rare isn’t much comfort when you’re the one in a million rarity.
I think the point is that not all cases are cut and dry. There are many for which evidence is inconclusive; and for those having a blanket regulation is worse than letting the patient and the doctor select a choice that the patient prefers.
Then they chose a poor example to illustrate their point, since anyone is free to book a cancer screening even if they are younger than the recommended age, if they so prefer.
You can try and book anything you like, but the doctor/technologist is under no obligation to actually run the screening test for you, and if they do there is not requirement that your insurance pay for it. So you can have a full body MRI reference done, but it will cost many k$ out of pocket, if you can get someone to do it for you.
Your video seems good and I don't know if he is an authority but his description he makes clear that he is not an authority.. but it's about asymptomatic screening, while my point was about continuous symptom minimization and mischaracterization.
There are also some obvious mistakes in his overessentialization of the statistics, which imply that early detection never results in a nonfatal prognosis.
This analysis assumes there is no harm from false positives in screening tests. This is obviously false even if the only side effects are cost and stress induced by say a false cancer diagnosis.
> "scientific evidence" does not support screening before age 50
There is a difference between science has no idea and science suggests it would be harmful (in aggregate). My understanding is that cancer screening is more the latter not the former.
As the meme goes:
> Being an old-timey doctor would rule, just drunk as hell like “yeah u got ghosts in your blood, you should do cocaine about it”
> Yes, we have an expectation today that medical procedures be backed by scientific evidence of efficacy.
Statistical evidence of efficacy, you mean. Doctors today are much less "scientific", insofar as they're less willing to work with a patient to try to experimentally derive an intervention that will work uniquely well for that patient. Instead, modern doctors try to fit the patient into a coarse-grained statistical mold, and then apply the flowcharts of rote treatments that are "proven" to work for people who were labelled as fitting that mold according to some arm of a trial. They persist in this, even when it can be seen that the individual patient isn't responding.
A doctor who's actually practicing medicine as science would, for example, run a patient up the current DSMV flowchart for treatment of depression, rather than down it — first determining, as the most important step, whether the most hard-line treatment will do anything at all for the patient; before then finding the weakest treatment that will still have a useful effect.
Also, a doctor practicing medicine as science would be doing a lot less "try this because it has no side-effects, regardless of whether you're likely to be a responder to it", and a lot more measurement to "cleave the problem-space at the joints."
(Yes, ER doctors can't afford time to measure. Most doctors are not ER doctors.)
I'm glad somebody is making the distinction between scientific experimentalism and executing a protocol based on scientific research.
I've worked in medicine as an experimental phycisist (radiology, imaging), and I found so-called evidence based medicine anything but. Evidence based is used to cement existing methods over new ones into protocols that are very, very slow to evolve.
This is just the trolley problem from ethics.
A doctor who follows those course grained recommendations derived from statistical evidence will provide the best outcomes to the most patients in aggregate.
A doctor who tries to uniquely discover the best outcome for each individual as they come through, may provide the best outcome for any given individual. But overall the deviation from the statistically recommended procedure will lead to worse outcomes in aggregate. It has to, because if it lead to better outcomes, the doctors 'personalized' process should become the statistically validated process with time.
When initially presented with the trolley problem, most people side with the saving the group over the individual. It's funny how quickly their minds change when they realise that in a healthcare context, they are never the group, they are always the individual.
Measurement in medicine is also in many cases not particularly quantitative. E.g., fatigue, pain, cognitive dysfunction etc. So taking more measurements doesn't necessarily give you any useful information.
In fact, near as I can tell. In the US, there is so much fear from doctors of misdiagnosing and starting patients on the wrong treatment plan, that they order too many measurements. Overall reducing the quality of care. The time needed to take measurements, as well as the risks of measurements are not negligible factors in healthcare outcomes.
> But overall the deviation from the statistically recommended procedure will lead to worse outcomes in aggregate. It has to, because if it lead to better outcomes, the doctors 'personalized' process should become the statistically validated process with time.
Yes, but not for the reasons you're implying.
Following the impersonal process leads to better outcomes in aggregate because it's less labor-intensive; and so doctors end up seeing more patients; and so more patients end up being seen.
But "number of doctors per patient" is only a bottleneck because we make it one, with medieval-guild-like limited-acceptance-per-year medical-bar licensing.
(And the medical bar does what it does, IIRC, because doctors really like being paid as much as they are; and having a more efficient market for doctors would mean doctors would be paid less. Even if it'd also mean that e.g. hospital doctors could work 8-hour shifts rather than 24-hour shifts.)
There's also the fact that flowchart-based diagnosis is liability-minimizing from a medical-malpractice-insurance perspective. With the flowchart, a hospital being sued can always use the defense that the doctor took the lowest-risk, best-practice next step they possibly could at each juncture. (Mind you, it's the best practice because it's the lowest-liability-risk — not for any other reason.)
> Measurement in medicine is also in many cases not particularly quantitative. E.g., fatigue, pain, cognitive dysfunction etc. So taking more measurements doesn't necessarily give you any useful information.
You only need quantitative instruments if your goal is to aggregate data to achieve statistical significance. An individual patient can be evaluated perfectly well ("clinical significance") with qualitative instruments. There are tons of objective-yet-qualitative instruments — e.g. observation of signs (rather than symptoms) of a syndrome, where there's no clear weightings to give to any given sign, but where one can always track each sign "dimension" of the syndrome separately, and then observe whether a given intervention improves outcomes along the "dimensions" you're tracking.
>Yes, but not for the reasons you're implying.
Following the impersonal process leads to better outcomes in aggregate because it's less labor-intensive; and so doctors end up seeing more patients; and so more patients end up being seen.
If the personalized process performs better on medical outcomes. Then over time doctors should be pushed to include more personalized steps in their treatment plans. I actually think that in many cases, personalized steps are already included in treatment plans that contain many branching paths.
It's also quantitatively true that in some cases (I believe most cases, but I don't have a good data set in front of me), a well validated flowchart leads to much better diagnoses and healthcare outcomes.
A good example: When a standardized checklist for the diagnosis of a heart attack was first introduced, doctors were upset about it, claiming that it took away professional judgement from clinical assessments.
Over time though, the checklist proved itself to be much more effective at diagnosing heart attacks than the vast majority of doctors. And most people who were having a heart attack were diagnosed correctly.
Of course some people will still be misdiagnosed (and unfortunately the misdiagnosed ones often fall into minority groups). But the statistically validated processes are not aiming for perfect. They're aiming for better than a human can do, most of the time.
And research will improve the flowcharts over time.
It also means that we can begin to think about delegating routine assessments where outcomes are very well understood to nurses, leaving doctors free to think about more complicated cases.
If doctors did science on each patient (which would open up a huge can of legal liability worms), you'd pay ten times as much for healthcare.
... and then we have dentists. With the treatment variability of x10 in price and procedures 'needed'.
My understanding is the price variability in dentistry is much less then for various other medical procedures. I have been told it because much of dental work is non inssured but I am just relying what I have heard.
Who are you or some nameless fed to tell me I can’t take drugs of choice? That’s insanely authoritarian.
The government routinely legislates public health issues.
That's not responsive. Nobody is asking what does happen, they're asking why it should happen on this specific issue. I can make you pray in school and call it public health.
Yes, an the government in the west is very totalitarian by historic views.
Recall the United States declared independence over 1/4 the taxes we have today and “no representation”.
Now, I can’t buy antibiotics for myself (but I can for my fish or cow) over the counter. Wtf world is this.
Antibiotic use in food-producing animals is regulated by the FDA.
you are angry that antibiotics are restricted? You know why that is, right?
> My grandfather, trained in an era before strong FDA regulation of medications, was mostly distrustful of medications.
Technically that Supreme Court ruling on the EPA is going to likely impact the FDA. At least, it’s a sign of where the Supreme Court is at on the issue. All the FDA has congressional authority over is labeling between states. That is to say; the FDA labels a drug as safe and you can advertise for said drug. That’s it.
There is nothing stopping you from ordering and taking almost any drug. At least in a legal sense. Provided it’s not regulated by congress (such as opium and derivatives). It’s why doctors can prescribe “off label” and what not. It’s very common.
There's no way this Supreme Court is going to alter the CSA.
Edit: Thank you Peyton for the additional context. I didn't realize that. I was reacting to "There is nothing stopping you from ordering and taking almost any drug." and I'd be shocked if the Supreme Court altered the interpretation of the CSA in such a way to allow arbitrary people to order controlled substances without a doctors prescription. Even if their state law allowed it.
To add to Peyton's comment:
"On June 27, 2022, the United States Supreme Court ruled that doctors who act in subjective good faith in prescribing controlled substances to their patients cannot be convicted under the Controlled Substance Act (“CSA”). The Court’s decision will have broad implications for physicians and patients alike. Practitioners who sincerely and honestly believe – even if mistakenly – that their prescriptions are within the usual course of professional practice will be shielded from criminal liability.
...
The Court’s decision will protect patient access to prescriptions written in good faith. However, for the government, the Court’s decision means prosecutors face an uphill battle in charging, much less convicting, physicians under the CSA. Indeed, the Court’s decision may have a chilling effect on the recent surge in DOJ prosecutions of medical practitioners and pain clinics. "
https://www.natlawreview.com/article/update-opioid-liability...
They did a couple days ago.
This is a ridiculous take. Veterinary medicine is not some capitalist utopia. Most vets are miserable and, unlike doctors, most of them don't even make any money for their suffering.
First of all, a substantial portion of the job is putting animals down, and I'm not talking about 20-year-old dogs with so many health issues that it's a mercy. A portion of the animals are in this case, of course; but a lot of the time, these are animals who'd be fine with proper treatment, and the issue is of owners who either don't care (yuppie shits who can afford the treatment, but who bought the pet for the kids, who are now in college, and see the pet as "just an animal") or who can't afford treatment at all. The idea that veterinary medicine is some capitalist utopia just because the prices are more reasonable (for now) is absurd... because the fact is that we live in what free-market capitalism has reduced (due to runaway wage collapse) to a third-world country, and so most people can't even afford basic services for beloved pets, even at the relatively low service prices of a few hundred dollars instead of a few thousand, because so many Americans don't even have that.
Veterinarians have an astronomically high suicide rate. They are right in the firing line of this shitfucked economic system that should have been overthrown forty years ago when it stopped functioning for the people who do the actual work.