Researchers chart path to drastically lower administrative costs of health care(med.stanford.edu)
med.stanford.edu
Researchers chart path to drastically lower administrative costs of health care
http://med.stanford.edu/news/all-news/2021/04/researchers-chart-path-to-lower-health-care-administrative-costs.html.html?mkt_tok=ODg0LUZTQi0zMDcAAAF84YXDwjcow7qSEyVjeiYYymJxwwegZeKlZ0lY80KpvyGXnFFbRZ5F3f95hhsB45PHpP51zf1pFjdkKSLmKtSenWlsRIWs1W9g06_HVvcnbA
220 comments
I agree with the three issues they identify driving up costs. But I fear “Medicare for All” won't fix all the issues, which go much deeper. For example, the US has extremely high standards restricting who can practice medicine compared to the rest of world, limiting the supply of doctors and artificially driving up their demand. There is a need for standards, but perhaps the AMA has too much political influence. Likewise, manufacturers of medical supplies operate as monopolies because the moat to reach approval is really high. I fear the US medical system is becoming so insane the only fix will be to replace it entirely (It's not just about tearing down, but replacing institutions)
> For example, the US has extremely high standards restricting who can practice medicine compared to the rest of world
Rest of the world, yes. Rest of the developed world, not at all. The major difference is that becoming a doc in the US is much more expensive than pretty much anywhere else. You could also argue it's proportionally harder because of the more numerous competitors. But on an absolute level of knowledge and capability no, it's not harder than say, in western european countries.
Rest of the world, yes. Rest of the developed world, not at all. The major difference is that becoming a doc in the US is much more expensive than pretty much anywhere else. You could also argue it's proportionally harder because of the more numerous competitors. But on an absolute level of knowledge and capability no, it's not harder than say, in western european countries.
I believe it takes longer in the US, when all is said and done.
It’s hard to casually verify this because each country uses different terms and has a different track but I think, when you include the various phases of training, starting from the bachelors degree, the US one is more total years.
Edit:
So for example the UK and France don’t appear to require any sort of bachelor’s degree as a prerequisite for medical. Which saves you 4 years on average. So their tracks may be longer but you can start sooner.
It’s hard to casually verify this because each country uses different terms and has a different track but I think, when you include the various phases of training, starting from the bachelors degree, the US one is more total years.
Edit:
So for example the UK and France don’t appear to require any sort of bachelor’s degree as a prerequisite for medical. Which saves you 4 years on average. So their tracks may be longer but you can start sooner.
Citation definitely needed here
And just to be sure, I would like you to start from the beginning of the person's medical training and not include the gatekeeping bit of having to get a bachelors in a random subject unrelated to medicine.
I note this Wikipedia article that suggests 4 years messed school plus 1 year internship could get me a license in the US. That sounds like Western Europe to me. Or India...
https://en.m.wikipedia.org/wiki/Medical_education_in_the_Uni...
And just to be sure, I would like you to start from the beginning of the person's medical training and not include the gatekeeping bit of having to get a bachelors in a random subject unrelated to medicine.
I note this Wikipedia article that suggests 4 years messed school plus 1 year internship could get me a license in the US. That sounds like Western Europe to me. Or India...
https://en.m.wikipedia.org/wiki/Medical_education_in_the_Uni...
> I would like you to start from the beginning of the person's medical training and not include the gatekeeping bit of having to get a bachelors in a random subject unrelated to medicine.
Why? An apples-to-apples comparison would be to see how long it takes to become a general physician after completing secondary school. In the UK or India it's something like 5.5-6 years.[1]
In the US it's 3-4 years of "pre-med", then 4 years of med school. That's from the article you referred.
1. https://en.wikipedia.org/wiki/Medical_school_in_the_United_K...
Why? An apples-to-apples comparison would be to see how long it takes to become a general physician after completing secondary school. In the UK or India it's something like 5.5-6 years.[1]
In the US it's 3-4 years of "pre-med", then 4 years of med school. That's from the article you referred.
1. https://en.wikipedia.org/wiki/Medical_school_in_the_United_K...
> Why? An apples-to-apples comparison would be to see how long it takes to become a general physician after completing secondary school.
Because if the requirement in the US is indeed "bachelor's degree required, any will do", then it exists solely for gate-keeping and says nothing about the standards of education.
Edit: looking at wiki, the requirements are actually a bit more reasonable, but it does seem strange that they are not just rolled into the first year (or two) of medical degree. Why force people to finish undergrad studies if only a few courses are relevant?
Because if the requirement in the US is indeed "bachelor's degree required, any will do", then it exists solely for gate-keeping and says nothing about the standards of education.
Edit: looking at wiki, the requirements are actually a bit more reasonable, but it does seem strange that they are not just rolled into the first year (or two) of medical degree. Why force people to finish undergrad studies if only a few courses are relevant?
Some universities in the US offer a 7 year undergrad and medical degree. Those usually have an extremely high GPA requirement but it's possible to do just that.
They typically have acceptance rates in the low single digits too.
Interesting, thanks! That's more in line with what I'd expect coming from Poland - medical degree is 6yrs (& is equivalent to Master's, I don't believe you get a Bachelor's degree during those), specialization then takes additional 5-6 years. For context, "normal" degrees are 3y (BSc) + 2y (MSc), which is also 1 year shorter than comparable education in the US. OTOH, I believe there's no such thing as "associate degree", and colleges are more focused from the get-go - you pick your major when applying for college (& the admission criteria are different based on that).
Of the people who attempt the pre-med track not all will make it. Forcing students to get an actual Bachelor's degree gives students some fallback.
I think really it's just the system was built this way and nobody's going to change it now.
I think really it's just the system was built this way and nobody's going to change it now.
> Forcing students to get an actual Bachelor's degree gives students some fallback.
That may be one reason, but seems to me that it doesn't really raise the standard of education. So it doesn't really help with proving that "US > the world" in this aspect.
I imagine you could still fall-back from medical college to undergrad & get credit for the completed coursework that is relevant towards the Bachelor's degree you fall-back to. This way, you don't incur unnecessary costs on folks who succeed.
> I think really it's just the system was built this way and nobody's going to change it now.
Channeling my inner cynic: nothing's going to change given that the decision-makers benefit financially from the system being set up like this.
That may be one reason, but seems to me that it doesn't really raise the standard of education. So it doesn't really help with proving that "US > the world" in this aspect.
I imagine you could still fall-back from medical college to undergrad & get credit for the completed coursework that is relevant towards the Bachelor's degree you fall-back to. This way, you don't incur unnecessary costs on folks who succeed.
> I think really it's just the system was built this way and nobody's going to change it now.
Channeling my inner cynic: nothing's going to change given that the decision-makers benefit financially from the system being set up like this.
They can switch to a Bachelors when they transfer off the med track.
Not at all, because the question at hand was 'how long does it take to train to be an doctor in the US'. I don't understand why one would include time spent training to be something else? It is like saying 'it took me 30 years to learn to code, 3 months on Udemy and 29 years learning to solve problems as a carpenter'.
Premed is gatekeeping, and not all countries enforce that form of gatekeeping.
Premed is gatekeeping, and not all countries enforce that form of gatekeeping.
> 'how long does it take to train to be an doctor in the US'. I don't understand why one would include time spent training to be something else?
Because you can't train to be a doctor in the US without that gatekeeping? I thought the point GP was making was it takes in the longer because of this pointless gatekeeping.
Because you can't train to be a doctor in the US without that gatekeeping? I thought the point GP was making was it takes in the longer because of this pointless gatekeeping.
I'll bring an example for the sake of comparison. In Italy the path to becoming a physician involves a six year degree focused entirely on medicine (so not a bachelor), followed by a specialized degree of variable length (4-6 years depending on the chosen specialty) during which you practice in a hospital and study for exams at the same time, mostly the former. Entrance exams are required at both levels and acceptance rates are very low. Also, many students end up needing 1-2 extra years to complete it all.
Well, I can answer that very clearly from personal experience: you are wrong. Medical education is much shorter in the US compared to most western countries. You have to understand that in medicine, school years are not all there is to it. The real issue is when do you get to truly practice without supervision, and that's much earlier in the US. Basically, a short residency and 1-2 years of fellowship and... done! In Europe, you're still a junior at 35.
> The real issue is when do you get to truly practice without supervision, and that's much earlier in the US.
Is it? If a doctor in the UK can graduate from medical school and practice as a GP 6 years out of secondary school, but for a US doctor it takes 8-9 years, it's not really "earlier". What you're talking about is status within the profession.
Is it? If a doctor in the UK can graduate from medical school and practice as a GP 6 years out of secondary school, but for a US doctor it takes 8-9 years, it's not really "earlier". What you're talking about is status within the profession.
For GPs, it may be true. I admit I was speaking from the POV of a specialist.
Isn't the problem that US requires having bachelor's degree before you even can start studying medicine, which effectively makes people start 4 years later?
The question is not "when do you leave school?" it's actually "when are you employable as an independent practitioner?". In my personal experience, it's _much_ easier to get an attending/private practice position in the US at a younger age. Just because the country is huge and lots of places lack docs, probably. Of course, that's my experience and I could be wrong.
Just because there is a Dr shortage in the US due to having a limited number of medical schools, there are still thousands of students who get their degree and can't find a residency:
>.... The matching challenge comes as the U.S. faces a physician shortage. The nation could be short as many as 139,000 physicians by 2033, according to the Times, which cites Association of American Medical Colleges data. Despite this shortage, thousands of medical school graduates are consistently rejected from residency experience, rendering their MD or DO "virtually useless," according to the report.
https://www.beckershospitalreview.com/hospital-physician-rel...
>.... The matching challenge comes as the U.S. faces a physician shortage. The nation could be short as many as 139,000 physicians by 2033, according to the Times, which cites Association of American Medical Colleges data. Despite this shortage, thousands of medical school graduates are consistently rejected from residency experience, rendering their MD or DO "virtually useless," according to the report.
https://www.beckershospitalreview.com/hospital-physician-rel...
That must be understood in the context of the number of applicants to U.S. residency programs from Caribbean medical schools (which are well-known to be a little predatory).
From that article you cited: International medical graduates in particular have low match rates for residency programs. American medical students have a 94 percent match rate, according to the Times, which cites information from the National Resident Matching Program. However, Americans who study at international medical schools have a match rate of 61 percent."
Kids from the U.S. get sold on a Caribbean M.D. school, and spend thousands and thousands of dollars only to find out that things get really complicated when it comes time to do clerkship rotations or apply to residency.
An M.D. or a D.O. from a school on U.S. soil is definitely not useless, and your chances at matching a residency are extremely high, as cited above.
From that article you cited: International medical graduates in particular have low match rates for residency programs. American medical students have a 94 percent match rate, according to the Times, which cites information from the National Resident Matching Program. However, Americans who study at international medical schools have a match rate of 61 percent."
Kids from the U.S. get sold on a Caribbean M.D. school, and spend thousands and thousands of dollars only to find out that things get really complicated when it comes time to do clerkship rotations or apply to residency.
An M.D. or a D.O. from a school on U.S. soil is definitely not useless, and your chances at matching a residency are extremely high, as cited above.
It really is harder in the US. The standards are much higher in the US than anywhere else. The US only accepts doctors who went to Canadian or American medical schools. And then on top of that, it is much harder to get into a medical school here in NA than practically anywhere else, except maybe India. I know that in the UK you can go directly from high school, meanwhile in the US & Canada you need a 515 MCAT, 3.7 GPA, and lab time to even get in to a mid-range school.
You are either deliberately misleading people or are ignorant of the UK education system.
Highschool in the uk ends at 16, you graduate with GCSEs. After this there are 2 extra years of education (compulsory in England), you start university at 18 (at the youngest).
Medical schools are competitive and require strong a-level results, typically 3 As (the second highest grade, after A*) [0]. It's a 4 year degree, you then go onto train for another 5 years as a junior doctor.
There is a _lot_ of training for UK doctors.
[0] https://www.manchester.ac.uk/study/undergraduate/courses/202...
[1] https://www.healthcareers.nhs.uk/explore-roles/doctors/train...
Highschool in the uk ends at 16, you graduate with GCSEs. After this there are 2 extra years of education (compulsory in England), you start university at 18 (at the youngest).
Medical schools are competitive and require strong a-level results, typically 3 As (the second highest grade, after A*) [0]. It's a 4 year degree, you then go onto train for another 5 years as a junior doctor.
There is a _lot_ of training for UK doctors.
[0] https://www.manchester.ac.uk/study/undergraduate/courses/202...
[1] https://www.healthcareers.nhs.uk/explore-roles/doctors/train...
From the link numbered [1] above, medical school in the UK is normally five years long. Followed by 2 years of Foundation training, and 5-8 years of specialist training, or 3 years if you go into general practice.
Note that the US education system is more expensive though, so becoming a doctor costs more.
Note that the US education system is more expensive though, so becoming a doctor costs more.
> You are either deliberately misleading people or are ignorant of the UK education system.
I don't think either is necessarily the case - he isn't saying it's easy to become a doctor in the UK, he's saying it's easier than in the US, and that's sort of true, if not by all that much.
In the US you also start university at 18 - med school is a 4 year degree you must have completed your undergraduate degree to begin, then you go on to train for 3-7 years as a resident, depending on specialization. Then maybe more for a fellowship.
That said, I've got both doctors trained in the UK and in the US in my immediate family, I don't really see much of a distinction in difficulty of training to be honest but I'm not a doctor myself so what do I know.
I don't think either is necessarily the case - he isn't saying it's easy to become a doctor in the UK, he's saying it's easier than in the US, and that's sort of true, if not by all that much.
In the US you also start university at 18 - med school is a 4 year degree you must have completed your undergraduate degree to begin, then you go on to train for 3-7 years as a resident, depending on specialization. Then maybe more for a fellowship.
That said, I've got both doctors trained in the UK and in the US in my immediate family, I don't really see much of a distinction in difficulty of training to be honest but I'm not a doctor myself so what do I know.
22.5% of students get 3 As or better so that doesn't sound very impressive to me. US med schools are much more competitive than that.
There is a weird discontinuity in the data for 2020 which your quote - it was 12.3% the previous year according to https://lginform.local.gov.uk/reports/lgastandard?mod-metric...
This is also a proportion of students who take A levels which is already filtering down to about 38% of the population in that age group (766k 18 year olds in U.K. so about 643k in England of which about 250k take at least one A level.)
So in a normal year that 12.3% of A level students getting 3 A’s is only 4.8% of the age cohort.
Edit: I should add that medicine is about the hardest subject to get into in U.K. (other than vet med which has so few places) and one of the only ones where they expect you to demonstrate suitability beyond academic performance, e.g. work experience in a caring setting. (Source: shared a house with a med student in undergrad.)
This is also a proportion of students who take A levels which is already filtering down to about 38% of the population in that age group (766k 18 year olds in U.K. so about 643k in England of which about 250k take at least one A level.)
So in a normal year that 12.3% of A level students getting 3 A’s is only 4.8% of the age cohort.
Edit: I should add that medicine is about the hardest subject to get into in U.K. (other than vet med which has so few places) and one of the only ones where they expect you to demonstrate suitability beyond academic performance, e.g. work experience in a caring setting. (Source: shared a house with a med student in undergrad.)
The US only accepts doctors who went to Canadian or American medical schools.
That's absolutely not true. Foreign medical graduates do have to take the US board exams, complete a US-based residency, and possibly take additional courses to fill educational gaps, but they absolutely can practice in the US with a foreign medical degree.
That's absolutely not true. Foreign medical graduates do have to take the US board exams, complete a US-based residency, and possibly take additional courses to fill educational gaps, but they absolutely can practice in the US with a foreign medical degree.
-> complete a US-based residency
This is the kicker. There are incredibly difficult to get, they are incredibly stressful, and it's another 3-5 years of your life.
If you allowed any non-us developers to practice in the US but you made them work a 5 year 80hr/week internship for 1/6th of what professional developers made first, that basically bans non-us developers from writing code in the U.S.
This is the kicker. There are incredibly difficult to get, they are incredibly stressful, and it's another 3-5 years of your life.
If you allowed any non-us developers to practice in the US but you made them work a 5 year 80hr/week internship for 1/6th of what professional developers made first, that basically bans non-us developers from writing code in the U.S.
Absolutely. And that's due to AMA lobbying in the 90s. It doesn't have anything much to do with stringency of US medical licensing or ensuring quality and everything to do with existing MDs protecting their lucrative practices.
Practicing medicine must be lucrative because it costs an individual student around $240,000 in tuition for the M.D. itself, excluding cost of living.
Doctors are made out to be predatory vultures, but unless they come from money they must undergo massive debt burdens that they are not able to even begin paying down the principal on until they're well-into their thirties. Imagine the feeling of taking out half-a-million dollars in student loans to cover both undergrad, and graduate-level training. After that look forward to your 80-hours a week of residency making below hourly minimum wage. [1]
Make medical school free, and you'll have people lining up the door to practice for low-cost. Make it half-a-million pay-to-play, and you'll have people desperately clawing their way out of debt so that some day they can have a family and own a home after a decade of hellish training.
Cut the docs some slack. They're taking on unimaginable debt burdens for a job that often isn't in the same universe of cushiness as something at FAANG (inspecting that anal fissure in the ED at 3am with perks including, well, hospital food), but involves an tremendous service to society.
[1] https://www.mdlinx.com/physiciansense/is-it-better-to-be-a-d...
Doctors are made out to be predatory vultures, but unless they come from money they must undergo massive debt burdens that they are not able to even begin paying down the principal on until they're well-into their thirties. Imagine the feeling of taking out half-a-million dollars in student loans to cover both undergrad, and graduate-level training. After that look forward to your 80-hours a week of residency making below hourly minimum wage. [1]
Make medical school free, and you'll have people lining up the door to practice for low-cost. Make it half-a-million pay-to-play, and you'll have people desperately clawing their way out of debt so that some day they can have a family and own a home after a decade of hellish training.
Cut the docs some slack. They're taking on unimaginable debt burdens for a job that often isn't in the same universe of cushiness as something at FAANG (inspecting that anal fissure in the ED at 3am with perks including, well, hospital food), but involves an tremendous service to society.
[1] https://www.mdlinx.com/physiciansense/is-it-better-to-be-a-d...
Here's an article that describes the pathway by which foreign doctors can get a medical license in the US: https://www.voanews.com/student-union/how-indian-doctors-get...
In brief, they have to sit the MLE (medical licensing exams), but the real hurdle is getting into a US-based residency program beforehand. In practice, this means only the best candidates tend to make it.
In brief, they have to sit the MLE (medical licensing exams), but the real hurdle is getting into a US-based residency program beforehand. In practice, this means only the best candidates tend to make it.
I'm european, never set foot in a us or canadian medical school but worked in Boston. So no, it's not as set in stone as you think it is.
> The US only accepts doctors who went to Canadian or American medical schools.
This is factually incorrect. There are tons of doctors that graduated from European, Indian and Chinese medical schools. To practice medicine in the USA they need to pass the ECFMG tests (US graduates take similar USMLE tests) and then complete medical residency. The last part is the hardest, for the medical residency admission offices are routinely discriminating against the foreign medical graduates.
This is factually incorrect. There are tons of doctors that graduated from European, Indian and Chinese medical schools. To practice medicine in the USA they need to pass the ECFMG tests (US graduates take similar USMLE tests) and then complete medical residency. The last part is the hardest, for the medical residency admission offices are routinely discriminating against the foreign medical graduates.
Why shouldn't domestic medical students have priority over foreign medical graduates?
Why should they? If I take the same tests as US medical students and pass, am I not at least as good as they are?
Global market?
It's much easier for an us citizen anyway as it is easier for an employee.
It's much easier for an us citizen anyway as it is easier for an employee.
Only accepting doctors who went to medical school in the u.s or Canada is not the same as having higher standards (necessarily).
In Germany the grades you need to study medicine is really high. You need the best grade of 1.0. you can wait if you just have something like 1.3
Do you have sources which shows your argument?
Do you have sources which shows your argument?
mr_woozy(2)
The bottleneck is not the number of people with an MD. The bottleneck is the number of residency programs. These are funded by Medicare and I believe they are not profitable for hospitals.
I don't know how residencies could not be profitable for hospitals. Hospitals receive something like $120k/yr per resident, then work residents 80+ hours/week at $50k/yr pay, amounting to right around minimum wage (for my city). Residents do a tremendous amount of work in supporting the hospital, so much so that a single resident getting deathly ill and needing to stay home (e.g a surgery resident getting covid, which I witnessed) is enough to send a massive shock through a hospital and force other residents into 100+ hr/week schedules. I know this because my wife is a surgery resident and I'm describing a situation from this year.
Edit: But there are still way too few residency spots. I think it has to do with the difficulty and administrative work around starting a new program or with getting federal funding for more spots.
Edit: But there are still way too few residency spots. I think it has to do with the difficulty and administrative work around starting a new program or with getting federal funding for more spots.
The residency slots are so limited right now because the AMA lobbied hard against expanding them in the 1990s (fearing a "glut" of doctors).
Edit: Every time this comes up I go down a rabbit hole of looking for an article from the mid-to-late 90s where a medical lobbyist spoke about how doctors would be forced to leave the profession and do "mundane" jobs like driving cabs if the residency slots weren't capped. It did not paint the lobby in a good light, and I've love to see it trotted out today. I never have been able to find the article online. If somebody with better search-engine-fu than me can find it I'd be greatful.
Edit: Every time this comes up I go down a rabbit hole of looking for an article from the mid-to-late 90s where a medical lobbyist spoke about how doctors would be forced to leave the profession and do "mundane" jobs like driving cabs if the residency slots weren't capped. It did not paint the lobby in a good light, and I've love to see it trotted out today. I never have been able to find the article online. If somebody with better search-engine-fu than me can find it I'd be greatful.
The AMA is actively lobbying for more residency slots.
https://www.ama-assn.org/press-center/press-releases/ama-fun...
https://www.ama-assn.org/press-center/press-releases/ama-fun...
They are now. They weren't back in the 90s.
I don't know how residencies could not be profitable for hospitals.
If it helps, think about it this way,
how does the malpractice work?
There are a lot of indirect costs around residents. For example, staffing mandates. Think what implications there are to regulations that say, for instance, no more than 4 patients for each RN on duty. That said, there are a lot of indirect funding sources too. The problem is, of course, sometimes the funding doesn't equal the costs depending on where you are.
And now we come to the rub. Which of the MDs are willing to do their residences in places where everything matches up nicely to support a lot of residents? Keeping in mind that those places may not be Sarasota, or Tampa, or Charlotte, but rather places in Alaska, a small desert city in New Mexico, or some small place on the tundra of North Dakota.
If you're asking, does the US government give enough funding? You can get an answer that's "Yes" if you consider nothing else.
Does that funding cover every regulatory cost of having a provider on staff? Not likely, depending on the rules in the state you're in.
Does that funding get to where MDs want to practice? Rarely at all does that happen.
If it helps, think about it this way,
how does the malpractice work?
There are a lot of indirect costs around residents. For example, staffing mandates. Think what implications there are to regulations that say, for instance, no more than 4 patients for each RN on duty. That said, there are a lot of indirect funding sources too. The problem is, of course, sometimes the funding doesn't equal the costs depending on where you are.
And now we come to the rub. Which of the MDs are willing to do their residences in places where everything matches up nicely to support a lot of residents? Keeping in mind that those places may not be Sarasota, or Tampa, or Charlotte, but rather places in Alaska, a small desert city in New Mexico, or some small place on the tundra of North Dakota.
If you're asking, does the US government give enough funding? You can get an answer that's "Yes" if you consider nothing else.
Does that funding cover every regulatory cost of having a provider on staff? Not likely, depending on the rules in the state you're in.
Does that funding get to where MDs want to practice? Rarely at all does that happen.
There's some good reason to think that residencies are profitable: in 2019, 550 of them were auctioned off for $55 million in a controversial bankruptcy case.
https://www.inquirer.com/business/hahnemann-university-hospi...
https://www.inquirer.com/business/hahnemann-university-hospi...
It is not that the residencies themselves are profitable. It is that medical schools need to be able to provide residency slots to their students to have an effective program. Definitely an issue for newly formed for-profit medical schools.
This is correct and needs to be upvoted more. The number of residency slots is artificially capped and already fails to serve the number of medical school graduates in the country. The Balanced Budget Act of 1997 is the basic vehicle for this cap. In Dec 2020 the first expansion in decades was passed, adding a whopping 1000 residency spots.
Look up Graduate Medical Education program for more info. For more key words, see this document from the U of California system that has an agenda (increase capacity) but also effectively lists salient points: https://www.ucop.edu/federal-governmental-relations/_files/f...
Look up Graduate Medical Education program for more info. For more key words, see this document from the U of California system that has an agenda (increase capacity) but also effectively lists salient points: https://www.ucop.edu/federal-governmental-relations/_files/f...
A helpful link on this subject. Apparently, medical schools in the US are now allowing more graduates. Not sure about profitability of residency programs, but certainly not all hospitals are teaching hospitals and the latter are federally subsidized.
https://www.aamc.org/news-insights/us-medical-school-enrollm...
https://www.aamc.org/news-insights/us-medical-school-enrollm...
I don't think it's about the profit it's the fact that anything involving Medicare is a big political fight
Agreed.
Entrenched institutions are the general problem with America. It's the police unions protecting bad policing, the restricting of doctor supply via the residency bottleneck, and local governments preventing new building for burgeoning populations.
They're all the same problem really. Beneficial to the incumbent group at the expense of those they service. It's kind of amazing.
Entrenched institutions are the general problem with America. It's the police unions protecting bad policing, the restricting of doctor supply via the residency bottleneck, and local governments preventing new building for burgeoning populations.
They're all the same problem really. Beneficial to the incumbent group at the expense of those they service. It's kind of amazing.
> the restricting of doctor supply via the residency bottleneck
Assuming that you're referring to the AMA here, their role is pretty unclear to me. They appear to have played a lobbying role to get Congress to freeze residency funding in 1997 to avoid having lots of doctors [1], but for several years now, the AMA has at least publicly claimed that they've been lobbying congress to increase funding for residency slots [2]. Maybe they're lying? But I for one don't actually know who is keeping residency funding low.
[1] https://qz.com/1676207/the-us-is-on-the-verge-of-a-devastati...
[2] https://www.ama-assn.org/press-center/press-releases/ama-bui...
Assuming that you're referring to the AMA here, their role is pretty unclear to me. They appear to have played a lobbying role to get Congress to freeze residency funding in 1997 to avoid having lots of doctors [1], but for several years now, the AMA has at least publicly claimed that they've been lobbying congress to increase funding for residency slots [2]. Maybe they're lying? But I for one don't actually know who is keeping residency funding low.
[1] https://qz.com/1676207/the-us-is-on-the-verge-of-a-devastati...
[2] https://www.ama-assn.org/press-center/press-releases/ama-bui...
AMA is a bad actor. They refuse to allow junior doctors (doctors who are MD school graduates but who have not completed residency) to practice medicine in ANY capacity.
Common sense says that junior doctors should have the same practice rights as physician assistants - but the AMA refuses to let that happen. They are a medical cartel.
A few states have allowed junior doctors to start practicing medicine in a limited capacity, because every other doctor so damn expensive. But the AMA does not support those states' decision.
Common sense says that junior doctors should have the same practice rights as physician assistants - but the AMA refuses to let that happen. They are a medical cartel.
A few states have allowed junior doctors to start practicing medicine in a limited capacity, because every other doctor so damn expensive. But the AMA does not support those states' decision.
The AMA also argues against prescription rights for other health professionals like pharmacists (who often have much more in-depth education on drugs)
What do you have to do before you prescribe a drug? Make a diagnosis, which is what is taught in medical school and not in pharmacy school. Pharmacists are frequently embedded in care teams in hospitals and primary care clinics where they make medication recommendations and know how to get drugs approved by insurance companies (sad that this has to happen...).
you are correct, doctors should stay in their lane and diagnose and leave treatments to others
It's totally possible to have one party diagnose and another prescribe.
Does the AMA want that or is that the purview of state medical boards? AMA doesn't set practice laws. The people who lobby against new grad MDs having the same practice rights as NPs/PAs are NPs and PAs (more NPs). NPs lobby against assistant-physician laws because why would you want someone who has had 500 hours of clinical shadowing while completing their part-time online, direct-entry, 100% acceptance, diploma-mill school (NP) vs. a new-grad physician who's had 2 years of physiology, anatomy, and pharmacology and 2 years with 5000 clinical hours where there's actually an expectation that you contribute treatment plans and care to the team. The fact that the AMA has been asleep at the wheel and unable to stop NPs from getting independent practice in 20+ states show that they don't have any real influence on who practices where.
Is there any reason the slots can't be privately funded?
Like, could minting more doctors drive down costs for hospitals (that need doctors for services)?
Like, could minting more doctors drive down costs for hospitals (that need doctors for services)?
Institutional trust is certainly a huge problem right now.
I just realized Physician Assistants (PAs) and Nurse Practitioners (NPs) have been forgotten in this equation.
126,000 practicing PAs [0]
325,000 licensed NPs [1]
985,000 practicing physicians (MDs and DOs) [2]
I know that nurse practitioners are not under the same artificial residency constraints of MDs/DOs. I'm not sure about physician assistants.
For someone not in the U.S., NPs and PAs often do the same role as general practitioners/family doctors e.g. see patients, prescribe medicine, etc. They can also specialize.
[0] https://www.thepalife.com/physician-assistant-stats/
[1] https://www.aanp.org/about/all-about-nps/np-fact-sheet
[2] https://en.wikipedia.org/wiki/Physicians_in_the_United_State...
126,000 practicing PAs [0]
325,000 licensed NPs [1]
985,000 practicing physicians (MDs and DOs) [2]
I know that nurse practitioners are not under the same artificial residency constraints of MDs/DOs. I'm not sure about physician assistants.
For someone not in the U.S., NPs and PAs often do the same role as general practitioners/family doctors e.g. see patients, prescribe medicine, etc. They can also specialize.
[0] https://www.thepalife.com/physician-assistant-stats/
[1] https://www.aanp.org/about/all-about-nps/np-fact-sheet
[2] https://en.wikipedia.org/wiki/Physicians_in_the_United_State...
PA/NA education is a complete joke compared to what your average MD gets.
They are not qualified to practice as general doctors at all.
However, they are really cheap, which is why corporations are pushing them so hard. Substandard care in the name of profits.
They are not qualified to practice as general doctors at all.
However, they are really cheap, which is why corporations are pushing them so hard. Substandard care in the name of profits.
Wow I was about to gush about how much I LOVE my NP compared to my old crappy, braindead MDs. I could share stories of how bad MDs are...and the horrors of insurance.
She is sharp as a whip. Smarter and more motivated than ANY MD I've EVER had. Anything she doesn't know about, she researches (on her own time/dime). She prescribes everything - dirt cheap. Lets me text/call/email ANY time. Refers me to a specialist for anything beyond her expertise (just like any MD would!) DIRT CHEAP (eg: MRI for $300, scheduled within a day or two down the street). A single, cheap, monthly fee ($65/mo!) lets me see her any time day and night, ask anything, discuss as long as I like...and I do all these things! No MD going through standard insurance would allow anything even remotely similar.
...I could go on...
imo the NP model is FAR superior than the traditional insurance+MD crap model we have right now. It's one of those things "they" don't want people learning about since it'll crush the traditional way of doing things once people realize how amazing that model is.
Yes I have basic insurance since it's required. And, just in case - she obviously doesn't have an emergency room.
She is sharp as a whip. Smarter and more motivated than ANY MD I've EVER had. Anything she doesn't know about, she researches (on her own time/dime). She prescribes everything - dirt cheap. Lets me text/call/email ANY time. Refers me to a specialist for anything beyond her expertise (just like any MD would!) DIRT CHEAP (eg: MRI for $300, scheduled within a day or two down the street). A single, cheap, monthly fee ($65/mo!) lets me see her any time day and night, ask anything, discuss as long as I like...and I do all these things! No MD going through standard insurance would allow anything even remotely similar.
...I could go on...
imo the NP model is FAR superior than the traditional insurance+MD crap model we have right now. It's one of those things "they" don't want people learning about since it'll crush the traditional way of doing things once people realize how amazing that model is.
Yes I have basic insurance since it's required. And, just in case - she obviously doesn't have an emergency room.
Your access to care is the result of the direct primary care model not your NP necessarily. Your NP might be good, but I'm willing to bet on average the people who have a minimum of 15,000 hours of clinical training (MDs/DOs) before independent practice are more competent than the ones who only are required to get 500.
More motivated? Why wasn't she more motivated to go to school for four years, get in-depth training in residency, and become an expert in her field rather than taking the easy "route" to practice "medicine"? I guarantee the IM docs and surgeons slugging it for 80+hour work weeks in residency to become experts are more dedicated and motivated to care for patients than the NPs who train part-time and online.
More motivated? Why wasn't she more motivated to go to school for four years, get in-depth training in residency, and become an expert in her field rather than taking the easy "route" to practice "medicine"? I guarantee the IM docs and surgeons slugging it for 80+hour work weeks in residency to become experts are more dedicated and motivated to care for patients than the NPs who train part-time and online.
> They are not qualified to practice as general doctors at all.
The way we train MDs is... highly counter-productive to say the least. First a completely unrelated undergrad, which really adds no value (hint: Foreign doctors can do a fellowship and get licensed to practice in the US without having an unrelated undergrad degree pre med-school). Then med school, which is completely detached from any clinical experience. Then residency, where practical knowledge is theoretically built but in practice is more of a legally sanctioned hazing (patient outcome doesn't really matter, what matters the most is impressing whoever is slightly higher on the pecking order in order to get the spot you want).
Multiple years of zero sum games and competition against your peers. Then, once you get your license, you are supposed to make a complete 180 and start becoming a team player.
To be completely honest, if you add up the useful time spent in school, an MD is just about on the same footing as a PA/NA.
The way we train MDs is... highly counter-productive to say the least. First a completely unrelated undergrad, which really adds no value (hint: Foreign doctors can do a fellowship and get licensed to practice in the US without having an unrelated undergrad degree pre med-school). Then med school, which is completely detached from any clinical experience. Then residency, where practical knowledge is theoretically built but in practice is more of a legally sanctioned hazing (patient outcome doesn't really matter, what matters the most is impressing whoever is slightly higher on the pecking order in order to get the spot you want).
Multiple years of zero sum games and competition against your peers. Then, once you get your license, you are supposed to make a complete 180 and start becoming a team player.
To be completely honest, if you add up the useful time spent in school, an MD is just about on the same footing as a PA/NA.
[deleted]
Cheaper salary and they order more unnecessary tests, imaging, and consults, which, what do you know, the hospital system also makes money off of. It's a win-win for the hospital, but patients and the healthcare system lose.
If only we could have stopped doctor salary inflation instead, like other developed countries :)
> For example, the US has extremely high standards restricting who can practice medicine compared to the rest of world, limiting the supply of doctors...
Really? Can you give some examples? There are a lot of immigrant physicians in the USA.
An anecdotal counter example: my mother is a physician with medical licenses from Australia, UK and the USA (obviously two have lapsed) and though she is quite critical of countries X and Y and positive about country Z she has never expressed any such opinion or said that one might be tougher than another, which is exactly the kind of thing she would point out.
Really? Can you give some examples? There are a lot of immigrant physicians in the USA.
An anecdotal counter example: my mother is a physician with medical licenses from Australia, UK and the USA (obviously two have lapsed) and though she is quite critical of countries X and Y and positive about country Z she has never expressed any such opinion or said that one might be tougher than another, which is exactly the kind of thing she would point out.
all those immigrant physicians went thru the same programs as the non-immigrants.
In fact, I hear this is continuously a problem for well qualified , practicing, and established physicians to migrate to the US. They are fed up with their own home countries lack of security, opportunities for their children, freedom etc, but they cannot imagine going back to medical school to be accredited to practice in the US.
This does not apply to every country. Notably, 4, all here:
https://www.theabfm.org/become-certified/i-am-certified-coun...
While many foreign physicians will have years of experiences diagnosing, treating patients, and administering medicine, in order to practice as a US doctor, it essentially requires them to start all over again academically, especially when the curriculum differs from overseas qualifications. [1] https://www.fnu.edu/foreign-physicians-work-healthcare-pract...
In fact, I hear this is continuously a problem for well qualified , practicing, and established physicians to migrate to the US. They are fed up with their own home countries lack of security, opportunities for their children, freedom etc, but they cannot imagine going back to medical school to be accredited to practice in the US.
This does not apply to every country. Notably, 4, all here:
https://www.theabfm.org/become-certified/i-am-certified-coun...
While many foreign physicians will have years of experiences diagnosing, treating patients, and administering medicine, in order to practice as a US doctor, it essentially requires them to start all over again academically, especially when the curriculum differs from overseas qualifications. [1] https://www.fnu.edu/foreign-physicians-work-healthcare-pract...
No, they most certainly did not. I've spent a large chunk of my career in healthcare technology, and one thing I can say for sure is that with very few exceptions, foreign doctors are no where close to the knowledge and capability of those educated in the US.
I'm not going to specify to avoid slamming particular countries, but I would definitely refuse to be treated by doctors from several major countries that crank out tons of doctors, many of whom worm their way into US practice. (This isn't based on race, etc, at all just competency, and I have a much larger exposure to this than most people. These people kill way too many patients with their incompetence, but (especially lately) they cannot be criticized for fear of being branded racist. My body, my choice.)
I'm not going to specify to avoid slamming particular countries, but I would definitely refuse to be treated by doctors from several major countries that crank out tons of doctors, many of whom worm their way into US practice. (This isn't based on race, etc, at all just competency, and I have a much larger exposure to this than most people. These people kill way too many patients with their incompetence, but (especially lately) they cannot be criticized for fear of being branded racist. My body, my choice.)
I disagree.
I've spent my own career in healthtech and at actual clinics.
While I won't dispute the fact that medical care abroad can be hit or miss, we are certainly not strangers to substandard doctors ourselves.
The difference between your experience and reality, is that the bad US doctors get put in corners where you have not been looking.
You should read marty makary's book unaccountable.
So, while your heuristic may be valid for someone living in a large metro area with tons of options, I would make a safe bet that it wouldn't be as useful in rural, underserved areas where the bad doctors end up.
I've spent my own career in healthtech and at actual clinics.
While I won't dispute the fact that medical care abroad can be hit or miss, we are certainly not strangers to substandard doctors ourselves.
The difference between your experience and reality, is that the bad US doctors get put in corners where you have not been looking.
You should read marty makary's book unaccountable.
So, while your heuristic may be valid for someone living in a large metro area with tons of options, I would make a safe bet that it wouldn't be as useful in rural, underserved areas where the bad doctors end up.
> one thing I can say for sure is that with very few exceptions, foreign doctors
The word ‘foreign’ is doing a lot of work here. It encompasses nearly everywhere, and likely includes the best and worst training systems in the world.
The word ‘foreign’ is doing a lot of work here. It encompasses nearly everywhere, and likely includes the best and worst training systems in the world.
>Likewise, manufacturers of medical supplies operate as monopolies because the moat to reach approval is really high.
I can tell you for a fact this simply isn't true. The reason manufacturers of medical supplies operate as a monopoly is because they have turned to acquiring everyone and anyone in the medical supply/device business and there's been 0 opposition to it.
https://www.beckersspine.com/orthopedic-a-spine-device-a-imp...
https://mergr.com/abbott-laboratories-acquisitions#cma-tab
https://www.greenlight.guru/blog/top-100-medical-device-comp...
You can go through the last link which is a list of device manufacturers and look at their acquisitions. They just eat up every small player that shows even a hint of providing competition. Some of them have been averaging an acquisition a month for years.
I can tell you for a fact this simply isn't true. The reason manufacturers of medical supplies operate as a monopoly is because they have turned to acquiring everyone and anyone in the medical supply/device business and there's been 0 opposition to it.
https://www.beckersspine.com/orthopedic-a-spine-device-a-imp...
https://mergr.com/abbott-laboratories-acquisitions#cma-tab
https://www.greenlight.guru/blog/top-100-medical-device-comp...
You can go through the last link which is a list of device manufacturers and look at their acquisitions. They just eat up every small player that shows even a hint of providing competition. Some of them have been averaging an acquisition a month for years.
You just conflated two partners in the whole mix of what we call "healthcare" in the US.
Payers = Medicare for All, UNH, Aetna, etc.
Providers = Hospitals, doctors, medical supplies, etc.
It's entirely possible to have one payer and then having a governing body regulate a free market[0] comprised of providers in the market.
[0] - I'm using the word free market not in its purest form (which rarely exists) but rather in a more colloquially way.
Payers = Medicare for All, UNH, Aetna, etc.
Providers = Hospitals, doctors, medical supplies, etc.
It's entirely possible to have one payer and then having a governing body regulate a free market[0] comprised of providers in the market.
[0] - I'm using the word free market not in its purest form (which rarely exists) but rather in a more colloquially way.
> limiting the supply of doctors
Possibly, but the cost of doctors (+nurses, technicians, etc) is in the noise, just a distraction. The vast majority of the cost of medical care in the US goes to the middlemen who contribute no value at all, just extract profit.
A 15 minute session with a general practicioner here (CA) costs around $300. That doctor isn't making $1200/hr ($2.5M/yr).
That doctor is likely only making a bit over 200K: https://www.salary.com/research/salary/benchmark/family-phys...
The other $2M+ are going hangers-on who're not contributing to health care, just inserting themselves into the chain to get rich. Take a look at the billions in revenue collectively by all insurance companies. That's all a tax on health care that provides no value.
Possibly, but the cost of doctors (+nurses, technicians, etc) is in the noise, just a distraction. The vast majority of the cost of medical care in the US goes to the middlemen who contribute no value at all, just extract profit.
A 15 minute session with a general practicioner here (CA) costs around $300. That doctor isn't making $1200/hr ($2.5M/yr).
That doctor is likely only making a bit over 200K: https://www.salary.com/research/salary/benchmark/family-phys...
The other $2M+ are going hangers-on who're not contributing to health care, just inserting themselves into the chain to get rich. Take a look at the billions in revenue collectively by all insurance companies. That's all a tax on health care that provides no value.
Huh? You'd need to look at billions in profit, not revenue, since insurance does pay out for the cost of care. When you look at that, the margin is actually lower than most industries. It is true that there are a lot of middlemen with hands in the pot but it's not quite that simple.
The biggest driver of healthcare is that Americans just consume a lot of it. We get surgeries, we opt for long, expensive treatments at the end of our lives, we use extremely sophisticated and expensive medical equipment a lot, we pay people to take care of our old people exorbitant sums of money.
Like, in other countries, when your lungs and kidneys start going, you don't go to the hospital for a multiple surgery. When you fall and you can't move around and wipe your own ass, you don't get moved into a facility where people are paid to take care of you, you move in with your family. And, if you don't have those options, you die.
I'm with you that the system is fucked but the underlying reason doesn't _really_ have anything to do with greed in medicine and everything to do with the way that we treat medicine culturally: the duty that children (don't, in this country) have to care for their elders, the attitude we have about prolonging death. That every part of the medical system says: we will never, ever make the decision to let someone pass away, even when "fixing" their problem (of death!) with all the technology and labor we've got turns out to be ludicrously expensive.
The biggest driver of healthcare is that Americans just consume a lot of it. We get surgeries, we opt for long, expensive treatments at the end of our lives, we use extremely sophisticated and expensive medical equipment a lot, we pay people to take care of our old people exorbitant sums of money.
Like, in other countries, when your lungs and kidneys start going, you don't go to the hospital for a multiple surgery. When you fall and you can't move around and wipe your own ass, you don't get moved into a facility where people are paid to take care of you, you move in with your family. And, if you don't have those options, you die.
I'm with you that the system is fucked but the underlying reason doesn't _really_ have anything to do with greed in medicine and everything to do with the way that we treat medicine culturally: the duty that children (don't, in this country) have to care for their elders, the attitude we have about prolonging death. That every part of the medical system says: we will never, ever make the decision to let someone pass away, even when "fixing" their problem (of death!) with all the technology and labor we've got turns out to be ludicrously expensive.
> profit, not revenue
No, because profit is substracting all the operating costs of the insurance company, including salaries of hundreds of thousands of paper pushers and multi-million dollar bonuses to their executives. All of this is just overhead that provides no health-care value and can be eliminated.
No, because profit is substracting all the operating costs of the insurance company, including salaries of hundreds of thousands of paper pushers and multi-million dollar bonuses to their executives. All of this is just overhead that provides no health-care value and can be eliminated.
It's not that the standards are high, it's that they are protectionist. I think one of the biggest hurdles is the US residency requirements.
Everything you say is true, though.
Everything you say is true, though.
The United State's healthcare don't even appear in any "Top-10 global healthcare" rankings available anywhere, and are consistently overshadowed by many European countries, Singapore, Australia, Japan etc. I don't think you can use "extremely high standards restricting who can practice medicine" as reasoning when it doesn't appear to impact the quality of care at all.
They state early in the article that this research details how to tackle those three issues without resorting to Medicare for All.
If we do medicare for all or some other kind of universal healthcare in the US we're also going to need to train doctors way more cheaply than we do now. At the least we're going to need to offer free or heavily subsidized education to incentivize more people to go into medicine without graduating with debt higher than many mortgages.
The supply of doctors in a lot of primary care roles is supplemented by Nurse Practitioners and Physicians Assistants who have less restricted licensing bodies. Like NPs and PAs aren't required to go thru residency and can switch specialties more easily than a doctor.
The bottleneck is the cost of medical school. That cost is linked to the colleges raising prices because they can.
Medicare for All will surely help this, but free college will help as well.
The U.S. is like a dysfunctional family where the parents will not pay for the kids college even though they have the money.
Medicare for All will surely help this, but free college will help as well.
The U.S. is like a dysfunctional family where the parents will not pay for the kids college even though they have the money.
The cost of medical school is not a bottleneck. Lower prices would be nice, but even with current high prices all accredited medical schools have essentially full enrollment.
The real bottleneck is in lack of federal funding for residency programs. Every year students graduate from medical school with an MD but are unable to practice medicine because they don't get matched to a residency slot.
The real bottleneck is in lack of federal funding for residency programs. Every year students graduate from medical school with an MD but are unable to practice medicine because they don't get matched to a residency slot.
Demand is also "artificially" driven up by the American diet and lifestyle.
If the preventables (e.g., Type 2 Diabetes) were prevented, otherwise mitigated (less sugar!) then the resources / system could focus on real disease.
The issue with the USA is it wants its cake, it wants to eat it, and expects to pay less for consistently making unhealthy choices.
If the preventables (e.g., Type 2 Diabetes) were prevented, otherwise mitigated (less sugar!) then the resources / system could focus on real disease.
The issue with the USA is it wants its cake, it wants to eat it, and expects to pay less for consistently making unhealthy choices.
Sure but most other countries are on track to have the same diet and lifestyle health problems as the USA. They're running a few years behind us but they'll catch up eventually.
Germany doesn't.
I can think of plenty other European countries.
I can think of plenty other European countries.
Germany has a high rate of obesity just like most comparable countries.
I worked in a hospital for 13 years. The economic incentives for the current system are quite perverse.
The FDA has no cost constraints and so maximizes safety instead of QALYs.
Medical equipment and drug manufacturers maximize profit and so fill the highest margin niches first instead of maximizing QALYs.
Radiology and lab services are lucrative and separate themselves from clinical providers to maximize profits instead of QALYs.
Individual physicians and especially surgeons can maximize profits by having their own practices vs. hospital or clinic environments where coordinated care maximizes QALYs.
Hospitals and clinics and especially ERs, cancer treatment, and skilled nursing facilities try to make ends meet with inpatient population and try to hold on to outpatient surgery, radiology, and lab services to make ends meet while providing whatever level of coordinated care they can, but still optimizing for profit over QALYs.
Insurance companies maximize profits by building actuarial plans that stratify patient populations by plan cost, skewing the burden of healthcare costs to the unemployed, underemployed, and low wage earners. A patient becoming uninsured is an economic win for insurance companies and employers. QALYs are proxied by cost/patient/year for anyone managing to stay insured which ignores deductibles, co-insurance and other out of pocket pay.
Medicare and medicaid programs are left to pick up the pieces by trying to piece together effective care with compensation restricted by arbitrary budgets and arbitrary service providers (many specialists, independent physicians, and facilities flatly refuse medicare/medicaid patients).
Actual patients have no clue how any of this works and end up with a pile of bills they try to pay off or if they know the trick they negotiate with the healthcare provider to settle for something slightly above the ~2% face value of debts written off to debt collectors who will hound sick people and their families incessantly.
Maximizing QALYs is hard enough in a centralized single-payer or universal healthcare system. Almost nothing in the U.S. healthcare system is aligned with that goal.
The FDA has no cost constraints and so maximizes safety instead of QALYs.
Medical equipment and drug manufacturers maximize profit and so fill the highest margin niches first instead of maximizing QALYs.
Radiology and lab services are lucrative and separate themselves from clinical providers to maximize profits instead of QALYs.
Individual physicians and especially surgeons can maximize profits by having their own practices vs. hospital or clinic environments where coordinated care maximizes QALYs.
Hospitals and clinics and especially ERs, cancer treatment, and skilled nursing facilities try to make ends meet with inpatient population and try to hold on to outpatient surgery, radiology, and lab services to make ends meet while providing whatever level of coordinated care they can, but still optimizing for profit over QALYs.
Insurance companies maximize profits by building actuarial plans that stratify patient populations by plan cost, skewing the burden of healthcare costs to the unemployed, underemployed, and low wage earners. A patient becoming uninsured is an economic win for insurance companies and employers. QALYs are proxied by cost/patient/year for anyone managing to stay insured which ignores deductibles, co-insurance and other out of pocket pay.
Medicare and medicaid programs are left to pick up the pieces by trying to piece together effective care with compensation restricted by arbitrary budgets and arbitrary service providers (many specialists, independent physicians, and facilities flatly refuse medicare/medicaid patients).
Actual patients have no clue how any of this works and end up with a pile of bills they try to pay off or if they know the trick they negotiate with the healthcare provider to settle for something slightly above the ~2% face value of debts written off to debt collectors who will hound sick people and their families incessantly.
Maximizing QALYs is hard enough in a centralized single-payer or universal healthcare system. Almost nothing in the U.S. healthcare system is aligned with that goal.
For anyone else who didn't know, QALY stands for "Quality-adjusted life year."
Four pigs of health care:
- providers (doctors, hospitals) - drug/device companies - lawyers - insurance companies
All of them point to someone else to blame and defend their part of the trough with knives. All have very developed lobbying arms and are fully entrenched in congressional election funding.
I mean, the Bush Administration started part D medicare. Republicans. An entirely new entitlement.
- providers (doctors, hospitals) - drug/device companies - lawyers - insurance companies
All of them point to someone else to blame and defend their part of the trough with knives. All have very developed lobbying arms and are fully entrenched in congressional election funding.
I mean, the Bush Administration started part D medicare. Republicans. An entirely new entitlement.
Well, that's because Americans have an aversion to QALYs. It might be related to the idea that the country is fundamentally Christian in a deep way.
A common accusation of anyone attempting to do a QALY based system would be that they are "sacrificing grandma for the dollar".
The recent COVID crisis is an example where QALY based evaluations (which may well have gone either way) were summarily considered "putting a number on the value of a life".
In that respect, it's not that the institutions are perverted but that the society they are in prefers them this way.
A common accusation of anyone attempting to do a QALY based system would be that they are "sacrificing grandma for the dollar".
The recent COVID crisis is an example where QALY based evaluations (which may well have gone either way) were summarily considered "putting a number on the value of a life".
In that respect, it's not that the institutions are perverted but that the society they are in prefers them this way.
> The recent COVID crisis is an example where QALY based evaluations (which may well have gone either way) were summarily considered "putting a number on the value of a life".
I think a clarification is that a lot of U.S. citizens agree with putting a number on the value of a life but they value lives by the amount of wealth a particular life owns. What they actually don't like is the perception of having to pay their own money for other lives that they don't particularly value while simultaneously discounting their own risk of catastrophic medical costs. Irrational self-dis-interest, to coin a term.
I think a clarification is that a lot of U.S. citizens agree with putting a number on the value of a life but they value lives by the amount of wealth a particular life owns. What they actually don't like is the perception of having to pay their own money for other lives that they don't particularly value while simultaneously discounting their own risk of catastrophic medical costs. Irrational self-dis-interest, to coin a term.
You know, I'd agree, except that the criticisms were directed at people who claimed that there may be some balance of kick-starting the economy (saving some number of QALYs) and allowing some number of people to die (losing other QALYs).
are you saying Christians are against quality life?
Their solution in the TFA is to focus on straight-through billing through standardization of payment mechanisms, arguing that each physician is paying $100K / year. Of course, this also puts the lie to the insurance companies, who are the other side of the transaction and essentially add another 20% in cost just to pay the bill! (Their loss ratios due to medical costs are about 80%.)
Insurance companies are basically just bill paying services, as almost all employer sponsored healthcare is self-insured by the employer as the risk pool is large enough to take care of the true "insurance" nature of the mutual pooling of risks.
So how do you think insurance companies will react to making it "easier to pay the bill through standardization?"
Chance of movement = zero.
Insurance companies are basically just bill paying services, as almost all employer sponsored healthcare is self-insured by the employer as the risk pool is large enough to take care of the true "insurance" nature of the mutual pooling of risks.
So how do you think insurance companies will react to making it "easier to pay the bill through standardization?"
Chance of movement = zero.
One of the big lies is that Insurance Companies have an incentive (aligned with the customer) to lower costs.
In fact Insurance Companies have an incentive to pay no more than competition, but for costs to rise. Due to regulated %overhead this is one of the few ways they increase profits every year.
To maintain current inflation adjusted stock valuations (based on earnings and growth) Insurance companies need prices to rise and they are incentivized to produce this outcome. Surprise!
In fact Insurance Companies have an incentive to pay no more than competition, but for costs to rise. Due to regulated %overhead this is one of the few ways they increase profits every year.
To maintain current inflation adjusted stock valuations (based on earnings and growth) Insurance companies need prices to rise and they are incentivized to produce this outcome. Surprise!
Agreed, the insurance companies are effectively capped on the profits they can declare, otherwise they'll expose themselves to regulation and stricter price controls.
So that's how places like UnitedHealthCare have such exhorbitant salaries and a bloated executive structure. It's the same as colleges, which also have constantly expanding revenues but are "nonprofit". So a vampiric parasitic management class attach themselves to the organization and suck all the money away, while costs soar.
So that's how places like UnitedHealthCare have such exhorbitant salaries and a bloated executive structure. It's the same as colleges, which also have constantly expanding revenues but are "nonprofit". So a vampiric parasitic management class attach themselves to the organization and suck all the money away, while costs soar.
My reaction exactly. This article basically says we can achieve much of the savings of Medicare for all if insurance companies and providers put aside self-interest to voluntarily and in a coordinated manner adopt the aspects of Medicare for all that reduce costs! And if apes had tails they'd be monkeys!
I just started at a health insurance startup that is doing exactly what the article recommends: simplifying billing. Patients pay for procedures "in cash", using a card debiting the insurance company's account. Because doctors charge less for people paying in cash, the insurance is cheaper than traditional insurance.
We're already operating in a few markets. It'll be interesting to see how the traditional insurance companies react once we start significantly encroaching on their market share.
We're already operating in a few markets. It'll be interesting to see how the traditional insurance companies react once we start significantly encroaching on their market share.
Cut out the insurance company and drop 20% out of the system.
Hope it fixes medical inflation (it won’t) or you’ll be back to the same place in 3-4 years.
Hope it fixes medical inflation (it won’t) or you’ll be back to the same place in 3-4 years.
Worthless paper, administrative costs is only a piece of the many issues with US "Healthcare". Medicare For All is the better and cheaper way forward. No one ever talks about what is the value all these Health Insurance companies bring? The whole point of their existence when they were created was to control costs. Obviously they have failed miserably. Medicare For All handles lowering or eliminating student loans for Doctors and Nurses. It regulates costs for pharmaceuticals and medical equipment. By having the government be the insure. It relieves business on having to provide insurance and creates a much healthier workforce. It would also create an explosion of entrepreneurship. Now that insurance isn't tied to a job.
> ...Medicare For All is the better and cheaper way forward.
I'm puzzled why the article prefaces one of its rationales with this:
'...“With Medicare for All seemingly off the table, our paper suggests we can still tackle administrative costs through structural changes to the payment process,” said Kevin Schulman, MD, MBA, ...'
Why is that Medicare for All is off the table?
I'm puzzled why the article prefaces one of its rationales with this:
'...“With Medicare for All seemingly off the table, our paper suggests we can still tackle administrative costs through structural changes to the payment process,” said Kevin Schulman, MD, MBA, ...'
Why is that Medicare for All is off the table?
Thats by design. Every major player is trying to make Medicare For All go away. They don't want to lose there golden egg. Insurance companies, Pharmaceutical companies, Pro Capitalists organizations, Medical device vendors, etc
> Why is that Medicare for All is off the table?
Perhaps because of this:
https://www.politifact.com/factchecks/2020/mar/10/facebook-p...
Perhaps because of this:
https://www.politifact.com/factchecks/2020/mar/10/facebook-p...
Or we could make it legal to open hospitals, or charge differential pricing based on the time of day... you know, basic stuff?
Most people have no idea how captured healthcare is. There's no competition, indeed most healthcare is government granted monopolies already.
Having lived in countries with "free" healthcare, that isn't all it's cracked up to be either. A good example of cost cutting: just make the disease illegal, like ADHD in the UK. If it doesn't exist, nobody can claim medication for it. Problem solved.
Most people have no idea how captured healthcare is. There's no competition, indeed most healthcare is government granted monopolies already.
Having lived in countries with "free" healthcare, that isn't all it's cracked up to be either. A good example of cost cutting: just make the disease illegal, like ADHD in the UK. If it doesn't exist, nobody can claim medication for it. Problem solved.
The rest of your post I agree with but
> just make the disease illegal, like ADHD in the UK
What in the world are you talking about?[1]
1. https://www.nhs.uk/conditions/attention-deficit-hyperactivit...
> just make the disease illegal, like ADHD in the UK
What in the world are you talking about?[1]
1. https://www.nhs.uk/conditions/attention-deficit-hyperactivit...
You need a psychiatric evaluation for diagnosis, which is exceptionally hard to get. So there's a nice shiny website and then there's the reality. Getting the diagnosis and then medication can literally take years, and it looks like this is on purpose.
So not actually "illegal", just a different bar for diagnosis. Also, do you not need a psychiatric evaluation in other countries?
You make some good points otherwise, I don't understand why you're resorting to hyperbole or distortion like this.
You make some good points otherwise, I don't understand why you're resorting to hyperbole or distortion like this.
No, you don't. For adults it should be either a psychiatrist or a doctor with training and expertise; for children it should be a paediatrician.
https://www.nice.org.uk/guidance/ng87/chapter/Recommendation...
> 1.3.1 A diagnosis of ADHD should only be made by a specialist psychiatrist, paediatrician or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD, on the basis of:
https://www.nice.org.uk/guidance/ng87/chapter/Recommendation...
> 1.3.1 A diagnosis of ADHD should only be made by a specialist psychiatrist, paediatrician or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD, on the basis of:
The alternative take is that ADHD is over diagnosed in the United States.
Prescribing data is open. We can easily see plenty of ADHD meds being prescribed.
Lisdexamfetamine Dimesylate https://openprescribing.net/chemical/0404000U0/
Methylphenidate Hydrochloride https://openprescribing.net/chemical/0404000M0/
Atomoxetine Hydrochloride https://openprescribing.net/chemical/0404000S0/
There are problems with lots of NHS treatment. You don't need to spread misinformation.
Lisdexamfetamine Dimesylate https://openprescribing.net/chemical/0404000U0/
Methylphenidate Hydrochloride https://openprescribing.net/chemical/0404000M0/
Atomoxetine Hydrochloride https://openprescribing.net/chemical/0404000S0/
There are problems with lots of NHS treatment. You don't need to spread misinformation.
Have you ever actually had someone on medicare navigate healthcare?
Its only partial coverage and the supplemental plans also are partial. Retirees regularly rake up thousands a year in medical expenses on medicare.
If anything we need medicaid for all. Its a total mess with the piecemeal systems that exist, but in PA at least (where I live) medicaid recipients pay like a dollar for basically any service. None of the copay nickle and diming (to the tune of $30 a pop) my grandmother is hounded with constantly.
And even that is a bitter pill. Its giving private insurance companies all the money and power still. The single payer has strong negotiating power but they still have to get someone to insure the citizenry and the cartel of insurers that exist can predate off that and do so eagerly.
Its only partial coverage and the supplemental plans also are partial. Retirees regularly rake up thousands a year in medical expenses on medicare.
If anything we need medicaid for all. Its a total mess with the piecemeal systems that exist, but in PA at least (where I live) medicaid recipients pay like a dollar for basically any service. None of the copay nickle and diming (to the tune of $30 a pop) my grandmother is hounded with constantly.
And even that is a bitter pill. Its giving private insurance companies all the money and power still. The single payer has strong negotiating power but they still have to get someone to insure the citizenry and the cartel of insurers that exist can predate off that and do so eagerly.
Medicare For All is not just an extension of the existing Medicare. It expands it to everyone and fixes some of those holes. Medicaid would still be there for services outside MFA like senior long term care.
So it’s like “defund the police” where they don’t actually mean defund the police?
>It regulates costs for pharmaceuticals and medical equipment.
This is an underappreciated requirement if we want to significantly lower costs. Drug patents, medical device patents and illogical government regulations imposed by corrupt and incompetent regulators lead to massive costs for patients. Allowing drug to charge hundreds or thousands of dollars for a dose of a drug that costs .50 cents to manufacture is an atrocity. This is doubly true since a large portion of medical research that these patents rely on is done by publicly funded research at universities and research clinics. Patent laws need to be completely rewritten to allow for a decent return on investment while disallowing price gouging.
This is an underappreciated requirement if we want to significantly lower costs. Drug patents, medical device patents and illogical government regulations imposed by corrupt and incompetent regulators lead to massive costs for patients. Allowing drug to charge hundreds or thousands of dollars for a dose of a drug that costs .50 cents to manufacture is an atrocity. This is doubly true since a large portion of medical research that these patents rely on is done by publicly funded research at universities and research clinics. Patent laws need to be completely rewritten to allow for a decent return on investment while disallowing price gouging.
Free goods have infinite demand. Medicare for All will simply degrade outcomes a lower common denominator. Interestingly, will the government allow private medical practices to exist in a Medicare for All regime? If so, it seems we would simply end up where we are now.
With Medicare For All the government would act as an insurer, that is all. All hospital services stay private.
The introduction of high-deductible health care plans has accelerated consumerism (shopping for best deal) in health care delivery driving down costs.
Deloitte study: https://www2.deloitte.com/content/dam/Deloitte/tr/Documents/...
Deloitte study: https://www2.deloitte.com/content/dam/Deloitte/tr/Documents/...
But it would be paid for by taxes spread across the tax-paying citizens. It would appear to all people in the US that their healthcare is free as they are not directly paying for it. Hence infinite demand.
That’s the worst argument I’ve ever heard against Medicare for All.
Rephrased in another way, you’re saying “the plebs are going to get medical treatment and overwhelm the system by doing so if we let them!”
I don’t think there is infinite demand for healthcare as people are not infinitely sick.
Rephrased in another way, you’re saying “the plebs are going to get medical treatment and overwhelm the system by doing so if we let them!”
I don’t think there is infinite demand for healthcare as people are not infinitely sick.
But they may be excessively worried that they are sick and demand excess testing and excessive stays in hospitals.
This isn't a free sandwich promotion that ends with irrational people waiting hours in line! People are not going to go hangout in doctors offices, hospitals, clinics, etc... for fun. Most people that have good insurance, like myself, almost never go to the doctor because it's a pain, not because of a co-pay.
And if by some chance there is a big increase the use of medical care / services ... maybe that's a good thing, that people are going and finding issues before they become severe life threatening issues and everyone saves more overall in the long run. And they have better quality of life and less suffering from going untreated... Did you consider that?
And if by some chance there is a big increase the use of medical care / services ... maybe that's a good thing, that people are going and finding issues before they become severe life threatening issues and everyone saves more overall in the long run. And they have better quality of life and less suffering from going untreated... Did you consider that?
> Free goods have infinite demand.
I, too make unnecessary doctor appointments and hospital trips because my insurance covers them. I've developed a paraphilia for having blood drawn, and I'm considering having some perfectly functional limbs amputated.
I, too make unnecessary doctor appointments and hospital trips because my insurance covers them. I've developed a paraphilia for having blood drawn, and I'm considering having some perfectly functional limbs amputated.
Silly response.
One study found 20.6% of overall medical care was unnecessary. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5587107/
Simple example is testing. If free to consumer, they will get too many cat scans and other expensive tests, "just in case."
One study found 20.6% of overall medical care was unnecessary. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5587107/
Simple example is testing. If free to consumer, they will get too many cat scans and other expensive tests, "just in case."
Testing is “free” to the provider, so they suggest it just in case.
The much maligned HMO was an early attempt at applying market discipline to medical care. Guess what? People hated it.
The much maligned HMO was an early attempt at applying market discipline to medical care. Guess what? People hated it.
> The much maligned HMO was an early attempt at applying market discipline to medical care. Guess what? People hated it.
HMOs remain common, and none of the satsifaction data I can find shows satisfaction with them significantly lower than PPOs or traditional insurance. Not sure why you act like they are something that exist only in the past or universally hated.
HMOs remain common, and none of the satsifaction data I can find shows satisfaction with them significantly lower than PPOs or traditional insurance. Not sure why you act like they are something that exist only in the past or universally hated.
>The most common cited reasons for overtreatment were fear of malpractice (84.7%), patient pressure/request (59.0%), and difficulty accessing medical records (38.2%).
so not relevant to this coversation.
so not relevant to this coversation.
LOL...love it
There are two issues in healthcare. Efficiency and and access.
Medicare for all solves the access problem, but it doesn't do anything for the efficiency problem.
Medicare for all solves the access problem, but it doesn't do anything for the efficiency problem.
Do you know why efficiency is such a problem? Its because people put off going to the doctor because THEY CAN'T AFFORD IT!. Thats why vists sky rocket when people become eligible for Medicare.
https://www.uclahealth.org/u-magazine/u-s-ranks-near-bottom-...
Your link doesn't have any analysis on how preventive care is the cause of increased costs.
But there are lots of ways that are obviously not related to preventative care that drive up costs.
Our doctors and nurses make way more money than doctors and nurses in other countries.
We spend more money on questionable, or low yield procedures that have low returns that other countries don't.
Not to mention medicine just isn't that good at preventative care. The only real preventative medicine are diabetes medications and cardiovascular medications.
But there are lots of ways that are obviously not related to preventative care that drive up costs.
Our doctors and nurses make way more money than doctors and nurses in other countries.
We spend more money on questionable, or low yield procedures that have low returns that other countries don't.
Not to mention medicine just isn't that good at preventative care. The only real preventative medicine are diabetes medications and cardiovascular medications.
> Worthless paper, administrative costs is only a piece of the many issues with US "Healthcare". Medicare For All is the better and cheaper way forward.
As frustrating and arcane as the current system may be, the government fully in charge for the provisioning (rationing) and financing will only increase 'worthless paper, administrative costs'.
As frustrating and arcane as the current system may be, the government fully in charge for the provisioning (rationing) and financing will only increase 'worthless paper, administrative costs'.
This is clearly not the case with Medicare. The only guaranteed savings with M4A is in administrative costs.
edit: even the researchers in the linked article doesn't claim to reduce administrative overhead as much as M4A, they claim to be able to get most of the way there.
edit: even the researchers in the linked article doesn't claim to reduce administrative overhead as much as M4A, they claim to be able to get most of the way there.
It's really simple to lower administrative costs, just spend more money and don't look for fraud.
The government would act as an insurer, that is all. All hospital services stay private. And having all medical services have to go through one system to get paid would streamline it SIGNIFICATLY.
Like the IRS has streamlined taxes and the US postal service has streamlined mail delivery?
That’s interesting, because your latter example is pretty excellent. USPS can deliver to anyone in the country (unlike the private companies) and I’d say it’s pretty streamlined. The IRS is definitely in a bad position, but there are two problems: firstly, they’re only enforcing the tax code written by Congress. They can’t just streamline the tax code. Secondly, there are private companies lobbying to prevent the IRS from being as good as it could be. And that will obviously be the same with health care.
As a country, we’ve decided it’s in everyone’s best interest to be able to get mail. Private enterprises cannot solve global access problems because they have no incentive to go the extra mile for the last few people the system can’t reach. (Which is why internet is so shitty in rural parts of the country.)
So why not health care as well? To me, it seems like the problem are solvable.
As a country, we’ve decided it’s in everyone’s best interest to be able to get mail. Private enterprises cannot solve global access problems because they have no incentive to go the extra mile for the last few people the system can’t reach. (Which is why internet is so shitty in rural parts of the country.)
So why not health care as well? To me, it seems like the problem are solvable.
We clearly differ on the USPS. FedEx, UPS, DHL, etc clearly provide superior service for overnight and courier service. Rural service could be solved - it simply has a cost. To your point, "as a country we've decided that it's in everyone's best interest to be able to go get mail." We have also decided to subsidize the cost of the service with metropolitan customers subsidizing the rural (similar to phone service). If the US used taxes to pay a FedEx, there would be better quality service at a lower cost.
Having the government provide the service introduces politics to the operation of running a business. Where should post offices be located, how often should mail be delivered, what products should we offer, should prices vary according to cost to delivery, etc. These issues make the USPS what it is today - a bureaucratic behemoth that is still delivering Christmas cards from 2020.
Having the government provide the service introduces politics to the operation of running a business. Where should post offices be located, how often should mail be delivered, what products should we offer, should prices vary according to cost to delivery, etc. These issues make the USPS what it is today - a bureaucratic behemoth that is still delivering Christmas cards from 2020.
Of course the problems are solvable if you have desirable incentives. But as Pournelles Iron Law of Bureaucracy points out that the incentives to solve the problem are ALWAYS eventually replaced to preserve and grow the bureaucracy. And that’s why a universal, government solution is doomed to fail.
Funny you mention bad rural Internet considering that’s a problem technology and competition is about to solve.
Funny you mention bad rural Internet considering that’s a problem technology and competition is about to solve.
If they are the only payer, they control the prices. And when prices are controlled, shortages are the result.
Right now the buy controls the prices. There is no real negotiation. Think that's better?
Doesn't hold water, USA actually has less doctors per capita than most of the developed world.
Citation needed
We have standardized health care billing in Germany, both for the around 100 public health insurances and the private ones. We still have a relatively expensive health care system when compared with other European countries.
... and much cheaper than the US, currently.
I pay 759€/month for my German public health insurance while in the US according to Google the average cost of platinum insurance (the best?) is $750/month.
Is it calculated as a percentage of income? In that case, it is effectively a tax, and like any progressive taxation, higher income individuals pay more.
Yes it is.
Also of note: when you're insured with a public health insurance in Germany, a spouse and kids without income of their own are automatically insured as well, without extra cost.
Also of note: when you're insured with a public health insurance in Germany, a spouse and kids without income of their own are automatically insured as well, without extra cost.
Your wage is payed from that insurance, so it makes sense that you pay accordingly to what you earn.
That is without employer subsidy or tax credits?
We can purchase insurance from state (ACA state) or federal exchange (non-Aca state), and also from the companies themselves. The cost will be either $0-1500+ Per month per person, yeah it varies a bit. Many employers will charge about $50-150 per month and subsidize the rest.
There are also high deductible plans that they are paying though, but they usually have a $3000-6000+ deductible per person, these are not good if you want to have kids or have a family history of chronic illness.
In my opinion the whole system is a huge inconsistent mess though. They will literally send you bills for hundreds of dollars (got a $350 therapist bill a few months ago) and I had to call them up an very politely tell them that yes I do have insurance with the credit card history to prove I’ve been paying the premiums, and to very politely fuck off.
The bill went away.
We can purchase insurance from state (ACA state) or federal exchange (non-Aca state), and also from the companies themselves. The cost will be either $0-1500+ Per month per person, yeah it varies a bit. Many employers will charge about $50-150 per month and subsidize the rest.
There are also high deductible plans that they are paying though, but they usually have a $3000-6000+ deductible per person, these are not good if you want to have kids or have a family history of chronic illness.
In my opinion the whole system is a huge inconsistent mess though. They will literally send you bills for hundreds of dollars (got a $350 therapist bill a few months ago) and I had to call them up an very politely tell them that yes I do have insurance with the credit card history to prove I’ve been paying the premiums, and to very politely fuck off.
The bill went away.
Half of it is paid by my employer. There are no deductibles (generally) and no surprise bills here but the health insurance is useless for e.g. the dentist, the insurance only pays for the minimum (the joke is they only pay for the removal of teeth and a blender).
But for the sake of comparison I don't have the impression that US health care costs are much worse than in Germany. Certainly not to the extent the internet wants to make one believe.
But for the sake of comparison I don't have the impression that US health care costs are much worse than in Germany. Certainly not to the extent the internet wants to make one believe.
US spends twice as much as Germany per capita on health.
https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
Everything is cheaper than US. Even Switzerland.
Even fairly mundane steps like assigning people uniform medical record numbers, so that every single organization doesn't need its own system, is a heated political issue in the US: https://ehrintelligence.com/news/house-votes-to-overturn-nat...
That's because companies like Epic exist.
Their entire business is fixing impedance mismatches.
Your implicated solution is to eliminate impedance mismatches.
Do you think the major med tech firms will be for or against that? What do you think their lobbyists will recommend?
Their entire business is fixing impedance mismatches.
Your implicated solution is to eliminate impedance mismatches.
Do you think the major med tech firms will be for or against that? What do you think their lobbyists will recommend?
Epic and their competitors never lobbied to retain the national patient identifier ban. The political opposition to national identifiers was based on concerns about patient privacy and federal government overreach.
I'd lay the blame closer to interface engine companies (whose job is often to disambiguate MR#) and individual practices (who don't want the overhead of working with centralized MR# source of truth) since Epic makes an entire EHR and can almost certainly interface with any ADT (admit, discharge, transfer) system as a source of truth for medical records.
Recently I got laser eye surgery to help my vision. This was not covered by my insurance. It also happened to be the simplest medical procedure/payment I ever had to interact with. They told me "this procedure will cost $X.XX and we have a discount we can offer you that will save you X%" I said okay and paid them the money.
Compare that to insurance being involved recently in my wife's diabetes supplies. My wife is a type 1 diabetic and needs supplies that monitor her blood sugar, we noticed her supplies didn't arrive on the scheduled date, we waited a week to see if they would show up and they didn't. My wife called the company that was supposed to send them, they said our account was in collections? Why, we never received a bill, we never were notified, but in collections we were. We eneded up paying and got that sorted out and waited another week, still no supplies. I'll cut it short and just say it took us 3 weeks being on the phone multiple times a day being bounced around between our insurance, the supplier and her dr, to finally get told we couldn't get the supplies because my wife had gotten a new phone and so the insurance company didn't have enough data to prove that she needed these supplies, and wouldn't reauthorize them. The drama is still ongoing.
Let's get this straight a huge part of the healthcare costs are directly related to insurance and the money and laws tied up in that. We need to get rid of insurance, and the way it works if we honestly want to make any change. Any other effort will only further entrench the confusopoly.
Compare that to insurance being involved recently in my wife's diabetes supplies. My wife is a type 1 diabetic and needs supplies that monitor her blood sugar, we noticed her supplies didn't arrive on the scheduled date, we waited a week to see if they would show up and they didn't. My wife called the company that was supposed to send them, they said our account was in collections? Why, we never received a bill, we never were notified, but in collections we were. We eneded up paying and got that sorted out and waited another week, still no supplies. I'll cut it short and just say it took us 3 weeks being on the phone multiple times a day being bounced around between our insurance, the supplier and her dr, to finally get told we couldn't get the supplies because my wife had gotten a new phone and so the insurance company didn't have enough data to prove that she needed these supplies, and wouldn't reauthorize them. The drama is still ongoing.
Let's get this straight a huge part of the healthcare costs are directly related to insurance and the money and laws tied up in that. We need to get rid of insurance, and the way it works if we honestly want to make any change. Any other effort will only further entrench the confusopoly.
Several years ago, I lived in a country where I had high-deductible private insurance in lieu of the (then relatively new) national healthcare plan.
I was able to walk into a fairly large hospital, get a full battery of tests along with a thankfully minor diagnosis and medication for a small amount of money paid up front. The bill was itemized, translated, and I received excellent customer service.
I was able to walk into a fairly large hospital, get a full battery of tests along with a thankfully minor diagnosis and medication for a small amount of money paid up front. The bill was itemized, translated, and I received excellent customer service.
Time dealing with our shitty medical billing system is a huge hidden cost of it. I'm also not sure how well accountings of US healthcare costs factor in things like the hours HR folks spend negotiating rates, or government folks in areas related to benefits et c. have to screw around with sorting out who has what private insurance.
Simpler question is why you have to go through your health care insurer to buy the diabetes supplies. One of the distortions of having healthcare insurance paid for by companies is it makes it tax deductible. Thus $100 spent on healthcare by the company only costs them $60. If you paid the expense directly, it would cost you $100.
Imagine if auto insurance were eligible to be provided by your company as a tax deductible expense. We would all be buying our gasoline through our car insurance company.
Imagine if auto insurance were eligible to be provided by your company as a tax deductible expense. We would all be buying our gasoline through our car insurance company.
I have had some private pay medical treatment and can concur. Come in, write the check/present the card, and walk out. Fortunately it wasn't very expensive.
You're talking about an elective procedure, too, re: your laser eye surgery. Arguably there's "sales" involved.
I required a non-elective procedure not covered by my grandfathered pre-ACA insurance back in 2014. I attempted to "shop" the procedure around. It was was not at all easy. I would have rather dealt with insurance.
I required a non-elective procedure not covered by my grandfathered pre-ACA insurance back in 2014. I attempted to "shop" the procedure around. It was was not at all easy. I would have rather dealt with insurance.
Sorry to hear about your ongoing issues. Sadly, it's the same story thousands of times per day, often for people experiencing the final moments of their lives.
The healthcare insurance industry absolutely needs to be destroyed.
One day, we'll look back at this debacle similar to cigarettes, big industry manipulating the population and millions of people dying unnecessarily because of it.
It's time to end the suffering.
The healthcare insurance industry absolutely needs to be destroyed.
One day, we'll look back at this debacle similar to cigarettes, big industry manipulating the population and millions of people dying unnecessarily because of it.
It's time to end the suffering.
I'm skeptical, because a key element of the US payment system is that everyone is highly motivated to shift costs to someone else, to be paid more money and to pay out less money, so doctors hire armies of accountants to do battle with similar armies deployed by insurance companies, hospitals, and drug companies. How will they fix that?
[deleted]
I think under "administrative costs" they might have hidden consolidation of the providers market. Anecdote: I wen to podiatrist about 4 years ago and now. The same doctor the same place, everything is the same. Except 4 years ago it was ~ $200 per visit, now I am looking at ~$350. What's changed? His practice became part of the big group footandankle. Similar situation happens with other specialists and family doctors, hospital networks consolidate all they could find in vicinity under their roof. There's no promised administrative cost reduction. Everything goes up in price. But apparently it's a "faux pas" to criticize hospital networks because somehow it reflects may reflect bad on the doctors.
> Estimates suggest that the country wastes more than $265 billion annually due to this administrative complexity, and that the rate of increase in administrative costs has outpaced that of overall health care expenditures
This happens for a reason. A 265 Billion industry (however fragmented) has developed to create/maintain and profit off the complexity. I am extremely pessimistic that they will allow this to be fixed. It might be just too big to fail at this point. However, it might plague "medicare for all" systems too, unless it's completely a separate system somehow. These entities will make every effort to get into the "medicare for all" flows as well.
This happens for a reason. A 265 Billion industry (however fragmented) has developed to create/maintain and profit off the complexity. I am extremely pessimistic that they will allow this to be fixed. It might be just too big to fail at this point. However, it might plague "medicare for all" systems too, unless it's completely a separate system somehow. These entities will make every effort to get into the "medicare for all" flows as well.
Private insurance companies are already deeply ingrained in Medicare, and I’m not just talking about Medicare Advantage. HHS has 5 or 6 large regional contracts where they have a private insurance company handle most of the administration. Uncle Sugar just pays the bills.
Which isn’t really too much different from private insurance at a large employer: Cigna or whoever just brings admin and a network of providers, while your employer pays the bills out of some actuarially sound pool of money.
Smaller employers can’t usually swing this, and that’s where the crappy rates come from.
Which isn’t really too much different from private insurance at a large employer: Cigna or whoever just brings admin and a network of providers, while your employer pays the bills out of some actuarially sound pool of money.
Smaller employers can’t usually swing this, and that’s where the crappy rates come from.
Considering how enmeshed everything is at Standard is with private sector businesses, and how many of these businesses can prosper due to these inefficiencies, I am quite skeptical.
Even if the particular businesses these professors work with stand to gain from such reform, this sort of approach that thinks we can technocrat our way around the antagonism that is precisely why things like medicare-for-all are so difficult seems incredibly politically naive.
Even if the particular businesses these professors work with stand to gain from such reform, this sort of approach that thinks we can technocrat our way around the antagonism that is precisely why things like medicare-for-all are so difficult seems incredibly politically naive.
Some have noted 'bottlenecks' at the MD entrance level.
There is an opportunity to allow for procedural specialization so that 'techs' can do a lot of the work normally done by docs and nurses.
'Early detection' is a new, major shift in how medicine works, because the things we get now 'come on slowly in a hidden way'. Allowing for technical specialists to run operationalized testing with standards, clear rules etc. may enable us to get costs down and possibly improve outcomes.
My bet is that someone with very narrow and focused training may be even 'better' at that thing - so long as we can put a nice dotted line around it because of course it's always more complicated than just 'one thing'.
Perhaps requiring 'best price' for all so that individual payers can get the same price as insurers might work, though it's not exactly 'free market' it mostly is. Transparency - so that everything is published and public might work as well.
It may also be worth not billing specifically for low-cost materials used, and just roll it into the type of visit.
There is an opportunity to allow for procedural specialization so that 'techs' can do a lot of the work normally done by docs and nurses.
'Early detection' is a new, major shift in how medicine works, because the things we get now 'come on slowly in a hidden way'. Allowing for technical specialists to run operationalized testing with standards, clear rules etc. may enable us to get costs down and possibly improve outcomes.
My bet is that someone with very narrow and focused training may be even 'better' at that thing - so long as we can put a nice dotted line around it because of course it's always more complicated than just 'one thing'.
Perhaps requiring 'best price' for all so that individual payers can get the same price as insurers might work, though it's not exactly 'free market' it mostly is. Transparency - so that everything is published and public might work as well.
It may also be worth not billing specifically for low-cost materials used, and just roll it into the type of visit.
Can anyone grok what the actual proposed reforms are? It’s missing from the article.
Looks like it's mostly an abstract of something that was published in a journal but they hint at it saying 3 scenarios: simplifying/streamlining individual plans, standardizing plans across all groups ie. more standardization, and a combination of those two things. This would lead to less complexity and administrative overhead which would lead to savings etc.
I'm not much for the genius of government to correct things, but you really can make a strong argument for the standardization to a small number of insurance plans with stated rules, third party arbitration, etc.
You would definitely see more of a free market by producing fungible products with (hopefully) a bit less obfuscation. The insurance companies would still do their best to not cover a claim of course, so this is only a partial solution.
One nice side effect is that it's a small nudge in an organically 'designed' system rather than the inevitable chaos by changing the whole machine at once.
If you believe in single payer healthcare, it would be easy to attach redesigns in cash inflow to a set of standardized policies.
I've always admired the size of office staff in a doctor's office, no doubt mostly due to the complexity of the cashflow in the backend. Perhaps simplification of billing would result in less bookkeeping and more caregivers.
You would definitely see more of a free market by producing fungible products with (hopefully) a bit less obfuscation. The insurance companies would still do their best to not cover a claim of course, so this is only a partial solution.
One nice side effect is that it's a small nudge in an organically 'designed' system rather than the inevitable chaos by changing the whole machine at once.
If you believe in single payer healthcare, it would be easy to attach redesigns in cash inflow to a set of standardized policies.
I've always admired the size of office staff in a doctor's office, no doubt mostly due to the complexity of the cashflow in the backend. Perhaps simplification of billing would result in less bookkeeping and more caregivers.
Yes, I'm bullish on the potential savings of standardization, of course in healthcare the devil is in the details so it matters what they mean by those things.
Exactly right. I hate even having an opinion on this kind of thing. Software people tend to be filled with concepts on the way-things-oughtta-be-why-are-people-so-stupid usually without any domain knowledge and it's good to watch out for that tendency.
Medicine is like tax law, there's a whole lot to it. Some historical, some arbitrary, some greed, some altruism.
Medicine is like tax law, there's a whole lot to it. Some historical, some arbitrary, some greed, some altruism.
Or perhaps look at other western countries that don't have any of this vampire squid stuff.
Like Japan that has a published book which contains the prices for all procedures.
https://en.wikipedia.org/wiki/Health_care_system_in_Japan#Co...
https://en.wikipedia.org/wiki/Health_care_system_in_Japan#Co...
>simplifying/streamlining individual plans, standardizing plans across all groups ie. more standardization, and a combination of those two things
It's the factory system, but for health care!
It's the factory system, but for health care!
I thought a major aspect was also standardizing contracts between insurers and providers.
By analogy, automobiles would be cheaper if you could only by green sedans using an online portal. Sure it would be less expensive, but you also eliminate many choices.
The problem with healthcare is that inefficiency and lack of transparency is profitable.
The government has deep pockets, and everyone is trying to get as much money as they can from it. Pharmaceutical industries, insurance providers, healthcare facilities, etc.
Pharmaceutical research is important and expensive, but there must be a way for that research to happen without doing stupid shit like making insulin expensive.
Labor costs in healthcare are high, but there must be a way to not make a bag of water with salt not cost $500.
People pay for costs that are completely unrelated for the products and services they are receiving.
The government has deep pockets, and everyone is trying to get as much money as they can from it. Pharmaceutical industries, insurance providers, healthcare facilities, etc.
Pharmaceutical research is important and expensive, but there must be a way for that research to happen without doing stupid shit like making insulin expensive.
Labor costs in healthcare are high, but there must be a way to not make a bag of water with salt not cost $500.
People pay for costs that are completely unrelated for the products and services they are receiving.
This speaks about standardizing contracts but neglects to mention that the competing proprietary electronic medical record standards also add cost, complexity, and increase medical errors.
And there are still about 14 other layers of the healthcare onion to peel.
Medical talent is kept artificially scarce thanks to the lobbying and control of licensing by the AMA. We should hand control of licensing over to the AARP and the March of Dimes instead.
Hospitals and insurance have perverse incentives because they are separate. But when insurance and provisioning is combined as with Kaiser Permanente, then incentives are aligned and bureaucracy can be streamlined.
Hospital consortiums currently carve up monopolies within a given piece of turf. We should break that up, and allow a proliferation of low-cost community clinics for less advanced procedures.
And this hasnt even covered obscene pharmaceutical costs, electronic medical device manufacturers, the diagnostic industry oligopoly, and so on.
And there are still about 14 other layers of the healthcare onion to peel.
Medical talent is kept artificially scarce thanks to the lobbying and control of licensing by the AMA. We should hand control of licensing over to the AARP and the March of Dimes instead.
Hospitals and insurance have perverse incentives because they are separate. But when insurance and provisioning is combined as with Kaiser Permanente, then incentives are aligned and bureaucracy can be streamlined.
Hospital consortiums currently carve up monopolies within a given piece of turf. We should break that up, and allow a proliferation of low-cost community clinics for less advanced procedures.
And this hasnt even covered obscene pharmaceutical costs, electronic medical device manufacturers, the diagnostic industry oligopoly, and so on.
I started a project last week requiring me to learn the proprietary EDI file format that CMS mandates. I was surprised to learn that in order to exchange healthcare data with our government we have to use a file format owned by a private entity. And of course you have to pay to get access to the full implementation documentation.
This headline by itself could be a stand-alone Simpsons joke.
Universal Healthcare, free at the point of delivery.
Link to the actual paper (paywall): https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.13649
So how do they plan on getting private capitalist enterprise to start implementing reforms that would lower their profits? Because by definition administrative cost to the consumer is profit for the company.
I disagree with the assertion "administrative cost to the consumer is profit for the company." Anyone who has looked at customer support expense from a company's perspective knows it is a burden that the company would gladly do away with.
What was not discussed in the paper was the effect the administrative complexities have on creating a moat are health care plans. The greater the complexity, the less healthcare providers will want to associate with multiple healthcare organizations/insurance companies.
What was not discussed in the paper was the effect the administrative complexities have on creating a moat are health care plans. The greater the complexity, the less healthcare providers will want to associate with multiple healthcare organizations/insurance companies.
By making it possible for them to compete to the consumer on price versus quality?
Why is this not happening now? Because they hide the prices on purpose.
And when I am having a manic episode it is kind of hard for me to search for the cheapest hospital to have myself involuntarily committed.
There are just some thing capitalism really sucks at, just admit it.
And when I am having a manic episode it is kind of hard for me to search for the cheapest hospital to have myself involuntarily committed.
There are just some thing capitalism really sucks at, just admit it.
Emergency care is a tiny portion of all healthcare costs.
In 2017 ED healthcare costs were $76 billion. That is about 10%.
Just go on amazon and try to buy something if you think finding the "cheapest price" would help people get healthcare.
But also, am I supposed to suffer higher prices because of my specific illness that they can charge whatever they want?
Just go on amazon and try to buy something if you think finding the "cheapest price" would help people get healthcare.
But also, am I supposed to suffer higher prices because of my specific illness that they can charge whatever they want?
Lots of ED health care costs aren't emergency, and the reason they can charge whatever ever the want is because of special government privileges.
It's much easier to address the cost of non ED care and since it's 90% of spending, that seems like a good place to start?
It's much easier to address the cost of non ED care and since it's 90% of spending, that seems like a good place to start?
Let more people compete? Remove restrictions and anti-competitive laws?
The majority of hospitals in the US are non-profit. They don't benefit from passing administrative costs to patients.
Non-profit doesn't mean that people aren't making money from it, it just means that the excess funds aren't used to drive stock growth and the organization "doesn't exist for the purpose of making money", but if the Administrators in the hospital find a way to slash the budget by $5 million there's nothing saying they can't then give themselves a raise for doing such a good job.
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Paper is paywalled :(
What a joke. The only thing that would lower the costs would be to increase the competition, but the government has allowed merger after merger after merger (in health insurance, and in providers, just like everything else lately), taking away more and more pressure to compete.
Why is every other ad on TV for one of the car insurance companies? Competition, which drives down price. The way to fix US health care is to create a market environment where I can buy health insurance like I can buy car insurance. It's too regionally regulated now. Make the market national. Make it possible for a young, unmarried man to buy into a group policy with other young, unmarried men (with zero benefits for maternity or female-specific illnesses), and let the market sort it out.
Tying insurance to employment has got to be one of the most BALLER moves of Capitalism the world has ever seen. I mean, how much harder could you force your employees to bend over than to tie their literal life and health to working for the company?
GET MY EMPLOYER OUT OF MY FUCKING INSURANCE. People say there's no money for nationalized healthcare. Bullshit. We're already paying it. Give me the money that my company is paying on my behalf -- about $20,000/year -- and let me combine that with my portion -- about $8,000 -- and let me go buy a plan that makes sense for me on the open market.
Do these 2 things, and the market would sort this out in a New York minute.
Why is every other ad on TV for one of the car insurance companies? Competition, which drives down price. The way to fix US health care is to create a market environment where I can buy health insurance like I can buy car insurance. It's too regionally regulated now. Make the market national. Make it possible for a young, unmarried man to buy into a group policy with other young, unmarried men (with zero benefits for maternity or female-specific illnesses), and let the market sort it out.
Tying insurance to employment has got to be one of the most BALLER moves of Capitalism the world has ever seen. I mean, how much harder could you force your employees to bend over than to tie their literal life and health to working for the company?
GET MY EMPLOYER OUT OF MY FUCKING INSURANCE. People say there's no money for nationalized healthcare. Bullshit. We're already paying it. Give me the money that my company is paying on my behalf -- about $20,000/year -- and let me combine that with my portion -- about $8,000 -- and let me go buy a plan that makes sense for me on the open market.
Do these 2 things, and the market would sort this out in a New York minute.
To be clear, I agree we should eliminate the deduction for employer paid health care.
For historical reference, employer-paid insurance only became prevalent in the US during/after World War II as a way to compete for labor after the government implemented wage controls. When the wage controls were lifted, people had become used to the benefit of employer-paid health care and it stuck.
My sense is the US will never move to the model you describe with young men creating a buying group for very specific policies. Society is simply not going to accept extreme differences in premiums for young, healthy people vs much older, less healthy people.
For historical reference, employer-paid insurance only became prevalent in the US during/after World War II as a way to compete for labor after the government implemented wage controls. When the wage controls were lifted, people had become used to the benefit of employer-paid health care and it stuck.
My sense is the US will never move to the model you describe with young men creating a buying group for very specific policies. Society is simply not going to accept extreme differences in premiums for young, healthy people vs much older, less healthy people.
i think the main difference is if i have car insurance A and get into an accident they send me to body shop A, or at worst i go to body shop and send insurance the bill. If i need to see one of the 15 dentist in my area and there 100s of dental insurances there is no guarantee they take my insurance. When i switched dental insurance to another big regional one, my current dentist didn't accept that insurance, so now im paying out of pocket or finding a new dentist.
Health insurance merges help drive down costs.
Provider merges drive up costs.
Health insurance is the buyer of medical care, so when they are monopsony (buyer side monopoly) they drive down costs.
Provider merges drive up costs.
Health insurance is the buyer of medical care, so when they are monopsony (buyer side monopoly) they drive down costs.
They also reduce choice and supply. They get to decide who gets what treatments. The death panel analogies sound ominous, but at the end of the day they are accurate. Someone has to decide what will be covered. For most people, if it is not covered, it won't be done.
I have an idea. Remove government management of this industry.
Exactly.
Everyone should know it's completely illegal to open a hospital. It's illegal to charge less at 3am when you're not busy.
Any and all competition, even weak competition like Urgent Care, should be encouraged.
Everyone should know it's completely illegal to open a hospital. It's illegal to charge less at 3am when you're not busy.
Any and all competition, even weak competition like Urgent Care, should be encouraged.
So your solution to overly complex/cumbersome regulations and laws...is to completely deregulate the healthcare industry? You can't think of something in the middle that's not as reckless?
It's not just cumbersome - it's completely illegal to open a hospital. The lack of competition is the root of all of this mess.
Are they getting rid of the Health Insurance companies finally???
Nope. More neoliberal capitalist apologetics....
Nope. More neoliberal capitalist apologetics....
> A new analysis by Stanford researchers suggests the health care industry can reap many of the economic benefits of a “Medicare for All” program through incremental changes to the private health care market.
Why not just implement Medicare for All, instead of trying to band-aid the private healthcare market?
Why not just implement Medicare for All, instead of trying to band-aid the private healthcare market?