Doctors Unionize to Resist the Medical Machine | Hacker News Reader

Doctors Unionize to Resist the Medical Machine

nytimes.com

104 pointse15ctr0n113 comments

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For what it's worth, people have been calling the AMA a union by another name for several decades.

http://www.forbes.com/sites/johngoodman/2014/09/03/the-docto...

They lobby, they control the supply of doctors, they restrict competition, and they even engage in price fixing:

https://www.washingtonpost.com/business/economy/how-a-secret...

They shape a lot of medical legislation, for example killing the Affordable Care Act's "public option."

http://www.nytimes.com/2009/06/11/us/politics/11health.html

This isn't a recent thing. The AMA was key in killing Truman's universal healthcare proposal starting in 1945.

http://umhm.mededu.miami.edu/?p=394

> They lobby, they control the supply of doctors, they restrict competition, and they even engage in price fixing

It saddens me that those are your go-to ideas of what a union is.

> The AMA was key in killing Truman's universal healthcare proposal starting in 1945.

Actual unions have been pushing for universal healthcare for much earlier than I was born. On this front AMA has been the enemy of real organized labor for decades.

A real union is about workers banding together to stand up to a boss who says "fuck me or you're fired", or to resist management giving themselves millions while cutting pay for workers.

Please don't dishonor the good name of organized labor by comparing them to the millionaire doctors who killed our chances for a sane healthcare system.

I mean, the difference between "resist management giving themselves millions while cutting pay for workers" and "price fixing/restrict competition" is just an arbitrary, subjective distinction based on your opinion on how much money people should make. Either way the goal is to get more money for members of the group. If you don't think doctors deserve the inflated value the AMA has captured for them but think that other union workers deserve more money then that's fair enough but practically it's the same game.

There's also a word for what you're doing. A tautology I think? It seems disingenuous to classify unions based on "good" value capture. It creates a position where unions literally can do no wrong because they'll just stop meeting your definition of union.

>I mean, the difference between "resist management giving themselves millions while cutting pay for workers" and "price fixing/restrict competition" is just an arbitrary, subjective distinction based on your opinion on how much money people should make.

Who would you prefer was paid more? Your doctor or his non-medical MBA manager?

Whichever leads to the best, most efficient medical industry and provides myself as a consumer with the most value.

According to the MBA manager, most efficient = most profits. And most value = more tests and more expenses by the 'consumer'. Looks like you are on with the Kool Aid!

No True Scotsman Fallacy https://en.wikipedia.org/wiki/No_true_Scotsman

Unions primarily engage in collective bargaining with the employers of their members. The AMA is not a union.

Very likely to be true and I wont disagree! I'm not actually even from the US so I'm unfamiliar with their scope. I disagree with the person I'm replying tos reasoning more than anything. Their objection was of a different nature than yours.

You're right, it isn't a union, it's a cartel!

No, a cartel is a group of competing firms in the same industry that form an alliance.

The best analogy for the AMA would be something like a guild.

No True Scots Union...

The dynamics of medical practice are changing substantially. Regional medical organizations are consolidating and creating vertically integrated medical behemoths.

As a result, MDs are losing their independence and becoming just another group of highly paid employees. Once big corporate entities take over, neutralizing noisy, highly paid employees is always part of the playbook.

That being said, when looking at the pie charts of where all the healthcare dollars go, MD/DO, and even nursing salaries are a tiny slice of the pie. Most of it goes to administrator and insurance fees, followed by nursing home and ICU level care, followed by hospital costs, medicine costs. AMA isn't really the big problem here.

That Washington Post article is a straight up hit piece on the Relative Value Update Committee.

Here's how medical compensation is decided in the US (simple simple SIMPLE edition):

All office visits, procedures, labs, radiology tests, everything, are assigned a CPT code. That code is then assigned a relative value unit (RVU) to determine the amount of "work" each code represents. The RVU itself has three components--Physician Work, Practice Expense, and (expected) Malpractice Expense.

These arrive at some number or RVUs. To then determine compensation, CMS (and insurers) use the following formula:

[(Work RVU * Work GPCI) + (Facility or Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * [Conversion Factor adjusted for budget neutrality] = $Compensation for a given CPT.

GPCI - Geographic Price Cost Index, and represents a regional adjustment for a given cost of services.

------------------------------------------

The Post article acts like it's some big conspiracy that the RVU numbers haven't really changed much as if that's the reason healthcare costs are rising so rapidly. Except, the RVU itself doesn't determine the compensation. The values of a single RVU is determined arbitrarily by Medicare and Insurers. The whole point of the RVU committee is the make sure that all various parts of medicine are weighted according to some arbitrary value scale. You shouldn't expect Colonoscopies to suddenly become worth less RVUs just as time progresses. The "value" provided by a colonoscopy as technology progresses possibly counteracts the decrease in costs. I can tell you in Radiology that more resolution = more things to evaluate and = requires time to interpret the study despite a study acquisition time now in seconds.

CMS changing how much each RVU is worth is what determines what gets paid out. And I can tell you, CMS pays less for each RVU as time goes on.

http://www.acro.org/washington/rvu.pdf

The AMA doesn't restrict the number of doctors really either.. that's an old trope that isn't really true. The number of doctors is restricted by the number of residency slots available, which is restricted by congressional funding since they're all paid for via Medicare. If congress were serious about increasing the number of doctors, they could pass a bill tomorrow authorizing more money for new residency programs.

We've dramatically increased the number of medical students but haven't kept up in residency spots.

NEJM lays it out:

http://www.nejm.org/doi/full/10.1056/NEJMp1306445?viewType=P...

All of this rings true from what I've heard my dad, a GP, complain about for years. It's hard for him to watch other doctors game the system to increase their earnings -- not only seeing more patients with unaccountably short sessions, but also up-coding their maladies and ordering unnecessary tests.

In addition to the pressure of seeing more patients per day, they have all this new administrative bullshit (ironically in the name of efficiency) preventing them from doing so. For example, doing charts went from dictation, to data entry in absurdly bad (understatement) EMR software on cheap, outdated hardware that they weren't properly trained to use. And oh yeah, you can have pay withheld if you fall behind on that, too.

It's just sad, and many older doctors don't even recommend the profession to young people at this point.

My doctors usually spend less than 5 minutes talking to me and 10 minutes hunting and pecking at the computer. Some offices will have other staff do much of the data entry, but it doesn't seem to result in the doctor any spending more time with me.

Precisely we just created an start-up with a product that helps doctors making the EHR much faster and intuitively so they can focus on the patients.

I believe you, but when I worked in a medical office in 1993 vendors were saying that exact same thing.

I know, I hope my Background as MD and CS plus the idea we had will make it different. We are working on something similar to an IDE :)

Break a leg :-)

And whatever you do, just don't let anyone deploy it on some overloaded Citrix server.

Congratulations in advance for when EPIC buys your company and then ruins your product.

Epic doesn't acquire.

You sound like me and this sounds like software I created more than a decade ago. Good luck. It is an incredibly difficult sale (yes, I am a little bitter :))

Cool, me too :) would be interested to hear more on what you are working on if you are in the city. (SF)

Me too and I am near SF. Would also be interested in talking

The hospital system my dad works for just got all the doctors scribes to take the data entry burden off of them.

You could try looking for Direct Primary Care, another growing movement among doctors in reaction to how messed up the system is.

I wrote a bit about it recently:

Http://micheleincalifornia.blogspot.com/2015/12/how-to-fix-americas-financial.html

Similar story in the UK. My aunt, who works for the NHS (not a GP), has cried in the toilets a few times because she is forced to use bad software to the point of utter frustration, and she is not of the computer generation. There are ~10 people in her team in a simular situation. They should just have a dedicated person doing data entry in to the computer system.

Not having dictation is just dumb. Voice rec is quite capable these days and the doctor's time is too valuable to waste on their typing speed.

One note though, the PC never really has to be any good because most of the EMR crap is accessed over Citrix... To make IT's life easier (in theory) and avoid having the need for fancy PCs on the wards.

Hell, I'm only in my second year of med school in the US, and I wouldn't recommend young people go into this profession.

I'm in the last year and I would totally do it again. It's true college it's abusive(http://www.kevinmd.com/blog/2016/01/physicians-arent-burned-...), but I find it amazing as a career.

(MD here...)

With all due respect, wait until you have been in the profession for at least one decade. Then, I'd like to hear your opinion again.

I'm sure the work is super hard, and I will change my opinion, everybody said that to me, but at least academically, I found it amazing. :)

>>It's hard for him to watch other doctors game the system to increase their earnings

Make no mistakes this isn't just restricted to the US. This is quite common in India too.

>>not only seeing more patients with unaccountably short sessions, but also up-coding their maladies and ordering unnecessary tests.

In India there practices are almost in the fraud territory. Start from doctors having small testing labs in their clinics. Where they order unnecessary test for patients they don't need. Almost every clinic has a neighboring pharmacy, that sells medicines of brands only the doctor next to it prescribes. You won't be able to buy that medicine anywhere else, plus the doctor makes commission in the medicine sold in the pharmacy. Prolonging treatments to maximize per consultation fees is extremely common.

Its very common for hospitals to indulge in advising patients with either incorrect treatments or prolonging treatments. Pointless tests, doctors cooking up stories to scare patients to spend more at hospitals is all common.

>>It's just sad, and many older doctors don't even recommend the profession to young people at this point.

I talked to many doctors(friends, relatives and acquaintances) actually many feel cheated opting to chose a career in medicine. They are told they are very smart people, and all. Told they are super smart hence they deserve to go to medical college. Hence they expect to be paid proportionally. Most watch their friends in engineering, who they think have it(apparently, that's how they perceive it) a lot easier. While they spend a lot of studying, piling up a good deal of student debt, plus on a average making the same money at the end anyway. Except that every thing in life happens decades later.

They look at engineers, especially programmers as people who have a lot of opportunity to switch streams, learn and move on to new stuff, work at big companies, start companies. Especially programmers who are good investors come across as people who made far more sensible career decisions.

Doctos at the end of the day are humans, and are driven by peer financial pressures.

One thing that I never understood about the US medical education is the requirement of the bachelor's degree (pre-med) before applying for most med schools. In my home country and many others, you can directly apply to med school. Now that the college costs are quite considerably expensive, four-additional year of college studies simply adds to the cost of becoming a doctor and therefore, the newly minted doctors expect to make a lot of money. This pre-med education requirement adds unnecessary, in my opinion, burden not only to wannabe-doctors, but also to the medical system (create scarcity of doctors to say the least).

It's a bit pedantic, but most medical schools don't actually require a bachelor's degree. They do, however, require something in the order of 80+ credits worth of classes, at which point you might as well finish the degree.

Personally, I think it's a good requirement. It forces people to spend a bit more time maturing before they finish school, and it also providers an opportunity to pursue a different field before entering medical school, or provides a different background when practicing clinically.

I also can certainly agree that not having it can be beneficial in points you mentioned as well

I actually prefer the US system in that it potentially provides doctors with a more well-rounded education.

Ah yes, the moral duty American colleges feel for ensuring a rounded education at the low low price of tens of thousands of dollars per year.

My CS degree focused on a rounded education, which would have been okay if it had also taught me how to, say, write a useful program. I didn't realize 'til I'd graduated that I would have to teach myself if I wanted a career.

To be fair it was never called a degree in programming.

When I signed up for classes, I said I wanted to be a programmer, and the advisor said "oh, you want Computer Science, then." That was just as much a lie as if they'd called it Programming outright.

Running a democratic country is expensive, but better than any of the alternatives!

Once upon a time in a fantasy land called... the 1970s? most people thought a high school diploma was a well rounded education.

If you are going to bring up costs of college, you also need to bring up why college is expected to replace high school.

I'm torn, because on the one hand it is good for people to have a decently broad base of knowledge. On the other hand, most US colleges' idea of a "well-rounded education" is a straight-up holdover from educational programs whose only purpose was to prepare rich men's sons to make interesting conversation at parties and handle Daddy's business. When modern students actually want career prep, universities tell them they're getting career prep, and instead feed them dinner party prep at umpty-thousand dollars a year.

Doctors are already paid absurd salaries in the US and the barriers to entry already high. As much as we all hate dealing with insurance companies, when I lost my insurance and had to pay for things out of pocket, the difference between what they charged me and what they would have charged an insurance company was obscene. Insurance companies actually do a pretty good job of reducing the costs of medical care, although some of the same power and information asymmetries still exist (that is, I'm saying that doesn't necessarily make the insurance companies the good guys). But the consumer has no bargaining power on his own and he doesn't know enough to challenge or negotiate. And the entire regulatory structure puts all the power in the hands of the doctor, not the patient. I don't see this as being a good trend for consumers. I find this to be very worrying.

Edit: since this my "absurd salaries" remark seems like it might be the most controversial bit, I was thinking of I was referring more to information like this: http://www.motherjones.com/files/blog_physician_compensation...

That's because it sidesteps many issues like how hard it is to become a doctor by simply comparing the pay of American doctors to the pay of doctors in countries with national healthcare. By "absurd salaries" what I really should have said was that American doctors are paid significantly more than other countries.

Of course everyone, no matter what their job, thinks they work too hard for too little pay.

What do you consider to be ''absurd salaries''? A friend of mine is a hard working (50 hours/week) 35 year old GP in San Francisco and makes about $175k all-in, which is about the same as the average base + cash bonus (excluding options) of all our white collar friends (mostly software developers, but also some in finance and other fields). He left medical school with about $50k in student debt (very low relative to the average) and only started a ''real'' job at 30 (8 years after his peer group, who by then had accumuluated savings of several hundred thousand dollars each).

I also know a neurosurgeon who makes significantly more than this but given the sacrifices required to train into and hold that job, I'm not sure any amount of money would be fair compensation.

Medicine is unique in that you have to pay providers higher salaries to work in more remote, less desirable locations, which is the opposite of how most professions are structured. But without this, rural populations would have almost no access to specialist care.

I know a couple of neurosurgeons who basically don't practice outside of federal/military facilities, and are covered by the Federal Tort Claim Act [0].

The salary is significantly less than a private practice neurosurgeon, but they don't have malpractice insurance or support staff costs.

In under-served and rural locations there are community clinics, also known as Federally Qualified Health Centers, and as part of the package, student loan repayment by the US government for the doctors. These doctors are usually civilian, and not in uniform (US Military or PHSCC). The repayment program is part of the National Health Service Corps[3].

[0] https://en.wikipedia.org/wiki/Federal_Tort_Claims_Act

[1] https://en.wikipedia.org/wiki/Federally_Qualified_Health_Cen...

[2] https://en.wikipedia.org/wiki/National_Health_Service_Corps

Do you think we could maintain the current staffing level of nsx across the entire US with all their current responsibilities (level 1 trauma etc) if they averaged $200k/year each? How do you ask 2 or 3 surgeons to evenly share 24/365 call to keep a trauma center open at that comp level?

How is 175K not absurd? Only a white collar engineer in SF would say that's a piddly salary. Wake me up when your doctor friend has to commute in from Stockton.

Out of curiosity then, what would you consider appropriate salaries for GPs, general surgeons, and specialized surgeons like neurosurgeons, orthopods, or ENT?

Keeping in mind that medical school costs an extra $250k (whether in debt to sallie mae or paid for by mom and dad), and the post-bac education timelines are 7 years for GPs (4+3), 9 years for surgeons (4+5), and 11 years for neurosurgeons (4+7).

Right now the price is set by a government granted monopoly which determines supply. Many people here believe a more correct way to decide this is through the free market.

I think the Doctor has a little more job security as well. Medical industry has a higher barrier to entry.

It's not absurd because of the costs of becoming a doctor, both direct costs and opportunity costs. By the time heavily indebted doctors can hang out their shingles, professional peers have been working almost ten years, racking up a million dollars or so in gross earnings.

For some perspective. A 22 year old college graduate can make $175k per year in total comp with a CS degree working for Facebook or Google. To repeat that. A 22 year old with a BS degree can make $175k per year with absolutely no experience whatsoever.

For some more perspective :).

A $175,000 is close to top compensation in our field. The average software engineer(obviously not just out of school) earns around $96,000. The average GP earns $211,000 and the average specialist earns $411,000.

Don't forget that it's also standard to have accumulated hundreds of thousands of dollars by the age of 30. What are you, some kind of pathetic loser outside the Software Master Race making the median US salary of about 35000?

> Doctors are already paid absurd salaries in the US

To put it in context, when I finish all my training, I will owe over $600,000.

It's not the doctors being "paid absurd salaries" that makes medical care in this country expensive. It's lawyers - malpractice insurance can take upwards of 25+% of your income - and it's insurance companies, who have shareholders they are responsible to, and it's hospital administration, whose positions keep multiplying.

>> Doctors are already paid absurd salaries in the US

>To put it in context, when I finish all my training, I will owe over $600,000.

> It's not the doctors being "paid absurd salaries" that makes medical care in this country expensive. It's lawyers - malpractice insurance can take upwards of 25+% of your income - and it's insurance companies, who have shareholders they are responsible to, and it's hospital administration, whose positions keep multiplying.

It's a red herring. If you compare physician compensation in the UK to the US, the costs of medical education are made up within the first ten years. Yes, even after malpractice insurance. Hospital administrators are also wildly overpaid, but there just aren't as many of them. Physician compensation as compared to foreign doctors, which get the same or better results, is just too large a piece of the pie to brush under the rug by pointing at other problems.

As of ~2012, physician compensation was something like 8.5% of healthcare spending in the USA. This means that in the United States, physician compensation is actually a smaller component of healthcare costs than it is in the UK (where it's ~10% of overall cost).

This is because the U.S spends 2.6 times as much on health care per capita as the united kingdom.

And if you paid physicians $0, the US would still spend about 2.4 times as much on health care per capita as the United Kingdom. In the context of this thread, this is the relevant point.

Which college/medical school cost that much?

In either Federally Qualified Health Centers [0], or other federal/military hospitals, the Federal Tort Claim Act [1] basically covers the malpractice insurance. There other programs that allow non-profit medical centers limited coverage under the FTCA.

[0] https://en.wikipedia.org/wiki/Federally_Qualified_Health_Cen...

[1] https://en.wikipedia.org/wiki/Federal_Tort_Claims_Act

Do you think lawyers consume malpractice insurance? Juries and lawsuit winners consume malpractice insurance

Do you have a source for that 25% number. Eveeytime I've looked before it was closer to 10% which is still high, but other industries have similar rates.

This article is about how the unionized doctors are more interested in performing their work at high quality for less money, and how that's in conflict with their administrator's incentives to have the doctors get paid bonuses to favor quantity at the expense of quality. The administrators are failing at appealing to these doctors' greed because it is outweighed by their sense of professionalism and satisfaction with their current pay.

Also, consider that medical expenses in the US are over 3 times what they are in similar countries, while the chart you've linked to shows doctors in the US being paid about 25% more. That's significantly more, but not enough to be driving the absurd costs.

I agree that its unfair for the patients to have no bargaining power.

If you think MD salary increases are even a tiny speck of the driving force for cost increases in US healthcare, you know less than nothing about the topic.

Ah, then I must have a negative amount of knowledge about the subject.

Insurance creates all sorts of weird market abstractions. There's a phony "rack rate" that you pay as an individual. Everyone else negotiates discounts.

Medicare is the price floor, and gets the best price. Everyone else is in the middle.

Reading the Hippocratic Oath right now, it's painfully hilarious how far removed that pledge is from the way medicine is practiced right now

(taken from wikipedia)

"Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient;"

"I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug."

"I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick."

How quaint! That's what a Norman Rockwell painting would sound like if it came to life.

>the difference between what they charged me and what they would have charged an insurance company was obscene

Those numbers you see are entirely imaginary.

Insurance companies don't pay them, individuals don't pay them, they're just artificially inflated prices used for negotiation.

They give a significant discount to people without insurance. Insurance companies individually negotiate (significant) discounts to this base price. It's inflated to make people think they're getting a better discount.

We can negotiate treatment down without insurance just as effectively (likely more so) with single payer health care.

So the US healthcare market doesn't work because... doctors??

With the whole "Everyone Should Learn to Code" movement taking on so much steam, I cannot help but wonder why there isn't a similar "More People Should Learn to Do Basic Diagnosis" movement. We need a shit ton more Nurse Practitioners and "basic" doctors to diagnose and treat minor ailments, so doctors who have gone to 6-year plus medical school can spend time on the more serious ailments.

Some of it is a perception issue, no one wants anything but the very best for their loved ones. So nurse practitioners, while great in theory, are only acceptable for others...

Of course if you live in the boonies, a nurse here is a heck of a lot better than a doctor 4h away.

Similar line of reasoning happens with anesthesiologists versus nurse anesthetists (CRNA). Most anesthesia is administered by a CRNA with a anesthesiologist overseeing most, but there's been pushback b/c it cuts into the salaries of the anesthesiologists.

Milton Friedman gave a lecture on the economics of the medical industry: https://www.youtube.com/watch?v=ss5PxPlnmFk . He discusses the AMA's guild-like tactics at one point (https://www.youtube.com/watch?v=MAjOryNaDkA), but their folly is a theme throughout.

I don't understand this about healthcare in the USA. Why not import a few thousand doctors from Asia through H1Bs, and drive down the cost of medical care? Remove artificial caps on licenses imposed by the AMA while at it.

Because you have to spend years re-training and certifying to US standards, all the time without a job and earning money to pay for said training:

http://www.npr.org/sections/money/2013/02/15/172108835/shoul...

And that's putting aside the fact H1-Bs are not exactly easy to come by right now.

Not trying to undermine your point, but I believe it won't take much long to re-train those "imported" doctors. Only those who are ambitious and bright would come to the US and I have at least a handful of friends from the medical school in Myanmar, who were in the same class year as I was, already doing their residencies. Most of them took ~2-3 years of taking the USMLE and applying for hospitals in the US which sponsors H1B (mostly the rural ones). They seem to be liking what opportunity they've been given to as far as I can tell. I actually regret quitting med school there and leaving for college in the US after my 2nd year just because I want to be an aerospace engineer (turns out, I cannot because there's almost no company that would hire an H1B aerospace engineer, so I had to change my studies back to comp sci).

If the world made sense we would have doctors working 6 hour shifts at 100k a year rather than having one doctor work 12 hour shifts for 200k a year. But then you need people to actually want to be doctors rather than MBAs or financial accountants or lawyers, and strangely enough when the money isn't better and the work is way harder pressure to remove the artifical doctorate of medicine graduation rate caps is lacking.

The AMA is a very powerful lobbying group in the U.S. They have been able to steer regulations/laws on the state & federal level to limit competition.

Because the cost of healthcare isn't doctor's salaries. It's nursing care, medicines, hospital care and administrative fees.

Culturally, I suspect this would not go over well. There are a shocking number of people that would be less than impressed to be served by a doctor with a non-Anglo-Saxon last name, even if they spoke perfect English.

Especially older people, who are the largest consumers of healthcare.

People are accustomed to having foreign physicians, other-than-white physicians and certainly other-than-Anglo-Saxon physicians.

Nearly 30% of US primary care physicians trained abroad.

Source: http://www.nytimes.com/2010/08/12/health/12chen.html

Only 8.7% of the US are descended from the English (Anglo-Saxons)

Source: http://www.census.gov/prod/2004pubs/c2kbr-35.pdf

That said, the US could easily recruit physicians from Europe including the UK so you may very well get more Anglo-Saxon physicians!

Good luck with that, considering europe already gets huge number of physicians from India.

http://www.ndtv.com/indians-abroad/india-biggest-exporter-of...

It doesn't follow that because many European physicians come from India that few European physicians would choose to work in the United States.

I don't think this is true. A "shocking number" doesn't mean "the majority" or anywhere close to it in this case, but rather more than there should be(none).

> Especially older people, who are the largest consumers of healthcare

the old bigots can learn to live with it.

> The basic accounting problem for hospitalists is that they are not a profit center. That is, when they treat patients, the amount a hospital can bill Medicare and insurance companies is typically less than what the hospital must pay them. The opposite is true for other specialists, like surgeons.

The rest of the article focused on peoples' emotional reactions, but that paragraph is key. Medicare, Medicaid, and the insurance companies will pay more than enough for tests and surgeries, but not for the diagnoses and treatments that hospitalists and GP's perform themselves. So the folks running the hospital budgets are naturally trying to change the model so that the hospitalists quickly refer patients to the more profitable departments.

The only actor able to change this model is the US Congress, which makes the legislation that sets the Medicare and Medicaid reimbursement rates. There were major improvements with the ACA/Obamacare, but it's a dysfunctional system that can only be fixed by an even more dysfunctional system.

> it's a dysfunctional system that can only be fixed by an even more dysfunctional system

Indeed, the health industry is probably one of the worst places for capitalism/markets to rule. Not that I believe unionization and a further regulated industry is the answer either.

While I'll defend markets to death in most other areas, there are admittedly a few industries where it the corrective benefits of competition/market pricing just doesn't make sense. Healthcare is the perfect example of where abiding strictly by these incentives create perverse side-effects which ultimately create a net-negative environment for the industry and the consumers.

Living in Canada has given me perspective on this matter, where our public health insurance system functions very well without markets.

It's a shame politics drives everyone to think they should be purists on each matter. Sometimes the data and emotional experience will demonstrates otherwise. Or worse, politics often create a muddled middle-of-the-road compromise, easily manipulated by either-side's special interests.

It takes quite a bit of self-delusion to believe a particular economic theory should be applied uniformly everywhere when results show otherwise.

The more middle-men you have between the consumer and the provider - be it a product or a service - the more the middle-men will constantly fight for 1) higher prices, and 2) marginalizing both the service provider and the customer.

This applies to education (universities, private schools), healthcare (large hospitals, insurance companies), social services, food, electronics...

Why do people insist on having objective criteria for performance when it's inherently subjective whether your care was any good?

I've seen this with the NHS in the UK. They have a bunch of numbers they have to make, but what do the numbers actually mean? What happens when people end up gaming the system, because the rules tell them to?

> objective [...] subjective

They should be trying to capture the subjective stuff too. See, for example, the Friends and Family test which is everywhere. Service Use Experience Committees also try to capture the subjective stuff. Complaints department mostly deal with subjective stuff. Healthwatch independently deal with mostly subjective stuff too. There's a wide range of subjective stuff that's measured using things like PLACE (Patient Led Assessment of the Care Environment) or 15 Steps Challenge.

But people paying the money tend to like things that are more directly measurable. They might have CQUINs (Commissioning Quality through Innovation (or something like that) to ask people to implement 15 steps challenge, without worrying too much about what the results are.

> They have a bunch of numbers they have to make, but what do the numbers actually mean? What happens when people end up gaming the system, because the rules tell them to?

I dislike the focus on numbers, but if you compare areas where they have strict numbers (4 hour A&E limit) and areas where they don't (access to talking therapy) you see that most (it was national scandal when it dropped to 85%) people who attend A&E are triaged and then treated + released or admitted into hospital within four hours versus, well, untold wait. Very recently (or maybe it's not in place yet) there's an 18 week limit for access to community based psychological therapies, so it'll be interesting to see if it makes a difference.

> What happens when people end up gaming the system, because the rules tell them to?

Various regulators and scrutineers hate that, and they have some power to drive change. Or NHS England / DoH force change. Some hospitals were transferring people to an observation ward from A&E, rather than treating them or admitting them into hospital. That got stopped pretty quick.

I first read this as "un-ionize". Poster's username probably helped prompt that.

Best of luck with that union, it might win you a little reprieve but that profession is now more susceptible to foreign trained Doctors coming here to take their place.

Unions of professional workers are last resort actions. If you are at that point the chance has blown by to take corrective action, all they can do is slow it down.

Plus, if the ACA doesn't get axed next year hospitals and management companies won't be the biggest threat to their pay or number of patients they will see. The government will set rates and if they want to eat they are going to have to see more patients, if they even get them as there will be nurses who will step into those roles too

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