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Comment by jbob2000 | Hacker News Reader

jbob2000

This is only a problem in the US (aka "list of countries with private healthcare"). In Canada, we are actively trying to prevent any medical procedure possible because of the huge expense.

I just completed a huge app to educate and prevent diabetic foot amputations. It costs $70,000 to remove a foot and the government is really trying to cut down on these if they are preventable. Patient gets to keep their foot, government doesn't have to spend money - win win!

In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations? You don't get the $70k from the surgeries and you also don't get to subscribe them to a lifetime of therapy and prosthetics. Chop off more feet, I say!

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The article specifically addresses the fact that profit motive alone does not account for the prevalence unnecessary treatment. Further, only about 20% of US hospitals are private, for-profit endeavors. Over 75% are not-for-profit or government. Of course, they are still affected bybthings like revenue, prestige, "performance" metrics, etc. But Canadian hospitals suffer from those same drivers.

I applaud the work you are doing, but I question your confidence that the US system is the only system with these issues.

the issue is funding... it doesn't matter if the hospital is run as a non-profit, as long as they are funded by insurance claims then the incentive is to do more expensive treatment... paying for more equipment, doctors etc

publicly-funded health care has the opposite problem - constant pressure to reduce the budget

Does the insurance company have an incentive to pay as much as possible?

IIRC, the ACA has stipulation that 80% of premiums must be spent on medical services, so...a larger spend -> increased premiums -> a larger 20% piece of pie they can keep.

That's true, the minimum MLR creates a distorsion to the incentives.

[Gross oversimplification] Nope - insurers are incentivized to pay as little as they can get away with. Which leads to healthcare providers being incentivized to bill the insurers as much as they can get away with. They'll meet somewhere in the middle.

Don't get confused by the label "non profit". Not for profit hospitals still make a lot of profit for their management. Their incentives are similar to for profit hospitals. The money just God to different people.

There is different math for each system.

In the USA:

if riskFromTreatment <= riskFromNoTreatment: doTreatment

In most public systems:

if (treatmentCost <= someThresholdPerBenefit) && (riskFromTreatment <= riskFromNoTreatment): doTreatment

In practice, treatment outcomes are pretty similar, but more treatments are preformed in the USA system. Being a for-profit system is one cause, but so is the litigation culture. Not doing every possible treatment and test can lead to the physician being accused of being negligent.

That's a bit of a strawman argument. In your math, you need to include the point that the article makes - that the American system always considers riskFromNoTreatment to be close to infinite. The risk is completely skewed on the American side, doctors are saying "EVERYTHING WILL KILL YOU TREAT IT NOW"!

That's an overbroad generalization. Not even close to all doctors constantly push for aggressive treatment of all medical conditions.

I like the idea of more tests and data-driven medical decisions.

It would be nice if most of those tests were usually 'effective' (fairly accurate, or really cheep with rarely a false negative and a better confirmation test if warranted).

It would be nice if the goal was to /prove/ someone was healthy, just like how burn-in tests 'prove' that built systems function within the desired parameters.

You have the US math wrong.

    if profitFromTreatment <= profitFromNoTreatment:
        doTreatment

The legal system enters into it because it affects profit. Health risks only enter into it indirectly through the legal system.

It is easier to sue for not treating than for over treating, and treating generates a profit. Therefore the default is excess treating EVEN THOUGH health outcomes are equivalent to worse.

(If you think this might be absurdly expensive, you are right. A glance at the costs and outcomes in the US vs other countries verifies this.)

> In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations?

My Uncle died a few years ago when a tree fell on him while working in his back yard. While trying to stabilize him, a doctor put in a request to have a surgeon amputate his leg to prevent complications once he was stabilized. My uncle died that day, and a day later a surgeon and anesthesiologist came to amputate his leg. When he wasn't found in his hospital room, they went down to the morgue, amputated his leg there, and billed the insurance company for the procedure... including the cost of anesthetizing the dead man.

Ridiculous stories like this abound in the American system of healthcare.

I don't believe that incident actually happened. While there are a few crooked doctors it's highly unlikely that 2 of them would commit easily detected criminal insurance fraud in a hospital setting for a relatively small surgery fee. Do you have any hard evidence?

Honestly it sounds like you either made this story up or you got the details completely wrong.

That simply isn't how it works in the US. There are specific standards of care for diabetes including annual foot exams. Insurance companies, and federal and state governments, require providers to report on those quality measures and penalize them for insufficient compliance.

https://www.qualitymeasures.ahrq.gov/summaries/summary/48831...

>This is only a problem in the US (aka "list of countries with private healthcare").

This is complete nonsense and I'd like to see the source of this. Do you really think the state has any incentive to prevent health insurance and treatments from costing a lot? Spoiler alert: It doesn't. The state never has any incentive to save, it grows and grows. The more socialised and rigid your healthcare system, the more bloated it gets, and the more doctor and insurance mafia you get.

The strongest incentive to save is if the customer is free to decide. We see this time and time again. We do not have to force the people to save money, the market forces do a wonderful job all by themselves.

Now, what's got to happen is that patients inform themselves and diversify diagnosis. The crux of the problem is that patients seek advice from the exact same people who can make large financial gains if the patient opts for a certain treatment. Now, this is really just a beginner's mistake in negotiation and not something you can fix at the state level (since if you try to do that, the costs are socialised, but the poor judgement of the patient remains)

What needs to happen is that if doctors say "Don't inform yourself about your condition and don't read on the internet", get up, tell them to fuck off and get informed - like you would about every other service you like to buy. NEVER tolerate being taught ignorance. Nothing good comes out of ignorance, ever.

> The more socialised and rigid your healthcare system, the more bloated it gets, and the more doctor and insurance mafia you get.

I'd like to see your source for this. Many reports have demonstrated that the US spends dramatically more on healthcare to get equal or worse results than the majority (almost all?) of developed countries. Those countries don't have one system, they have a variety - state run health care, state-paid health care, state heavily regulated health care...and they all work better than our system.

1) My understanding is that Medicaid/Medicare has consistently spent less money on overhead than private insurance.

2) Have you TRIED to get pricing information from a hospital? The market has done a terrible job.

3) Or, in simply talking to my doctor, if I need a second opinion from someone who has no incentive to mis-state the risks/benefits, AND is knowledgable enough to give me accurate opinions, exactly to whom should I turn? Or should I become a subject matter expert on every service in my life, so that I know that the non-FDA drugs I'm using actually work (which assumes that there is actual public evidence one way or the other in the absence of govt requirements), that the food I eat is safe, that my medical treatments are necessary and helpful....

> NEVER tolerate being taught ignorance.

Here, however, we are in agreement.

FWIW, I lived with someone who chopped diabetics' feet off for her living, and she always, always, always did her best to make that option a last resort, "the only alternative is total incapacitation" medical decision.

She would have loved to have an app like this.

So in my anecdotal experience at least, doctors are at least trying to do the right thing.

It would really hammer home your argument if you showed that outcomes for diabetes patients in the US were worse.

In the US, a hospital would be stupid to make an app like this

Perhaps, but in this example, shouldn't you be considering the insurance company as the entity with the motive to prevent expensive treatments?

No, because the insurance company needs a reason to jack rates year-after-year. They need the number of diabetic foot amputations to increase so that they can justify increasing premiums.

Do you think insurance companies enjoy increasing rates for the sake of increasing rates?

If they're increasing rates because their costs have gone up, they're not making more profit. And other insurance companies that have done more to control costs are likely to start taking their customers over time.

That is an extremely ignorant statement and not at all reflective of how the medical insurance business actually works. In reality most large group buyers are self-insured now and the "insurance company" just administers claims and payments without bearing risk. So they have no financial incentive to increase the number of diabetic foot amputations.

> In the US, a hospital would be stupid to make an app like this. Why would you want less foot amputations? You don't get the $70k from the surgeries and you also don't get to subscribe them to a lifetime of therapy and prosthetics.

Isn't the prognosis something like 2 years after foot amputation for people with diabetes?

Better early treatment keeps them alive for longer and thus buying all the test strips and injecting pens plus needles plus etc.

I may be mistaken, but I don't believe amputation cure the diabetic. They continue to have and manage the disease with the methods you mention.

It is difficult to make rational decisions when there is a political advantage to be had by misrepresenting the facts. Every system, whether private or socialized, medical or otherwise, has to decide to how allocate limited resources. When party leaders, along with popular media, can successfully label this "death panels," I don't see hope for a rational solution.

Insurance companies have the incentive, not hospitals themselves. There are plenty of US insurance companies that would pay for the app if it meant they could avoid paying $70K for a foot amputation.

Perhaps the problem is the socialized part of our system where you can get any prescription on Medicare for $5. That sure creates a lot of demand.

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