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Comment by brightball | Hacker News Reader

It's not. People don't see the prices. It's whatever the insurance company can be convinced to pay. People don't get to pick their insurance plan either because it's locked into corporate contracts for the employees (for most people). This model happens because the government allows companies to tax deduct the cost of health insurance as a benefit but not individuals...which happened from union demands.

When people are totally removed from the cost, people aren't being exploited. Removing people from the cost increases the cost.

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It eventually is exploitation no matter how you slice it. Doctor's salaries and the money that is made in medical just because it is medical is insane. How much money does a doctor need to make? Why is $400,000+ a year okay when it is bankrupting thousands of people's lives?

> which happened from union demands

Explain????

Well, doctors have to go to school for a very long time, especially to specialize. Then they go through residency programs. In all their general education before practicing on their own tends to be about 10 years more than the average American. Which is 10 years less income and 10 years more of expenses/loans. Most specialties cause doctors to be on call. Working in hospitals creates difficult hours.

And with all that we have a shortage of doctors in the US.

So, supply, demand, cost, working lifetime to make up those costs, hours, volume of paperwork to deal with insurance, even more for Medicaid, malpractice insurance and now the shift to EMR.

Doctors pay is the most justified thing in the medical industry. Until we have an excess supply of doctors that isn't going to change.

The other costs in medical are where the story really is.

> Explain????

Company provided health care became a standard thing from union demands years ago. Never allowing individuals to tax deduct insurance costs removed insurance from the consumer market, purchased for millions of people without any choice from the employees about who provides it and this became the primary mechanism for paying for health care.

Individuals are 2 steps removed from the costs of care, so what do they care if a hospital stay cost $30,000 if $29,000 is covered?

That's how your costs rise. Medical costs haven't been even remotely participating in the free market for decades.

I find it really interesting that we don't have, for example, a cheaper way of doing front-line health care than teaching people to diagnose every possible ailment.

Similarly that that the mechanics of surgery aren't considered a manual skill practicable in a largely assembly line fashion.

Apparently, everyone gets artisanal health care, regardless of the level of complication (or not) of their condition.

Nothing wrong with doctors at all, but curious that this field above all others is so resistant to the methods of industry which have worked so well to reduce costs in every other field.

> Apparently, everyone gets artisanal health care, regardless of the level of complication (or not) of their condition.

Because biology is complicated.

Generic OTC drugs are healthcare. They often cost ~$3-5 a month. Pretty cheap, available to treat a wide variety of issues.

And increasingly, first contact will not be with an MD or DO (there's several paths, nurse practitioners, physicians assistants, etc).

And in fact, lots of common prescription drugs that people may take daily don't even hit $15 copay levels for a month's supply.

You do have to go through a relatively expensive gatekeeper for those though. And they won't lightly pass on the opportunity to monitor things.

Robots have been in the operating room for several years now. People are just not aware they certainly aren't there to reduce cost as much as reduce risk from human error.

http://fortune.com/2016/07/11/robots-medical-surgeons/

The two concerns are intertwined, as reduced risk from human error means fewer malpractice claims, and slower premium increase (assuming a well functioning malpractice insurance market).

Also, improved outcomes (due to fewer errors) also improve costs, as patients won't have to come back due to complications as often.

It's a valid concern and this is where the free market aspects really come into play.

If a school opened up with the goal of training people to diagnose and treat cold and flu symptoms, so that the graduates could diagnose those symptoms and their severity, then recommend a course of care or call in a prescription...here are the potential barriers.

1. Insurance companies wouldn't pay for it at all because those graduates would lack any type of professional credentials.

2. Those graduates wouldn't actually be allowed to call in prescriptions, also due to lack of credentials.

3. Getting credentials approval would require a lot of money to push things through the process, if at all. Then the school would have to be setup in an effort to recoup those costs. The school would be setup with the goal of making money most likely and everything else in the process would have to happen before the school even became feasible.

Assuming all of those things happen, then insurance companies would largely decide whether or not to even pay for those services and people who had companies that wouldn't...would not likely go to those providers. If they did pay for them and the pay was too low to justify the time commitment of dealing with the insurance companies, additional costs would be involved in terms of staff to deal with billing and followup. (Insurance companies often deny on first request, requiring rebilling).

When it comes to cash flow, insurance changes at the beginning of every year can cause payments to be delayed for up to 3 months which becomes a huge problem for office leases and payroll. Between all that if the compensation isn't high enough, it disincentives people to go into the field at all.

The alternative is pure private pay and allowing individuals to decide, this care is good enough for me. Which would require signing something indemnifying the practitioner from legal recourse since they wouldn't be able to get malpractice insurance. If that care costs more than the co-pay at their regular doctor...they will have no reason to choose it. And even with private pay, those same practitioners still wouldn't be able to call in prescriptions.

That is the industry that has been created by removing health care from the free market.

LNPs have the ability to write prescriptions for low schedule drugs. That's pretty much the basis of those tiny clinics in retail stores.

More movement in that direction could lower health care costs, or at least improve utilization.

Agreed and much needed.

Not Unions' fault. I don't understand the animosity towards Unions specifically to this revisionist history of Health Care.

> The Birth of Employer-Provided Health Insurance

During World War II, the federal government was wary of post-war inflation. The administration saw the terrible devastation hyperinflation wreaked on post-World War I Germany and they were determined to hold it at bay through wage and price controls which they instituted during the war. In reaction to the wage controls, many labor groups planned to go on strike en masse. In order to avert the strike, in a concession to the labor groups, the War Labor Board exempted employer-paid health benefits from wage controls and income tax. https://www.zanebenefits.com/blog/part-1-the-history-of-u.s....

> Company provided health care became a standard thing from union demands years ago.

I have heard that for years and I can't see anything that wasn't really the Federal Government's plan to stop all wage increases. Yes the Unions got mad and were going to strike but that was because the federal government was going to freeze all wages. Hardly a Union fault.

Still, that concession created the imbalance that got us where we are today.

But it is not the Unions' fault.

> In order to avert the strike, in a concession to the labor groups, the War Labor Board exempted employer-paid health benefits from wage controls and income tax

How is this interpreted?

>Well, doctors have to go to school for a very long time, especially to specialize. Then they go through residency programs. In all their general education before practicing on their own tends to be about 10 years more than the average American. Which is 10 years less income and 10 years more of expenses/loans. Most specialties cause doctors to be on call. Working in hospitals creates difficult hours.

The "number of years" argument doesn't explain it. For most doctors, it is comparable to someone doing a PhD - maybe a year or two longer on average. PhD's don't get paid anywhere near the amount doctors do.

There's less demand for most PhDs. Clearly different fields for PhDs average quite different salaries, so there's plenty of evidence some are worth more to the market than others.

Having a shortage of doctors is most consistent with insufficient reward to attract more entrants.

It's because being a doctor is uniquely stressful and the training and work takes an emotional toll to a degree that is hard to explain. I think the reasoning behind their pay is that you want those people to have essentially no other stressors in their lives in order to facilitate the quality of their work. In our society material support is how that is achieved. Public respect and deference used to play a larger role, today people are more comfortable questioning doctors. Normally I wouldn't make excuses for wildly exorbitant compensation, but for so many doctors it is what holds their world in place.

Granted there are specialities like dermatology that derive their compensation more from severely limiting the size of the specialty training programs, and the work itself is not as stressful as I'm claiming doctors in general have to bear.

All this said, yes of course they're all overpaid. But the way we got here makes perfect sense, and if we're going to change it there must be a new way to aid them that is just as impactful.

>It's because being a doctor is uniquely stressful and the training and work takes an emotional toll to a degree that is hard to explain.

Knowing several doctors, it is not that hard to explain.

And frankly, most of your answer is merely a reflection of the status quo, but not why that status quo exists.

Look at most developed countries and I wager you'll see less stress in becoming a doctor. Are they providing lower quality of service than US doctors?

And not all doctors work highly stressful jobs. All the PCP's I've had had a comparatively relaxed lifestyle compared to people like surgeons. Sure, they get paid less, but still get paid a lot. In my company I know plenty of engineers who work longer hours with greater stress (roughly 10-12 hour days and then being on call on top of that - PCP's are usually not on call). Their pay is a lot lower than that of a PCP.

I'm not saying they don't deserve to get paid a lot. Just that the "number of years of training" is not a good justification for it.

There is also somewhat of a correlation between the years spent in training and their pay. Not all doctors are making 400k, not by a long shot.

However, your statement about the doctor shortage. For some cases, like PCPs it is due precisely because they dot get paid nearly as Wells's you intimate. OTOH in general the supply of doctors across the board is carefully metered my the medical community. We could easily turn that dial up if we wished. They don't like that for various reasons, including watering down their pay.

The increase in medical costs is mostly not because of physicians, https://economix.blogs.nytimes.com/2008/11/14/do-doctors-sal...

> How much money does a doctor need to make?

If patients are looking for open heart surgery, brain surgery, or something else that's life-and-death? It's amazing how quickly people start looking for "one of the best surgeons in our state." And I don't blame them! If somebody is going to saw open your skull and stick a scalpel in your brain, you want the medical equivalent of a respected senior Google engineer, and not a fly-by-night outsourced IT subcontractor.

Similar issues apply with rare or weird medical conditions. In these cases, front-line doctors might see a condition once in their career. But there's a specialist somewhere that deals with those conditions all day long. If you ask your regular physician to try to diagnose something weird, you may wind up getting expensive tests like an MRI, whereas a specialist might instantly recognize that an MRI is useless.

The story of why the US has such a bizarre system of paying for healthcare is more complicated and interesting than just union demands and WW II price controls. Here's a great podcast discussing it: http://www.econtalk.org/archives/2017/06/christy_ford_ch.htm...

Yes I also believe it is possible to spin a web of the intellect to make this seem like something else than what it is, but all you get from this is the satisfaction of a web well spun, and the exploitation continues.

It's what happens when you hide the price in a supply/demand chart.

It gets tiresome to see accusations of things like "mental gymnastics" and "web of intellect" every time someone attempts to discuss a non-trivial political issue. If we could just snap our fingers and fix all of our problems, we'd have done so by now.

Law, politics, and economics are hard, and they sometimes involve considering multiple factors. We shouldn't allow ourselves to be goaded into an unprincipled anti-intellectual stance by people trying to expedite their own solution.

Everyone agrees that the economics of health care in the US are bad. I don't know anyone who is happy with this state of affairs. Everyone feels like the other parties are out to screw them. Docs feel that they get fleeced by facilities and insurers, insurers feel that they get fleeced by beneficiaries and providers, etc. I had a medical device manufacturer as a client for a while and they too felt that the industry was unfair to them and that they had to set high prices to try to survive.

With so many people in the U.S. receiving their care on differing bases, it's hard to really get a single, strongly-motivated group to coalesce and push some real change through. Every employer negotiates their own contracts; some are good and some are bad, depending on how much your employer cares about benefits and such. Some people have state-provided care through Medicare or Medicaid. Others have to pay private (which is where things get really bad).

With everyone's experiences on such a deeply personal issue differing so widely, unification is difficult. Mix in a little political brou-ha-ha and it becomes nearly impossible. I'm sure that fracturing is part of the game by the insidious elements that lie underneath the covers, but it is a reality we must recognize and address legitimately.

On top of that, medicine is one of the largest industries in the U.S., and changes to that structure threaten to disrupt the employment of many people. There is no surer way to get a political position dismantled (and its elected purveyors destroyed in the next election cycle) than to threaten the livelihoods of a meaningful portion of the constituency.

Changes to the regulatory structures impacting all of this should be carefully considered, and I would hope that we at least run them through the "intellectual paces", as it were. Let's not jump on each other's backs with silly accusations for not acquiescing quickly enough.

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