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Is there a way to actually request a specific doctor have some time dedicated to figuring your case out at your expense? i.e. "Please do more troubleshooting for me above what insurance pays."

I like your idea - but I fear the industry might have already ruled it out.

-edit- Granted, I've done this in my own life by going to specialists at their own offices/outside of a hospital or medical group.

Unfortunately, no. Your doctor is contractually bound to the insurer’s fee structure; they can’t take an extra penny off of you. You’d have to go to someone that doesn’t take your insurance at all (or just don’t tell them you have that insurance).

The side effect of all this, honestly, is that doctors stop learning how to turn off 7-minute-mode. When it comes to very serious problems, it pays to go to a practice that doesn’t accept insurance at all, because they never got into the bad habit to begin with.

Almost makes the red envelope culture in Chinese hospitals seems appealing.

https://en.wikipedia.org/wiki/Red_envelope

I’d never heard of this before.

On the situation in hospitals specifically:

https://www.seattletimes.com/opinion/the-red-envelope-capita...

Lol, that's exactly life in Eastern Europe/ex-USSR. There's socialized medicine, but if you want better service, you have to bring a gift (whisky, chocolate, money, the latter is always desirable). Not just hand cash over, that's disrespectful nowadays.

My grandmother was a pediatrician in Kiev in Soviet times. Her salary was about on par with anyone else, but she got tons of gifts.

Not at all.

Having to slip the doc and the anaethetist a red envelope and hoping it's the enough that they'll take proper care of you is not a good system to live under.

You're right that it's difficult for physicians to "turn it off". The contractual requirements you reference, however, are basically unenforced. The only way a physician will get "caught" charging more than agreed is if the patient calls the insurer to complain. Presumably you wouldn't do that to her after she saved your life.

> Presumably you wouldn't do that to her after she saved your life.

Oh, you grossly underestimate what people are capable of. At least in China there are many reported cases of such horrible patients. Maybe US being a developed country have fewer these people, but definitely not zero.

You're right of course, and this isn't limited to the Chinese. It's best to have physicians in the family; marry one if there isn't one already! This isn't practical for everyone, so perhaps it's best to choose a capable young physician early in life, so that by the time such trust is required it has already formed.

Probably there are other professions in which one gets better service if one has an inside connection, but this situation really speaks ill of how medicine is practiced.

> Probably there are other professions in which one gets better service if one has an inside connection, but this situation really speaks ill of how medicine is practiced.

Having a doc in the family is a mixed blessing at best. You can get priority treatment, and the benefit of your family members full attention. On the flip side, all the docs I know that aren’t fools or morons don’t treat their own family for anything more serious than a scrape. You’re biased, you don’t want the guilt of an error, and you don’t want to be the bearer of bad news. I frequently ask my wife not to ask me about her mother’s health developments; I’d rather tell comforting lies than be a source of sour truth.

Being a VIP in a medical center due to your relatives gets you more ass kissing, not better care. People don’t want to step on toes, or give the impression that useful care is being withheld. And if your relative is a worse doc than the one you’re seeing? No one is going to overrule your family member to your face.

The value I would see in having a physician as a close relative is in learning how to communicate effectively with other physicians. Then one could in theory need fewer visits to their own doc to get to the bottom of a problem.

That’s actually a problem. When I myself see a doc, I make a point of being as colloquial about it as possible. Part of our training is about taking what people say and converting it into technical symptoms; when people start to “communicate effectively” it heavily biases us towards certain diagnoses. The more intelligent/educated the patient the more likely we are to take one of their word choices at face value.

Personally, all I ever want from a patient is a clear timeline of events, their best attempt to articulate what they felt, a list of scripts, and old medical records (especially imaging.) The patient that can give me that has made the task of helping them 1000x easier.

That’s really helpful to know.

> Presumably you wouldn't do that to her after she saved your life.

I wish that were so, but disease is not confined to the reasonable, the rational, the kind, the respectful, or the grateful. On the contrary, the stress of disease and it’s associated burdens (social, financial, psychological, etc) tends to diminish those qualities in even the best of us.

Harvard did a huge study on malpractice suits a while back. They found that most medical errors that caused the death of a loved one did not result in suits, and most suits did not originate from medical errors. That is to say, the good or ill you do a patient isn’t the reason they sue.

> You’d have to go to someone that doesn’t take your insurance at all

There are some doctors at teaching hospitals who specialize in diagnosing rare diseases and don't take insurance for this reason.

Glad I live in a country with a free health service.

Isn't this what concierge doctors offer?

Some. Some push the same old practice model but with reasonably cheap prices, so they can keep their old patient base and make their income off the slightly higher billings and the reduced overhead of eliminating your billing (read: calling the insurer and arguing) staff.

Some possible search terms that might help (but I don't actually know the answer): concierge medicine, direct primary care, fee-for-service, out-of-network

Yes, I've done this. I paid an out-of-network specialist for a second opinion on a cancer treatment. My HMO ended up following that specialist's recommendation. While I likely would have survived either treatment, this one was shorter and had fewer long-term side effects. I paid for the consultation out of pocket. It was less than $1,000.

Not that outcome matters much to your question, but I have fewer scars, more original body parts, and better overall body function than I would have had with my HMO's original plan.

Why doctor? It's the most expensive part of your healthcare. But it can be trainee/researcher/AI. Which could be absolutely out of expensive healthcare system. Service which you could buy for additional cost from company which has good guess/prediction ratio based on input parameters from doctor. Service which could be in any part of the world.

What? The doctor’s visit is the cheapest part of healthcare. Procedures cost far more, and pharm far more again. Perhaps you’re outside of the US, though I can’t think of a country where this isn’t true.

Don't forget diagnostic scans and tests. Those are quite expensive. However GP is proposing a service that doesn't actually exist now: paying a medical expert to spend a lot of time considering a challenging case. It would have obvious benefits, so we shouldn't dismiss it out of hand just because it would be too cheap.

There was a now-defunct attempt at this called MetaMed: https://en.m.wikipedia.org/wiki/MetaMed

I'm curious if any others have succeeded.

I have often thought that the Freestyle Chess model (a variation of Advanced Chess https://en.wikipedia.org/wiki/Advanced_Chess ) could be applied to medical diagnosis.

Create a team consisting of one or more human doctors with a medical diagnostic AI.

From the article it sounds to me that a lot of the research could have been done by an AI, with the human doctors making the final decision on the "best" diagnosis.

The technical term is "clinical decision support system".

https://en.wikipedia.org/wiki/Clinical_decision_support_syst...

There's an analogy here for software and engineering too. Getting to root cause and finding solid solutions - takes curiosity, energy... and time.

You know what they call software organizations that don’t have time to do this? “Fast paced”

For some time my read on this situation has been that the "doctor shortage" that produces 7-minute diagnoses stems from a restricted number of residency slots, which is set (I believe?) by the federal government. I had thought the AMA was influential in lobbying to keep the number of such slots low to prop up doctors' salaries, but with some research it's unclear how true this is. Anyone know? How strong a lobbying force is the AMA, anyway?

The AMA has actually been lobbying quite strongly to expand the number of residency spots. Doctors salaries are generally pushed from the top down by Medicare and not by general supply-and-demand principles. So these shortages don’t lead to salary bumps, they lead to inferior substitutions (expansion of mid-level practice privileges), which actually puts a downward pressure on salary while also providing worse care for the public.

The problem with residency slots is that they’re funded as part of the larger Medicare legislation, and no one wants to push for the bump in funding/taxes for Medicare needed to expand it.

The reason visits are seven minutes long is because part of a trend that started with the HMOs in the 80s. The hypothesis on the part of insurers was that docs have a general target income - that they don’t work at maximum capacity (in general - obviously wonky things happen at the extremes.) If you reduce per-service billing, docs would maintain constant output to hit their personal target income goal. And... that’s exactly what happened. Since then, insurers have continued to hit against per-service fees, and docs and facilities have continued to shrink the time they alot to each service in order to keep afloat. In fairness, docs don’t have an awful lot of flex on this - they have to meet overhead costs which are fixed regardless of how small their reimbursement gets, and even with pitifully short visits doc real earning power has gone down quite a lot in the last 30 years. Docs work about 3x as hard as they used to, for about one third of the real income.

It’s actually a bit scary: there’s not a lot of leeway left in this, and medical education is more expensive than its ever been. Docs carry the financial risk and massive increase in burnout, patients bear the risk of the reduction in time and quality of care, and everyone else is squeezing the juice out of the grapes. Something’s gonna give.

Interesting. It seems like I was wrong about the AMA then. Is there a reason that a standalone bill cannot secure federal funding for addition residency slots, or is the stumbling block that increasing the number of residency slots will be expensive (even in federal money terms) regardless of how it's enacted?

Your comment wasn't wrong. In 1997, The AMA along with five other medical groups lobbied congress to limit the number of medicare-funded residency slots [1, 2]. This limit was enacted in the Balanced Budget Act of 1997 and hasn't changed since then [3]. Hospitals were paid hundreds of millions of dollars to voluntarily reduce the size of their resident training programs [4].

[1] http://articles.baltimoresun.com/1997-03-01/news/1997060012_...

[2] http://www.nytimes.com/1997/03/01/us/doctors-assert-there-ar...

[3] https://www.cnn.com/2017/03/13/health/train-more-doctors-res...

[4] http://www.cnn.com/HEALTH/9708/24/doctor.glut/

You posted this two hours after I replied with a list of google results showing you’re two decades out of date. Now it’s -clear- you’re being disingenuous, but for the life of me I cannot fathom why.

None of this is outdated. You're trying hard to to rewrite history with downvotes.

The 1997 cap on medicare-funded residency slots has remained in place since that time, unchanged despite population growth and an aging population. The current crisis and physician shortage is in large part a result of that two-decades-old legislation which was engineered by the AMA and other major medical groups.

Based on your comment history, you trained as a doctor, which is great and absolutely commendable [1].

However, do you feel compelled to troll and post obviously slanted information due to your personal association with the AMA?

For the record, I think doctors should get paid well and more than they currently do. Clinics should be run by physicians. But allowing guilds like the AMA to artificially restrict the availability of critical healthcare has resulted in millions of avoidable deaths and serious suffering across the entire population.

"The predicted physician shortages will result in decreased access to care for millions of individuals. [...] [A]dding one PCP per 10,000 people would reduce predicted all-cause mortality [...] by 5.31 percent. Translated nationally, this would avert 127,617 deaths." [2]

[1] https://news.ycombinator.com/item?id=16337410

[2] https://web.stanford.edu/group/sjph/cgi-bin/sjphsite/the-loo...

"In 1997, a consortium that included the AAMC, the AMA, and other major organizations declared that [...] 'the United States is on the verge of a serious oversupply of physicians'. The consortium recommended limiting the number of residency positions funded by Medicare, a goal that was partially achieved in the Balanced Budget Act of 1997" [1]

See also the 1997 senate finance committee hearings on graduate medical education [2].

[1] http://annals.org/aim/fullarticle/717927

[2] https://www.finance.senate.gov/imo/media/doc/hrg105-901.pdf

I know the Mayo Clinic has a totally different pay structure for docs, maybe there's other places out there like that as well. I think this is why people go there for answers to hard problems. Docs get paid a salary, they then choose how many patients they see, and that's it. I assume that's also why it can be tough to get an appointment there.

Mayo is a bit of a special case. Guwande hyped their fee structure in comparison to private practice, but it’s largely the same as every hospital: the doctor is an employee with an annual salary, the hospital is reimbursed per unit service by payors. Guwande compared them to private practices, where the doctor acts as his own employer, and thus has to maintain their own volume.

The difference is that given their prestige and the number of out-of-state (read: mostly cash-paying) patients, they get much higher reimbursement than most places and can afford not to push the patient mill so hard. Normal hospitals have a patient base that is mostly insured or, if uninsured, the impoverished kind, not the globe-trotting wealthy kind. So their reimbursement is negotiated with insurers, so... they have to push the mill hard.

Well, I suppose he could end up in a country where health isn’t in the insurance straitjacket

> there’s enormous value in chucking insurance out the window and just paying the doc for their time

I'm sure there's enormous value in chucking economic realities out the window for everyone's job, but that doesn't make those realities go away.

You perhaps misread what I wrote. I don’t know how to reply, since I don’t know what it is you think I said. I don’t believe it “throws economic realities out the window” to say that sometimes you need an extended interaction with an expert, and that if you want more than 7 minutes of an expert’s time, you should engage with a reimbursement model that pays for more than 7 minutes. That doesn’t ignore the economic realities of healthcare at large; it’s saying sometimes you need a premium good, and those have premium prices.

I thought you were proposing just forgetting about insurance and having the doctor's time paid for by magic.