Hacker News Reader

Comment by txcwpalpha | Hacker News Reader

> Where as other high income/developed countries, citizens don't have to shop around because everyone is insured by the State and pays the same prices.

Exactly. Everyone praising this is doing so because they think it's great that this will allow Americans to "shop around" when it comes to healthcare, but they seem to be missing the fact that even the very concept of "shopping around" for healthcare is absurd.

If you're having a heart attack, or just have a broken bone, or even if you just have a stomach ache, the last thing that you are going to want to have to spend time doing is "shopping around" before getting your problems fixed. Being able to shop around isn't something that should be praised, it's something that should be relentlessly mocked and is evidence of a failing healthcare system.

View on HN

very concept of "shopping around" for healthcare is absurd

No it's not. A very large percentage of medical care is planned, not urgent. There is no reason why price comparison can't happen for those.

A great example of a highly functional healthcare market is vision correction laser surgery. Every time I look around some deal is being offered. Competition is what drove those prices down.

Can you do that with everything? Of course not. But you can do it with a lot of planned medical care.

And it's not purely a race to the bottom; as expected price levels are achieved, it also becomes possible to read signals in the price, so that medical practitioners who are willing to do extra work (reduce wait times, better followup, home visits, etc.) can charge more to compensate for that, rather than just doing the minimum amount of work necessary in order to get the fixed payment.

>No it's not. A very large percentage of medical care is planned, not urgent.

And for those procedures, a hybrid system should suffice. All Americans, should, at minimum, be able to get urgent, surprise medical issues addressed in a way that doesn't completely destroy them financially.

Of course, nothing is black and white. Issues that could have been treated in a planned way become urgent if they're left to fester. Obamacare started shifting the incentives to make preventative measures more palatable, and healthcare cost growth has come down as a result. ACA is a /conservative/ set of policies. Even still, it elicits extreme reactions from loud people on the fringes.

I’d suggest a slight addition:

> All Americans should, at minimum, be able to get routine and urgent, surprise medical issues addressed in a way that doesn't completely destroy them financially.

Elective procedures are obviously a thorny issue people will debate over where to draw the lines. But standard checkups, routine wellness procedures, and covering the unexpected ought to be the bare minimum—the healthcare floor of social decency beneath which we do not allow any member of society to fall without recognizing we are failing as a society.

>No it's not. A very large percentage of medical care is planned, not urgent. There is no reason why price comparison can't happen for those.

The idea is that money shouldn't enter into the decision to have planned care at all. Let's say the price for a regular checkup goes from $200 to $100 (just an example). Okay but there are still people who will put off the checkup because of the cost. That shouldn't happen, people should just go to the doctor when they feel they need to, planned or unplanned.

>A great example of a highly functional healthcare market is vision correction laser surgery. Every time I look around some deal is being offered. Competition is what drove those prices down.

You mean LASIK? I mean besides the fact that you're falling for a markup-then-sale strategy there is a lot of contention around lasik surgeries - that they're misleadingly advertised, not that effective, bad side effects, etc. Heap a bunch of advertising on top that makes it hard for consumers to know the quality of what they're purchasing and you have basically all the hallmarks of bad un(der)regulated markets.

The idea is that money shouldn't enter into the decision to have planned care at all.

Money always enters the decision, even in a single payer system. Someone decides what will and won't be paid for. Your example of preventative care isn't a good one, since every US insurer had to cover it at no copay.

You mean LASIK?

Yes I do. And I mean the fact that it went from several thousand dollars in cost to under $1000 in pretty short time due to competition.

And of course consumers know what quality they are purchasing, any smart person would make the decision on more than just price.

Lasik eye surgery is a terrible example for you to pick for this. Lasik is notorious for being a market where laser clinics bought the machines when Lasik was a fad and were hoping demand would stay high, and are now having to resort to unscrupulous sales tactics to recoup their losses. Laser clinics give sales commission to their eye counselors as an incentive to get you to purchase Lasik even when you might not need it or it may not be best for you [1]. They have incentives to use deceptive marketing techniques to make you think that you need it and that it is affordable, even though the price you hear on the radio is almost never the actual price you will pay (they will tell you that the advertised price is only for some eyes, and that yours are more complicated and require more money). They will try to convince you that there are no side effects, despite an FDA study showing that 46% of people reported visual issues caused by Lasik, with 30% of all recipients stating that Lasik caused them to have chronic dry eye [2]. This is so commonplace that the FDA and FTC had to get involved to guide consumers about how to avoid these shady clinics and to tell these Lasik marketers to knock it off [3], [4].

I don't know about you, but I certainly don't think the 'marketplace' for procedures such as childbirths, biopsies, transplants, bone replacements, etc should look anything like the marketplace for Lasik does.

1: https://www.washingtonpost.com/archive/politics/2001/09/04/l...

2: https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedu...

3: https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedu...

4: https://www.ftc.gov/tips-advice/business-center/guidance/mar...

How does that differ under a single payer system where a doctor might do surgery that isn't needed. The problem of bad actors exists whether you have a market or not.

My comment wasn't meant to say anything about single payer systems. You used the Lasik surgery market as an example of a "highly functional medical market" and acted as if it is something to aspire to, when it clearly isn't. That's all I'm saying.

But if we want to go down that rabbit hole, a single payer system like the NHS isn't profit-driven like laser eye clinics are, so there's one way it differs. Doctors aren't incentivized to "sell" unnecessary surgeries.

They might not incentivized with the NHS (doctor's are salaried), but they sure as hell are in Canada with it's fee-for-service model.

More procedures, more $$$.

This analysis ignores the secondary effects of the mere ability to shop around.

Right now, for many insurance plans, consumers of care are 100% price insensitive. If even, say, 5% of a market starts to take their business elsewhere out of concern for price, it starts to put more cost discipline onto the system, which encourages competition.

You can't suggest a huge change and then assume the world will stay the same post-change. It won't. What the health system needs is some incentive to control cost; today, it has very few.

Completely disagree. Providers are not all the same. Some doctors are so incompetent they should not be allowed to practice, some are excellent. People should have full information on their providers, including costs, to be able to make informed choices.

>Some doctors are so incompetent they should not be allowed to practice

Which is yet more evidence of a failing healthcare system, and is certainly not reason to praise the concept of having to "shop around" just to get adequate and reasonably priced care.

You seem to be using the wrong (though obvious) definition of what it means to be incompetent. A doctor who is incompetent because of poor treatment is handled by the system.

However there are other incompetents that someone who is medically competent can not the less fall into. The doctor with poor human interaction skills makes the patient feel horribly before, during and after treatment. The doctor who takes "bribes" to prescribe a more expensive treatment when a cheaper alternative would work as well. Those are just a couple examples of how someone can be incompetent yet still not raise to the level of not being allowed to practice.

I'm not using the wrong definition. A doctor who is considered "incompetent" because they take "bribes" should certainly be terminated by the system. If they aren't, it is a failing system.

I put bribes in quotes for a reason. Outright bribes are handled by the system. However I'm implying any way to get around the rules without getting caught. Some are legal loopholes, some are illegal. The only point is by some way you got around the rules without getting caught.

That doesn't change my answer. If you have a system in which doctors carry out shady tactics and are able to "get around the rules without getting caught", and that system is so rife with such issues that you have to actively "shop around" to avoid them, then the system is failing.

This makes sense in theory, but the healthcare market isn't a great example of a free market. One example, especially for emergency care, you don't have many repeat customers (I realize there are exceptions). Word of mouth doesn't travel very far, even if people had time to examine reviews on Yelp. People aren't educated enough to understand if they received quality care or not anyway, beyond bike shedding (ie. bedside manner). If you receive poor care, you don't typically have options when it comes to getting a refund.

Emergency room costs are less than 10% of the total in the US. A popular, credible figure is 2%.

In any case it's less than 100%. And even if it were 100%, wouldn't transparency provide substantial, concrete benefits?

Really, I'm not sure how "some customers won't shop around" works as an argument against public knowledge of price and quality.

Not an argument against, just an observation that it's unlikely to be part of a realistic solution to the problems we face in healthcare. Interesting point about emergency care costs. Do you have a source you could share?

Late reply, sorry, and an old third-hand source: http://www.politifact.com/truth-o-meter/statements/2013/oct/...

I figure "it can't hurt, there is a significant market failure, and price transparency can only help."

I'd like to hear someone knowledgeable provide a counterargument, though. Maybe it would be expensive or impossible to enumerate those costs. Maybe preferential ("discriminatory") pricing is really important to the smooth functioning of the system.

Thanks for sharing. Looks like anywhere from 2-10% could be reasonable. Even if it's 2%, that's almost $50B a year. There isn't just one problem in healthcare; we'll need to solve multiple problems.

FTR, I think my original post did have several points that pertained to nonemergency care as well.

It's absurd, but as long as it's politically untenable to go all the way to something reasonable, things like this which will presumably be a lot easier to defend is still better than nothing - a huge proportion of medical needs are not emergency care, after all.

Emergency care for things like a heart attack or broken bone only account for 2% of healthcare spending. So your primary case for why "shopping around" is bad is mostly irrelevant. Nothing is stopping you from creating a not-for-profit healthcare co-op, getting participants to voluntarily turn over their healthcare decisions to you, and then demanding reduced prices from vendors. All I ask is that you don't force me to join it against my will.

http://www.politifact.com/truth-o-meter/statements/2013/oct/...

I never said anything about emergency care being my "primary case". My comment even specifically lists 2 instances of non-emergency care. Needing to shop around is an absurd concept for any medical care.

Please don't force me against my will to live by the whims of what you personally consider absurd in your own life. You are free to abdicate responsibility and choice to a third party all you like.

Your choice to live by an absurdly low standard of care is what forces the rest of us to suffer from a low standard of care as well (against our will). Your request to "don't force me against my will" is hypocritical.

And when you're dying on the sidewalk in front of the hospital, do you expect them to just let you die there and leave it to the county to dispose of the body? Like it or not it's unreasonable and inhumane to let capitalism condemn someone to a preventable death. Someone has to foot the bill for this. The only question is who and how. The naive answer is to let the hospital eat the loss but ultimately that just means that the rest of the patients pay it in increased costs. You can't sell yourself into slavery, you can't sell your organs, and you can't sign a contract to let the hospital ignore you dying on the sidewalk in front of the ER.

The total sum of all emergency care is less than 2% of healthcare spending in the US. And obviously the majority of that is going to be paid for by the patients, either directly or via insurance. The scenario you're talking about is a rounding error in healthcare spending costs. It certainly doesn't justify forcing people to accept what the likes of Donald Trump considers to be sufficient healthcare.

Could you please not do flamewars on Hacker News?

https://news.ycombinator.com/newsguidelines.html

Reply on news.ycombinator.com