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Comment by entee | Hacker News Reader

One thing that sometimes gets lost in the "health care is inefficient" discussion is that one person's inefficiency is another person's living. The cost controls the paper appears to advocate for literally mean someone is making less money, that someone will advocate strongly against it. I've spent the past 3.5 years in healthcare, everyone is convinced they're not the problem, that they're underpaid or overworked or whatever. I would love for some sort of centralized system to push down costs, but I fear it's not realistically every going to happen.

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> One thing that sometimes gets lost in the "health care is inefficient" discussion is that one person's inefficiency is another person's living.

You are not entitled to a living as bureaucratic waste. We should of course help retrain those who lose their jobs, just as we're doing for coal workers who are going to be out of a job within the next five years. I want my healthcare dollars going to healthcare providers (doctors, nurses, nurse practitioners, CNAs, drug research R&D, medical technology innovators), not private insurance companies, not administrators or third party billers, and most assuredly, not shareholders. I want the AMA to be handicapped from preventing us from dramatically increasing the number of doctors in the US (the American Medical Association operates as a cartel/cabal, attempting to limit supply to keep wages high); they also attempt to reduce the authority given to nurse practitioners [1].

> I would love for some sort of centralized system to push down costs, but I fear it's not realistically every going to happen.

The majority of Americans say the government should be responsible for ensuring health care coverage for all Americans [2]. Universal healthcare will arrive in the US eventually, the question is when. The current model is unsustainable, and will reach a tipping point.

[1] https://www.modernhealthcare.com/article/20171214/NEWS/17121...

[2] http://www.pewresearch.org/fact-tank/2017/01/13/more-america...

Only a few generations ago, healthcare was not so ruinously expensive in the USA. We've never had taxpayer-funded universal care. So what caused the explosion in costs?

TL;DR Lack of cost controls and unnecessary administrative costs.

> In the U.S., they point out, drugs are more expensive. Doctors get paid more. Hospital services and diagnostic tests cost more. And a lot more money goes to planning, regulating and managing medical services at the administrative level.

So, we're all getting a lower quality of care for a lot more money, due to how the healthcare "market" is configured.

https://www.nytimes.com/2018/03/13/upshot/united-states-heal...

https://www.cnbc.com/2018/03/22/the-real-reason-medical-care...

https://www.cnn.com/2017/11/07/health/health-care-spending-s...

https://www.consumerreports.org/cro/magazine/2014/11/it-is-t...

This fails to address the elephant-sized American in the room. Any analysis of increasing healthcare costs that doesn't quantify the fiscal impact of the average American's failure to care for themselves is just beating around the bush. The obesity rate alone has gone from 10% in the 60s to 40% today. These people need more care that is harder to provide, and to not expect healthcare costs to rise significantly from that is to expect healthcare workers to work for free.

Our system is a little sick, sure, but the bulk of the responsibility for the current situation lies squarely at our own feet as individuals. This problem will never be solved before America puts down the fork.

The elastic nature of health care costs and the disconnect between the people making the purchases and the people paying the bills.

If you have insurance, chances are that you are not asking your doctor how much something is going to cost. You are not likely to shop around or work to get the best deal. As a healthcare provider, where is the incentive to bring costs down.

Also, hospitals typically won't tell you how much something will cost, so you can't shop around even when you are willing to.

Also sometimes hospitals will lie about what they will charge -- happened to my daughter regarding her appendectomy. Should count as fraud.

You’re missing the point. The parent isn’t suggesting this situation is good, or that we shouldn’t eliminate bureaucratic waste. They’re saying that there are a ton of people highly incentivized to keep the system as it is, because it pays for their salary. Concentrated benefits, diffuse costs.

> that they're underpaid or overworked or whatever

Having family in healthcare and being a lifelong patient due to a congenital defect, a job in software (including management obv) is a breeze compared to health care worker jobs across the board. They require more "schooling" (via mind-numbing training), are underpaid, have much more serious consequences from mistakes, have less oversight, work longer hours and under worse conditions. It's disheartening.

People's work shouldn't be reduced, but drugs and devices should be to an extent. Firefighters told the portable EKG costed thousands of dollars (5 or 10 don't recall). That thing had bad 2G connectivity so the graph coudn't be sent to a cardiologist. The sensor/dsp part is worth money, the rest would cost 100$ from any smartphone maker today with better performance and portability.

I'm sure the price is rigged for margins. This shouldn't be a market, it should be an open duty to make these cost efficient.

The real cost is not so much in the hardware but in the certification requirements. Medical devices need to be built to and work at a higher standard than consumer electronics, for obvious reasons.

But if the cost becomes so high that people simply go without the devices, is that really a good tradeoff? Maybe a device with 1 in 10,000 failures is better than no device at all, for some subset of illnesses?

Also, I suspect this is FUD by some entrenched medical devices companies who know how to play the game of complying with standards. Anyone here ever gone through compliance testing with software? I've seen systems pass that are worse than what I would have just thought up in 30 minutes and coded up for fun. It's just a warm fuzzy feeling.

That's one thing. But there's other problems:

1) certification that takes 10 years (more like 3, but ...) means you, at the very best, have 10 year old technology

2) Certified at a higher level. That can for various reasons be very different from reliable at a different level. For instance, circumstances change or knowledge advances.

For instance certification tends to take "proof" that something works. Yet the most reliable robots are pretty bad hardware, with the ability for multiple components to do the same job "most" of the time. Such a device, despite being much more reliable, is disqualified a priori in nearly all certification processes I've seen.

(needless to say, every time the things they take as proof tend to be ... less than proof)

Plus we've all been in a company having this discussion. "For the price of this one 'reliable' server we could have 20 normal ones, and they would be a hell of a lot more reliable together. Hell, just give me 3 of the cheap ones and I'll make it more reliable". And we all know what the boss's answer and the resulting reliability was.

3) You assume no regulatory capture (or outright dishonesty on the part of government employees and/or lawmakers)

Of course, but the interface and connectivity part of that EKG machine wasn't even up to 2005 cellphones standard. On that point, it's a scam.

So you would trust a random baseband chip to never ever in a thousand years lie to you about the success or failure of its operation or its internal status? Or to behave in an unexpected way that interferes with the core function of the device? E.g. by suddenly sending random junk to the main CPU?

How do you verify that the display controller is not acting up and not blanking out a region of the display that contains essential data?

If you cannot prove things like that for your medical device, you won't be allowed to sell it.

If only. I work in the same town as a big medical device manufacturer, and several co workers over the years had worked there and immediately nope-ed out on moral grounds. Stuff like panics on anything out of the order in a morphine pump that defaults to full on while resetting. Apparently those killed a few people.

Meeting the FDA guidelines is more about finding the cheapest way to technically meet the spec rather than trying to build something safe.

I do get that such a device panics on the smallest error. But then it is supposed to go into a safe mode. "Full on" does not seem safe to me. Full off and emitting an acoustic alarm until it is actively acknowledged would be the right thing to do. Whoever designed this thing to do what it did was frankly a morron.

But gaming the certification process is unfortunately also a thing. In the EU the certification is performed by private companies who are themselves certified by the government for this job. The kicker is that they are competing against each other on a free market. Potentially shopping around for the most lenient certification process could be a thing. I haven't witnessed it yet but it certainly is possible in that system. The thought alone scares me.

Oh yeah EU certifications are sadly super weak. Now to your original point, I think it's quite possible to have an open review system. Linux and the likes have shown great capabilities in finding and fixing issues fast. With a national effort to ensure paid engineers it's not science fiction.

You know this mindset is becoming the norm. Everything is about doing the minimum to be legal and avoid lawsuit.

I think primary care workers are generally underpaid and specialists are generally overpaid. That said there's a lot of variation in the data. If you look at some studies of why the US spends more than other countries on healthcare without better outcomes, the difference in prices between the US and other systems is a significant driver. Labor (particularly physicians), drugs and administration costs more here than elsewhere [1]. It's true doctors go through a lot of training, but I'm not terribly sympathetic to stories of a surgeon not being paid enough. Family practice, primary care I'd be more inclined, but even there we spend more than most countries it seems. [EDIT] I'm less sure on what the "blue collar" healthcare workforce (health aides, etc.) wages looks like, I would totally buy that many are underpaid.

Administrative costs are a terrible drag, and I say that knowing that currently I am personally paid by administrative costs. We could bring them more in line to the international norm, but we'd still be substantially more expensive because administrative costs are still not the bulk of total expense.

Drugs are an interesting story because the US effectively subsidizes international drug costs [2]. Also, drugs are a way to stop way more expensive interventions (better to take a $100K drug that cures Hepatitis C than get a liver transplant that will cost far more than that and won't give as good quality of life), so maybe in some ways we should spend more there if the treatments are worthwhile. That said there are disturbing pricing trends in the industry that are clearly exploitative.

In summary, what nationalized systems buy you is fewer administrative costs (good), price controls on medical services (maybe good, but necessarily docs get paid less down the line), price controls on drugs/devices (maybe good, but maybe trade-offs in developing treatments that are less expensive than other interventions). All of the parties involved will be fighting this "efficiency", some more justifiably than others. Who knew healthcare could be so hard?

[1] https://www.hsph.harvard.edu/news/press-releases/labor-pharm...

[2] https://www.vox.com/science-and-health/2016/11/30/12945756/p...

I'm pretty sure most people, even administrators in hospitals and insurance, are overworked. Health care in the US is the textbook definition of big business. The only people making easy, stupid money are shareholders.

Like, the living of some drug middleman who is a leach on the system and only exists because of some lobbying or other screwed up structure?

More like the doctor who has dropped six-figures + a crazy amount of years in education and certification to work very long hours seeing a lot of patients, many of whom think you're a quack and trust an online forum over anything you say.

Oh and don't forget the high premiums for malpractice insurance, as you're working crazy hours without breaks, and if you make a mistake you're sued up the whazoo.

And that's just describing a PCP - never mind a surgeon, EHS driver, hell even the nurses (though the latter are most likely unionized.)

Cost controls also have a cost. The UK NHS has chronic staffing shortages, UK doctors are going abroad for better pay; currently the favourites are Australia, Canada and the Middle East. I have heard quite a few people say they actively discourage their children from being doctors.

Australia and Canada have universal healthcare.

Poor purchasing power / stagnant wages is a problem across all sectors (except finance?) in the UK, not just healthcare.

Doctors aren’t a huge cost issue. Their pay isn’t that outrageous or out of line. It’s the pharmacy costs and administrative costs (and I think also DME costs?) that are seriously out of whack in this country.

Oh I'm not claiming they're out of line - they deserve that pay. My point was that it's not all these evil salesmen / drug capitalists driving high-costs in medicine. Sometimes better quality care just costs more.

These people get paid very well in Australia.

People will stop making lame arguments pretending that socialized medicine is impossibly unworkable maybe about 30 years after it's been successfully implemented in the US.

Why do we constantly pretend that America is an island universe and ignore that the rest of the developed world has already done this?

And a lot of this is administrative overhead. Coming from a country outside of the US, I was also shocked by the price of medecine, every medecine magically seems to be 5-10x more expensive in the US.

The prices help pay for the huge cost involved in developing drugs. How many drugs were developed in France in the past 10 years compared to how many were developed in the US? You know the answer.

I know that's what's pushed, but how much of that is true? Federal grants pay for a lot of initial frubt work, and drug companies spend around twice as much on marketing as they do on R&D. And that's with all sorts of tax benefits behooving them to call as much as possible of their budget R&D.

Marketing is needed everywhere, pharma included. You dont spread awareness of a new drug just by filing an application to the FDA. And marketing expenses are high because potential returns are high and make or break a drug. Note that you dont have really new drugs every year so you need marketing anyway to convince prescribers why your version of the drug in the same class as your competitor is slightly better. In reality most drugs of the same class are pretty similar in efficacy and side effects, but thats a tangential topic.

This is pretty specious reasoning. The US is a leader in a lot of industries that aren't healthcare.

Ever heard of Sanofi ?

Yeah and you know that their main drug market is the US and they target that market when deciding which drugs to develop? Also, ever heard of the concept of multinationals, where companies are spread around the world and not in a single country? same for Sanofi.

That's crap, often 80% of the price of a drug is marketing and profit.

Thats only if you consider the drug itself without all the cost of running operations and research. The actual profit margin at the company level is far from 80 percent. I suggest you read annual reports to educate yourself.

I think you're mischaracterizing the costs a little. It's certainly true that Company level profit margin is not in the 80s, but operating income is certainly fairly high. The profits come from compensating the Company for the risk that they have taken, and not necessarily straight for costs. There's certainly room to argue that the pharmas are capturing a too-large slice of the pie, and I personally welcome the debate.

Since Sanofi based in France is one of the top 3 pharma companies, along with Roche based in neighbouring Switzerland, I'm guessing the answer will be quite a lot.

The answer is very little compared to the whole market. And Sanofi targets the US market to fund its drug development. If they were not active there they would be a super minor company.

Personally, I would’ve liked to be asked whether I consented to paying 10x the price that every other country pays, in order to subsidize drug development, cause I definitely don’t recall ever agreeing to that deal.

The problem is your other option is likely not having the drug at all.

No, this is a myth. We know this because the same drugs often times cost a fraction of the price in other countries.

The real reason drug prices are astronomical in the US is because the US government is legally prohibited from negotiating drug prices. So the pharmaceutical companies can literally set any price they want.

You don’t have this problem with certain government agencies that are exempt from this prohibition. For example the VA can often acquire the drugs for much cheaper.

Does not matter how much it costs in other countries. the reality is that pharma companies make their revenues in the US at the level of 70 or 80 percent. You can be sure the level of investment would be very different if prices in the US were much lower. In practice the US is subsidizing drug development for the rest of the world.

If we removed the profit paid to investors, isn't there additional money to be paid to people facilitating healthcare and to bring the costs down?

It looks like there was $47 Billion, (~9%) in profit in healthcare companies in the US in 2018. https://www.axios.com/health-care-industry-on-track-massive-...

This accounts for less than 10% of the difference between healthcare spending between the US and other OECD states. See this report for a much more detailed analysis:

https://www.mckinsey.com/~/media/McKinsey/Industries/Healthc...

The cost problem in healthcare is exactly that: many pigs at the trough, and everyone points at the other pig for being the problem.

Healthcare administrators! Drug companies! Device companies! Trial Lawyers! Insurance companies! Doctors (especially specialists)!

They're all the problem, and yes lots of them should make less money. I know cardiologists pulling down 500k+ and that is ridiculous. I can see highly skilled surgeons making that much, but pill pushers?

> I know cardiologists pulling down 500k+ and that is ridiculous. I can see highly skilled surgeons making that much, but pill pushers?

I don't know about you but I'm not willing to be a student until I'm in my mid 30s, working crazy hours, likely accumulating a significant amount of debt along the way, without some kind of a substantial payout on the other side.

Which is a good reason to not make doctors spend so many years in school. The Europeans don't and their doctors are just fine.

Also a good reason for state-funded higher education.

Cardiologists aren’t pill pushers. They are interventional radiologists of the heart. They do need lots of skill also.

I’ve always worried about the political consequences to the loss of insurance jobs.

I also view that job loss as a foregone conclusion due to insurance companies fighting even moderate changes tooth and nail. If even minor improvements to a nakedly broken system are going to get fought against with such ferocity, it’s not surprising that their opponents would try and move the Overton window in response.

This is the problem with a for-profit healthcare system. Meaningful reform is almost impossible because there's jobs on the line and therefore voters to contend with. More importantly, they are also probably highly educated and well paid voters. Doctors, software engineers, sales, etc.

How much white collar employment comes from healthcare inefficiencies? Probably a good percentage of the sector.

These workers will need to acknowledge they are part of the problem and willingly give up these positions (or their absurd payouts from them) and vote accordingly. Or not and continue being part of the problem, which I think is your concern.

US has a host of not-for-profit providers, they’re not drastically cheaper.

Mostly due to the existing for profit system. Not for profits still have to reside within the existing construct of American healthcare and hardly provide any real advantages when they negotiate with for profit entities.

"cost controls the paper appears to advocate for literally mean someone is making less money"

Reference Table S1.

Cost controls would account for ~14.5% of the total savings.

Hardly seems onerous. Medicare's medical loss ratio is approx 4% (?), whereas ACA caps private insurers at 15%. So clearly there's plenty of fat to be trimmed.

TL;DR: Single payer is cheaper, people live longer. Transition will be painful.

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