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Comment by toomuchtodo | Hacker News Reader

The crux is hospitals and doctors don’t want their pay cut, when it should be cut (Sanders’ bill does this). This is the result of the AMA attempting to keep wages high through quotas (as well as bloated hospital admins), and the resulting policy required to fix cost inflation.

Healthcare is a utility, not a profit center, of course we’re going to compress unnecessarily high wages (or cut unnecessary non-provider jobs ruthlessly).

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Compressing "unnecessarily" high wages will inevitably cause less people to want to assume large amounts of debt for the necessary education and training to become doctors. The doctors that I know chose their career explicitly because of the salary and status that comes with being a doctor. Remove the incentive and you will diminish the supply. Diminishing the supply while also promising free care to all (increasing demand greatly) will result in very long wait times and diminished quality of care.

Those folks can depart the system and we’ll put an express lane visa in for doctors who want to immigrate to the US. Lots of highly educated healthcare professionals in the world who would want to immigrate to the US and aren’t anchored to unreasonably high wages.

Those doctors you mention picked the wrong career for fat cash and prestige. We can’t allow a broken system to continue because of previously made bad decisions.

Interesting solution - I don't know how the visa system works but if these doctors decided to switch careers after they got here in order to provide better for themselves/their family is there anything stopping them? It still seems like it's misaligning the incentive structure to produce the desired results.

At the base of the issue is that being a doctor is a difficult, stressful job that requires high intelligence and sometimes even high physical dexterity. While it's nice to think that people would choose to do it because it's moral to take care of people, I don't think it's fair to expect that these people wouldn't want to be appropriately financially rewarded for their gifted skillset.

Ah yes, the best of both worlds; socialized medicine provided at rock bottom prices through mass immigration undercutting the salaries of US citizens that are paying billions towards non-dischargable loans taken in good faith.

Sarcasm of course. In my opinion, these are two great ideas for getting Trump re-elected.

You can always count on America to do the right thing after having exhausted all other options.

Given that many more people want to go to medical school than are allowed, we are no where near running out of would-be doctors. Except that existing doctors constrain the pipeline.

People want to go because it is a lucrative career. Lowering the education requirements would result in lower quality of care.

Yep. There are a lot of people making good money off the current system. They see no need for change unless it makes them even more money.

> They see no need for change unless it makes them even more money.

I think even "they" would appreciate the efficiency of consistent single-payer system. Just imagine the incredible overhead of bureaucracy that would be achieved, no more need of departments set to deal with insurance problems and all. Surely they appreciate how this will all be streamlined and made efficient.

The unneeded departments are also quite powerful and want to survive. We call them “deep healthcare”....

>The crux is hospitals and doctors don’t want their pay cut

Whether hospitals and doctors are really charging fair prices aside can't cost reductions also be accomplished by cutting out middlemen? I think there's going to be far more pushback from those rent seekers than the service providers.

Of course. Current middlemen are around 9% of healthcare expenditures.

The mentioned 15-20% off the top for insurance, but the insurance/billing industry is two sided, wouldn't there also be a ton of administrative savings by having a fraction of the 'billing/coders'? They'd only have to deal w/ the U.S. government which isn't going to be as nitpicky and litigious over every little line item.

On the contrary. Medicare is extremely nitpicky on every claim line item.

Only because they can be, if hospitals and law-makers meet in the middle come up w/ across the industry iron-clad rates for services, or hell -- what if hospitals just get a flat average monthly lump sum -- no piecemeal at all, just based on # of patients that go through their door in a month?

Dr's get x% based on patients they saw + hours booked in the OR. Hospital administrators would have pay caps of 1 million per year. Hospitals that struggle could get grants and loans while the system corrects and adjusts to pay them more so they meet their budget constraints.

Yes capitation is already being tried in some areas as one approach to shifting the market from a fee-for-service model to value-based care. However provider organizations still struggle with it because most lack the data, tools, and expertise to properly price the risk.

Medicare administrators and lawmakers already do set iron-clad rates for service. The rates are relatively low, which is why there's a shortage of doctors willing to treat Medicare patients.

And being nitpicky on claims isn't so much a matter of pricing. Instead the insurers are trying to prevent waste, fraud, and abuse.

An option I've thought of btw -- also is what about hospitals BEING the insurer? For instance, say they simply charged 6% of income for insurance. You'd signup through your local/favorite nearby hospital -- and pay your 6% of salary (nothing if you are in poverty), the hospital benefits because they have recurring monthly income that they can count on for budgets and things. When you travel your hospital pays other doctors and hospitals. Your hospital also pays your primary doctor, and other professionals as needed. This would basically cut out the insurer middleman, still leave it fairly privatized, but also lower the need for billers. Hospitals aren't going to gouge prices when they're the ones paying the bill right?

Government could also give grants/subsidies to help w/ the system as needed or tax relief. I think fair % might be 2% per 30k annual salary upto 10% of income.

Apart from your idea of signing up to a specific hospital this is how systems like the NHS work. They are funded from a specific tax in the UK and general taxation in some other countries. They either don't bill anyone for the care they provide and have no bureaucratic machinery for doing so, like the UK NHS or a here in Norway we pay a sort of co-pay for each doctor or hospital visit but it is capped at quite low levels, a couple of hundred dollars a year. And it is not related to the fine details of the treatment you have received so again there is very little bureaucracy.

Kaiser Permanente already acts as both a provider and payer in a single organization. The rest of the industry is gradually moving toward that model. But patients probably won't pay based on an income percentage.

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