The Business of Health Care Depends on Exploiting Doctors and Nurses | Hacker News Reader

The Business of Health Care Depends on Exploiting Doctors and Nurses

nytimes.com

49 pointsyhoneycomb50 comments

That's because if you run critical services like a generic for-profit business you almost automatically exploit everyone who is in it for more ethical or intrinsically motivated reasons.

There is a big disconnect between why you'd do the doctoring and hospital-running vs. the admin side of things. Once a business has a certain size it all becomes the same: bottom line, marginalisation, and bubbles of speculation under the name of financial management. The issue with doing that to healthcare is that you have to recoup your business failures in a way that is incompatible with saving lives; i.e. you have to make things more expensive to get your money but since for the people at the bottom of the chain that means having someone die vs. live they will not really be give a choice; choosing between getting healthy (but paying a butload of money) and getting dead (so you don't have to pay) is basically extortion.

A lot of excuses are made that 'you pay for what you get' meaning the quality is super high and thus expensive, or that the cost is very high, and that has to be calculated in to the prices, or that the business side is very hard and complex and can only be done that way; but unless they have unicorns and rainbows we don't know about those excuses are just that: excuses. The cost is high, and the quality doesn't match it - almost all healthcare systems in other developed countries is both higher quality and cheaper at the same time as well as having lower mortality rates.

Exploiting people that are intrinsically motivated to help people who put their lives their hands is just another sign of the administrative side of this deal completely doing it wrong.

The same people, buildings, services, machines, procedures in a different country with a better end-result and lower mortality rate should be enough proof.

I guess the UK NHS is run like a for profit business: https://www.theguardian.com/society/2019/feb/17/nhs-staff-qu...

> Health unions have been warning for years that NHS personnel are cracking under heavy workloads, rising demand for care and widespread understaffing. Many staff report routinely working beyond their normal hours to complete all their tasks.

Cost cutting can happen in the public sector too, especially with governments which only care about cutting taxes for the rich.

I've seen no evidence that non profit hospitals treat doctors and nurses any better than for profit hospitals. There are plenty of powerful non profit hospital systems that engage in aggressive business practices

Nurses and doctors in the US work a lot, but they also get paid very well compared to say the UK. Nurses in particular. Starting salary for a nurse in the UK NHS is 23,000 pounds: https://fullfact.org/economy/pay-rises-how-much-do-nurses-po.... That’s about $29,000. (This is a bachelors degree required position.) Starting salary for a US nurse with a bachelors degree is well over double that: https://online.drexel.edu/online-degrees/nursing-degrees/nur....

EDIT: Adding taxes to the calculation adds an additional dimension. Online calculators show that the total tax on 23,000 pounds with a 9% NHS pension contribution amount to 25%, leaving 17,500 pounds or about $22,300. In Maryland the total tax rate is the same for someone making $65,000, leaving $48,000. That’s after paying for social security, which will pay out about as much as an NHS pension would pay. A US nurse typically will receive health benefits on top of the salary. Even if the employer doesn’t cover 100% of premiums, the out-of-pocket premium payments (which are per-tax) are unlikely to be more than $5,000.

Keep in mind that this salary for the US do not count in healthcare and pension that the UK nurse is entitled to. I know it may feel like a nitpick, but it does make a huge difference when you add that cost of living.

This. The American urge to compare only base salaries (because that's all you have in America) is why Americans don't understand what they're missing. It's not in the salary! Its in the alleviation of $1000/month medical insurance premiums, in addition to $4000 ER visits (inclusive of said insurance), and pensions.

And before someone bemoans the taxes, let me clarify that those medical premiums and ER visits are AFTER-TAX dollars, so add an additional 15-30% on top.

The annual base salaries Americans quote are AFTER medical insurance premiums. They are not deducted from your quoted base pay.

This is completely untrue.

I'm an American citizen and not a single one of the 6+ W2 jobs I've held have quoted the base salary with insurance premiums deducted.

The quoted base salary does not include the employer paid portion of health insurance. For the 57% of people who receive health insurance coverage through their employer, that amounts on average to 82% of total premiums.

Minor addendum: Unless you decide on a plan whose cost is greater than the base plan provided by the employer, in which case the difference is deducted from your salary.

The NHS nurse is also paying health insurance and pension contributions! An online calculator shows they’d pay a national insurance contribution of 2,500 pounds and a pension contribution of 2,700 pounds.

Also, nurses don’t pay $1,000 per month in insurance premiums in the US. 57% of Americans have employer provided insurance, and employers cover on average 82% of premiums. A single US nurse likely would pay less in out of pocket premiums than the UK nurse’s national insurance contribution would be.

That’s why the US health situation persists. Most voters (who skew higher-income, older, and more established) don’t see the real cost of health insurance premiums because they’re an employer-provided benefit.

For my education, is this pension provided by the employer, or is this a state-provided pension?

The salary for the US also doesn’t count the healthcare and retirement benefits a US nurse is entitled to. US nurses generally receive health insurance coverage. As to pension benefits, NHS pensions for new employees aren’t very good. Each year, you earn 1/54th of that year’s salary as a defined benefit. If you work 40 years, you’re entitled to a pension of 75% of your average salary. Say that your career average salary is 30,000 pounds.[1] That gives you a pension about equal to your starting salary, or $30,000. That’s about what US social security would pay out for someone in that income level.

Also note that the retirement contribution for the NHS is about 9%, versus the 6.2% social security contribution.

[1] Apparently nursing salaries go up about 20% for nurses with more than 20 years of experience: https://blog.jobmedic.co.uk/nursing-salary-list.

This doesn't seem to hold up to scrutiny. Are you saying it's worse to double your salary but sacrifice a pension? How many years do people spend in the workforce? Usually 25 at least often 30 or more (say you start work at 21 and retire at 55, that would be 34 years). Life expectancy at 60 is around 25 years [1], actually 23 for USA, so people would be collecting pension about the same 30 years as they spent working. So unless your pension is equal to your salary, then doubling your salary is the better choice. Actually it's much better than that, because this money can be invested and you'll be gaining decades of interest on these savings.

And that doesn't even scratch the fact that pensions are subject to political changes and tax cuts. That pension could go away if politicians decide it's too expensive to pay out.

1. https://www.helpage.org/global-agewatch/population-ageing-da...

your nurses are grossly underpaid

not really; you can't compare the two because the cost of living is so different. You don't spend 10k out of your own salary on things like healthcare and insurances because they are already included in the cost.

US nursing salaries are at least as high as Canadian salaries, so this Canadian nurse's experience appears to contradict your claim:

https://www.theguardian.com/healthcare-network/views-from-th...

>Starting salary for a US nurse with a bachelors degree is well over double that

Your overall point stands however the text on the linked page seems to be a lie, the page it references actually says that the median salary is ~$70k NOT starting salary.

I’m referencing the section further down, showing salaries for BSN holders with less than 1 year experience.

Starting pay for an English nurse is £24,214, so you're at least $1,500 off. You consistently post incorrect information about the NHS.

I grabbed the salary from the page I linked. It’s for 2018-2019, while your number is for 2019-2020. Obviously the number is going up every year. I don’t know why I’d use 2019-2020 NHS figures when the US figures aren’t for 2019-2020. (Because there is no nationwide salary scale for nurses in the US, most pages quote BLS data which lags a year or two.)

Health care is the US is broken; I recently hurt myself, the diagnosis alone (xray, CT and doctor apt) was over $4,000 out of pocket, with good insurance that my CEO sent a email last year telling me was the reason we won't get raises.. that damn health insurance cost. I had a cousin talking about retirement, the only thing preventing them is... health insurance

My aunt was bitten by a rattlesnake on her finger. It cost 46,000 dollars for a vial of anti-venin and and one night stay for observation.

This happens in India all the time with King Cobras and I know they can't afford 46,000.

It's a total racket and scam because on a system of supply and demand like American capitalism... what has a greater demand to someone than a their life so the only limit to price is on the supply side.

> This happens in India all the time with King Cobras and I know they can't afford 46,000.

Your larger point notwithstanding, it's important to remember that overall cost of living in India is lower as well. So hospitals are inherently cheaper to run.

That's not why it's cheaper: money doesn't universally trump wellbeing in Inda like it does in USA.

No, it's because insurance hasn't hijacked the system in India like it has in the US.

Watch pet health costs...with the recent advent of pet health insurance, it's just a matter of time before costs skyrocket for veterinary care.

The prices may well rise somewhat, but demand for veterinary care is always going to be much more elastic. As much as people love their pets, they will also eventually decide it's not worth the cost.

You can't really do that with human health care.

I think there are lots of factors that collectively contribute to the price disparity—some cultural, some economic, some systemic. It's not black and white.

I happen to be vacationing in Dallas right now. Local costs for self pay CT is $235 on the first Google result. One big problem seems to be hospitals don't compete on price the way other providers do. So if you are hurt bad enough that you are kinda stuck in a hospital unable to shop around you get double screwed.

>with good insurance that my CEO sent a email last year telling me was the reason we won't get raises

That's almost certainly bullshit on the CEO's part.

That doesn't sound like good health insurance at all. Recently a coworker got a concussion snowboarding and food poisoning that same day. Was in the hospital for 4 days. Total out of pocket? $500, which included the ambulance ride ti the hospital.

We have a pretty typical health plan for a midsize company. At my previous (much larger) employer, her out of pocket would have been about $200.

The article cites the fact that there are 10 administrators for every actual doctor or nurse, and these lines should be cut in half to instead be spent on more doctors and nurses.

I think this represents a gross oversimplification, overlooking the necessary work of administrative staff. It's not unlike the airforce: there are about 23,000 pilots but 500,000 personnel, a ratio of more than 20:1. It takes a lot to support the enterprise that keeps planes in the air.

In the medical profession, someone has to keep the enterprise running. Cataloging medical imagery & seek and retrieve records as needed. Accountants and HR departments, IT departments, working with insurance companies, all of it. Even with the amount of EMR work doctors & nurses may do themselves, it takes a tremendous amount of background "plumbing" work to allow them to focus on the actual treatment. I'm not saying there isn't any administrative bloat anywhere, but I am saying that non-practitioner staff in the industry feel this resource crunch quite a bit themselves too. The technician running the radiology suite feels just as much pressure to help fit in that extra patient and stay beyond scheduled hours to do so. Treating the entire non-doctor/non-nursing staff as bloat is an extreme disservice to the mission critical work they perform.

I am literally taking my 1.5 year old son home from the hospital today after an emergency visit that kept us there for days, and during this ordeal I dealt with at least 3 or 4 non practicing staff that went above and beyond their duties to help with something and smooth the process over for the work that doctors and nurses needed to perform. These staff feel the ethical drive to serve every bit as much, it just happens to be less visible.

How much of the administrative staff you mention is only needed because hospitals have to work as for profit organizations? And don't forget to add the administrative staff from the insurance companies themselves.

Insurance companies are a separate issue, though some of their administrative functions would be required in any healthcare system. (Certainly not all though). As for hospitals working for-profit, about the only administrative function I can think of that is unique to that model is marketing. I may be missing something, but even so it would be very, very much less than the 50% the author of the article would do away with.

Non profit status isn't an instant fix for a dysfunctional system. Once the profit motive is removed, other incentives take over as primary motivators. The not for profit, Government-run Veterans Affairs hospitals have a higher administrator to physician ratio than most private hospitals and are well known within medicine for inane administrative roadblocks to effective patient care.

Yes, the profit motive does enforce at least a little pressure on reducing unnecessary overhead. This is of course not universally the case.

That's the nice thing about 996ICU for doctors and nurses: they don't have to walk very far to get to the ICU.

Oh and also, they're pulling pretty good money for their "exploitation" at least in the US. Want to address the overwork issue? Increase medical residency opportunities and available medical-school admission seats.

Healthcare is under stress everywhere, but those of you in the USA who don't understand how fundamentally broken your system is need to give your heads a shake. It's precisely because of how it's treated like a business first, thinking that competition is the solution to the problem, and applying other business principles is the way to improvement that things are the way they are. Read medical forums like KevinMD and you hear constantly about highly trained physicians ready to abandon the profession because they're treated like automatons, high suicide rates, and the best way to find a side hustle because their jobs suck so badly. Your country is being held back by the ludicrous way healthcare is structured, citizens shackled to employers, with the worst results for money spent anywhere in the civilized world. Citizens are so brainwashed they're unwilling to acknowledge the ideological morass that created and sustains this all. People who remain so frightened when people say the word 'socialism' that they double down on stupidity. Or refuse to look outside your borders because you're self-evidently the greatest country on earth. Pitiful.

I’m a provider.

Yes, it does. And they have a perfect opportunity. With the amount of student debt they have, they have to work. It is a perfect exploit. Plus, the license is on the individual, not the health care entity. They can just get another provider.

The entities have their own licenses also. For example a famous heart transplant program was shut down recently. The providers just found other jobs.

Edit: I am a provider also

The scariest thing about quitting a job you are deeply unhappy with is what to do about health insurance. I totally agree.

Does it though? Given how much they charge, does it really depend on exploiting those folks? Are they really being exploited given how high their salaries are?

Like, just for patient safety, I agree, these folks should not be working the ridiculous hours they work, but would they really agree to that if it meant a salary decrease?

As it is, everyone accepts that if you want lots of money and no quality of life, be a doctor. There should be a middle option like in other careers where they can be moderately well off with only moderate commitment.

> hey can be moderately well off with only moderate commitment

Primary care physician is like this, no? I guess your quality of life is still awful during training and residency.

There is, if you like emergency medicine: you get paid per hour, so you can work as much or as little as you like.

I completely agree to be honest, but it seems like when you see Doctors and nurses complaining on social media, it's almost like they do it as a badge of honor and not because they actually want fewer hours, given the implications that come with fewer hours (i.e. lower salaries).

That's assuming hospitals are actually operating on a tiny profit margin, but if the margin is huge, then there should be more demands. I mean, there's the nurses union at least, but what about the doctors, or the various technicians.

Either way though, the system is still broken with respect to how much the patients have to pay.

It really does. I have 6 family members in healthcare some on provider side and some on admin side. The provider side always talking about lack of resources and longer hours. Staff leaving and not being replaced. But then talk to the admin side and they talk about reimbursement being so bad taking on some patients are a money pit. Seems like the exploitation is the only way the admin side knows how to keep the wheels from falling off.

There is a lot of complaining in health care but there are a lot of people making very good money and the overall system is way too expensive. The whole system is ripe for an overhaul but I bet they will fight any reform tooth and nail because there is much money to be made with the current system.

That's not exploitation. Exploitation is the admin side doing great and still demanding long hours and minimal staff.

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