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Comment by HNcantBtrustd | Hacker News Reader

I have a friend with a similar story.

My wife diagnosed it over Snapchat. After that, the Physician she had been seeing agreed. (edit, Wife is a doctor of Physical Therapy)

The longer I live, the less I think Physicians deserve their Monopoly.

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What do you mean Physicians shouldn't deserve their monopoly? Are you suggesting crowdsourced diagnosis?

Perhaps a better approach would be "no cure, no pay".

That way, physicians would have an incentive to actually cure people rather than bill them for some inconclusive diagnostic tests.

This is the wrong incentivization model because it means physicians will do everything to treat the symptoms and not even bother diagnosing the causes.

We already have a pain killer epidemic, and that would make it worse.

I don't know if it's the right incentivization model but there's a difference between diagnosis + cure vs. treating symptoms.

Painkillers treat symptoms but they don't cure anything.

You can't cure what you don't know exists, but you can cure that admitting abdominal pain with painkillers and still get paid (with that model).

The point is that diagnostics are expensive, and if you're not going to be reimbursed to run them, you're going to take the risk to find the cause. What's left is curing the symptoms.

But insurance companies will demand a cure, as they will not pay for a subscription of painkillers.

Insurance companies are incentivized to not pay anything.

They currently demand that patients do not even go to a hospital, hence the price penalties for going to an ER and lack of preventative care coverage. The only thing an insurance company will demand is what they currently do - the lowest cost, which is an Rx for pain pills.

This is a terrible idea. What do you think of software companies that pay "per bug fixed"?

Um, how about - pay per hour of program running without crashing.

Shouldn't I get payed for the work my software does, without interruption, day after day after day?

So if you join a company with terrible infrastructure that needs a ton of work, you don't get paid until it's operational? What if there are organizational issues within the company that prevent you from actually resolving things long-term? Rarely is a single engineer empowered to make a difference in the up-time.

Physicians face similar challenges when it comes to the bureaucracy in the world of medicine, but with the added challenge of working on the unpredictable biology of human beings rather than a bunch of transistors that are predictable in their behavior.

And imagine if the system was setup in the way you suggest, which doctor in their right mind would take on patients where the treatments aren't as clear cut? Who wants to work for months or years with no guarantee of pay?

Honestly, comparing the two fields is pointless. I do not envy physicians. They are working within a broken system and most are doing the best they can. Blaming them will get us nowhere.

Good points. I certainly agree that there's no good comparison between the two professions as it relates to compensation systems.

There is a movement commonly referred to as "Outcomes-based Healthcare" that is rethinking the way the system approaches treatment. The focus isn't necessarily on compensating physicians for their outcomes, but changing the metrics that are used to evaluate potential treatment options. [https://www.healthcatalyst.com/Outcomes-Based-Healthcare-Top...]

I've been following ZDoggMD for a couple years now and I really like listening to his perspective on the world of healthcare. Check him out if you have any interest: https://www.youtube.com/watch?v=9hEnAmfTBZs

This generalises to an interesting question: What is the true utility value of any service?

Is it:

- Increased capabilities gained?

- Risks avoided?

- Alternative opportunities enabled (I babysit your kids, you get a night on the town)?

- Enablement of specialisation, expertise, and concentrated and efficient use of capital?

- Other?

Probably some combination of these.

That's a good idea, as long as software companies also pay for bugs introduced.

This sounds like a recipe for 90% of the money to be wasted debating the line between bug and missed requirement.

Medicaid and medicare are switching to a value based program, where hospitals and providers are paid more for better outcomes instead of the previous pay for service model where they are effectively incentivized to over treat, and not fix the root cause.

However this would lead to over treatment, which also isn't good.

What is worse?

Also, insurance companies are an opposing force here.

Heh interesting, an incentive structure that has insurance companies going to bat for the little guys for the little ones.

Then you can expect doctors to be strict about which cases they will handle.

do you get a refund if you die?

Yes. The check will be in the mail upon receipt of a death certificate. But the form is at the confusion level of a stripper with a W4. Also for some reason we are going to have the postal service manage the reimbursement.

How do you apply that when so many conditions are managed, not cured?

Consider the proposal a starting point.

Managing conditions is clearly a useful outcome.

Avoiding conditions is even better.

Payment based on some quality outcome measure -- QALY, or quality-adjusted life-years is one such standard.

https://en.wikipedia.org/wiki/Quality-adjusted_life_year

The Chinese healthcare model -- you pay the doctor when you're well -- is an alternative approach. (The doctor is obliged to try to get you well again.)

Congratulations, you've ensured surgeons don't undertake complex surgeries, oncologists pick and choose the less critical cases, and no one staffs hospices any more.

I agree. I think it kind of happens now when surgeons are ranked on their success rates. They start refusing complex surgeries that might impact their ranking.

There's a reason malpractice insurance exists.

So I guess only people with easy to diagnose diseases will be treated. People with diseases like cancer, etc. will simply be rejected outright.

This is a hilarious free market solution when compared to universal healthcare.

A number of states allow nurse practitioners, or physicians assistants to do many of the things that only doctors can do in most states, practice independently, admit patients, prescribe medication. But they do not need to go through the match process and residency, so there is not the same kind of monopoly

Nurses and PAs are similarly limited by available slots in their respective educational programs. Our local community college has a 4-5 year wait list for their RN program, as an example.

It is really not comparable though. Doctors are limited by residency and the match in addition to medical school.

They are comparable, though.

In both cases, there's a limited number of slots available for what's fundamentally a required educational program, and increasing that number of slots is difficult on a structural and staffing level.

There is no set limit like with the match or residencies. New schools can open up, existing schools can increase class size or run additional classes to match demand, and they have the incentives to do so.

The match can do that, too. 2019's had 6% more, because more programs joined in. There's no set limit; there's a limit to how many slots Medicare subsidizes, but programs are free to offer self-funded slots over that.

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