Why Some Doctors Purposely Misdiagnose Patients
theatlantic.com
theatlantic.com
Most dentists are perfectly capable of providing the correct diagnosis. Unfortunately, even if and when they are, there are obstacles:
- Weak incentives to provide an accurate diagnosis
- Strong incentives to provide a particular inaccurate diagnosis
Giving a correct diagnosis often means investing more resources, as well as continuously investing in education and tooling. If the patient doesn’t see the difference between a correct diagnosis and “probably correct diagnosis” then they will react the same in both cases.
This situation where every diagnosis is perceived as the same, an examination is one of the least profitable services provided by dentists and, naturally, falls into the problem of “adverse selection.”
Some dentists recognise the opportunity of giving the wrong diagnosis to get a higher benefit. Be it by keeping or winning over the patient or by leaving room for the ability to recommend costly treatments.
The results of this are:
- Patients on average get a less correct diagnosis
- Dentists earn little to nothing for their diagnostic work
I've seen dentist offices that were just cavity filling mills that filled anything remotely resembling a cavity and using three different methods of pain management during the procedure. The dentist literally had rows of chairs in the same room getting cavities filled.
I've sat in a dentist's chair and been told I had a cavity that needed and could be filled that day. Unfortunately I was not in a position to pay for the procedure so I deferred. I saved up the $$$ needed and returned at my next appointment prepared to have it filled only to be told I didn't have any cavities.
When I was a kid, you didn't get braces until you lost all your baby teeth, now Dentists have started recommending braces for children as young as 4 with the expectation that they'll need braces again as a teen.
Dentists are able to recommend wrong therapy plans without patients knowing. Even when a patient gets the correct diagnosis, they can be recommended drastically different therapy plans.
This happens because there are many ways to solve the same medical problem. Depending on the financial capacity of the patient and the desired quality which is most commonly measured by the length of durability or visual appearance, as well as other factors.
Another related issue is the aesthetic dental work paid for by the patient, which can cause the need for more treatments down the line. All these decisions influence the health of the patient in a way they aren’t able to fully comprehend, and they rely on dentists as experts to advise them.
Generally, advice and diagnosis are not separate. This creates a venue for unethical behaviour. For example, dentists might resort to recommending "tools from their toolbox.” In your case, it was fillings. When you buy a hammer, suddenly everything looks like a nail.
The results of all this are:
- Patients get suboptimal/wrong health treatments
- Treatments are still performed long after there are better approaches available
- Dentists are less able to give the right advice
Dentists routinely recommended the more-expensive ceramic teeth replacements for teeth in the back, even though ceramic is less durable than the metal counterparts. Even though you basically can never see the hind teeth, so cosmetic reasons shouldn't have applied as they do for front teeth.
Why not have a specialist collect the data needed: pictures, temperatures, blood pressures, basic answers to questions, etc...
Then farm this data out to several doctors who make a diagnosis -- until you've reached a statistical significance.
Then, use this data to train a machine learning model.
I notice metal in peoples hind teeth all the time. This is still a cosmetic need.
Food for thought. If teeth are constantly grinding against each other, is it good for the opposing teeth to constantly be grinding against a hard material like metal?
Choosing the correct tradeoff between cost, appearance and durability is a value judgment. While the importance of appearance is lesser for the rear teeth, I wouldn't write it off entirely.
Knew a dentist. She told me how her mentor mentored her in the art of billing to the max on everything and pushing every procedure under the sun for financial gain.
I fly 3000 miles to see the same dentist I have seen since childhood. Honest guy who has a conservative mind about treatment. It's worth the extra airfare.
They should be sued out of existence, both criminally for fraud and after that civilly.
The incentive was probably to focus competency to certain hospitals, but you can imagine how this plays out in reality.
Especially people not familiar about medical necessities should always get a second opinion. Otherwise you might end up with an extra hip or something like that.
At least it begins to be common knowledge that hospitals do operate too often.
Still, with all its problems, and there are many, I certainly would prefer to be operated in any country of the EU compared to the US. Not because of capabilities of doctors, but to me it seems US health care as a example how private business can be worse than governmental services. Common market mechanisms don't work if your life depends on it. It is just about extracting the most amount of money from suffering and this article describes a problem to which there is no solution in my opinion.
When all you have is a hammer, everything looks like a nail.
So yes the US health care system needs a push to be more socialized or less regulated, but it’s not some prime example of a free market gone awry.
This will be a big issue in any kind of health care reform in the US. if they want to get costs even remotely in line with other countries a lot of people will either lose their job or make much less money. That won’t happen without a lot of resistance.
there is no such thing as having this cake and eating it too: there will be immense pain for a sizable part of the economy whenever this gets tackled.
And a saved dollar is spent less than a spent dollar.
https://www.forbes.com/sites/niallmccarthy/2019/08/08/how-us...
The average schmuck will not. Hopkins probably isn't in-network for him even if he works across the street from it.
Hopkins probably isn't in-network for a lot of people who physically work in the hospital every day. Custodial, cleaning, security, etc. often are contractors and therefore do not have access to employee benefits of their platinum-level customers.
Network Providers - The EHP Medical Plan gives you access to The Johns Hopkins Hospital[1]
[1]https://www.hopkinsmedicine.org/human_resources/_docs/benefi...
JH may be relatively unique in being a 100% employee shop, but it would definitely be a case of the exception proving the rule.
*Edit -- it looks like JH has a history of fairly high-profile labor conflicts. If they are 100% employees, I would bet their history is a factor in why they are this way now.
(hip replacement is not one of those)
For example transplant work in the UK is very concentrated I went to the royal free and they have the best equipment and surgeons and do world leading operations.
The guy across from me was the oldest patient in the world to have a new type of key hoe surgery for example.
I see misdiagnosis happening at a very high rate but I also understand they don’t have the time and/or energy to dig very deep into each patient and they do fine (money and respect-wise) by doing the bare minimum so many don’t try to fight it by e.g. setting up their own consultation and trying to do better (not necessarily making less money).
Of course, a bunch of exceptions can be found and they do shine a lot, but the average doctor isn’t going to be helpful after the very typical and simple checks don’t yield anything and they’ll happily prescribe things that won’t actually help you. That’s been my experience in at least couple european countries.
Edit: typo
The alternative is spending 20 minutes talking to someone filling out forms on a PC and pretending to listen before working as quickly as possible to get you out of their office. Oh, you have some kind of acid-related chest pain? We'll just prescribe a proton pump inhibitor for the rest of your life rather than worry about fixing anything, thank you come again.
Hell, when I was a child and my thyroid failed physicians spent 2 years telling my mother that I was just lazy. My symptoms were so textbook that a coworker of hers diagnosed hypothyroidism, sight unseen, from the mere description. Even so, she had to demand they perform the incredibly simple blood test to confirm.
Needless to say, I have very little respect for physicians in general.
I know in theory they are supposed to look at the big picture and weigh a myriad of factors in coming to a diagnosis. In practice, they mostly just check if any of the blood test results are outside of the reference range and call it good.
I'm sure there are great primary care doctors out there that want to defy their own incentives and do the right thing, but trying out a bunch of doctors can take a lot of time and money, often with no payoff.
My mother did this on my behalf when I was an infant, just a few weeks old.
"Nothing is staying down. Always throwing up. Not gaining wait."
"Oh yea yea sure new mother. You'll get the hang of it. Come back next month see you then. Naturally under weight since birth it's normal for the kid. Thanks bye."
Rinse and repeat until some doctor got bloody tired of the repeat visits. "Fine, come on in and I'll take a look." A few minutes later it was "oh fuck" and I was on a gurney being wheeled into surgery.
So now that it's decades after I didn't starve to death thanks to a procedure that didn't exist before 1912 [official diagnostic criteria at 1888] ... yea. Maybe sometimes you should bother your doctor(s). Sure, humour them and leave a lot of the time but when you know it's Not Good ... make them stop humouring you.
And yes, "I have the scar to prove it".
Main treatment program for a doctor: go home and see if it gets better
Anyway, the school system should be changed dramatically everywhere. The current paradigm is hurting children and should be abolished.
Not sure I follow. Busing was premised on the exact opposite of this?
I’m all for structural change on many fronts, but I’m not sure that private schools should even exist. It’s hard to build successful, high performing universal services, and especially for education, if the wealthy can just construct a separate, parallel system that becomes a social marker for perpetuating elite status.
More specifically, rich families put their kids through private schools and abandon the public school system. Without skin in the game, they vote to reduce the budget of the public school system. Rich families generally have more time and resources to spend being involved in the schools. They won't be spending those resources advocating for improving the public school systems. Additionally, their kids, who are well-cared for and come from a family who values education, do not form a peer group with the other less fortunate kids. This deprives those kids of better peers to model.
Now, you can argue that the freedom of and benefits to the rich families trumps the benefits that the poorer families would receive, but there is a greater good argument.
I've seen it argued that universal social programs are generally seen to work better and are more popular compared to means-tested ones. For example, Medicare and social security vs Medicaid and TANF.
1. Rural telecommunication is highly subsidized. People living in cities almost entirely fund the expensive infrastructure needed to connect those living outside them. 2. Rural electric is mostly done through semi-governmental agencies (co-ops) that are largely built using government-subsidized loans (small hand-out) and grants (larger hand-outs). Urban electricity is more (but still not completely) private. 3. Farmers (the basis of most rural economies) are generally protected by government-subsidized and run crop insurance programs, and have a number of programs that pay them to fallow their land at times (direct payments not to plant things to manipulate the market). There are also numerous subsidy programs to make direct payments to shore up effective commodity prices. 4. Social Security is just a baseline everywhere. Despite the system that is designed to fool you into thinking you pay for your later payments through wage taxes, most people who make it to retirement get out much more than they ever put in (even adjusted for interest and inflation).
So I would submit that those same people who talk about not being dependent are in face highly dependent.
No, but it is one of many problems.
The students are more likely to be facing food insecurity and odd parental schedules at home. The school may need to spend more keeping their student body safe. And one kid with a violent parent who reacts by being violent in turn can wreck havoc on the rest of the classroom. That kind of person might need an education that is more therapy than academic.
To see that publicly education can work very well. Look at Finland e.g. But there are also many asian countries showing good results with public education.
Based on my experience as a foreigner in the US, the US school system strikes me as something operating far more like private enterprise. Schools compete for students while there are no strong national standards and so you get insane grade inflation. I was shocked when I studied in the US how high grades where. Anything to please the "customers" I mean the students I guess.
So why is the common reaction to fund public schools even more? To me the logical reaction is to cut funding and try something different
There aren't that many schools on par with Stuyvesant or Thomas Jefferson or Bronx Science (all testing admission) in the world.
It has in most the rest of the developed world; maybe (as with healthcare) the problem is that the system has been deliberately compromised to benefit private providers for financial and (more for education than healthcare, though it's a factor in both) sectarian reasons by the same people that use the poor results to rail against the public system and for (usually, publicly subsidized) privatization to further benefit the same private financial and sectarian interests. And not a fundamental problem with the service being publicly provided, which plenty of countries manage to do quite well.
> Agree on health, law / police though
To be fair, public provision of both of those are pretty bad in America, too, though the private provision of the former is worse.
Everyone I have ever meant who want police reform, at their core, want accountability and a lesser reliance of lethal weapons as a primary tool.
There are other topics depending on where you come from, e.g. racial diversity, but I've yet to meet someone who wants the police to act like a private force.
https://timeline.com/rockefellers-hired-militias-to-shoot-at...
The speaker, an MS researcher and clinician, noted among other things that we've been really really wrong about how many folks in the US have multiple sclerosis - like, by a factor of 2. There are lots of reasons for this, but it's not JUST the lack of easy diagnostic tests.
Until relatively recently, there were NO real therapies for MS, so doctors were hesitant to make the pronouncement. Add to this that a diagnosis of MS would qualify as a pre-existing condition, and would prevent the patient from getting health insurance (pre-Obamacare, anyway), and would absolutely put the kibosh on life insurance.
So there were real world consequences, and they were therefore hesitant.
Take cancer, for example. The treatment is so toxic (potentially deadly) that we want to make sure that our diagnosis is as close to 100% as possible. To the point where if you want to transfer where you get your chemotherapy, the new place will insist that you bring not just the biopsy report that shows that you have cancer, but the actual 'slides', the actual biopsy tissue for them to independently evaluate.
Contrast this with MS where there is virtually no therapy (until recently), the tests themselves are very expensive (multiple MRIs over time) and the tests aren't even that much better than just talking to the patient and examining them. But, both the MRIs and the clinical exams/interviews require multiple visits, sometimes with years of monitoring in between to truly make the diagnosis.
The system just doesn't incent this type of care and certainly doesn't reimburse it very well. Patients want answers and answers now. Doctors are hurried. Insurances change so you have to change networks, etc, etc, etc.
I think you're ignoring how obscure some symptoms of cancer are, though. My cousin went back and forth with the doctor about a recurring cough, for 3 or 4 years. It turned out to be bowel cancer, and while they did treat it, it was too late by the time anyone in the medical system thought of that. The only indication that would point them towards bowel cancer, was the medical history of her family, her grandmother had it too. She was rather young as well, late 20s/early 30s, so they just didn't consider it.
There have been approved therapies for MS since the mid-90s.
There's so many experiences reported in MS and other neuro-based communities online where people were given the stress and anxiety label only to be diagnosed months, years, and sometimes decades later with an actual illness like MS. I feel truly bad for people that have the extraordinarily rare diseases because chances are slim they'll find someone to actually investigate beyond the standard textbook procedures.
This can make a doctor which was semi-decent and quickly turn him into a greedy immoral person.
I don't think it should be legal for companies to pay doctors to promote their products. Do anyone disagree?
Experiencing that dinner and seeing my host family mom (a practicing psychiatrist in the US for a private psychiatry hospital) getting food every week from pharma reps, makes me feel disgusted about the connection between doctors and pharma companies in the US.
Lawyers have to pay for our required continuing education classes. Sponsored courses and retreats are clearly a conflict of interest for MDs.
Also, as lawyer, I remain shocked and saddened to see how US medical providers have abandoned patient privacy in the wake of the US opioid crisis. Patients prescribed any controlled substance are now put on registers that almost any state actor (or local police) can review at will.
US MDs have thrown their patients under the bus because they (or their colleagues) were (lazily/blindly/greedily) writing too many opioid prescriptions.
My GP didn't even think it was an issue -- here sign this. I couldn't believe what I was reading. I refused and didn't get the meds I needed -- resulting in harm to put it mildly. I am lucky that I am not suicidal because it got pretty dark for me, after a few weeks I had to crawl back to get the meds I need.
Wow. That's a violation and could get the company the smack-down. No way that family members should be included, even if they pay for their own meal.
"The Code provides that it is not appropriate to include a spouse or guest at a meal in connection with an informational presentation, regardless of who pays for their meal, unless the spouse or guest would independently qualify as a healthcare professional for whom the informational presentation is appropriate."
Again, it isn't perfect. I don't have answers, just a knowledge about how complex things are.
That coupled with genetic diversity, ignorance of their customers and relative ignorance of the practitioners itself (we still don't know more than we know) could truly be a recipe for disaster.
My celiac was misdiagnosed for pharyngitis for long, and since I've stopped taking any doctor very seriously. I read A LOT, visit a bunch of doctors (preferably leading to specialists) and ask a lot of questions before deciding what course of action I want to take.
Luckily, in India, doctors don't charge as much (~$20-40) per session.
Not in countries with a national health system, where the government is incentivized to keep people healthy in order to reduce cost.
I don't really believe that doctors are keeping people sick on purpose to keep demand for their profession high, but if that were going on, I don't think socialized healthcare would necessarily erase that incentive. There are plenty of government and private sector workers who try to preserve their own jobs to the detriment of the whole.
Of course, it’s far from perfect just like any regulatory agency ever.
On short: much better to be a healthcare provider in US; much better to be a patient in EU.
The ability of national health systems to say “no” is one of the big levers to controlling cost, in the US, that control is quite fragmented.
Because the NHS doesn't optimise for cost, it optimises for cost per QALY (quality adjusted life years). Given the high impact to quality of life for blindness your claim is dubious.
NICE make the decisions over cost effectiveness of treatments, and publish their findings. If you can tell me the name of the drug we can find the actual report.
Avastin / Lucentis does not support the point being made. Lucentis, a very expensive medication, was both licenced for AMD and was approved by NICE for that use.
Avastin is identical, but was not licenced for AMD and so NICE was not able to recommend its use for AMD.
Doctors were using Avastin off label, and they wanted the government to force Avastin to be licenced for AMD which would have allowed it to be recommended by NICE.
The makers of Avastin and Lucentis fought this in the courts for years, and took action against NHS Trusts using Avastin off-label. The NHS won that legal case.
https://www.bbc.co.uk/news/health-30138097
https://www.hsj.co.uk/finance-and-efficiency/breaking-nhs-wi...
There is a problem of people going blind while waiting for treatment, but this is related to cataracts and glaucoma, not AMD, and it has nothing to do with NICE (who are the organisation that decides about cost effectiveness) and everything to do with a government that has chosen to de-fund the NHS.
This is what I was referring to.
The cost decision involved was of course not to have the follow up appointments sooner.
Some Trusts were attempting to make this the first line treatment as an off-license prescription as it was cheaper and the pharmaceutical companies were trying to sue the Trusts for "not providing NICE approved medications and therefore disadvantaging patients" while simultaneously not seeking to license Avastin for wet AMD.
This was a few years ago so I may have misremembered some details.
I'm getting really repetitive but transparency transparency transparency.
Let's make public the cases where the suppliers collude to withhold drugs for actual effective usages "because we have this other more expensive option that's the only one we sent in for approval" whine bitch stfu and do what's best for the patients you money grubbing bastards.
Lots of hits in google.
https://www.independent.co.uk/news/health/glaucoma-nhs-delay...
https://www.thetimes.co.uk/article/elderly-go-blind-as-nhs-i...
https://www.telegraph.co.uk/news/2018/06/06/hundreds-going-b...
https://www.dailymail.co.uk/health/article-122995/You-blind-...
https://www.lbc.co.uk/news/long-nhs-delays-mean-patients-are...
https://www.thesun.co.uk/news/10702618/nhs-delays-left-patie...
https://www.dailymail.co.uk/health/article-7864729/22-glauco...
The cost decision involved was of course not to have the follow up appointments sooner..
In 2012 they issued a report about the usage of Visudyne/photodynamic terapy which the Royal National Institute of Blind People objected to.
It's hard to see how this can be true, since government operations are infamous for excessive cost.
At the same time most average employees will struggle to buy a house.
And the social security will reimburse well only medical costs (visit to family doctors or medical acts done in hospitals). For other costs, hospital care, glasses, dental or hearing costs, it reimburses very little.
So for me France's SS is actually a kind of mandatory way to channel money towards doctors.
I'd rather be alive and renting than dead with an estate that has ownership of a building.
Thus, that money doesn't just go to health care. It also goes to other social security programs and government projects.
0: https://www.theguardian.com/us-news/2020/jan/07/americans-he...
If a lot of people in the US can’t afford treatment, then why does the US lead the world in several cancer outcomes? If people were just dying for lack of treatment, that would make outcomes far worse.
The US even had a popular TV show about someone who got cancer and started making and selling meth to be able to afford treatment. Fantasy, sure, but nobody outside the US would even consider that a remotely plausible premise.
Sounds like you've never had a friend or family member die because the NHS found a reason to refuse treatment for their non-terminal cancer. At that point, if you don't want to die, your options are actually more expensive than in the US.
Yes, this happens - a lot more than people on HN like to admit. It's one of the reasons that the UK has one of the worst success rates for cancer treatment out of all of Europe.
Sounds like this is more a problem with NHS-specific bureaucracy or NHS funding rather than universal healthcare in general, though.
For a system designed to heal people, the priority should be to heal people, and to make the cost of doing so as low as possible. In this system, when somehow someone is unable to access healthcare they need, it's a failure of this particular implementation of the system, and something that needs to be fixed. The goal of the system is to take care of everybody.
The US system isn’t designed at all. Many if not most hospitals and insurers are non-profits, while others are operated by varying levels of government. The resulting patchwork is regulated on multiple levels of government with a variety of differing policy outcomes, but “profit” is not generally one of them.
There are, indeed, for-profit producers of drugs and medical equipment, but this is also true in the UK (GlaxoSmithKline is a British drug company).
> For a system designed to heal people, the priority should be to heal people, and to make the cost of doing so as low as possible. In this system, when somehow someone is unable to access healthcare they need, it's a failure of this particular implementation of the system, and something that needs to be fixed.
Minimizing cost and maximizing access are, in fact, competing goals. If a certain medical treatment is inherently costly to provide, you have to make a specific choice between cost and access. If you are unwilling to budget for competitive pay for health care professionals, you directly affect the availability of care by risking shortages of these professionals. Likewise if you don’t build enough hospitals. This fundamental constraint applies to all health care systems.
I would argue that having the government individually operate each hospital and directly employ each doctor and nurse imposes a heavy administrative burden that is fundamentally impossible to optimize for cost-efficacy. “Failures of implementation” are inevitable and systemic in this model; you may have paved a road with good intentions but that doesn’t mean it leads where you want to go. This is why the NHS is relatively unique even among universal systems and was not broadly replicated even in other European or Commonwealth countries, most of which seem to have better health outcomes.
I’m not saying the US system is perfect, or even better for that matter, but countries like Switzerland and a Singapore have systems that are arguably more privatized than the US while providing better outcomes as well. Even most countries with universal health insurance have some private sector involvement. The problems with the US health care system are far more complicated than the oversimplified conspiracy theories people keep spouting (theories that aren’t far off from those of anti-vaxxers or known frauds like Kevin Trudeau).
That isn't what happens in the English NHS. https://www.kingsfund.org.uk/audio-video/how-does-nhs-in-eng...
Current inefficiencies in the NHS are caused by lack of investment in buildings and in staff. The NHS has less management than similarly-sized commercial companies, and none of that management is The Government.
> CCGs buy services from organisations of different shapes and sizes – from NHS trusts that run hospitals and community services, to GPs and others that provide NHS care, including organisations run by charities and the private sector.
Right, so “the government” funds a few public agencies which themselves pass on money to the CCG’s, which also seem to be quasi-autonomous public agencies. The actual care providers are sometimes in the private sector. I’m not sure what distinguishes NHS England or the CCG’s from “the government” other than semantics, but sure.
This is still more administrative overhead than other “universal” systems and does not seem to address the tradeoffs between cost and availability of care. Per Wikipedia:
> A survey of CCGs by the Health Service Journal in April 2015 found that more than a third were planning to save money by restricting access to services, particularly on "procedures of limited effectiveness", podiatry, IVF, and limiting access to procedures based on aspects of a patient's health, for example whether they smoke or are obese, which can affect outcomes.[30] A similar survey by the GP magazine Pulse, in July 2015, found that many CCGs were planning to restrict access to routine care in various ways.[31]
They're not run by a government minister; they're not staffed by civil servants; they're not a government department.
> This is still more administrative overhead than other “universal” systems
It really isn't though. Of course some management exists, it's a budget of over £100bn. But compared to other healthcare systems the NHS is relatively efficient. "The NHS is over-managed" is a persistent myth. See for example chapter 2 of this study: https://www.nuffieldtrust.org.uk/files/2018-06/the-nhs-at-70... (This study does contain a lot of stuff that the NHS is poor at).
>> They found that the NHS spends relatively little on overseeing and planning care, relative to other comparable systems. In 2014, the UK, Portugal and Ireland all devoted 1.5% or less of their government or compulsory health care expenditure to administration. This compares with an average of 3.1%, with 4.1% in France, and 7.9% in the United States.
> "procedures of limited effectiveness"
They're not going to fund things that don't work. Why is that a bad thing?
But, again, I've said that there are problems caused by the choice to de-fund the NHS and that if we had comparable funding as other nations we'd start seeing better outcomes.
The US system is very far from a free market.
It is extremly expensive to run the "insurance industry", much more than inefficiency in goverment run healthcare.
Do you think your insurance agent work without getting paid?
Sure, private businesses want to charge as much as possible. But they only succeed when they've managed to get the government to limit or eliminate their competition (as goes on in health care).
Well, sort of. Some treatments are free. Some other treatments are not covered at all by the NHS, which counterintuitively makes those conditions more expensive to treat in the UK than they would be in the US.
> longer life expectancy
Life expectancy is a horrible way to compare healthcare systems, because there are far too many confounding variables to draw any meaningful conclusions. In reality, factors such as genetics, economic history, and demographics will overpower any effects that healthcare delivery could possibly provide.
> and better health outcomes
Not quite. The UK scores better on some healthcare outcomes, but it scores dramatically worse on others. For cancer treatment, in fact, it's one of the worst in Europe, and far behind the US. (This has been demonstrated by a series of studies that have been replicated multiple times over the past 20 years, the most recent being published only one year ago).
It's only hard to see when you believe what business lobbyists tell you. It's actually easy to see when you look at the numbers.
The real lesson here is: don't believe everything people tell you. Look at the evidence first.
Now there are plenty of government projects that are woefully inefficient, but health insurance seems to be one that governments are actually good at. Maybe not great, but better than an unregulated market.
The US health system is very highly regulated. For what an unregulated market looks like, see the software business. Consumer costs for software have been largely driven to zero.
The software market is a very different market from the health care market. An unregulated software market may not quite be a free market due to monopolies and vendor lock-in, but for consumers, it's quite possible to say no to any software purchase. That's not the case with health care, where often your options are to pay or die. That means that in a profit-driven health care market, prices can be raised indiscriminately, especially in the case of the US where health care prices are often kept hidden, because the people who can afford to, will pay anyway. There's better margins in providing health care to the rich than in providing it to the poor. It's profitable to let the poor go without healthcare.
This makes the healthcare market a very poor market to let be government primarily by a profit motive. Of course health care companies in other systems still make a profit, but they are very limited in how far they can rip off their customers compared to the US.
Except that in such countries healthcare costs completely explode over time as well.
0: https://www.businessinsider.com/cost-of-healthcare-countries...
Can you elaborate? Genuinely interested in the details.
About 50% of all R&D worldwide happens in the US. The US's global share has shrunk a bit, but only because China and India have grown rapidly, not because Europe has ramped up (it hasn't).
Some new drugs are developed in European countries, or by European pharmaceutical companies - that's true. But European pharmaceutical companies all make a disproportionate amount of their revenue off of sales in the US market. So Europeans quite literally benefit the most from the fact that Americans pay more for the same drugs.
Yes, I agree that it's a foolish choice for the US to subsidize foreign countries' healthcare in this manner. Regardless of this decision that we both agree is foolish, it means that it's misleading to compare cost-effectiveness between the US and other countries directly.
Yes, the US has the highest cost. But the ratio between the US and others has stayed roughly the same over the last 50 years (maybe longer--that's as far back as my data source goes). The US pays twice as much as France now because we paid twice as much as France in 1990, and both systems have had costs explode by about the same factor since then.
Here's a table of costs per capita in US dollars for the UK, France, and the US:
Year UK FR US
1980 385 659 1036
1990 782 1458 2700
2000 1561 2686 4557
2010 2871 4048 7939
2018 4070 4965 10586
Year UK FR US
1990 2.0 2.2 2.6
2000 4.1 4.1 4.4
2010 7.5 6.1 7.7
2018 10.6 7.5 10.2
Source:
1. Go to https://data.oecd.org/healthres/health-spending.htm
2. Uncheck "latest data available". This enables the year range selector control.
3. Use the year range selector to expand the range to 1970-2018.
4. The chart will then show the total costs in US dollars/capita by year of health care in 50 countries. You can use the "Highlighted Countries" drop down to narrow that to select a "background" of OECD, EU, Euro Area, G7, or G20 if you want. You can then add individual countries using the list on the left of that dialog.
5. You can change what is shown from total to government/compulsory, voluntary, or out-of-pocket and you can change the measure from per capita to % of GDP.
I know Canada used to be fee-for-service. The more the doctor does, the more they get paid.
They certainly had an incentive to “do more”.
Not just because it’s unethical. The mechanism doesn’t work: your future income will benefit a lot more from being regarded as a competent doctor, than it ever would from the minuscule damage you could do to public health with being purposefully bad.
I’ve also rarely seen doctors that cared about patient acquisition in the way normal businesses do. Since health care is somewhat expensive, governments tend to try running the system with a slightly low number of people.
> Not just because it’s unethical. The mechanism doesn’t work: your future income will benefit a lot more from being regarded as a competent doctor, than it ever would from the minuscule damage you could do to public health with being purposefully bad.
Almost none - certainly not when it comes to preventive care. The original article shows misaligned incentives with a tiny, short feedback loop, and even then these instances are (thankfully) not common on a large scale.
The idea that a GP would encourage their patients to have unhealthy diets and never exercise, just so that in twenty years some other doctor - a cardiologist, endocrinologist, etc. - could have a greater supply of patients in need of care is absurd. The GP's expected lifetime earnings are not going to go up if their patients decide not to engage in preventive care, and the GP's expected lifetime earnings definitely will go down if they actually discourage preventive care, because they'll develop a reputation as a shoddy doctor.
I can not believe I had an issue for decades and no medical professional suggested an elimination diet.
Having consulted for the healthcare sector a little bit, I am terrified of ever going into the system if I develop anything slightly unusual.
This is a sector that really needs to be overhauled with evidence based practice and heavy, heavy use of automation and ML to minimise the human element.
I don't think that's correct. Many states require a certain amount of continuing medical education to maintain a medical or nursing license. It's often not a TON of training and you have some flexibility in what topics you choose to study, but it's something.
Doctors get one thing wrong and then people want to self-diagnose with the internet. It's like a programmer originally thinking a bug is in one function when it's really in another. And then the customer reads a Java for dummies book and thinks they can find the answer.
It's hard to compare doctors with other fields because a fuckup in most fields will cost money, but a fuckup in medicine will cost permanent damage and lives. If doctors can't live up to a higher standard (and they can't) then we need to minimise the human element in diagnosis and treatment as quickly and aggressively as possible.
Anecdotal but I've personally been saved from a potentially permanently-crippling medical procedure only because my med student friend visited me in the ward and questioned the procedure as it didn't make sense given my condition. If he wasn't around, I would be spending the rest of my life with a mild disability. That's not acceptable, but it happens all the time.
This is a fantastic example! I often think about the distribution of talent/competence in fields and that is a very interesting anomaly.
Does anybody know why this is the case? I understand that it's a (fairly) repetitive task, and technology certainly assists, but I think I recently read that there are .2 "incidents" per million commercial flights.
How has an entire industry created a standard that seems to be well above any other?
Nothing like this exists in the medical industry. In fact surgeons and doctors are notoriously anti-process, anti-statistics, and basically don't want anyone scrutinising how they work. I'm not sure how they've been able to get away with it for so long.
Sounds an awful lot like the situation every GP is in... no one human can know everything about the body, so there are GPs that legitimately can't diagnose you.
On the other hand, the person with a particular bug to troubleshoot in themselves has all the time in the world to become their own specialist and do the knowledge synthesis that the generalists don't have the scope for.
I've read way more about my relatively common condition than anyone but the specialist I'm seeing, and I've come up with some things that he was not aware of in the process. Once down a certain condition's rabbit hole, the patient/specialist dialog really should be a give and take.
The reason it's unquestionably better than humans is because it's not possible for humans to be aware of every recorded case of every recorded disease and the various ways it presents itself. But as long as data capture capability exists, an ML model can be updated to incorporate all that knowledge on a regular basis.
The second element of this is that the vast majority of doctors just follow a primitive flowchart to diagnose conditions. It's not like Dr House where they're experts on human anatomy and drug interactions etc. GPs are better compared to phone customer service reps running through a script. ML is better than that.
My issue happened to be with sesamoid/metatarsal fracture, flat rootedness, and poor gait. No doctor cared about my gait which turned out to be the root cause of my other symptoms. They all wanted to do surgery/orthotics and basically thought that would fix it alone vs combined with PT.
Maybe in the short term. In the long term, people will get older and will get more ailments due to age and still go to the doctor. When I visit a GP in the Netherlands, I mostly see children and old people in the waiting room.
Those companies where you count some kind of points as you eat and pay membership to turn up for a weekly weigh-in and pep talk rely on the good habits being poorly embedded so that you get fat again without the meetings.
I disagree with the conflict of interest RE doctors.
At least with doctors, people will always get ill. If people no longer turn up for lifestyle-related ailments, they will still come in with a rash or pain or whatever. They will also have fewer complications or confounding factors for diagnosis.
In a profit-driven healthcare system, I would imagine that lots of healthy patients is more profitable for a GP than a few sick ones. The sick ones incur more costs, and end up getting referred away to specialists for much of their care anyway.
For me, losing a bunch of weight was as simple as cutting out big sugar bombs and alcohol. After about a month, anything that could be classified as a "dessert" became cloyingly sweet and gave me indigestion. I pretty much eat whatever I want otherwise.
I don't know how much weight you lost, but I can't imagine it was all that much if all you had to do was cut out sugar and booze, unless that was the majority of your caloric intake.
Encouraging this shift is largely how eating disorders are treated; though in my case it came as a result of dealing with a lot of trauma that I had buried. But ultimately it's about holistic emotional and physical health, and reframing your relationship to food in that context.
Even if it is only 10% of the caloric intake, it works. Obviously not for losing 100kg, but a 200kcal deficit per day (one less dessert or one bottle of beer) adds up to 10kg weight loss within a year.
My luck ran out last time I tried to find one. I wonder why there isn't any repercussions for lot of self claimed doctors...though government tried to deny the WHO report that said approx 65% doctors are not qualified in India and the rest are dubious to good. Doubled down and passed a bill for recognising ayurveds, homoeopaths, etc as actual doctors.
There's this crowdsourced list:
https://docs.google.com/spreadsheets/d/1pzckT6ns2H1IlmwYwJa8...
Sad reality.
Private prisons come close. They incentivize having more people in prison.
So, when you see people lobbying against legalizing weed, some of that is genuine concern, but it also aligns very closely to people who realize what a drop in prison inmates could mean for there business...
It's insane.
https://www.snopes.com/fact-check/drug-law-lobbying-by-corre...
The corrections corporation of America only spends a million a year on lobbying- this would be small change even if it was solely spent on anti-marijuana lobbying. But It's more likely that the majority of their lobbying budget would be spent on issues directly related to regulation and spending for private prisons
Several judges took bribes from private prisons to incarcerate juveniles for minor offenses. While the judges have substantial jail sentences, the developers got off light at <2 years in jail and some fines. For wrongly keeping minors imprisoned, and leading to the suicide of at least one of the wrongfully jailed.
I couldn't find anything about this on the link you provided. Any other sources?
this [1] doesn't differentiate between violent and non-violent
https://www.marijuanalawyerblog.com/how-many-federal-prisone...
from the second link: "This is a total of 11,533 people incarcerated as a result of their involvement with cannabis products."
Considering that the percentage of prisoners in private prisons is below 10%, we can see that there are less than 1100 people in private prisons for marijuana related crimes.
There is no way that you can generate returns on lobbying for one of the most hot issues in US off of the profit of 1100 prisoners
(their, BTW)
Cf. the California prison-guards' union: https://www.latimes.com/politics/la-pol-ca-road-map-prison-g...
I've been through this, and I've seen a close friend go through this, and doctors have been far more harmful than helpful in my n=2 experience. They're quick to diagnose the most common possibility, and dismissive of any other possibility. But here's the thing: that all makes sense! Given the demands on doctors time and the ROI for quality of life for patients, doctors are, and should be incentivized to spend as little time as possible per patient and to diagnose them with what is most likely, given the evidence and previous knowledge.
I think medicine is one of the last great frontiers for the people to relaim through the internet. We don't take anyone's word for it when it comes to any other field, only medicine. I think we should all come to accept that we are our own doctors, first and foremost. We need to research how to take care of ourselves. Doctors are dramatically undertrained on preventive medicine (particularly diet), and I've had them tell me things that are flat out wrong, including outdated science: "losing that much weight is bad for you" when I dropped from being obese over a 6 month period, "that diet is very unhealthy" when I tried Paleo, "fat's will give you heart disease" when I tested with keto and wanted blood work done, "there really is no need to supplement" when my blood work showed severe deficiencies in vitamin D and Magnesium (both extremely important), etc etc.
Preventive medicine and health optimization does not come from doctors, we need to stop expecting it.
After 2 years of weekly injections, during which my health declined precipitously, and a couple of surgeries that took ~4x longer than expected for recovery, I abandoned this approach. I have since gotten my condition almost entirely under control through diet and other lifestyle changes.
If a doctor had told me the simple rules I now follow, perhaps surgery and $4k/mo biologics could have been avoided, but the incentives are aggressively aligned against this option.
The problem is health care companies. To them patients are just faceless entities with wallets. The executive making decisions screwing them over never have to see their pain.
There is a parallel to Nazi Germany here one could use. The reason concentration camps were made was because it was mentally taxing to just gun down innocent people day after day for normal soldiers. Concentration camps in contrast got organized so that the victims had to pick up the dead ones and car them off. All the ugliness was out of view for the evil people running the show.
It was easy for Nazi bureaucrats to kill people with the stroke of a pen. Just names on a list. Never had to see somebody choking or bleeding to death.
Hence you get a big problem when power is moved away from doctors to companies. In this example e.g. the doctor while immoral may not have been quite as immoral had it not been for a company actively pushing him to provide patients.
Private enterprise should not be allowed to provide financial incentives to doctors. Who the doctor sends their patients to, should be entirely decided by medical necessity and not influenced by a potential for profit.
One side of the coin. Pharmacy benefit management companies should be scrutinised for their choice of drugs included in an insurance policy and how they price them, etc.
https://en.wikipedia.org/wiki/Pharmacy_benefit_management#Co...
Wrong incentives = unexpected outcomes!
If warning or outlier condition identified, double check w/ alternative means if sought.
The problem is in the US incentive structure, not with the doctors.
For some co's the data may be worth making it free.
Good luck with that, I'm sure you will be much happier and healthier when the current AI tries to decide whether you are acutely dying of hypercalcaemia or a cardiac tamponade and Marshalls the robots to save you.
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For all the faults and failings of doctors (read: humans), I find many Hacker Newsers vastly oversimplify what doctors do and vastly overinflate what AI is able to do now, or will be able to do in the next ten, twenty, or even 30 years.
It's great that we not have some AI that can diagnose a stroke better than a radiologist on a CT scan. But it can't tell you the scan also shows a space occupying lesion. Or hydroencephaly. Or an extra dural haematoma. Or any other intracranial pathology. And that's about the state of the art.
I welcome new diagnostic aids as I think most clinicians do, but I would take the fleshy system we have of human healthcare providers and suspect that will be the case for a good while yet.
Disclaimer: am doctor and engineer
Why couldn't a model report all discernable co-morbidities?
I don't see any form of objective data analysis remaining optimally in the hands of humans for long.
Double checked by humans, in the short term, sure.
There's arguably zero 'creativity' in diagnostics. It'll be automated within a decade or two IMO.
It could, but it's not there yet. I was trying to illustrate the enormous chasm which AI has yet to cross. Even if an AI model is trained to interpret all head CT pathologies, that is an absolutely minuscule part of practicing medicine.
Let me be clear that I agree that many of the functions of doctors are theoretically replicable with technology. I just have radically different view to the timescale that this will be on compared to many HN-ers who seem to equate treating patients with analysing a computer program, a comparison which is woefully inadequate.
The advances in image interpretation AIs in medicine are a bit misleading as they are literally the lowest of the low hanging fruit. There are huge amounts of data to mine with both normal results and pathological ones, and the data is already in a relatively consistent and nice format for the model to be trained on.
And yet it's 2020 and we don't even have accurate computerised diagnostics for ECG interpretation which is essentially 12 arrays of floats.
I relish the advances in tech, but the chasm between what "robo-doctors"/"AI" etc can actually achieve right now to benefit patients and what a doctor even just out of medical school can do on a day to day basis is vast. The progress in "potential doctor replacements" we have seen from the technology sector is hugely hyped but realistically has a minuscule effect on patient outcomes at present.
I understand people become very frustrated with inadequate healthcare systems and especially when mistakes are made. The go-to answer of "doctors are scumbags, they don't do anything anyway and AI will replace them in a decade" is facile and ill-informed.
Yesterday I walked past a patient who was vomiting fresh blood. She needed urgent wide bore IV access, bloods, blood transfusion, review from upper GI surgeons and head and neck surgical oncology and immediate return to theatre to open up her neck and explore what was going on to hopefully fix it. There is not the slightest hint of a technological solution to this managing this single random example of which I could have picked many thousands more.
Last week I was called to ED to review a patient who had had an industrial accident with heavy machinery and had an almost complete degloving of his arm and almost complete amputation of the same. The diagnosis is easy in this case, but which software is going to keep the man alive and try and save his arm?
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Diagnosis may not be "creative" but as another commenter points out it is nuanced. I've commented about this before but the main challenge with tech for diagnosis is data collection. It's easy to train and run models on numerical data such as CT scans and blood results because the data collection is easy. Even then the tools we have are pretty useless at present. In my hospital we have an automatic warning if the system suspects a patient has sepsis, which is great. However, it's also often wrong. Which, were it allowed to and able to manage the patient would be a complete disaster. ECGs provide automated interpretation which are usually complete BS.
However, patients are not numbers, or programs; eliciting the information you need to make the diagnosis is the hardest part and that is significantly more challenging than a flowchart. E.g. patient found unresponsive at 3am by a canal, no further info. Where is the AI solving this right now?
Once you have a diagnosis, or at least a working diagnosis, you then need to be able to actually instigate the management for that patient. I have yet to see anything that can automatically take blood, cannulate a patient, intubate a patient, perform a ring block with local anaesthetic, run a cardiac arrest, etc.
The chasm looks small from a distance but when you get up close, it's actually really big.
Personally, I had a number of very large lipomas on my body that no insurance would normally ever cover the removal of as they were cosmetic and socially stigmatizing and not dangerous to my health. My doctor filled out all the necessary forms with the proper magic language and my insurance paid the bill. These are simple, 10 minute, outpatient medical procedures that require a knife and $.25 of numbing agent. I could have done it myself if I could buy something OTC to numb myself.
Not all doctors are just looking to pad their billables.
Of course it helps being in a large city with many options and excellent insurance. Without this, I’d probably be getting g second and third opinions constantly.
A: "No"
https://nutritionfacts.org/video/is-it-worth-getting-an-annu...
"Healthy" is also a bit of a misnomer, as there are plenty of (currently) incurable conditions that require treatment not to improve, but to keep from getting worse. For those people, healthy is either not achievable, or is a very different state of being than others.
"Let's go ahead and schedule your MRI for January. I've almost hit my "health patients" target this year and wouldn't want to mess that up"
More, short visits that align with high cost billing codes.
And a high % of doctors are walking medical maladies themselves that don't read research studies even in their own field. Simply focused on bill high, follow procedural algorithm, don't lose job/get sued.
The incentives are misaligned in many other countries, including Germany and the UK. This article focuses on examples in the US, but as noted elsewhere in these comments, there are plenty of articles that show examples of similar perverse treatment incentives in other countries.
In the US you have companies which have no scrupulous because they don't see or know the patients they screw over, actively push and incentives doctors to work against the interests of their patients.
The prevalence of companies paying doctors to prescribe certain pills or suggest certain procedures seem to me more of an American problem. At least in my home country I highly doubt such an arrangment would even be legal.
I mean this just fits in with the opioid crisis in the US. Where medical companies would basically send young prostitutes to doctors to try to persuade them to push their drugs. Yes this is a fact. These companies hired young pretty women, which frequently slept with the doctors they were supposed to influence. The companies made billions while patients died left and right from their drugs.
I cannot think of anywhere in the developed world where anything remotely as horrible has been going on in the health care sector. While everybody has challenges in their health care sector, everything pales compared to what is going on in the US. Greed as completely taken over.