Google’s search monopoly complicates a mental health crisis
bloombergquint.com
bloombergquint.com
So this comes down to therapists living in expensive areas complaining about competition from therapists from cheaper areas. Given there are still people who need/want local therapy, there will be a new price equilibrium but most likely it will be lower than before. No amount of complaining about Google or ads or arbitrage like BetterHelp will make the price stay as before. Nothing much to see here - this looks mostly like a market adapting to a new changed market condition.
It's unclear that this is ACTUALLY competition for the service or just competition for the ads. I personally would not do therapy remote unless I had to so any therapist I would be looking for would be local even if I have to do therapy remote in the short term.
In the 90s part of the promise of the web was that it would disintermediate service provision, these economics would seem to act against that possibility. With large aggregator middle men best positioned to profit with large scale small margin offerings.
One possibility I see is for many shrinks to come together form a co-operative and compete with vc backed alternatives.
This isn’t clear to me at all. I actually associate low-margin business with worse outcomes for traditionally high-touch services.
I suspect that this would be at least somewhat balanced by therapists who work for said online therapy providers suddenly needing to work directly with clients again... but I could see that leading to less therapists per capita in areas of high cost of living, like major cities.
But I hadn't really thought about the potential human harm that could be caused by their failure, which is scary to think about.
Kind of like non-profits in 3rd world countries who warp the local economy by providing some things for free, destroying the market for those, and then pulling out of the country after businesses previously filling that role have closed.
It's like any random problem around Google and Facebook can be chalked up to a monopoly claim.
If you want to break up companies to make it easier for independent therapists, those are the ones to break up. Google is just the marketplace.
This is like blaming the sidewalk or the interstate highway system when Wal-Mart causes your local mom and pop store to shut down. Google isn't driving her prices up, competition is.
It would probably be considered a problem if Wal-Mart paid the state/highway department to ensure that major town roads "flow naturally" to Wal-Mart and are better maintained than roads that lead elsewhere.
This is definitely similar to major companies in a specific domain buying the top search result from google for any query within that domain.
I agree with you that there are inherent properties of physical transit pathways that make them difficult to compare "one to one" with digital index searches. But I do not think these differences make the two completely incomparable.
I completely disagree that the 1st page of google is "just" an ideal place to show an ad.
While it definitely is an ideal place to show an ad it is also much more than that.
That is like saying a supermarket that can give cash-back at the register is just an ATM.
Being the closest doesn't mean it's actually close. The 1st page of google is not a "shared public resource" and not just in the physical sense. The roads are collectively owned by society and are designated and maintained for the explicit prerogatives of the public good.
The first page of google is a privately owned webpage that many businesses rely on for increased sales, but it isn't even close to the only resource for society to search/index the web.
> it is also much more than that
Like what?
> That is like saying a supermarket that can give cash-back at the register is just an ATM.
This analogy doesn't fit. Cash-back is a negligible ancillary function of a supermarket while serving up ads is the sole business purpose of google.com.
The major telehealth bying google ads is Wal-Mart bying 10 large highway billboards. The indie therapist not being able to afford the auction is the mom-and-pop shop not being able to afford those buidboards.
now if the major telehealth would get a dedicated bandwidth and the indie therapist's video calls were getting throttled we would be talking roads etc.
For now it's the 'walmart moving into a small town' scenario but the bloomberg article blames the company that operates the billboards.
A billboard ad is not an explicit and direct "physical" connection to the product the way that a search result is.
Dedicated bandwidth and throttling, to extend my original analogy, would be like the roads going only to Wal-Mart or being difficult in some significant way to take anywhere other than Wal-Mart. It is the same problem only more pronounced.
The first search result you encounter when executing some search is much more similar to the first store you encounter when searching for some store (by taking the easiest or "most natural" path into the shopping district) than it is to viewing a billboard.
Edit -- To clarify what I mean about billboard ads: A billboard ad is something you see that is unrelated to whatever else you are doing. Yes, a digital "billboard" ad is still a direct connection to the product being advertised but it is also distinctly separate from whatever content or activity it displays alongside.
A search result is the content/activity you have sought out by searching. There could definitely be a grey area if google's design made sponsored search results stand out more or be distinct in some way that causes them to read as some content other than a search result (either by position, border, size, color, etc) but that is very clearly not the case of their current design.
Sponsored search results look exactly the same as non-sponsored search results apart from the "Ad" text displayed with the URL. They are clearly intended to look and function the same as the "normal" content of the page and not intended to be an incidental "secondary" experience alongside your search.
And in this case, I don't see how Google specifically is the problem.
In this specific instance, I don't see that Google's dominance of search is a cause of the problem. Imagine that there were ten search engines all owning 10% of the market. The independent therapist was buying ads on all of them. Then COVID hits and she starts facing ad competition from national telehealth providers on all ten of those ad networks, driving up ad prices.
She will have essentially the same experience, and the exact same article could be written. Maybe I'm missing something, but I don't see how Google's larger marketshare is a large piece of what's going on here. To me, it looks almost entirely like a small business all of a sudden facing much larger competition because of telehealth.
Imagine if one day every restaurant got a free teleportation terminal at their front door. If you run a local barbecue restaurant in your small town, it's going to be a lot harder to stay competitive when everyone nearby can freely choose between you, Franklin in Austin, Joe's in Kansas City, or even just the comparatively larger marketing budget of Smokey Bones.
Like it or not, these independent therapists got dumped into a much larger pond.
> If you want to break up companies to make it easier for independent therapists, those are the ones to break up.
It's not clear breaking up BetterHelp and Talkspace will do good at this point. Fundamentally, it's not efficient or possible for all of therapists in the entire US to compete for everyone's eyeballs independently. It's impossible for consumers to meaningfully compare and "shop" against tens of thousands of therapists, nor tens of thousands of suppliers to compete for tens of millions of consumers. You need some mechanism to funnel this down and organize this market. This is why retailers and various dealers and brokers exist, and BetterHelp and Talkspace are the retailers of therapist service, just like Amazon and Walmart are the retailer for many different goods suppliers.
There are special regulations for almost all aspects of Healthcare; so it's not unreasonable that there might be special rules or regulations for ads on Google as well.
That's the problem. It's a marketplace masquerading as a library.
What is wrong with the article :
- So one small Psychiatrist is losing business to other Psychiatrists.
It is perfectly possible that Ross is an inefficient Psychiatrist here and patients are better served by other Psychiatrists. This is a loss for Ross but barely a "complication". Also it is not clear to me if the market was divided 50-50 between say Google and Bing why would it be any difference. From over 10 years of experience in ad industry I have realized that it is a ruthlessly free market system where the inefficient player will get punished very quickly.
What Google has done here is that opened up a lager pool of customers for the suppliers and that has resulted into fierce competition among suppliers. The customers invariably will benefit here as they have more options.
- The rant about smart campaigns
This is one of the real bad arguments. A couple's councilor is upset that Google is unable to differentiate between a PTSD councilor and couple's Councillor. Will the world be better served if a couple's councilor has to compete with a florist or a nanny ? [That it what yellow pages were].
The article laments that customers have more choice and it is not easy for the suppliers to rely on information asymmetry to make profit. They take some fictional futuristic scenario and compare google against it and blame those problems on Google. But in reality it is a good problem to have.
PS. This is by no means to claim that Google's ad algorithms are perfect, but it is without dispute that they are better than all available alternatives.
Perhaps you're approaching this from a technical standpoint because you're a computer person. He's not supposed to represent the entirety of the problem. He's there to illustrate the problem. Journalists do this to "humanize" the story, to make it more understandable by the audience. This is done all the time. If there's space available, several people are added. Or there may have been several examples in the reporter's original writing, but they were cut for various reasons like lack of space.
As an HN reader, you're probably not the audience.
I share your uncertainty about the relevance of Google’s market share. It was however clear to me that Ross is a psychologist, not a psychiatrist, working as a psychotherapist.
> Ellen Ross ... a psychotherapist ... her practice, True North Psychology ... “I’m a fairly good psychologist,” she says.
The exact service on offer is central to the more relevant issue of competition among suppliers. The psychotherapy market is increasingly competitive. Hopefully she’s an efficient psychotherapist as the flood of money into that space is likely to require some adaptation.
Some have simple sites, most have marketing-sites, plenty with keyword domains.
No. In most countries doctors and drugs don't need any SEO, because the doctor is provided by the health service, and the doctor picks the drugs based on clinical indication.
Most people I know go private (out of pocket, it's about £20-80 per session in London so on average about £200/mo).
Discovery is done through word of mouth or looking at various schools of therapy and shopping about to find a therapist that works for you.
Most therapists here don’t accept insurance, many insurance plans don’t cover mental health, and government programs don’t cover it at all.
£20-80 per session sadly sounds like a deal here in the US.
I just searched what it’d cost me here in NYC to purchase and go through the insurance my therapist does take (in-network): The plan costs about $650/month and I’d have to hit a $5,500 deductible before mental health coverage kicks in. Then it’s a 50% coverage after that. I’d pay about $6700 out of pocket with insurance versus about $7350 without it. This doesn’t include the $7800 I’d have to pay for the plan itself.
I wouldn’t really call that a mental health benefit, it’s easier to just find a therapist you like and just figure out a way to pay for it if you can. Most people can’t and it’s a shame because good therapy is transformative. My life is so much better because of it.
Germany has a rule for public insurance where you need a referral to specialists from your general physician (but that's not the case for the ~10% that are privately insured), but you can freely choose that doctor, your dentist etc. Since the public option doesn't cover a lot of the latest therapies (... not even glasses unless your eyes are very bad!), there's a secondary market where patients pay privately, or have a special private insurance for certain things.
Patients are to be given therapies, to be helped and in the best cases cured. Not to be sold drugs seen in advertisements.
Medicine is not a free-market economy sector in Europe. Doctors should educate themselves about new therapies and use them when appropriate.
In countries other than America, healthcare is not for profit. It's not to maximize gains, it's to maximize care and allocate available resources for the public good.
Doctors are the ones who prescribe. Imagine: doctors don't even know what a drug costs, and nether do patients. The customers are government health systems, who study the value of a drug, negotiate prices and make it available iff the negotiated price is less than the value it provides. Its true facts that in Europe, healthcare is not a free market. This is how Canada works too.
Patients receive care as needed and don't need to be advertised to because they're not the customers.
ADHD meds are a great example. In America long lasting ADHD meds with fewer side effects were available for literal decades before they were available in certain EU countries.
Modern drug delivery systems that can slowly dose a medicine over 12 hours (!!!) are the direct result of pharmaceutical companies working to improve QoL for the patient.
The doctor, and especially the healthcare system, don't consider the patient's UX to be of that much importance.
This is analogous to having the CTO make a software purchase VS giving user's input.
Should the IT directors and CTO have a majority of the say? Of course. But the end users must be considered or you end up with painful to use software.
Patients aren't the customer in Europe because they're not buying the drugs. They're consumers, end-users even, but they're not buying them so they're not the customers. Frankly the same is true at any US HMO. The reduction in side-effects is considered by the health system when making purchasing decisions (as side-effects cost the health system money and reduce its ability to provide care on a fixed budget).
And yeah, at a company, the CIO is the decision maker, and the company is the customer. The employees are the end-users. That's why at a big company, employees may not always get to use the tools they want; they're not customers, and they're not making the purchasing decisions.
In both cases, the end-users and their needs are considered, but ultimately, it's not their names on the invoice and they're not the customers.
And sub-optimal results thus occur.
What happens with crappy drugs that technically work is that patient adherence is bad and the government + doctors say "well those poor people with mental disorders are just incapable of following the rigorous treatment protocol that we know works." (and you literally end up with people dying on the street)
Maybe now and then some innovation happens to try and improve adherence, but progress is slow. You can see this in the glacial pace that drugs in certain areas of the the mental health space have progressed. For mental health disorders where the patient is making a decision on the drug, each decade sees tons of innovation. Meanwhile for drugs that are "assigned" to a patient, progress is much slower and an untold number of people have suffered as a result.
I'm not saying free market healthcare is a panacea or that people should be able to pick any drug they want, but medicine should be designed to make people's lives easier.
And letting drug companies advertise "this drug is like the current drug you are taking but has 1/2 the side effects and won't cause your hair to fall out so ask your doctor today!" isn't the worst thing in the world. It means patients will demand their health insurance covers the drug, and it means patients will force their doctor to read up on the drug.
Without the patient being a forcing function there is literally zero motive (beyond altruism) for those two things to happen.
Depends, employees at higher end employers have more say. Since health benefits are "feature" employers have motivation to make their benefits package better to attract employees.
Heck one of Microsoft's defining features as a company used to be their health insurance package. Everything imaginable was covered 100%, no out of pocket costs ever.
I'm still completely confused as to how acupuncture is covered by so many insurers though...
Fertility treatments would likely be another "by popular demand" addition.
Doctors become the customers and sales reps will go directly to them.
But what is covered or not covered are decisions made by governments. Those decisions sometimes forces bad medical practices. On the extreme end a doctor in Toronto was giving a drug to force the baby out of mothers before the due date always on the weekend so he could get overtime. Minor examples are being sent for slightly related tests meds because they are covered vs a more expensive test that would work better but is restricted (the ultra sound vs mri)
It’s like my non-technical boss coming into the office and telling me that we should start using technology X that he saw in an advertisement. Typically, with my boss, he sees something at a trade show or a trade magazine or in an email, and becomes convinced that it is the best thing ever for us and will solve all of our problems. Then we have to put forth a lot of effort convincing him that he is wrong (he has never brought us anything remotely useful) without making him feel dumb.
How about he lets us technical people recommend to him the appropriate technologies instead of the other way around?
After I saw what is happening regarding the coronavirus, this scares me.
That's why pharmaceuticals have sales reps visiting MDs, sponsoring seminars, etc.
People act like "doctor knows best; don't question their wisdom; they have their secret sources of information and you need not concern yourself with that"... yet I as a patient would like to know about all the options on the table available to me so I can do my own research. How do I know an old doctor isn't being biased toward old tried-and-true treatments, and new doctors aren't being biased toward shiny new bleeding-edge treatments?
The same fallacies and biases that affect software developers affect doctors too. Doctors have limited time to think about and research ("debug") my condition, I have a lot of time to research ("debug") my condition.
I'm not saying "advertising" is the correct solution to the information dissemination problem, but surely there could be an alternative solution like some kind of "medicine wiki" that would allow patients to discover medicines related to their conditions.
I think Viagra is a good example of this -- it used to be common for people to assume ED was just a part of "getting old" and not a treatable condition that they even could talk to their doctor about.
In a report from 2015, the FDA found that there were benefits (shocking!) and drawbacks to DTC advertizing.
Positives:
- Most physicians agreed that because their patient saw a DTC ad, he or she asked thoughtful questions during the visit.
- Many physicians thought that DTC ads made their patients more involved in their health care.
- The study demonstrated that when a patient asked about a specific drug, 88 percent of the time they had the condition that the drug treated. And 80 percent of physicians believed their patients understood what condition the advertised drug treats.
- Eighty-two percent responded either "very well" or "somewhat" when asked whether they believe that their patients understand that only a doctor can decide whether a drug is right for them.
Negatives:
- 65 percent believe DTC ads confuse patients about the relative risks and benefits of prescription drugs
- Eight percent of physicians said they felt very pressured to prescribe the specific brand-name drug when asked.
[1]https://www.fda.gov/drugs/drug-information-consumers/impact-...
But do you want your doctor prescribing something they’ve glanced at for 5 min?
Take a look at the label for a random drug, it’s often 20 pages or more of data. Doctors, rightfully so, don’t want to prescribe something unless they are well versed in benefits and risks. That takes time and effort.
I’d much rather have them base it on a 30 second tv commercial I’ve watched.
That's a huge negative in my mind. Blind faith in doctors is terrible for health.
DTCs have a point and being involved in your care makes sense. Doctors also get plenty of doctor-targeted specific advertisements/incentives as well (some less ethical than others)
The main issue I see is that ads might be pushing for the "latest" treatment which might not be the most effective or have the best cost-benefit.
On top of this, the majority of drug consumers are old people, who (statistically speaking) are far less likely to even use the internet at all. This is why drug advertising can be quite useful for them.
[edit] Nobody's making the case this information should be secret, just that it shouldn't be delivered directly to your face during episodes of Futurama. If you want to know what your options are by all means, pick up the pharmacopoeia.
I made this argument recently -- in Canada, DTC advertising of prescription drugs is illegal, too. Has been for years. There's a reason physicians go through years and years of medical training, and its not least to be able to identify and manage side-effects, drug interactions and perform appropriate diagnostics. You spending 30 seconds watching an ad are not ready to self-prescribe Skyrizi or Oxycontin.
Doing it wrong could lead to death, dependency, or in the case of self-prescribing antibiotics, community issues in the form of antibiotic resistance.
This is something you need to have a minimum basis of knowledge to interpret and understand, and pharma companies are taking advantage of a knowledge gap to push drugs circumventing the professionals. It's people who know more than you taking advantage of the fact you don't to make a buck.
The same argument could be made of drivers licenses, right? Well I know how to drive, so what business does a cop have telling me I need a license or to go to traffic school? The answer is simple: you can harm yourself or others if you don't know what you're doing, and the decision is made at the population level.
Plus we're dreadful at self-administering medicine. 75% of American adults take some form of multivitamin or supplement. Most supplements are useless or harmful [1] and multivitamins are associated with an increase in all-cause mortality [2,3].
Let's leave the medicine to the medical professionals, yeah?
[1] https://informationisbeautiful.net/visualizations/snake-oil-...
[2] https://jamanetwork.com/journals/jamainternalmedicine/articl...
Partially disagree. Yes, they are a very important source of information, but ultimately it is your body and information should flow freely both directions so you (the patient) are empowered to make the best possible decision.
Anecdote:
Doctors are not omniscient. One time when my sister was in high school, she went to the doctor because she had a weird rash. My mom researched skin rash images online for hours and concluded it was shingles. When she brought it up to the doctor he laughed and said my sister was far too young for shingles and that it was probably just an allergic reaction to something she ate. He prescribed some topical ointment to see if it helped.
Well, my mom didn't like that and took her to a different doctor who, unprompted, said: "wow, that looks like zoster (shingles)!"
My personal trainer took a look and was like "dude, one side of your right leg is jacked, the other side's not, that's your problem".
Heck a few months ago my dentist wanted to give me a root canal because hot food was causing pain in one of my front teeth. I started wearing my night guard again (...) and the problem went away in a week.
And let's not even get into how miserable doctors are at treating acne, when I was a teenager the official medical word was that diet didn't impact acne. Well, turns out, it's been shown through nice detailed studies that milk can inflame acne.
My first blog was detailing an elimination diet to find out what food stuffs made my acne worse, few years later studies started coming out confirming what people had been saying for literally decades, food can impact acne!
Heck to this day if I splurge on cream I'll get a white head or two.
What the doctor did do was prescribe me an antibiotic that I took for 5 years (!!!) that ended up causing low iron and didn't do much of anything for my acne.
Doctors have to cover a lot of ground, they don't always have time to learn about every treatment option for every possible human ailment.
You'd need some sort of non-profit repository that indexes all drugs as they become available maybe?
I actually like Canada's compromise, where drug advertisers are allowed to tell you that a drug exists to treat a condition (without telling you what that drug is), or reminding you that a certain drug of a certain name exists, without telling you what it does.
[1] https://en.wikipedia.org/wiki/United_States_Pharmacopeia
The above probably isn't humanly possible for everything.
That is unfortunately what most people do and it can lead to poor results for the patient:
>...Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the U.S.
https://www.hopkinsmedicine.org/news/media/releases/study_su...
They counted every death the involved medical care as a medical error death if any sort of imperfection at all was noticed in the case. One of their famous examples was a patient who had a stroke or something and then died "because" he wasn't adequately warned to not go for a jog during recovery, who then had another attack during a jog.
We can (and should) do better than that. Part of this is that patients have to take some responsibility for their care and get second opinions, read up on the diagnosis they've been given, etc.
A 30 second commericial isn't enough but a 5 minute doctor appointment isn't that complete either.
Direct to consumer pharmaceutical ads are the global exception.
https://en.wikipedia.org/wiki/Direct-to-consumer_advertising
https://www.fda.gov/drugs/prescription-drug-advertising/back...
I've been growing more concerned lately that today's youth might not be aware that things really were better just a few decades ago. I'm seeing a lot of mental gymnastics to rationalize behavior by big business that I consider indefensible.
Or to rephrase, I think that youth today do know that they are getting screwed, but for whatever reason, they often place blame on the wrong culprits. If we want to get back to the glory days, I feel that we need to revisit fundamental American values like truth, justice, civics, etc etc etc.
Or we can like, have even more billionaires and regulatory capture by multinational corporations taking us on an arrow's trajectory towards fascism. I can't even believe I have to write this, but that's how much the US has changed since I was young.
Part of why we aren't seeing that reoccur is that while expensive there is FDA regulation and the drugs more or less work even if there may be rightful concerns about side effects. They made sure they actually work so they rake in way more money than any small time quack.
Part of the issue with any return to glory days movement is that tradition is fundamentally a cargo-culted lie via induction. Traditions never were first done because they were tradition. The hard truth is the rot has always been there.
Ads for the former remain rare in my experience. Supply is tight (imagine an ad to join a 10 month waiting list) and insurance coverage is the critical entry point in searches for a new provider ( that a mental health provider is buying ads is testament to the continued lack of mental health parity / vibrant cash market there ).
Pharma ads are older than the FDA itself which practically grew out of the snake oil market. What many people experience as the explosion in pharma ads is really a broadcast explosion. FDA guidance around balanced reporting of side effects changed in the late 90s such that the brief “this may kill you” was newly possible. Lots written about this, eg:
Looking younger, the 20-something crowd doesn't seem to have much of a clue about socioeconomic issues and only sees politics through the lens of racial/gender/sexual orientation/gender identity politics. Their indifference to economic issues may be driven by the fact that they aren't yet old enough to have real adult financial responsibilities. The side-effect, however, is that the idea that socioeconomic conditions for the median person were better in the past is outside their scope of understanding.
Sadly, I don't see a solution for either incorrect blame targeting by 30 year olds or indifferent ignorance by 20 year olds. How these people are educated and what they are exposed to by mass culture is determined by the billionaires, and the billionaires are very happy with a status quo that deflects blame for social decay to anyone and everyone but themselves.
1. patient sees ad for drug promising them a normal life full of beer and children, and ample slightly serious sport/exercise. 2. patient calls doctor and excitedly informs doctor about awesome new life changing drug. 3. doctor tells patient why drug is not appropriate. 4. patient gets revenge for crushed dreams by leaving horrible reviews for doctor everywhere they can. 5. oh right it's a business, society tells the doctor, not health care. 6. doctor accepts stupid reality, and prescribes medication.
Bing and Yahoo are still about 20% of the American market. It is not inconsequential.
I suspect that prices have soared there as well though, simply because the pandemic severely disrupts therapists. In a world of video calls, there is no local market.
There are as many places seeking to sell you therapy as sell you gasoline now.
https://gs.statcounter.com/search-engine-market-share/all/un...
https://gs.statcounter.com/search-engine-market-share/deskto...
So I found only the desktop market share.
This is absolutely not true in the United States. Therapists are licensed in each state and it can cause severe professional problems and ethics situation. A counselor cannot technically even see a client telehealth if they are on vacation out of state that week unless the counselor is also licensed in the State the client is vacationing in.
Source: My wife is a licensed practical counselor and regularly studies for her mandatory continuing education credits in the evening. I hear her watching the lectures and answering questions on those exams.
Private practice may be somewhat different in that State and Federal insurance rules are not at play for private pay, but most sensible counselors will not want to risk their license. You don't have to be prosecuted criminally to lose your ability to practice.
Isn't there a problem with regulation?
And if so ... what exactly is the workable alternative? This is all just market forces. The cost of advertising and acquiring new business has been around for much longer than Google.
She charges $250 a session. Lets say she sees 6 patients per day generating $1500 gross revenue a day. She spends $20 a day in ads which works out to around 1.3% of gross revenues spent on advertising. That is an extremely low amount spent on advertising. The US Small Business Administration recommendation for businesses with revenues less than $5 million per year is to spend 7-8% of gross revenues on marketing.
Goal is to offer breathing room for innovation
where predatory ad approach doesn’t serve as the arbiter of information on webs
This problem is amplified by VC funded start ups. They're willing to lose billions in order to gain a dominant market share. How can little ole therapy service compete with VC funded therapy market when they don't care about making money? Eventually little ole therapy service folds and the therapists have to go work for VC funded therapy market. The long term outlook is that we get one (or a handful) of therapy platforms that are just middle men extracting value.
Instead, the article talks about how individual therapists are losing out as ad prices rise and newer tech-mediated therapy platforms are gaining attention & market share. (and working for those platforms doesn't pay nearly as well) Also google has a near-monopoly for online advertising, so these therapists have few options if they aren't born natural marketers, and Google customer support is bad. In short, it's bad for therapists.
Nothing much said about this being bad for patients though. It's possible patients have greater access to care with these new platforms.
No regulation will fix the fact that people have limited attention, besides banning ads altogether.
Google does a lot of bad stuff, but auctioning ads is not one of them.
Also somebody dares to bill people ONLY 50$ per hour! How dare they to not bill 250$?! ...
She is her brand, so we probably won't get more doctors. But we have slowly raised prices from 50$ to 75$ per hour.
Next we are going to stop accepting some government health insurance because they only pay $60/hr. Long term I can see 125$-200$/hr private pay only.
The alternative to her 1 on 1 care is a hospital/clinic where you get 37 minute visits shared with multiple other clients, and have a new doctor every few weeks due to high turnover.
Word of mouth is more powerful than ads.
Do you think there's a major difference in expected outcome for the average patient, between your wife's practice and a hospital/clinic?
I can totally grok how a patient would find her services valuable enough to pay a much higher rate, out of pocket; but I'm trying to figure out if the payer's arbitrary cut-offs are rational.
Maybe 60/hr is close to the price-point of exponentially-diminishing returns, from the risk-carrier's perspective?
Obviously, institutional payers are way more conservative with risk than financially-well-off individuals, so maybe they're making mistakes on the margin.
Anyways, hope I'm making sense. It's a fascinating topic.
My wife has worked at those places and the difference in patient outcomes is night and day. Sure some people will get better regardless, but there's something special about people saying a 3 year old injury has 0/10 pain. At a big name company, they get people "good enough".
She's one of those people that would prefer to be a Physical Therapist rather than a business owner.
As a side note, many of her patients came from that 60$/hr insurance because most places don't accept it. It seems like it's a stepping stone. Knowing her, they will be grandfathered in.
Something I didn't mention is how often she does free work/eat the cost because insurance will deny payment for services that were approved but later deemed "not necessary". (Despite the person being unable to work) It's complicated because a phone call, or Physician, or patient can sometimes fix this.
I wonder how much of the outcome difference is due to selection bias, so to speak.
For example, your patients are more likely to have better outcomes, because the fact that they are willing to pay OOP for your services implies that they are bullish regarding the valuation of their physical health, which means they are likely proactive in seeking preventative care, solving health problems earlier rather than letting them fester, etc.
Similarly, I'd imagine that the better doctors probably self-select into your wife's situation, because they want to work with active patients and they want to capitalize on their skills and passions. It's a feedback loop where good-follows-good.
Good income -> good outcome, if you will.
But tragically, this implies that good doctors are less likely to be found in the big hospitals, where the people who need healthcare "most" are in need of them. "Most" used here in a marginal sense, where the needy, insurance-using patient receiving 1 hour of your wife's attention provides 10x value in terms of QoL-adjusted life expectancy, than the average proactive OOP patient.
So, we're kind of bound to have a two tier system, with this set of incentives.
In your wife's case, it seems that the price cap of insurance will prevent 10x patients from seeking her out, exacerbating the tiers. But, you can't really blame any of the individual actors in this equation (payer, patient, or provider), it's the incentives that are wacky.
I know of some doctors who "volunteer" some of their time working at a hospital/clinic, in addition to their private practice. Like, one day a week or something like that. If your wife feels guilty about her role in this dance, she might consider doing this, in addition to grandfathering-in the insured folk.
Anyways, I don't really have a point, just thinking out loud. Thank you for your perspective, curious to hear anything more on this topic you'd like to share.
There is a difference between hands on care for 1 hour, and 1 hour being divided between 9 people (seriously, there are some clinics that do that).
For a while I had individual insurance (prior to obamacare). Because it had pretty high deductibles, I would just do a private pay / cash doctor for primary care etc.
Some big wins:
NO discussion about whether something was covered or not! You want to get service, just call.
No crazy surprise bills - yes - I once tried to go to urgent care for something at the main hospital, but NO ONE would tell me what I would be charged as a cash pay client. Yes, it can be expensive to do cash pay, but with a doctor billing by the time you can basically predict / know your cost.
Service - you are paying by the hour. I never felt pressured out the door (no surprise). The service is good to great.
Convenience - I got someone close who used his downstairs as his office. Have a problem, go in and get checked out. Because you don't need the huge billing infrastructure I think you can get away with smaller office sizes. To pay for a full time biller you need a few doctors, who then need a receptionist etc etc.
However, it's hard to replace insurance for nonelective/emergency procedures (heart attack, stroke, aggressive cancers).
Insurance-tailored billing systems are really geared towards non-elective procedures (that's where all the money is). When they encroach on the "normal" stuff, it feels invasive.
Advocating for the insurance infrastructure, there is a preponderance of medical waste out there. Doctors prescribe blood tests, urine samples, or MRI scans even though they aren't medically-necessary, just because the hospital group needs to make some money. When the patient is paying, they are on the lookout for medical waste, because they don't want to pay.
Of course, this means that there will be false negatives from the insurance carrier, when they try to clamp down on medical waste. The only loser in this game is the patient.
I talk a big game about raising prices but I know my wife has done free services for disabled children. She's a sucker, and we claim it's advertising/marketing.
Hospitals and big name clinics would never do this.
sounds like she's a regular compassionate human, rather than a sucker. far better than those hospitals and big name clinics.
[a] Five therapists offering 2/hrs per week to the community isn't nothing - it is a drop in an ocean of need, however.
[b] No. Trying to launch an insurance debate won't help answer this question in a helpful way. Thanks for asking tho.
Doesn't high ad pricing mean there is a glut of supply for the service in question?
The article subject seems upset that someone else gets the customers, but that's not a problem for anyone. If the subject got the customers, that wouldn't be "fair" to their competitors.
Ad space can be seen as land rented out a user request at a time.
Having more competitors to Google will help only a little bit. There's only so many user request x ad space x keyword units to be split among the companies. So the total amount of "land" advertisers bid for remains constant, so prices will be roughly similar. The only difference will be that Google will command a smaller cut of the auctioned price. I doubt that will make as much of a difference as an influx of entrants to the bidding market. Some Google keywords are 10s or 100s of dollars; the Google cut isn't driving hat, but the value of a new customer acquisition.
Disclaimer: I work at Google but not on ads.
They're not just being outbid by larger outfits, but are being lead to believe that they can compete with said outfits by using Google's "Smart Campaigns". Google gets the money from both, but one is being relegated to space that leads to nothing.